Pediculosis (Lice) Medication

  • Author: Lyn Guenther, MD, FRCP(C), FAAD; Chief Editor: Burke A Cunha, MD   more...
 
Updated: Feb 9, 2012
 

Medication Summary

The goal of therapy is to eliminate lice and eggs. Chemical pediculicides are the mainstay of pharmacotherapy. Treatment should be repeated in 7-10 days (the time needed for the eggs to hatch) because nits are less effectively killed than adults. Eyelash infestation can be treated effectively with petrolatum ointment (eg, Vaseline) or mercuric oxide.

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Antiparasitic Agents

Class Summary

Treatment options include malathion, permethrin cream, pyrethrins, and spinosad. For treatment failures, ivermectin—given orally in doses 1 week apart—may be used in the nonpregnant or non-breastfeeding woman and in children weighing more than 15 kg.

Parasite biochemical pathways are different from the human host; thus, toxicity is directed to the parasite, egg, or larva. Mechanism of action varies within the drug class. Antiparasitic actions may include the following:

  • Inhibition of microtubules causing irreversible block of glucose uptake
  • Tubulin polymerization inhibition
  • Depolarizing neuromuscular blockade
  • Cholinesterase inhibition
  • Increased cell membrane permeability, resulting in intracellular calcium loss
  • Vacuolization of the schistosome tegument
  • Increased cell membrane permeability to chloride ions via chloride channels alteration

Resistance to pediculicides has increased over recent years. Therapeutic agents can be rotated to slow the emergence of resistance. Benzyl alcohol lotion needs to be applied twice, but it might be an easier and safer alternative to lindane and malathion. With all treatments that are used to eliminate live lice, careful combing and removal of all nits from the hair as well as cleaning of other articles (ie, hair accessories, towels, bedding, clothing) are essential steps to prevent reinfestation.

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Permethrin (Nix, A200 Lice, Rid)

 

Permethrin is the drug of choice recommended by most authorities as the first line of treatment in head, pubic, and severe body louse infestation, especially for infants older than 2 months and small children. This agent is a neurotoxin that causes paralysis and death in ectoparasites. It is more effective than crotamiton in treating symptoms and reducing the chances of secondary bacterial infection. One benefit of permethrin is a residual effect in the hair for several hair wash cycles.

Resistance probably has developed in many areas, however. Physicians in some countries select different pediculicides on a rotating basis to discourage development of resistance.

Permethrin is very effective in killing adult lice and nymphs but is not as effective in killing nits (eggs). A fine-toothed comb is an important adjunct to remove nits. Patients should wash hair with a nonmedicated shampoo.

An over-the-counter (OTC) 1% concentration (Nix) may be insufficient for treatment of pubic lice and for some cases of head lice. The 5% prescription preparation marketed for scabies (Elimite) may be more effective in some cases. Strict adherence to the treatment regimen is essential.

Pyrethrins and piperonyl butoxide (RID Maximum Strength, Pronto, R&C, A200 Maximum Strength)

 

Pyrethrins are first-line treatment in head, pubic, and severe body louse infestation. These agents stimulate the parasitic nervous system, causing seizures and death of parasites. This is an older OTC agent that still appears to be effective. It lacks the residual action of permethrin and is more likely to require repeated applications. Pyrethrin products are contraindicated for patients with contact allergy to ragweed, turpentine, or chrysanthemums

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Malathion (Ovide)

 

Malathion is approved by the FDA for the treatment of head lice. It is an irreversible cholinesterase inhibitor that is hydrolyzed and therefore detoxified rapidly by mammals but not by insects; it is both ovicidal and pediculicidal. It binds to hair and provides some residual protection after therapy. Malathion is available as 0.5% and 1% aqueous-based lotions.

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Ivermectin topical (Sklice)

 

Topical ivermectin causes parasite death by selective, high-affinity binding to glutamate-gated chloride channels located in invertebrate nerve and muscle cells. It is a topical pediculicide that treats head lice with a single 10-minute application without nit combing in adults and children aged 6 months or older.

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Ivermectin (Stromectol)

 

Ivermectin binds selectively with glutamate-gated chloride ion channels in invertebrate nerve and muscle cells, causing cell death. Its half-life is 16 hours; it is metabolized in the liver. Ivermectin is the drug of choice for onchocerciasis and strongyloidiasis; it has been shown to be effective against pediculosis and has been used in mass epidemics. It is not effective against nits.

Few serious adverse effects have been reported when ivermectin is used to treat lice or scabies. This agent is not associated with evidence of selective fetotoxicity in pregnant women inadvertently exposed (based on limited data). Limited animal data also fail to show evidence of selective fetotoxicity.

Ivermectin is available in the United States as an oral 6-mg pill marketed for treatment of Strongyloides. Physicians have used this drug for lice and scabies (off-label use) in cases where such therapy was in the best interest of patients and conventional therapy failed. Health care providers in the United States are encouraged to read the FDA statement concerning off-label use of approved drugs, which appears in the Physicians' Drug Reference.

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Lindane

 

Lindane stimulates the nervous system of parasites, causing seizures and death. It is a chlorinated insecticide available as 1% lotion, cream, and shampoo. It is a second-line treatment if other agents fail or are not tolerated.

Lindane is not very safe in children because of transcutaneous absorption that leads to neurotoxicity. In March 2003, the FDA issued a public health advisory warning of increased risk of adverse effects of lindane treatment in persons who are young, small, or elderly. Heightened caution should be exercised if lindane is used in such patients. Overall, permethrin is a safer choice.

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Isopropyl myristate (Resultz)

 

Isopropyl myristate is not available in the United States (it is currently in phase III clinical trials), but it is available in Canada and Europe. It is a non-insecticide-based drug containing isopropyl myristate, an ingredient commonly used in cosmetics. Its mode of action is a mechanical process that weakens the waxy shell of lice, resulting in internal fluid loss and dehydration.

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Benzyl alcohol (Ulesfia, Zilactin)

 

Benzyl alcohol inhibits lice from closing their respiratory spiracles, allowing the lotion to obstruct the spiracles, which ultimately results in asphyxiation. It does not elicit ovicidal activity. This product contains 5% benzyl alcohol.

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Spinosad (Natroba)

 

Spinosad causes neuronal excitation in insects, followed by hyperexcitation, paralysis, and death. It is a pediculicide indicated for topical treatment of head lice infestations. This agent is available as a 0.9% suspension.

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Contributor Information and Disclosures
Author

Lyn Guenther, MD, FRCP(C), FAAD  Professor, Department of Medicine, Division of Dermatology, University of Western Ontario; Medical Director, The Guenther Dermatology Research Centre, Canada

Lyn Guenther, MD, FRCP(C), FAAD, is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Society for Dermatologic Surgery, Canadian Dermatology Association, Canadian Dermatology Foundation, Canadian Medical Association, Canadian Medical Protective Association, College of Physicians and Surgeons of Ontario, European Academy of Dermatology and Venereology, International Society for Dermatologic Surgery, Ontario Medical Association, Royal College of Physicians and Surgeons of Canada, Society for Investigative Dermatology, and Society for Pediatric Dermatology

Disclosure: L'Oreale Consulting fee Consulting; Johnson & Johnson Consulting fee Consulting

Coauthor(s)

Sheilagh Maguiness, MD  Assistant Clinical Professor, Department of Dermatology, University of California San Francisco School of Medicine; Associate Physician, Department of Dermatology, Kaiser Permanente

Sheilagh Maguiness, MD is a member of the following medical societies: American Academy of Dermatology, Canadian Dermatology Association, Canadian Medical Association, Society for Pediatric Dermatology, and Women's Dermatologic Society

Disclosure: Nothing to disclose.

Thomas W Austin, MD  Professor Emeritus, Department of Medicine, Division of Infectious and Sexually Transmitted Diseases, University of Western Ontario, Canada

Thomas W Austin, MD is a member of the following medical societies: Canadian Infectious Disease Society, College of Physicians and Surgeons of Ontario, Ontario Medical Association, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD  Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Additional Contributors

David F Butler, MD Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Edward F Chan, MD Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania School of Medicine

Edward F Chan, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Pamela L Dyne, MD Professor of Clinical Medicine/Emergency Medicine, David Geffen School of Medicine at UCLA; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center

Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Dirk M Elston, MD, Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Joseph F John Jr, MD, FACP, FIDSA, FSHEA Clinical Professor of Medicine, Molecular Genetics and Microbiology, Medical University of South Carolina; Associate Chief of Staff for Education, Ralph H Johnson Veterans Affairs Medical Center

Disclosure: Nothing to disclose.

Daniel J Hogan, MD Clinical Professor of Internal Medicine (Dermatology), Nova Southeastern University College of Osteopathic Medicine; Investigator, Hill Top Research, Florida Research Center

Daniel J Hogan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Contact Dermatitis Society, and Canadian Dermatology Association

Disclosure: Nothing to disclose.

Edmond A Hooker II, MD, DrPH, FAAEM Assistant Professor, Department of Emergency Medicine, University of Cincinnati College of Medicine

Edmond A Hooker II, MD, DrPH, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Public Health Association, Society for Academic Emergency Medicine, and Southern Medical Association

Disclosure: Nothing to disclose.

Abdul-Ghani Kibbi, MD Professor and Chair, Department of Dermatology, American University of Beirut Medical Center, Lebanon

Disclosure: Nothing to disclose.

Rick Kulkarni, MD

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

David A Peak, MD Assistant Residency Director of Harvard Affiliated Emergency Medicine Residency, Attending Physician, Massachusetts General Hospital; Consulting Staff, Department of Hyperbaric Medicine, Massachusetts Eye and Ear Infirmary

David A Peak, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine, and Undersea and Hyperbaric Medical Society

Disclosure: Nothing to disclose.

Nelly Rubeiz, MD Consulting Staff, Department of Dermatology, American University of Beirut Medical Center; Associate Professor, Department of Dermatology, American University of Beirut, Lebanon

Nelly Rubeiz, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology

Disclosure: Nothing to disclose.

Robert A Schwartz, MD, MPH Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi

Disclosure: Nothing to disclose.

Russell W Steele, MD Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Jeter (Jay) Pritchard Taylor III, MD Compliance Officer, Attending Physician, Emergency Medicine Residency, Department of Emergency Medicine, Palmetto Health Richland, University of South Carolina School of Medicine; Medical Director, Department of Emergency Medicine, Palmetto Health Baptist

Jeter (Jay) Pritchard Taylor III, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Pharmacy Editor, eMedicine

Disclosure: Nothing to disclose.

Wayne Wolfram, MD, MPH Associate Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center

Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Neil W Yoder, DO Staff Physician, Department of Emergency Medicine, St Vincent Mercy Medical Center

Neil W Yoder, DO is a member of the following medical societies: American College of Emergency Physicians and Emergency Medicine Residents Association

Disclosure: Nothing to disclose.

Jeffrey M Zaks, MD Clinical Associate Professor of Medicine, Wayne State University School of Medicine; Vice President, Medical Affairs, Chief Medical Officer, Department of Internal Medicine, Providence Hospital

Jeffrey M Zaks, MD is a member of the following medical societies: American College of Cardiology, American College of Healthcare Executives, American College of Physician Executives, and American Medical Association

Disclosure: Nothing to disclose.

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Nit on a hair. Note the thin, translucent cement surrounding the hair shaft. Photo courtesy of David Shum, MD, Division of Dermatology, University of Western Ontario.
Nit from Pediculus humanus capitis on a hair.
Two empty nits from Pediculus humanus capitis. Note the open shells still attached to the hairs and the porous operculi through which the lice have hatched. Photo courtesy of David G. Schaus.
Three specimens of Pediculus humanus capitis.
Pediculus humanus corporis.
Phthirus pubis. Note the clawlike talus.
The head louse, Pediculus humanus capitis, has an elongated body and narrow anterior mouthparts. Body lice look similar but lay their eggs (nits) on clothing fibers instead of hair fibers.
The pubic louse, Pthirus pubis, is identified by its wide crablike body.
 
 
 
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