Background
Pediculosis (ie, louse infestation) dates back to prehistory. The oldest known fossils of louse eggs (ie, nits) are approximately 10,000 years old.[1] Lice have been so ubiquitous that related terms and phrases such as "lousy," "nit-picking," and "going over things with a fine-tooth comb" are part of everyday vocabulary.
Louse infestation remains a major problem throughout the world.[2] In the United States, the incidence of pediculosis has risen steadily over the last 3 decades, making the diagnosis and treatment of louse infestation a common task in general medical practice. Head louse infestation among school children has reached epidemic proportions in many parts of the United States.
Lice are ectoparasites that live on the body. Lice feed on human blood after piercing the skin and injecting saliva, which causes pruritus. Lice are able to survive away from their human host. However, they will die of starvation within 10 days of removal from their human host.
A mature female louse lays 3-6 eggs, also called nits, per day. Nits are white and less than 1 mm long. Nits hatch in 8-10 days, reach maturity in 12-15 days, and live as adults for about 10 days.
Different species of lice prefer to feed on certain locations on the body of the host. Louse species include Pediculosis capitis (head lice), Pediculosis corporis (body lice), and Pediculosis pubis or Pthirus pubis (pubic lice, sometimes called crabs).
See the louse images below.
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. Pediculosis spreads from person to person by close physical contact or through fomites (eg, combs, clothes, hats, linens). Overcrowding encourages the spread of lice. The body louse is the vector of typhus, trench fever, and relapsing fever.
Human lice have been used as a forensic tool. A mixed DNA profile of 2 hosts can be detectable in bloodmeals of body lice that have had close contact between an assailant and a victim.[3]
This article describes 3 forms of lice: Pediculus humanus capitis (ie, head louse), (2) Pediculus humanus corporis (ie, body louse), and Phthirus pubis (ie, pubic louse).
Pathophysiology
Louse infestation is prevalent throughout the animal kingdom. Mallophaga, or chewing lice, are common pests of birds and domestic animals. Humans sometimes are affected as accidental hosts.
Human lice (P humanus and P pubis) are found in all countries and climates. They belong to the phylum Arthropoda, the class Insecta, the order Phthiraptera, and the suborder Anoplura (known as the sucking lice). Mammals are the hosts for all Anoplura, and, although lice prefer human hosts, P humanus is also known to live and reproduce on pigs.
The Anoplura are wingless and have 3 pairs of legs, each ending with a clawlike talus for grasping. The size and shape of the claws are adapted to the texture and shape of the hairs and/or clothing fibers they grasp. Their bodies are flat and covered with tough chitin.
Lice are blood-sucking insects. Human lice have small anterior mouthparts with 6 hooklets that aid their attachment to human skin during feeding. The sucking mouthparts retract into the head when the lice are not feeding. In general, lice feed approximately 5 times per day for approximately 35-45 minutes each time.
In each species, the female louse is slightly larger than her male counterpart. The life cycle of lice is 30-35 days from egg to adult. Early death is common, resulting from gut rupture during feeding or cementing of the female to the hair shaft during ovipositioning.
The 3 types of human lice are the head louse, Pediculus humanus capitis (also known as Pediculus humanus humanus); the body louse, Pediculus humanus corporis; and the crab louse, Pthirus pubis. Body lice infest clothing, laying their eggs on fibers in the fabric seams. Head and pubic lice infest hair, laying their eggs at the base of hair fibers.[4, 5] Head and body lice in particular move freely and quickly, which explains their ease of transmission.
Head and body lice are similarly shaped, but the head louse is smaller. Nevertheless, the 2 species can interbreed. The pubic louse or "crab," is morphologically distinct from the other two.
Pediculus humanus capitis
The head louse (see the image below) is the most common of the 3 species. Most infestations involve 10-20 adult lice. The average length of the head louse is 1-2 mm. The louse is wingless and white to gray and has a long, dorsoventrally flattened, segmented abdomen. It has 3 pairs of clawed legs. Its average life span is 30 days. After incubation of the ova (8-10 d), the nymph molts 3 times before reaching its adult form (8-10 d later).
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 adult female louse lays eggs, called nits, and glues them at the base of the hair shaft (see the image below). Nits are placed within 1-2 mm of the scalp, where the temperature is optimal for incubation. The female head louse lays as many as 10 eggs per 24 hours, usually at night. Egg and glue extrusion onto the hair shaft takes 16 seconds. Nits are typically found at the posterior hairline and postauricular areas.
Nit from Pediculus humanus capitis on a hair. Nits hatch in about 6-10 days if they are kept near body temperature, and they mature in another 8-9 days. Nits can survive for up to 10 days away from the human host. Cooler temperatures retard both hatching and maturation. The adult head louse survives only 1-2 days away from its host.
Head louse infestation is spread by close physical contact and by shared fomites (eg, combs, brushes, hats, scarves, bedding). Lice can be dislodged by combs, towels, and air movement (including hair dryers in either low or high setting).[6] Hair combing and sweater removal may eject adult lice more than 1 meter from infested scalps. Head lice can travel up to 23 cm/min. The head louse is unable to move on smooth surfaces (eg, glass, plastic).
Pediculus humanus corporis
The body louse is larger than the head louse. Body lice range in size from 2-4 mm; the female lice are larger than the male lice. Like the head louse, the body louse is flat and white to gray with a segmented abdomen.
Unlike the head louse and the pubic louse, the body louse does not live on the human body. P humanus corporis prefers cooler temperatures; it lives in human clothing, crawling onto the body only to feed, predominantly at night. Females lay 10-15 eggs per day on the fibers of clothing, mainly close to the seams.
The adult female body louse, unlike the head louse, can survive as long as 10 days away from the human body without a blood meal. The life cycle from nit to death is approximately 35 days, with 3 episodes of molting before maturity. On average, 20 adult female lice can be found on a person with an infestation.
Pthirus pubis
The pubic louse gets the nickname of "crab" from its short, broad body (0.8-1.2 mm) and large front claws, which give it a crablike appearance. The pubic louse is white to gray and oval and has a smaller abdomen than both P humanus capitis and P humanus corporis. The average life cycle of P pubis is also 35 days, although the period from ova to adult (15 days) is slightly longer than that of the other 2 forms. The average female pubic louse lays only 1-2 eggs per day.
Their large claws enable pubic lice to grasp the coarser pubic hairs in the groin, perianal, and axillary areas. Heavy infestation with P pubis can also involve the eyelashes, eyebrows, facial hair, axillary hair, and, occasionally, the periphery of the scalp.
Pubic lice are less mobile than P humanus and P corporis, mainly resting while attached to human hairs. They cannot survive off the human host for more than 1 day.
Nits
The average nit (ie, ovum) of the 3 types of lice is 0.8 mm long. The nit (see the images below) attaches to the base of the hair shaft or to fibers of clothing with a strong, highly insoluble cement; thus, nits are very difficult to remove. The nit is topped with a tough but porous cap known as the operculum. This porous sheath allows for gas exchange while the nymph develops in the casing.
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. The ova require optimum conditions of 30°C and 70% humidity to hatch within the average time frame of 8-10 days; the incubation period is longer at lower temperatures. Ova do not hatch at temperatures lower than 22°C but can remain alive for as long as 1 month away from the body (ie, on fomites, clothing, brushes).
Lice as vectors
Evidence exists that shows that some infectious organisms are altered by their arthropod vector and that disease manifestations may be vector specific. For example, bartonellosis spread by a louse has different manifestations from bartonellosis spread by a flea or biting fly. This may explain, in part, the varying syndromes caused by closely related species of Bartonella organisms (eg, acute Oroya fever, Peruvian bacillary angiomatosis, bacillary angiomatosis of AIDS, bacillary peliosis hepatis, catscratch disease, infective endocarditis).[7]
Etiology
Pediculosis is usually spread by contact with an infested person. Fomites, such as clothing, headgear, combs, and hairbrushes, may play a role in the spread of lice. Risk factors include overcrowding, poor hygiene, debilitated and malnourished individuals, and sexual promiscuity. Causative organisms are P humanus capitis (head louse), P humanus corporis (body louse), and P pubis (pubic louse)
P humanus capitis
Factors that predispose to head louse infestation include young age; close, crowded living conditions; female sex; white or Asian race; and warm weather. The risk of nosocomial transmission is low, unless close patient-to-patient contact (eg, playrooms, institutions) is present.
P humanus corporis
The risk factors for body louse infestation include close, crowded living situations (eg, crowded buses and trains). Social circumstances in which the washing and/or changing of clothing is not possible are also significant risk factors for body lice infestation.
P corporis can be acquired via bedding or clothing recently used by an individual infested with lice; thus, individuals who are homeless, who are impoverished, or who are living in refugee camps are at high risk for infestation.
P pubis
Risk factors for infestation of the pubic louse also include crowded living conditions. Intimate or sexual contact with an individual who is infested is another common risk factor.
Because these organisms are most often spread through close or intimate contact, P pubis infestation is classified as a sexually transmitted disease (STD). Condom use does not prevent transmission of P pubis. Upon diagnosis of pubic lice, concern should be raised about the possibility of concomitant STDs.
In children, infestation is usually contracted from a parent who is infested. Sexual transmission to children is rare. In most cases of infestations in children, transmission is due to shared bed linens and close nonsexual contact.
Epidemiology
Pediculosis tends to be underreported because of the social stigma attached—namely, the preconceived notion that lice of any kind are related to dirt and poor personal hygiene. In fact, personal cleanliness is not a factor in infestation rates.
This stigma facilitates the spread of infestation. Affected families are reluctant to share information with their neighbors. Individual children are treated, but the community fails to address the infestation as a community-wide issue. School-wide and community-wide programs to eradicate lice are necessary to halt their continued spread.
United States statistics
Pediculosis is extremely common; more than 12 million Americans are infested each year. Head louse infestation is more common in the warmer months, while pubic louse infestation is more common in the cooler months.[8]
Head louse infestation is most common in urban areas. Major infestations are seen in all socioeconomic groups. Head louse infestations occur most commonly in school-aged children, typically in late summer and autumn. The reported prevalence ranges from 10-40% in US schools. One study estimates that 12-24 million days of school are lost because of "no-nit" school policies.[9]
Body louse infestation in the United States mainly affects the homeless. Pubic lice generally are spread as a sexually transmitted disease (STD). Pubic louse infestation serves as a marker for other STDs, which may have been acquired simultaneously.
International statistics
Pediculosis has a worldwide distribution and is endemic in both developing and developed countries. Hundreds of millions of cases of louse infestation are reported annually worldwide, with an apparent increase over the past few decades.
In a study of 6,169 Belgian school children aged 2.5-12 years, the prevalence of head lice was 8.9%.[10] The prevalence in 1,569 school children in Izmir, Turkey, was 16.6%.[11] In 2005, the incidence of pediculosis doubled in the Czech Republic.[12] Live lice were detected in 14.1% and dead nits in another 9.8% of 531 children aged 6-15 years in 16 schools.[12]
P capitis was found in 9.6% of adolescent schoolboys in Saudi Arabia.[13] In Mali, the prevalence of head lice in children was 4.7%.[14] Among attendees of an STD clinic in South Australia, pubic lice were found in 1.7% of men and 1.1% of women.[15] P corporis is now uncommon in developed countries except among the homeless.[16]
Black populations appear somewhat resistant to P humanus capitis infestation, although they may develop scalp infestation by P pubis. The patterns of pubic and body louse infestation throughout the world mimic those in US refugee populations, which commonly have a tremendously high rate of louse infestation.
Racial differences in incidence
Louse infestation affects all races. However, in North America, the reported incidence of head louse infestation is lower in African Americans than in any other racial group. This is probably due in part to the use of pomades and in part because the claw size of the head louse is more adapted to the round shape of the hair shaft found in white persons and Asian persons.[17] However, blacks may experience scalp infestation by P pubis.
Sex- and age-related differences in incidence
Girls are at higher risk of head louse infestation than boys because of social behavior (eg, social acceptance of close physical contact; sharing of hats, combs, hair ties); hair length is not a factor. No sexual predilection exists in body or pubic louse infestation; males and females are equally likely to become infested.
Children aged 3-11 years are most likely to become infested with head lice because of close contact in classrooms and day care facilities. Head lice are much less common after puberty. Age is not a significant risk factor in body louse infestation; body lice are indiscriminate in regard to the age of their host. P pubis infestation is more common in people aged 14-40 years who are sexually active.
Lice as disease vectors
Louse-borne disease is a potential problem whenever body lice spread through a population. Body lice are vectors for Bartonella quintana, an agent of infective endocarditis among the homeless and the cause of many thousands of cases of trench fever and epidemic typhus during World War I.[18] The organism that caused trench fever persists among the homeless in urban areas, spread from person to person by lice.
Human reservoirs of typhus also exist in the population. Following natural disasters, body lice have the potential to spread rapidly throughout the population, causing great epidemics similar to those seen during World War I.
Prognosis
Treatments are highly effective in killing nymphs and mature lice but less effective in killing eggs. Appropriate therapy produces a cure in more than 90% of cases. After proper treatment, children may return to school, provided that repeat therapy is performed in 7-10 days.
Causes of therapeutic failure include the following:
- Misdiagnosis
- Inappropriate treatment
- Noncompliance
- Insufficient application of pediculicide (ie, amount, duration)
- Lack of ovicidal activity of pediculicide and failure to re-treat in 7-10 days
- Lack of removal of live nits
- Lack of environmental eradication
- Reinfestation
- Resistance to pediculicide
Frequent use of pediculicides may cause persistent itching. Body lice can be vectors for disease such as epidemic typhus and relapsing fever. Violation of the integrity of the skin from a bite can lead to bacterial infection with organisms such as methicillin-resistant Staphylococcus aureus (MRSA). More commonly, infestation with lice produces social embarrassment and isolation rather than medical disease.
Patient Education
Noncompliance is the most common cause of treatment failure. Therefore, time is well-spent providing patients with detailed instructions regarding the application and timing of medications used in the treatment of lice.
Most patients benefit from an understanding of the life cycle of lice and the limitations of medical therapy (eg, medications are incompletely ovicidal). Compliance with re-treatment in 7-10 days may be enhanced if patients understand the need for re-treatment to kill newly hatched nymphs.
In cases of school-wide infestations, the social stigma associated with infestation must be addressed. Poor hygiene is not a risk factor in acquiring pediculosis capitis.
The community must address the problem honestly and openly, or the infestation will continue. Louse infestation is a community-wide problem. Management must include examination of all individuals exposed (both children and family members) and treatment of all those who are infested. Education has been shown to reduce the number of lice infestations in schools. "No nit" policies exclude many children from the classroom, but they have not been shown to reduce the number of louse infestations.[19]
Fomite control is essential. Hats lined up on pegs or placed in adjacent cubbyholes provide an avenue for spread of the infestation. Cubbyholes can be sprayed with a permethrin spray or other insecticide, but the most effective method is for each child to "ground your clothing" (ie, hat, coat, scarves) under each individual chair or desk. Common cloakrooms may suggest an antiquated charm, but they should be viewed as merely antiquated and a site for spread of the infestation.
Combs, brushes, and headbands should not be shared. Shaving of hair is effective but not socially acceptable in most societies.[20] Young nits do not have a nervous system and are immune to neurotoxic pediculicides.
For patient education information, see the Parasites and Worms Center, as well as Lice and Crabs.
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