Pediculosis (Lice) Treatment & Management

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

Approach Considerations

Treatment of pediculosis has 2 aspects: medication and environmental control measures. Consider providing medical treatment to all persons who have contact with infested patients, especially sexual partners.

Increasing emphasis is being placed on understanding the life cycle of lice in order to treat effectively. Not all treatment preparations are ovicidal. Therefore, repeat treatment may need to be performed to kill the newly hatched eggs not affected by the initial treatment. It is extremely important to use medications as directed to ensure total eradication of the lice through their life cycle.

In the treatment of body lice, medications are less essential than environmental measures. Many infectious disease authorities recommend only environmental measures to treat body lice. Patients with body lice should have infested clothing removed and destroyed.

Related clinical guideline summaries include the following:

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Pesticides

A variety of topical pediculicidal agents are available for treatment of head and pubic lice. Pyrethrin shampoos and permethrin 1% rinse are available over the counter; permethrin 5%, malathion, lindane, ivermectin topical, and spinosad are prescription agents.

Permethrin appears to have a wide margin of safety, although some data suggest a possible connection between insecticides and leukemia.[26, 27] Malathion has proved to be more ovicidal than permethrin and has a higher lethal effect and decreased frequency of reinfestation, if used properly. Lindane may not be suitable for use in patients with a defective cutaneous barrier. Seizures may result from abnormal absorption or gross overuse of the product. Many authors recommend that it not be used as a first-line therapy.

Spinosad was approved the US Food and Drug Administration (FDA) in 2011 for the treatment of head louse infestation in patients aged 4 years and older. The product is applied to dry hair as a cream rinse, left in for 10 minutes, and then shampooed out. Spinosad has ovicidal activity; consequently, no combing to remove nits is necessary.[28]

In February 2012, topical ivermectin (Sklice) was approved in the United States as a single-dose, 10-minute application without the need for nit combing.

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Oral Agents

Oral anthelmintics, including ivermectin, levamisole, and albendazole,[29] have been found to be effective against head louse infestation. Administration should be repeated in 7-10 days to kill lice emerging from nits that may have survived the first treatment. Trimethoprim-sulfamethoxazole was initially reported to be effective; however, controlled studies have shown only minimal eradication.

Resistance

Resistance of lice to the most commonly used medications for treatment of infestation (permethrin and pyrethrin) is increasing.[30, 31, 32, 33] Resistance has been reported in the United States as well as countries in South America and Europe

A possible mechanism of resistance development includes mutations of target enzymes (eg, acetylcholinesterase) so that the enzymes no longer bind the organophosphate permethrin with the same affinity. Another possible mechanism is increasing the metabolism of the insecticides through an increase in monooxygenase enzyme activity, turning them into harmless compounds before they can cause damage.[34, 35, 36, 37]

In the United States, malathion retains the best efficacy among chemical pediculicides.[38] Resistance to malathion is now starting to be reported in the United Kingdom, but it has not been reported in the United States. This may be due to the difference in preparations: the US formulation of malathion is coupled with isopropyl alcohol and terpineol, whereas the UK formulation contains malathion only.

It is becoming evident that alternative medications or treatments will likely be needed to continue to treat lice effectively. New research incorporating treatment with ivermectin and trimethoprim-sulfamethoxazole is under way and may eventually show some promise for future treatment preparations.[39]

Note that, at this time, ivermectin use for treatment of lice is off label, as traditionally, ivermectin is used for treatment of helminthic infections and onchocerciasis. Reports suggest the possibility of neurotoxicity from ivermectin in a population of nursing home patients treated for scabies.[40, 41, 42, 43, 44]

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Treatment for Head Louse Infestation

Medicated lotions or shampoos may be used to eliminate head lice. Infested family members and sexual partners should also be treated. Re-treatment after a time interval of 7-10 days is recommended with many agents, to eradicate any lice that hatched from nits after the initial treatment. In addition, 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.

Some families may choose to enlist the help of a trained professional. A"lice nurse" can often be found who will come to the home, evaluate the family members, remove lice and nits from hair, and provide education and lice combs. This service may allow faster return to school and useful counseling.

Mechanical removal and shaving

Mechanical removal of nits with fine-tooth combs is a valuable adjunct to pediculicidal treatment. Nit combs are provided with many pediculicidal products. Metal nit combs (eg, LiceMeister) are sturdier and more effective and can be purchased over the Internet.

Wet combing is preferable. Soaking the hair in a solution of equal parts water and white vinegar and then wrapping the wet scalp in a towel for at least 15 minutes may facilitate removal. Commercial products include an 8% formic acid preparation (GenDerm Step 2) and an enzymatic nit remover (Clear).

The major action of each of these products, however, may be to make combing easier. Little evidence indicates that they actually dissolve the nit sheath that attaches the nit to the hair shaft. In fact, the composition of the nit sheath is similar to that of human hair, so agents designed to unravel the nit sheath may also damage hair.[45]

Most studies have shown that mechanical removal alone (ie, wet-combing every 2-3 days for a minimum of 2 weeks) is not as effective as mechanical removal combined with a pediculicide.[46] Proper treatment with medication is advised.

Shaving is effective but is usually not necessary or socially acceptable. However, in resistant disease, it may be a consideration.

Occlusive therapy

Agents that work by clogging the respiratory spiracles of lice offer an alternative to neurotoxic pediculicides.[47, 48] This is the mechanism of action of benzyl alcohol lotion 5% (Ulesfia), which is approved by the FDA for treatment of head lice in patients 6 months of age and older; the benzyl alcohol inhibits lice from closing their respiratory spiracles, allowing the lotion to obstruct the spiracles.

The lotion is given in 2 applications 1 week apart for 10 minutes; it needs to be applied twice because it kills lice only, not nits. Benzyl alcohol lotion may be an easier and safer alternative to lindane and malathion. Because its mechanism of action is physical rather than chemical, development of resistance should not be a concern.

In clinical studies, more than 75% of those treated with benzyl alcohol lotion became lice-free.[49] As with all treatments 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.

One study reported efficacy of 4% dimeticone lotion (a silicone-based lotion believed to disrupt the louse's ability to manage water).[50] Another study found that 4% dimeticone lotion was a significantly more effective treatment compared with malathion for most people.[51] An over-the-counter lotion containing dimethicone (LiceMD) provides lubrication that eases the use of a lice comb.

Other occlusive therapy techniques, such as vinegar, mayonnaise, petroleum jelly, olive oil, butter, isopropyl alcohol, and water submersion as long as 6 hours, have been advocated, but most have not been scientifically evaluated. However, a dry-on, suffocation-based pediculicide (DSP) lotion was found to be effective in open trials.[47]

Various botanical agents have been used. Essential oils demonstrate variable efficacy and may be contact allergens.[52] In general, the evidence supporting their efficacy is of poor quality.[50, 53] Monoterpenoids are promising agents.[50, 54, 55]

Environmental eradication

Treatment of the patient environment (control measures) is important. Reinfestation occurs if the problem is not addressed on a school-wide and community-wide basis.

Any object that the infested child or parent has come into contact with should be considered a potential fomite. It may be beneficial to launder potential fomites (eg, towels, pillowcases, sheets, hats, toys) in hot water, followed by machine drying using the hottest cycle. Temperatures exceeding 131° F (55° C) for more than 5 minutes kill eggs, nymphs, and mature lice. Items that are not machine washable may be placed in a dryer at high heat for 30 minutes. Dry cleaning may be an effective alternative.

Because adult lice cannot survive for long if separated from a host and because eggs hatch in 6-10 days and will die without a blood meal, carefully sealing potential fomites in plastic bags for 2 weeks can be effective. This technique works well for objects, such as stuffed animals, that do not tolerate laundering or dry cleaning. Vacuuming selected areas of the home, such as couches used by infested patients, is recommended by some as an adjunctive control measure.

Combs and hair brushes should be discarded. Alternatively, they can be treated by soaking for longer than 5 minutes in very hot water (>131°F, or 55°C) or treated with pediculicides.

Chemical insecticide sprays used in the home environment have not been shown to be effective in the control of head lice.

Providing education to children about the sharing of hats, combs, and hair-ties is also a good idea. Giving children separate areas to store their belongings in the classroom may help prevent the spread of lice.

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Treatment of Pubic Louse Infestation

The same pediculicides used for head louse infestation are also used for pubic louse infestation. In addition, P pubis infestations of the eyelashes are treated with occlusive therapies.

Petrolatum (twice daily for 7-10 days) is often used, with good results, as an asphyxiant for eyelash infestation. The petrolatum covers the lice and their nits, preventing respiration. The dead lice are removed mechanically, usually with tweezers. Mercuric oxide ointment is also useful in the treatment of eyelash infestation with P pubis.

Fluorescein dye strips, which are used in the diagnosis of corneal abrasions, may be used in combination with white petrolatum. The strips are applied to the eyelashes for 3 nights.

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Treatment of Body Louse Infestation

Use of a pediculicide is usually unnecessary with P humanus corporis infestation because the louse lives on the clothing. Treatment of clothing and bed linens includes laundering in hot water, ironing with a hot iron, or drying in a hot dryer. Dry cleaning is also effective for killing lice and their nits on clothing.

Education about hygiene and accessibility to laundering facilities are important in preventing the spread of body lice and reinfestation.[56]

Topical agents should be applied to clothing, especially the seams. Published data suggest that permethrin spray can help prevent body louse reinfestation.

In cases of heavy pediculosis, treatment of the body with a pediculicide shampoo or lotion may be beneficial, especially if the patient also has confirmed or suspected concomitant head or pubic louse infestation. Oral ivermectin 12 mg given as 3 doses 7 days apart has also been shown to be effective in a cohort of homeless men.[15] None of these agents currently is labeled or marketed for treatment of body lice in the United States. In some cultures, monkeys are used as patient nit pickers to groom the hair and to remove adult lice and nits.

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Treatment of Contacts

The treatment of family members, friends, and/or other close contacts is important in helping to prevent further spread of lice and in preventing reinfestation.

Patient education regarding treatment of contacts is essential. Parents with children who are infested should be advised to treat all infested family members with a pediculicide and to provide environmental fomite control.

Education about hygiene and accessibility to laundering facilities are important in preventing the spread of body lice and reinfestation.[56]

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Deterrence and Prevention

To prevent reinfestation, all household members and contacts of a patient should be examined and treated at the same time if infested. Launder bedlinens and other clothes at the same time as treatment with medication. Washing combs, brushes, and other fomites reduces reinfestation.

Do not allow children to exchange or use another child's hat, comb, or brush. Some parents choose to extend this prohibition to use of "common" headwear such as is available in the dress-up area of various play spaces or public libraries.

Once an infestation has been identified and treated, ongoing vigilance with close, direct visualization of hair and scalp at periodic intervals is recommended. Sensitivity may be enhanced by use of a lice-specific comb.

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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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