The Prevention and Treatment of Head Lice in Children

Suzanne Albrecht, PharmD, MSLIS

US Pharmacist

Abstract and Introduction

Introduction

Head lice (Pediculus humanus capitis) are ectoparasites, meaning that they live on or within the skin rather than inside the body. Annually, approximately 6 to 12 million U.S. children aged 3 to 11 years become infested with head lice.^[1] Lice infestations are a substantial economic burden on the health care system. Although difficult to assess, the annual direct and indirect costs of infestations, including treatment, lost wages, and school-system expenses, are estimated to be $1 billion.^[2,3]

Preschool-age and school-age children are most commonly infested, with household members also at increased risk.^[2] Not only is lice infestation a nuisance, but if it is left untreated, it may result in a secondary bacterial infection. Infestation has nothing to do with hygiene practices or hair length, nor do lice transmit disease.^[2] Despite these facts, the social stigma, embarrassment, and anxiety resulting from infestation can be considerable for both the child and the parent(s).^[2,4]

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Table 1. Medication Application Instructions
Permethrin
Shampoo hair with nonconditioning shampoo, then towel it dry. Apply to damp hair and leave on for 10 minutes. Rinse off with warm water. Repeat if live lice are seen after 7–10 days.
Pyrethrins With PBO
Apply to dry hair. Rinse out after 10 minutes. Repeat after 9 days.
Malathion
Apply an amount sufficient to entirely cover dry hair and scalp (keep eyes tightly shut). Allow hair to air dry. Hair should remain uncovered after application. Shampoo hair after 8–12 hours. Use a nit comb after shampooing to remove lice and eggs. Repeat if live lice are seen after 7–9 days.
Benzyl Alcohol
Apply to dry hair, using enough to completely saturate hair and scalp.^a Rinse off with water after 10 minutes. Repeat in 7 days (although waiting until day 9 may be more effective).
Spinosad
Apply first to dry scalp, then to dry hair in amount sufficient to cover entirely. Apply up to 120 mL (depending upon hair length). Leave on for 10 minutes. Using warm water, thoroughly rinse hair and scalp. Repeat if lice are seen after 7 days.
Ivermectin
Apply to dry hair in amount sufficient to coat hair and scalp (up to 1 tube). Leave on for 10 minutes. Rinse off with water.

^aFor hair ≤4" long, 1 bottle will suffice; hair up to 16" long may require up to 3 bottles; hair longer than 22" may require up to 6 bottles.
PBO: piperonyl butoxide.
Source: References 2, 7, 10, 12, 17.

Table 2. Treatment Counseling Points
Shake bottle before using and wash hands after applying. Use warm (not hot) water to rinse off products over a sink (rather than in a bathtub or shower). This limits systemic exposure. Be sure to treat all of the hair and scalp. Pay close attention to the back of the neck and behind the ears. Check all household members, and treat those with live lice or nits occurring ≤1 cm from the scalp. Family members who share a bed with the patient should be treated. Pediculicidal agents ideally involve 2 treatments administered 9 days apart. Using a nit comb after treatment may increase the likelihood of complete eradication. Itching/burning sensations do not necessarily mean that treatment has failed. Topical corticosteroids and/or antihistamines may alleviate these adverse effects. Although indirect transmission is rare, personal items may be washed at 130°F. Items that cannot be washed (e.g., furniture, car seats, carpet) should be thoroughly vacuumed. Since nits need warmth to hatch, pediculicide spray is not recommended for personal items. Although probably unnecessary, large items (e.g., pillows, comforters) may be bagged in plastic for 2 weeks.

Source: References 2, 4, 10, 12.

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