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Continuing Nursing Education
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Clinical Practice Update:
Pediculosis Capitis
Brittany Bohl, Jessica Evetts, Kymberli McClain,
Amanda Rosenauer, and Emily Stellitano
P
ediculosis capitis infestations
are a common health problem, with cases ranging in the
hundreds of millions worldwide. In the United States, infestations are most prevalent among preschool-aged children attending childcare, elementary school students, and
the household members of infested
children (Bowden, 2012). Incidence is
rising, largely related to increased
resistance to treatment with current
first-line therapies (Connolly, 2011;
Durand et al., 2012). Resistance is also
growing due to inadequate and
unnecessary treatments. The convenience and availability of over-thecounter pediculicide products to consumers make clinician management
by moderation and selectivity very
difficult. This review is intended to
provide an updated source of information on new products, as well as
changes in the efficacy of known
treatments. Further, adequate diagnosis, consideration of alternative therapies, environmental recommendations, and general education are cornerstones of Pediculosis capitis management in primary care.
Brittany Bohl, BSN, RN, is an MSN student
at The University of Texas School of Nursing,
Austin, TX.
Jessica Evetts, BSN, RN, is an MSN student at The University of Texas School of
Nursing, Austin, TX.
Kymberli McClain, BSN, RN, is an MSN student at The University of Texas School of
Nursing, Austin, TX.
Amanda Rosenauer, BSN, RN, is an MSN
student at The University of Texas School of
Nursing, Austin, TX.
Emily Stellitano, BSN, RN, is an MSN student at The University of Texas School of
Nursing, Austin, TX.
A review of the current evidence on primary treatment modalities of head lice
demonstrates increasing resistance to current regimens. New and alternative
therapies are now available. A treatment algorithm was created to address safety
and efficacy of treatments, as well as to guide clinicians through navigation of the
regimens. Through an online journal search, 59 articles were selected for the
review. Literature searches were performed through PubMed, Medline, Ebsco
Host, and CINAHL, with key search words of “Pediculosis capitis” and “head lice”
in the title, abstract, and index. Meta-analyses and controlled clinical trials were
viewed with greater weight if they had a large sample size, were statistically significant, and did not allude to bias. When resistant infestations are well-documented in a locality, changes to the treatment regimen are indicated, and alternative treatments should be considered. Recent studies and U.S. Food and Drug
Administration (FDA) approvals have changed the available treatment options for
Pediculosis capitis, including benzyl alcohol, topical ivermectin, spinosad, and
the LouseBuster™. Further, environmental management and prevention measures should be taken to avoid reinfestation and to prevent the spread of head
lice. Continued study is recommended to establish long-term safety of new and
alternative agents.
Description of the Parasite
The parasitic louse, Pediculosis capitis, is 1 to 3 mm long (Gunning,
Pippitt, Kiraly, & Sayler, 2012). Its
color varies based on hair color of the
host and ranges from grayish-white to
darker shades. Pediculosis capitis only
infests humans. The average lifespan
of a louse on the human scalp is 30
days; without a host, lice will die within 1 to 2 days. An adult female louse
can lay from 8 to 10 nits daily. Nits are
eggs that are laid within 1 mm of the
scalp to allow for ambient temperature for them to hatch (Centers for
Disease Control and Prevention
[CDC], 2010). They are difficult to see
due to camouflage by hair and are
most easily seen along the hairline
(Frankowski, Bocchini, & Council on
School Health and Committee on
Infectious Diseases, 2010). Sometimes
mistaken for dandruff, they range in
size from 0.3 mm to 0.8 mm. After 7 to
12 days, the nits hatch and release a
nymph (Frankowski et al., 2010).
Nymphs grow into adult lice 7 days
PEDIATRIC NURSING/September-October 2015/Vol. 41/No. 5
after hatching (CDC, 2010). Lice feed
every 3 to 4 hours by injecting saliva
that precipitates anticoagulation and
vasodilation in the scalp; pruritus is a
result of reaction to the injected saliva
(Frankowski et al., 2010).
Epidemiology
Worldwide, Pediculosis capitis is a
parasite that affects individuals across
all age groups. In the United States,
preschool and school-aged children
have the highest prevalence of infestations (Frankowski et al., 2010), estimated to be 6 to 12 million cases
annually (CDC, 2010). In certain
areas, such as Brazil, reinfestation can
occur 15 to 19 times a year (Feldmeier
& Heukelbach, 2008). Head lice infestation is spread by direct contact with
an affected person. Head-to-head contact is the most frequent form of transmission. Rarely does transmission
occur through use of infested clothing, combs, towels, or bedding (CDC,
2010).
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Clinical Practice Update: Pediculosis Capitis
Clinical Manifestations
Head lice and nits are found
almost exclusively on the scalp, particularly around and behind the ears,
as well as near the neckline. The most
common symptom of infestation is
scalp pruritus, although this reaction
is caused by a delayed hypersensitivity to the enzyme in louse saliva. This
normally intensifies 3 to 4 weeks after
the initial infestation. Patients with
repeat infestations will develop pruritus within 1 to 2 days of exposure.
Most patients will present with complaints of scalp itching and irritation
most commonly affecting the occipital and postauricular area, a tickling
feeling of something moving in the
hair, or irritability and difficulty sleeping due to head lice being more active
at night (Connolly, 2011). The bite
reaction is very mild and can rarely be
seen between the hairs. Due to
intense itching, secondary erythema,
scaling, and excoriation of the skin
may occur from scratching. With long
standing infestations, the skin may
become lichenified and hyperpigmented. In children, head lice infestation is commonly first suspected
when the child is observed scratching
his or her head vigorously. Listlessness or poor school performance may
also be clues, indicating the child’s
high level of distraction. In rare cases,
the itch-scratch cycle can lead to secondary infection with impetigo, cellulitis, and pyoderma (CDC, 2010).
Diagnosis
There are a few controversial perspectives on the diagnosis of head
lice. However, research and expert
opinion direct clinicians toward specific recommendations. An individual
may be deemed infested if any live
lice are found on inspection of the
scalp. The presence of nits is often
mistakenly used for diagnosis. Nits
can be non-viable and often remain
present for several days after the eggs
have hatched. However, one should
consider that nits within 1 cm of the
scalp are more likely to be viable. The
presence of nits within this close
proximity to the scalp should raise
the investigator’s index of suspicion
and encourage a thorough search for
live lice. Diagnosis and treatment
should be reserved only for individuals with live lice present (Feldmeier,
2010; Finlay & MacDonald, 2008;
Frankowski et al., 2010; Goundrey228
Figure 1.
Nit Comb
Smith, 2011; Gunning et al., 2012;
Mumcuoglu, Meinking, Burkhart, &
Burkhart, 2006; Tebruegge, Pantazidou,
& Curtis, 2011).
Detection of live lice is often performed by direct visual inspection,
dry combing, or wet combing. Visual
inspection involves parting the hair
with a screening stick or linear object,
such as a tongue depressor or writing
utensil, while looking for live lice.
This is often performed in haste beccause it promotes larger sections of
hair being turned, thereby decreasing
the amount of area searched. Utilization of this method makes it difficult to systematically search the entire
scalp. Detection of lice using a finetooth louse comb has been shown to
be significantly more effective than,
and twice as fast as detection using
visual inspection (Mumcuoglu, Friger,
Ioffe-Uspensky, Ben-Ishai, & Miller,
2001).
The diagnosis of head lice is best
made by combing the individual’s
hair with a fine-tooth louse comb
(Balcioglu et al., 2008; Feldmeier, 2012;
Finlay & MacDonald, 2008; Frankowski
et al., 2010; Goundrey-Smith, 2011;
Gunning et al., 2012; Ibarra, 2010;
Jahnke, Bauer, Hengge, & Feldmeier,
2009; Mumcuoglu et al., 2001, 2006;
Tebruegge et al., 2011). These combs
are specially made for louse detection
and have less than 3 mm between
teeth. It is recommended to perform
combing on wet hair because a wet
environment may slow lice, aiding in
their detection. The comb should be
inserted until it touches the scalp and
combed through the hair from root to
tip (see Figure 1). After each stroke,
the comb should be visualized for any
lice. Adequate time should be allotted
for thorough combing so live lice are
not overlooked. Predilection sites that
lice favor include the back of the
head, retroauricular areas, and nape
of the neck (Feldmeier, 2012;
Frankowski et al., 2010; Gunning et
al., 2012; Madke & Khopkar, 2012;
Shmidt & Levitt, 2012).
Recommended Treatments
Treatment modalities vary, from
well-studied pediculicides to unproven home remedies. This update will
address recommended and alternative
treatment regimens, which include
pharmacological and non-pharmacological treatments. Only those most
relevant to current practice are discussed; home remedies, such as suffocation with mayonnaise or other
household items, are not addressed.
Permethrin. Permethrin (Nix®)
was introduced in 1986 by prescription only and then made available
over the counter in 1990 (Frankowski
et al., 2010). This medication works
by inhibiting sodium ion influx,
eventually leading to louse paralysis
and death (Eisenhower & Farrington,
2012). The surplus of research sup-
PEDIATRIC NURSING/September-October 2015/Vol. 41/No. 5
porting permethrin’s safety profile
secures its place as a first-line agent
unless regional resistance is documented (Bowerman, Gomez, Austin,
& Wold, 1987; Brandenburg et al.,
1986; Diamantis, Morrell, & Burkhart,
2009; Finlay & MacDonald, 2008;
Frankowski et al., 2010; Gunning et
al., 2012; Heukelbach, Pilger, Khakban,
Ariza, & Feldmeier, 2008; Meinking et
al., 2002; Meinking et al., 2007;
Taplin, Meinking, Castillero, & Sanchez,
1986). However, in recent research
found by DNA typing of lice in several
locations in the U.S. and Canada, the
rate of T1 mutation (the gene mutation most responsible for permethrin
resistance) varied between 84.4% and
99.6%. It is important to keep in
mind that the study examined a small
number of lice from only 12 U.S.
states and studied the potential for
resistance, rather than a clinical measurement of actual resistance (Yoon et
al, 2014). Information regarding regional resistance, if available, should
be accessible from the CDC website or
local health department.
For treatment, cream rinse is applied to the hair and scalp for 10 minutes and then rinsed out with water. A
second treatment is advised 7 to 10
days later to ensure cure. Permethrin
is safe for infants 2 months and older,
and is a Pregnancy Category B drug.
Stough and colleagues report a 43% to
45% success rate for permethrin
(Stough, Shellabarger, Quiring, &
Gavrielsen, 2009). Among the available pediculicides, it is the most
affordable, along with pyrethrin/
piperonyl butoxide at a cost of $20.
Pyrethrin/piperonyl butoxide
(PPB). Like permethrin, pyrethrin/
piperonyl butoxide (PPB) 4% (Pronto®,
RID®) has also had reports of resistance. Despite this, PPB has a wellestablished safety profile and continues to be recommended as first-line
treatment unless regional resistance is
documented (Diamantis et al., 2009;
Finlay & MacDonald, 2008; Frankowski
et al., 2010; Gunning et al., 2012). A
theoretical risk of cross sensitivity
with plant allergies, such as ragweed
and chrysanthemum, exists, but it is
rare (Prescriber’s Letter, 2010). However, in the case of a severe plant allergy, it is reasonable to recommend permethrin in preference to PPB topical.
PPB works similarly to permethrin,
but the addition of piperonyl butoxide prevents the metabolism of pyrethrin by lice, increasing killing time,
and therefore, making it more effec-
tive (Eisenhower & Farrington, 2012).
Before application, hair should be
shampooed and towel dried. The
product is then applied and rinsed
after 10 minutes. A second treatment
is advised 7 days later to ensure cure.
PPB may be used in children 2 years
and older and is a Pregnancy Category C drug. Like permethrin, cost of
treatment is approximately $20.
Malathion. Malathion 0.5% lotion (Ovide®) is a prescription ovicidal
agent. It is a weak organophosphate
that inhibits cholinesterase activity of
head lice, resulting in acute toxicity
followed by cell death (Taro Pharmaceuticals, 2013). It has been shown to
be safe and effective with low observed resistance for those 6 years of
age and older (Chosidow et al., 2009;
Frankowski et al., 2010; Gunning et
al., 2012; Lebwohl, Clark & Levitt,
2007; Meinking et al., 2004, 2007;
Nofal, 2010; Taro Pharmaceuticals,
2013). The use of malathion lotion is
contraindicated for neonates and
infants because of increased permeability of the scalp, which may lead to
increased absorption (Taro Pharmaceuticals, 2013). It is a Pregnancy
Category B drug (Taro Pharmaceuticals, 2013).
Malathion lotion should be
applied on dry hair in a sufficient
amount to thoroughly wet the hair
and scalp. Malathion is flammable,
and hair dryers or other heat-producing appliances must not be used. It is
therefore recommended that after
application of the lotion, the hair
should be allowed to air dry. After 8 to
12 hours, the hair should be shampooed, rinsed, and a fine-toothed
(nit) comb should be used to remove
dead lice and eggs. A second application should be repeated in 7 to 9 days
(Lebwohl et al., 2007; Taro Pharmaceuticals, 2013). Ovide® costs $185
per bottle.
Benzyl alcohol 5% lotion. Benzyl alcohol 5% lotion (Ulefsia®) has
been an approved treatment by the
U.S. Food and Drug Administration
(FDA) for the indication of head lice
in individuals 6 months of age and
older since 2009 (FDA, 2009a). It
works by suffocating lice because it
prevents the closing of the respiratory
spiracles via obstruction, leading to
asphyxiation (Lexi-Comp Online,
2012; Shionogi Pharma, Inc., 2012).
This prescription product provides
the first non-neurotoxic pediculicidal
alternative for parents who are concerned about the use of those agents.
PEDIATRIC NURSING/September-October 2015/Vol. 41/No. 5
In terms of safety, benzyl alcohol is
classified as a Pregnancy Category B.
If treated with benzyl alcohol,
neonates could be at risk for gasping
syndrome as a result of both a potentially immature skin barrier and a
high ratio of skin surface area to body
mass (Shionogi Pharma, Inc., 2012).
Although expected systemic exposure
of benzyl alcohol from proper use is
substantially lower than those reported in association with the gasping
syndrome, the minimum amount of
benzyl alcohol at which toxicity may
occur is not known (Shionogi
Pharma, Inc., 2012).
Benzyl alcohol lotion should be
applied to dry hair until completely
saturated. After 10 minutes, the lotion
should be completely rinsed from the
hair and scalp with water. Hair may
then be shampooed, and if desired, a
lice comb may be used to remove the
dead lice. Benzyl alcohol lotion kills
lice but is not ovicidal, so a second
application is needed one week after
the initial application (Meinking et.
al, 2010; Shionogi Pharma, Inc.,
2012). This medication is a Pregnancy
Category B. Research reports a success
rate of 75% to 76.2% for benzyl alcohol lotion at 14 days after the final
application (Meinking et al., 2010).
Each 8-ounce bottle costs $63 to $81,
and up to 6 bottles may be necessary
per application based on the length of
hair.
Spinosad. Spinosad (Natroba™)
is a new topical pediculicide approved
for effective and convenient treatment of head lice (Stough et al.,
2009). Spinosad is a fermentation product of Saccharopolyspora spinosa, first
identified and developed from soil
samples taken in the Caribbean in
1982. It has been used in insecticide
products since 1997 (Cole & Lundquist,
2011). Spinosad has ovicidal properties in nit embryos (Cole & Lundquist,
2011), and provokes hyperexcitation
and eventual death by paralysis in
live lice (Gunning et al., 2012).
Spinosad does not require nit combing because of its ovicidal properties
(Stough et al., 2009). This drug is indicated for children 6 months and
older, and is to be avoided in infants
younger than 6 months because it
contains benzyl alcohol; studies with
children 6 months of age and above
indicate there is no systemic absorption of active ingredients (ParaPRO,
2015). It is Pregnancy Category B and
prescription only. Because it is a suspension, it is necessary to shake the
229
Clinical Practice Update: Pediculosis Capitis
bottle well before application. Gunning
et al. (2012) advises providers to
instruct patients to apply a sufficient
amount of product to dry hair for 10
minutes, rinse off, and repeat in 7
days only if live lice seen. Spinosad
has demonstrated treatment success
rates of 84% and 87% (Stough et al.,
2009). The cost of this prescription
treatment is approximately $220.
Ivermectin topical. Ivermectin
5% lotion (Sklice®) was also recently
approved by the FDA for use in head
lice treatment. It works by binding
selectively to glutamate gated chloride channels in nerve and muscle
cells of parasites, resulting in paralysis
and death of lice (Meinking, MertzRivera, Vellar, & Bell, 2012). Approval
was granted in 2012 for the indication of head lice in adults and children aged 6 months and older. Use of
topical ivermectin should be avoided
in infants less than 6 months of age
due to the risk for increased absorption across their immature skin barrier (Eisenhower & Farrington, 2012).
Further, because it was not studied in
pregnant women, it is considered a
Pregnancy Category C drug (Eisenhower
& Farrington, 2012). Although side
effects are very mild when used topically, if accidentally ingested, patients
may require parenteral fluids and
electrolytes, respiratory support, pressor agents, and/or gastric lavage
(Eisenhower & Farrington, 2012).
Ivermectin lotion should be
applied to dry hair in an amount sufficient to fully coat the hair and scalp.
It should then be rinsed off in 10 minutes. Manufacturer information instructs that treatment must not be
repeated without first contacting a
health care provider (Eisenhower &
Farrington, 2012). Ivermectin has a
success rate of 73.8% on day 15 posttreatment (Pariser, Meinking, Bell, &
Ryan, 2012). Like Spinosad, this product is available by prescription only
and costs approximately $270 per
treatment.
Alternative Treatment
Lindane. Lindane 1% (Kwell®) is
an organochloride and slow killer of
lice. It is no longer recommended as a
pediculicide by the American Academy of Pediatrics (AAP) (Eisenhower
& Farrington, 2012). Since 1995, lindane has been designated as a secondline treatment, meaning it should be
used only when other first-line treatments for lice have failed (Thomas et
al., 2006; FDA, 2009b; Frankowski et
230
al., 2010). The FDA determined that
benefits of lindane outweigh the risks
when used appropriately (FDA, 2009b).
However, overuse, misuse, or accidental ingestion of lindane may be toxic
to the central nervous system (CDC,
2010). The FDA issued a public health
advisory deterring the use of topical
lindane in neonates and infants, children, the elderly, persons weighing
less than 50 kg, persons with HIV, persons with a seizure disorder, and
women who are pregnant or breastfeeding (Eisenhower & Farrington,
2012; FDA, 2009b). It has been classified as a Pregnancy Category C drug
(Humphreys et al., 2008; Meinking et
al., 2010). Labeling for lindane products includes a boxed warning that
emphasizes its use as a second-line
treatment and states that these products are to be used with caution in the
populations listed above.
To use, apply 1 ounce or 30 mL (2
ounces or 60 mL maximum for long
or thick hair) of lindane to dry hair.
After 4 minutes, add water and work
into a lather. Immediately and thoroughly rinse off with warm, not hot,
water. Avoid unnecessary contact to
other body parts, especially the eyes.
Following treatment, the hair should
be wet-combed with a fine-tooth
comb to remove nits. Do not use
again for retreatment. Based on the
lifecycle of a louse and ova, a single
eradication would not reliably eradicate lice, 2 to 3 treatments would be
required, and the FDA has concluded
this would not be safe (Lebwohl et al.,
2007). Lindane costs $126 to $137 for
a 60 mL bottle.
Ivermectin oral. Oral ivermectin
(Stromectol®) is not approved by the
FDA for treatment of Pediculosis capitis
(CDC, 2010; Frankowski et al., 2010).
It is an anthelmintic drug that is FDAapproved for onchocerciasis and
strongyloidiasis, both parasitic diseases. It has been used off-label in a
single oral dose of 200 micrograms/
kg, repeated in 7 to 10 days, and has
been demonstrated to be effective
against head lice (Ameen et al., 2010;
Chosidow et al., 2010; Currie,
Reynolds, Glasgow, & Bowden, 2010;
Dourmishev, Dourmishev & Schwartz,
2005). However, given its potential
neurotoxicity when crossing the
blood-brain barrier, it has been recommended that ivermectin be avoided in
children weighing less than 15 kg
(Eisenhower & Farrington, 2012;
Martinez-Diaz & Mancini, 2010). It is
also not recommended for pregnant
or lactating mothers (Madke &
Khopkar 2012), and is a Pregnancy
Category C drug. The cost of treatment cost is $20 to $60, depending on
patient weight.
Trimethoprim-sulfamethoxazole. Oral trimethoprim-sulfamethoxazole (Bactrim®, Septra®, Sulfatrim®), which reportedly kills symbiotic bacteria in the gut flora of the
head louse, thereby interfering with
its ability to synthesize B vitamins,
has been suggested as an effective
agent against head lice. However, the
FDA has not evaluated it for this use
(AAP, 2009; Frankowski et al., 2010;
Frankowski & Weiner, 2002; Hipolito,
Mallorca, Zuniga-Macaraig, Apolinario,
& Wheeler-Sherman, 2001). Use of
trimethoprim-sulfamethoxazole should
be weighed against the risk of severe,
life-threatening allergic reactions,
such as Stevens-Johnson or drug hypersensitivity syndromes (MartinezDiaz & Mancini, 2010). It is also a
Pregnancy Category C medication.
Treatment cost is approximately $10
to $15.
Essential oils (tea tree oil, lavender oil, eucalyptus oil). There are no
formal controlled clinical trials demonstrating efficacy, potential side
effects, or toxicity of eucalyptus, lavender, and tea tree oil. Therefore,
these cannot be recommended as a
treatment option (Connolly, 2011;
Eisenhower & Farrington, 2012;
Tebruegge et al., 2011).
Wet combing. The wet combing
method for eradication of head lice
can be used in combination with topical pediculicides or as monotherapy.
Randomized controlled studies evaluating its effectiveness as monotherapy
are limited. However, a meta-analysis
of 5 studies on the use of wet combing for treatment of Pediculosis capitis
showed variable cure rates from 38%
to 57% when carried out every 3 to 4
days (Tebruegge & Runnacles, 2007).
Although much more time-consuming and labor-intensive, not to mention less effective, than standard treatment with a pediculicide, it is a
cheap, non-invasive, non-chemical
alternative that may be preferred by
patients or parents who wish to avoid
the use of chemicals (Connolly, 2011;
Gunning et al., 2012).
To perform wet combing, hair
should be wet, and a lubricant of
choice applied to facilitate the process; conditioner, vinegar, or olive oil
has been suggested (Connolly, 2011).
Hair should be systematically combed
PEDIATRIC NURSING/September-October 2015/Vol. 41/No. 5
from root to tip with a lice comb.
Combing should be performed every
3 days for 2 weeks, although combing
for up to 24 days may increase the
cure rate (Gunning et al., 2012). No
adverse effects have been documented regarding wet combing. It is
regarded as an affordable and accessible option.
LouseBuster™. The LouseBuster™
is a custom built medical device
designed to kill lice and lice eggs
(Rush, Rock, Jones, Malenke, &
Clayton, 2011). It offers a non-chemical alternative treatment for head
lice, and was developed based on the
observation that hot water and hot air
kill lice/eggs on fomites. The University of Utah first tested this premise in children 6 years and older with
safety and efficacy; the LouseBuster™
was later developed (Eisenhower &
Farrington, 2012). The LouseBuster™
costs $2,000, and each individual
treatment costs $11. Lice desiccation
is noted to be as high as 94.8% when
the device is used by an experienced
operator and 93.6% when used by
novice operators (Rush et al., 2011).
An advantage of LouseBuster™ is the
lack of resistance (Madke & Khopkar,
2012), and the only adverse effect
reported was discomfort experienced
during treatment, which was relieved
by removal of heat (Goates et al.,
2006). The LouseBuster™ appears to
offer a safe and effective alternative to
pharmacological treatments; however, studies are limited, and local availability is unknown.
Prevention
The focus for prevention of Pediculosis capitis involves better detection, control, and treatment of affected individuals to prevent the spread
of infestation. Environmental management is also a factor, as are standard hygienic practices.
To prevent further transmission,
education about detection of current
infestations needs to be promoted.
Clinicians, school nurses, and community workers should educate the
community on signs and symptoms
of Pediculosis capitis. Parents and clinicians need knowledge about screening and diagnosis. To decrease transmission, the community and children
should also be taught general hygienic practices, such as not sharing
combs, brushes, hats, headgear, and
pillows.
When an individual is found to
Although the primary mode of
transmission is head-to-head contact,
there is ongoing debate about the
potential for reinfestation from
fomite sources.
be infested, proper management following evidence-based guidelines
should be implemented. Children
identified as having head lice should
be referred for treatment and excluded from school only until the day
after the recommended treatment has
been completed (AAP, 2009). The clinician recommending a treatment
regimen should be mindful of failed
treatment regimens locally because
these may indicate resistant infestations. “No nit policies” that require
children to be free of nits before
returning to schools and child-care
institutions should be abandoned.
Only a small number of children with
nits on their scalp are also infested
with living lice. Excluding all children
with nits leads to unnecessary treatment and loss of school/work days
(Frankowski et al., 2010; Gunning et
al., 2012; Mumcuoglu et al., 2006).
Utilization of “no nit policies” has
not been effective in controlling
transmission and is therefore not recommended (AAP, 2009).
Research involving schools that
promote periodic whole-school “bugbusting” days have been shown to
reduce the incidence of infestation
and the demand on staff for management support. This enables health
staff to focus on supporting families
with persistent infestations. The studies reviewed promoted entire school
home screening on a specific louse
detection day. This led to simultaneous detection and treatment of active
infestations, thereby decreasing transmission. Parents were instructed to
screen their children via wet combing
with a special louse comb. Infested
individuals were provided with treatment recommendations. This method was both effective and widely
accepted by parents (Ibarra et al.,
2007).
When an individual is diagnosed
with an infestation and started on a
treatment regimen, all household
members and close contacts should
also be examined for infestation.
PEDIATRIC NURSING/September-October 2015/Vol. 41/No. 5
These contacts should be treated only
if live lice are discovered (Frankowski
et al., 2010; Feldmeier, 2010;
Gunning et al., 2012; Madke &
Khopkar, 2012; Mumcuoglu et al.,
2006; Tebruegge et al., 2011)
Environmental
Management
Although the primary mode of
transmission is head-to-head contact,
there is ongoing debate about the potential for reinfestation from fomite
sources. For this reason, disinfestation
of the environment is recommended
to adequately de-bug and prevent
relapse. It is advisable to launder
clothes, towels, and bed linen used
within two days at a minimum temperature of 60° Celsius, or to place the
items in a dryer at high heat for at
least 40 minutes. Combs and brushes
may be immersed in 60° Celsius water
for at least 10 minutes to kill lice and
eggs (Canyon & Speare, 2010;
Diamantis et al., 2009; Eisenhower &
Farrington, 2012; Finlay & MacDonald,
2008; Gunning et al., 2012; Ibarra,
2010; Izri & Chosidow, 2006;
Lebwohl et al., 2007; Speare, Cahill, &
Thomas, 2003; Takano-Lee, Edman,
Mullens, & Clark, 2005; Tebruegge et
al., 2011). Items that cannot be laundered or placed in a dryer can be
sealed in a plastic bag for 2 weeks
(Diamantis et al., 2009; Finlay &
MacDonald, 2008; Frankowski et al.,
2010; Lebwohl et al., 2007).
It is unnecessary to fumigate carpets, car seats, pillows, and mattresses
because lice are unable to live away
from human hosts for more than 48
to 55 hours. Avoiding use of these
items for this period of time is
advised. Vacuuming is a safe alternative to fumigation (Diamantis et al.,
2009; Eisenhower & Farrington, 2012;
Frankowski et al., 2010; Finlay &
MacDonald, 2008; Lebwohl et al.,
2007; Shmidt & Levitt, 2012).
231
232
Permethrin
Age greater
than 2
months, less
than 2 years
No
Return to
school
Malathion
Benzyl alcohol
Spinosad
It is advisable to launder clothes,
towels, and bed linens used within 2
days at minimum temperature of 60
degrees C or place in dryer at high
heat for at least 40 minutes.
Combs/brushes may be immersed in
60 degree C water for at least 10
minutes to kill lice/eggs.
Recommended
treatments
“No nit” policy
should be
abandoned; only
children with live
lice should stay
home from
school.
Pyrethrin or
permethrin
Age
greater
than
2 years
Yes
Regional resistance
to pediculicides
Treatment with
pediculicides
Yes
Live lice
detected
No
Oral
iIvermectin
Bactrim
Vacuuming is a
safe and effective
alternative to
fumigation of
carpets, car seats,
and mattresses.
Wet
combing
Alternative
Treatments
Household
members/close
contacts should
be examined for
infestation; treat
only if live lice
discovered.
LouseBuster™
Pediculicidal
treatments
should be
rinsed with
cool water.
General
Recommendations
*Refer to guideline for further
information on each pediculicide,
including cost, contraindications, and
age appropriateness.
*Follow up and special considerations
also addressed in the guideline.
Presence of eggs within
1 cm of scalp should raise index
of suspicion and prompt further
examination with louse comb.
Topical ivermectin
Lindane
Items that
cannot be
laundered or
placed in dryer
can be sealed
in a plastic bag
for 2 weeks.
Environmental
Decontamination
Diagnosis: Comb hair
with louse comb to
inspect for live lice.
Figure 2.
Clinical Algorithm for the Treatment and Management of Head Lice
Clinical Practice Update: Pediculosis Capitis
PEDIATRIC NURSING/September-October 2015/Vol. 41/No. 5
Conclusion
Head lice are a worldwide pest
costing Americans money, work productivity, and school time. The wide
availability of pediculicides and alternative treatments can be difficult to
navigate for the clinician, not to mention the lay person. An algorithm (see
Figure 2) was developed to include
new and alternative therapies, environmental decontamination, and general recommendations. This guideline
is intended to be interpreted by primary care clinicians in light of individual patient circumstances, needs,
and desires.
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1016/j.clinthera.2011.11.026
PEDIATRIC NURSING/September-October 2015/Vol. 41/No. 5
Instructions For
Continuing Nursing Education
Contact Hours
Clinical Practice Update:
Pediculosis Capitis
Deadline for Submission:
October 31, 2017
PED 1505
To Obtain CNE Contact Hours
1. To obtain CNE contact hours, you must
read the article and complete the evaluation through the Pediatric Nursing website at www.pediatricnursing.net/ce
2. Evaluations must be completed online
by the above deadline. Upon completion
of the evaluation, your CNE certificate
for 1.3 contact hour(s) will be mailed to
you.
Fees – Subscriber: Free Regular: $20
Goal
The purpose of this learning activity is to
provide an overview of the primary treatment modalities of head lice, including new
and alternative therapies.
Objectives
1. Define Pediculosis capitis.
2. Identify the process for diagnosing lice.
3. Discuss treatment options for lice.
Statement of Disclosure: The author(s) reported no actual or potential conflict of interest in
relation to this continuing nursing education activity.
The Pediatric Nursing Editorial Board members
reported no actual or potential conflict of interest
in relation to this continuing nursing education
activity.
This independent study activity is provided
by Anthony J. Jannetti, Inc. (AJJ).
Anthony J. Jannetti, Inc. is accredited as a
provider of continuing nursing education by the
American Nurses Credentialing Center's Commission on Accreditation.
Anthony J. Jannetti, Inc. is a provider
approved by the California Board of Registered
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Licenses in the state of California must
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activity is completed.
This article was reviewed and formatted for
contact hour credit by Rosemarie Marmion,
MSN, RN-BC, NE-BC, Anthony J. Jannetti, Inc.,
Education Director; and Judy A. Rollins, PhD,
RN, Pediatric Nursing Editor.