Diagnosis
H&P:
Risk factors:
Common presentation:- Pruritus is the most common presenting symptom in pediculosis.
How a diagnosis is made: Head and pubic lice infestations diagnosed by visualization of live lice.
Ddx and cause:
Treatment
–Permethrin 1% lotion or shampoo (1st-line treatment).
-Follow permethrin 1% treatment with nit removal and wet combing. The treatment should be reapplied at day 9, and if needed, at day 18.
-Wet combing is an effective nonpharmacologic treatment alternative.
-In addition to home eradication measures, regular nit combing recommended.
-Patient encouraged to wash affected clothing and bedding.
-Will evaluate for other STIs if pubic lice
If there is resistance to 1% permethrin, spinosad or topical ivermectin is recommended.
-all household members should be checked.
Background
“Head lice is a nuisance, not a serious disease or a sign of poor hygiene.”
“a healthy child should not be restricted from attending school because of head lice or nits (eggs). Pediatricians are encouraged to educate schools and communities that no-nit policies are unjust and should be abandoned. Children can finish the school day, be treated, and return to school.”
“Nits located further than a ¼ inch from the base of hair shaft may very well be already hatched, non-viable nits, or empty nits or casings.” CDC.gov.
-Findings of nits alone indicate a historical infestation. A “no nit” policy for schools and daycare centers no longer is recommended because nits can persist after successful treatment with no risk of transmission.
Other treatment options.
Ivermectin – 2nd line. Not FDA approved.
Topical benzoyl alcohol. FDA approved. Expensive.
Lindane – Has an increased risk of toxicity. Don’t use in children < 50 kg.
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*** permethrin 1% is for lice and permethrin 5% is for scabies.
Alternative treatments
-Ivermectin, not FDA approved, not first-line
-Lindane carries an increased risk of toxicity and should not be used in children weighing <50 kg.
-Topical benzyl alcohol is FDA-approved for treatment but is expensive.
*** Children found to have lice in school shouldn’t be sent home but returned to their classroom immediately. They only need to be discouraged from close contact with others until treated.
“Transmission generally requires head-to-head contact, as lice cannot survive when separated from their host for more than 24 hours and do not fly or hop. Visible nits are generally present at the time of diagnosis, confirming that the infestation has been present for some time, so immediate isolation from other children would not be expected to change the natural course of events. The American Academy of Pediatrics (AAP) recommends that children found to be infested with lice remain in class but be discouraged from close contact with others until treated appropriately with a pediculicide. The AAP position also recommends the abandonment of “no nits” school policies, which prohibit attendance until no visible nits are identified. Nits can be found long after their deposition at the scalp level and generally have already hatched by the time they are easily noted at some distance from the scalp.”
Key points from 2015 AAP Update on Lice Treatment.
- “No healthy child should be excluded from school or allowed to miss school time because of head lice or nits. No-nit policies for return to school should be abandoned.
- 1% permethrin or pyrethrins are a reasonable first choice for primary treatment of active infestations if pediculicide therapy is required unless resistance to these products has been proven in the community.
- Use per manufacturer’s guidelines.
- Because current products are not completely ovicidal, applying the product at least twice, at proper intervals, is indicated if permethrin or pyrethrin products are used or if live lice are seen after prescription therapy per manufacturer’s guidelines.
- Manual removal of nits immediately after treatment with a pediculicide is not necessary to prevent spread. In the school setting, nit removal may be considered to decrease diagnostic confusion and social stigmatization.
- Consider the manual removal of lice/nits by methods such as “wet-combing” or an occlusive method (such as petroleum jelly or Cetaphil cleanser), with emphasis on careful technique, close surveillance, and repeating for at least 3 weekly cycles, IF resistance to available OTC products has been proven in the community, if the patient is too young, or if parents do not wish to use a pediculicide.
- Benzyl alcohol 5% can be used for children older than 6 months, or malathion 0.5% can be used for children 2 years or older in areas where resistance to permethrin or pyrethrins has been demonstrated or for a patient with a documented infestation that has failed to respond to appropriately administered therapy with permethrin or pyrethrins. Spinosad and topical ivermectin are newer preparations that might prove helpful in difficult cases, but the cost of these preparations should be taken into account by the prescriber.
- Head lice screening programs have not been proven to have a significant effect over time on the incidence of head lice in the school setting and are not cost-effective. Parent education programs may be helpful in the management of head lice in the school setting.” AAP 2015
Reference:
Pediatrics. 2015 May;135(5):e1355-65. Head lice. From Council on School Health and Committee on Infectious Diseases, American Academy of Pediatrics. https://www.ncbi.nlm.nih.gov/pubmed/25917986
https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0072513/
Pediatrics 2010;126(2):392-403. http://pediatrics.aappublications.org/content/126/2/392
Am Fam Physician 2012;86(6):535-541. http://www.aafp.org/afp/2012/0915/p535.html.
Pediatrics 2010;126(2):392-403. https://www.ncbi.nlm.nih.gov/pubmed/20660553.
https://www.aap.org/en-us/about-the-aap/aap-press-room/pages/aap-updates-treatments-for-head-lice.aspx