Get Your Head in the Game: Revised Head Lice Clinical Review

Mary Wu Chang, MD reviewing Devore CD et al. Pediatrics 2015 Apr 27.

No healthy child should be excluded from school because of head lice or nits, these reviewers find.

Head lice are not a health hazard, do not signify poor hygiene, and do not cause spread of any disease. However, social stigma, ostracization, and mandated school absence are problematic. Recent treatment costs have been estimated at $1 billion/year. These authors present a revision of the 2010 clinical report on head lice published by the American Academy of Pediatrics to clarify current diagnosis and treatment protocols and guide the management of children with head lice.

Lice are transmitted by direct head to head contact; lice crawl, they can't jump or fly. Lice survive for <1 day off the scalp. Nits (eggs) attached >1 cm from the scalp are unlikely to be viable and cannot hatch at temperatures lower than those near the scalp. Therefore, indirect transmission is uncommon.

Other key points to keep in mind:

1. No healthy child should be excluded from school because of head lice or nits. No-nit policies for return to school should be abandoned.
2. Do not treat a child unless live lice or eggs (not just empty nit cases) are present.
3. 1% permethrin and pyrethrins (over the counter) are very safe, inexpensive, and remain the first-line treatment for active infestations, unless resistance in the community is proven. These products are not ovicidal; thus at least two treatments are required at proper intervals (day 0 and day 9, or day 0, 7, and 13-15 days).
4. Manual removal of lice/nits (wet-combing), although time-consuming, is an alternative to the topical treatment, but it requires close surveillance and repeat efforts weekly for at least three treatments.
5. Benzyl alcohol 5% can be used in children older than 6 months, and malathion 0.5% can be used in children older than 2 years. Spinosad and topical ivermectin are effective alternatives, but they are very expensive.
6. Other treatments include the off-label use of scabicides — topical (permethrin, crotamiton) or oral (ivermectin).
7. Alternative approaches are found in abundance on the internet but are unproven and may result in treatment failure or even cause contact dermatitis (e.g., essential oils).

CITATION(S):

Devore CD et al. Head lice. Pediatrics 2015 Apr 27; [e-pub].