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Pediatrics
John Ciuppa
➼ Between 6 million and 12
million infestations of head lice occur
every year in the United States. 1 Children
between the ages of 3 and 11 are the most
often affected, with occurrence more
frequently in girls. 1
Although head lice pose no public
health threat or transmission of disease,
they are an expensive nuisance.
Treatments, lost wages and school
expenses total an estimated $1 billion
annually — an amount almost three
times the estimated expenditure in the
1990s. 2 The direct and indirect costs of
treatment could be reduced by ending
the “no-nit” policies enforced by most
school systems and by delivering efficacious
treatments.
Current Issues
Pediculus humanus capitus is a six-legged
parasite that grows no larger than 2 mm
or 3 mm. Each leg has claws that allow
the organism to grasp a hair follicle. Head
lice survive by feeding off human blood
every 3 to 6 hours. In optimal conditions,
adult lice can survive more than 3
weeks. Pruritus of the scalp is the most
common symptom of an infestation, a
result of localized allergic reaction to
the louse bites. An infestation may be
present for 6 weeks before symptoms
become evident. The female lice
lay eggs, or nits, within ¼ inch
of the scalp. These hatch in 5
to 10 days. The adult stage
is reached about 10 days
after hatching. 1,3
Head lice infestation
has historically
been associated
with lack of personal
hygiene, lack of cleanliness
in the home environment
and (erroneously) lower
The direct and indirect
costs of treatment could
be reduced by ending the
“no-nit” policies enforced
by most school systems
and by delivering
efficacious treatments.
socioeconomic status. The truth is that
head lice infestations affect 5% to 10%
of school-age children across all facets
of life; rates of infestations among black
children are lower. 1,2
Head lice are most commonly transmitted
through direct contact with the hair
of an infected person. Environments in
which direct contact often occurs include
school, home, sporting practices/events,
camps and slumber parties. Although
parents and schools have long recommended
that children avoid sharing hats,
scarves, coats, combs, brushes and bed
linens to prevent head lice spread, these
are uncommon forms of transmission. 1,2
In an attempt to curtail the transmission
of head lice, the National Pediculosis
Association advocates a “no nit” policy: 4
screening children for head lice to identify
any evidence of lice or nits and immediately
removing students with nits or
lice from class until a re-examination
proves clearance.
Given the $1 billion burden associated
with treating head lice and missing school
and work, is this the best policy The
American Academy of Pediatrics, the
National Association of School Nurses
and the Centers for Disease Control and
Prevention recommend that children
return to class as soon as treatment has
been provided. 1,2,4 The CDC goes a step
Kara L. Caruthers is an assistant professor in the physician assistant program at the University
of Alabama at Birmingham and works clinically in emergency medicine. Patricia R. Jennings
is director of the physician assistant program at the University of Alabama at Birmingham and
also serves as a professor. She works clinically in the Division of Infectious Diseases at the
University of Alabama Medical Center and the Birmingham Veterans Affairs Medical Center. The
authors have completed disclosure statements and report no relationships related to this article.
further by stating that children should not
be immediately dismissed from school after
a positive lice finding; instead, they should
be allowed to complete the school day. 1
Head lice do not fly, hop or jump. They
crawl through the head, staying close to
the scalp for both warmth and access
to their food source (blood). They usually
do not survive longer than 48 hours
when away from the host. 1,3 Nits cannot
hatch and usually die within 7 days if
the temperature is not comparable to
that of the scalp. 1 These facts support
recommendations for discontinuing nonit
policies. The cost of unnecessary
absenteeism exceeds the risks associated
with head lice.
Permethrin
The longstanding pharmacologic treatment
of choice for head lice infestation
is permethrin 1% lotion. 5 Permethrin
(Nix) is a pediculicide that has reported
secondary ovicidal properties. It is indicated
for patients older than 2 months.
Permethrin lotion was introduced in 1986
and has been available over the counter
since 1990. 2 It is associated with low
levels of toxicity. 2
Before using permethrin, hair must be
washed with a nonconditioning shampoo
and towel dried. A sufficient amount of
lotion must be applied to saturate the
hair and scalp; it should be rinsed off
after 10 minutes. Current labeling for the
product recommends a routine second
treatment 7 to 10 days later. 2
In recent years, reports of treatment
failure with this therapy have surfaced
throughout the world. Experts initially
believed that the treatment failures were
due to user error (nonadherence or failure
to properly comb out nits), but in the
United States, treatment failure is mostly
attributed to increased resistance as a
result of overuse and formula changes. 4,6
Malathion
Malathion 0.5% (Ovide), an organophosphate,
is a prescription pediculicide with
ovicidal properties. It is available in a
lotion or gel, and studies show it is more
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