The Pharmacist’s Guide to Head Lice Treatment

RELEASE DATE

August 1, 2024

EXPIRATION DATE

August 31, 2026

FACULTY

Debra L. Stevens, PharmD, BCPP
Associate Professor

Lauren Boecker, PharmD Candidate 2023

Melanie Claborn, PharmD, BCACP
Associate Professor

Brooke L. Gildon, PharmD, BCPS, BCPPS, FPPA
Professor
Southwestern Oklahoma State University
College of Pharmacy
Weatherford, Oklahoma

FACULTY DISCLOSURE STATEMENTS

Drs. Stevens, Claborn, and Gildon and Ms. Boecker have no actual or potential conflicts of interest in relation to this activity.

Postgraduate Healthcare Education, LLC does not view the existence of relationships as an implication of bias or that the value of the material is decreased. The content of the activity was planned to be balanced, objective, and scientifically rigorous. Occasionally, authors may express opinions that represent their own viewpoint. Conclusions drawn by participants should be derived from objective analysis of scientific data

ACCREDITATION STATEMENT

acpePharmacy
Postgraduate Healthcare Education, LLC is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

UAN: 0430-0000-24-084-H01-P
Credits: 2.0 hours (0.20 ceu)
Type of Activity: Knowledge

TARGET AUDIENCE

This accredited activity is targeted to pharmacists. Estimated time to complete this activity is 120 minutes.

Exam processing and other inquiries to:
CE Customer Service: (800) 825-4696 or cecustomerservice@powerpak.com

DISCLAIMER

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patients' conditions and possible contraindications or dangers in use, review of any applicable manufacturer's product information, and comparison with recommendations of other authorities.

GOAL

To review the diagnosis and treatment of head lice and educate the pharmacist on recommendations and counseling points for proper use of treatment options.

OBJECTIVES

After completing this activity, the participant should be able to:

  1. Describe the diagnosis and transmission of head lice.
  2. Discuss the pharmacologic and nonpharmacologic options for the treatment and management of head lice.
  3. Explain the administration instructions for pharmacologic treatment options for head lice.
  4. Identify measures for head lice prevention and control.

ABSTRACT: Head lice infestation is a common problem, particularly in children, and patients and their families may seek help for treatment and prevention of this condition. Diagnosis of a head lice infestation is made via visual inspection of the scalp and hair and identification of live lice or nits, but the condition can be mistaken for similar-looking particles, such as dandruff or hair-product residue. Wet-combing has been proposed to be a more systematic detection method. Numerous FDA-approved pharmacologic products are available, as are various natural products and other nonpharmacologic treatment measures. Specific counseling points regarding head lice treatment are important for pharmacists to discuss with patients and caregivers. Pharmacists can take an active role in reassuring patients and caregivers and providing information about optimal treatment and management as well as instructions for product use.

Infestation with Pediculus humanus capitis, or head lice, occurs only in humans and can take place at any age, but it is more common in children. Head lice infestation is not a reportable disease; however, it is estimated that 6 million to 12 million infestations occur each year in children in the United States.1,2 Head lice infestation affects all races and ethnicities, and this condition has the potential to result in a significant economic burden on healthcare systems. Head lice are not known to transmit disease, but their presence is associated with significant social stigma.2 The burden of head lice infestation may include anxiety in the child, absence from school or daycare, and secondary bacterial infections resulting from excessive scratching of the scalp.

Head lice infestation is a common problem, and patients or caregivers may seek help from pharmacy personnel on head lice treatment, management, and prevention. This article will review the diagnosis and treatment of head lice, with a focus on children, and educate pharmacists on recommending appropriate agents and counseling on their proper use.

Transmission and Diagnosis

Head lice are whitish-gray parasitic insects that are typically about 2 to 3 mm in length, about the size of a sesame seed. The louse has hooks that help it attach to its host’s scalp. The louse injects small amounts of saliva into the scalp and feeds on the host’s blood up to five times per day. Once on the scalp, the louse lays eggs on the hair shaft close to the scalp. The eggs, or nits, are small, white, ovalshaped cases that usually hatch after 5 to 9 days. Adult head lice can live about 1 month on the scalp, but they can survive only 1 to 2 days away from the scalp.1-3

Lice cannot jump or fly from person to person. Head lice are generally spread by close physical contact with the hair of an infested person, but they can also be transmitted indirectly via fomites (i.e., shared clothing, hats, helmets, bedding, hairbrushes, etc.). The spread of lice may be related to the extent of the infestation and the duration of potential exposure. It should be noted that head lice infestation is not a sign of poor hygiene.1-3

Some studies suggest that girls get head lice more often than boys do, probably because of more frequent head-to-head contact (e.g., shared hair tools).2 The patient may be asymptomatic for several weeks after first getting head lice. The most common symptom of a head lice infestation is itching, which is a reaction to louse saliva. Head lice infestation is diagnosed by a visual inspection of the scalp and hair that identifies live lice or nits. One live louse is enough to confirm a diagnosis; however, the condition is often misdiagnosed. This misdiagnosis may be due to failure to differentiate the eggs from other similar particles (e.g., dandruff, dry skin, hair product residue).2,3 Wet-combing has been proposed to be a more systematic way to detect an active lice infestation.4,5 In one study, the wet-combing technique had higher sensitivity for detecting lice compared with visual inspection (90.5% vs. 28.6%; P < .001).5 Management must include inspection of all persons exposed, with treatment reserved only for those found to have an active lice infestation. It may be challenging to detect an active infestation if a patient was recently treated.

Pharmacologic Treatments

The goal of head lice treatment is to eliminate the lice and nits. To avoid potential adverse effects from exposure to pharmacologic agents, it is important to treat only individuals who have an active infestation. TABLE 1 summarizes the currently available FDA-approved treatment options.2,6-13 Some agents are available OTC, whereas others are prescription-only. As discussed below, one newer agent has FDA approval but is not currently available in the U.S., and another agent was discontinued by the manufacturer.

Permethrin 1% Cream Rinse and Permethrin 5% Lotion: Permethrin 1% cream rinse is a pyrethroid-based product that is available OTC. Permethrin’s mechanism of action is to block sodium channels, resulting in paralysis and death of the louse.14 It is effective against live lice, is relatively low in cost, and is safe for use in infants aged 2 months and older and in pregnant women.2 The cream rinse is a first-choice option for treating head lice as long as pyrethroid resistance is not suspected.2 Prior to application of the cream rinse, the patient’s hair should be washed with a nonconditioning shampoo, and the use of conditioner and other silicone-based hair products should be avoided. Next, the patient’s hair should be towel-dried so that it is damp but not excessively wet. The bottle should be shaken well and the cream rinse applied to the hair and scalp until it becomes saturated; the areas behind the ears and the back of the neck should be treated also. The cream rinse should be left in the hair for 10 minutes, then rinsed immediately with warm water. Following treatment, nits should be removed manually with a fine-tooth comb, which has narrow teeth that are very close together; this provides the nits with a solid grip, making them easier to remove.2 Common side effects include itching, redness, and scalp irritation; additionally, caution should be exercised in patients who are allergic to ragweed, as difficulty breathing and asthma attacks have been reported with the use of these products in this patient population.14

Permethrin 5% lotion, a prescription-only product, is not currently FDA approved for the treatment for head lice. However, pharmacists may encounter off-label use for treatment-resistant cases. The lotion is applied to the hair and scalp and left on for approximately 8 hours, usually overnight.15 With both permethrin formulations, a second treatment course may be required in the range of 7 to 10 days following the first treatment if live lice or nits are still observed.14

Pyrethrin and Piperonyl Butoxide Shampoo: Pyrethrin and piperonyl butoxide shampoo is an OTC product. Pyrethrin is derived from natural chrysanthemum extract.3 Piperonyl butoxide is combined with pyrethrin to improve its effectiveness by decreasing the metabolism of pyrethrin in the louse.16 This product is available in various formulations, such as mousse or “daily defense” shampoo, or in a kit with a nit comb. The American Academy of Pediatrics (AAP) recommends that the shampoo be used in patients aged 2 years and older.2 Pyrethrin and piperonyl butoxide shampoos are considered safe for pregnant and breastfeeding women. The shampoo should be applied to the scalp while the hair is dry, with enough product used to saturate the area, and left on for 10 minutes. Next, the shampoo should be lathered into the hair and then rinsed out with warm water. It is not necessary to wash the hair with regular shampoo immediately after treatment.16 Because of variations in products, the pharmacist should check for differences in instructions prior to counseling. The patient will need retreatment after 7 to 10 days because the lack of continuous pediculicidal activity following treatment enables surviving nits to hatch unaffected.17 Upon accidental exposure to pyrethrin and piperonyl butoxide shampoo, patients may experience local skin or scalp irritation or ocular irritation. Serious side effects include signs or symptoms of an allergic reaction, such as hives, difficulty breathing, and swelling of the face, mouth, or throat.16

Ivermectin 0.5% Lotion and Ivermectin 3-mg Tablets: Ivermectin 0.5% lotion, an anthelmintic agent, is available OTC. Ivermectin acts by binding to glutamate-gated chloride channels, leading to paralysis and death of the louse. Ivermectin results from the fermentation of the actinomycete Streptomyces avermitilis, which is present in the soil. The patient or caregiver should use only enough product to fully coat the hair and scalp and then discard the remainder. The patient or caregiver should be advised to avoid shampooing the hair for 24 hours after treatment. Per the manufacturer’s instructions, lotion should be applied to dry hair, starting with the scalp and the hair closest to the scalp; next, the patient or caregiver should apply the lotion to the hair, working outward to the tips of the hair. Finally, 10 minutes should elapse before the product is rinsed out with water only.8 Mild side effects include a burning sensation, scalp irritation, and dandruff; however, hypersensitivity reactions such as hives, facial swelling, or difficulty breathing can occur.18 Other products are preferred over ivermectin to treat lice in pregnant and breastfeeding women.18

According to the AAP, oral ivermectin is a potential treatment option for children with refractory head lice, although it is FDA approved only for head lice treatment in adults. Ivermectin 3-mg tablets are a prescription-only product, and pharmacists should be prepared to check weight-based dosing accuracy in the pediatric population. Typically, an effective dosing regimen in both children and adults is two single doses of 200 mcg/kg separated by 7 to 10 days.2,18 The AAP recommends oral ivermectin use only in children weighing more than 15 kg, based on potential safety concerns over effects on the central nervous system.2

Malathion 0.5% Lotion: Malathion 0.5% lotion is a prescription-only organophosphate product that inhibits the cholinesterase activity of lice and nits. When using this product, the patient or caregiver should let the hair air-dry uncovered after application and refrain from using any electrical heat sources to speed up the drying because some formulations contain isopropyl alcohol, which is flammable.19 A second treatment may be performed 7 to 9 days later if lice are still present, but this likely will not be necessary given malathion’s high ovicidal activity.16 If accidental ingestion occurs, the patient or caregiver should seek medical attention and call poison control (1-800-222-1222) immediately for potential organophosphate poisoning. Mild topical reactions include scalp irritation, second-degree chemical burns, and (in the case of ocular exposure) conjunctivitis.9

Spinosad 0.9% Suspension: Spinosad 0.9% topical suspension is a prescription-only product created from the fermentation of Saccharopolyspora spinosa, a soil-derived actinomycete. Spinosad causes hyperexcitation of the neurons in lice, leading to louse paralysis and death.10 Spinosad may be used in patients aged 6 months and older. Before application, the bottle should be shaken well. Next, the suspension should be applied to the scalp and then the hair (which must be dry), using enough product to ensure full coverage. Finally, 10 minutes must elapse before the suspension is rinsed out with warm water. The patient may be retreated if live lice are still present after 7 days.20 Some patients may experience redness of the scalp or eyes after application. Despite its relatively mild adverse-effect profile, this product should not be used in patients younger than age 6 months because it contains benzyl alcohol, which could lead to toxicity and death in neonates.10 Spinosad is not significantly absorbed systemically after topical use, and a fetus or breastfeeding child is unlikely to be exposed to benzyl alcohol, making spinosad a potential treatment option during pregnancy or while nursing.20

Abametapir 0.74% Lotion: Abametapir 0.74% lotion is an FDA-approved treatment for head lice, but it is not currently available in the U.S. The mechanism of action of abametapir is inhibition of metalloproteinases, which are necessary to the survival of lice and nits. This topical product is indicated as a single treatment for head lice in patients aged 6 months and older.2

Benzyl Alcohol 5% Lotion: Benzyl alcohol 5% lotion was previously approved by the FDA for the treatment of head lice in patients aged 6 months and older. The lotion was applied for 10 minutes, followed by a recommended retreatment 1 week later. Note: This treatment option is no longer available because the product was discontinued by the manufacturer; the product was not removed for safety reasons, however.2

Lindane 1% Shampoo: Lindane is an FDA-approved organochloride insecticide; however, it is no longer recommended by the CDC or the AAP for treatment of head lice based on its potential for neurotoxic adverse effects.1,2 Lindane 1% shampoo is no longer marketed in the U.S., although it may be available by prescription in other countries.

Pharmacologic Agents’ Place in Therapy

Although head lice infestation is a global issue that affects persons of all ages, the focus of this article is treatment for children in the U.S. Currently, the AAP recommends the use of pyrethroid agents, which are available OTC, in patients aged 2 months or older (permethrin approved for ages 2 months or older, pyrethrin and piperonyl butoxide approved for ages 24 months or older) if there is no suspected pyrethroid resistance in the community. If treatment with pyrethroids fails, the choice of agent is based on the patient’s age. In patients younger than age 6 months, the AAP recommends using manual removal of lice and/or occlusive agents (dimethicone or others). In patients aged 6 months up to 6 years, ivermectin 0.5% (OTC) or spinosad 0.9% (prescription-only) is recommended. In patients aged 6 years and older, ivermectin 0.5%, spinosad 0.9%, or malathion 0.5% (prescription-only) is indicated. Some topical treatments must be repeated in 7 to 10 days, depending on the product’s efficacy against nits. If resistance to all topical agents is observed in a patient aged 6 months or older, oral ivermectin (prescription-only) may be considered if the patient weighs 15 kg or more.2

Nonpharmacologic Treatments

Natural products and nonpharmacologic treatments may be considered for head lice. Any method or product that does not involve chemicals is less likely to lead to resistance.21 Some caregivers may prefer to use products derived from plants instead of chemical products.21 Plant-derived compounds are not regulated by the FDA, so they cannot be deemed safe and effective. The effectiveness of physical methods of removal depends on the meticulousness and technique of the person who is performing the removal. Physical-removal methods take a significant amount of time and consistency over a number of days to ascertain that all nits have been removed. The wetcombing method is summarized in TABLE 2, which may be used for patient education.1,4,5

Essential Oils: Essential oils have been employed in the treatment of head lice; however, based on a lack of safety and efficacy data, these products are not recommended.22 Essential oils that have been used for treatment include tea tree, lavender, lemongrass, eucalyptus, safflower, and coconut oils, among numerous others.22 Skin irritation and allergic contact dermatitis have been reported with the use of essential oils on the scalp. An additional concern with essential oils is the potential for accidental ingestion, which could result in systemic toxicity.22

Occlusive Agents: Various occlusive agents have been used in the treatment of head lice. Petrolatum, mayonnaise, melted butter or margarine, and olive oil have been suggested as occlusive agents.22 The chosen agent is applied liberally to the scalp and hair, with a shower cap worn overnight before the hair is washed. However, evidence on these agents’ effectiveness is lacking, and they tend to be messy and difficult to wash out of the hair.22 Dimethicone, an OTC product that is not FDA approved, is an occlusive agent that appears not to act by suffocation but rather prevents the louse from excreting water, leading to its death.23 Cetaphil lotion has also been used as an occlusive (the “Nuvo” method); the recommendation is to apply it to the hair and scalp and dry it with a hair dryer, leave it on the head overnight, and then wash it out. A potential disadvantage is that drying takes a significant amount of time.24

Desiccation: Various nonpharmacologic products for treating head lice infestation involve desiccation. Natrum muriaticum (Vamousse, Licefreee) is a sodium chloride–based ingredient that is used to dehydrate both lice and nits. Another product, AirAllé (former name: Lousebuster), is a device that delivers heated air to the scalp to kill live lice as well as eggs; a benefit is that because it lacks the use of chemicals, resistance is not a problem. This treatment takes approximately 30 minutes, which could be a disadvantage if the patient is unable or unwilling to sit for that long. The use of this device is not recommended in children who are younger than age 4 years.25

Manual Removal: To treat the infestation, manual removal of live lice and nits can be performed exclusively or it can be done following another lice treatment. Manual removal without the use of other agents may be recommended when there is a concern about the toxicity of pediculicides, as with children younger than age 2 years, pregnant or nursing women, and patients with open head wounds.22 The effectiveness of this method depends on the design of the comb—differences in effectiveness between various brands of nit combs are to be expected—and the user’s skill in correctly using the comb.21 For removal of lice and nits, a nit comb with teeth spaced 0.09 mm to 0.19 mm apart is recommended. The nit comb is more effective when used on wet and conditioned hair as opposed to dry hair, and the hair should be sectioned and combed from root to tip.22 Although nit combs are often recommended for head lice treatment, consideration should be given to the patient’s hair type. Nit combs may be inappropriate for patients with kinky or curly hair, which is more vulnerable to damage.26 Also available are electronic nit combs, which not only remove nits but also kill any live lice that come in contact with the comb. This type of nit comb must be used on dry hair, which can make removal more difficult because lice move faster in dry hair. Electronic nit combs are not recommended in patients with seizure disorder or in those who have a pacemaker.2

Vinegar-based products have been used to make nit removal easier. Vinegar-based products dissolve the “cement” attaching nits to the hair shaft, facilitating their removal while combing.2 Other techniques for making it easier to treat lice include cutting the hair short and shaving the scalp, but these methods can be stigmatizing and may lead to embarrassment for the patient.21

Prevention and Control

Prevention of head lice is difficult, as head-to-head (hair-to-hair) contact is quite common, especially in children and adolescents.2 However, certain tips and tricks may help lessen exposure. Personal items such as hairbrushes, hair ribbons, hats, scarves, helmets, pillows, and blankets should be person-specific and not shared. For the prevention of head lice, head-to-head contact should be avoided during play and other activities. However, it is important not to avoid protective headgear based on concerns about head lice spread.

Control Measures at Home: Items that can be disinfected, such as combs and towels, may be soaked in hot water (at least 130°F) for 5 to 10 minutes to prevent the spread of head lice.1 Proper cleaning of bed linens, clothing, stuffed toys, and towels of the infected patient is also important. These items can be machine-washed in hot water and dried on the hot dryer cycle. It is also essential to vacuum the floor and any furniture associated with the infestation. Cleaning the environment to control the spread of head lice should include items used within 2 days of the infestation, as louse survival beyond 48 hours is unlikely.2

The control of head lice is more challenging in congregate settings such as college dormitories, group homes, shelters, and long-term care facilities.2 In these settings, individuals are more likely to have direct head-to-head contact or fomite-related transmission from persons outside their circle of family or friends. If an outbreak occurs, the primary goal is to limit the number of persons impacted. Secondarily, education about control strategies is imperative to prevent future infections or spread of head lice.

Control Measures in Schools: Routine head lice screening in the school setting should be discouraged based on a lack of efficacy and a poor cost-to-benefit analysis.2 Mass screenings and subsequent school exclusions are linked to unnecessary missed school days, which can have negative impacts on students’ social, emotional, and academic well-being. Also, studies have shown that occurrences of head lice in the classroom have low rates of contagion.2,27 It is important to educate caregivers on the diagnosis and treatment of head lice as well as the necessity of examining the head of any symptomatic child. Although it can be helpful for the school nurse to check a child for head lice, it is imperative that the caregiver perform a more careful examination.

If a child is found to have an active head lice infestation, the caregiver should be notified that proper treatment is required but that the child should stay in school.2 Because of the amount of time it takes for symptoms to develop, the child likely has had an active infection for 4 to 6 weeks.3 At this point, the child poses very little risk to others but should be directed to avoid close head-to-head contact.2 Confidentiality is also important in this scenario to protect the student. Any symptomatic classmates or friends should be checked to prevent further transmission. A child should not be excluded from attending school because of a head lice diagnosis.2,28 The “no-nit” policy is outdated and should not be supported.

The Pharmacist’s Role

Pharmacists should advise caregivers of children with head lice to administer products with the child’s head over the sink rather than in the shower to minimize exposure of the skin to the topical agent. Warm rather than hot water is recommended for rinsing to avoid increased absorption.1 Each head lice product carries its own specific directions for application and potential adverse effects, which were discussed previously. Pharmacists may need to provide instructions for retreatment or alternative products, as nonadherence or incorrect use can result in treatment failure.

Conclusion

Although head lice infestation is associated with low morbidity, this condition frequently triggers anxiety in patients and family members. Patients and caregivers often seek help from their local pharmacist on the treatment and prevention of head lice. Various OTC and prescription pediculicide products are available, and each has its place in therapy. The treatment of head lice infestation should be safe, effective, easy to use, and age-appropriate. Pharmacists can take an active role in reassuring patients and caregivers and in providing information about optimal treatment and management as well as instructions for correct product use.

REFERENCES

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23. Burgess IF. The mode of action of dimeticone 4% lotion against head lice, Pediculus capitis. BMC Pharmacol. 2009;9:3.
24. Pearlman D. Cetaphil cleanser (Nuvo lotion) cures head lice. Pediatrics. 2005;116(6):1612.
25. Bush SE, Rock AN, Jones SL, et al. Efficacy of the LouseBuster, a new medical device for treating head lice (Anoplura: Pediculidae). J Med Entomol. 2011;48(1):67-72.
26. Shea LA, Lourenço Freitas E, Nguyen T, et al. Over-the-counter Pediculus humanus capitis treatment: the nit comb is not appropriate for all hair types! J Am Pharm Assoc (2003). 2023;63(1):46-49.
27. Mathias RG, Wallace JF. Control of headlice: using parent volunteers. Can J Public Health. 1989;80(6):461-463.
28. Hootman J. Quality improvement projects related to pediculosis management. J Sch Nurs. 2002;18(2):80-86.