Head Lice: 11 Tips That Parents Are Itching To Know
Medically reviewed by Leigh Ann Anderson, PharmD. Last updated on May 11, 2021.
Head Lice At School: Don't Panic
Did you get a notice that there is a outbreak of head lice in your child's school?
5 Facts You Should Know:
- Head lice are found worldwide. In fact, anyone can get infected.
- Preschool and elementary children seem to be the primary targets of head lice, with 6 to 12 million infestations each year.
- Head lice do NOT transmit diseases. Luckily, head lice are more of a nuisance than a serious health concern.
- It's a widespread myth that head lice only affect those with poor hygiene, or disadvantaged or low-income groups.
- There's a stigma that having head lice means that person is “dirty” or lives in poor conditions, but this is a not true.
But How Did My Child Get Head Lice?
It's always a shock, but they are more common that you might think.
The head louse, also known as Pediculus humanus capitis, is a parasite that can be found in human hair, eyebrows, and eyelashes. Head lice are spread by direct contact with the hair of an infested person; they don't fly or hop around.
Once on the scalp, they feed on blood and can lead to bothersome itching. Their egg sacs, or nits, attach firmly to hair strands.
Here's a drawing of how head lice and nits attach to hair.
The American Academy of Pediatrics recommends that children should not be restricted from attending school because of head lice or nits (eggs). Experts also state that contact with clothing or personal items (such as a hat, hairbrush, or coat) is an uncommon way to transmit lice, but it’s probably a good idea not to share personal items.
What Are The First Signs of Head Lice?
The first sign of head lice, known as pediculosis capitis, may be excessive itching around the neck and behind the ear. Symptoms do not always appear, and your only clue may be the presence of nits or lice.
To check for lice, part your child’s hair and look at the scalp for small white or yellow-brown specks attached to the hair shafts. These are nits - lice eggs in their shell casings. Adult lice are more difficult to spot because they are small and will move quickly away when exposed to light.
Check with the school nurse to see if there have been any infestations reported. If indeed you do find head lice or nits on your child, alert the school so families can be notified, and children can be monitored and treated, if needed. Don't worry, your child's identity will be kept strictly confidential.
OTC Head Lice Treatments
Over-the-counter (OTC) treatments (called pediculicides) come in a variety of shampoos, cream rinses or lotion. OTC products available for lice treatment include:
- Pyrethroids, such as piperonyl butoxide / pyrethrins topical (brand names include: A-200, Pronto, R and C, RID Shampoo, Triple X, Licide, others)
- Permethrin 1% (brand names include: Nix Cream Rinse, Nix Ultra, others)
- Sklice (ivermectin 0.5%) topical lotion.
For some products, a repeat treatment may be needed after 7 to 9 days to kill any newly hatched lice (follow directions and timing on the individual product). Use a metal nit (lice egg) comb instead of plastic one, if possible.
OTC Head Lice Products: No Rx Required
Check with child's doctor before treatment. Note age differences for different product and always follow the directions on the package or as directed by your doctor.
- Typically used only if 2 YEARS of age and older. Check labels before use.
- Side effects: skin irritation. Pyrethrins are pyrethroid extracts from the chrysanthemum. In general, don't use pyrethrins if you're allergic to chrysanthemums or ragweed and speak with your doctor about other options.
- Per the CDC, pyrethrins kill only live lice, not the eggs. A second treatment is recommended 9 to 10 days after the first treatment to kill any newly hatched lice before they can produce new eggs.
- If treatment fails to clear up the infestation, contact your healthcare provider.
- Side effects: skin irritation. Permethrin is a synthetic pyrethroid similar to naturally occurring pyrethrins.
- Per the CDC, permethrin kills live lice but not unhatched eggs. Permethrin may continue to kill newly hatched lice for several days after treatment. However, a second treatment often is necessary on day 9 to kill any newly hatched lice before they can produce new eggs.
- If treatment fails to clear up the infestation, contact your healthcare provider.
- Approved for use if 6 months or older; repeat application not needed; do not use for retreatment without talking to your doctor.
- Use when your hair is dry. Apply enough lotion to completely coat all of your hair and scalp. Leave on your hair and scalp for a full 10 minutes and then rinse off with water. Wait 24 hours to shampoo. Adults should apply Sklice lotion on children's hair.
- Side effects: skin or eye irritation, dandruff, dry skin, skin burning sensation. Sklice kills both nits (eggs) and live lice, so combing afterwards is not needed, but can be done to remove empty egg cases if preferred.
- In October 2020, Sklice underwent an Rx-to-OTC switch approved by the FDA. Sklice is no longer available as a prescription drug. A generic option for OTC Sklice is not yet available.
What If OTC Products Don't Work for Head Lice?
Keep in mind that head lice are developing resistance (sometimes called "super lice") to the common over-the-counter (OTC) treatments like permethrin or pyrethrins / piperonyl butoxide. This mean they may not fully work to kill all lice and other treatments may be needed.
If you've fully treated for head lice, but they did not go away or came back quickly, contact your doctor for other options.
A prescription product may be needed for resistant cases. If lice are still present the day after the final treatment with an OTC product, contact your doctor.
Prescription products that may be more effective on resistant lice include:
Note: Benzyl alcohol lotion and the Ulesfia brand have been discontinued in US. The American Academy of Pediatrics NO longer recommends lindane to treat head lice.
Prescription Head Lice Products
- Spinosad 0.9% (Natroba topical suspension): Approved for use if 6 months or older; reapply after 7 days only if live lice still seen. Side effects: skin or eye irritation, redness.
- Abametapir (Xeglyze lotion): Approved in July 2020 for the treatment of head lice in people six months of age and older. Xelgyze lotion is fully applied to dry hair and scalp, thoroughly massaged into the hair and scalp, and left for 10 minutes before rinsing off with warm water. Do not repeat treatment. Side effects include: redness or rash, skin burning, contact dermatitis, vomiting, eye irritation, itching, and hair color changes.
- Malathion lotion: Malathion is intended for use on persons 6 years of age and older. Repeat use in 7 to 9 days if live lice still seen. Side effects: bad odor, highly flammable due to alcohol content (do not smoke or use electrical heat sources, including hair dryers, curlers, and curling or flat irons, when applying malathion lotion and while the hair is wet), skin irritation, including chemical burns. Discontinue use and call doctor if skin irritation occurs
An tablet version of oral ivermectin only available with a prescription may be prescribed by a doctor for patients whose lice are resistant to topical treatment.
The CDC states that lindane 1% shampoo is not recommended as a first–line treatment for head lice. Overuse, misuse, or accidentally swallowing lindane can be toxic to the brain and other parts of the nervous system; its use should be restricted to patients for whom prior treatments have failed or who cannot tolerate other medications that pose less risk.
- Lindane should not be used to treat premature infants, persons with HIV, a seizure disorder, women who are pregnant or breastfeeding, persons who have very irritated skin or sores where the lindane will be applied, infants, children, the elderly, and persons who weigh less than 110 pounds.
- Retreatment should be avoided.
Treating Household Members for Head Lice
Are you worried that others in the house may have contracted head lice? All household members should be examined for head lice, and treated at the same time if needed. Anyone who sleeps in the same bed as someone with head lice should be treated even if lice or eggs are not seen. No need to treat your household pets; dogs or cats cannot transmit human lice.
In fact, lice cannot live off of the scalp for longer than 48 hours, so gather and wash items used in the last two days. To kill lice and eggs from clothes, stuffed animals, and bedsheets, you can use one of 3 methods:
- Use hot, soapy water (at least 130 degrees F or 54.4 degrees C) and the high heat cycle when drying.
- Have items professionally dry cleaned.
- Seal items in a plastic bag for 2 weeks.
Vacuum furniture and floors to remove stray hairs that may contain nits. Soak combs, brushes, and hair accessories in very hot, soapy water for 5 to 10 minutes. Household spraying with insecticides is not recommended.
Wet Combing for Head Lice
The available OTC and prescription pediculicides have been shown to be safe and effective when used according to the directions. However, some people prefer not to use them for a variety of reasons.
A method known as "wet combing" is an alternative for patients too young to use these products or for those who would prefer to avoid use of insecticides. Keep in mind the process can be time consuming and careful and repeated combing is needed over several weeks.
To perform wet combing:
- Lubricate wet hair with a hair conditioner.
- Use a fine-tooth nit comb from the crown, and firmly draw down and examine for lice after each stroke.
- Combing is done until no lice are found for each session (15 to 30 minutes per session is needed).
- The process should be repeated every three to four days for several weeks -- at least two weeks after no more lice are found.
Unproven Head Lice Treatments
Some people believe (and questionable Internet sites may promote) that head lice can be "suffocated" by coating the hair in "natural" oily products such as olive oil, mayonnaise, butter, or petroleum jelly. However, head lice are difficult to suffocate, and at least one report states that these methods are not effective.
Plus, extreme methods, like using gasoline or kerosene can be very toxic and highly flammable and should NEVER be used to try to kill head lice. Fatal injury can occur.
Shaving the head has not been shown to be effective to kill lice and may be psychologically distressing to a school age child. Avoid this practice.
Head Lice Support Group
Don't panic if your child, or other family member, comes down with head lice. It sounds awful, but it's really fairly common and easy to treat. Remember that head lice cannot transmit disease and are more of a nuisance than anything else.
However, you may still have questions or want to ask other parents for advice.
Finished: Head Lice: 11 Tips That Parents Are Itching To Know
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- American Academy of Pediatrics. Head Lice: What Parents Need to Know. Accessed May 11, 2021 at https://healthychildren.org/English/health-issues/conditions/from-insects-animals/Pages/Signs-of-Lice.aspx
- Koch, E., Clark, J. M., Cohen, B., et al. Management of Head Louse Infestations in the United States—A Literature Review. Pediatr Dermatol 2016;33:466–72. Accessed May 31, 2019
- U.S. Centers for Disease Control and Prevention (CDC). Head Lice. Treatment. Accessed May 11, 2021 at https://www.cdc.gov/parasites/lice/head/gen_info/index.html
- Devore C, Schutze, G. The Council on School Helath and Committee on Infectious Diseases. Pediatrics May 2015, 135 (5) e1355-e1365; DOI: 10.1542/peds.2015-0746. Reaffirmed June 2020. Accessed May 11, 2021 at https://pediatrics.aappublications.org/content/135/5/e1355
- Lice in at least 25 states show resistance to common treatments. American Chemical Society. Press Release. Accessed May 31, 2020 at https://www.acs.org/content/acs/en/pressroom/newsreleases/2015/august/lice.html
- Goldstein AO, et al Patient education: Head lice (Beyond the Basics). UpToDate. April 2021. Accessed May 11, 2021. at https://www.uptodate.com/contents/head-lice-beyond-the-basics
- Super lice: Should I be worried about these treatment-resistant pests? Mayo Clinic. Drugs.com. July 24, 2019. Accessed May 11, 2021 at https://www.drugs.com/mcf/super-lice-should-i-be-worried-about-these-treatment-resistant-pests