— nit-removal combs do not appear to be effective adjunct to topical pediculicide — “no nit” policies for return to school ■ discouraged by AAP and APHA ■ may be required for reentry to school or day care based on local regulations • oral medications — not approved by FDA for treatment of head lice — options may include ■ trimethoprim-sulfamethoxazole 5 mg/kg twice daily ■ oral ivermectin 400 mcg/kg twice 7 days apart ■ pediculicide considered effective if lice dead or slowly moving 8-12 hours after treatment
• live eggs not removed • acquired resistance to pediculicide • treatments to consider if proven resistance or active infestation documented include — benzyl alcohol 5% if age >6 months — malathion 0.5% if age >24 months — manual removal via wet combing or occlusive method (such as petrolatum jelly or suffocation product) for younger patients, with 2-4 treatment cycles Complications
• secondary bacterial skin infection due to scratching (rare) Prognosis
• physical nit removal (evidence for effectiveness limited and inconsistent) • nit-removal combs do not appear to be effective adjunct to topical pediculicide
• pruritus may persist 7-10 days after effective treatment • current resistance rates unknown • most children with nits but no active lice do not develop active lice • re-infestation may be common
Desiccation
Contacts of index cases
• blowing hot air through custom-built hair dryer for 30 minutes reported effective • desiccation with regular blow-dryer not recommended (due to potential spread)
• screen all household members • treat if live lice or nits identified within 1 cm of scalp • consider treating family members who share a bed with index case even if no live lice found
Treatments not recommended
School attendance
• head shaving (effective but distressing) • flammable or toxic substances such as gasoline or kerosene products • nit-loosening agents (such as vinegar, vinegar-based products, acetone, bleach, vodka, and WD-40) • topical spray (dyes nits bright pink)
• do not restrict children from school due to lice, due to low risk of contagion within classrooms ■
Other management
Follow-up
• confirm treatment success 1-2 days after final application of pediculicide — if moving lice of all sizes present, resistance — if only 1 adult-size louse present, re-infestation • re-treat with different pediculicide if re-infestation occurs within 1 month Causes of treatment failure
• • • • •
misunderstanding/noncompliance instructions inappropriate instructions from product/clinician misdiagnosis inappropriate product used failure to re-treat at recommended interval
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www.ClinicalAdvisor.com • THE CLINICAL ADVISOR • FEBRUARY 2018 51