Treatment of Head Lice in Children

First-Line Treatment

The American Academy of Pediatrics recommends permethrin 1% cream rinse as the first-line treatment for head lice in children, applied to damp hair for exactly 10 minutes, then rinsed off, with a mandatory second application 7-10 days later 1, 2
Permethrin 1% cream rinse should be applied to damp, towel-dried hair, not soaking wet, and rinsed off with warm water after 10 minutes 1, 2
The treatment has a low mammalian toxicity and does not cause allergic reactions in patients with plant allergies 3

Pyrethrins with piperonyl butoxide can be used as an alternative first-line treatment, applied to dry hair for 10 minutes, then rinsed, and requires a second application in 7-10 days 3
Malathion 0.5% can be used as a second-line treatment, applied to dry hair, allowed to air dry naturally, then washed off after 8-12 hours, and has the highest ovicidal activity of all treatments 1, 3, 4

Malathion 0.5% contains 78% isopropyl alcohol, making it highly flammable, and should not be used near open flames or sparks 1, 4
Lindane 1% should not be used as a first-line treatment due to severe safety concerns, including the risk of seizures in children 1, 3, 4

Only treat individuals with live lice or nits within 1 cm of the scalp, and treat family members who share a bed with the infected person 1, 2, 3
Nit removal is not necessary to prevent spread, but can help decrease diagnostic confusion, and can be done using a fine-tooth nit comb and vinegar or vinegar-based products 1, 3

Wash all clothing, bedding, and linens in hot water and dry on hot cycle on the same day as treatment, and wash hair care items in hot water 2
Remove items that cannot be washed from body contact for at least 72 hours, as lice cannot survive off the human body for more than 2-3 days 2

Post-treatment itching is not a sign of treatment failure, and should not be treated with additional medication unless live lice are seen 7-10 days after treatment 1, 2, 3
Most "resistance" to treatment is actually due to improper application, and before assuming resistance, consider misdiagnosis, noncompliance, reinfestation, or improper application technique 1, 2, 3