Head Lice Management

Diagnosis and Exclusion

No healthy child should be excluded from or allowed to miss school time because of head lice, and "no-nit" policies for return to school should be abandoned, as recommended by the American Academy of Pediatrics (AAP) 1
Children can return to school immediately after appropriate treatment has been initiated, as the presence of nits alone is not a reason to exclude a child from school, according to the AAP 1

The AAP recommends 1% permethrin cream rinse or pyrethrins (unless resistance is proven in the community) as a treatment option, which requires a second application 7-10 days after the first treatment to kill newly hatched lice 1
Benzyl alcohol 5% is also recommended as a treatment option for children ≥6 months old, as per the AAP 1
Wet-combing or occlusive methods (petroleum jelly, Cetaphil) are additional treatment options, according to the AAP 1
Alternative treatment options include:
Pregnant and breastfeeding women should be treated with permethrin or pyrethrins with piperonyl butoxide, as recommended by the Centers for Disease Control and Prevention (CDC) 3
Children under 2 years should not be treated with lindane, and malathion should be avoided in children under 24 months, as recommended by the CDC and the AAP 3, 1
Ivermectin should be avoided in children weighing less than 15 kg, as recommended by the AAP 1

Machine washing clothing, bedding, and towels in hot water and drying on high heat cycle for at least 20 minutes can help prevent re-infestation, as recommended by the CDC 2
Soaking combs and brushes in hot water (>130°F) for 5-10 minutes can also help prevent re-infestation, according to the CDC 2
Items that cannot be washed should be removed from body contact for at least 72 hours, as recommended by the CDC 2
Drying items using the hottest setting for at least 20 minutes can also help decontaminate them, as recommended by the AAP 1
Children should be educated to avoid head-to-head contact with others, and parents should discourage sharing of personal items like combs, brushes, and hats, with regular examination using a louse comb and checking the child's head before and after sleepovers, as recommended by the AAP 1
Regular examination using a louse comb and machine washing clothing, hats, scarves, and bedding in hot water can help prevent future infestations, as recommended by the AAP and the CDC 1, 3

Failure to complete a second treatment can lead to ineffective management, as most products are not completely ovicidal, and a second application is essential, according to the AAP 1
The CDC and the AAP recommend re-treating with permethrin 1% cream rinse 7-10 days after the first treatment to kill newly hatched lice 1, 4
If not responding to initial treatment, retreat with an alternative regimen, as suggested by the CDC 3
Patients should be evaluated after 1 week if symptoms persist, and re-treating if live lice are found, with consideration of switching to an alternative regimen if initial treatment fails despite correct application, as recommended by the CDC 2

Possible adverse effects of permethrin treatment include pruritus (itching), erythema (redness), and edema, which may persist for days after treatment but are not reasons for re-treatment, as reported by the AAP 1
Topical corticosteroids and oral antihistamines may provide relief for itching or mild burning of the scalp, as recommended by the AAP 1