Pediculosis Background Pediculosis (ie, louse infestation) dates back to prehistory.

The oldest known fossils of louse eggs (ie, nits) are approximately 10,000 years old.[1] Lice have been so ubiquitous that related terms and phrases such as "lousy," "nit-picking," and "going over things with a fine-tooth comb" are part of everyday vocabulary. Louse infestation remains a major problem throughout the world.[2] In the United States, the incidence of pediculosis has risen steadily over the last 3 decades, making the diagnosis and treatment of louse infestation a common task in general medical practice. Head louse infestation among school children has reached epidemic proportions in many parts of the United States. Lice are ectoparasites that live on the body. Lice feed on human blood after piercing the skin and injecting saliva, which causes pruritus. Lice are able to survive away from their human host. However, they will die of starvation within 10 days of removal from their human host. A mature female louse lays 3-6 eggs, also called nits, per day. Nits are white and less than 1 mm long. Nits hatch in 8-10 days, reach maturity in 12-15 days, and live as adults for about 10 days. Different species of lice prefer to feed on certain locations on the body of the host. Louse species include Pediculosis capitis (head lice), Pediculosis corporis (body lice), and Pediculosis pubis or Pthirus pubis (pubic lice, sometimes called crabs). See the louse images below.

The head louse, Pediculus humanus capitis, has an elongated body and narrow anterior mouthparts. Body lice look similar but lay their eggs (nits) on clothing fibers instead of hair fibers.

The pubic louse, Pthirus pubis, is identified by its wide crablike body. Pediculosis spreads from person to person by close physical contact or through fomites (eg, combs, clothes, hats, linens). Overcrowding encourages the spread of lice. The body louse is the vector of typhus, trench fever, and relapsing fever. Human lice have been used as a forensic tool. A mixed DNA profile of 2 hosts can be detectable in bloodmeals of body

lice that have had close contact between an assailant and a victim.[3] This article describes 3 forms of lice: Pediculus humanus capitis (ie, head louse), (2) Pediculus humanus corporis (ie, body louse), and Phthirus pubis (ie, pubic louse). Pathophysiology Louse infestation is prevalent throughout the animal kingdom. Mallophaga, or chewing lice, are common pests of birds and domestic animals. Humans sometimes are affected as accidental hosts. Human lice (P humanus and P pubis) are found in all countries and climates. They belong to the phylum Arthropoda, the class Insecta, the order Phthiraptera, and the suborder Anoplura (known as the sucking lice). Mammals are the hosts for all Anoplura, and, although lice prefer human hosts, P humanus is also known to live and reproduce on pigs. The Anoplura are wingless and have 3 pairs of legs, each ending with a clawlike talus for grasping. The size and shape of the claws are adapted to the texture and shape of the hairs and/or clothing fibers they grasp. Their bodies are flat and covered with tough chitin. Lice are blood-sucking insects. Human lice have small anterior mouthparts with 6 hooklets that aid their attachment to human skin during feeding. The sucking mouthparts retract into the head when the lice are not feeding. In general, lice feed approximately 5 times per day for approximately 35-45 minutes each time. In each species, the female louse is slightly larger than her male counterpart. The life cycle of lice is 30-35 days from egg to adult. Early death is common, resulting from gut rupture during feeding or cementing of the female to the hair shaft during ovipositioning. The 3 types of human lice are the head louse, Pediculus humanus capitis (also known as Pediculus humanus humanus); the body louse, Pediculus humanus corporis; and the crab louse, Pthirus pubis. Body lice infest clothing, laying their eggs on fibers in the fabric seams. Head and pubic lice infest hair, laying their eggs at the base of hair fibers.[4, 5] Head and body lice in particular move freely and quickly, which explains their ease of transmission. Head and body lice are similarly shaped, but the head louse is smaller. Nevertheless, the 2 species can interbreed. The pubic louse or "crab," is morphologically distinct from the other two. Pediculus humanus capitis The head louse (see the image below) is the most common of the 3 species. Most infestations involve 10-20 adult lice. The average length of the head louse is 1-2 mm. The louse is wingless and white to gray and has a long, dorsoventrally flattened, segmented abdomen. It has 3 pairs of clawed legs. Its average life span is 30 days. After incubation of the ova (8-10 d), the nymph molts 3 times before reaching its adult form (8-10 d later).

The head louse, Pediculus humanus capitis, has an elongated body and narrow anterior mouthparts. Body lice look similar but lay their eggs (nits) on clothing fibers instead of hair fibers. The adult female louse lays eggs, called nits, and glues them at the base of the hair shaft (see the image below). Nits are placed within 1-2 mm of the scalp, where the temperature is optimal for incubation. The female head louse lays as many as 10 eggs per 24 hours, usually at night. Egg and glue extrusion onto the hair shaft takes 16 seconds. Nits are typically found at the posterior hairline and postauricular areas.

maturity. On average, 20 adult female lice can be found on a person with an infestation. Pthirus pubis The pubic louse gets the nickname of "crab" from its short, broad body (0.8-1.2 mm) and large front claws, which give it a crablike appearance. The pubic louse is white to gray and oval and has a smaller abdomen than both P humanus capitis and P humanus corporis. The average life cycle of P pubis is also 35 days, although the period from ova to adult (15 days) is slightly longer than that of the other 2 forms. The average female pubic louse lays only 1-2 eggs per day. Their large claws enable pubic lice to grasp the coarser pubic hairs in the groin, perianal, and axillary areas. Heavy infestation with P pubis can also involve the eyelashes, eyebrows, facial hair, axillary hair, and, occasionally, the periphery of the scalp. Pubic lice are less mobile than P humanus and P corporis, mainly resting while attached to human hairs. They cannot survive off the human host for more than 1 day. Nits The average nit (ie, ovum) of the 3 types of lice is 0.8 mm long. The nit (see the images below) attaches to the base of the hair shaft or to fibers of clothing with a strong, highly insoluble cement; thus, nits are very difficult to remove. The nit is topped with a tough but porous cap known as the operculum. This porous sheath allows for gas exchange while the nymph develops in the casing.

Nit from Pediculus humanus capitis on a hair. Nits hatch in about 6-10 days if they are kept near body temperature, and they mature in another 8-9 days. Nits can survive for up to 10 days away from the human host. Cooler temperatures retard both hatching and maturation. The adult head louse survives only 1-2 days away from its host. Head louse infestation is spread by close physical contact and by shared fomites (eg, combs, brushes, hats, scarves, bedding). Lice can be dislodged by combs, towels, and air movement (including hair dryers in either low or high setting).[6] Hair combing and sweater removal may eject adult lice more than 1 meter from infested scalps. Head lice can travel up to 23 cm/min. The head louse is unable to move on smooth surfaces (eg, glass, plastic). Pediculus humanus corporis The body louse is larger than the head louse. Body lice range in size from 2-4 mm; the female lice are larger than the male lice. Like the head louse, the body louse is flat and white to gray with a segmented abdomen. Unlike the head louse and the pubic louse, the body louse does not live on the human body. P humanus corporis prefers cooler temperatures; it lives in human clothing, crawling onto the body only to feed, predominantly at night. Females lay 10-15 eggs per day on the fibers of clothing, mainly close to the seams. The adult female body louse, unlike the head louse, can survive as long as 10 days away from the human body without a blood meal. The life cycle from nit to death is approximately 35 days, with 3 episodes of molting before

Nit on a hair. Note the thin, translucent cement surrounding the hair shaft. Photo courtesy of David Shum, MD, Division of Dermatology, University of Western Ontario.

Nit from Pediculus humanus

capitis on a hair. Two empty nits from Pediculus humanus capitis. Note the open shells still attached to the hairs and the porous operculi through which the lice have hatched. Photo courtesy of David G. Schaus.

The ova require optimum conditions of 30C and 70% humidity to hatch within the average time frame of 8-10 days; the incubation period is longer at lower temperatures. Ova do not hatch at temperatures lower than 22C but can remain alive for as long as 1 month away from the body (ie, on fomites, clothing, brushes). Lice as vectors Evidence exists that shows that some infectious organisms are altered by their arthropod vector and that disease manifestations may be vector specific. For example, bartonellosis spread by a louse has different manifestations from bartonellosis spread by a flea or biting fly. This may explain, in part, the varying syndromes caused by closely related species of Bartonella organisms (eg, acute Oroya fever, Peruvian bacillary angiomatosis, bacillary angiomatosis of AIDS, bacillary peliosis hepatis, catscratch disease, infective endocarditis).[7] Etiology Pediculosis is usually spread by contact with an infested person. Fomites, such as clothing, headgear, combs, and hairbrushes, may play a role in the spread of lice. Risk factors include overcrowding, poor hygiene, debilitated and malnourished individuals, and sexual promiscuity. Causative organisms are P humanus capitis (head louse), P humanus corporis (body louse), and P pubis (pubic louse) P humanus capitis Factors that predispose to head louse infestation include young age; close, crowded living conditions; female sex; white or Asian race; and warm weather. The risk of nosocomial transmission is low, unless close patient-topatient contact (eg, playrooms, institutions) is present. P humanus corporis The risk factors for body louse infestation include close, crowded living situations (eg, crowded buses and trains). Social circumstances in which the washing and/or changing of clothing is not possible are also significant risk factors for body lice infestation. P corporis can be acquired via bedding or clothing recently used by an individual infested with lice; thus, individuals who are homeless, who are impoverished, or who are living in refugee camps are at high risk for infestation. P pubis Risk factors for infestation of the pubic louse also include crowded living conditions. Intimate or sexual contact with an individual who is infested is another common risk factor. Because these organisms are most often spread through close or intimate contact, P pubis infestation is classified as a sexually transmitted disease (STD). Condom use does not prevent transmission of P pubis. Upon diagnosis of pubic lice, concern should be raised about the possibility of concomitant STDs. In children, infestation is usually contracted from a parent who is infested. Sexual transmission to children is rare. In most cases of infestations in children, transmission is due to shared bed linens and close nonsexual contact. Epidemiology Pediculosis tends to be underreported because of the social stigma attachednamely, the preconceived notion that lice of any kind are related to dirt and poor personal hygiene. In fact, personal cleanliness is not a factor in infestation rates.

This stigma facilitates the spread of infestation. Affected families are reluctant to share information with their neighbors. Individual children are treated, but the community fails to address the infestation as a communitywide issue. School-wide and community-wide programs to eradicate lice are necessary to halt their continued spread. United States statistics Pediculosis is extremely common; more than 12 million Americans are infested each year. Head louse infestation is more common in the warmer months, while pubic louse infestation is more common in the cooler months.[8] Head louse infestation is most common in urban areas. Major infestations are seen in all socioeconomic groups. Head louse infestations occur most commonly in schoolaged children, typically in late summer and autumn. The reported prevalence ranges from 10-40% in US schools. One study estimates that 12-24 million days of school are lost because of "no-nit" school policies.[9] Body louse infestation in the United States mainly affects the homeless. Pubic lice generally are spread as a sexually transmitted disease (STD). Pubic louse infestation serves as a marker for other STDs, which may have been acquired simultaneously. International statistics Pediculosis has a worldwide distribution and is endemic in both developing and developed countries. Hundreds of millions of cases of louse infestation are reported annually worldwide, with an apparent increase over the past few decades. In a study of 6,169 Belgian school children aged 2.5-12 years, the prevalence of head lice was 8.9%.[10] The prevalence in 1,569 school children in Izmir, Turkey, was 16.6%.[11] In 2005, the incidence of pediculosis doubled in the Czech Republic.[12] Live lice were detected in 14.1% and dead nits in another 9.8% of 531 children aged 6-15 years in 16 schools.[12] P capitis was found in 9.6% of adolescent schoolboys in Saudi Arabia.[13] In Mali, the prevalence of head lice in children was 4.7%.[14] Among attendees of an STD clinic in South Australia, pubic lice were found in 1.7% of men and 1.1% of women.[15] P corporis is now uncommon in developed countries except among the homeless.[16] Black populations appear somewhat resistant to P humanus capitis infestation, although they may develop scalp infestation by P pubis. The patterns of pubic and body louse infestation throughout the world mimic those in US refugee populations, which commonly have a tremendously high rate of louse infestation. Racial differences in incidence Louse infestation affects all races. However, in North America, the reported incidence of head louse infestation is lower in African Americans than in any other racial group. This is probably due in part to the use of pomades and in part because the claw size of the head louse is more adapted to the round shape of the hair shaft found in white persons and Asian persons.[17] However, blacks may experience scalp infestation by P pubis. Sex- and age-related differences in incidence Girls are at higher risk of head louse infestation than boys because of social behavior (eg, social acceptance of close physical contact; sharing of hats, combs, hair ties); hair length is not a factor. No sexual predilection exists in body

or pubic louse infestation; males and females are equally likely to become infested. Children aged 3-11 years are most likely to become infested with head lice because of close contact in classrooms and day care facilities. Head lice are much less common after puberty. Age is not a significant risk factor in body louse infestation; body lice are indiscriminate in regard to the age of their host. P pubis infestation is more common in people aged 14-40 years who are sexually active. Lice as disease vectors Louse-borne disease is a potential problem whenever body lice spread through a population. Body lice are vectors for Bartonella quintana, an agent of infective endocarditis among the homeless and the cause of many thousands of cases of trench fever and epidemic typhus during World War I.[18] The organism that caused trench fever persists among the homeless in urban areas, spread from person to person by lice. Human reservoirs of typhus also exist in the population. Following natural disasters, body lice have the potential to spread rapidly throughout the population, causing great epidemics similar to those seen during World War I. Prognosis Treatments are highly effective in killing nymphs and mature lice but less effective in killing eggs. Appropriate therapy produces a cure in more than 90% of cases. After proper treatment, children may return to school, provided that repeat therapy is performed in 7-10 days. Causes of therapeutic failure include the following: Misdiagnosis Inappropriate treatment Noncompliance Insufficient application of pediculicide (ie, amount, duration) Lack of ovicidal activity of pediculicide and failure to re-treat in 7-10 days Lack of removal of live nits Lack of environmental eradication Reinfestation Resistance to pediculicide Frequent use of pediculicides may cause persistent itching. Body lice can be vectors for disease such as epidemic typhus and relapsing fever. Violation of the integrity of the skin from a bite can lead to bacterial infection with organisms such as methicillin-resistant Staphylococcus aureus (MRSA). More commonly, infestation with lice produces social embarrassment and isolation rather than medical disease. Patient Education Noncompliance is the most common cause of treatment failure. Therefore, time is well-spent providing patients with detailed instructions regarding the application and timing of medications used in the treatment of lice. Most patients benefit from an understanding of the life cycle of lice and the limitations of medical therapy (eg, medications are incompletely ovicidal). Compliance with retreatment in 7-10 days may be enhanced if patients understand the need for re-treatment to kill newly hatched nymphs. In cases of school-wide infestations, the social stigma associated with infestation must be addressed. Poor hygiene is not a risk factor in acquiring pediculosis capitis.

The community must address the problem honestly and openly, or the infestation will continue. Louse infestation is a community-wide problem. Management must include examination of all individuals exposed (both children and family members) and treatment of all those who are infested. Education has been shown to reduce the number of lice infestations in schools. "No nit" policies exclude many children from the classroom, but they have not been shown to reduce the number of louse infestations.[19] Fomite control is essential. Hats lined up on pegs or placed in adjacent cubbyholes provide an avenue for spread of the infestation. Cubbyholes can be sprayed with a permethrin spray or other insecticide, but the most effective method is for each child to "ground your clothing" (ie, hat, coat, scarves) under each individual chair or desk. Common cloakrooms may suggest an antiquated charm, but they should be viewed as merely antiquated and a site for spread of the infestation. Combs, brushes, and headbands should not be shared. Shaving of hair is effective but not socially acceptable in most societies.[20] Young nits do not have a nervous system and are immune to neurotoxic pediculicides. For patient education information, see the Parasites and Worms Center, as well as Lice and Crabs. History Patients may come to the attention of a health care provider after discovering lice or nits. Parents and teachers typically make the initial diagnosis of head louse infestation. In the case of head lice, a school nurse usually discovers infestation (routine nit inspections by school nurses are standard in many parts of the United States), or a generic letter is sent home to parents indicating that they should inspect their children for lice, and concerned parents bring their children to their health care provider or the local emergency department. Pruritus is the most common symptom of infestation. Children often have trouble sleeping because of intense pruritus at night when lice are feeding. Areas affected in head louse infestation include the scalp, the back of the neck, and postauricular areas. However, lice infestation may be asymptomatic. The duration of the problem is often valuable information because most children are infested with head lice for as long as 2 months before their discovery. Patients infested with P corporis experience nocturnal pruritus, particularly in the axillary, truncal, and groin regions, when the lice move from the clothing to the body to feed. The investigating physician should inquire about the patient's socioeconomic status and living conditions, as body louse infestation generally affects people of low socioeconomic status. Adults infested with P pubis are usually sexually active and have groin and body hair involvement. Involvement with pruritus of the groin, axillae, and eyelashes or eyebrows can help differentiate P pubis infestation from head or body louse infestation. Children have eyelash and eyebrow involvement. Parents of children infested with P pubis should be questioned about being infested because the parents are usually the source of infestation. Patients may describe associated features such as papules or wheals, indicating bite reactions. Patients may have a

history of secondary infection after excoriation, which may help to confirm the presence of an infestation. Physical Examination A diagnosis of any type of pediculosis rests on the observation of eggs (nits), nymphs, or mature lice. Detecting live lice is difficult. Nymphs and mature lice, although unable to hop or jump, can move rapidly through dry hair. Wetting the hair and using a fine-tooth "bugbusting" comb is useful to dislodge eggs and to remove live lice/nymphs. The use of a magnifying glass and knowing where to look for lice (based on the biology of each species) assists diagnosis. Lice move rapidly. A helpful technique is to fasten a piece of transparent adhesive tape to the infested areas. Lice stick to the tape, which then becomes a convenient coverslip for a microscopic slide. Mature lice are 3-4 mm long (approximately the size of a sesame seed), with an elongated body, 3 pairs of legs, and narrow anterior mouthparts. Wide crablike bodies and claws distinguish pubic lice. Nits are approximately 1 mm in length, transparent, and flasklike in appearance. (See images of lice below.)

typically is in the retroauricular scalp. For the diagnosis of P capitis, the use of a louse comb is more efficient than direct visual examination of the scalp.[21] Pruritus commonly leads to excoriation, secondary bacterial infection, and enlargement of the posterior auricular and cervical nodes. A generalized exanthem rarely accompanies louse infestation (pityriasis rosealike pediculid). If excoriations are present, secondary infection (ie, impetigo) should be excluded and treated, if present. Bite reactions manifested as pruritic papules and/or wheals may be present, depending on the length of time since the blood meal. Uncommonly, the hair of patients who are heavily infested and untreated is tangled with exudates, predisposing the area to fungal infection. This results in a malodorous mass known as a plica polonica. Numerous lice and nits are found under the matted hair mass.

Nits

The head louse, Pediculus humanus capitis, has an elongated body and narrow anterior mouthparts. Body lice look similar but lay their eggs (nits) on clothing fibers instead of hair fibers.

pubis,

is

identified

by

its

The pubic louse, Pthirus wide crablike body.

Nit on a hair. Note the thin, translucent cement surrounding the hair shaft. Photo courtesy of David Shum, MD, Division of Dermatology, University of Western Ontario. P humanus capitis Manifestations of head louse infestation include scalp pruritus, occipital lymphadenopathy, and impetigo. Examination of the scalp reveals excoriations, dark specks of louse feces, nits, and adult lice. The heaviest infestation

Nits can be differentiated from dried hairspray and hair casts by attempting to separate the nit from the hair; hair casts and dried hairspray separate easily, while nits remain securely attached. If the physician remains unsure, a Wood lamp examination can be performed. Live nits are fluorescent white when illuminated with a Wood lamp; empty nits are fluorescent gray. Eggs depend on body warmth to incubate, so nits are attached to the hair shafts just above the level of the scalp. Since human scalp hair grows at a rate of approximately 10 mm/mo (0.37 mm/day), the distance of nits from the scalp can be used to estimate the duration of infestation. Nits found several millimeters from the scalp are nonviable empty egg cases. They indicate chronic infestation. P humanus corporis Physical examination findings in body louse infestation include multiple lesions from bites. Uninfected bites present as erythematous papules, 2-4 mm in diameter, with an erythematous base. The development of secondary infections due to excoriations is also possible. Bites may be located anywhere on the body, but they are concentrated in the axillae, groin, and trunk (ie, areas most often covered by clothing). Thus, the face, feet, and arms are not commonly affected. Body lice tend to avoid the scalp, except at the margins. Eyelash nits are a manifestation of pubic louse infestation, not head louse infestation. The finding of maculae cerulea is believed to be pathognomonic for infestation with lice. Maculae cerulea are blue-gray macules, which are actually a discoloration of the skin due to the insect's bite. Enzymes in the louse saliva are believed to cause the breakdown of human bilirubin to biliverdin, causing the change in skin color associated with maculae cerulea. The diagnosis of body lice depends on the close examination of the patient's clothing for lice, nits, and insect feces. The inner seams of clothing worn on the axillae and groin regions are common sites of residence. The number of body lice per host is usually approximately 10, although as many as 1000 lice can be present. Body louse infestation is also known as vagabond disease, and patients who have an infestation for many years can develop a condition termed vagabond skin. The skin

becomes thickened and darkened after years of bites and subsequent rubbing and excoriations. Individuals with P corporis infestation should also be examined for the presence of pubic and head lice. It is also important to examine for systemic illness that may be related to one of the vector-borne diseases associated with P corporis (see Complications, below). P pubis The primary symptom in patients with pubic lice is pruritus in the affected areas. Another clinical feature of pubic louse infestation is the presence of pathognomonic maculae cerulea secondary to bites. Pubic hair is the most common site. Pubic lice and nits generally are plainly visible throughout the pubic hair. Because of the less-mobile nature of pubic lice, they are more likely to be found on affected areas clasping onto the hairs near the skin's surface. Involvement may spread to hair around the anus, abdomen, axillae, chest, and eyebrows and eyelashes. Rarely, facial hair is a site of infestation. Scalp involvement is rare and is usually confined to the marginal areas. In adults, eyelash involvement in the absence of genital involvement is rare. In prepubertal children, however, eyebrows and eyelashes are common sites of infestation. In children, P pubis infestation is usually acquired from an infested parent and is rarely the consequence of sexual abuse; however, P pubis infestation may be acquired secondary to sexual abuse, and the child should be examined for signs of abuse. Excoriations are common. Inguinal lymphadenopathy and axillary lymphadenopathy have also been reported with pubic louse infestation. Complications There is no evidence indicating that any species of louse has the ability to transmit HIV. However, lice may carry Staphylococcus aureus and group A Streptococcus pyogenes on their surface and transmit these coagulasepositive pathogens to humans. The body louse, P humanus corporis, is a known vector of 3 major bacterial diseases, all of which have caused epidemics: typhus, trench fever, and relapsing fever. Typhus The intracellular pathogen Rickettsia prowazekii causes typhus. Typhus fever epidemics have consistently been related to times when overcrowded conditions and body louse infestations were prevalent. For example, mass migration, refugee camps, and times of war have been linked to body louse infestations and secondary epidemics of typhus. The illness begins with a high fever and progresses over hours to days with malaise, backache, headache, and myalgia. A petechial rash appears approximately on day 4, beginning in the flank and axillary regions and quickly spreading to the trunk and extremities. By the second week, the fever begins to wane, profuse sweating occurs, and convalescence ensues. CNS involvement during this period places the patient at high risk of mortality. Trench fever The extracellular pathogen Bartonella quintana causes trench fever. Although rarely fatal, this disease has been the cause of many epidemics and is believed to be related to bacterial infective endocarditis. Infection in humans

results from autoinoculation of louse feces into abraded or scratched skin. The infection has a 10- to 30-day latency period and results in a fever similar to that of typhus, with headache, myalgia, and pain in the back and the legs. Relapsing fever The spirochete Borrelia recurrentis causes relapsing fever. This disease is highly fatal in malnourished persons. Although not common in North America, epidemics have been described during the last few decades in Asia, South America, Africa, and Europe. Human infection with this spirochete occurs only when a crushed louse comes into contact with an abrasion. The bacteria replicate in the louse hemolymph, not in the gut; therefore, no transmission occurs through the salivary glands or via the feces. The bacterial infection causes a high fever, headache, dizziness, and myalgia. Rash and sweating also appear and wane approximately on day 5. As the name indicates, this fever often returns several times. Diagnostic Considerations True nit infestation must be distinguished from hair casts (pseudonits). Hair casts are ringlike remnants of the inner root sheath of the hair follicle. They are amorphous and freely moveable along the hair fiber. Many scalp conditions can cause pruritus. Seborrheic dermatitis presents as erythema and scale. It affects the scalp, eyebrows, nasolabial folds, and central chest. Acne necrotica presents with folliculitis with superficial pustules within scattered hair follicles. It is extremely pruritic, and patients pick at the lesions. Secondary follicular excoriations typically are noted on examination. Free-living primitive psocid lice feed on decaying matter in leaves, old books, and animal habitats. They may cause human scalp infestation when children visit a library or doghouse that is infested. Psocids have large heads with massive jaws and are distinguished easily from Anoplura lice. Other problems to be considered in the differential diagnosis of head louse infestation include the following: Dandruff Dried hairspray/gel Dermatophyte infection Piedra (black piedra from Piedraia hortae, white piedra from Trichosporon asahii and other species of Trichosporon) Hair shaft abnormalities (ie, Monilethrix, trichorrhexis nodosa) Other problems to be considered in the differential diagnosis of body louse infestation include the following: Folliculitis Insect Bites Scabies Acne Delusions of parasitosis Xerosis with excoriations Impetigo Postinflammatory hyperpigmentation Other problems to be considered in the differential diagnosis of pubic louse infestation include the following: Dermatophyte infection Folliculitis Delusions of parasitosis Contact dermatitis

 Conjunctivitis (if eyelash involvement) Approach Considerations Because the diagnosis of infestation requires identification of a live louse and/or a viable nit, examining suggestive particles under the microscope confirms the diagnosis. Cellulose tape can be applied over an infested area to pick up lice and place them on a microscopic slide to be examined. A Wood lamp examination of the area considered to be infested shows yellow-green fluorescence of lice and nits. Dermoscopy can be used to reliably differentiate nymph-containing eggs from empty cases or pseudonits.[22] Infestation with Pediculus pubis is a sexually transmitted disease (STD), and 30% of these patients have an addition STD. Thus, it is appropriate to screen these patients for other STDs, including human immunodeficiency virus (HIV), syphilis, gonorrhea, chlamydia, genital herpes, and trichomoniasis. Scrapings for a fungal culture can be collected if dermatophyte infection is in the differential diagnosis. This is useful when the diagnosis is unclear (ie, no nits or lice have been identified). Properly evaluating persons who have been raped is essential. Evidence should be collected in such a way as to avoid contamination and to ensure a legal chain of custody. Human DNA can now be identified in the amount of blood present in a pubic louse. Lice recovered after an attack have the potential to provide evidence valuable in securing a conviction. Histology is rarely required for diagnosis. Examination of a bite shows intradermal hemorrhage and a deep, wedgeshaped infiltrate with many eosinophils and lymphocytes. Louse bites demonstrate intradermal hemorrhage and a polymorphous wedge-shaped infiltrate rich in eosinophils. Approach Considerations Treatment of pediculosis has 2 aspects: medication and environmental control measures. Consider providing medical treatment to all persons who have contact with infested patients, especially sexual partners. Increasing emphasis is being placed on understanding the life cycle of lice in order to treat effectively. Not all treatment preparations are ovicidal. Therefore, repeat treatment may need to be performed to kill the newly hatched eggs not affected by the initial treatment. It is extremely important to use medications as directed to ensure total eradication of the lice through their life cycle. In the treatment of body lice, medications are less essential than environmental measures. Many infectious disease authorities recommend only environmental measures to treat body lice. Patients with body lice should have infested clothing removed and destroyed. Related clinical guideline summaries include the following: British Association for Sexual Health and HIV United Kingdom national guideline on the management of phthirus pubis infestation[23] Centers for Disease Control and Prevention Ectoparasitic infections. Sexually transmitted diseases treatment guidelines 2006[24] University of Texas, School of Nursing, Family Nurse Practitioner Program - Guidelines for the diagnosis and treatment of pediculosis capitis (head lice) in children and adults 2008[25] Pesticides

A variety of topical pediculicidal agents are available for treatment of head and pubic lice. Pyrethrin shampoos and permethrin 1% rinse are available over the counter; permethrin 5%, malathion, lindane, ivermectin topical, and spinosad are prescription agents. Permethrin appears to have a wide margin of safety, although some data suggest a possible connection between insecticides and leukemia.[26, 27] Malathion has proved to be more ovicidal than permethrin and has a higher lethal effect and decreased frequency of reinfestation, if used properly. Lindane may not be suitable for use in patients with a defective cutaneous barrier. Seizures may result from abnormal absorption or gross overuse of the product. Many authors recommend that it not be used as a first-line therapy. Spinosad was approved the US Food and Drug Administration (FDA) in 2011 for the treatment of head louse infestation in patients aged 4 years and older. The product is applied to dry hair as a cream rinse, left in for 10 minutes, and then shampooed out. Spinosad has ovicidal activity; consequently, no combing to remove nits is necessary.[28] In February 2012, topical ivermectin (Sklice) was approved in the United States as a single-dose, 10-minute application without the need for nit combing. Oral Agents Oral anthelmintics, including ivermectin, levamisole, and albendazole,[29] have been found to be effective against head louse infestation. Administration should be repeated in 7-10 days to kill lice emerging from nits that may have survived the first treatment. Trimethoprimsulfamethoxazole was initially reported to be effective; however, controlled studies have shown only minimal eradication. Resistance Resistance of lice to the most commonly used medications for treatment of infestation (permethrin and pyrethrin) is increasing.[30, 31, 32, 33] Resistance has been reported in the United States as well as countries in South America and Europe A possible mechanism of resistance development includes mutations of target enzymes (eg, acetylcholinesterase) so that the enzymes no longer bind the organophosphate permethrin with the same affinity. Another possible mechanism is increasing the metabolism of the insecticides through an increase in monooxygenase enzyme activity, turning them into harmless compounds before they can cause damage.[34, 35, 36, 37] In the United States, malathion retains the best efficacy among chemical pediculicides.[38] Resistance to malathion is now starting to be reported in the United Kingdom, but it has not been reported in the United States. This may be due to the difference in preparations: the US formulation of malathion is coupled with isopropyl alcohol and terpineol, whereas the UK formulation contains malathion only. It is becoming evident that alternative medications or treatments will likely be needed to continue to treat lice effectively. New research incorporating treatment with ivermectin and trimethoprim-sulfamethoxazole is under way and may eventually show some promise for future treatment preparations.[39]

Note that, at this time, ivermectin use for treatment of lice is off label, as traditionally, ivermectin is used for treatment of helminthic infections and onchocerciasis. Reports suggest the possibility of neurotoxicity from ivermectin in a population of nursing home patients treated for scabies.[40, 41, 42, 43, 44] Treatment for Head Louse Infestation Medicated lotions or shampoos may be used to eliminate head lice. Infested family members and sexual partners should also be treated. Re-treatment after a time interval of 7-10 days is recommended with many agents, to eradicate any lice that hatched from nits after the initial treatment. In addition, careful combing and removal of all nits from the hair as well as cleaning of other articles (ie, hair accessories, towels, bedding, clothing) are essential steps to prevent reinfestation. Some families may choose to enlist the help of a trained professional. A"lice nurse" can often be found who will come to the home, evaluate the family members, remove lice and nits from hair, and provide education and lice combs. This service may allow faster return to school and useful counseling. Mechanical removal and shaving Mechanical removal of nits with fine-tooth combs is a valuable adjunct to pediculicidal treatment. Nit combs are provided with many pediculicidal products. Metal nit combs (eg, LiceMeister) are sturdier and more effective and can be purchased over the Internet. Wet combing is preferable. Soaking the hair in a solution of equal parts water and white vinegar and then wrapping the wet scalp in a towel for at least 15 minutes may facilitate removal. Commercial products include an 8% formic acid preparation (GenDerm Step 2) and an enzymatic nit remover (Clear). The major action of each of these products, however, may be to make combing easier. Little evidence indicates that they actually dissolve the nit sheath that attaches the nit to the hair shaft. In fact, the composition of the nit sheath is similar to that of human hair, so agents designed to unravel the nit sheath may also damage hair.[45] Most studies have shown that mechanical removal alone (ie, wet-combing every 2-3 days for a minimum of 2 weeks) is not as effective as mechanical removal combined with a pediculicide.[46] Proper treatment with medication is advised. Shaving is effective but is usually not necessary or socially acceptable. However, in resistant disease, it may be a consideration. Occlusive therapy Agents that work by clogging the respiratory spiracles of lice offer an alternative to neurotoxic pediculicides.[47, 48] This is the mechanism of action of benzyl alcohol lotion 5% (Ulesfia), which is approved by the FDA for treatment of head lice in patients 6 months of age and older; the benzyl alcohol inhibits lice from closing their respiratory spiracles, allowing the lotion to obstruct the spiracles. The lotion is given in 2 applications 1 week apart for 10 minutes; it needs to be applied twice because it kills lice only, not nits. Benzyl alcohol lotion may be an easier and safer alternative to lindane and malathion. Because its mechanism of action is physical rather than chemical, development of resistance should not be a concern.

In clinical studies, more than 75% of those treated with benzyl alcohol lotion became lice-free.[49] As with all treatments used to eliminate live lice, careful combing and removal of all nits from the hair, as well as cleaning of other articles (ie, hair accessories, towels, bedding, clothing), are essential steps to prevent reinfestation. One study reported efficacy of 4% dimeticone lotion (a silicone-based lotion believed to disrupt the louse's ability to manage water).[50] Another study found that 4% dimeticone lotion was a significantly more effective treatment compared with malathion for most people.[51] An over-the-counter lotion containing dimethicone (LiceMD) provides lubrication that eases the use of a lice comb. Other occlusive therapy techniques, such as vinegar, mayonnaise, petroleum jelly, olive oil, butter, isopropyl alcohol, and water submersion as long as 6 hours, have been advocated, but most have not been scientifically evaluated. However, a dry-on, suffocation-based pediculicide (DSP) lotion was found to be effective in open trials.[47] Various botanical agents have been used. Essential oils demonstrate variable efficacy and may be contact allergens.[52] In general, the evidence supporting their efficacy is of poor quality.[50, 53] Monoterpenoids are promising agents.[50, 54, 55] Environmental eradication Treatment of the patient environment (control measures) is important. Reinfestation occurs if the problem is not addressed on a school-wide and community-wide basis. Any object that the infested child or parent has come into contact with should be considered a potential fomite. It may be beneficial to launder potential fomites (eg, towels, pillowcases, sheets, hats, toys) in hot water, followed by machine drying using the hottest cycle. Temperatures exceeding 131 F (55 C) for more than 5 minutes kill eggs, nymphs, and mature lice. Items that are not machine washable may be placed in a dryer at high heat for 30 minutes. Dry cleaning may be an effective alternative. Because adult lice cannot survive for long if separated from a host and because eggs hatch in 6-10 days and will die without a blood meal, carefully sealing potential fomites in plastic bags for 2 weeks can be effective. This technique works well for objects, such as stuffed animals, that do not tolerate laundering or dry cleaning. Vacuuming selected areas of the home, such as couches used by infested patients, is recommended by some as an adjunctive control measure. Combs and hair brushes should be discarded. Alternatively, they can be treated by soaking for longer than 5 minutes in very hot water (>131F, or 55C) or treated with pediculicides. Chemical insecticide sprays used in the home environment have not been shown to be effective in the control of head lice. Providing education to children about the sharing of hats, combs, and hair-ties is also a good idea. Giving children separate areas to store their belongings in the classroom may help prevent the spread of lice. Treatment of Pubic Louse Infestation The same pediculicides used for head louse infestation are also used for pubic louse infestation. In addition, P pubis infestations of the eyelashes are treated with occlusive therapies.

Petrolatum (twice daily for 7-10 days) is often used, with good results, as an asphyxiant for eyelash infestation. The petrolatum covers the lice and their nits, preventing respiration. The dead lice are removed mechanically, usually with tweezers. Mercuric oxide ointment is also useful in the treatment of eyelash infestation with P pubis. Fluorescein dye strips, which are used in the diagnosis of corneal abrasions, may be used in combination with white petrolatum. The strips are applied to the eyelashes for 3 nights. Treatment of Body Louse Infestation Use of a pediculicide is usually unnecessary with P humanus corporis infestation because the louse lives on the clothing. Treatment of clothing and bed linens includes laundering in hot water, ironing with a hot iron, or drying in a hot dryer. Dry cleaning is also effective for killing lice and their nits on clothing. Education about hygiene and accessibility to laundering facilities are important in preventing the spread of body lice and reinfestation.[56] Topical agents should be applied to clothing, especially the seams. Published data suggest that permethrin spray can help prevent body louse reinfestation. In cases of heavy pediculosis, treatment of the body with a pediculicide shampoo or lotion may be beneficial, especially if the patient also has confirmed or suspected concomitant head or pubic louse infestation. Oral ivermectin 12 mg given as 3 doses 7 days apart has also been shown to be effective in a cohort of homeless men.[15] None of these agents currently is labeled or marketed for treatment of body lice in the United States. In some cultures, monkeys are used as patient nit pickers to groom the hair and to remove adult lice and nits. Treatment of Contacts The treatment of family members, friends, and/or other close contacts is important in helping to prevent further spread of lice and in preventing reinfestation. Patient education regarding treatment of contacts is essential. Parents with children who are infested should be advised to treat all infested family members with a pediculicide and to provide environmental fomite control. Education about hygiene and accessibility to laundering facilities are important in preventing the spread of body lice and reinfestation.[56] Deterrence and Prevention To prevent reinfestation, all household members and contacts of a patient should be examined and treated at the same time if infested. Launder bedlinens and other clothes at the same time as treatment with medication. Washing combs, brushes, and other fomites reduces reinfestation. Do not allow children to exchange or use another child's hat, comb, or brush. Some parents choose to extend this prohibition to use of "common" headwear such as is available in the dress-up area of various play spaces or public libraries. Once an infestation has been identified and treated, ongoing vigilance with close, direct visualization of hair and scalp at periodic intervals is recommended. Sensitivity may be enhanced by use of a lice-specific comb. Medication Summary

The goal of therapy is to eliminate lice and eggs. Chemical pediculicides are the mainstay of pharmacotherapy. Treatment should be repeated in 7-10 days (the time needed for the eggs to hatch) because nits are less effectively killed than adults. Eyelash infestation can be treated effectively with petrolatum ointment (eg, Vaseline) or mercuric oxide. Antiparasitic Agents Class Summary Treatment options include malathion, permethrin cream, pyrethrins, and spinosad. For treatment failures, ivermectingiven orally in doses 1 week apartmay be used in the nonpregnant or non-breastfeeding woman and in children weighing more than 15 kg. Parasite biochemical pathways are different from the human host; thus, toxicity is directed to the parasite, egg, or larva. Mechanism of action varies within the drug class. Antiparasitic actions may include the following: Inhibition of microtubules causing irreversible block of glucose uptake Tubulin polymerization inhibition Depolarizing neuromuscular blockade Cholinesterase inhibition Increased cell membrane permeability, resulting in intracellular calcium loss Vacuolization of the schistosome tegument Increased cell membrane permeability to chloride ions via chloride channels alteration Resistance to pediculicides has increased over recent years. Therapeutic agents can be rotated to slow the emergence of resistance. Benzyl alcohol lotion needs to be applied twice, but it might be an easier and safer alternative to lindane and malathion. With all treatments that are used to eliminate live lice, careful combing and removal of all nits from the hair as well as cleaning of other articles (ie, hair accessories, towels, bedding, clothing) are essential steps to prevent reinfestation. View full drug information Permethrin (Nix, A200 Lice, Rid) Permethrin is the drug of choice recommended by most authorities as the first line of treatment in head, pubic, and severe body louse infestation, especially for infants older than 2 months and small children. This agent is a neurotoxin that causes paralysis and death in ectoparasites. It is more effective than crotamiton in treating symptoms and reducing the chances of secondary bacterial infection. One benefit of permethrin is a residual effect in the hair for several hair wash cycles. Resistance probably has developed in many areas, however. Physicians in some countries select different pediculicides on a rotating basis to discourage development of resistance. Permethrin is very effective in killing adult lice and nymphs but is not as effective in killing nits (eggs). A fine-toothed comb is an important adjunct to remove nits. Patients should wash hair with a nonmedicated shampoo. An over-the-counter (OTC) 1% concentration (Nix) may be insufficient for treatment of pubic lice and for some cases of head lice. The 5% prescription preparation marketed for scabies (Elimite) may be more effective in some cases. Strict adherence to the treatment regimen is essential.

Pyrethrins and piperonyl butoxide (RID Maximum Strength, Pronto, R&C, A200 Maximum Strength) Pyrethrins are first-line treatment in head, pubic, and severe body louse infestation. These agents stimulate the parasitic nervous system, causing seizures and death of parasites. This is an older OTC agent that still appears to be effective. It lacks the residual action of permethrin and is more likely to require repeated applications. Pyrethrin products are contraindicated for patients with contact allergy to ragweed, turpentine, or chrysanthemums View full drug information Malathion (Ovide) Malathion is approved by the FDA for the treatment of head lice. It is an irreversible cholinesterase inhibitor that is hydrolyzed and therefore detoxified rapidly by mammals but not by insects; it is both ovicidal and pediculicidal. It binds to hair and provides some residual protection after therapy. Malathion is available as 0.5% and 1% aqueousbased lotions. View full drug information Ivermectin topical (Sklice) Topical ivermectin causes parasite death by selective, highaffinity binding to glutamate-gated chloride channels located in invertebrate nerve and muscle cells. It is a topical pediculicide that treats head lice with a single 10minute application without nit combing in adults and children aged 6 months or older. View full drug information Ivermectin (Stromectol) Ivermectin binds selectively with glutamate-gated chloride ion channels in invertebrate nerve and muscle cells, causing cell death. Its half-life is 16 hours; it is metabolized in the liver. Ivermectin is the drug of choice for onchocerciasis and strongyloidiasis; it has been shown to be effective against pediculosis and has been used in mass epidemics. It is not effective against nits. Few serious adverse effects have been reported when ivermectin is used to treat lice or scabies. This agent is not associated with evidence of selective fetotoxicity in pregnant women inadvertently exposed (based on limited data). Limited animal data also fail to show evidence of selective fetotoxicity. Ivermectin is available in the United States as an oral 6-mg pill marketed for treatment of Strongyloides. Physicians have used this drug for lice and scabies (off-label use) in cases where such therapy was in the best interest of patients and conventional therapy failed. Health care providers in the United States are encouraged to read the FDA statement concerning off-label use of approved drugs, which appears in the Physicians' Drug Reference. View full drug information Lindane Lindane stimulates the nervous system of parasites, causing seizures and death. It is a chlorinated insecticide available as 1% lotion, cream, and shampoo. It is a second-line treatment if other agents fail or are not tolerated.

Lindane is not very safe in children because of transcutaneous absorption that leads to neurotoxicity. In March 2003, the FDA issued a public health advisory warning of increased risk of adverse effects of lindane treatment in persons who are young, small, or elderly. Heightened caution should be exercised if lindane is used in such patients. Overall, permethrin is a safer choice. View full drug information Isopropyl myristate (Resultz) Isopropyl myristate is not available in the United States (it is currently in phase III clinical trials), but it is available in Canada and Europe. It is a non-insecticide-based drug containing isopropyl myristate, an ingredient commonly used in cosmetics. Its mode of action is a mechanical process that weakens the waxy shell of lice, resulting in internal fluid loss and dehydration. View full drug information Benzyl alcohol (Ulesfia, Zilactin) Benzyl alcohol inhibits lice from closing their respiratory spiracles, allowing the lotion to obstruct the spiracles, which ultimately results in asphyxiation. It does not elicit ovicidal activity. This product contains 5% benzyl alcohol. View full drug information Spinosad (Natroba) Spinosad causes neuronal excitation in insects, followed by hyperexcitation, paralysis, and death. It is a pediculicide indicated for topical treatment of head lice infestations. This agent is available as a 0.9% suspension.