▶Pediculicides are the treatment of choice and include
■Permethrin 1% cream rinse, available over the counter; first-line therapy; applied to hair that has been shampooed and towel dried; left on for 10 minutes and then rinsed; repeat treatment in 7 to 10 days; approved in infants 2 months and older.
■Synergized pyrethrins (pyrethrin + piperonyl butoxide), available in a variety of over-the-counter products; applied to dry hair; also used for 10 minutes; repeat treatment in 7 to 10 days; should not be used in individuals with allergy to chrysanthemums; approved in children 2 years and older.
■Malathion 0.5% lotion, available by prescription; applied to dry hair and rinsed in 8 to 12 hours; repeat therapy in 7 to 10 days if needed; approved in children 6 years and older (some endorse use down to 2 years of age); product is flammable.
■Spinosad 0.9% suspension, a fermentation product of the soil bacterium Saccharopolyspora spinosa; applied to dry hair and rinsed in 10 minutes; repeat therapy in 7 days if needed; approved in infants 6 months and older.
■Ivermectin 0.5% lotion; applied to dry hair and rinsed in 10 minutes; approved in infants 6 months and older.
■Abametapir 0.74% lotion received approval (for infants 6 months and older) but at the time of this writing is not yet available in the United States; applied to dry hair and rinsed in 10 minutes.
■Lindane 1% lotion is not recommended by the American Academy of Pediatrics (AAP) or the Centers for Disease Control and Prevention given concerns over neurotoxicity.
▶Repeat topical therapy (7–10 days after the initial treatment) is usually recommended to ensure killing of any eggs that hatch after first treatment but may vary by product (see earlier list).
▶Oral ivermectin (200 or 400 mcg/kg single dose) has been used off-label for children older than 2 years who weigh 15 kg or more with resistant disease; it is typically repeated in 9 to 10 days.
▶Alternative off-label therapies include trimethoprim-sulfamethoxazole and “suffocation” therapies (eg, petroleum jelly, mayonnaise, olive oil); problem with latter is ability of human head louse to close respiratory spiracles temporarily, reopening them after removal of the occlusive agent.
▶Before pediculicidal resistance is suggested, consider other causes of therapeutic failure, like misdiagnosis, repeat infestation, or treatment noncompliance.
▶Manual removal of lice and nits with nit combing of wet hair is possible for those who prefer not to use a pediculicide.
▶There now exist multiple lice-removal salons that offer manual nit removal and non-pediculicidal topical therapies; some also offer hot-air therapy.
▶Close contacts should be examined and treated (if necessary), and bedding and clothing should be machine washed and dried on a high-heat setting. Necessary shared headgear (eg, batting helmets, computer headphones) can be wiped with a damp cloth between uses.
▶“No-nit” policies, which prevent children with nits from attending child care or school, are not effective and can lead to academic and social struggles for children. The AAP recommends against no-nit policies and discourages routine classroom or school-wide screening for lice. No healthy child should be excluded from or allowed to miss schooltime because of head lice.
