Head Lice

Diagnosis of Head Lice

This small human parasite is an extremely common cause of outbreaks in schools and daycares; some experts say 1 out of every 4 school age child will get lice. Infestation with head lice is common in young children and does not imply a problem with hygiene or health of the child or family. Diagnosis is based on finding a live louse on the head or neck. The insects are very small (1/16th inch), move quickly and are difficult to find; they prefer to hide in hair at the neck or behind the ears. Finding many nits (lice eggs) and itching can be suggestive of infestation. The lice lay their nits on the lower part of the hair shaft – within ¼ inch of the scalp – so that they stay warm to hatch. Nits found further out on the hair shaft can be old and not suggestive of an active infection. Nits feel firm and are difficult to pull off. Dandruff, dirt and lint can be confused with nits but these should easily fall off the hair with gentle motion.

For pictures of lice and nits, please refer to the link to the Centers for Disease Control page on head lice below.

If you have concern for an infestation in your child, purchasing a fine-toothed nit comb is recommended. Combing through wet hair, in small 1 inch sections, starting at the scalp to roots with the nit comb may capture lice or remove nits. After combing each section of hair wipe the comb on a towel or rinse in a sink of water to look for dislodged insects or eggs. If your child is in a classroom with an active outbreak, doing this daily or every other day will ensure you catch this infestation early. Some experts recommended weekly combing throughout the school year in young children as an effective means of prevention.

When do I need to treat for lice?

If you find live lice on your child’s head they should stay out of school until you have used a treatment shampoo/cream (see below). Finding only nits is not a reason to keep your child home but is a reason to follow the combing procedure below and to continue to monitor your child closely for live insects. Finding many nits, close to the scalp, especially in clusters is likely an infestation and could warrant full treatment as well.

Treatment of Head Lice

There are three mainstays of thorough, effective treatment which we will go over in order. Many of the questions parents ask us about lice should be answered below. There is a lot of misinformation that parents hear through word of mouth or find on the internet. Following the instructions below should help address these concerns or we ask you to call our office during office hours to speak to one of our very experienced staff members. The link to the Centers for Disease Control information page also has very thorough, accurate information.

  1. Use of Treatment Shampoos/Creams = Pediculicides – i.e. – NIX or RID:

    The use of FDA approved, non-toxic lice shampoos and creams – which are pediculocides – is the main treatment to kill/injure the live insects with some benefit in injuring the nits. These products are extremely safe and well-tolerated and very effective; please call us for use in infants under age 2 years. Resistance to these products is not a wide-spread problem in our metro-Atlanta area. The majority of times when parents feel these products don’t work, we find that either the nits were not carefully removed and then hatched or the child returned to a classroom where another child still had live lice.

    • NIX is the most effective over-the-counter product. Please follow the directions on the package carefully. Follow the information below about the importance of insect and nit removal by combing. This product should be repeated in 7-10 days as it will not kill all eggs which may then hatch. However, if you are very diligent about daily nit combing and see no new live insects, this step may be avoided.
    • If you still see live, active insects 8-12 hours after using a treatment shampoo/cream then your lice may be resistant. Very slow moving, sluggish lice are in the process of dying and this means your product is working properly. These insects need to be removed as below. Please call our office during regular hours if you are concerned about resistance as we can prescribe another product.
  2. Combing for Nit and Louse removal:

    This step is very important to prevent a repeat infestation and from spreading lice to others. Careful combing to remove all insects and nits takes a lot of patience and up to 30 minutes of time depending on your child’s hair length and thickness. Use of Minecraft is highly recommended!

    • Careful combing with a fine-toothed nit comb should be done immediately after use of a treatment product. Comb daily for several days then every few days for 1-2 weeks until all evidence of nits and lice are gone.
    • Combing wet hair is best; use of a conditioner can make it easier but can also make it harder to grab a nit off the hair shaft.
    • Divide the hair into 1 inch sections and do a section at a time until the entire hair and scalp has been examined/combed.
    • If your comb does not knock the nit loose, comb backwards toward the scalp starting 1 inch away from the scalp - this will loosen the nit’s attachment. Then continue to comb forward to remove the nit from hair.
    • After combing each section of hair wipe your comb on a towel or rinse in a bowl of water to remove attached lice and nits.

    Note on Lice Salons (“Lice Ladies”) – These very popular businesses have a great success record with lice treatment because of the time and care they spend on this combing and nit removal process. The cost of this can be quite high, and the process can be done at home as above just as well – again, with giving yourself enough time and having enough patience.

    Note on non-FDA approved products or home remedies – We encourage you to call our office before you try other products as many have no proven efficacy. Suffocating the lice with Vaseline or mayonnaise may not work because they can “hold their breath” for a long time. Use of any flammable product (i.e. – kerosene or gasoline) is extremely dangerous and not recommended.
  3. Cleaning of personal items:

    Extensive household cleaning is not necessary with lice as the insects prefer to stay on the body and cannot survive off the scalp for more than 2-3 days. Items with direct contact to the head in the last 2 days – especially bedding, towels, hats and recently worn clothes – need to be washed in hot water with high heat dryer. Combs and brushes should be soaked for 10 minutes in a solution of rubbing alcohol or Lysol cleaner. Routine vacuuming is sufficient as nits and lice are unlikely to land far from the scalp and die quickly. For soft items that cannot be washed – hats, stuffed animals or toy – seal in a garbage bag for 2 weeks (nits hatch in 7-8 days and then the lice die in 2 days). Use of over-the-counter pediculicide sprays (including NIX spray) have not be shown to be effective.

Household and Close Contacts

Lice spread by crawling (they cannot jump or fly). The most at-risk people are ones who sleep with or have other close contact with a person with known lice. If you do not see lice on a close contact, daily or weekly combing to check for lice and nits is the best method. You do not have to use a treatment shampoo/cream unless you see live lice or many nits which are close to the scalp (see above).

Further Resources:





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