How to Treat Head Lice

School is officially back in Fall session, and that means our children return to the germ breeding ground. You’ve likely already experienced one, two, or even three bugs in your household by now since September. It’s a rite of passage of sorts. There’s no escaping it…sorry. I have two rambunctious five-year-old identical twin girls who take turns spreading the germs in our family. I completely empathize, believe me.

Like us, you and your family have likely already been plagued this season with the common cold or flu virus, or possibly pink eye or whooping cough (a current epidemic in many parts of the country)—all previously covered House Call Doctor topics. But there are other bugs in the kingdom, and one in particular that can make our skin crawl (no pun intended): head lice.

A five-year-old spunky little girl was brought in by Dad for possible head lice. The school nurse had called the parents and asked them to pick her up “right away” when the teacher spotted nits in her hair after finding her scratching away at her scalp.

“I want to go back to school!” She says with excitement and fervor in my office. She tells me she loves school because she “gets to learn new things.” Hard to keep such enthusiasm contained at home. Should she stay home or go back to school?

Dad is frustrated, as he had to take off from work to tend to this issue. The school will not allow her to return until she’s been treated, the nits eradicated, and a note to provide “proof” of this visit for the school.

That’s quite a tall order. After all, head lice doesn’t kill. There’s no long-term health effects. Let’s compare that to the flu, which kills up to 50,000 people in the U.S. alone. Strict rules as such do not exist for the flu or other more serious illnesses when they really should. Some perspective.

Does this sound familiar? Many of you with kids have surely experienced a similar scenario.

What is Head Lice?

“Pediculosis capitis” is the fancy medical term used to refer to head lice. It’s caused by the louse Pediculus humanus capitis, which lays up to 10 eggs (or “nits”) a day at the base of the hair shaft. Contrary to belief, they are transmitted via direct contact with the lice or nits. Head lice do NOT jump like fleas, or fly like bees. Simply sitting next to another child at school is not a common mode of transmission. It’s not nearly as contagious as you might think, compared to say the flu virus, measles, or chicken pox—all viruses with potential for significant complications.

They also can theoretically be transmitted via sharing combs, brushes, hats, or bedding. But solid evidence to back up these claims are lacking thus far.

Kids are particularly susceptible, but it can affect anyone regardless of age, sex, and socioeconomic status. Hygiene is irrelevant. Anyone can contract head lice if they are exposed. End of story.

Diagnosis of Head Lice

It is best visualized using a fine-toothed comb while inspecting the base where hair meets the scalp. Live lice and nits are often visible to the naked eye. The lice are 2-3 mm in length, and are often white, gray, or less commonly darker in color.

No special tests are required for diagnosis—your doctor should be able to diagnose it simply based on exam.

The Head Lice Controversy

How can we get rid of head lice? Believe it or not, eradicating them is not typically complicated, and certainly more efficient than the common cold or flu viruses,

One of my personal responsibilities as House Call Doctor is to interpret the medical jargon and information in order to better inform my listeners so that you are equipped with the best evidence-based information. Like the super over-hyped “pink eye,” head lice is up there with being one of the most stigmatized yet rather benign infectious processes.

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As I’ve shared with all of you prior, sometimes these more benign medical conditions are blown up way out of proportion in the media and community. Sure, head lice sounds gross; especially because they can be physically visualized, unlike microscopic bacteria and viruses. But there are many more ominous and more common bugs out there to be worried about than head lice.

But by all means…don’t ignore it either.

Treatment of Head Lice

Here are the top ways to treat head lice:

1. Topical Permethrin: Believe it or not, treatment for head lice is available over-the-counter (OTC); ask your pharmacist to show you the appropriate OTC formulas. Instead of applying it in the shower, use the sink in order to avoid skin exposure elsewhere. Permethrin should be the main active ingredient. And do not use any hair products, like shampoos or conditioners, prior to the application of the solution. Apply to dry hair and leave on for a minimum of 10 minutes, then rinse. Repeat in one week.
2. Oral Medications: If the above treatment fails, which is often due to re-exposure or improper use, there are oral prescription drugs available to treat head lice. Examples include malathion and ivermectin. They do carry some notable , less desirable side effects.
3. Antibiotics: The generic antibiotic, trimethoprim-sulfamethoxazole (Bactrim or septra) is an affordable and perhaps most effective option for more resistant head lice. It’s contraindicated in those with sulfa allergies, however.
4. Wet-Combing: For those who wish to avoid medicated solutions, this is an option. Apply olive oil, vinegar, or hair conditioner and slow comb through using a fine-toothed comb. Repeat numerous times, up to 30 minutes. And repeat for every 3-4 days until your last visible nit sighting. This may be rather time-consuming for older kids, but a possible consideration in younger children with little hair.

Let’s halt the propagation of archaic medical practices and protocols in schools.

When to Return to School?

Similar to pink eye, where schools erroneously require a “doctor’s note” and “antibiotic drops” (despite the fact pink eye is a virus) in order to return to school, those with head lice are often advised by schools to return to school once nits are no longer visible.

The Center for Disease Control (CDC) and the American Academy of Pediatrics (AFP) both agree that the “no nitz” school policies should be eradicated. Kids should not be kept from attending school for having nits in their hair. Head lice is not a health hazard. And it requires direct contact with the hair/scalp in order for transmission.

The Bottom Line

• Head lice do not pose adverse long-term effects or health complications, other than possible short-term psychologic distress and anxiety from societal pressures and over-hype.
• It doesn’t mean your child is “dirty.” Personal  hygiene is not a factor in contracting head lice. Anyone can get it.
• First line treatment is readily available, typically effective, is over-the-counter and doesn’t require a doctor’s visit.

In a nutshell, the only reason to see your doctor may be due to uncertainty around the diagnosis, or unfortunately, more often due to a school requirement, contributing to unnecessary missed school days, missed work days, and wages.

Let’s halt the propagation of archaic medical practices and protocols in schools. It’s time we dispel common medical myths and revise clearly outdated school policies that cause more harm than good. 

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Please note that all content here is strictly for informational purposes only.  This content does not substitute any medical advice, and does not replace any medical judgment or reasoning by your own personal health provider.  Please always seek a licensed physician in your area regarding all health related questions and issues.