Head Lice- AAP Guidelines

head-liceHead Lice is one of those things that makes me scratch my head just reading the words or each time I leave a room after seeing a patient with head lice.  The truth is, they don’t jump or leap off the head of one person to another.  Lice only crawl and thus require head to head contact or sometimes can come from hats, combs, or other direct contact.  I have never had head lice despite close contact with over a hundred patients over my career who I’ve examined their head and hair for lice.

When you look for lice, you most likely will find them above the ears and at the back of the neck, very close to the scalp.  They avoid light, so shining a light on the area may cause live lice to crawl away.  Nits (the eggs) are firmly attached to the hair and difficult to get off the hair which distinguishes them from a fleck of dandruff.

While headlice can’t live for more than 24 hours away from the human body, their nits can live a bit longer. But this is typically no longer than 2 weeks. It is important to go through your child’s room, cleaning and washing everything to help eliminate any nits that may be present. Wash all of their linens in hot water, remove large and “unwashable” items for at least two weeks, sealing them in plastic bags until all of the nits have died off. Combs and brushes should be soaked in an anti-lice shampoo solution, but there is generally no need to use an anti-lice room spray. Remind your children not to share combs and hats, and check the heads of others in your home. If any signs of lice or nits are present, begin a treatment immediately to limit the amount of any outbreak.

I favor the use of natural products that suffocate the lice, such as oils, mayonnaise, or cetaphil cleanser or petroleum jelly, worked extensively into the hair and left on overnight then washed out. Repeat this process weekly three times. Wet combing with a nit comb or carefully removing all nits can be effective, but you will need to do this daily for 1-2 weeks.

The products that are toxic to lice are (these should all be rinsed out after 10 minutes with repeat treatment in 7-9 days):


  • Permethrin 1% lotion (Nix) Pyrethrins + piperonyl butoxide (Rid) -Available without a prescription- use as directed.
  • Benzyl alcohol 5% (Ulesfia)- expensive and requires a prescription
  • Malathion 0.5% (Ovide)- toxic
  • Spinosad 0.9% suspension (Natroba)
  • Ivermectin 0.5% lotion (Sklice)- toxic


No longer recommended due to toxic risks are the scabicides:

  • Permethrin (5%)
  • Crotamiton (10%)


In the Portland area where I practice, we have a clinic dedicated to head lice and the treatment with natural non-toxic products: http://liceknowingyou.com/lice-knowing-you-portland-lice-clinic-now-open.html



  1. No healthy child should be excluded from school or allowed to miss school time because of head lice or nits. Pediatricians may educate school communities that no-nit policies for return to school should be abandoned.
  2. It is useful for pediatricians to be knowledgeable about head lice infestations and treatments (pediculicide and alternative therapies); they may take an active role as information resources for families, schools, and other community agencies.
  3. Unless resistance to these products has been proven in the community, 1% permethrin or pyrethrins are a reasonable first choice for primary treatment of active infestations if pediculicide therapy is required.
  4. Carefully communicated instructions on the proper use of products are important. Because current products are not completely ovicidal, applying the product at least twice, at proper intervals, is indicated if permethrin or pyrethrin products are used or if live lice are seen after prescription therapy per manufacturer’s guidelines. Manual removal of nits immediately after treatment with a pediculicide is not necessary to prevent spread. In the school setting, nit removal may be considered to decrease diagnostic confusion and social stigmatization.
  5. If resistance to available OTC products has been proven in the community, if the patient is too young, or if parents do not wish to use a pediculicide, consider the manual removal of lice/nits by methods such as “wet-combing” or an occlusive method (such as petroleum jelly or Cetaphil cleanser), with emphasis on careful technique, close surveillance, and repeating for at least 3 weekly cycles.
  6. Benzyl alcohol 5% can be used for children older than 6 months, or malathion 0.5% can be used for children 2 years or older in areas where resistance to permethrin or pyrethrins has been demonstrated or for a patient with a documented infestation that has failed to respond to appropriately administered therapy with permethrin or pyrethrins. Spinosad and topical ivermectin are newer preparations that might prove helpful in difficult cases, but the cost of these preparations should be taken into account by the prescriber.” You can read more here…


Dr. Paul




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