How Head Lice Is Treated

It can be distressing to discover head lice, but you can follow some simple steps to effectively treat the lice at home. Most infestations can be cleared up with over-the-counter anti-lice shampoos and wet-combing to check for lice and remove nits (lice eggs). Some prescription medications are available for resistant cases. If you want to avoid using chemicals, diligent wet-combing and nit-picking is an all-natural treatment. It's best to avoid some home remedies and alternative therapies that are unproven or, perhaps, even dangerous.

Over-the-Counter Therapies

The first-line treatment of head lice is using an anti-lice shampoo, such as Nix or Rid, which you can buy at the drugstore or online. These are called pediculicides. They will kill the adult lice outright, but they don't kill nits. 

Nits hatch in seven to 10 days and develop into egg-laying adults in another seven to 10 days. Given this, you usually have to re-treat with an anti-lice shampoo seven to 10 days after an initial application to kill any newly hatched head lice and break this lice life cycle. Many experts recommend doing the second head lice treatment on the ninth day.

Here are further details on the most popular OTC options:

  • Nix (permethrin): This 1 percent permethrin lotion is the first choice for treatment. It is the least toxic to humans and is less allergenic than Rid. It leaves a residue on the hair that should kill the nymphs that hatch from any viable eggs. However, since your regular shampoo and conditioner can keep Nix from adhering to the hair shaft, a second application on the ninth day is needed. Permethrin is toxic to the lice's neuro system. Some lice have developed resistance to permethrin.
  • Rid (pyrethrins plus piperonyl butoxide): Rid is a shampoo made from chrysanthemum extract that is toxic to lice but only has a low toxicity in humans and other mammals. However, there are rare allergic reactions in people who are sensitive to the flower. Unlike Nix, it doesn't remain on the hair, so a second application is needed. The effectiveness of this product has been decreasing as resistance grows.

LiceMD Pesticide Free is another type of OTC anti-lice shampoo. Known as an occlusive agent, it uses dimethicone, a non-toxic form of synthetic silicone oil that works by closing off the lice's breathing spiracles and smothering them. A benefit of this treatment is that it makes the hair slippery, so it's easier to use the lice comb on long or curly hair. Note: Dimethicone is being further researched and tested; there is concern that some products that contain it are flammable and must be used with caution.

A fine-toothed lice comb is included with all of these products, which you will use to remove the nits. You will continue to remove nits after application of the treatment, even if you have to check each night for a week or more until you get them all. The nits are tenacious and the closely-spaced tines of the comb, which are usually made of steel, can scrape them off individual hairs. (More on combing below.)

You shouldn't use dog shampoo. It's true that it may contain some of the same active ingredients as some anti-lice shampoos, but dog shampoo is not made for, nor has it been tested on humans. There is no way to know that it's safe or that it works.

Home Remedies

While combing is a recommended part of an anti-lice shampoo treatment, it's also a useful home remedy in and of itself. Cleaning is another important step not to overlook. Other home remedies have not been proven to be as effective.

Combing and Nit-Picking

You may remove the nits and live lice with a lice comb and tweezers. This is a recommended part of an OTC treatment course but is also useful as an alternative for those interested in a natural approach. This is the method that is advocated by The National Pediculosis Association.

For combing after treatment with an anti-lice shampoo, follow the directions and do not wash the hair for the recommended length of time (one or two days). You will do the combing eight to 12 hours after product application. For non-treated hair or after the no-wash period has expired, it is easiest to do the combing after you have washed the hair and used hair conditioner.

Note that it can take an hour or two to properly perform the lice combing. It can take longer for long or curly hair. Follow these steps:

  1. Assemble your supplies: a regular comb, fine-toothed lice comb, spray bottle of water, tweezers, magnifying lens, tissues, a bowl of hot water, clips and rubber bands (to use to secure the hair as you comb), and a towel.
  2. Settle the person being treated into a comfortable position with entertainment such as a video, book, or game. Place a towel around the person's shoulders to protect the clothing.
  3. Comb out damp hair with the regular comb so any tangles are eliminated. Wet hair is best for combing. Use the spray bottle to wet hair as needed.
  4. Start at the top of the head. Place the teeth of the lice comb as close to the scalp as possible (where any newly-laid eggs and adult lice will be). Lift a small section of hair, scoop the comb into the hair section at the scalp, and then comb upward along the hair shaft with a firm, even motion to the end of the hair.
  5. Return the lice comb to the scalp and rotate it 45 degrees from the original position. Again comb from the scalp to the end of the hair shaft. Do this two more times so you have combed the lock from each of four directions. If you observe any nits or adult lice that aren't removed with the comb, remove them with tweezers. You may want to use a magnifying glass to see them.
  1. Clip the section of hair you just finished with a hair clip. Wipe the lice comb frequently with the tissue and observe to see if there are any lice or nits being removed. Lift another section and comb it in the same way. Continue until you have combed all sections. Pay special attention to the areas around the ears and the hairline at the back of the neck, which are preferred by lice.
  2. Ensure the hair is wet and do a final pass with the lice comb, this time without parting the hair. This can make it easier to capture light-sensitive live lice.
  3. After you are finished, wash the hair.
  4. Clean the lice comb and hair products in hot water. Launder the towel and your clothes.

You should repeat the procedure daily for several days to make sure that you get all of the lice and nits. If you don't, the eggs will hatch and lice will be present again. Do the lice combing again two weeks after treatment to ensure the lice are gone.

No home remedies or products that claim to loosen the nits from the hair have been proven to be effective, so it's wise not to use them. Some, such as vinegar, can interfere with the residual activity of permethrin. Others, such as WD-40, bleach, or acetone can damage the hair as well as pose a toxic risk or risk of fire when used.

There is one other way to go. A lice removal specialist will do all the dirty work, at your home or at her place of business. It's even possible that your health insurance will cover head lice removal, or that you can get reimbursed through your health savings account. If so, it may be worth it, especially if it's you who has the lice; effective self-treatment is nearly impossible. Lice removal specialists really are pros at making sure every single nit gets picked.

Cleaning

The American Academy of Pediatrics (AAP) recommends cleaning any clothing or other items that have been in contact with the head of the person who has lice in the past 24 to 48 hours. Wash clothing and bedding in hot water and dry in a hot dryer. Use a vacuum to remove lice and nits from furniture, carpets, stuffed animals, car seats, and other objects. If there are any items you can't easily clean in these ways, put them into a large plastic bag and close it up tight for two weeks. If any lice hatch, they will starve without having access to blood.

Smothering (Occlusive) Agents

Most other natural home remedies involve putting something on the scalp and hair to "smother" the head lice, much like LiceMD. Popular choices include mayonnaise, olive oil, and Vaseline (petroleum jelly). These are usually left on overnight, often under a shower cap, and then washed out the next day. They can be very messy, though, and have not been proven to work. Some experts believe that any benefit this method may have comes from nits and lice being removed as you try to wash the agent out of your hair.

Prescriptions

See your pediatrician or family doctor if you can't get rid of lice. Lice can be stubborn, able to live through an entire course of lice shampoo treatment. A doctor can confirm whether live lice are still present and teach you how to better identify and remove nits. He or she will also likely know the patterns of resistance to the usual anti-lice shampoos in your area, if applicable, and what the best next treatment for you might be.

Prescription Shampoos

Your doctor may prescribe a prescription strength anti-lice shampoo, such as:

  • Ovide (malathion): This is the most common prescription option. The lotion is applied to dry hair and left to air dry, then washed off after eight to 12 hours. It will kill the eggs, and only one application is usually needed. It is highly flammable because it contains alcohol; you must not use a hair dryer or smoke while it is being applied or drying. It is not used for children younger than age 2, and the safety hasn't been assessed for children under age 6. If accidentally ingested (which hasn't been reported), it could suppress breathing.
  • Ulesfia (benzyl alcohol lotion 5 percent): Parents and pediatricians can also now to turn to Ulesfia as a non-pesticide prescription treatment for head lice. Ulesfia can be applied to the hair of children over 6 months of age until it is saturated, washed off after 10 minutes, and then reapplied seven days later. Unlike Nix, Rid, and other head lice shampoos, Ulesfia is thought to work by blocking the louse's respiratory spiracles, thereby suffocating it.
  • Natroba (spinosad 0.9 percent suspension): This suspension of benzyl alcohol and compounds formed by a soil bacteria during fermentation is approved for topical use in children 6 months of age and older. It works much like permethrin and lingers to have effects on any eggs that hatch, but needs a second application after seven days.
  • Sklice (ivermectin 0.5 percent): This topical lotion was approved by the FDA in 2012 for children 6 months or older. It causes muscle paralysis in the lice. Only one application is needed.
  • Elimite (permethrin 5 percent): This prescription-strength version of this drug is available, but its use for head lice is off-label (meaning doctors can choose to prescribe it to treat lice, though the FDA has not approved it for this purpose). If lice are resistant to the OTC concentration of this drug, they may also be resistant to this higher concentration.

Prescription Oral Agents

In addition to topical agents, there are two oral agents that doctors may use off-label:

  • Stromectol (ivermectin): This is an antiparasitic drug that has shown effectiveness in treating resistant head lice infestations. It is given in two doses, seven to 10 days apart. Because this drug will also cross into the human brain and may affect neural activity, it shouldn't be given to children who weigh less than 33 pounds. 
  • Septra or Bactrim (trimethoprim-sulfamethoxazole): You may be familiar with this antibiotic for other types of infections. You take a 10-day course. It has been shown to be effective at treating resistant infestations of head lice and may be used in combination with Nix.

Complementary Medicine

Essential oils are sometimes touted for treating a head lice infestation. A 2010 study of 123 people with head lice found that a topically-applied product that contained tea tree oil (melaleuca) and lavender oil was effective, with 41 out of 42 people treated being louse-free after the last treatment, compared with only 25 percent of the patients treated with a typical anti-louse shampoo. Products containing neem seed extract have shown potential for killing head lice with a single treatment in some small studies. However, most of the few studies on this are performed in a test tube, so the effectiveness of these treatments in humans is questionable.

If you do try essential oils, it is important to note that they shouldn't be applied at full strength to the skin, as they can be irritating and have adverse effects when absorbed. As there isn't much research, it isn't known whether the products containing essentials oils or neem extract are safe. This is especially true for vulnerable populations such as children, pregnant women, and nursing mothers. The American Academy of Pediatrics cautions against using herbal anti-lice products on infants and children.

And remember: When it comes to lice, completely effective treatment is critical to eradicating an infestation and preventing it from spreading. Opting for conventional treatments that are known to work offers you your best chance at putting this behind you.

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