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Pharmacist’s Guide to
Controlling Head Lice


With the exceptions of the common cold, head lice affect more school-aged children than all other communicable diseases combined.  Studies show that the public wants to receive more advice from their pharmacist, and the trend in pharmacy practice is to provide more consultative services.  All summed up, this means that pharmacists will, and should, assume a leadership role in the community effort to develop a sound and standardized approach to controlling head lice.

There is a lot of misinformation on this disease and its control.  This is especially true on the Internet.  There are many products being marketed as safe and natural alternatives yet labeled with pesticidal claims.  The majority of these products have not been reviewed or approved by the Food and Drug Administration for human safety, manufacturing practices, or efficacy.

Encourage everyone to get the facts and CHECK A HEAD.TM

1.  Determine if the patient has head lice: If there is not a diagnosis from a qualified health professional or knowledgeable parent, you may need to advise on how to identify an infestation.

  1. When inspecting the scalp and hair, look for nits – tiny yellowish-white oval eggs firmly attached at an angle to the side of the hair shaft.  Unlike what most pharmacists were taught in school, the nits a quarter inch from the scalp or further are not necessarily dead.  Viable eggs can be found anywhere on the hair.

  2. An infestation is often detected by seeing nits rather than by finding head lice.  Head lice, which shy away from the light and move quickly, may also be seen.  They are the size of a sesame seed; are transparent as nymphs but with blood meals take on a reddish brown to black color.

  3. Using an effective screening device, such as the NPA’s LiceMeister® comb, go through each section of hair from the scalp to the end of the hair.  (Head lice can also be found in the eyebrows and eyelashes.  Children should be examined by their physician in this situation.)  Pesticides should not be used on or near the eyes.

  4. Be sure that patients do not confuse nits with hair debris such as desquamated epithelial cells (DEC plugs), which are bright white and irregularly shaped clumps of dandruff stuck to the hair shaft, or haircasts (elongated segments of dandruff that encircle the hair shaft).  Both can occur in patients who have been over-treated with pesticides.  Such debris can cause diagnostic confusion.

  5. Nits may be found throughout the hair, but are often found at the nape of the neck, behind the ears, and at the crown.

  6. Remind parents that routine screening and early detection is the best and only prevention.  Pesticides should not be used to prevent head lice.

  7. Be mindful that some parents will assume that they or their children are infested whenever they hear that there is an outbreak.  This is okay if it prompts them to screen… but not if it causes them to use pesticides unnecessarily.

2.  Alert those who are at greatest risk from the use of pesticides.  These issues also apply to the person administering the treatment.  Some of the factors impinging on the treatment choice include:

  1. The health/age/size of the child.

  2. Whether the person applying or using the product is pregnant or nursing.

  3. Whether there are several infested family members to be treated by one parent.

  4. Individuals who have had repeated earlier pesticidal treatments.

  5. Patients on medication or with pre-existing medical conditions such as allergies, asthma, epilepsy, cancer, or with open wounds on the hands, scalp or neck.

3.  Product Recommendations:

  1. Based on increasing reports of head lice resistance on a national level, the NPA advises parents to discontinue the use of head lice pesticides at the earliest sign of treatment failure.  MANUAL REMOVAL IS THE BEST OPTION WHENEVER POSSIBLE AND ESPECIALLY WHEN TREATMENT PRODUCTS HAVE FAILED.

  2. Head lice treatments should be used over a sink, as opposed to a bath or shower as it will minimize the exposure of pesticides to the body.  Caution against allowing these products to get near the eyes.

  3. Warn against the use of head lice sprays.  Using head lice sprays on bedding, furniture, and carpets is unwarranted, has no scientific basis, and may pose personal and environmental hazards.

  4. Do not recommend products containing lindane.  The Food and Drug Administration (FDA) regards it as potentially more toxic than all other pediculicidal choices and no more effective.  None of the commercially available products will kill 100% of the nits.

  5. Provide educational materials about head lice control near the head lice products in the pharmacy, and encourage affected persons to discuss their experience with you.

  6. The current endemic nature of head lice among children challenges the traditional management concept that the lack of efficacy in pediculicides can be countered by retreating children in 7-10 days later to kill the newly hatched lice.  The 7-10 day time span is nebulous.  More importantly, such a measure does not take into account the opportunities to become reinfested from another child in the interim.

4.  Additional Control Measures for Patients

  1. Have parents screen as part of personal hygiene – routinely just as they brush their teeth.  Early detection is key and is consistent with traditional communicable disease control methods.

  2. Have parents machine wash all potentially exposed clothes, sheets, etc. in hot water, and dry them in a hot dryer.

  3. Any item that can’t be washed or dry-cleaned can be vacuumed.  Recommend vacuuming as the safest and most effective alternative to spraying.

  4. Some professionals have suggested “bagging” items in plastic bags.  Discourage bagging and encourage vacuuming.  Having head lice can be traumatic, especially for children.  Often it’s their favorite stuffed animal, or blanket that gets bagged, just when they need it most.  Parents should know to save their energy for that which benefits them the most: attention to the scalp and hair for early detection along with complete lice and nit removal.

  5. Do not recommend retreatment based on the patient’s scalp being “itchy.”  Remember that prior treatment itself can cause the scalp to itch and this symptom does not validate an infestation.

  6. Inquire about daily screening and thorough nit removal.  Remind the patient that an ongoing infestation is predictable without these measures.

5.  Prevent new outbreaks.

  1. Encourage parents to notify their child’s school, camp, childcare provider, and neighborhood parents regarding possible outbreaks.  Parents should check for head lice on a regular basis.  Remember that head lice affect all social groups.  Reporting should be encouraged.

  2. Advise AGAINST treating anybody who is not infested.  Do not recommend prophylactic treatment.

Public Health Aspects: Minimize community outbreaks by taking a leadership role in lice prevention in your community.

1.  Minimize Community Outbreaks

  1. Inform your community that you want to be part of a community approach – that you are available for educational information as well as advice about treatment and head lice management.

  2. You may choose to provide in-service training for local teachers, YMCA staff, camp directors, childcare personnel, etc.

  3. Support the important step of reporting outbreaks, treatment failures, and adverse reactions to the NPA’s National Reporting Registry, local health departments, and school officials.  Remember that early reporting can mobilize communities to do preventive screening.

  4. Encourage routine screening, early detection, and complete removal of both lice and nits.

2.  Take a leadership role in lice prevention in your community.

  1. Teach others how to minimize outbreaks.  Because most head lice information comes from product advertising, you should look to the National Pediculosis Association® for impartial resources and materials.

  2. Encourage everyone to join the NPA’s Back-To-School “National Pediculosis Prevention Month” activities that continue throughout the year.

3.  Advise others to exercise caution in selecting and using products for treatment.  Overuse of anti-lice pesticides has caused insect resistance similar to the current situation with some bacteria and antibiotics.

4.  Update physicians about possible new treatments and issues related to Pediculosis.
Head lice are often perceived as “unglamorous” and unworthy of serious attention.  As a result, there is conflicting information and no nationally standardized approach.  Encourage everyone to get the facts and CHECK A HEAD.

National Pediculosis Association
50 Kearney Road
Needham, MA 02494
(781) 449-NITS

in cooperation with Pharmacist's Letter®

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The National Pediculosis Association,® Inc.
A Non-Profit Organization
Serving The Public Since 1983.

2019 marks 36 years of Service.

The NPA is a 501(c)(3) tax-exempt non-profit volunteer organization, including scientific advisors, dedicated since 1983 to protecting children and their environment from the misuse and abuse of prescription and over-the-counter pesticide treatments for lice and scabies.
The LiceMeister comb® was developed by the NPA in 1997 to provide a higher standard for lice combing tools and a safe, cost-effective treatment alternative to pesticides. Proceeds from sales of the LiceMeister comb allow the NPA to be self-sustaining while accomplishing its mission.

©1997-2019 The National Pediculosis Association®, Inc.
All images ©1997-2019 The National Pediculosis Association®, Inc.

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