August 9, 2011 - Children across Georgia are heading back to school again. As they start the new academic year they’ll be connecting with old and new friends, but they might also find some unwanted friends in the classroom: head lice.

The Georgia Association of Physician Assistants (GAPA) wants to remind parents and school administrators to be on the lookout for these pests that no child wants to bring home or share with their friends at school. As the school year kicks off, it is not uncommon for children, particularly those between the ages of three and 12, to get head lice infestations. Also known as pediculosis capitis, head lice have been a frequent, controversial and frustrating problem for parents for years.

So, what are head lice?

Head lice are parasitic insects that can be found on the head, eyebrows, and eyelashes of their hosts. They feed on human blood several times a day and live close to the human scalp.

“The good news is they are not known to spread disease,” said Ben Taylor, PA-C, PhD. Taylor is the GAPA public information chair and works in multiple emergency departments in Georgia and South Carolina. “However, secondary bacterial infections of the skin may result from scratching.”

In the United States, infestation with head lice is most common among children in childcare facilities and elementary schools, and among household members of other infested individuals. It is estimated that six to 12 million infestations occur each year in our nation in children three to 11 years of age. Typically, females of all ages get head lice more often than males do, and in the United States infestation with head lice is much less common among African-Americans than among persons of other races. It is hypothesized that this may be because the claws of the head louse found most frequently in the United States are better adapted for grasping the shape and width of the hair shaft of other races.

Head lice cannot hop or fly, but move by crawling and are spread by direct contact with the hair of an infested individual. Anyone who comes in head-to-head contact with this individual is at greatest risk. It is uncommon, but head lice can also spread by contact with clothing (such as hats, scarves, coats) or other personal items (such as combs, brushes, or towels) used by an infested person.

“Some people think that somehow personal hygiene or cleanliness in the home or school has something to do with getting head lice,” said Taylor. “That is completely untrue.”

What are some of the symptoms of head lice?

Head lice infestations can be asymptomatic, particularly with the first infestation or when the infestation is light; however, there have been reported cases of heavy infestations with no symptoms in the individual. The two most common symptoms of lice infestation are pruritus (itching), which is caused by an allergic reaction to the louse bites, and a tickling feeling or a sensation of something moving in the hair. It may take four to six weeks for the itching to appear in some people affected with head lice. Other symptoms may include:
•    Irritability and difficulty sleeping since head lice become most active in the dark.
•    Sores on the head caused by scratching. These sores can sometimes become infected (may become crusty and ooze) with bacteria found on the person's skin.
•    Small red bumps on the scalp, neck and shoulders.
•    Tiny white specks (eggs, or nits) on the bottom of each hair shaft that are hard to get off.

Parents should examine their child's head, especially behind the ears and at the nape of the neck, for crawling lice and nits if the child exhibits symptoms of a head lice infestation. If crawling lice or nits are found, all household members should be examined for crawling lice and nits every two to three days.

It is also possible to develop something called “louse phobia,” where the individual may feel they have an infestation because they know others who do or have come in contact with someone who has been affected. For this reason it is essential to have a confirmed diagnosis before starting treatment.

Treatment

All individuals with an active infestation should be treated and all household members and other close contacts should be checked. If any close contacts show evidence of an active infestation, then they too, should be treated. Some experts believe prophylactic treatment is prudent for persons who share the same bed with actively-infested individuals. All infested persons (household members and close contacts) and their bedmates should be treated at the same time. Retreatment of affected individuals is usually recommended because no approved medication is completely ovicidal (kills the egg). To be most effective, retreatment should occur after all eggs have hatched, but before new eggs are produced. The retreatment schedule can vary depending on what kind of medication is used.

Many head lice medications are available over-the-counter without a prescription at your local drug store or pharmacy. Almost all products approved by the FDA for the treatment of head lice contain one of the following active ingredients:
1.    Pyrethrins combined with piperonyl butoxide; Brand name products: A-200, Pronto, R&C, Rid, or Triple X. Pyrethrins are safe and effective when used as directed. Pyrethrins can only kill live lice, not unhatched eggs (nits). A second treatment is recommended on day nine to kill any newly hatched lice before they can produce new eggs. Pyrethrins generally should not be used by persons who are allergic to chrysanthemums or ragweed. Pyrethrin is approved for use on children two years of age and older.
2.    Permethrin lotion 1%; Brand name product: Nix. Permethrin is a synthetic pyrethroid similar to naturally occurring pyrethrins. Permethrin lotion 1% is approved by the FDA for the treatment of head lice, and is safe and effective when used as directed. Permethrin kills live lice but not unhatched eggs. Permethrin may continue to kill newly hatched lice for several days after treatment, and a second treatment is often necessary on day nine to kill any newly hatched lice before they can produce new eggs. Permethrin is also approved for use on children two months of age and older.
3.    Malathion 0.5% in isopropanol (Brand name - Ovide) is FDA approved for the treatment of head lice but requires a prescription.  It is applied to dry hair until the hair and scalp are wet and left on for 12 hours. Malathion may be useful for resistant infections. Treatment with Malathion can cause significant side effects in children younger than six months old, the elderly and anyone weighing less than 110 lbs (50 kg), especially when the treatment is used repeatedly in a short period of time.

An important part of treatment is removing the eggs (nits). There are commercial products that make removing the nits easier. Some dishwashing detergents can help dissolve the "glue" that makes the nits stick to the hair shaft. Other measures include:
•    Removing the eggs with a nit comb. Before doing this, rub olive oil in the hair or run the metal comb through beeswax. This facilitates removal.
o    Metal combs with very fine teeth are stronger and more effective than plastic nit combs. These metal combs are easier to find in pet stores or on the Internet than in pharmacies.
•    Removing eggs may prevent the lice from returning if the medication fails to kill every one of them.
•    Repeat combing for nits for seven to ten days.

Supplemental Measures for Prevention & Control

When treating head lice, supplemental measures can be combined with those recommended; however, such additional measures generally are not required to eliminate a head lice infestation. Head lice do not survive long if they fall off a person and cannot feed (about one to two days only). Nits cannot hatch and usually die within a week if they are not kept at the same temperature as that found close to the human scalp. Thus, it is not necessary to spend a lot of time or money on housecleaning activities. Follow these steps to help avoid re-infestation by lice that have recently fallen off the hair or crawled onto clothing or furniture:
1.    Machine wash and dry clothing, bed linens and other items that the infested person wore or used during the two days before treatment using the hot water (130°F) laundry cycle and the high heat drying cycle. Clothing and items that cannot be laundered may be dry-cleaned or sealed in a plastic bag for two weeks to kill any lice that already are present or that might hatch from any nits that may be present on the items. Soak combs and brushes in hot water (at least 130°F) for five to ten minutes.
2.    Vacuum the floor and furniture, particularly where the infested person sat or lay. However, experts agree that the risk of getting infested by a louse that has fallen onto a rug or carpet or furniture is very small.
3.    Do not use fumigant sprays; they can be toxic if inhaled or absorbed through the skin.
4.    Instruct your children to avoid the following:
a.    Head-to-head (hair-to-hair) contact during play and other activities at home, school and elsewhere (sports activities, playground, slumber parties, camps).
b.    Sharing combs, brushes, hair accessories (such as ribbons and barrettes) or towels. Disinfect combs and brushes used by an infested person by soaking them in hot water (at least 130°F) for five to ten minutes.
c.    Lying on beds, couches, pillows, carpets or stuffed animals that have recently been in contact with an infested person.

Head Lice Information for Schools

Students diagnosed with live head lice do not need to be sent home early from school; they can go home at the end of the day, be treated, and return to class after appropriate treatment has begun. Nits may persist after treatment, but successful treatment should kill crawling lice.

“School administrators need to remember that head lice can be a nuisance but they have not been shown to spread disease,” Taylor reiterated. “Personal hygiene or cleanliness in the home or school has nothing to do with getting head lice.”

Some school systems may have "no-nit" policies that require a child to be free of nits before they can return to school. However, both the American Association of Pediatrics and the National Association of School Nurses advocate that "no-nit" policies should be discontinued for the following reasons:
•    Many nits are more than ¼ inch from the scalp. Such nits are usually not viable and very unlikely to hatch to become crawling lice, or may in fact be empty shells, also known as casings.
•    Nits are cemented to hair shafts and are very unlikely to be transferred successfully to other people.
•    The burden of unnecessary absenteeism to the students, families and communities far outweighs the risks associated with head lice.
•    Misdiagnosis of nits is very common during nit checks conducted by nonmedical personnel.

Advice for Parents

Unfortunately, some parents may react to the news their child has head lice by panicking, and then over-reacting, which could lead to over-treatment and producing anxiety in children who may be concerned that they have "bugs" in their hair. Here are some “don'ts” of head lice treatment:
•    Don't use a hair dryer on your child's hair after applying any of the currently available scalp treatments listed above because some contain flammable ingredients.
•    Don't use a cream rinse or shampoo/conditioner combination before applying lice medication.
•    Don't wash your child's hair for one to two days after using a medicated treatment.
•    Don't use sprays or hire a pest control company to try to get rid of the lice, as the chemicals can be harmful.
•    Don't use the same medication more than three times on one person. If it doesn't seem to be working, this may be caused by using the medicine incorrectly or by resistance to the medicine. A healthcare provider may recommend another medication.
•    Don't use extra amounts or more than one head lice medication at a time.
•    Don’t shave the child's head to get rid of head lice.
•    Don’t start treatment of a suspected case of head lice with “alternative treatments” like mayonnaise, Vaseline®, olive oil or Tea tree oil. Although they are 'natural' treatments, they are untested, and products like mayonnaise can be hard to get out of a child's hair. (Dishwashing liquid might make it easier.)
•    Don’t blame the family pet for the infestation. Pets do not play a role in the spread of head lice as they do not live on pets.

Most important, parents should understand that getting head lice might cause their child to feel embarrassed. They should tell their child that anyone could get head lice, that they haven't done anything wrong and that having lice doesn't make them dirty. Children should be reassured that as aggravating it may be, they will eventually be rid of the annoying insects. Being patient and following the treatments and prevention tips as directed by the healthcare provider for keeping the bugs at bay will help families be well on their way to being lice-free.

The mission of the Georgia Association of Physician Assistants is to promote high quality, cost-effective, accessible healthcare as part of a Physician-directed PA/Physician team. Georgians can find a member PA near them by clicking on the “Find a PA” tab at gapa.net.