Head Lice Are Becoming More and More Resistant to Lice Shampoos and other Insecticides

Interesting article in SciAm about the difficulty in treating head lice infestations. “Overexposure to insecticides has bred resistance in the parasites, making it harder than ever to treat infestation." The situation is different in Europe, where they've stopped using insecticides to kill lice and nits and use synthetic oils:

Further confounding matters, the co-pay for visiting a doctor, plus the cost of prescriptions, which may or may not be covered by insurance, can impede patient access to these newer medications. And despite their diminishing efficacy, over-the-counter lice shampoos remain the first response recommended by most doctors, health plans and even the American Academy of Pediatrics.

The situation is totally different in Europe, where treatment moved on from pyrethroids and virtually all insecticides about a decade ago, says Ian Burgess, president of Internationals Society of Phthirapterists (people who study lice). Instead most Europeans now rely on silicone and other synthetic oils to eliminate head lice.

The oils envelop the lice, preventing them from excreting water. As liquid builds up inside the louse, its internal organs start to shut down from the exhaustion of trying to pump out the water. Either it dies of this exhaustion", Burgess says, “or its guts rupture from the liquid.”

The Latest on Head Lice

Like many other parents, I’ve paid my dues when it comes to head lice. It was a while ago, back in day care, and there was a dress-up box with hats and crowns and helmets that was probably the smoking gun. We all had to do the whole routine, applying insecticide rinses to our children’s heads and washing sheets and pillow cases in hot water, and becoming somewhat fanatical about not sharing hats.

Meanwhile, my parents, who had grown up in New York tenements, were vaguely horrified that their affluent privileged grandchild was acknowledged to have what they thought of as a mark of disgrace, an infestation that went with poverty and dirt.

And yes, eventually I became convinced that my own head was itching, and bought my own bottle of rinse, though I suspect I was by that point treating phantom lice. Since then, I have checked many heads in the exam room, and I have seen kids with lice, kids with nits, and kids with nothing much going on in the lice department — and I have learned to suppress the phantom lice response; I wear gloves and I wash my hands.

One aspect of the confusion around head lice is that we may think of them as “infectious” because they are spread from person to person — but they do not actually carry infections. They’re just bugs, and technically, we call head lice an infestation rather than an infection, but that doesn’t necessarily make anyone feel any better. (Body lice are different — they can indeed spread infections, most famously typhus).

So when it comes to head lice, the pediatric role in recent years has largely been to reassure, to beg for calm, and to try to get kids back to school as quickly as possible.

The American Academy of Pediatrics put out its latest clinical report on head lice in 2015, a joint project of the group that focuses on school health and the committee on infectious diseases. The report reiterated longtime pediatric positions, emphasizing the importance of careful diagnosis, by trained observers, and arguing first and foremost that children should not miss school because of head lice or nits.

“Misdiagnosis is really common, even with medical personnel,” said Dr. Mary Anne Jackson, the director of infectious disease and professor of pediatrics at Children’s Mercy Hospital in Kansas City, Mo., who works with the A.A.P. committee on infectious diseases.

She said administrators at one school she worked with worried that its football field might be a source of lice, and were concerned with fumigating or otherwise disinfecting it. But unless the players are sharing helmets they are unlikely to transmit head lice.

There are many misunderstandings about head lice, Dr. Jackson said, including the persistent idea that a child with head lice is evidence of an unclean home. (Head lice are, in fact, one of the great equalizers; just look at all the high end “salons” offering to pick to child’s nits for a hefty fee.)

It’s not necessary to treat all the children in a classroom, or all the people who live in the house, though anyone who shares a bed should get treated. We no longer use some of the more toxic insecticidal drugs that used to be employed, like lindane, which was a potential neurotoxin. The over-the-counter preparations that are available now are much safer, but there are concerns about resistance, so many people resort to prescription drugs. One that is commonly prescribed is topical ivermectin, a drug with what Dr. Jackson called “a strong safety portfolio,” but it can be expensive.

And there are many treatments out there that have no evidence to back them up. For example, Dr. Jackson said, there are clinics using heat on children’s hair, which may work under certain conditions, but there is no regulation of how it is being used “to quote unquote inactivate the lice,” she said. “I am skeptical.”

And then there are the “suffocation treatments,” from olive oil to mayonnaise, applied to the hair in hopes of killing off the insects without resorting to chemicals and insecticides. Some of these probably work some of the time but “all will work no matter how you place them if you don’t have lice,” Dr. Jackson said.

So diagnosis is key — someone experienced should look at the child’s head, looking for lice and not just for nits, since all kinds of debris in the hair can be mistaken for nits; everything from dandruff to dirt to drops of hair care products. And someone who knows the resistance patterns in your area should advise you about whether to use the over the counter preparations or the prescription medications.

The head louse life cycle takes about three weeks; the adult female, about the size and color of a sesame seed, lays about 10 eggs a day, and glues each one to a hair near the scalp. Eggs hatch in about nine days, warmed by body heat emanating from the scalp, and the larvae then leave the egg case (which remains glued to the hair, though it’s now empty) and go through several different developmental stages over the next nine to 12 days, before reaching adulthood and starting to lay their own eggs.

That’s why it can be helpful to treat more than once, usually after about nine days, if you are using a product that does not kill the eggs, or if you see live lice after a first treatment. And there are indeed some lice that are resistant to some insecticides, so it’s important to know what is common in your community.

Removing nits with a fine-toothed comb can be done after treating the child’s head, and usually is most effective when the hair is wet, though still not a short or simple process.

From an infectious diseases point of view, Dr. Jackson compared head lice with pinworms, another parasitic infestation parents regard with fear and sometimes with shame, and which may be treated repeatedly without a firm diagnosis that establishes beyond question the presence of these unwanted passengers on the child’s head — or the child’s tail. People worry, kids get treated, sometimes repeatedly, and the treatments cost money and take time. We spend a billion dollars a year on treatments for head lice, according to the American Academy of Pediatrics.

The A.A.P. has fought hard against “no nit” policies in schools, in the interest of reducing the school absence associated with head lice; the C.D.C agrees, and schools are increasingly unlikely to exclude children for nits, but still, in some schools, the policies persist.

“There should never be a case for a child with head lice spending days out of school,” Dr. Jackson said. “Families should be notified, they should be able to access topical medication and they should be able to re-enter the next day.”

I Spent Years Dreading the Day My Daughter Would Get Lice — and Then It Happened

I had just escaped from my kids, handing them off to my husband to take a few minutes to myself before the chaos of bath and bedtime began. The calm didn't last long. Five minutes later, he entered our bedroom and announced that our daughter had lice. "Are you sure?" I responded, hoping, of course, that the answer was no. "Look for yourself," he replied instead. I did, and yep, that definitely wasn't a case of dandruff. Those were bugs crawling around on my daughter's head.

Her lice took me by surprise (though is anyone really expecting it?). Months before, when I got notes home from school about the cases reported in her classroom, or when her best friend's mom called to let me know her daughter and son, who had been in my carpool just that afternoon, were both lice-infected, I had braced myself for an impending doom that never came. I heard horror stories from my neighbor, mom to one of my daughter's classmates, about her whole family battling lice. At one point, she said, she was seriously considering shaving her own head just to ensure she'd gotten them all. 

My own scalp immediately began itching, though my husband couldn't spot a single nit (weeks later, that phantom itching still happens every time I even think about the word "lice"), and I began picturing the long, complicated, and annoying process that ridding our family and home of lice would entail. I'm glad to say that although it was pretty annoying (never have my washer and dryer worked harder), we were able to defeat the lice — it ended up only affecting my daughter, who luckily had a mild case — within 24 hours. Here are six things I learned about lice and getting rid of it that I never knew. If your house comes down with a case, don't despair. You can vanquish those annoying bugs quickly and thoroughly. 

Related:

My Toddler's Eardrum Ruptured and I Didn't Even Know It

• Lice are only passed through head-to-head contact. Head lice don't crawl, jump, or fly. The main way they spread is from close, prolonged head-to-head contact, and to a lesser degree, they spread through items that come into contact with an infected head, like brushes, hats, and (at our school found out last year) the helmets used in gym class. 

• You'll almost certainly know them when you or your child gets them. When friends and classmates of my daughter's got lice, I checked her head obsessively, wondering if I was missing something. I wasn't. She was clear. When she actually did have lice, she complained about her head itching, and when we checked, it was pretty easy to spot a few bugs (they're called a louse, are around two millimeters long, and are pale gray in color) crawling around on that head of hers. Because she's blond, the nits (tiny white or yellow eggs that attach to the hair with a sticky substance that holds them firmly in place) were harder to spot, but because of the bugs, we knew they were there.

• Lice don't live long off a head. Head lice only live with the aid of a scalp to feed on (gross, I know). Once they leave a head, they're usually dead in a day, two tops, so don't feel like you have to fumigate your whole house. Instead, focus on the things that have come in contact with your child's head over the past 48 hours (beds, brushes, hats and hair bands, towels, and clothing are the big ones).

• A laundry cycle will kill lice. Wash all bedding and clothing that's come in contact with the a louse-infested person in very hot water, then put it in the hot cycle of the dryer for at least 20 minutes, and you're golden. I continued to wash my daughter's pillowcases every morning for a few more days just to be safe.

• Isolate or clean items that can't be washed. You can put items like stuffed animals in a bag or simply isolate them from your child and you can be assured that they'll be lice free in a few days. Simply vacuum rugs, carpets, upholstered furniture, and your car. Hair items like brushes, hair ties, and headbands, you can either wash in hot water, soak in rubbing alcohol for an hour, or simply toss. 

• Don't be afraid to call in the professionals. When I texted my neighbor who was threatening to go bald the previous year because of lice, she directed me to a nearby "salon" that focuses solely on removing lice. While the service wasn't cheap (because of my daughter's mild case, we opted for the shorter comb out, which was still around $150). However, they were able to remove almost the 55 nits that were still inhabiting my daughter's head after we used special lice shampoo and spent three hours combing out her hair the night before. We also bought a far superior comb than the one that came with the drugstore lice shampoo we'd used. After that one service, the lice were gone, so in my mind, it was definitely money well spent. We followed their comb-out advice and kept checking for the next few weeks, but thankfully, not a nit was found.

De-lousing the house

Parents frequently ask us at Larger Than Lice how to remove head lice within the home. If I can only count how many times I, or one of our Lice Specialists have arrived to a home only to find ten, twenty, thirty garbage bags full of “household things”. One family even went as far as removing their curtains, just in case. On top of all that, countless numbers of laundry loads have already been done. No wonder head lice becomes such a stressful event for many parents. I almost feel bad telling the families that all this cleaning is just excessive and not necessary at all. That’s right. Excessive cleaning is not at all required when you, or your child has a case of lice.

The reason? Head lice live on the head. They do not live on inanimate objects. They have no interest in leaving one’s head to go wander around on the living room couch, or kitchen floor, or roam the car. A human host is the only place they want to be, the only place that they can potentially survive a whole month while they feed off of the blood of an individual. Typically, a louse that has fallen off the head is not healthy and is in the process of dying. Once they are away from their feeding source, a louse can only survive up to 24 hours. And let's pretend as though a healthy louse has fallen off and has found its way onto the couch- it will not burrow or sit around and wait for another human to sweep it off its feet and place it back into a new head. The chances of getting a displaced louse back into one’s hair are as small as finding a needle in a haystack, nearly impossible.

• Remember that lice are not living in your environment, they are living with you!

Don’t get me wrong, there are some things that need to be cleaned and laundered, but the list is very minimal. Laundering the bedding, any recently used towels and bathrobes is important. Same goes for all recently used hairbrushes and hair accessories. Bagging, laundering or drying on high heat should be considered for any stuffed toys that reside in your child’s bed. That is it. Use the rest of your energy on properly eliminating head lice and nit picking. Being meticulous is essential if you want to rid head lice for good. Removing every single nit is crucial to being lice free so make sure that no nits are left behind, which is exactly what Larger Than Lice are experts in.

When Larger Than Lice dispatches a Lice Specialist for an in-home lice removal treatment, you can rest assured that every single live louse and viable nit will be removed – in just one visit. After one lice treatment, and minimal laundering, you can rest at ease and be confident that your home will be lice-free.  

What Are Crabs (Pubic Lice)?

"Crabs" is the common term for lice found in the pubic hair of humans. Crabs is a parasite infection medically known as Pediculosis pubis or pubic lice. Barely the size of a pinhead, lice are organisms that live only with the help of another organism, called a host. There are thousands of types of lice, some of which have developed an attraction to humans. The official name for the organism responsible for pubic lice is Pthirus pubis. Other lice that often infect humans are Pediculus humanus capitis (head lice) and Pediculus humanus corporis (body lice). The term "crabs" seems to come from the microscopic appearance of the pubic louse. The pubic lice organisms are visible to the naked eye in affected areas. The lice are typically seen attached to hair in pubic areas, but may sometimes appear in other areas of the body where coarse hair is present (such as beard, chest, armpits, etc.).

The pubic louse is distinct morphologically (somewhat rounded with three pairs of legs on either side of the body from which it takes its descriptive name) from the head and body louse. The female lifespan is slightly shorter (three weeks), and she produces fewer eggs per day (three) than her counterparts. The eggs attach to the base of the pubic hair shaft for approximately six to eight days before hatching.

A new case study in The New England Journal of Medicine tells a torrid tale of an unnamed 65-year-old man who showed up at a dermatology clinic complaining of an itchy crotch. On examination, the man didn’t appear to have a rash or any lesions, so the doctors investigated his pubic area with a hand-held dermoscope.

The first bit of evidence they uncovered was a nit firmly implanted on a pubic hair. And then came the culprit itself—a freakishly agile, crab-shaped parasite moving from hair to hair like it was nobody’s business.

For the dermatologists, it was a classic case of pubic pediculosis—also known as “crabs.” This happens when the pubic louse, Pthirus pubis, infests a person’s hairy nether regions.

“Pubic pediculosis is usually sexually transmitted but can occur after contact with fomites [materials that are likely to carry infection] such as clothing, bedding, and towels used by an infected person,” write the researchers, who work out of Mexico City’s General Hospital. “The condition most commonly affects teenagers and young adults. This patient reported that he had had no recent sexual contact, and no other sexually transmitted infections were identified on screening.”

The doctors prescribed the oral drug ivermectin, and after two weeks the itching was gone. Which is all fine and well—but what about the psychological scars?

Three things you probably didn't know about crab lice.

Crab lice (Pthirus pubis) aren’t crabs at all—they’re parasitic insects that feed exclusively on human blood, and their bites can cause intense itching in their hosts. Often, this itching happens in the pubic area, which is why they’re also known as “pubic lice”—which, it turns out, is actually a misnomer.

• They’re not just spread by sexual intercourse.

Although sexual relations are the most common way to pick up these particular passengers, any prolonged close physical contact can do the trick, including breastfeeding or sleeping in the same bed as an infested individual. A few reports have suggested that crab lice can tolerate being away from a human host for as long as 36 hours, which opens up the possibility that the lice could hang out on previously used towels and sheets to wait for a new host.

• Their closest cousins live on gorillas.

Studies comparing DNA from the three species of human louse with the lice that infest other primates found that the crab louse’s closest relative is the gorilla louse. Head lice and body lice belong to a completely different genus of lice and are more closely related to the lice that live on chimpanzees. But researchers don’t think that humans picked up crabs from screwing gorillas. It’s much more likely that we got them by eating gorillas. Lice are very sensitive to body heat, and it’s possible that way back in the distant past, some gorilla lice abandoned a cooling dead host for the warm human that was butchering it.

• They don’t just live in pubic hair.

Crab lice certainly prefer the pubes, but their short, thick legs are just as well adapted to hang on to any coarse hair on the human body. They’ve been found in armpit hair, beards and mustaches, eyelashes, and eyebrows. They’re not big fans of densely packed hair, so they’re rarely found on the scalp. But if your scalp hair is sparser than average, as in people with curly locks, they might make an exception. Take home message? If you have a head louse infection, you only need to treat your scalp. A crab louse infection means all bets are off. Treat all of your hair. All of it.

How Do I Prevent my Kids from Getting Head Lice at Camp?

Practice Prevention - Lice Away

With kids getting out of school this week and camp season fast approaching.  It is time to give consideration to head lice prevention.  The following tips will help you avoid head lice this summer and if you happen to get head lice there is help readily available.

Educate Yourself and Your Children about Lice Prevention

• Pre-camp registration forms explain your camp’s policy on head lice. They may include some identification and treatment tips so parents can pre-screen children and treat children before putting them on the bus to camp.   Let your children know the things that they can do to avoid getting head lice and how to recognize the symptoms.  Use tools such as educational coloring books, a reputable website, pictures and educational hands outs.

• Get a quality head lice comb so you can check the hot spots once a week.  If you check ahead, you avoid the spread.  Take a peek once a week is a great preventative measure that parents can take.  Don’t be fooled by knock off and copy cat combs with short tines, plastic or poor tolerances.  You can expect to pay $15 to $20 for a quality lice comb, but these will last you a lifetime and can be sanitized between uses for multiple family members.  Finally a quality lice comb has the proper tolerances with long tines that go through the thickest of hair and do not break or tear the hair.

• Keeping hair up and away from other people’s heads is the best thing that you can do to avoid getting head lice.  Sharing hats, combs, brushes, towels, and other hair items are not advised.  Also avoid sleeping on someone else’s pillow or using their blanket.  Pay special attention to sharing sport wear and head gear.  If you need to share headgear such as a helmet, use a hair bonnet under the helmet.  Keep in mind that you may also get head lice from car and bus seats and couches.   Do a visual inspection of the head rest and wipe or blow off the surface before use.  There are some cleaning products available and hair sprays that will leave a scent on the hair and these can help repel lice.

• Ask Camp Directors about the Screening, catching a head lice infestation early is key and it helps to avoid spreading it to others in the camp and creating a severe infestation.   Ask your camp director if they provide help and if they are screening campers and staff as they arrive to camp.  Screening is the best method of keeping lice outbreaks to a minimum.  Keep in mind that all campers and staff need to be checked and that checking must be done on dry hair and within at least the first week of arriving at camp.  – Check-A-Head and avoid the spread.
• Report, Re-check and Treat, Don’t send your child to camp with lice and report it if you do find head lice.  Others need to be told so the campers in the cabin or at home can be checked.  Follow the camp policy on head lice.  If your camp treats campers on site, ask if they use pesticide and make sure follow up is being done.  Most head lice treatments are pesticide based.  Some children are sensitive to this and may not be good candidates for its use.  Speak with the camp about the treatment options.  There are many natural treatment options available and the best tools a camp could have on hand are high quality lice combs.   Treat the camper and then re-check the others in close proximity or in the same cabin.  Keep checking for a two week period and always follow up.
• The Environment, Head lice will die within 24 to 48 hours without a blood meal.  It is best to tell your children to keep their sleeping environment to themselves.  Sharing pillows, blankets, towels and any head gear may result in lice transmission.  There is no need to spray pesticide or to wash pillows and mattresses.  Focus on items that have had close head to item proximity such as pillow cases, sheets, hats, brushed, coats, etc.  Never spray an insecticide on bedding in cabins as the toxic residue will linger for several days and may cause some campers have breathing issues or other reactions. Remember the most important thing about head lice is to practice prevention and to catch it early so it can be treated in a timely and effective manner.  Most camps will experience head lice, but the severity of it can be reduced when everyone works together.

Head Lice Prevention – is it even possible?

When we provide lice removal services in a family’s home, the nice lice experts at Larger Than Lice are always asked “How can we prevent this from happening again?”

We wish there was an easy answer.  Or at least an answer that would guarantee a person would never have to have the head lice experience again.

But the fact is that head lice are an incredibly common infliction and no-one is immune!   Lice can happen to anyone at any time, regardless of hair type, hair color, gender or household income. Lice are common in schools, in daycares, in camps – pretty well anywhere kids (or adults) gather.

How is Head Lice Spread?

Head lice spreads by direct head-to-head contact with someone who has a case. The louse crawls along the hair and simply crawls onto another person’s head via a strand of hair.  Nits, or lice eggs cannot be spread from head-to-head.  Eggs are laid on the hair shaft with a cement-like glue which keeps them securely on the hair until the bug hatches from the egg.

Head lice spread within families, especially if parents and children lie down together, sit closely or sleep together. Lice spreads easily in schools as well because young children typically have close contact with one another, either with desks set side-by-side or during normal play and school activities. Though head lice do not hop, jump, or fly, they do crawl very quickly.

A secondary way of contracting lice is through an object which could have a live bug on it. Items like hairbrushes, hair accessories, helmets, headwear and scarves should not be shared.  It’s even possible for a louse to be left behind on a movie theatre chair or train seat headrest.  Note that this is NOT the typical way to contract lice, but it is possible.

Being in the same room or taking place in an activity in which someone has a case of head lice does NOT mean you will catch a case.  There must be direct head-to-head contact with the infected head.   Activities like sleepovers are an example of where children might have this kind of direct head-to-head contact over a period of time, exposing them to the possibility of contracting head lice.

How to Prevent Head Lice

It’s not an option to home-school every child or put them in quarantine, keeping them from everyday social activities.

But there are a few methods of prevention that might reduce the risk.

Keep long hair tied up in ponytails or even better, braids or a bun. Use tea tree oil or Buzz Off Lice Repellent Hair Spray either by adding a few drops to your regular shampoo, or by making a spritz by adding a few drops to water in a spray bottle. Tea tree oil can be very drying, so only use a few drops (as directed).

• Take a peek once a week. Catch head lice early and it is easier to remove.
• Educate your kids what to do to avoid getting lice and of the symptoms like scratching.
• Don’t share hair items and visually check head rests before laying or placing your head on them.

Parents should be alert to the common sign of head lice – scratching the head.  Watch for children who are scratching or who might even wake up in the night saying that their head is itchy.  Pay attention to kids who are visiting and watch to see if they are scratching their scalps as this could indicate a case of lice.

1. Once a Week, Take a Peek

Regular checking can identify a new case early. If a case is caught early enough, the life cycle of the louse can be interrupted. No further eggs will be laid and a case can be eradicated in just a few days. The best way to screen for head lice is to lather the hair with conditioner and thoroughly comb the hair out with a head lice removal comb (Professional Lice & Nit Terminator Comb), wiping the comb on a white paper towel after a few passes. Inspect the paper towel looking for brownish-colored eggs or actual bugs.

If checking for head lice visually, be sure to use direct sunlight or a very good table lamp. Carefully inspect the hair paying particular attention to the area when the hair shaft meets the scalp.  Look around the ear, nape of the neck and especially the crown of the head, as these are common areas for lice to be found.

When checking for head lice, look for lice eggs attached securely to the hair close to the scalp. Viable eggs will be brownish in color and cannot be flicked off the hair. They have to be removed between the fingernails, with tweezers, or with a good nit comb. Though head lice move very quickly, you may see an actual bug. Lice are the size of sesame seeds and are brownish-gray to caramel in color. They are see-through and can appear to take on the color of the hair.

Preventing Lice in the Community

It takes a community to prevent head lice. Advocating for regular lice screening in the school can go a long way to preventing a head lice outbreak. If children are regularly screened, cases might be identified and therefore treated before they have a chance to spread.

Professional screening staff from Larger Than Lice can provide screening services in schools, daycares and camps. For as little as $3 per head, each child can be checked for lice. School volunteers can also be trained to identify lice so that regular screenings can easily be scheduled.

Stop the Stigma

If you or a family member does contract head lice, don’t panic. This very common condition has nothing to do with cleanliness and it can be treated without the use of pesticides. Millions of North Americans have a head lice experience every year. A whole range of treatments is available and head lice removal services also exist in many communities nationwide.