Pediculosis capitis B85.0

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 18.01.2022

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Aphid infestation; Head lice; Head lice infestation; Head lice manifestation; Lice; Lice Eczema; Trichome; Vistula plait

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Infection with the head louse (Pediculus humanus capitis), a 2.0-3.5mm long, motile, slender parasite of the capillitium.

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Infestation with head lice is increasing worldwide. Pediculosis capitis is the most common epizoonosis in children. More than 100 million infections are suspected worldwide every year. In industrialized countries, the prevalence is estimated at 1-3%. Small endemics are reported repeatedly.

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The transmission is mostly direct from person to person, rarely via other articles of daily use such as caps, combs, brushes.

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Mainly occurring in children (especially at the age of 5-11 years) and people with long hair. Head lice are mainly transmitted during the winter months.

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Affected are the scalp hair, temple region, neck, retroauricular region. Rarely infestation of beard and pubic hair.

Clinical features
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Hours to days after the head lice bite, highly red, urticarial, very itchy papules and scratching effects with subsequent eczematisation (lice eczema) and possibly impetiginisation occur. Escaping secretion causes the hair to become sticky and matted ("Vistula plait"). Painful lymphadenitis in the occipital and neck area.

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Nep detection by inspection (possibly with magnifying glass) and nep comb. Nits adhere to the hair shafts and are visible to the naked eye as fine, bud-like nodules about 0.8 mm in size. Dark nits still contain larvae, light nits are empty shells. Unlike dandruff, nits are difficult to strip off. It is recommended to go through the hair strand by strand with a lice comb after a conditioner. After each comb stroke the comb should be wiped off on a light-coloured cloth. The rapidly moving lice are usually not visible during inspection.

Differential diagnosis
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General therapy
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School ban, no kindergarten attendance.

Restoration of the environment (contact persons, wigs, hairpieces, hats, combs, etc.). Restoration: keep objects sealed in a plastic bag at room temperature for 3 days.

Wash clothes and bedding at 60ºC (boil wash) or dry clean.

External therapy
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Standard therapies: Not only the lice but also the embryos in the nits must be killed safely!

  • Comb out the moistened hair treated with a conditioner (or better before with malathion [Organoderm; available through the international pharmacy]) with a fine nits comb (tooth spacing 0.2 mm) strand by strand.
  • Dimeticon preparations(=Polydimethylsiloxane; e.g. EtoPril, Nyda, Jacutin Pedicul Fluid) or combinations of silicone oils and castor oil (e.g. Itax) work by the physical principle of forming a breathable oil or silicone film. This suffocates the lice.
    • Aesculo Gel L Silicone/Castor Oil: use for at least 1-2 hours and then wash out.
    • Jacutin Pedicul®: 10 minutes' application time, then comb out the hair with a nit comb, then wash the hair with shampoo lukewarm. The application should be carried out 2 times at intervals of 3-7 days. Can be used at any age. Also during pregnancy and lactation.
    • EtoPril ® a 4% dimethicone application; exposure time: 8 hours. Then wash out.
  • 1% permethrin cream(e.g. Nix Creme; not approved in Germany, off-label use!) or 0.5% permethrin spirit (e.g. Infectopedicul) with good anti-parasitic but also relatively good ovoid effect. Rub the hair once for 30-45 minutes, then comb out the nits with a fine comb.

Alternative therapies:

  • Applypyrethrum extract, e.g. Goldgeist forte Lsg., to hairy head and distribute. Leave on for 30 minutes, then rinse with clean water. Cave! In infants, the procedure should only be performed under medical supervision! Substance is irritating to the scalp and can cause burning when applied. Do not apply to mucous membranes, protect eyes! Pyrethrum belongs to the pyrethroids, a chemically not exactly defined mixture of different substances. Pyrethrins, cinerines, jasmines. Pyrethrins are insecticidal ingredients of Chrysanthemum cinerariifolium and other chrysanthemum species; chemically they are esters of chrysanthemic acid or pyrethric acid.
  • Allethrin I, a synthetic analogue of pyrethrin ( pyrethroids, synthetic structural relatives of naturally occurring pyrethrins), e.g. Jacutin Pedicul Spray. Spray onto the hairy head, leave on for 10-30 minutes, rinse. Caution: The preparation is irritating to mucous membranes. Do not use on asthmatics.

Special questions

  • Treatment of the nits: Pre-treatment with a 3% vinegar solution (1 part 6% vinegar/2 parts water) to dissolve the glue that makes the nits adhere to the hair shaft. The hair is soaked with the vinegar solution, a towel is moistened and wrapped around the head. After one hour remove the towel, comb out the nits with a lice comb.
  • Pregnancy: use of vegetable pyrethrum extracts (e.g. Goldgeist forte) or allethrin (e.g. Jacutin Pedicul Spray, contraindication in the 1st trimester), see above.
  • Matting of the hair: cutting off the hair is highly recommended!
  • Pyodermization: In cases of pronounced pyodermized dermatitis of the capillitium and neck with swelling of the lymph nodes, the internal use of trimethoprim/sulfamethoxazole(e.g. Cotrimox Wolff; adults and children over 12 years 2 times/day 2 tbl.) or a broad-spectrum antibiotic (e.g. doxycycline 100-200 mg/day p.o.) for 6 days. Trimethoprim/Sulfamethoxazole kills living (bloodsucking) head lice.
  • After-treatment of the inflammatory changed capillitium with a glucocorticoid containing O/W-emulsion (e.g. Hydro-Wolff, as formulation: hydrocortisone emulsion hydrophilic 0,5-1%).

Internal therapy
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If local therapeutic methods fail, oral ivermectin can be prescribed as a single oral dose (200 ug/kgKG p.o.) with good success ( off-label use; evidence level Ib).

For pyoderma: trimethorpime/sulfamethoxazole is one of the most common triggers for SJS/TEN in children and should no longer be used (see page 543, Pediatric Dermatology Höger Edition 2021).

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Preparations containing coconut oil (e.g. Aesculo Gel L)

Soybean oil (Mosquito Lice Shampoo)

Less well documented is the effectiveness of tea tree oil, lavender oil and anise.

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  • Head lice can only crawl, not jump!
  • There is no medical obligation to register pediculosis capitis according to § 6 IfSG (Infektionsschutzgesetz). However, the managers of community facilities (e.g. kindergartens, schools) are obliged, according to §34 Abs. 6 IfSG, to inform the responsible public health department immediately of any detected head lice infestation and to provide personal information.
  • Infestation with head lice is not dependent on hygienic conditions. Frequent hair washing at most leads to "clean lice"!
  • Lindane has been banned by the WHO for use on humans since 2008!

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  1. Khosidov O et al (2010) Oral ivermectin versus malathion lotion for diffcult to treat head lice. N Engl J Med 362: 1199-1201
  2. Feldmeier H (2017) Putting the kibosh on head lice. Hautnah Dermatologie 33: 38-40.
  3. Hausstein UF (1991) Pyrethrins and pyrethroids (permethrin) in the treatment of scabies and pediculosis. Dermatologist 42: 9-15
  4. Jones KN et al (2003) Review of common therapeutic options in the United States for the treatment of pediculosis capitis. Clin Infect Dis 36: 1355-1361
  5. Nenof P (2014) Pediculosis capitis. Hautnah 30: 37-39
  6. Nofal A et al (2010) Oral ivermectin against head lice: a comparison with 0.5% topical malathion lotion. JDDG 8: 985-989
  7. Sadhasivamohan A et al (2021) Pediculosis capitis with Id reaction and plica polonica. Am J Trop Med Hyg 105: 862-863.
  8. Steinhorst M (2004) Coconut oil as a therapeutic alternative. Dermatologist 55: 329-330
  9. Witkowski JA, Parish LC (2002) Pediculosis and resistance: the perennial problem. Clin Dermatol 20: 87-92


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