Source: Manual of Ambulatory Pediatrics 2010
SOAP Note – Pediculosis Capitis, Corporis, and Pubis
Pediculosis capitis, or human lice that live in the hair; Pediculosis corporis, or human lice that live on the body and in seams of clothing; Pediculosis pubis, or human lice that live in pubic hair, and may also infest the eyebrows, eyelashes, beard, moustache, and hair of the trunk and legs.
I. Etiology
A. Capitis: Pediculus humanus capitis (head louse)
B. Corporis: Pediculus humanus corporis (body louse)
C. Pubis: Phthirus pubis (pubic, or “crab,” louse)
D. These lice, which are in the order Anoplura, are ectoparasites. They are sucking lice and are completely dependent on their host’s blood for nourishment.
E. They are transmitted by close personal contact and by clothing and bedding.
F. Because they are obligate parasites, they cannot survive away from their hosts for more than 10 days. However, most pubic or head lice that are on fomites are dead or dying, so the danger of spread from toilet seats, for example, is minimal.
II. Incidence
A. Occurs without regard to socioeconomic status, age, or sex
B. Infestation is seen most frequently in areas of overcrowding where sanitation facilities and hygiene are poor.
C. In general, lice are more common among children than adults and females than males.
D. Pubic lice are commonly found on adolescents who are engaged in multiple sexual relationships.
E. Head lice are common among elementary school children.
F. African Americans are rarely infested.
G. Infestation by pediculosis capitis and pubis is nearly always by direct contact; they cannot fly or jump, they crawl from host to host.
H. Pediculosis corporis is transmitted by clothing as well as by direct contact.
III. Incubation period for ova
A. Variable depending on temperature, but averages 8 or 9 days
B. Ova may lie dormant for up to 35 days.
C. Ova develop to adulthood in 10 to 15 days and generally live for 30 days.
D. Newly hatched nymphs must feed within 24 hours to survive.
IV. Subjective data
A. Pediculosis capitis
1. Pruritus of scalp
2. “Bugs” in head
3. “Dandruff” that sticks to hair
4. History of exposure
B. Pediculosis corporis
1. Pruritus of body
2. Multiple bite and scratch marks, particularly on upper back, around the waist, and on upper arms
3. History of exposure
C. Pediculosis pubis
1. Pruritus of pubic area; most intense at night
2. Multiple bite and scratch marks in pubic area
3. “Bugs” in pubic hair, in eyebrows, or in axillae
4. History of exposure
V. Objective data
A. Pediculosis capitis
1. Lice on scalp; most commonly found behind the ears and the back of the head
2. Ova visualized as whitish ellipsoids on hair shafts, firmly attached and difficult to remove. These are the usual signs of infestation.
3. Bites on scalp
4. Scratch marks on scalp; may be secondarily infected
5. Occipital and cervical adenopathy
B. Pediculosis corporis
1. Body lice rarely found
2. Lice found in seams of clothing
3. Bite marks where lice have fed, generally on upper back, waist, and axillae
4. Excoriations from scratching
5. Secondary infections in areas of excoriations
6. Regional adenopathy
7. Occasionally, nits on body hair
C. Pediculosis pubis
1. Lice attached to pubic hair
2. Lice may also be found in eyebrows, axillae, thighs, and beard.
3. Ova visualized as whitish ellipsoids firmly attached to hair shaft
4. Bite marks on abdomen, lower thighs, and genital area (bluishgrey, faint purpuric-like lesions)
5. Excoriations from scratching
6. Secondary infections in areas of excoriation
7. Inguinal adenopathy
8. Rule out sexual abuse if found in child.
VI. Assessment
A. Diagnosis is made by the characteristic signs and symptoms and by history of exposure.
B. With head and pubic lice, diagnosis is generally made by observation alone.
VII. Plan
A. Follow selected treatment plan.
1. Do not overtreat.
2. Chemical irritation from medication or hypersensitivity to the bite of the louse may result in persistent itching and may be misinterpreted as treatment failure.
3. Order only enough medication for the treatment schedule.
B. For all infestations, all family members and other close contacts should be examined and treated if any evidence of lice or nits is found. All sexual contacts should be treated simultaneously.
C. Pediculosis capitis
1. Nix Creme Rinse (permethrin 1%)—OTC
a. Shampoo and rinse hair; towel dry.
b. Apply Nix Creme Rinse; thoroughly saturate hair and scalp.
c. Allow Nix to remain on hair for 10 minutes, then rinse.
d. Repeat application in one week
e. Advantages
(1) Ovicidal
(2) Active for 14 days after treatment
(3) Action of rinse not affected by shampooing
(4) 83% effective
(5) Minimal systemic absorption
(6) No potential for sensitization or
2. Ovide (malathion lotion 0.5%); for use in children over 6 years
a. Apply to dry hair—an amount sufficient to wet hair and scalp
b. Allow hair to dry naturally—uncovered
c. Leave on for 8–12 hours
d. Shampoo and fine comb hair
e. Repeat application if lice present after 7–9 days
f. Ovide lotion is flammable—keep child away from open flames or electric heat source
or
3. Kwell shampoo (lindane 1%); do not prescribe for pregnant women, children under 2 years of age, or children with a history of seizures. Prescribed as second line of treatment.
a. Shampoo with regular shampoo and dry thoroughly.
b. Apply Kwell shampoo to dry hair without adding water. Work thoroughly into hair.
c. Leave in hair for 4 minutes.
d. Add water to lather.
e. Rinse thoroughly, avoiding contact of lather with other body surfaces.
or
4. OTC products
a. Rid (pyrethrin), A200 (pyrethrin), Lice Arrest (enzyme-based)
b. Use according to manufacturer’s instructions. or
5. Wet combing—good option for children under 2 years
a. Wet hair and add lubricant such as hair conditioner or olive oil
b. Comb hair from the scalp to the end with a fine tooth comb
c. Comb all parts of the hair twice, inspecting for lice and nits with each pass.
d. Repeat the process every 3–4 days for several weeks
e. Continuing combing for two weeks after a live louse is found.
6. Comb out all residual eggs and nits (egg cases); this is a critical component of successful treatment.
7. Repeat treatment in 10 days to prevent reinfestation. Most lice hatch in 6 to 9 days.
D. Pediculosis corporis
1. Because body lice are rarely found on the body except when they are feeding, hygiene, clothing, and bedding are the main foci of treatment. Pediculicides may be used if lice are found on the body.
2. Kwell cream or lotion (lindane)
a. Bathe or shower thoroughly. Allow skin to dry and cool.
b. Apply cream or lotion to affected hairy areas and surrounding skin and to suspect areas.
c. Leave medication on for 8 to 12 hours.
d. Shower or bathe thoroughly with soap and warm water.
e. Bed linen and clothing must be changed and laundered or dry cleaned.
f. Application may be repeated in 4 days if necessary. or
3. RID
a. Bathe or shower thoroughly. Allow skin to dry and cool.
b. Apply RID to all infested areas and suspect areas until wet; do not apply to eyelashes or eyebrows.
c. Allow to remain on for 10 minutes.
d. Bathe or shower thoroughly with soap and warm water.
e. Bed linen and clothing must be changed and laundered or dry cleaned.
f. If necessary, treatment may be repeated once only in 24 hours.
4. Clothing (see Education, below)
5. Treat all sexual contacts prophylactically.
E. Pediculosis pubis
1. Kwell lotion (lindane).
a. Shower and towel dry.
b. Apply sufficient quantity to thinly cover skin and hair of pubic area and, if involved, the thighs, trunk, and axillae.
c. Rub into skin.
d. Leave lotion on for 8 to 12 hours.
e. Shower thoroughly.
f. Repeat treatment in 7 days. or
2. Kwell shampoo
a. Shower and towel dry.
b. Apply sufficient shampoo to thoroughly wet hair and skin of affected and adjacent hairy areas.
c. Add small amount of water, working shampoo into hair and skin until lather forms.
d. Allow to remain for 4 minutes.
e. Rinse thoroughly.
f. Towel dry.
g. Repeat application after 7 days if living lice were found on exam.
3. Oral antihistamine (rarely indicated if treatment has been effective); Benadryl, 12.5 to 25 mg tid
4. Treat all sexual contacts prophylactically.
F. Infected lesions: Follow protocol for Impetigo (see p. 322).
VIII. Education
A. Infestation with lice can be a traumatic emotional experience for both the child and family. Education and support are important in helping them cope with the problem.
B. Lice are highly contagious and can affect all social classes.
C. Most head and pubic lice that are on inanimate objects are dead or dying.
D. Human lice are not transmitted by animals; they live and breed only on humans.
E. Lice cannot jump or fly from one person to another.
F. Head lice are transmitted by direct contact with an infested person’s hair or by contact with hats, brushes, combs, or bedding. Head lice can crawl from one place to another.
G. Head lice do not normally live on the hair shafts of African Americans.
H. Head lice will leave the body if the host temperature rises due to fever or drops due to death. (Ova cannot hatch at temperatures below 22C.)
I. Eggs are laid close to the scalp. Because hair grows approximately a quarter inch each month, any eggs found a greater distance from the scalp are probably empty shells.
J. Do not borrow combs, barrettes, ribbons, hats, helmets, scarves, or pillows.
K. Do not stack or hang coat or hat so it is touching another person’s clothing.
L. Nits must be removed with a fine-tooth comb or manually. No pediculicide is 100% successful in destroying nits.
M. Body lice are transmitted by direct contact or by contact with infected clothing or bedding.
N. Lice usually cling to clothing, particularly in the seams, and are least prevalent in areas where personal and general hygiene are good.
O. Pubic lice are transmitted through close personal contact and through clothing, bedding, and, less commonly, toilet seats.
P. Pubic lice are particularly common among people age 15 to 25, probably because of close physical contact, especially sexual intercourse.
Q. Do not use lice spray on a person or a pet.
R. Laundry
1. Use hot water and detergent.
2. Use hot dryer.
3. Use hot iron.
4. Change all clothing and bed linen daily.
S. Woolens
1. Dry clean.
2. Press with hot iron, paying particular attention to seams of clothing if infestation with body lice.
3. If expense of dry cleaning is prohibitive, place articles in sealed plastic bag for 35 days (ova generally hatch in 8 to 9 days but may remain dormant for up to 35 days, and newly hatched nymphs must feed within 24 hours to survive).
T. Furniture
1. Vacuum.
2. Use R&C Spray (lice-control insecticide) on upholstered furniture. or
3. Use hot iron on upholstered furniture.
4. Damp dust or wash other furniture.
U. Kwell
1. Avoid unnecessary skin contact. If treating more than one child, use rubber gloves for applying.
2. Do not use on open cuts or extensive excoriations.
3. It has no residual effects; therefore, it should not be used for prevention.
4. Kwell requires a prescription.
V. Notify school nurse. Most schools have a “no nit” policy.
W.Examine all contacts.
X. Do not treat prophylactically; this can increase the possibility for resistance to develop.
Y. All treatment failures do not represent resistance. It may indicate improper procedure or re-exposure.
IX. Follow-up: Recheck in 3 to 5 days if child presents with secondary infection.
X. Complications
A. Secondary bacterial infection
B. Concomitant sexually transmitted diseases seen with pediculosis pubis
XI. Consultation/referral
Concomitant sexually transmitted disease, such as gonorrhea, syphilis,
Trichomonas, Chlamydia
XII. Resource
National Pediculosis Association, Inc. Address: PO Box 610189, Newton, MA 02461. Telephone: 781-449-NITS. Website: http://www.doit4thekids.org, http://www.headlice.org