Guidelines for Nurse Practitioners in Gynecologic Settings 2016
Care Plan – Pediculosis
B85.0: Pediculosis due to Pediculus humanus capitis
I. DEFINITION
Pediculosis is the state of being infested with lice, which may be found on the skin, particularly on the hairy areas, such as the scalp and pubis, which may cause intense itching.
II. ETIOLOGY
A. Two species that look like each other but have different feeding habits are:
1. Pediculus humanus var. capitis inhabits the skin of the head or body; it is transmitted by shared clothing, towels, brushes, combs, batting helmets, stuffed animals, car seats, bedding, headphones, hats; P. humanus var. corporis body louse lives in clothes
2. Phthirus pubis (“crab louse,” pubic louse) inhabits the genital area but may colonize other areas, including axillae, eyelashes, head hair; it is transmitted by close personal contact, bedding
B. Nits hatch in 5 to 10 days of incubation; adult pubic lice probably survive no more than 24 hours off their host; nits can survive in hot and humid climates up to 10 days. Symptoms may manifest in 2 to 3 weeks to develop pruritus.
III. HISTORY
A. What the patient may present with
1. Pruritus
2. Visual identification of the parasite or its feces on bed pillow
3. Known exposure to household member or intimate partner with head, body, or pubic lice
4. Rarely, lymphadenopathy at back of neck; an allergic reaction to saliva and feces of lice
B. Additional information to be considered
1. Lifestyle
a. Shared clothing, towels, beds, and pillows
b. Shag rugs or carpets
c. Upholstered furniture
IV. PHYSICAL EXAMINATION
A. Pediculosis capitis (infestation with head lice): examine for
1. Parasite
2. Greenish-white oval attachments to hair shaft (nits)
3. Secondary impetigo and furunculosis
4. Cervical lymphadenopathy
B. Pediculosis corporis (infestation with body lice): examine for
1. Parallel linear scratch marks on back, shoulders, trunk, buttocks (areas easily reached for scratching)
2. Impetigo lesions and furuncles associated with scratch marks secondary to scratching
3. Lice on clothing, especially the seams, as lice are rarely found on the body
C. Pediculosis pubis (infestation with pubic [crab] lice): examine for
1. Parasite (rarely found)
2. Oval attachments on pubic hair (nits)
3. Black dots (representing excreta) on surrounding skin and underclothing
4. Nits in eyebrows, eyelashes, scalp hair, axillary hair, and other body hair
5. Crusts or scabs in pubic area
V. LABORATORY EXAMINATION
May be able to see parasite on microscope slide after removal from hairy area.
VI. DIFFERENTIAL DIAGNOSIS (SEE ETIOLOGY, II)
VII. TREATMENT
A. General measures
1. Wash all contaminated clothing, hats, towels, bedclothes, and so on with hot water, dry-clean, or run through a dryer on heat cycle to destroy nits and lice; wash combs and hairbrushes in hot soapy water, letting them soak for at least 15 minutes.
2. Spray couches, chairs, car seats, and items that cannot be washed or dry-cleaned with OTC product (A-200 Pyrinate [pyrethrin]), Triplex, or RID (permethrin); alternative is to vacuum carefully to pick up living lice and nits.
B. Specific treatment
1. P. capitis (infestation with head lice)
a. Thoroughly wet hair with permethrin 1% cream rinse applied to affected areas and washed off after 10 minutes or Triplex Kit (pyrethrins + piperonyl butoxide); Pronto (piperonyl butoxide), RID (permethrin) shampoo, or R&C shampoo (pyrethrins and piperonyl butoxide), or End Lice (pyrethrins and piperonyl); work up lather, adding water as necessary; shampoo thoroughly, leaving shampoo on head for 5 minutes; rinse or use Pronto shampoo/conditioner (piperonyl butoxide); or Clear lice-killing shampoo (pyrethrin based) and lice egg remover (permethrin based) per directions on product or Klout (nonpesticide ingredients include isopropanol, methylparaben, propylparaben) per directions on product.
b. Rinse thoroughly, towel dry
c. Remove remaining nits with fine-tooth metal comb or tweezers (use of vinegar solution and hair conditioner or olive oil make combing easier)
d. Use LiceMeister comb to remove nits and check hair preventively
2. P. corporis (infestation with body lice)
a. Bathe with soap and water if no lice are found
b. Wash with hot water and dry in dryer all clothing, bedclothes, towels, and so on
c. Dry-clean items that cannot be washed; for items that cannot be washed or dry-cleaned, seal in a plastic bag for 1 week—lice
will suffocate (in cold climates, put bags outside for 10 days; temperature change kills lice)
d. If evidence of lice is found or patient is not relieved by methods a and b, malathion 0.5% lotion is applied for 8 to 12 hours and thoroughly rinsed off.
3. P. pubis (infestation with pubic lice—also called crab lice)
a. Permethrin 1% cream (Nix) rinse applied to affected area and washed off after 10 minutes or
b. Pyrethrins with piperonyl butoxide (RID, Clear, A-200, Pronto, generics) applied to affected area and washed off after 10 minutes or
c. Malathion 0.5% lotion applied for 8 to 12 hours and thoroughly rinsed off or
d. Ivermectin 200 μg/kg in a single dose. Adult minimum/maxi- mum dose is 0.15 or 0.2 mg/kg. Taken with food to increase bio- availability and thus penetration of the drug into the epidermis
e. Pregnancy, lactation: use permethrin or pyrethrins with pipero- nyl butoxide, not lindane
f. Lindane is not recommended as first-line therapy because of toxicity; it should only be used as an alternative when other therapies fail and only in adults; not in pregnancy or lactation; limited to the recommended 4-minute period; not used imme- diately after a bath or shower.
g. Treat sexual partners within past month
h. Wash in hot water and thoroughly dry on heat cycle or dry- clean all clothing, bed linen, towels, and so on or remove from body contact for at least 72 hours
C. Stress the importance of careful checking of family and household members and close contacts; no treatment is needed unless there is evidence of contamination.
D. Put nonwashable items in hot dryer or spray with permethrin (RID, Nix)—check safety with children and pets
E. Screen patients with P. pubis for STIs
VIII. COMPLICATIONS
A. Secondary infection
B. Sensitivity reactions to treatment
C. Excoriations
D. Resistance of lice to pediculicides
IX. CONSULTATION/REFERRAL
A. Lice found in eyelashes: Because shampoo cannot be used, occlusive ophthalmic ointment is applied to the eyelid margins.
B. Treatment failures
C. Coexisting dermatologic conditions
X. FOLLOW-UP
A. Evaluate in 1 week if symptoms persist
B. Instruct patient to return for repeat treatment if symptoms or parasites recur
C. Treat with alternative regimen if patient’s infestation is nonresponsive
See Appendix I and Bibliographies.
Websites: www.health.state.ny.us/diseases/communicable/pediculosis/fact_sheet
.htm; http://www.headlice.org; www.medicinenet.com/image-collection/crabs_ pubic_lice_picture/picture.htm