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A 6-year-old girl was brought to the clinic by her father for concerns that she has lice. There was a case of lice diagnosed in one of the other students in her first-grade class 2 weeks ago. After hearing this, he bought permethrin 1% lotion from the store and applied it as directed in 2 applications 9 days apart. The second treatment was applied 2 days ago. He reports that despite the treatment, he thinks he can still see eggs in her hair. On exam of her hair and scalp under magnification, you see numerous translucent oval-shaped nits attached to her hair shaft approximately 2 inches from her scalp. You see no live adult lice or nymphs. Which of the following is true regarding the exam and treatment for this patient?

A. She has an active infection with lice. She should be treated with a second-line agent such as ivermectin 0.5% lotion to completely rid her of the infestation.

B. She no longer has an active infection. She needs no further topical treatment, but combing of her hair with a fine-toothed comb can help to remove the empty nits.

C. She has an active infection with lice. She should be treated with permethrin 1% lotion again as she failed the first treatment.

D. She no longer has an active infection with lice; however, she is at risk of repeat infestation. She should be treated prophylactically with a second-line agent such as ivermectin 0.5% lotion.

E. She has an active infection with lice. She should be treated with a second-line ovicidal agent such as lindane 1% lotion to completely rid her of the infestation.

Answer: B

The exam of this child shows that she no longer has an active infection with lice. She has no adult lice or nymphs on exam. She also has empty nits, no longer containing viable nymphs because they are ovoid, translucent, and on the hair shaft away from the scalp. Nits containing viable nymphs are ovoid shape and of brown coloration and are attached firmly within one-fourth of an inch of the base of the hair shaft. Nits are frequently found at the bilateral temples, behind the ears or near the neck. Nits are not a reliable marker of active disease and may appear viable on gross inspection for weeks after hatching or death of the nymph. Permethrin 1% lotion is an over-the-counter product approved for use in children > 2 months old and is recommended by the American Academy of Pediatrics. A second treatment with permethrin 9 days after the first is recommended as it is not ovicidal and nymphs ...

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