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Referral and warning signs
When to refer
Refer if: Diagnosis uncertain. Treatment failure after appropriate therapy. Severe secondary infection. Eyelash infestation needing confirmation/guidance. Suspicion of disease transmission by body lice.
Red flags
- Signs of severe secondary bacterial infection.
- Suspicion of typhus or other louse-borne disease (body lice).
Signs and symptoms
- Head Lice (Pediculosis Capitis):
- - Itching (pruritus) of the scalp (often intense).
- - Visualization of live lice (small, greyish insects) moving on scalp/hair.
- - Visualization of nits (eggs) firmly attached to hair shafts (small, oval, white/yellowish dots). Nits >1cm from scalp are usually hatched/non-viable.
- - Excoriations, secondary bacterial infection, cervical lymphadenopathy (severe cases).
- Body Lice (Pediculosis Corporis):
- - Itching, mainly on trunk/neck.
- - Lice/nits found primarily in seams of clothing, not usually on body.
- - Excoriations, secondary infection, post-inflammatory hyperpigmentation ('vagabond's disease' in chronic infestation).
- - Associated with poor hygiene, homelessness, crowded conditions. Can transmit diseases (typhus, trench fever, relapsing fever).
- Pubic Lice (Pediculosis Pubis / Pthiriasis):
- - Itching in pubic area, axillae, eyelashes, eyebrows.
- - Visualization of crab-like lice attached to skin/hair base.
- - Nits attached to hair shafts.
- - Bluish-grey macules (maculae ceruleae) on skin where lice have fed.
- - Usually sexually transmitted.
Risk factors
- Head Lice: Close head-to-head contact (school children common), sharing hats/combs/brushes.
- Body Lice: Poor hygiene, lack of regular bathing/laundering, homelessness, crowded conditions.
- Pubic Lice: Sexual contact, sharing bedding/towels.
Diagnosis
Clinical assessment
Diagnosis based on visualization of live lice or viable nits (close to scalp for head lice) on examination of affected area (scalp, body clothing seams, pubic hair).
Differential diagnosis
- Head Lice: Seborrhoeic dermatitis (dandruff - scales flake off easily), Hair casts, Psoriasis, Tinea capitis.
- Body Lice: Scabies, Eczema, Insect bites.
- Pubic Lice: Scabies, Folliculitis, Eczema.
Investigations
- Visual inspection is key.
- Wood's lamp may make nits fluoresce slightly.
Management
Non-pharmacological management
- Head Lice:
- - Wet combing with fine-toothed nit comb: Systematically comb through wet, conditioned hair section by section to remove lice/nits. Repeat every 3-4 days for 2 weeks. Can be used alone or adjunct to pediculicides.
- - Avoid sharing combs, brushes, hats.
- - Wash bedding/clothing in hot water.
- Body Lice:
- - Improve Hygiene: Regular bathing.
- - Launder Clothing/Bedding: Wash items in HOT water (>55°C) and dry in hot dryer. Ironing seams can kill lice/nits.
- - Discard infested items if washing not possible.
- - Pediculicide treatment of body usually NOT necessary if hygiene/laundering adequate.
- Pubic Lice:
- - Avoid sexual contact until infestation cleared.
- - Treat sexual partners concurrently.
- - Wash clothing/bedding in hot water.
- - Shaving affected area (UCG suggestion).
Pharmacological treatment
- Pediculicides:
- - Head Lice:
- - Permethrin 1% lotion/cream rinse: Apply to shampooed, towel-dried hair, leave 10 mins, rinse. Repeat in 7-10 days.
- - Malathion 0.5% lotion: Apply to dry hair, leave 8-12h (overnight), wash out. Flammable. Repeat if needed in 7-9 days.
- - Benzyl Alcohol 5% lotion.
- - Spinosad suspension.
- - Ivermectin lotion (topical) or Oral Ivermectin (off-label, for resistant cases - specialist).
- - UCG recommends Benzyl Benzoate 25% application overnight (dilute for children). (LOC: HC2)
- - Body Lice: Treat clothing/bedding. Topical pediculicide if heavy infestation on body hair.
- - Pubic Lice:
- - Permethrin 1% cream rinse OR Pyrethrins with Piperonyl Butoxide: Apply to affected areas, leave 10 mins, rinse. Repeat in 7-10 days.
- - Malathion 0.5% lotion (apply 8-12h).
- - Oral Ivermectin (alternative if topicals fail/contraindicated).
- - UCG recommends Benzyl Benzoate 25% application overnight (dilute for children). (LOC: HC2)
- - Eyelash Infestation (Phthiriasis palpebrarum): Apply bland ophthalmic ointment (e.g., Vaseline) thickly to lashes BID for 10 days to suffocate lice. Manually remove nits. Avoid topical pediculicides near eyes.
- Treat Secondary Bacterial Infection: If present, with appropriate antibiotics.
Monitoring
Check for live lice 24h after treatment and again at 7-10 days (before repeat application if needed). Monitor for re-infestation.
Complications
- Secondary bacterial infection (impetigo, cellulitis).
- Excoriation, eczematization.
- Psychosocial distress, stigma.
- Transmission of disease (body lice - typhus, trench fever, relapsing fever).
Prevention
- Regular surveillance in schools (head lice).
- Avoid head-to-head contact.
- Avoid sharing personal items (hats, combs).
- Good personal hygiene (body lice).
- Safe sexual practices, partner notification (pubic lice).
- Treating infested individuals and contacts promptly.
Patient education
- Explanation of lice infestation and type.
- Correct use of pediculicide treatment (application time, need for repeat).
- Importance of wet combing (head lice).
- Environmental measures (washing clothing/bedding).
- Need to treat contacts (household for head lice, sexual for pubic lice).
- Prevention of re-infestation.
- Reassurance that lice do not reflect overall cleanliness (head lice).
Uganda-specific notes
Head lice very common in schoolchildren. Body lice associated with specific populations (displaced persons, poor hygiene). Benzyl Benzoate often recommended in UCG, Permethrin/Malathion availability varies. Emphasis on combing/environmental measures important.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 22, Section 22.4.2