Medical Professional Publications

What is your treatment plan for head lice, and when do you consider an individual treatment a failure?

Columbus, OH — October 2017

Patricia M. Witman, MDBy Patricia Witman, MD, Chief, Dermatology

If the patient has live lice 14 days after a therapy, most would consider that particular treatment a failure. Many treatments do require active nit picking (because they are not ovidical) in addition to applying medicine, which makes the treatment more challenging. In that scenario, it is not uncommon to see new nymphs ("baby lice") being born in the days following treatment as the eggs hatch. That is why a second treatment is necessary 7 days later for treatments that are not ovicidal.

Most still consider over-the-counter 1% permethrin cream rinse a first line treatment, but this is not entirely ovicidal and therefore requires nit picking and a second treatment in 7 days if lice are still being found. Nit picking is tedious, and complete removal of all of the nits is challenging for some families. Fortunately, paid nit-picking services now exist in many metro areas to help families. 

Other treatments are now available by prescription. Their arrival on the market has been driven by a rising resistance to permethrin in some areas of the country. Some of these treatments are ovicidal, and so do not require a second treatment or nit-picking. Coverage of these products by insurance companies varies. 

The treatments include:

Ovide lotion (malathion). This product was once taken off of the market by the FDA but brought back when resistance to permethrin was recognized in the late 1990’s. It is an organophosphate, and must not be used in infants due to concerns of toxicity. It must stay on the scalp for 8-12 hours, has a strong odor and is very flammable, so it is not recommended for smoking households. It is, however, almost 100% ovicidal, limiting the need for nit-picking or a second treatment.

Ulesfia lotion (5% benzoyl alcohol) was FDA approved in 2009 and is safe to use in infants 6 months and older. It is applied for only 10 minutes before washing out. This product is not ovicidal so nit-picking and possible retreatment may be necessary in seven days but 75 percent of patients achieve clearance by two weeks.

Natroba solution (0.9% spinosad in benzyl alcohol) has been available since 2011 and is also safe to use in infants 6 months and older. Applied directly to dry hair for 10 minutes before washing out, this product clears 85 percent of cases of head lice by 14 days with no nit-picking and only one treatment.

Sklice lotion (0.5% ivermectin) became available in 2012 for infants 6 months and older. Also applied to dry hair and washed out 10 minutes later, this product is about 75% effective in clearing lice in 14 days, also with no nit picking or retreatment.


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