Initial assessment
The management of pediculosis should begin by confirming the diagnosis through the identification of live lice. The presence of nits alone does not necessarily confirm active infestation, as they may represent empty eggs or remnants of a previous infestation.
Physical examination should focus particularly on the postauricular and occipital regions, where the parasites tend to cluster. The most common symptom is itching, although some children may remain asymptomatic.
Head lice infestation
For head lice infestation, first-line treatment options include topical permethrin 1% or dimethicone, depending on age, availability and contraindications.
Correct application of the product is essential, and the recommended contact time should be observed. As most pediculicides have limited activity against eggs, a second application on day 7–10 is usually recommended to eliminate newly hatched lice.
The use of a fine-toothed comb may help with the mechanical removal of lice and nits, although it does not replace pharmacological treatment.
Contacts and environmental measures
Close household contacts should be examined, and only those with evidence of active infestation should be treated. Hair cutting is not necessary and is not considered a recommended therapeutic measure.
Environmental measures should be simple and proportionate. Recently used bed linen, towels, clothing and hats should be washed, ideally at temperatures above 50–60°C.
Items that cannot be washed may be temporarily sealed in a closed bag. Brushes and combs may be cleaned with hot water.
Treatment failure
If live lice persist after appropriate treatment, reinfestation, incorrect application or treatment resistance should be considered.
In these situations, alternative treatments may be required, including ivermectin in selected cases or after multiple treatment failures.
Pubic lice infestation
The management of pubic lice infestation has additional considerations. Given the possibility of sexual transmission, recent contacts should be assessed and treated, and screening for sexually transmitted infections should be considered.
Possible extension to the eyebrows or eyelashes should also be assessed, as this may require specific treatment strategies.
Treatment goals
It is important to remember that the goal of treatment is not the complete removal of all nits, but rather the absence of live lice after appropriate treatment and clinical resolution of symptoms.
