Head lice: treatment, remedies and video visits in Puerto Rico

Head lice are insects 2 to 3 millimeters long that live on the scalp and feed on blood. Their eggs, called nits, are white specks stuck to the hair close to the scalp; unlike dandruff, they do not shake off. They take 6 to 9 days to hatch.

They spread mainly through direct head-to-head contact; less often, through shared hats, combs or towels. They are most common in preschool and elementary school children and the people who live with them. If your child itches around the bottom instead, especially at night, see pinworms. If the itch is on the body, between the fingers or on the wrists and worse at night, it may be scabies, which does not live in the hair. According to the AAP, it does not matter whether hair is clean or dirty: lice are not a sign of poor hygiene. Head lice do not spread disease.

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Head lice are handled in a doctor visit, the same price for every age, with no membership. You pay by card when you request the visit, and you get a full refund if the clinic can’t see you. We do not bill insurance; the pharmacy charges separately. See all prices.

The most common signs are:

• An itchy scalp, the most common sign
• A tickling feeling, or a feeling of something moving in the hair
• White specks (nits) stuck to the hair near the scalp
• Red bumps or sores on the scalp from scratching

Head lice do not need a lab test: they are diagnosed by seeing them. First-line treatment is sold over the counter. Permethrin 1% is approved from 2 months of age and pyrethrins from 2 years. Neither kills every nit, which is why you treat twice.

• Use the product exactly as the label says. Do not use conditioner or a shampoo with conditioner before, and do not wash the hair for 1 to 2 days afterwards.
• Use a metal nit comb every 2 to 3 days for 2 to 3 weeks.
• Treat again after 7 to 9 days, depending on the product.
• Check everyone in the household and treat everyone who has lice at the same time.
• Do not use more product, or use it more often, than the label says.

If you still see live lice after following these steps carefully, get checked. There are prescription options for children from 6 months of age, depending on the medicine. The doctor chooses based on your child’s age and what you have already tried.

The lice treatment with evidence behind it is an FDA-approved product used exactly as labeled, plus a nit comb. According to the CDC, the over-the-counter options are permethrin 1% (from 2 months) and pyrethrins with piperonyl butoxide (from 2 years). Prescription options include benzyl alcohol and spinosad lotions (from 6 months) and malathion (from 6 years). Ivermectin 0.5% lotion (from 6 months) is another option; the FDA approved it for nonprescription sale in 2020.

Home remedies are not proven. The CDC says it has no scientific evidence that smothering lice with mayonnaise, olive oil, margarine, butter or similar substances works. Skip sprays and fogs too: they can be toxic if breathed in or absorbed through the skin. If a product failed, don’t layer another one on top by yourself: the doctor reviews what you used and how, because the problem is often conditioner or a missed second treatment.

Lice do not survive long off the head, so there is no need for extreme cleaning:

• Wash clothes, sheets and towels used in the 2 days before treatment in hot water (130 °F or 54 °C) and dry them on high heat.
• Seal anything that cannot be washed in a plastic bag for 2 weeks.
• Vacuum floors and furniture.
• Do not use sprays or fogs: they are not needed and can be harmful.

Does your child need to miss school? The American Academy of Pediatrics (AAP) says a child should not miss or be excluded from school because of head lice, and discourages "no-nit" policies. Your child can finish the day and start treatment at home. If your child has a rash you are not sure about, see rash in children.

Head lice are almost never an emergency. For your safety, call 911 if someone has trouble breathing or swelling of the face or lips after using a product. If someone swallowed a lice product or got it in their eyes, call Poison Help at 1-800-222-1222. Get checked soon if the scalp is red, warm or has pus. See when to go to the ER.