Head Lice: a report for Consultants in Communicable Disease Control (CCDCs)

Headlice: notes and guidance for the primary care team

General

• Please read the attached Statement carefully.
• Head louse infection is not primarily a problem of schools but of the wider community.
• As for any other infectious condition in their patients, primary care teams should be knowledgeable and competent in the control of head lice. They should be able to teach patients the technique of detection combing, and be prepared to advise appropriate treatment when there is confirmed infection.
• Health professionals should make sure that they are able to identify a louse at all stages of its development. It helps to have a magnifying glass to hand.
• Patients should be made aware that head lice are only transmitted by direct, prolonged, head-to-head contact.

Specific

• Do consider nominating a member of staff to be responsible for advising patients on head louse problems. This may be a practice nurse or health visitor, but other non-clinical staff may be appropriate as a first contact. If examination is thought necessary, referral can then be made.
• Do consider asking the Consultant in Communicable Disease Control to arrange training for nominated persons from local practices.
• Do liaise, as appropriate, with your local pharmacists, school nurses, health visitors, head teachers, infection control nurses, and Consultant in Communicable Disease Control. Only a concerted approach can be effective.
• Do not refer patients to the School Nurse.
• Do adhere to the following principles of control:

  • definite diagnosis; a living, moving louse found by detection combing
  • listing and examination of contacts
  • simultaneous thorough and adequate treatment of all confirmed cases with one of the standard chemical insecticidal lotions
  • repeat of the treatment after seven days

• Do make sure that the patients are provided with information, advice and support. At a first consultation, it may be sufficient to ensure that they know how to undertake detection combing and what to do if there are head lice present (See Appendices 5 and 6: "Have you got head lice" and "How to treat head lice".)
• Do not confirm a diagnosis of head louse infection unless you yourself have seen a living, moving louse, or you have physical evidence from the patients; ask them to stick one of the lice on a piece of paper with clear sticky tape and bring it in.
• Do be aware that patients are often mistaken when they believe they have lice. Recurrent scalp problems may be missed if it is simply assumed without evidence that lice are the cause.
• Do make every effort to discourage unnecessary or inappropriate treatment with insecticides.
• Do not ever recommend treatment unless a louse has been clearly identified (as described above). If you do recommend treatment, ensure that it is done adequately for the case and infected contacts.
• Do make sure that patients know that the correct use of insecticidal lotions is the scientifically confirmed way to treat head louse infections.
• Do follow the British National Formulary’s recommendation of two applications of lotion (not shampoo) seven days apart.
• Do not assume that "reinfections" or "treatment failures" are truly infections. Make sure that a louse is found or produced.
• Do not ever recommend retreatment without first of all establishing that living, moving lice are still present after two applications of lotion seven days apart and after a full professional assessment as to the ways in which the family may not have complied carefully with the first attempt.
• Do resist the temptation to agree with parents’ suggestions that a first course of treatment has failed, that "it must be a resistant strain", and that a further course of treatment should be given. There is no substitute for a proper professional assessment.
• Do seek the advice of the local Consultant in Communicable Disease Control on appropriate insecticidal lotions. Generally, malathion or one of the pyrethroids is considered as first line treatment, and carbaryl as second line treatment.
• Do consider using carbaryl for cases in which true resistance to one of the other agents has been established (see above). There is so far little resistance to carbaryl, but it is available only on prescription.
• Do bear in mind that different formulations of the same active ingredient may have different efficacies. When a first treatment has definitely failed, it may be useful to try the same agent in a different formulation.
• Do not recommend or support any mass action, including wet combing campaigns.
• Do not support the use of electronic combs, repellent sprays, or chemical agents not specifically licensed for the treatment of head louse infections.

(This document was originally appendix 1 of Head Lice: a report for Consultants in Communicable Disease Control (CCDCs).)