Tackling head lice in schoolchildren

16 November 2018

First published August 2012

What are the best strategies for controlling head lice?

Head lice (Pediculus humanus capitis) are man's most common ectoparasite. They can affect anyone of any age, but in the UK, they are particularly common amongst children of primary school age (4-11 years).1


Around the world, estimates of head lice prevalence in children vary widely - from about 1 to 60%.2 Levels are generally lower in Europe, but regional studies indicate that head lice are still a significant problem in primary schools throughout the UK. In a study of 31 Welsh primary schools, 8.3% of the 2,793 children screened had head lice.4 In a questionnaire-based survey involving 21,556 children from 204 Essex primary schools, 37% of parents reported that their child had head lice during the previous year. 5 

People often think head lice are more prevalent in autumn, but incidence doesn't follow a clear seasonal pattern.2

Children can pick up head lice through close head-to-head contact at any time of year. However, the start of a new school term is a particularly common time for parents to detect head lice - possibly because this is when they are most aware of the problem.


Children may find the feeling of lice moving through their hair a nuisance, and some children develop intense itching, but head lice don't cause any significant physical health problems. Their main impact is psychological. Children suspected of having head lice can suffer intense anxiety, embarrassment and shame - whether they actually have head lice or not. Head lice provoke strong negative reactions in most people, and unfortunately, the associated stigma therefore persists. 2 In consequence, children may encounter bullying and unkind comments from those who mistakenly believe that catching head lice indicates poor cleanliness and a lack of hygiene. Misguided teachers might also inappropriately exclude affected children from school. This may add to the child's distress, increase their sense of isolation, and potentially damage their self-esteem.

Children's head lice infections also cause anger, annoyance and frustration amongst parents. They may unjustly blame infections on the inaction of others and criticise the child's school for not addressing the problem. This can lead to inappropriate over­reactions by the school and a great deal of unnecessary distress for everyone.

Does the child really have head lice? 

Often, children thought to have head lice do not actually have them at all. Misdiagnosis may result from:

  • Psychogenic itching (prompted by hearing about head lice)
  • Eczema, scalp psoriasis, or other causes of itchy scalp
  • Discovery of dandruff, hair muffs, or other debris in the hair
  • Extinct infections with persistent itching or nits (empty egg cases) remaining in the hair. 

Children should only be diagnosed with head lice when a living head louse is found amongst their hair. 1

The role of the community practitioner

As a community practitioner, you have a vital role to play in providing parents and schools with support and practical advice. This section provides best-practice advice to help you guide your clients.

Lessons in lice

Ideally, parents of primary school children should receive advice about head lice on a regular basis - not just when concerns are raised or in reaction to an outbreak. Letters notifying parents about outbreaks in school can produce unnecessary alarm and inappropriate prophylactic treatment and are not advisable. Instead, school nurses should work with their primary schools to ensure every parent receives appropriate and consistent head lice information - preferably as part of a package with other issues - before their child joins the reception class and at regular intervals throughout each school year. Health visitors can support this process by presenting head lice advice as early as the 18-month screening and reinforcing this at the pre-school stage.

Schools may be just as misinformed as parents, so it is useful if school nurses share advice with school staff too. And, all community practitioners should be prepared to teach the appropriate detection technique and recommend suitable treatment options.

Detection advice

The most reliable way to determine if a child has head lice is to systematically comb through their hair using a lice detection comb. These reusable plastic combs have parallel-sided teeth, spaced <0.3 mm apart - dose enough to trap the smallest nymph.1 Detection combing can be done when the hair is wet or dry, but a recent review concluded that wet combing was the optimal method.7 Having to wash the child's hair and apply conditioner makes wet combing a little more time consuming. However, the conditioner makes combing easier ( for both parties) and helps stop the lice crawling away. The sensitivity of the wet combing method is 90% - even when very few lice are present. 7

Box 1: Facts of lice for parents

  • Head lice are six-legged insects, not much bigger than a pinhead.
  • Anyone can catch head lice - they don't care if hair is dirty or clean.
  • Head lice spread through direct head­to-head contact - which often happens between children. 
  • Head lice can't jump, swim or fly, but they can crawl quickly (about 23 cm per minute) along hairs, from one head to another. Transmission on clothes, brushes, hats, and other items is unlikely.
  • A 'nit' is just an empty egg case that remains firmly stuck to the hair after the louse has hatched.
  • Having nits doesn't necessarily mean you have head lice. 
  • Head lice cause itching - and little else.


School nursing service doesn't routinely screen children for head lice and that this is a parental responsibility. As detection combing takes 5 to 15 minutes per head (depending on hair length), thorough screening of every child at school is not feasible. Community practitioners should encourage parents to check their children's hair for lice regularly using the correct method. Ideally, parents should do this once a week as part of their child's usual hygiene routine - perhaps every Sunday evening or at bath time. It is important to emphasise that nits are empty lice eggs and that finding nits in their child's hair doesn't necessarily mean that they have head lice. Live lice must be seen to confirm the diagnosis. 

Wet detection combing - a step-by-step guide for parents

  1. After washing hair as usual, apply ample conditioner and leave it in.
  2. Untangle the hair using a normal comb.
  3. If the hair is long, it may help to divide the hair into sections using clips.
  4. Switch to using a lice detection comb (available from pharmacies) and comb the hair section by section.
  5. Slot the teeth of the lice comb into the roots and draw it down to the tips of the hair at every stroke.
  6. After each stroke, check the comb for lice, or wipe the comb on a tissue and check for lice on that.
  7. Once you have found a live louse or you have finished combing through all the hair, rinse out the conditioner.
  8. If you are unsure if what you have found is a louse, stick it to a piece of paper with sticky tape and ask your GP, school nurse or health visitor to check. 

Breaking the cycle of infection

If a parent finds a live louse on their child's hair, they should ensure that all other household members (including themselves) have their hair checked by detection combing. Those found to have head lice ( or their parents) should contact anyone likely to have recently had head-to-head contact and advise them to check for lice too. Parents should be reminded that this could include: 

  • siblings, grandparents and other relatives
  • friends and classmates
  • teachers and childminders
  • after-school dubs/teams ( e.g. rugby team, dance class, Cubs, Brownies, etc.).

Parents may be embarrassed about contacting others, but this is necessary to break the cycle of infection and help stop their child being re-infected. Ideally, all contacts found to have live head lice would be treated simultaneously.

School head lice policies

Parents need to understand that regular detection combing and prompt treatment are necessary to stop head lice spreading, but that there is no need for children with head lice to be kept away from school or any other setting.8 Head lice are not a major health problem and children shouldn't miss valuable schooling because of them. In many cases, the lice will have been present long before detection anyway.

Treatment advice

Once head lice are confirmed, parents should be advised to treat the problem as quickly as possible using one of the clinically proven treatment options (see Figure 2).1

Physical removal

One option is to physically remove the lice by wet combing. This requires at least four combing sessions over a 2-week period, continued until no lice are seen for three consecutive sessions. The method is similar to detection combing but takes longer as the comb must be carefully deaned of lice after every stroke, and the procedure has to be repeated after washing out the conditioner. The method is suitable for all ages and can be recommended as an option for pregnant and breastfeeding women. However, the process is laborious and time­consuming - especially for parents who need to treat several family members at the same time. Even with meticulous combing it only offers a 50-60% success rate. 1


Topical pediculicides can provide parents with a more effective and convenient way to tackle head lice. There are two main types. Chemical pediculicides ( also known as neurotoxic or traditional insecticides) kill head lice by disrupting their nervous system. Physical pediculicides kill lice by coating them in an oily substance, causing them to dehydrate or suffocate.

Treatments to recommend (where suitable) include the chemical pediculicide, malathion 0.5% aqueous liquid - a water­based formula that kills lice and eggs when applied overnight, or one of the physically acting pediculicides: 

  • Isopropyl myristate/cydomethicone solution (IPM/C)
  • Coconut, anise and ylang ylang spray, or
  • Dimeticone 4% lotion.

Head lice have increasingly developed resistance to older chemical pediculicides, such as permethrin. However, resistance is unlikely to develop with the physical pediculicides, so complex rotational or mosaic treatment policies are not necessary when using these.

Parents may seek your advice about which treatment they should try. Success rates are generally highest with the physical pediculicides, but there are various other pros and cons to consider.1 For example, dimeticone 4% lotion must be applied for 8 hours, whereas IPM/C has a quick and easy 10-minute treatment time. Whichever option parents select, it is important to check its suitability for their child (or anyone else needing treatment) and remind them to follow the instructions carefully.

Maximising success

You should explain to parents that they could maximise their chances of success if they treat all affected contacts simultaneously and apply the treatment correctly ( according to the instructions). Most treatments require a second application after 7 days because the first might not kill all the louse eggs. The second application kills the lice that hatch in the intervening period. Parents should be encouraged to check treatment success by detection combing 2-3 days after completing a course of treatment, and again 7 days later.1 Do remind parents that it is usual to find empty egg cases (nits) long after the lice have gone. They can use a fine-toothed nit comb to remove these.

Figure 2
Persistent lice problems 

When a parent reports that a treatment hasn't worked, there are several possible explanations: 

  • Misdiagnosis
  • Use of treatment formulation of unproven efficacy ( e.g. shampoo and mousse)
  • Treatment not applied correctly ( e.g. insufficient volume or treatment time)
  • Re-infection due to affected dose contacts not being treated simultaneously
  • Head lice resistant to treatment ( not an issue with physical pediculicides).

Families with recurrent or continuing head lice may need your support to deal with the problem. This may involve visiting the family at home. It is vital to check that the child actually has an ongoing head lice problem, recommend all dose contacts are checked, and reiterate appropriate treatment advice. If you suspect a genuine treatment failure, you should advise the parent to try one of the alternative treatment options. 





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  1. CKS (2010) Head lice. NHS Clinical Knowledge Summaries. Available at: www.cks.nhs.uk/head lice [Accessed 10 April 2012].
  2. HEUKELBACH J (2010) Management and control of head lice infestations. Bremen, UNI-MED.
  3. FELDMEIER H (2012) Pediculosis capitis: New insights into epidemiology, diagnosis and treatment. Eur J Clin Microbial Infect Dis 2012 Mar 1 [Epub ahead of print]. Available at: www.nchj.nlm.nih.gov/pubmed/22382818 [ Accessed 10 April 2012].
  4. THOMAS DR, McCARROLL L, ROBERTS R, et al (2006) Surveillance of insecticide resistance in head lice using biochemical and molecular methods. Arch Dis Child91(9);777-778.
  5. HARRIS J, CRAWSHAW JG and MILLERSHIP S (2003) Incidence and prevalence of head lice in a district health authority area. Commun Dis Public Health 6(3);246-249.
  6. PUBLIC HEALTH MEDICINE ENVIRONMENTAL GROUP (2012) Head lice: Evidence-based guidelines based on the Stafford report - 2012 update. Available at: www.phmeg.org.uk [Accessed 10 April 2012].
  7. FELDMEIER H (2010) Diagnosis of headlice infestations: An evidence-based review. Open Dermatol J 4;69-71. Available at: www.benthamscience.comlopen/todi/articles/V004/SI0062TOD [/69TODI.pdf [Accessed 10 April 2012].
  8. HEALTH PROTECTION AGENCY (2010) Guidance on infection control in schools and other childcare settings. Available at: www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/ SchoolsGuidanceOninfectionControl/ [ Accessed 10 April 2012]
  9. BURGESS IB, LEE PN and BROWN CM (2008) Randomised, controlled, parallel group clinical trials to evaluate the efficacy of isopropyl myristate/ cyclomethicone solution against head lice. The Pharmaceutical Journal 280;371-375.
  10. NHS CHOICES (2010) Head lice. Available at: www. nhs.uk/conditions/head-Hce/pales/introduction.aspx [Accessed 10 April 2012].

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