So, your kid came home with a head full of creepy-crawlies. Put down the matches and back away from that kerosene can. There’s no need to burn the house down. We know a lot more about head lice these days, and it doesn’t require tearing up and cleaning every last piece of bedding and furniture anymore.
The latest guidance from the Centers for Disease Control suggests lice cannot infest your house or your pets. They don’t survive for very long off a human head. Nits that fall off the head cannot hatch or reattach. As such, its no longer necessary to launder everything you own and bag it for weeks on end. That’s the good news.
The bad news? Some over-the-counter lice treatment kits sold at your local pharmacy may not be as effective as they used to be, according to the Mayo Clinic, because lice have genetically mutated to withstand the chemical used in those kits. They’re called “super lice” because they have evolved to resist pesticides such as permethrin, the active ingredient in many over-the-counter remedies.
Emily Remus, a pediatrician at The Kidz Docs in Alexandria, says she prescribes SKlice, a topical lotion or shampoo containing ivermectin, which is effective against both lice and nits. Approved by the FDA in 2020, the drug is available in both prescription-strength and over-the-counter versions.
“It’s very rare for patients to have live lice after treatment with ivermectin,” Remus says. If they do, “it’s usually due to incorrect medication application. In these cases we complete a second treatment a week later to achieve eradication.”
Nancy Pfund, founder and owner of Lice Happens, an in-home treatment service with specialists throughout the DMV, says she’s been aware of the bugs’ resistance to permethrin ever since she started her company in 2009. Families often call her company after a drug store box kit has failed to do the job.
“It’s not for a lack of following directions,” she says. “What we find—our parents are meticulously following directions, and often going above and beyond, and they’re still not able to eradicate it.”
Darlene LaFramboise, owner of Lice Clinics of America, Falls Church, offers a similar assessment. The waning effectiveness of permethrin-based treatments means that some kids are being sent back to school with bugs still in their hair.
“Once it’s in a school, it’s very, very difficult to get it out because [of the] reinfestation cycle,” she says. “People think they’re doing well, they think they’re doing what they’re supposed to do, but they haven’t cured it.”
“I’m probably seeing in my clinics about four times [the number of cases] I was pre-pandemic,” says LaFramboise, who started her first clinic in Herndon ten years ago. Today she runs three franchises in Northern Virginia. “We’re at a point where we can’t take people [as fast as] they want to come in.”
Five years ago, same-day appointments were easy to book. Now, she says, parents are being told they have to wait until the next day—which is not what they want to hear when they’re anxious to contain critter-filled heads at home. The clinic offers appointments until 8 p.m. but keeps its phone lines open until 11 p.m. for parents who call in a panic.
Clinics across the country are reporting a similar increase in lice outbreaks.
“We’re the business that nobody knows about,” LaFramboise says. “Nobody wants to talk about lice until their kid has it.”
Head lice are parasitic insects that live on human scalps, feed on human blood and lay eggs (called nits) along the hair shaft. Adult head lice are about the size of a sesame seed. They can cause itching and sores on the scalp, although not everyone experiences symptoms.
The CDC estimates about 6 to 12 million children, mostly between ages 3 and 11, get head lice each year, but because lice do not transmit disease, they are not considered a health risk. Head lice are much less common in African Americans than people of other races.
Lice spread through direct contact with the hair of a person who has lice. Becoming infected is not related to the cleanliness of your hair or environment.
To treat lice, LaFramboise’s clinic uses an FDA-approved device called AirAllé that dehydrates both the adult insects and the eggs, killing them all. While this approach is fast and effective, it does cost money. A signature treatment is $198 per person and comes with a 30-day guarantee. An express treatment ($149) is cheaper and quicker, but does not come with the guarantee.
The clinic also does comb-out treatments for $99 per hour, plus the cost of an at-home comb-out kit. This treatment option requires 30 minutes of combing every day for 10 days, along with oil applications and an in-clinic recheck.
Pfund’s company takes a different approach. She dispatches trained specialists to client’s homes, where they apply a pesticide-free product that loosens the nit’s bond to the hair and makes it easier and more efficient to comb them out.
“It’s all about convenience,” she says. “Children are able to work on their homework and play and watch TV. It’s less of an impact. We find working in the home is the least traumatic for families. During that appointment, we give parents hands-on training and leave them with the skill to accurately check [for lice].”
Pfund says she was offered the opportunity to use and distribute the AirAllé devices but opted not to.
“Here’s the thing: If I’m helping a family with any kind of apparatus and they don’t have that apparatus at home, then I have created a dependency. You have to come back and pay me more money because you don’t have what I have. That’s that’s not our business model. We’re trying to empower.”
Pfund’s company charges $150 for an in-home service call, plus an hourly rate of $100 per hour. A typical service call takes about two hours, she says.
Many families choose lice clinics over topical treatments because they are reluctant to use chemicals. Some are nervous about ivermectin after the drug was erroneously touted as a cure for the Covid-19 virus. Remus says ivermectin is safe when used in the correct dose for lice.
“Not every patient can afford expensive lice treatments. Ivermectin shampoo is available for $25-$50, which makes it accessible to many families,” she says. Medicaid and some forms of Tricare and commercial insurance may even cover the cost.
Drugstore kits containing permethrin run about $30-$50, but in order for them to be truly effective, you must carefully comb out all the lice and nits with a special, fine-tooth comb—and then do it all again about a week later in case anything new has hatched. The length of the treatment period is a downside.
“It’s a two-week treatment process, and technically, you have lice during that time,” LaFramboise says. The nits often remain. It takes about a week for the eggs to hatch into new lice (hence the need for diligent follow-up treatment).
What about dousing your child’s head in mayonnaise or olive oil—or any of the other remedies you’re likely to find on the internet? LaFramboise warns that these and other homeopathic tricks purported to “drown” the lice are ineffective. Household condiments and oils are not actually thick enough to suffocate mature lice, and they don’t kill the nits.
Because lice are very small, move quickly and avoid light, they can be elusive. If you do not see crawling lice on your child’s head, look for nits attached firmly to the base of hair shafts, especially behind the ears and at the back of the neck. Those warm and toasty spots are favorite places for them to incubate their eggs. (Insert barf emoji.)
The nits look like little white grains of sand attached to hair near the scalp. “If it doesn’t flick away, and you can move your finger along the hair shaft, and your finger sort of goes buh-bump, and that thing is very firmly glued in place, that’s a nit. And if you have nits, you have lice,” LaFramboise says.
The latest CDC guidance states that students with head lice do not need to be sent home early from school. They can go home at the end of the day, be treated, and return to class after beginning treatment.
Many schools no longer conduct mass head lice screenings, which have been deemed ineffective, costly and potentially stigmatizing by organizations including the American Academy of Pediatrics (AAP) and the National Association of School Nurses (NASN).
The latest recommendation is that schools focus on educating families about head lice management and prevention. Arlington Public Schools follow this guidance, as do Falls Church City Public Schools and Fairfax County Public Schools. (APS did not respond to a request for comment.)
Both Pfund and LaFramboise say it’s time to eradicate the shame surrounding the pests. Pfund’s company offers free presentations to school PTAs. LaFramboise says open communication will help stop lice in their tracks.
“Let’s just get rid of all of the shame and the embarrassment around lice, and let’s just start telling each other,” she urges. “Nobody questions when their child gets a cold or something. It’s just a childhood thing.”
“The more we can start treating this as just something that happens,” she adds, the easier it will be to treat outbreaks and prevent them from constantly reoccurring.
To prevent and control the spread of lice, the CDC recommends avoiding hair-to-hair contact (read: no more selfies with friends!). Kids should also avoid sharing hats, hair ties, ribbons, barrettes, combs, brushes and towels.
Another way to keep lice away? Lice-repellant hairsprays sold online and in drugstores and grocery stores. These products provide a form of camouflage by covering up the scent of hair that lice find attractive. The most effective ones last all day and smell like strawberries or cupcakes, LaFramboise says. Those are the ones the kids like and will agree to wear every day.