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A 8 years old female has developed complaint of itching on scalp with pain and discharge on scalp
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Diagnosis: Pediculosis Capitis (Head Lice Infestation) with Secondary Bacterial Infection (Impetiginization)
Image Analysis
The scalp examination reveals:
- Thick, yellowish-brown honey-colored crusting at parted areas - highly characteristic of dried purulent/serous discharge
- Matting of hair around the crusted lesion from dried exudate
- Fine whitish-grey scaling throughout the scalp
- Localised erythema around the crusted lesion indicating active inflammation
- Possible nits (lice eggs) on hair shafts (whitish specks require fine-tooth comb confirmation)
Diagnosis
| Feature | This Patient |
|---|---|
| Age | 8 years (peak age 3-11 years) |
| Primary complaint | Scalp pruritus |
| Secondary complaint | Pain + discharge |
| Scalp finding | Honey-colored crusting, matting, scaling |
| Mechanism | Pediculus humanus capitis → intense scratching → secondary bacterial impetiginization (Staph. aureus) |
Differential to consider:
- Tinea capitis (kerion formation can look similar - boggy, tender, purulent) - confirm with KOH prep / fungal culture
- Seborrheic dermatitis with secondary infection
Clinical diagnosis of pediculosis capitis is confirmed by visualizing live lice or nits - best done with a fine-toothed nit comb through wet hair. Nits fluoresce under Wood's lamp. - Tintinalli's Emergency Medicine
Treatment Plan
Step 1: Treat the Head Lice (First-Line)
Permethrin 1% cream rinse - First-line treatment
- Apply to hair and scalp
- Leave overnight, rinse off in the morning
- Repeat in 7-10 days (to kill newly hatched lice)
Alternative options:
- Ivermectin lotion 0.5% - apply for 10 minutes, rinse off
- Pyrethrin cream - apply for 10 minutes, rinse off
- Malathion 0.5% - applied overnight (not recommended in children <6 years; flammable)
"First-line treatment is topical pediculicides (permethrin, topical ivermectin, malathion, benzyl alcohol, topical dimethicone)." - Harriet Lane Handbook, 23rd ed.
Step 2: Treat Secondary Bacterial Infection (Impetiginization)
Since there is active discharge, crusting, and pain indicating secondary bacterial superinfection:
- Oral antibiotic is required - Amoxicillin-clavulanate or Cephalexin (covers Staph. aureus/Streptococcus)
- If MRSA suspected: Trimethoprim-sulfamethoxazole
- Duration: 5-7 days
"Secondary infection usually from Staphylococcus aureus may be associated with tender pustules requiring treatment with oral antibiotic." - Harriet Lane Handbook, 23rd ed.
Step 3: Mechanical Removal
- Use a fine-toothed nit comb on wet hair to physically remove nits and lice
- This is an essential adjunct to pharmacological treatment
- Wet combing alone is an alternative for patients preferring to avoid medication
Step 4: Environmental Measures
| Action | Purpose |
|---|---|
| Wash all clothing, hats, bed sheets in hot water (>60°C) | Kill lice/nits on fomites |
| Soak combs/brushes in hot water for 10 min | Decontaminate |
| Bag and seal stuffed animals for 2-3 days | Adult lice cannot survive >24 hours without a blood meal |
| Examine and treat close contacts (family, classmates) | Prevent reinfestation |
Step 5: Follow-Up
- Assess in 7-10 days for treatment response
- No need to exclude from school - "No-nit" policies are considered excessive - Tintinalli's Emergency Medicine
- If resistance to permethrin is suspected, switch to oral ivermectin (200 mcg/kg single dose, repeat in 2 weeks)
Key Points Summary
| Causative organism | Pediculus humanus capitis (head louse, 2-3 mm) |
| Transmission | Head-to-head contact (lice do not fly or jump) |
| First-line treatment | Permethrin 1% cream rinse x 2 applications (7-10 days apart) |
| Secondary infection | Oral antibiotic (amoxicillin-clavulanate or cephalexin) |
| Confirm diagnosis | Fine-toothed nit comb through wet hair; nits >7mm from scalp = inactive infestation |
| Warn family | Check and treat all household contacts |
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