What is the assessment and management for a 4-year-old female with a 1-week history of pruritus (itching) of the scalp, leading to scratching and subsequent development of furuncles (infected hair follicles) after consuming eggs and chicken?

Assessment and Management of Scalp Furuncles in a 4-Year-Old

This child most likely has scalp furuncles (infected hair follicles) secondary to scratching from head lice infestation, not a food allergy, and requires immediate examination for live lice, incision and drainage of large furuncles, and treatment with a topical pediculicide. 1, 2

Initial Assessment

Rule Out Head Lice First

• Examine the scalp carefully for live lice using a fine-toothed louse comb, as this is the gold standard for diagnosis and is quicker and more efficient than visual inspection alone 1
• Look specifically at the posterior hairline and behind the ears for viable eggs (nits) within 4 mm of the scalp, which appear camouflaged to match hair color 1
• The reported temporal association with eating eggs and chicken is likely coincidental—the 1-week timeline and scratching-induced furuncles strongly suggest pediculosis capitis with secondary bacterial infection 2, 3
• Scalp pruritus leading to scratching and subsequent furuncles is a well-documented complication of persistent head lice infestation, particularly when mechanical removal is delayed 2, 3

Examine for Complications

• Inspect for signs of secondary bacterial infection: crusting, weeping, pustules, or coalescent inflammatory masses (carbuncles) 1
• Check for regional lymphadenopathy, which commonly occurs with extensive scalp infection 1, 2
• Assess for systemic signs: fever, tachycardia, or other evidence of systemic inflammatory response syndrome (SIRS) 1
• Look for excoriations, impetiginization, and areas of alopecia from chronic scratching 2, 3

Management of Furuncles

Drainage Approach

• Apply warm, moist compresses to small furuncles several times daily to promote spontaneous drainage, which has an 85-90% cure rate with drainage alone 4, 1
• Perform incision and drainage for large furuncles that do not respond to moist heat, as this is the definitive treatment 1, 4
• Simply cover the surgical site with a dry sterile dressing after drainage—packing causes more pain without improving healing 1

Antibiotic Considerations

• Systemic antibiotics are usually unnecessary for uncomplicated furuncles in otherwise healthy children 1, 4
• Prescribe antibiotics only if the child has fever, extensive surrounding cellulitis, multiple lesions, or signs of SIRS 1, 4
• If antibiotics are needed, use clindamycin 10-13 mg/kg/dose orally every 6-8 hours if local resistance is <10% 4
• Avoid tetracyclines (including doxycycline) in children under 8 years of age 4, 5
• Obtain Gram stain and culture of pus from carbuncles and abscesses, though treatment without these studies is reasonable in typical cases 1

Treatment of Head Lice (If Present)

Pediculicide Selection

• Use permethrin 1% lotion as first-line treatment, as it is the most studied and least toxic pediculicide in the United States 1
• Apply to dry hair, leave on for 10 minutes, then rinse thoroughly 1
• Repeat application in 7-10 days to kill newly hatched nymphs, as no pediculicide is 100% ovicidal 1
• Consider malathion 0.5% lotion for resistant cases, applied to hair, left to air dry, then washed off after 8-12 hours 1

Mechanical Removal

• Use a fine-toothed louse comb with a lubricant (water, oil, or conditioner) to slow lice movement and facilitate removal 1
• Remove nits after treatment for aesthetic reasons and to decrease diagnostic confusion, though this is not necessary to prevent spread 1

Prevention of Recurrence

Household Measures

• Examine all household members for live lice or nits within 1 cm of the scalp and treat those who are infested 1
• Treat family members who share a bed with the child, even if no live lice are found 1
• Change and launder the child's pillowcase, as head lice can transfer to pillowcases at night (though incidence is low at 4%) 1
• Clean hair care items and bedding used by the child 1

Decolonization for Recurrent Furuncles

• If furuncles recur after treating head lice, consider nasal colonization with Staphylococcus aureus as the cause 1, 5
• Apply intranasal mupirocin ointment twice daily for the first 5 days of each month, which reduces recurrences by approximately 50% 1, 4, 5
• Implement daily chlorhexidine washes and thoroughly launder clothing, towels, and bedding 1, 4, 5

Common Pitfalls to Avoid

• Do not attribute the symptoms to food allergy without first ruling out head lice—the temporal association with eating is likely coincidental 2
• Do not exclude the child from school once treated, as she poses little risk to others and has likely had the infestation for a month or more by the time of discovery 1
• Do not use systemic antibiotics routinely for simple furuncles without signs of systemic infection 1, 4
• Do not rely on "no-nit" policies, as these are not evidence-based and cause unnecessary school absence 1
• Maintain confidentiality to avoid embarrassing the child 1

Symptomatic Relief

• Apply topical hydrocortisone 1% cream to affected areas not more than 3-4 times daily for itching and inflammation 6
• Consider oral antihistamines for pruritus relief 1
• Keep the child's nails short to minimize trauma from scratching 1