How to manage a 5-year-old girl with head lice who has developed a small wound due to itching?

Management of Head Lice with Secondary Wound from Scratching in a 5-Year-Old

Treat the head lice infestation promptly with 1% permethrin or pyrethrins applied twice (initial application and repeat in 7-10 days), while simultaneously managing the scalp wound with gentle cleansing and topical antibiotic ointment if signs of secondary bacterial infection are present. 1

Immediate Wound Management

Address the secondary skin infection first to prevent complications:

• Clean the wound gently with mild soap and water to remove crusting and debris 1
• Apply topical antibiotic ointment (such as mupirocin or bacitracin) if there are signs of impetigo or bacterial superinfection from scratching 1, 2
• Monitor for signs of infection including increased redness, warmth, purulent drainage, or local lymphadenopathy, which may require oral antibiotics 1
• Keep fingernails trimmed short to minimize further trauma from scratching 2

Pediculicide Treatment Protocol

Start lice treatment immediately, as the infestation is the root cause of the itching and subsequent wound: 1

First-Line Treatment (Age-Appropriate for 5-Year-Old)

• Use 1% permethrin lotion or cream rinse as first-line therapy unless local resistance is documented 1
• Application technique: Apply to damp hair after shampooing with non-conditioning shampoo (conditioners impair permethrin adherence), leave on for 10 minutes, then rinse thoroughly 3
• Mandatory second application in 7-10 days to kill newly hatched nymphs, as current products are not completely ovicidal 1
• Alternative first-line option: Pyrethrin-based products with the same application schedule 1

Second-Line Options if Treatment Fails

• Malathion 0.5% can be used if permethrin fails or resistance is documented, though it requires caution due to high flammability (78% isopropyl alcohol content) 1
• Benzyl alcohol 5% is appropriate for children older than 6 months as an alternative 1

Critical Safety Considerations

Common pitfalls to avoid that could worsen the wound or delay healing:

• Never apply pediculicides to broken or inflamed skin - wait until the wound shows initial healing before treating, or apply very carefully avoiding the wound area 1
• Do not use lindane - it has the highest toxicity profile and is no longer recommended by the American Academy of Pediatrics 4
• Avoid malathion near heat sources - no hair dryers, curling irons, or smoking near the child due to flammability risk 1
• Supervise application to prevent accidental ingestion, particularly with malathion which carries theoretical risk of respiratory depression as a cholinesterase inhibitor 4

Symptomatic Relief for Itching

Control pruritus to prevent further scratching and wound worsening:

• Oral antihistamines (such as diphenhydramine or cetirizine) can reduce itching and help prevent additional scratching 2
• Cool compresses to the scalp may provide temporary relief
• Reassure the family that itching may persist for several days even after successful lice eradication due to hypersensitivity reaction 1

Household and Environmental Management

Prevent reinfestation which would perpetuate the cycle of itching and scratching:

• Check all household members for live lice; treat only those with confirmed active infestation 3
• Siblings sharing a bed should be treated even without visible lice 3
• Wash bedding and recently worn clothing in hot water, though environmental measures are less critical than treating the scalp 3
• Clean hair care items (combs, brushes) used by the child 3

Follow-Up Assessment

Verify treatment success to ensure the wound can heal without ongoing trauma:

• Recheck in 7-10 days after initial treatment to confirm no live lice remain before second application 1
• Assess wound healing at the same visit; if infection worsens despite topical treatment, consider oral antibiotics
• If live lice persist after proper treatment, consider resistance and switch to alternative pediculicide with different mechanism of action 1, 5

Key Clinical Pearls

• Treatment failure is most commonly due to improper application rather than true resistance - ensure parents understand correct technique 3
• The wound itself is not a contraindication to treating the lice, but requires careful application to avoid direct contact with broken skin 1
• Never initiate pediculicide treatment without confirming live lice - misdiagnosis leads to unnecessary chemical exposure 1, 4
• The child should not miss school due to head lice once treatment is initiated 1