How to manage itchy head lice with resulting small wounds in a child?

Management of Head Lice with Secondary Wounds from Scratching in Children

Treat the head lice with 1% permethrin lotion or cream rinse applied twice (initial treatment and repeat in 7-10 days), while simultaneously managing the scalp wounds with gentle cleansing and topical antibiotic ointment if signs of bacterial infection are present. 1

Immediate Wound Care

Clean the scratched areas gently with mild soap and water to remove crusting and debris. 1 This prevents further bacterial contamination while preparing the scalp for pediculicide treatment.

• Apply topical antibiotic ointment (such as mupirocin or bacitracin) if you observe signs of impetigo or bacterial superinfection, including honey-colored crusting, increased redness, warmth, purulent drainage, or local lymphadenopathy. 1
• Monitor closely for worsening infection that may require oral antibiotics (such as cephalexin or amoxicillin-clavulanate for suspected Staphylococcus or Streptococcus). 1

Critical Safety Consideration Before Pediculicide Application

Avoid applying pediculicides directly to broken or inflamed skin. 1 You have two options:

• Wait until the wound shows initial healing (typically 2-3 days with proper wound care) before treating with pediculicides, OR
• Apply the pediculicide very carefully, avoiding the wound areas entirely 1

This prevents systemic absorption of the insecticide through broken skin and reduces local irritation.

First-Line Pediculicide Treatment Protocol

Use 1% permethrin lotion or cream rinse as first-line therapy unless local resistance is documented in your community. 2, 1

Application Instructions:

• Shampoo hair first with a non-conditioning shampoo (conditioners and silicone-based additives impair permethrin adherence to hair shafts and reduce effectiveness). 3, 4
• Apply 1% permethrin to damp (not soaking wet) hair, ensuring thorough coverage of the scalp and hair, particularly behind the ears and at the back of the neck. 1, 4
• Leave on for exactly 10 minutes, then rinse thoroughly with warm water. 1, 4
• A mandatory second application must be performed in 7-10 days to kill newly hatched nymphs, as permethrin is not completely ovicidal. 2, 1

Alternative First-Line Option:

• Pyrethrin-based products can be used with the same application schedule if permethrin is unavailable or if the family prefers this option. 2, 1, 4

Managing Itching and Discomfort

Apply cool compresses to the scalp for temporary relief of itching. 1

• Reassure the family that itching may persist for several days even after successful lice eradication due to hypersensitivity reaction to louse saliva, not necessarily treatment failure. 1
• Avoid oral antihistamines unless itching is severe and interfering with sleep, as they do not address the underlying infestation.

Follow-Up Assessment

Recheck the child in 7-10 days after initial treatment before applying the second dose. 1

• Look for live lice by parting the hair in sections and examining the scalp systematically, particularly behind the ears and at the nape of the neck. 1, 4
• Assess wound healing at the same visit—if infection is worsening despite topical treatment, prescribe oral antibiotics. 1
• If live lice persist after proper treatment, consider resistance and switch to an alternative pediculicide with a different mechanism of action (see below). 1

Second-Line Treatment for Resistant Cases

If live lice remain after two properly administered treatments with permethrin/pyrethrins, switch to:

• Benzyl alcohol 5% for children older than 6 months, OR 2
• Malathion 0.5% for children 2 years or older (highly ovicidal but flammable—must air dry, no hair dryers or heat sources). 2, 3

Household Management

Check all household members for live lice by systematic scalp examination with good lighting. 1, 3

• Treat only those with confirmed active infestation (live lice or nits within 1 cm of the scalp). 3
• Siblings who share a bed with the infested child should be treated even if no live lice are found. 3
• Wash bedding and recently worn clothing in hot water (above 54°C/130°F) and dry on high heat for at least 20 minutes. 4
• Environmental measures are less critical than treating the scalp—do not waste time or money on extensive environmental decontamination. 1

Common Pitfalls to Avoid

Do not diagnose based on nits alone—nits can remain glued to hair for months after successful treatment. 2, 5 Only live lice or nits within 1 cm of the scalp indicate active infestation requiring treatment.

Do not use lindane—it has the highest toxicity profile with risk of seizures and neurotoxicity, and the American Academy of Pediatrics no longer recommends it. 6

Do not keep the child out of school—head lice have low contagion in classrooms, and the child should return to school immediately after initiating treatment. 2, 1

Treatment failure is most commonly due to improper application, not resistance—ensure families understand the exact instructions, including the mandatory second application. 3, 7

Key Clinical Pearl

Verify treatment success to ensure the wound can heal without ongoing trauma from scratching. 1 The combination of effective pediculicide treatment and wound care will break the cycle of infestation, scratching, and secondary infection.