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What's The Diagnosis #11

A 55 year old patient comes in with itching to her scalp – so bad that it is setting off her migraine headaches.

She’s been to her family physician twice already and was first prescribed antibiotics for a scalp infection, then was prescribed steroid lotion for the inflammation. She was feeling worse.

When I examined her, she had several bite marks to the base of her neck and over the ears. You could also see the dried hydrocortisone cream in her hair. Then I saw movement and I pulled out the insect pictured.

What is the diagnosis and what is the treatment?


OK, you all are too smart. Head lice, it is.
I had never seen a live head louse before and had to look it up on the internet. I knew it wasn’t a bedbug and suspected it was a louse because of the couple of lice nits on the patient’s hair.
Treatment recommendations vary.
Shaving the head is a radical but curative approach.
The American Academy of Pediatrics recommends copious amounts of amoxicillin, then Augmentin if that doesn’t work just came out with an excellent¬†clinical report on head lice last month (.pdf format).
Pediculicides (chemicals) such as “Quell,” “Nix” and “Rid” are still the mainstay of treatment according to this paper. Benzyl Alcohol also works well. While oils have been used to remove lice, the report states that their effect is not reproducible. Occlusive agents such as petroleum shampoos, mayonnaise, and herbal oils “have not been evaluated for effectiveness in randomized, controlled trials.”
A dessicator can be used to blow hot air on the lice to kill them – with good results. Using a blow dryer to try this at home will cause live lice to become airborne and spread all over your house. Don’t do it.

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  1. I find it hard to believe a pediatrician missed this twice. We see it on a regular basis. I use nix and lots of combing to treat. Some pediatricians I know are using bactrim.

    • Bactrim might be a prophylactic against any complications, but if the manifestation is that worrisome a shave as mentioned above is warranted.

      Early in High school I picked up a lice infestation in my head hair, of a variety other than the head sort. I was prescribed a shave and bactroban bid covering the whole scalp. Contemporary me might have opted for an old fashioned kerosene massage after the shave.

      Contemporary me though would have not won out over high school me in making the decision that lead to contracting pubic lice in my scalp I will humbly admit. On a male child though a complete head shave in my case was minimal in its potential emotional trauma.

      I wonder though if the original practitioner might benefit from an retirement offer or contract buyout from the local hospital forcing retirement. Head lice are pretty f-ing big critters and if a medical practitioner can’t spot them, then I wouldn’t trust them to read the printed language at any commonly sized font.

  2. Qwell worked just fine when I got the crabs from that red-headed stew in Ontario.

  3. My girls have had HL multiple times. The last time I used my Gram’s remedy. Vaseline on the head for 24 hours in a closed shower cap. Sweaty and hot, yes. Then a treatment of NIX. But combing those little buggers out and no more hatching was awesome.
    Both now hate to have the back of their neck messed with because of all the combing. Boys never got them. They are the nastiest things I have ever seen.
    Now my head itches! :)

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