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.


  1. Ew. Bedbugs… burn the house down. Or, in less of a knee jerk reaction, calamine lotion, steam clean everything with fabric & call an exterminator.

  2. Cuterebra (sp?)? Had one removed from my dog last summer. It appears that you removed it successfully, without a delicate procedure – some of the writeups I saw mentioned that you really want to be sure not to rupture the bug when removing it because of the risk of sepsis. Treatment: check whether patient has more than 1 of these parasites… not sure what ointment to apply to the hole they dig in the skin… (pardon my non-medical idiom – I’m not in medicine, just a lay person following for amusement).

  3. Oops. Forgot the treatment.

    They are getting resistant. There is the mayonnaise treatment. They are resistant to Kwell. Nix resistance is rising too. There is new treatment available in Europe but not here.

  4. nevermind this lay person’s previous guess – nits are evident on hair strands. Sad to say I’ve had to deal with this in my kids. Treatment is controversial – vegetable oil is an option.

  5. Isn’t the active ingredient in mayo the oil? Used to smother the insects? Couldn’t you use mineral oil instead? At least your head wouldn’t smell like a turkey sandwich.

  6. @Chuck: The active ingredient in mayonnaise is likely the oil. There was a letter in the January 2006 Pediatrics about a study that used Cetaphil cleanser left in the hair for 8 hours to smother lice.

  7. Anyone had any success with Ulesfia? It’s not ovicidal, but it’s supposed to paralyze the bug’s ability to close it’s spiracles, thus causing asphyxiation. I’ve heard it’s expensive.

  8. that’s a head louse. bedbugs have a fatter body and less arrow-shaped head. i think you can also see a nit on one of the hair strands in the picture. fine comb, kwell (permethrin shampoo), and if that doesn’t work, agree with shaving head and retreating.

  9. Nits! That’s what they’re universally known as in English primary schools, anyway. And yes, I’m aware that the term technically refers only to the egg cases.

    No drugs, just twice-daily combing with a very very fine-toothed comb and oodles of conditioner, incredibly thoroughly and carefully in small sections of hair (and maybe an antihistamine for the itching).

    I bet the patient is a parent or teacher of kids under 10… at least one of whom will also be needing the above treatment.

    Save the chemical treatment for patients who are having – or are at risk of – nasty complications. The little bastards seem to become resistant faster than pharmaceutical R&D can keep up with over here.

  10. I’m a veterinarian, not a doctor, but is ivermectin an option in human medicine? Clear the hair of visible eggs, topical shampoo for control, and systemic treatment for the kill would have been my guess for treatment.

    • Ivermectin is available in humans but not FDA approved for use in head lice. That was the treatment in Europe I was thinking of.

  11. I agree it’s lice. One more treatment if resistent to medicated shampoos is olive oil. Saturate the hair, use a nit comb and then if hair is long enough braid tightly and leave in overnight. Use a plastic shower cap to protect linens. Wash out in the morning and repeat for a minimum of 3-5 days.

    Single treatments aren’t effective given the life cycle once you see mature head louse.

    Oh and the patient probably should just bag up and throw out all of her hair brushes, combs, pillows and rewash bed linens and towels in hot water that she has used in the past few weeks.

    Been there, did that.

  12. Thanks. Now my head itches. Had to deal with those little critters after my kids went on a field trip where everyone got to dress up in pioneer clothes – including shawls, hats, sun bonnets…

    Cover hair with oil (also massage into scalp). There are some eo’s that can be mixed in, too, but aren’t required. Cover with a shower cap, then wrap a towel around all and smother the little critters while wash all the bedding and vaccum all the furniture. Remove all stuffed animals from home and shove them into a big plastic garbage bag for two weeks.

    Use a nit comb on oiled hair. It took 8 hours to comb one daughter’s hair, and only 6 hours for the other daughter. For boys, shaving the head is an excellent solution.

    Phone the family of every child you’ve had contact with recently so that they can also delouse their children. Otherwise you just get them again if the friends still have them.

    REPEAT to catch anything you missed the first time through. Even one missed egg can turn into a whole new infestation.

  13. Ugh! I was gonna guess bed bug because of article I read about Empire State building having to exterminate them and that they are in other areas of NY.

    I did see the little white things though at base of neck. I just thought head lice looked different.

    I don’t know.

    But ..I am SKEEVED! That poor woman and staff. Must’ve all been itching after that.

    Aside from the horror of having that on you ..also the horror of having to clean/sanitize *EVERYTHING* in the house, car or where ever would really be disturbing. family members and pets too ..right?

    The bed bug thing is scary. How can anyone know their motel/hotel is safe and other places?

    Also heard people should check their paper grocery bags because cockroaches in wear houses can crawl into bags and then you can bring them home. I never check tho.

  14. Judging from the narrow body as opposed to a fat body, I’d go with head lice over bed bugs. Treatment would be trivial.

  15. It doesn’t really look like any tick i’ve ever seen, but could it be one? Could the lady have contacted Lyme Disease?

    • It is far too large to even be an engorged deer tick (the big disease carriers), but there are larger tick species. The give away with most ticks is that once they attach to skin they really don’t move around unless you disturb them before they latch on.

      After moving into my new apartment last week and sitting on the grass outside I found my legs just lousy with deer ticks. Most of them weren’t embedded yet so removing them wasn’t bad. Dandruff shampoo is my folk remedy of choice for dislodging them. In addition to the smothering factor I like that the zinc compounds in the shampoo are a broad spectrum antiseptic and might even mess with the actual tick.

      One of them managed to avoid detection until it dislodged itself. It was destroyed with extreme prejudice, and the site is subjected to watchful waiting but looking clear so far.

  16. Oh, poor thing. Head lice is the worst. I am having flashbacks to 6th grade when there was an epidemic in the softball scene. Kids have to buy their own helmets these days!

  17. Aaron Ick, sorry about your tick experience. Here in VA, i found a very engorged tick on one of our poor Scotties (Sorry i didn’t find it sooner, Jackson!). It was at least a quater to a third inch long…really had a good meal at the pup’s expense…i know, makes me a terrible pet owner, not finding it sooner….i wonder how long it took for it to get that size…i know now to used the flea and tick medicine! And to check more carefully! (we had just barely moved to VA).

    • Sounds like the aptly named “dog tick.” Those are big (at least for ticks) even before they bite and they aren’t quite the disease carriers that their smaller venison affiliated brethren are.

  18. 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.

  19. 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! 🙂

Leave A Reply