The Creepy Crawlies-Scabies and Lice

Author: Mark Parkinson RPh:  President  AFC CE

Credit Hours 1.5- Approximate time required: 90 min. 

Educational Goal:  To educate Care providers about Head, Body and Pubic Lice and Scabies and help them control outbreaks.

Educational Objectives:

1. Give a description of Lice and Scabies that infest Humans.

2. Provide the signs and symptoms of outbreaks.

3.  Tell the importance and details of a home screening program.

4.  Enumerate the different treatment strategies.

5. Discuss the necessity follow up on therapy.


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  The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.



The Creepy Crawlies: Scabies and Lice


The Caregiver’s Nightmare


Not all skin infections are caused by bacteria, viruses, and fungi. Some of the most common infections that trouble mankind are the result of infestations of slightly bigger critters, lice and mites.

Lice and mites are parasites that live off the blood of their unwilling hosts and are found anywhere humans gather.  They are extremely annoying and a major pain in the neck to get rid of. Although they are not usually the cause of any serious health consequences, they do carry several social stigmas. Those who are infested claim to die of embarrassment. 

For a business that lives and dies on its reputation, lice and mites outbreaks can be a real caregiver’s nightmare. Your business can die from embarrassment. If you think your home is immune from such troubles, just think of all the visitors who come IN to your home. Friends, children, grandchildren, and home health nurses (who are exposed to who knows what in their daily rounds).  Whether you operate an Adult Foster Care, Developmentally Disabled or a Mental Health Home, stay in business long enough and chances are you will have to deal with the Creepy Crawlies.

Just what are these things and how do you get rid of them, or, better yet, keep them out of your home in the first place? By the end of the article, you should have the answers to these questions.

Lice (Cooties)

Lice infestations are medically known as Pediculosis and can occur in all classes and environments, anywhere humans gather together.  Lice are tiny, wingless, parasitic insects. The three most common varieties that infest humans are head lice, body lice, and public lice (crabs).  They live exclusively on humans and die without human host.  They do not jump or fly but crawl or fall from one human host to another.  Spread of an outbreak usually occurs by direct skin or hair contact but also can spread thru fomites (inanimate objects that spread the condition, like shared hats, bedding, or clothing).While lice can occasionally cause significant illness (typhus and trench fever), most commonly lice infestation causes skin irritation (pronounced itchiness) and embarrassment from social stigmas.

Head Lice

According to the National Pediculosis Association (NPA) “With the exception of the common cold, head lice affects more school aged children than all other communicable childhood diseases combined.” Head lice are 2-3 mm in length (about the size of a sesame seed), are gray-white in color, and can live for about one month. Mature females can lay between seven to 10 eggs a day. The eggs are deposited into yellowish white colored cases called nits and attach to hairs by a glue-like substance. In six to 12 days, the eggs hatch into nymphs. In an additional 10 days, the nymphs mature into egg-producing adults.  Head lice must feed every 24 to 48 hours and require host bodies’ humidity to survive.

Body Lice

A slightly larger cousin to the head louse is the body louse.  It lives in the seams of clothing and transfers to the body to feed. It has a similar life cycle to that of head lice, but unlike head lice this louse can live up to 30 days away from the host’s body.  Because body lice live on the clothing or bedding of the host, it is more susceptible to proper hygiene.

Pubic Lice (Crabs)

Pubic lice are shorter and more round, giving them a crab-like appearance. Pubic lice have shorter life spans (three weeks) and lay fewer eggs (three per day), but their eggs hatch quicker (six to eight days).  Primarily thought of as a sexually transmitted disease, crabs can unfortunately be transferred to children and can be found on the host’s eyebrows and lashes and arm pits.

Scabies (the seven-year itch)

Scabies are caused by parasitic itch mites. They are arachnoids and are related to spiders. Individual mites are very tiny - 0.3 to 0.4 mm long - and can be detected by a magnifying glass or microscope.  These mites burrow into the skin, which results in an allergic response causing intense itching.  Like lice, itch mites do not fly or jump and are transmitted from host to host by direct contact or from fomites.  The eggs hatch in three to 10 days, mature into adult in another 10 days, and adults mites live three to four weeks. Females can begin laying eggs within two to three hours after burrowing into the host’s skin and lay two to three eggs a day.  Because they are so tiny their presences can go unnoticed for weeks until the allergic response becomes pronounced. It may take up to three to four weeks for the host to notice any signs of infestation. The outbreak can spread to quite a few contacts before it is noticed, thus making the condition very contagious.  Human scabies are very dependent on their hosts and can only live away from them for 24 to 36 hours.

Caregiver Strategies

Lice and itch mites have plagued mankind for thousands of years and have resisted all attempts at eradication. Fortunately, individual infestations are easily controllable, but you cannot control where the next possible source of these critters will come from.  The first and best defense against these parasites is alert and well-informed caregivers. This defense strategy has been described as hyper-responsiveness. Caregivers  must know what to look for,  screen their charges regularly, and quickly and aggressively treat any outbreaks.

Signs and Symptoms

To stop the spread of outbreaks, caregivers must be constantly on the lookout for the warning signs of infestation in patients. You might think that you should keep an eye out for the critters, but these creepy crawlies are very small and usually are not the first noticeable signs.  Other symptoms are easier to notice and therefore screen for.  Common to all of these outbreaks are:1) pronounced and persistent itch, 2) sores that might be weepy or crusted over, and 3) a tickling feeling, as if something is crawling on the skin or in the hair.

Lice Symptoms

Lice are sensitive to light and can quickly hide, but their nits are cemented down and do not move. So besides the itch, nit egg cases are the most easily recognizable infestation symptom.  Nits are yellowish-white oval and are less than a millimeter long. You can tell them apart from other everyday flecks because of how they are attached. Nits are cemented in place at a slight angle and are not easily removed. You can find viable nits anywhere around the body, but there are a few areas where they are more commonly found. Head lice commonly lay the nits at the base of the hair around the ears or neck line. Pubic lice nits are found in the groin area, and body lice nits can be found in the seams of clothing and bedding. I want to emphasize, though, that viable nits can be found almost anywhere around a host body.

Scabies Symptoms

Itch mites and the eggs are too small to see with the naked eye, so caregivers have to look for other signs.  The human body is allergic to mites and their feces. So caregivers will typically see allergic rashes around mosquito bite-like dots. Females burrow into the surface layer of the skin, so you might also see thin, pencil-like lines or four or more dots closely in a row.  Common wisdom says that rashes are found between the adult’s fingers but according to PubMed website  “Mites may be more widespread on a baby's skin, causing pimples over the trunk, or small blisters over the palms and soles. In young children, the head, neck, shoulders, palms, and soles are involved. In older children and adults, the hands, wrists, genitals, and abdomen are more involved.” Caregivers should not be surprised to see a scabies rash anywhere. Another common scabies sign is that the itch sometimes is felt more intensely at night when there are less mental distractions.

Screening For Just the Possibility

Lice and mite infestations are socially and emotionally charged issues.To keep you out of hot water, I recommend establishing a solid outbreak prevention policy and stick to it with no favoritism.  The NPA -National Pediculosis Association, has some good guidelines that you can utilize, and there is  a reference at the end of the article for you to look through.  In addition, I recommend that every new client be screened by you.  Older patients can be screened at bathing time. Children, teens, and others should have regularly scheduled screenings. A strictly adhered to schedule is less socially judgmental, thus easier for clients to accept. The time frequency should be determined by how much uncontrolled interactions clients have with the public at large. 

Because of the contagious nature of infestation, if one household member is diagnosed, all household members should be screened, including caregivers.  Once treatment has commenced, the caregiver must screen the patient to see if the treatment is working. If after a few days the lice are slower or show no signs of death, then you might have a resistant critter and the doctor should be given the details.  Seven to 10 days after treatment, everyone should be screened again just in case some eggs hatched or there was a re-infestation from the original source. 

For lice screening, your job will be made easier by using a magnifying glass and a nit comb. Regular combs and brushes are not fine enough.  Nit combs are the tools of choice and metal is better than plastic.  Wet hair is also easier to comb through.  If the hair is very curly or tangled, a conditioner will facilitate easy combing.

The Next Step

Once there is a confirmed diagnosis and after everyone is screened, what is next? 

First, treat everyone affected. “Oregon allows providers to treat.  A best practice would be to consult the dotor or nurse who would then determine if the individuals condition requires physican care.  Another best practice would be to double check with the pharmacist that the otc will not interact adversely with the medications the person takes, especcially topical ointments.  The provider would have to have the residents consent to treat and it should be well documented”

Second, notify everyone concerned for at least 14 days prior to the first sign of symptoms. There is a good reason for this, and it is worth the possible embarrassment it might cause.  The infection has to have come from someone else. More often than not, an alert caregiver will see the signs of infestation before the source does. If you don’t send out the warning, then the outbreak will spread. There is even the possibility that your clients will be re-infested by the original source and you will have to go through the whole process again.  Be sure to give the notice in a non-judgmental way so you will get less flack and more cooperation.

Third, treat the house.

The House

The caregiver’s best friends for treating the house for scabies and lice infestations is the vacuum cleaner and the washer and dryer.  Most vacuum cleaners provide sufficient suction to remove lice, loose nits, and mites from the environment. You will have to vacuum things that you normally wouldn’t clean, like mattresses, chair backs, soft toys, anywhere the hair might touch.  If you can’t clean or vacuum the item, isolate it for at least14 days, (or a month if body lice are diagnosed). Remember that these critters die after a day or two away from the host, but there may be eggs that hatch a week later. There are furniture lice sprays that can be effective, but these are pesticides that can be harmful to people, pets, and the environment. The eggs will most likely survive such treatments. House fumigation is expensive and probably overkill. Washing and drying clothing and bedding will remove eggs and pests. Remember “water removes but HOT kills.” Cleaning dryer vents and screens make them hotter. Commercial driers at laundry mats are hotter still and when in doubt a steam iron is the hottest. Dry cleaning also works. Don’t forget items away from the home like toys, combs and brushes in school lockers, or uniforms and hats stored at work.


There are medication, topical and manual eradication treatments available. The doctor will decide which treatments to use but you, your client, and the budget have a say in the decision.

Ivermectin (Stromectol) is an oral antiparasitic medication  usually reserved for scabies and treatment failures because of side effects, especially in the elderly.

Topical lotions and shampoos are usually the treatment of choice because of the ease of use and cost. They are OTC- Pyrethrins (A-200, Pronto, R&C, Rid and Triple X), Permethrin 1% (Nix), RX- Permethrin 5% (Elimite cream)Malathion (Ovid),  Benzyl Alcohol (Ulesfia)- the only non- pesticide treatment. It kills lice by shock and suffocation, Lindane (Kwell)- most toxic to humans. Permethrin 5% cream is the treatment of choice for scabies. 

These are powerful medications, and the instruction and side effects profiles should be read, understood, and followed. Conditioners and lotions will block the effect of topical medications. Long hair may require more than one bottle. Getting one large bottle and treating others with it is prescription and insurance fraud. Keep yourself out of trouble and get everyone their own prescription.  It may take up to 12 hours for the lice to start to die. Meticulously using a nit comb every two or three days will help ensure no re-infestation occurs. There is no such thing as overkill in the  meticulous use of nit combs. That’s where the term “nitpicker” comes from. As a general guideline, we are not talking minutes, we’re talking about taking an hour or more if the hair is long. Hair pins can act like bookmarks and can speed up the process. Some clinicians say the main reason for treatment failure is a result of not being thorough enough with the nit comb.

Because of side effects and environmental concerns, the National Pediculosis Association-(NPA) is steering the public away from pesticides, favoring an approach that is more labor intensive. It is possible and may even be required by circumstances that you avoid medication and manually remove all lice and their nits. The NPA website has full instructions, if you are so inclined. See Other Source of Help.  Remember this would be considered treatment and must be doctor-approved.

There is no product that kills 100% of the eggs, so there will be some manual eradication efforts required. There is one new treatment that has just been approved for use in the U.S. It is called the LouseBuster. It uses a control flow of heated air to kill lice and their eggs. It requires a trained technician so you, the caregiver, would not be the one to do the work. Insurance coverage and availability of the treatment maybe an issue. It does have the additional advantage of a very quick kill off. Usually, no  time quarantine is necessary for students to return to school after treatment. (That alone might make it worth it). Even with the LouseBuster treatment, a two-three day follow-up nit comb screening would be wise. 

Follow Up

As stated earlier, it is very important to screen everyone in the household in the case of a louse or scabies outbreak. Effectiveness of topical lice treatment should be verified after 12 hours. After two-three days, a follow-up screening should be conducted. Most Doctors will have you retreat for lice and scabies in a week to 10 days. These also have to be followed up on. You may get tired just reading about all the follow up that is required of you, but it is far better than re-infestation. They don’t call scabies the seven-year itch for nothing.


Scabies and louse infestations happen all the time and can come from anywhere. Once there is an outbreak, it will not go away by itself. The best solution to the problem is the hyper-responsive caregiver who is prepared to: 1. Recognize an outbreak by its symptoms, 2. Control its spread through socially responsible communication, 3. Properly clean and screen, 4.Treat the problem with proper medicines and meticulous techniques and 5. Prevent it from coming back with adequate follow through. I hope you never have to experience an outbreak, but if you do, I hope this article has made you more prepared. And, yes, I found myself itching more often while I wrote this article.


Other Sources of Help

1. Center for Disease Control and Prevention- Treatment general guidelines

Head lice -


2. The National Pediculosis Association

Click on the free education down loads line at the bottom of the page and follow the instruction to receive the following guide. (Child Care Giver Guide)



1. Alan Rockoff MD, Melissa Conrad Stoppler MD, Scabies.

2. Scabies. Wikipedia  The Free encyclopedia.

3. Peter Wannigan RPh, ND , Head Lice: An Update  on Diagnosis and Treatment, PowerPak C.E.Jul.31,2010

4.  John Mersch  MD, FAAP,  Lice,

5. A Pharmacist Guide to Controlling Head Lice, National Pediculosis Association

6. Parasites-Scabies, CDC Center for Disease Control and Prevention

7. Scabies, Illinois Dept of Public Health, Health beat

8. Parasites- Lice- Head Lice, CDC Center for Disease Control and Prevention


The Creepy Crawlies-Scabies and Lice

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