3 Ways to Treat Lice—and How to Know if Your Child Really Has Them

It's a call every parent dreads: Someone at your school, maybe even in your child's class, has just acquired some hangers-on. Though you fear your kid will bring home their own colony of crawlers, this can happen only after head-to-head (or head-accessory-to-head) contact with the infested party. So don't freak out yet—but take a look, particularly at the hairline along the neck and behind the ears. If you do find a live louse, panic is probably next on your agenda. (Kids tend to flip, too, icked out—not to mention itched out—by both the bugs and the stigma they carry.)

But then it's time to turn your attention to solutions, which is where things can get confusing. You've got three main options: over-the-counter chemical treatments like Nix or Rid; pediatrician-prescribed topical treatments, which also contain chemicals; and chemical-free methods, like hiring a local lice person to pick out nits (eggs) or coating your child's head with something greasy to choke each louse before combing them out yourself. Every lice parent is forced to make this call, and everyone has their own reasoning.

Rachel Ellis, a mom of three in Decatur, Georgia, who has powered through six bouts of lice, says she's "all about the chemical treatments. I feel guilty, but it takes care of the problem." Then there's Lisa Meyer (not her real name), a mom and stepmom of seven near New York City, whose entire household has had lice at least once. "I used to use the over-the-counter stuff," she says, "but I was never sure it had worked completely." Eventually, she shelled out hundreds for a lice pro. "Now I just copy what she did—a thorough comb-out after coating the head with conditioner—and I haven't touched a chemical since," Meyer says.

The sad truth is that ridding yourself of lice will never be easy. "Treating lice and getting all the eggs is hard no matter what method you use," says Sara Bode, M.D., medical director of Nationwide Children's Hospital's Care Connection School-Based Health and Mobile Clinics in Columbus, Ohio. Indeed, 71 percent of moms said they had failed to treat the condition successfully on their own, according to a 2017 report by Arbor Pharmaceuticals, the makers of the lice treatment Sklice. But with a little background knowledge on each method, you can improve your chances of success—and choose a remedy you're comfortable with.

Note that before you start a lice treatment, it's key to avoid one common mistake: Parents who are worried about lice may see what they assume are nits and treat their kids unnecessarily. "I often see parents who think they've found lice but haven't," says Bernard Cohen, M.D., professor of dermatology and pediatrics at the Johns Hopkins University School of Medicine. What else might it be? Dandruff, dried hair products, scaly skin, and more are often confused with nits. In order to truly diagnose a case of lice, you must spot a live and crawling louse. If after a thorough check you don't see anything moving, your child might just have an itchy scalp from cold weather, or their hair gel is flaking.

Over-the-Counter Chemical Lice Treatments

Obviously, no one enjoys putting insecticides on their kid's head, but over-the-counter options remain a go-to for many parents and pediatricians. One downside of these treatments, which contain the chemicals permethrin or pyrethrin, is that they can cause skin irritation. Another is that you need to apply them at least twice to see results. The first shampooing kills lice; the second kills any lice that have hatched since the first treatment. These remedies also do not kill nits, so every two to three days for two to three weeks, parents have to comb out lice and nits to make sure they're really gone. "It's a lot of work, but these products are inexpensive and safe," says Dr. Cohen.

Unfortunately, lice treatments often fail due to user error. "You need to get the chemicals all the way down to the base of the hair," Dr. Bode says. "Bugs like being close to the scalp where the temperature is the warmest, and you also need to remove all the eggs from this area." This can take a while. "Together with the treatment and combing, it took me two to three hours to do just one head of hair," Ellis says.

It's also imperative to vigilantly check (and treat, if needed) every member of the family. "If you don't, you're just going to keep getting reinfested. I see this a lot," Dr. Bode says. And even though lice can live "off head" for only 24 hours and don't jump or fly, it's prudent to wash the bedding of anyone who's infested in hot water. Also, advises Dr. Bode, "put anything on the bed that can't be washed, like a throw pillow or a stuffed animal, into a sealed garbage bag for two weeks. This prevents anyone from lying down on yet-to-be-hatched eggs." Do all of the above perfectly, and you've got a good chance of success.

If you're concerned about chemicals being ineffective on so-called super lice, given unnerving reports that lice are mutating in ways that make them more resistant to OTC treatments, there's good news. Though some studies have found that most lice have genetic mutations that may make them more resistant to the chemicals in OTC treatments, "that does not mean that these treatments won't work," says Richard J. Pollack, Ph.D., senior environmental health officer at Harvard University. "Many lice will likely still die, even if they possess that genetic mutation. From what I've seen, many folks still successfully eliminate their infestations by use of OTC products."

Another product that's popular—at least in Europe—is dimethicone, a type of silicone that smothers lice. "There's pretty good data from other parts of the world that show it can be just as effective as our prescription agents, "Dr. Cohen says. For instance, a report in BMC Pediatrics found that more than 96 percent of kids remained free of live lice and 81 percent had no viable nits 14 days after being treated with dimethicone. The only hitch: It's not as readily available as a lice treatment in the United States as it is abroad. But there are some products sold in the U.S. that contain dimethicone, such as Nix Ultra, which may make the treatment more effective.

Prescription Lice Treatment Options

There are also a handful of prescription options that are more powerful than OTC treatments (and which, happily, lice are less likely to be resistant to). One is benzyl alcohol lotion, which kills lice over two treatments but does not kill nits, and is approved for use on children 6 months and older. Another is the lotion sold under the brand name Sklice, whose active ingredient is ivermectin. (If the name of this drug sounds familiar, it's because you've likely heard about people attempting to treat COVID-19 with it—unsuccessfully, and at great risk to their health, since they're using a version of the drug meant for horses.) This treatment does not kill nits either. But another option, malathion lotion, kills both live lice and some nits, and can be used on kids age 6 and up. Finally, spinosad (brand name Natroba) is a topical medication that is effective at killing both lice and nits, requires no combing, and is typically effective after one treatment.

Perhaps you're wondering: If they work so well, why not just start with a prescription? Some doctors do recommend this, but many others insist that making prescription options the norm will only increase lice's resistance to these chemicals. Another major downside to prescription treatments is that these powerful topical pesticides can be even more irritating to the skin than OTC options, and even more potentially dangerous if they get into the eyes or are ingested. (If your child is prone to dry skin or eczema, mention this to your pediatrician so they can take this into account when prescribing.) In fact, it's worth noting that the American Academy of Pediatrics advises washing all chemical treatments, both prescription and OTC, out of the hair only over the sink, not in the shower, to prevent the lotions from coming into contact with other parts of the body.

So when should you pull the trigger on a prescription? Head to the pediatrician only after nothing else has worked. "If you've used an OTC treatment but your child still has active lice after five to seven days, don't wait to do the second treatment," Dr. Bode says. "Just go see your child's physician for a prescription." In this situation, it's very likely that the bugs aren't all from just-hatched eggs but are instead survivors of the first treatment. "It's also smart to see the doctor if you did the recommended two treatments, then within a month the lice are back," Dr. Bode adds.

Non-Chemical or "Natural" Lice Treatments

For many parents, dousing a child's head with an insecticide is simply a nonstarter. That's a reasonable position to take, Dr. Bode says. "I think it's always important to have some concerns anytime you're giving your child medication or a topical treatment." However, not all "natural" treatments are superior. For instance, excessive or inappropriate application of essential oils (tea tree and other oils are often falsely billed as treatments) can poison children, even through the skin.

Other popular alternative treatments aren't as potentially dangerous but do tend to lack clear data indicating that they work. Many methods involve the application of food-grade oils, hair conditioner, or lotions to the head. "These are thought to smother lice on the scalp," Dr. Pollack says. "But none of them have been sufficiently tested for use against lice, and none are labeled for this purpose." That said, there was one small study that reported a 96 percent cure rate when Cetaphil face cleanser was applied to hair, combed out, dried with a blow-dryer, left overnight, and shampooed in the morning. (This was repeated once a week for three weeks.) However, "this wasn't a randomized controlled trial, which is the gold standard of studies," Dr. Cohen says. "There's really no definitive data to support that this is effective."

What we do have, though, are anecdotal reports from parents who say it works. "While there's no proof that covering your child's hair with a thick or oily substance, like mayo or Cetaphil, suffocates lice, I do think this practice could be an effective treatment if you're lucky enough to catch the infestation very early, with just a couple of live crawlers and nits," Dr. Bode says. But she speculates that it's actually the extensive combing that's effective, not the attempted smothering. Also, "when the hair shaft is coated with something greasy, it makes it easier for you to detach and remove the nits and bugs with a lice comb," she says.

But the leading "natural" method for ridding yourself of lice is just manually removing them one by one. Is it pleasant? No—not for you or for your child. Nor is it quick. "I'd use an extra-large bottle of thick white conditioner on my child's head, and spend 45 minutes to an hour combing through the hair, section by section, with a light, a magnifying glass, and a long-toothed metal nit comb, wiping the nits and lice that got stuck on the comb onto a paper towel," says Meyer, who'd repeat the process until no lice were spotted. (Dr. Pollack notes that this sort of manual lice removal requires a comb-through daily, or at least every few days, until you haven't seen a crawling louse in two weeks.) "Because there's no chemical killing the lice, you need to pick off every single bug and nit, and check regularly," Dr. Bode says. "So this is best for mild cases, in which there are relatively few bugs and nits. And the failure rate is still high, meaning that it's very easy to miss nits that later hatch into lice, perpetuating the problem." (Also, note that the "treat everyone in the house" and "wash the bedding" rules apply here too.)

There is one no-chem alternative that's effective and FDA-cleared: a special form of heat from a device called AirAllé. "Both lice and nits can be killed by it," Dr. Pollack says. "But it can be used only by trained persons, so there may not be a center near where you live, and it can be costly." (It's only available at one of the 350+ Lice Clinics of America and costs more than $150 a pop.) A study in Pediatrics showed that one 30-minute treatment killed nearly 100 percent of nits—that's a better rate than most prescription options—and 80 percent of live lice. (By the way, if you're thinking that a blow-dryer will do the job just as well, let us assure you that this is not a good idea. Not only are there no standard heat levels on hair dryers, meaning you could burn your child's scalp, but using one could cause live lice to become airborne and land on surfaces where they might spread to new hosts.)

In the end, no matter which method you choose, know this: "Of all the nasties your child might bring home, at least head lice aren't dangerous to your child's health," Dr. Pollack says. (Your mental health, on the other hand ...) Sure, remedying lice takes a good deal of work, and their very presence is understandably upsetting, but you'll get through it. Ellis agrees: "The first time my kids got lice, I was completely overwhelmed and stressed by the whole ordeal. I somehow felt it was a reflection on me." Not anymore. Today, she greets lice with a sigh and a shrug. "I finally get it. Lice are just an annoyance, not a scarlet letter to bear or a big worry. I just grab a box of the OTC stuff off the drugstore shelf, roll up my sleeves, and get to work."

The Truth About Lice Prevention

Don't be fooled by any "clinically proven" statements on OTC lice repellents, which claim to stave off infestation with herbs like rosemary, citronella, or tea tree oil. "'Clinically proven' is just an advertising term for subjective testing on one or a few persons," says Harvard University's Richard J. Pollack, Ph.D. "While some repellents seem to affect the behavior of lice in the laboratory, I've yet to see anything that wards off lice in real life." The only true ways to keep lice away are shaving your child's head (please don't do this) or ensuring they have zero head-to-head contact with other people. In other words, it's pretty much impossible.

This article originally appeared in Parents magazine's January/February issue as "The Facts of Lice."