Pediculosis pubis

Pediculosis pubis (also known as "crabs" and "pubic lice") is an infestation by the pubic louse, Pthirus pubis, a wingless insect which feeds on blood and lays its eggs (nits) on mainly pubic hair. Less commonly, hair near the anus, armpit, beard, eyebrows, moustache, and eyelashes may be involved.[1][2][3] It is usually acquired during sex, but can be spread via bedding, clothing and towels, and is more common in crowded conditions where there is close contact between people.[1][4]

This article is about the disease. For the animal known as crab louse, see Crab louse.

Pediculosis pubis
Other namesCrabs, pubic lice, phthiriasis, phthiriasis pubis
Pubic lice in genital area
SpecialtyInfectious disease
SymptomsItch, scratch marks, grey-blue marks, visible lice and nits
ComplicationsSecondary bacterial infection
Causespubic louse
Risk factorsSexual activity, crowded situations
Diagnostic methodDirect vision of lice with or without magnifying glass
Treatment
  • Application of permethrin containing lotions
  • Removing nits with comb

The main symptom is an intense itch in the groin, particularly at night. There may be some grey-blue discolouration at the feeding site, and eggs and lice may be visible.[1][2][3] Scratch marks, crusting and scarring may be seen, and there may be signs of secondary bacterial infection.[1]

Diagnosis is by visualising the nits or live lice, either directly or with a magnifying glass.[5] Investigations for other sexually transmitted infections (STIs) are usually performed.[6]

First line treatment usually contains permethrin and is available over the counter.[3] Two rounds of treatment at least a week apart are usually required to kill newly hatched nymphs.[5] Washing bedding and clothing in hot water kills the lice and transmission can be prevented by avoiding sexual contact until no signs of infestation exist. Eggs may be removed by combing pubic hair with a comb dipped in vinegar.[6] Sexual partners should be evaluated and treated.[6]

Infestation with pubic lice is found in all parts of the world, occurs in all ethnic groups and all levels of society.[6] Worldwide, the condition affects about 2% of the population.[7]

Definition

Pediculosis pubis is an infestation by the pubic louse, Pthirus pubis, a wingless insect which feeds on blood and lays its eggs (nits) on mainly pubic hair. Less commonly, hair near the anus, armpit, beard, eyebrows, moustache, and eyelashes may be involved.[1][2][3] Although the presence of pubic lice are associated with the presence of other sexually transmitted diseases, pubic lice do not spread infectious diseases.[8]

Signs and symptoms

The onset of symptoms is typically three weeks after the first infestation of lice and is mainly an intense itch in the pubic area and groin, particularly at night, resulting from an allergic reaction to the saliva of feeding lice.[1][4][9] In some infestations, a characteristic grey-blue or slate coloration macule appears (maculae caeruleae) at the feeding site, which may last for days. Nits or live lice may be seen crawling on the skin.[3][10][6] It may be noticed as a black powder in the underwear.[9]

Scratch marks, crusting, scarring, rust-coloured faecal material, blood stained underwear and secondary bacterial infection may sometimes be seen. Large lymph nodes in the groin and armpits may be felt.[1] Some people with pubic lice infestation may not have any symptoms.[10]

  • Pubic lice lay eggs on hair shaft
  • Pubic lice on the abdomen
  • Pubic lice on the eyelashes

Causes

Spread

Pubic lice are usually transmitted from one person to another during vaginal, oral or anal sex, whether a condom is used or not.[4][9] One sexual encounter with an infected person carries a high risk of catching pubic lice.[11] In some circumstances transmission can occur through kissing and hugging, and less likely via bedding, clothing and towels. The lice spread more easily in crowded conditions where the distance between people is close, allowing the lice to crawl from one person to another.[1][9]

Infestation in a young child or teenager may indicate sexual abuse.[6]

Characteristics and life cycle
Main article: Crab louse
Crab Lice

Pubic lice (Pthirus pubis) have three stages: the egg (also called a nit), the nymph, and the adult. They can be hard to see and are found firmly attached to the hair shaft. They are oval and usually yellow to white. Pubic lice nits take about 6–10 days to hatch. The nymph is an immature louse that hatches from the nit (egg). A nymph looks like an adult pubic louse but it is smaller. Pubic lice nymphs take about 2–3 weeks after hatching to mature into adults capable of reproducing. To live, a nymph must feed on blood. The adult pubic louse resembles a miniature crab when viewed through a strong magnifying glass. Pubic lice have six legs; their two front legs are very large and look like the pincher claws of a crab—thus the nickname "crabs." Pubic lice are tan to grayish-white in color. Females lay nits and are usually larger than males.[6] To live, lice must feed on blood. If the louse falls off a person, it dies within 1–2 days. Eggs (nits) are laid on a hair shaft. Females will lay approximately 30 eggs during their 3–4 week life span. Eggs hatch after about a week and become nymphs, which look like smaller versions of the adults. The nymphs undergo three molts before becoming adults. Adults are 1.5–2.0 mm long and flattened. They are much broader in comparison to head and body lice. Adults are found only on the human host and require human blood to survive. Pubic lice are transmitted from person to person most-commonly via sexual contact, although fomites (bedding, clothing) may play a minor role in their transmission.[4][12]

Diagnosis

Diagnos is made by carefully looking at the pubic hair for nits, young lice and adult lice.[4] Lice and nits can be removed either with forceps or by cutting the infested hair with scissors (with the exception of an infestation of the eye area).[5] A magnifying glass, dermatoscope or a stereo-microscope can be used for identification.[2][5] Testing for other sexually transmitted infections is recommended in those who are infested with pubic lice.[4]

Treatment

Pubic lice can be treated at home. Available treatments may vary from country to country and include mainly permethrin containing creams and lotions applied to cool dry skin.[2]

Treatment with medication is combined with combing pubic hair with a fine-toothed comb after applying vinegar directly to skin or dipping the comb in vinegar, to remove nits.[1][3] It is recommended to wash bedding, clothing and towels in hot water or preferably in a washing machine at 50°C or higher. When this is not possible, the clothing can be stored in a sealed plastic bag for at least three days.[2][13] Re-infestation can be prevented by wearing clean underwear at the start of treatment and after completing treatment.[2] Shaving the affected hair is not essential.[2]

First line
Nit comb

At first, treatment is usually with topical permethrin 1% cream, which can be bought over the counter without a prescription. It is applied to the areas affected by pubic lice and washed off after 10 minutes.[6] Brands of permethrin include 'Lyclear', available in the UK as a creme rinse or dermal cream at 5% strengths.[14][15] In the US, permethrin may be familiar as NIX, Actin and Elimite[16]

An alternative is the combination of pyrethrins and piperonyl butoxide, in a topical application, which include the brands Licide, and A-200, Pronto and RID shampoos.[13][17] These medications are safe and effective when used exactly according to the instructions in the package or on the label.[6] To kill newly hatched lice, both treatments can be repeated within the following seven to ten days.[5][18]

European guidelines state alternatives to permethrin as including either the application of 0.2% phenothrin (washed off after two hours) or 0.5% malathion lotions (washed off after 12 hours).[2] The CDC states alternatives as topical 0.5% malathion or oral ivermectin.[13]

Other treatments

Lindane is still used in a shampoo form in some non-European countries. Its licence was withdrawn by the European Medicines Agency in 2008.[2] It may be considered as a last resort in some people who show resistance to other treatments, but is not recommended to be used for a second round of treatment.[2][4] Lindane is not recommended in pregnant and breastfeeding women, children under the age of two years, and people who have extensive dermatitis.[4][6] The FDA warns against use in people with a history of uncontrolled seizure disorders and cautious use in infants, children, the elderly, and individuals with other skin conditions (e.g., atopic dermatitis, psoriasis) and in those who weigh less than 110 lbs (50 kg).[6][19] Carbaryl has been used since 1976 but found to have the potential to cause cancer in rodents and not to be as effective as previously thought. It is either not used at all or its use is restricted.[2][20]

Sexual partners should be evaluated and treated, and sexual contact should be avoided until all partners are better. Because of the strong association between the presence of pubic lice and sexually transmitted infections (STIs), affected people require investigation for other STIs.[6]

Eyes

Infestation of the eyes is treated differently to other parts of the body. Lice can be removed with forceps or by removing or trimming the lashes.[21] Eyelashes may be treated with a gentle petroleum jelly for occlusion.[21]

Complications

Complications are usually as a result of persistent scratching and include thickening of the skin, darkened skin, and secondary bacterial infection including impetigo, conjunctivitis and blepharitis.[1][9]

Epidemiology

Infestation with pubic lice is found in all parts of the world, occurs in all ethnic groups and all levels of society.[6]

Current worldwide prevalence has been very approximately estimated at two percent of the human population. Accurate numbers are difficult to acquire, because pubic lice infestations are not considered a reportable condition by many governments. Many cases are self-treated or treated discreetly by personal physicians, which further adds to the difficulty of producing accurate statistics.[7]

It has been reported that the trend of pubic hair removal has led to the destruction of the natural habitat of the crab louse populations in some parts of the world, thereby reducing the incidence of the disease.[2][22][23]

Etymology and history

Infestation with pubic lice is also called phthiriasis or phthiriasis pubis, while infestation of eyelashes with pubic lice is called phthiriasis palpebrarum or pediculosis ciliarum.[24] Linnaeus was first to describe and name the pubic louse in 1758, when he called it Pediculus pubis. The disease is spelled with phth, but the scientific name of the louse Pthirus pubis is spelled with pth (an etymologically incorrect spelling that was nonetheless officially adopted in 1958).[25]

Other animals

Humans are the only known hosts of this parasite,[3] although a closely related species, Pthirus gorillae, infects gorilla populations.[26]

References
  1. "Pediculosis". Lippincott's Guide to Infectious Diseases. Lippincott Williams & Wilkins. 2011. p. 236. ISBN 978-1-60547-975-0.
  2. Salavastru, C. M.; Chosidow, O.; Janier, M.; Tiplica, G. S. (2017). "European guideline for the management of pediculosis pubis". Journal of the European Academy of Dermatology and Venereology. 31 (9): 1425–1428. doi:10.1111/jdv.14420. ISSN 1468-3083.
  3. "Pubic lice: MedlinePlus Medical Encyclopedia". medlineplus.gov. Retrieved 4 December 2017. This article incorporates text from this source, which is in the public domain.
  4. P. A. Leone (2007). "Scabies and pediculosis pubis: an update of treatment regimens and general review". Clinical Infectious Diseases. 44 (Suppl. 3): S153–S159. doi:10.1086/511428. PMID 17342668.
  5. Williams gynecology. Hoffman, Barbara L., Williams, J. Whitridge (John Whitridge), 1866-1931. (2nd ed.). New York: McGraw-Hill Medical. 2012. pp. 90–91. ISBN 9780071716727. OCLC 779244257.CS1 maint: others (link)
  6. Prevention, CDC - Centers for Disease Control and (2 May 2017). "CDC - Lice - Pubic". www.cdc.gov. Retrieved 4 December 2017. This article incorporates text from this source, which is in the public domain.
  7. Alice L. Anderson; Elizabeth Chaney (2009). "Pubic lice (Pthirus pubis): history, biology and treatment vs. knowledge and beliefs of US College students". International Journal of Environmental Research and Public Health. 6 (2): 592–600. doi:10.3390/ijerph6020592. PMC 2672365. PMID 19440402.
  8. Gratz, Norman (2006). Vector- and Rodent-Borne Diseases in Europe and North America: Distribution, Public Health Burden, and Control. Cambridge University Press. p. 87. ISBN 978-0-521-85447-4.
  9. "Pubic lice". nhs.uk. 19 October 2017. Retrieved 13 November 2020.
  10. O'Donel Alexander, John (2012). "5. Infestation with Anoplura- Lice". Arthropods and Human Skin. Berlin: Springer Verlag. pp. 29–53. ISBN 978-1-4471-1358-4.
  11. Fred F. Ferri (2015). Ferri's Clinical Advisor 2016: 5 Books in 1. Elsevier Health Sciences. p. 936. ISBN 978-0-323-37822-2.
  12. "CDC - Lice - Pubic "Crab" Lice - Biology". www.cdc.gov. Centers for Disease Control and Prevention (CDC). 26 June 2019. Retrieved 29 October 2020. This article incorporates text from this source, which is in the public domain.
  13. "Ectoparasitic Infections - 2015 STD Treatment Guidelines". www.cdc.gov. 11 January 2019. Retrieved 20 November 2020.
  14. Patient Information Leaflet: Permethrin Archived 27 November 2020 at the Wayback Machine, Archived on the Electronic Medicines Compendium of the UK. Accessed 27 November 2020.
  15. World Health Organization Model List of Essential Medicines: 21st list. WHO. 2019. p. 38.
  16. Guenther, Lyn C C (16 August 2019). "Pediculosis and Pthiriasis (Lice Infestation) Medication: Antiparasitic Agents". emedicine.medscape.com. Retrieved 27 November 2020.
  17. "Pyrethrin and Piperonyl Butoxide Topical: MedlinePlus Drug Information". medlineplus.gov. Retrieved 23 November 2020.. Last revised 15 November 2015.
  18. Buttaravoli, Philip; Hudson, Page (2012). "178. Pediculosis (lice, crabs)". In Philip Buttaravoli (ed.). Minor Emergencies E-Book. Stephen M. Leffler (Third ed.). Elsevier Saunders. p. 701. ISBN 978-0-323-07909-9.
  19. "Lindane Shampoo, USP, 1%". FDA. 2002
  20. Sangaré, Abdoul Karim; Doumbo, Ogobara K.; Raoult, Didier (2016). "Management and Treatment of Human Lice". BioMed Research International. 2016. doi:10.1155/2016/8962685. ISSN 2314-6133. PMC 4978820. PMID 27529073.
  21. Saw, P. J.; Leonard, Jonathan (2016). "109. Dermatoses of the eye, eyelids and eyebrows". In Griffiths, Christopher; Barker, Jonathan; Bleiker, Tanya O.; Chalmers, Robert; Creamer, Daniel (eds.). Rook's Textbook of Dermatology, 4 Volume Set. 3. John Wiley & Sons. p. 42. ISBN 978-1-118-44119-0.
  22. N. R. Armstrong; J. D. Wilson (2006). "Did the "Brazilian" kill the pubic louse?". Sexually Transmitted Infections. 82 (3): 265–266. doi:10.1136/sti.2005.018671. PMC 2564756. PMID 16731684.
  23. Bloomberg: Brazilian bikini waxes make crab lice endangered species, published 13 January 2013, retrieved 14 January 2013
  24. N. P. Manjunatha; G. R. Jayamanne; S. P. Desai; T. R. Moss; J. Lalik; A. Woodland (2006). "Pediculosis pubis: presentation to ophthalmologist as pthriasis palpebrarum associated with corneal epithelial keratitis". International Journal of STD & AIDS. 17 (6): 424–426. doi:10.1258/095646206777323445. PMID 16734970.
  25. "Taxonomy of Human Lice | Phthiraptera.info". phthiraptera.info. Retrieved 9 November 2020.
  26. Robin A. Weiss (2009). "Apes, lice and prehistory". Journal of Biology. 8 (2): 20. doi:10.1186/jbiol114. PMC 2687769. PMID 19232074.
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