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Background: Pubis (Pubic Lice, Sometimes Called "Crabs")
Background: Pubis (Pubic Lice, Sometimes Called "Crabs")
Pediculosis (ie, louse infestation) dates back to prehistory. The oldest known fossils of louse
eggs (ie, nits) are approximately 10,000 years old.[1] Lice have been so ubiquitous that related
terms and phrases such as "lousy," "nit-picking," and "going over things with a fine-tooth
comb" are part of everyday vocabulary.
Louse infestation remains a major problem throughout the world, making the diagnosis and
treatment of louse infestation a common task in general medical practice.[2] Pediculosis capitis
results in significant psychological stress in children and adults and missed schooldays in
children, particularly in areas with a no-nit policy.[3]
Lice are ectoparasites that live on the body. Lice feed on human blood after piercing the skin
and injecting saliva, which may cause pruritus due to an allergic reaction.[4] Lice crawl but
cannot fly or hop.[4]
A mature female head louse lays 3-6 eggs, also called nits, per day. Nits are white and less
than 1 mm long. Nymphs (immature lice) hatch from the nits after 8-9 days, reach maturity in
9-12 days, and live as adults for about 30 days.[4]
Different species of lice prefer to feed on certain locations on the body of the host. Louse
species include Pediculus capitis (head lice), Pediculus corporis (body lice), and Pthirus
pubis (pubic lice, sometimes called crabs).
See the louse images below.
Pathophysiology
Louse infestation is prevalent throughout the animal kingdom. Mallophaga, or chewing lice,
are common pests of birds and domestic animals, but humans are only rarely affected as
accidental hosts.[6]
Human lice (P humanus and P pubis) are found in all countries and climates. They belong to
the phylum Arthropoda, the class Insecta, the order Phthiraptera, and the suborder Anoplura
(known as the sucking lice).[6] Mammals are the hosts for all Anoplura.
The Anoplura are wingless and have 3 pairs of legs, each with a single tarsal segment ending
with a claw for grasping. The size and shape of the claws are adapted to the texture and shape
of the hairs and/or clothing fibers they grasp. Their bodies are flat and covered with tough
chitin.
Lice are blood-sucking insects. Human lice have small anterior mouthparts with 6 hooklets
that aid their attachment to human skin during feeding. The sucking mouthparts retract into
the head when the lice are not feeding. In general, lice feed approximately 5 times per day. In
each species, the female louse is slightly larger than her male counterpart.
The 3 types of human lice include the head louse (Pediculus humanus capitis), the body louse
(Pediculus humanus corporis), and the crab louse (Pthirus pubis). Body lice infest clothing,
laying their eggs on fibers in the fabric seams. Head and pubic lice infest hair, laying their
eggs at the base of hair fibers.[7, 8]
Head and body lice are similarly shaped, but the head louse is smaller. Nevertheless, the 2
species can interbreed. The pubic louse, or "crab," is morphologically distinct from the other
two.
Head louse infestation is spread by close physical contact and occasionally by shared fomites
(eg, combs, brushes, hats, scarves, bedding).[4] Lice can be dislodged by combs, towels, and
air movement (including hair dryers in either low or high setting).[9] Hair combing and
sweater removal may eject adult lice more than 1 meter from infested scalps. Head lice can
travel up to 23 cm/min.[6] The head louse has difficulty attaching firmly to smooth surfaces
(eg, glass, metal, plastic, synthetic leathers).[4]
Pthirus pubis
The pubic louse gets the nickname of "crab" from its short, broad body (0.8-1.2 mm) and
large front claws, which give it a crab-like appearance. The pubic louse is white to gray and
oval and has a smaller abdomen than both P humanus capitis and P humanus corporis. Pubic
lice live for approximately 2 weeks, during which time the females lay 1-2 eggs per day.[6]
Nymphs emerge from the eggs after 1 week and then mature into adults over the subsequent 2
weeks.[6]
Their large claws enable pubic lice to grasp the coarser pubic hairs in the groin, perianal, and
axillary areas. Heavy infestation with P pubis can also involve the eyelashes, eyebrows, facial
hair, axillary hair, and, occasionally, the periphery of the scalp.
Pubic lice are less mobile than P humanus and P corporis, mainly resting while attached to
human hairs. They can crawl up to 10 cm/day.[6] They cannot survive off the human host for
more than 1 day.
Nits
The average nit (ie, ovum) of the 3 types of lice is 0.8 mm long. The nit (see the images
below) attaches to the base of the hair shaft (in the case of head or pubic lice) or to fibers of
clothing (in the case of body lice) with a strong, highly insoluble cement; thus, nits are
difficult to remove. The nit is topped with a tough but porous cap known as the operculum.
This porous operculum allows for gas exchange while the nymph develops in the casing.
Lice as vectors
Head lice are not vectors for other organisms that cause disease.[4]
Pubic louse infestation is usually spread as a sexually transmitted disease (STD). Thirty
percent of infested individuals may have other concurrent STDs (eg, HIV infection, syphilis,
gonorrhea, chlamydia, herpes, genital warts).[6]
The body louse can be the vector of R prowazeki, which causes typhus; B quintana, which
causes trench fever; and B recurrentis, which causes relapsing fever. Evidence shows that
some infectious organisms are altered by their arthropod vector and that disease
Etiology
Causative organisms include P humanus capitis (head louse), P humanus corporis (body
louse), and P pubis (pubic louse)
P humanus capitis
Pediculosis capitis is spread by direct contact with an infested person. Head-to-head contact
with an infested individual at school, at home, and while playing may result in head lice
infestation; personal hygiene and environmental cleanliness are not risk factors.[4] Fomites,
such as clothing, headgear, hats, combs, hairbrushes, hair barrettes, may occasionally play a
role in the spread of head lice.[4] Factors that predispose to head louse infestation include
young age; close, crowded living conditions; female sex; white or Asian race; and perhaps
warm weather.[13] The risk of nosocomial transmission is low, unless close patient-to-patient
contact (eg, playrooms, institutions) is present.
P humanus corporis
Risk factors for body lice infestation include close, crowded living situations (eg, crowded
buses and trains, prison camps)[11] and infrequent washing and/or changing of clothing. P
corporis can be acquired via bedding, towels, or clothing recently used by an individual
infested with lice; thus, individuals who are homeless, who are impoverished, or who are
living in refugee camps are at high risk for infestation.[10]
P pubis
Intimate or sexual contact with an individual who is infested with pubic lice is a common risk
factor for pubic lice infestation. Risk factors for infestation of the pubic louse include sexual
promiscuity and crowded living conditions. Contact with clothing, bedding, and towels used
by an infested individual may occasionally be the cause of infestation.[14] It is a myth that
pubic lice are spread by sitting on a toilet seat; pubic lices feet are not designed to walk on
smooth surfaces such a toilet seats, and the lice cannot live for long away from a warm
human body.[14]
Because these organisms are most often spread through close or intimate contact, P pubis
infestation is classified as an STD. Condom use does not prevent transmission of P pubis.
Upon diagnosis of pubic lice, concern should be raised about the possibility of concomitant
STDs.
In children, infestation of pubic lice is usually contracted from a parent who is infested.
Sexual transmission to children is rare. In most cases of infestations in children, transmission
results from shared bed linens and close nonsexual contact.
Epidemiology
Since pediculosis is not a reportable disease, exact numbers concerning incidence are
unknown. Pediculosis may be underreported because of the social stigma attachednamely,
the preconceived notion that lice of any kind are related to dirt and poor personal hygiene. In
fact, personal cleanliness is not a factor in head lice infestation rates. On the other hand,
false-positive nit diagnosis is common.[4]
Body louse infestation in the United States mainly affects homeless persons. Pubic lice
generally are spread as an STD. Pubic louse infestation serves as a marker for other STDs,
which may have been acquired simultaneously.[6]
International statistics
Pediculosis has a worldwide distribution and is endemic in both developing and developed
countries. The prevalence of pediculosis capitis is usually higher in girls and women and
varies from 0.7%-59% in Turkey, 0.48-22.4% in Europe, 37.4% in England, 13% in
Australia, up to 58.9% in Africa, and 3.6%-61.4% in the Americas.[3]
In a study of 6,169 Belgian school children aged 2.5-12 years, the prevalence of head lice
was 8.9%.[17] The prevalence in 1,569 school children in Izmir, Turkey, was 16.6%.[18] In 2005,
the incidence of pediculosis doubled in the Czech Republic.[19] Live lice were detected in
14.1% and dead nits in another 9.8% of 531 children aged 6-15 years in 16 schools.[19]
P capitis was found in 9.6% of adolescent schoolboys in Saudi Arabia.[20] In Mali, the
prevalence of head lice in children was 4.7%.[21] Among attendees of an STD clinic in south
Australia, pubic lice were found in 1.7% of men and 1.1% of women.[22]
P corporis is now uncommon in developed countries except among homeless persons.[23]
Girls are at higher risk of head louse infestation than boys because of social behavior (eg,
social acceptance of close physical head-to-head contact and, less commonly, sharing of hats,
scarves, combs, brushes, hair ties and lying on a sofa, carpet, or stuffed toy that has recently
come in contact with an infested person); hair length is not a factor. No sexual predilection
exists in body or pubic louse infestation; males and females are equally likely to become
infested.
Children aged 3-11 years are most likely to become infested with head lice because of close
contact in classrooms and day care facilities. Head lice are much less common after puberty.
Body lice are more common in adults, but can affect all ages.[25] Age is not a significant risk
factor in body louse infestation; body lice are indiscriminate in regard to the age of their host.
P pubis infestation is more common in people aged 14-40 years who are sexually active.
Prognosis
Treatments are highly effective in killing nymphs and mature lice, but less effective in killing
eggs.
Causes of therapeutic failure include the following:
Misdiagnosis
Inappropriate treatment
Noncompliance
Lack of ovicidal activity of pediculicide and failure to re-treat within 7-10 days
Sharing clothing, bedding and towels used by a person infested with body or pubic
lice
Re-infestation
Resistance to pediculicide
Frequent use of pediculicides may cause persistent itching. Body lice can be vectors for
diseases such as epidemic (louse-borne) typhus, trench fever, and louse-borne
relapsing/recurrent fever. Violation of the integrity of the skin from a bite can lead to bacterial
infection with organisms such as methicillin-resistant Staphylococcus aureus (MRSA). More
commonly, infestation with lice produces social embarrassment and isolation rather than
medical disease.
Patient Education
The social stigma associated with head lice infestation must be addressed. Poor hygiene is not
a risk factor in acquiring pediculosis capitis, although it is for body lice.
Management of head lice must include examination of all individuals exposed (all household
members and other close contacts) and treatment of all those who are infested. Individuals
who have no evidence of infestation should not be treated; however, if they share a bed with
an infested individual, it is reasonable to treat them prophylactically.[4]
Education has been shown to reduce the number of lice infestations in schools. "No nit"
policies exclude many children from the classroom, but they have not been shown to reduce
the number of louse infestations.[27] Schools with no-nit policies should be educated to
abandon these policies. The Centers for Disease Control and Prevention (CDC), American
Association of Pediatrics, and National Association of School Nurses recommend
discontinuation of these policies.[4]
Noncompliance is a common cause of treatment failure in all 3 types of lice infestations.
Therefore, time is well-spent providing patients with detailed instructions regarding the
application and timing of medications used in the treatment of lice. Fomites may harbor live
lice and therefore should be treated to prevent re-infestation and infestation of other
individuals.
To minimize acquiring head lice, during epidemics of head lice, children should be educated
not to share combs, brushes, headbands, hats, and scarves.[6] Hats and scarves should not be
piled in a common area, but rather separated for each child.[6] Shaving of hair is effective
treatment of head lice, but not socially acceptable in most societies.[28]
All sexual partners from within the previous month of a person infested with pubic lice
should be treated.[14] Sexual contact should be avoided until both parties have been
successfully treated. Individuals infested with pubic lice are at risk for other sexually
acquired diseases and should be screened for such.
In the case of body lice, infested clothing and towels need to be washed in hot water and with
a hot dryer; pediculicides are usually not needed. The infested individual should be counseled
on proper hygiene, changing clothing at least once a week, and proper laundering of clothing.
[10]
For patient education information, see the Parasites and Worms Center, as well as Lice and
Crabs.