Review Article CED

Clinical and Experimental Dermatology

CPD

A clinical review and history of pubic lice

P. U. Patel,1 A. Tan2 and N. J. Levell1
1
Department of Dermatology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK; and 2Genitourinary Medicine Department,
iCASH Norwich, Cambridge Community Services NHS Trust, Cambridge, UK

doi:10.1111/ced.14666

Summary The ectoparasite Pthirus pubis (PtP), commonly known as the crab or pubic louse,
has plagued primates from prehistoric apes to Homo sapiens. We combed the litera-
ture from antiquity to the present day, reviewing the pubic louse’s origins, its evolu-
tion with mankind, and its presentation and management. MEDLINE and EMBASE
provided the greatest yield of literature compared with other databases. Estimates for
PtP incidence range from 0.3% to 4.6% and for prevalence around 2% in adults.
War, disasters and overcrowding support lice transmission, but modern pubic hair
grooming has reduced the incidence of PtP in recent years. PtP, is usually found on
pubic hair, but may infest scalp and body hair, eyebrows and eyelashes. Reports sug-
gest the possibility of PtP as a vector for Bartonella spp. and Acinetobacter spp., which
require further study. Transmission of PtP is via close contact, so sexual abuse and
concomitant sexually transmitted infections should be considered. Symptoms and
signs of infestation include pruritus, red papules and rust/brown deposits from feed-
ing or faecal matter. Visualization of live lice confirms the diagnosis. Traditional
treatments include hand-picking and combing, but in modern times pediculicidal
products may generate faster resolution. Permethrin or pyrethrins are the first-line
recommendations. Resistance to pediculicides is common with head lice and is pre-
sumed likely with PtP, although data are lacking. Pseudoresistance occurs as a
result of poor compliance, incorrect or ineffective dosing, and reinfestation. In true
resistance, a different pediculicide class should be used, e.g. second-line agents such
as phenothrin, malathion or ivermectin. Lice have existed long before humans and
given their adaptability, despite habitat challenges from fashion trends in body hair
removal, are likely to continue to survive.

which diversified with mammals 75 Ma ago. The

Epidemiology
Lice fossils, infesting various species, date from ca.
100 million years (Ma) ago.1 Human lice origi-
nated from the great ape sucking lice (Phthiraptera
anoplura),2–4 sometimes called heirloom parasites,
Correspondence: Dr Priya Patel, Department of Dermatology, Norfolk and
Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich
NR4 7UY, UK
E-mail: priya.patel@nnuh.nhs.uk
Conflict of interest: the authors declare that they have no conflicts of
interest.
Accepted for publication 30 March 2021
sucking lice split into the chimpanzee louse (Pedicu-
lus schaeffi), which later resulted in the body and
head louse, and the gorilla louse (Pthirus gorillae),
which evolved into the human pubic louse
(Fig. 1).3–5 PtP are poorly studied in the literature,
with accurate incidences difficult to estimate
because of limited patient reporting. The incidence
may vary from 0.3% to 4.6%,2 while the average
prevalence is estimated at 2% in adult popula-
tions.2 Populations in crowded areas, during war
or natural disaster, or with poor sanitation are vul-
nerable to lice.6

ª 2021 British Association of Dermatologists Clinical and Experimental Dermatology 1

A clinical review and history of pubic lice  P. U. Patel et al.
Figure 1 Evolution of P. pubis from the sucking lice of the great apes. Ma, million years.
Correlations between decreasing lice populations and
increasing rates of body hair removal have been
observed. In the UK, during the period 1997–2003, the
Leeds Genitourinary (GU) Department observed a
decreased prevalence of PtP infestation (OR = 0.41)
linked to increased body waxing,7 while there were
increased rates of gonorrhoea (OR = 2.18) and chlamy-
dia (OR = 1.31).7 Also in the UK, the Milton Keynes GU
Unit showed a reduced incidence of PtP from 1.8% to
0.07% during the period 2003–2013, which was also
linked to hair removal.8 In 2017, a survey of US resi-
dents who practised genital or perianal hair removal
demonstrated low numbers of PtP but had higher rates
of sexual partners, and syphilis, HIV, herpes, chlamydia
and human papillomavirus infection.9
Lice can be used as forensic tools, mixed DNA from
two hosts can be detected in lice blood meals taken up
during close contact between victims and assailants.6
Unlike the human body louse, PtP is not usually consid-
ered a vector for disease. However, reports have demon-
strated that head and pubic lice can carry Bartonella
quintana and Acinetobacter DNA.10 Further research
may show that PtP can be a vector for other pathogens.
Morphology and lifecycle of P. pubis
The adult PtP louse is 0.8–3 mm in length and stocky,
with six legs. The rear two pairs of legs terminate with
pincer-like claws, whose grasp is designed to match
the diameter of pubic hair, other coarse hair and
2 Clinical and Experimental Dermatology
clothing fibres hence the name crab louse (Fig. 2).11,12
The smallest of the human lice, these wingless para-
sites are site-specific, attaching to the base of densely
packed hair, where they suck blood periodically and
move a few millimetres daily.13 They generally reside
in the pubic or perineal hair but can infest facial, scalp
and body hair.1,2 Transmission occurs via close con-
tact, or rarely by sharing of fomites such as bedding
or clothing. An adult female louse lays 3–10 eggs
daily and fixes ≤ 30 eggs to hair in a lifetime.13,14
These hatch over 6–10 days and transition into adult-
hood over 2–3 weeks. They have an average lifespan
of 3–4 weeks and feed five times a day.14 They die
within 24–48 h away from a host6 or if the humidity
exceeds 40% and the temperature exceeds 50 °C.14
The optimal conditions for PtP survival are humidity
levels of 70%–90% and temperatures of 29–32 °C,
while eggs can survive at lower temperatures for
≤ 16 days.14
Symptoms, clinical signs and diagnosis
Itching secondary to allergic sensitization from louse
saliva may be delayed for 2–6 weeks after expo-
sure,15,16 while subsequent exposure will generate
pruritus after 1–2 days. Visualization of live lice and
encased nits (eggs) by eye or dermatoscope constitutes
diagnosis. Microscopy is helpful, especially in GU units.
Feeding or fouling causes rust/blood-coloured spots on
clothing; a louse bite can cause bluish macules
ª 2021 British Association of Dermatologists

Pubic louse Body louse
Figure 2 Comparison of different types of human lice demonstrating the size and shape of pubic, body and head lice in their natural
environment.
(maculae ceruleae), commonly occurring on the lower
abdomen and thighs.17 PtP generates pruritic red
papules. Scratching and excoriations can cause sec-
ondary bacterial infections, while in chronic infesta-
tions, lichenification and pigmentary changes may
occur. If eyelash infestation occurs, the symptoms and
signs include blepharitis, visible lice and nits (which
can be challenging as they appear transparent, similar
to lash debris or Demodex mites), pruritus, burning,
punctate erythematous lesions from louse bites, brown
deposits of faecal matter, madarosis (loss of eyelashes
and sometimes eyebrows), eyelid oedema, follicular
conjunctivitis, marginal keratitis, keratoconjunctivitis,
preauricular lymphadenopathy, and rarely secondary
bacterial infections or eyelid cellulitis.18,19 Nits in iso-
lation indicate historical infestation, as they can persist
for months after successful treatment, with no trans-
mission risk, hence institutional ‘no-nit’ policies should
only be of historic relevance.16 Correct diagnosis can
help prevent overtreatment and reduce resistance.16
Nonpharmacological management
Combing, hand-picking or shaving are the oldest forms
of louse management.14 Hand-picking and crushing
were used prior to the invention of combs. The tombs
of Egyptian pharaohs have been found to contain fine-
tooth combs similar to modern lice combs and Ebers
papyrus (from ca. 1550 BCE) reported hippopotamus
fat to asphyxiate lice.1,2 Herodotus, the Greek
ª 2021 British Association of Dermatologists
A clinical review and history of pubic lice  P. U. Patel et al.
Head louse
historian, noted Egyptian priests shaved the whole
body to decrease louse infestation. Shaving improves
visualization, reduces reinfestation and creates a hos-
tile habitat for louse survival.14 Combing every 1–
3 days can be used for treatment or prevention of
head lice.14 For this process, conditioner is applied to
wet hair, the hair detangled with a wide-toothed
comb, then a fine-toothed comb (maximum 0.3 mm
tooth spacing) is used to comb from the skin surface
to the hair tips, removing any lice from the comb with
tissue after each pass.13 This can also be applied, but
is rarely performed, on pubic hair. Wet combing has
few adverse effects; however, it is time-consuming and
needs to be continued until no lice are observed for at
least 10 days.
Heating can be used to remove lice from clothing
(but not easily used for scalp or genital hair); however,
lice can adapt by secreting a heat-resistant substance,
sometimes withstanding temperatures > 100 °C.14
Fomites (clothes, bedding, towels or personal hygiene
products) should not be shared and should be
machine-washed at > 50 °C/122 °F.15–20 Alterna-
tively, items can be dry-cleaned or can be sealed in
plastic bags for 3 days to 2 weeks.6 Transmission via
toilet seats is not thought likely and is not prevented
by condoms.6
Concomitant sexually transmitted infections (STIs)
are found in ≤ 30% of infested patients.6,15–17 Close or
sexual contact should be avoided until all contacts are
cleared.8 A ‘look-back’ screening period of 3 months
Clinical and Experimental Dermatology 3
A clinical review and history of pubic lice  P. U. Patel et al.

(a) (b)

“For to kill lyce. Take the whare that remayneth of cheese making and put to it “To kill lise, and nies in the heade. Take the pouder or scrapinge of Hartes
a lile vinaigre, and drinke of it cartayne days: and all the lyce will dye and ther horne, & make the pacient to Drinke of it, and ther will no lise nor nies breede
will breede no more aboute yow” in his head, but if yow strowe the sayde pouder vpon his heade, allthe lise &
nies will die.”

Figure 3 (a,b) Extracts from the Folger Manuscript transcriptions collection. Receipt book. Manuscript V.a.140, folio 13. Transcriptions
made by Shakespeare’s World volunteers, explaining the remedies for lice for the general public in the 16th century.

Table 1 Summary of pharmacological P. pubis treatment, with options listed in descending order of least toxic and preferred (from
strongest to weakest strength of recommendations).

Medication Mechanism of action Adverse effects and considerations Applicationa

Permethrin 1% or Synthetic pyrethrin. Neurotoxin Contact dermatitis, increased Apply to wet hair, leave 10 min,
5% lotion, cream causing respiratory paralysis13 resistance.14 First-line agent 6,13,16
rinse.6,13,16 Repeat after 10 days
or shampoo
Pyrethrins 0.3% or Chrysanthemum extract. Neurotoxin Contact dermatitis, increased Apply to dry hair, leave 10 min,
piperonyl causing respiratory paralysis13 resistance.14 First-line agent6 rinse.6,13,16 Repeat after 10 days
butoxide 4%
shampoo
Malathion 0.5%– Organophosphate cholinesterase Flammable,13,16 skin irritation.17 Not Apply to dry hair, leave 8–12 h,
1% lotion inhibitor.14 Neurotoxin causing to be used in pregnancy. Use for rinse.6,13,16 Although ovicidal, may
respiratory paralysis, also resistant lice.16 Second-line agent6 still need another dose after 9 days if
ovicidal13,14 live lice seen
Ivermectin 0.5% Binds to glutamate-gated chloride Skin irritation.13 Second-line agent6 Apply to dry hair, leave 10 min,
lotion channels causing paralysis, also rinse.6,13 Repeat application during
ovicidal13 same session
Oral ivermectin Binds to glutamate-gated chloride Pruritus and headaches.16 200–250 lg/kg OD.6,16 May need
channels causing paralysis, also Not for use in pregnancy or in another dose after 7 days13
ovicidal13 children with weight
< 15 kg.6,13,16 Second-line agent6
Benzyl alcohol 5% Aromatic alcohol causes Skin/eye irritation.14 Can be Apply to dry hair, leave 10 min,
lotion asphyxiation13,14,16 costly13,16 rinse.13,16 Repeat after 10 days
Dimethicone Silicone-based product immobilizes Skin/eye irritation.13 Flammable. Low Apply to dry hair, leave 8 h.13 Repeat
solution louse and blocks water excretion, risk of resistance14 after 10 days
causing suffocation13
Spinosad 0.9% Acetylcholine agonist and Skin/eye irritation13,14, expensive13 Apply to dry hair, leave 10 min,
suspension c-aminobutyric acid receptor not fully evaluated for PtP6 rinse.13,16 Repeat in 10 days if live
antagonist. Neurotoxin causing lice seen16
paralysis, also ovicidal16
Isopropyl myristate Ester of isopropyl alcohol and myristic Low probability of resistance. Not Apply to dry hair, leave 10 min, rinse.13
and acid and silicon-based substance. ovicidal. Can stain fabrics. Eye and Repeat after 10 days
cyclomethicone Dissolves exoskeleton causing local irritation13
solution dehydration13
1% Gamma- Ovicidal, prevents reproduction16 Potential CNS toxicity,14,16 Only if above treatments are
benzene Resistance is increasing. Not to be unsuccessful.14–16 Apply, leave
hexachloride used for children or pregnant/ 4 min, rinse
cream, lotion or lactating women16
shampoo

OD, once daily; PtP, Pthirus pubis. Application guidance is based on headlice recommendations as specific guidance for public lice is less
documented.6,13–17

4 Clinical and Experimental Dermatology ª 2021 British Association of Dermatologists

 A clinical review and history of pubic lice  P. U. Patel et al.

Table 2 Phthiriasis palpebrarum treatments with least toxic and most relevant in descending order.a

Method Mechanism of action Advantages Disadvantages

Forceps/tweezers +/ Manual removal6,17,29 Low cost,28,29 better visibility Removal can be challenging and
trimming/shaving of louse heads can remain
eyelashes embedded28,29
White soft paraffin/tea- Asphyxiation 8–10 days6,17,29 Cost-effective, easy to use,6,17 Blurred vision eye contact,
tree oil/occlusive well tolerated, low ocular ineffective on eggs,29 low
agents toxicity evidence for tea-tree oil
1% Permethrin lotion Synthetic pyrethrin. Neurotoxin causing Easy application.6,29 Not Increasing incidence of allergic
or 5% cream respiratory paralysis13 irritating but eyes should be contact dermatitis6,14
kept closed17
0.5% or 1% Organophosphate cholinesterase inhibitor.14 Widely available,29 only 1–2 Flammable, can be irritating13,16
Malathion lotion Neurotoxin causing respiratory paralysis, applications
also ovicidal13,14
Pyrethrin Chrysanthemum extract. Neurotoxin causing Effective,6 easily accessible Increasing resistance and allergic
respiratory paralysis13 contact dermatitis6,14
Oral ivermectin Binds to glutamate-gated chloride channels Toxicity, low evidence for
causing paralysis, also ovicidal1 efficacy.28,29 Resistant cases only
Cryotherapy or argon Structural damage28,29 Scarring, pain. Laser treatment is
laser expensive
Topical botulinum toxin Neuromuscular paralysis Facilitates louse removal May need repeated applications.
Expensive
a
Developed from case reports/series as no clear guidelines on management currently exist.6,13,14,16,17,28,29

of sexual contacts is needed. Partners and family
members should be treated simultaneously.6,15
Increasing numbers of STIs are seen in those with
PtP, especially in men aged > 50 years.21 PtP in chil-
dren may not necessarily be due to sexual activity or
abuse, as transmission can occur from nongenital
body contact. However, sexual abuse should be consid-
ered in vulnerable people at any age, although the ter-
minal body hair required by PtP is not present pre-
puberty, other than in eyelashes. PtP infests adults
and is rarely seen in children before puberty.
Pharmacological management
There is a long history of lice treatments. Evidence of
infestation and treatments has been found in Egyptian
mummies and tombs. King Ferdinand II of Naples
(1452–1516) had pubic and head lice, and his hair
contained mercury, possibly from attempted ther-
apy.22,23 The 11th century Avicenna Canon of Medi-
cine24 advocated ‘mercury, oil long birthwort or wearing
wool smeared with oil or mercury’ as treatment. The
Trotula texts,25 a collection of three Italian medical
texts dating from the 11–12th century, suggested ‘a
mixture of ash with oil’ for pubic and axillary lice.
While for lice around the eyes, they had this sugges-
tion: ‘take one ounce of aloe, one ounce each of white lead
and frankincense, and bacon as needed. We grind the bacon
very finely and we place the remaining ingredients which
have been powdered.’ The 16th-century ‘receipt book’
had various remedies26 (Fig. 3a,b).
Culpepper27 in 1788 advised the following for lice:
black alder tree bark boiled in vinegar, broom or
broomrape boiled in oil, henbane, hyssop oil, southern
wood, tamarisk tree and meadow rue root boiled in
water, and for head lice in children, the suggested
remedy was tobacco in a juice. During World War II
(1939–45), insecticides [e.g. DDT (dichlorodiphenyl-
trichloroethane) and lindane] were developed; prison-
ers of war were coated in the insecticide, reducing lice
numbers and spread.14
Most current recommendations for pubic lice are
based on data for head lice, as no high-quality com-
parative studies for PtP exist.13,14,17 Pediculicides act
via a variety of mechanisms (Table 1). Ovicidal agents
should not require a second treatment, whereas non-
ovicidal agents require a second dose after 10 days.13
Often the literature reports repeat doses after 3–
9 days; however, this may contribute to ‘treatment
failure’ given that egg hatching can occur up to
10 days later, thus we recommend 10 days. The Euro-
pean Academy of Dermatology and Venereology 2017
and the US Centers for Disease Control and Prevention
2010 guidelines recommend permethrin or pyrethrins
with piperonyl butoxide as first-line agents6,16 and
malathion or oral ivermectin as second-line agents.14

ª 2021 British Association of Dermatologists Clinical and Experimental Dermatology 5

A clinical review and history of pubic lice  P. U. Patel et al.
Head lice are increasingly becoming treatment-
resistant, and although no documented evidence of
resistance exists for PtP, resistance is likely here
too.17–20 The geographical distribution of resistant lice
is unclear, and pseudoresistance may be secondary to
poor compliance, incorrect use, or underdosing and
reinfestation.6,11 Persistent infestation is seen in 40%
of people at 10 days post-treatment.6 If this occurs,
the treatment should be reapplied after 10 days.
Where this is due to true resistance or persistent infes-
tation, an alternative pediculicide class should be used.
No specific recommendations exist for transplant or
HIV patients, thus they should be treated as above.6
Migrating P. pubis: eyelashes and scalp
Phthiriasis palpebrarum, refers to eyelash infestation
with PtP (adult, nymph and eggs). When seen in chil-
dren, sexual abuse should be considered.18,19 Differen-
tial diagnoses include blepharitis, seborrhoeic
dermatitis and conjunctivitis. The eyelid needs careful
examination with good lighting, possibly requiring a
slit lamp. Case reports have suggested various treat-
ments, including tea-tree oil, physostigmine, pilo-
carpine and fluorescein ophthalmic drops; these seem
to be used for occlusive purposes with no obvious pedi-
culicidal properties.9,18,28,29 Cryotherapy, argon lasers
or botox have been used in difficult cases to struc-
turally damage the lice and facilitate removal.18–19,29
However, these are invasive and expensive options.
Recommended treatment options are summarized in
Table 2.6,13,14,16,17,28,29
Veraldi et al. documented PtP occurring solely on
the scalp. This is rare but easily overlooked, tending to
favour Asian or white patients with straight hair.
There may be more numerous nits and lice compared
with a head lice infestation, with more severe pruritus
and consequent excoriations.30
Conclusion
Pubic lice populations have waxed and waned over
time. Deforestation, due to genital hair removal
becoming more popular in the 2000s, had a devastat-
ing impact on PtP as they are largely fixed to the
pubic hair. Although PtP is often considered just a
nuisance, research is required to identify if it is a vec-
tor for other, more harmful, pathogens. Lice are
ancient, flexible and resourceful creatures so it is likely
that they will beat mankind in the evolutionary race
and be here long after humans are gone.
6 Clinical and Experimental Dermatology
Learning points
• The sucking louse of the great apes diversified
into the gorilla louse, which eventually became
the human pubic louse, with a current preva-
lence estimated as 2% in adult populations.
• Lice thrive in times of war and overcrowding,
but PtP have decreased in groups that remove
genital body hair.
• Pubic lice are the smallest of human lice and
can infest the pubic/perineal hair or facial, body
and scalp hair.
• Common signs include pruritic red papules,
maculae cerulae, rust-coloured spots and excoria-
tions.
• Diagnosis is based on visualization of live lice
or intact nits (not just the egg case), thus, good
lighting is essential.
• Recommended treatments include permethrin
or pyrethrins with wet combing and hand pick-
ing.
• PtP-infested patients and their close contacts
should also be examined and screened for STIs.
• Resistance of head lice to pediculicides is
increasing and is also likely to be happening with
pubic lice.
• Education to reduce poor compliance or incor-
rect product use may reduce resistance or reinfes-
tation.
References
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2 Chen KS, Yesudian PD. Why Pthirus pubis don’t watch
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17 Scott GR, Chosidow O, IUSTI/WHO. European guideline
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ª 2021 British Association of Dermatologists
A clinical review and history of pubic lice  P. U. Patel et al.
25 Green MH (ed. and trans.). The trotula: a medieval
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CPD questions
Learning objective
To gain up-to-date knowledge on the symptoms, treat-
ment and management of P. pubis infestation.
Question 1
Which of the following is the preferred treatment for
maximum lice destruction?
(a) Wet-combing.
(b) Occlusion.
(c) Dissolution of the exoskeleton, combined with
hand-picking.
(d) Hand-picking and crushing.
(e) Shaving.
Question 2
What considerations are required during P. pubis man-
agement?
(a) Regular changing of clothing.
(b) Avoidance of school or work until the infesta-
tion is cleared.
Clinical and Experimental Dermatology 7
A clinical review and history of pubic lice  P. U. Patel et al.

(c) Use of ovicidal products with a second dose after (a) Punctum, burrows, excoriations and dermatitis.
7–10 days. (b) Lichenification, maculae cerulae, pruritic
(d) Examination of contacts for sexually transmitted papules, rust-coloured spots.
infections (STIs) and screening of contacts for lice (c) Hyperpigmented papules, track lines, multiple
infestation. bite marks.
(e) Disposal of fomites such as bedding, towels or (d) Nocturnal pruritus with seborrhoeic dermatitis-
linen. like rash.
(e) Flat topped firm papules with scale and dark
grey areas of pigmentation.
Question 3

Which of the following treatments is ovicidal for lice?

Instructions for answering questions
(a) Isopropyl myristate.
This learning activity is freely available online at
(b) Benzyl alcohol.
http://www.wileyhealthlearning.com/ced
(c) Malathion.
Users are encouraged to
(d) Permethrin.
(e) Pyrethrin. • Read the article in print or online, paying particular
attention to the learning points and any author
conflict of interest disclosures.
Question 4 • Reflect on the article.
Which of the following is most helpful in the manage- • Register or login online at http://www.wileyhea
lthlearning.com/ced and answer the CPD questions.
ment of pubic lice infestation?
• Complete the required evaluation component of the
(a) Use of pediculicidal product as directed. activity.
(b) Use of ovicidal products once without a second
Once the test is passed, you will receive a certificate
application.
and the learning activity can be added to your RCP
(c) Screening and treating partners/family members
CPD diary as a self-certified entry.
simultaneously.
This activity will be available for CPD credit for
(d) Use of condoms.
2 years following its publication date. At that time, it
(e) Avoidance of close contact with others during
will be reviewed and potentially updated and extended
infestation.
for an additional period.

Question 5

Which of the following are possible physical signs of

pubic lice infestation?

8 Clinical and Experimental Dermatology ª 2021 British Association of Dermatologists