What does a head covered with lice look like?

Initial Visual Cues

Visible Lice

A scalp heavily infested with lice presents a distinct visual pattern. The hair shaft is dotted with small, elongated insects ranging from 2 to 4 mm in length. Their bodies are translucent to grayish‑brown, often appearing as faint specks when the hair is examined closely. Lice cling to hair close to the scalp, especially behind the ears and at the nape of the neck, making these areas the most densely populated.

The insects move in a jerky, crawling motion. When the head is tilted or brushed, lice may be seen scuttling rapidly across strands, occasionally falling onto the skin before re‑attaching. Their legs, six in total, are clearly visible as thin, segmented appendages that grip the hair shaft.

Nits—lice eggs—are unmistakable. They are oval, about 0.8 mm long, and adhere firmly to the base of each hair strand. Nits appear as tiny, white or yellowish caps that are difficult to remove without specialized tools. A cluster of nits often surrounds each adult lice, creating a pattern of closely spaced dots near the scalp.

Typical visual cues include:

Numerous gray‑brown bodies interspersed among hair fibers
Rapid, erratic crawling when disturbed
Small, white or yellow caps (nits) attached at the hair root
Concentration of insects and nits behind ears, at the crown, and along the neck line

These characteristics together define the appearance of a head overtaken by lice.

Nits (Louse Eggs)

Nits are oval, translucent to brownish eggs firmly attached to hair shafts near the scalp. Each measures about 0.8 mm in length, making them visible to the naked eye as tiny specks. They are glued by a proteinaceous cement that resists removal by routine combing.

Typical locations include the nape of the neck, behind the ears, and at the hairline. Because the cement secures the egg to the shaft, nits remain in place even after the host hair is washed or styled. When viewed against light, they may appear white, yellow, or amber, depending on the developmental stage.

Key visual cues of an infested scalp:

Numerous nits clustered close to the scalp, often in rows.
Live lice moving quickly along hair shafts, occasionally dropping onto the skin.
Persistent itching caused by saliva injected during feeding.

Distinguishing nits from dandruff:

Dandruff flakes are free‑floating, easily brushed off, and lack a solid attachment point.
Nits are anchored at a 45‑degree angle to the hair, requiring a fine‑toothed comb or forceps for removal.

The presence of nits indicates an active infestation, as eggs hatch within 7–10 days, releasing nymphs that mature into adult lice capable of reproduction. Detecting and eliminating nits is essential for breaking the life cycle and restoring a clear, itch‑free scalp.

Overall Appearance of Hair and Scalp

A head infested with lice presents a distinct visual profile. The hair shaft is densely populated with tiny, crab‑shaped insects, each measuring 2–4 mm. Live lice move rapidly when the scalp is disturbed, creating a brief, fluttering motion that can be seen upon close inspection. Alongside the insects, translucent oval nits adhere firmly to the hair base, often clustered near the scalp’s surface. These nits appear as pale, elongated specks, sometimes mistaken for dandruff, but they remain fixed despite brushing.

The scalp itself shows signs of irritation. Redness or mild inflammation is common, especially in the nape, behind the ears, and along the hairline. Small, dark specks—fecal deposits from the parasites—dot the hair and may be mistaken for dirt. In severe cases, excoriations from scratching become visible, and the hair may appear dull or clumped together due to the weight of the infestation.

Typical visual markers include:

Numerous live lice moving on the hair surface.
Attached nits positioned within 1 cm of the scalp.
Red, irritated skin with occasional micro‑abrasions.
Dark specks of lice feces distributed throughout the hair.

These characteristics together define the overall appearance of hair and scalp when lice are present.

Symptoms and Their Manifestations

Itching and Irritation

A scalp infested with lice generates persistent itching that intensifies after several hours of exposure. The sensation arises from the saliva injected by the insects as they feed, provoking a localized allergic response. Scratching amplifies the irritation, causing erythema, microabrasions, and occasional bleeding.

Typical signs of irritation include:

Red, inflamed patches around hair follicles
Small, raised bumps where nits attach to the shaft
Swelling of the scalp skin
Secondary bacterial infection in areas broken by scratching

The combination of constant pruritus and visible lesions creates a distinctive, uncomfortable condition that readily distinguishes a lice‑laden head from a healthy one.

Redness and Rashes

A scalp infested with lice often exhibits pronounced redness where the insects bite and feed. The skin becomes inflamed, showing a uniform pink to reddish hue that may intensify around the hairline and behind the ears. Scratching aggravates the irritation, producing small, raised welts that appear as discrete patches or a continuous rash.

Typical rash characteristics include:

Fine, erythematous lines tracing the paths of lice movement.
Clustered papules that feel tender to the touch.
Secondary excoriations caused by persistent scratching, which can bleed or crust over.

If the inflammation persists, the affected area may develop a moist, oozing surface indicative of bacterial infection, requiring medical attention. Early identification of these signs helps differentiate lice‑related irritation from other dermatological conditions.

Sores and Scabs

A head infested with lice often displays visible lesions caused by persistent scratching. The lesions appear as small, reddened sores where the skin has been broken, sometimes surrounded by a thin halo of inflammation. Repeated irritation leads to the formation of crusted scabs that cling to the hair shafts and scalp surface.

Typical features of these lesions include:

Irregularly shaped, shallow pits or ulcers, usually a few millimeters across.
Darkened edges where blood has pooled, giving a purplish hue.
Overlying dry, yellow‑white crusts that harden after the wound dries.
Distribution concentrated around the crown, temples, and nape, matching the areas where lice are most active.

The presence of scabs distinguishes lice‑induced damage from simple dandruff. Scabs are firmer, thicker, and may detach in pieces, exposing fresh wound tissue beneath. Sores caused by lice are often tender to the touch and may bleed slightly when disturbed.

Effective identification relies on observing these specific characteristics alongside the detection of live lice or nits. Recognizing the pattern of sores and scabs enables prompt treatment and prevents secondary infection.

Advanced Stages of Infestation

Matted and Tangled Hair

A head infested with lice typically displays hair that is heavily matted and tangled. The strands interlock into dense clumps that resist separation, often forming irregular knots several centimeters in size. Scales of dead skin and lice feces accumulate within these knots, giving the hair a dull, grayish appearance. Nits—tiny, oval eggs—adhere firmly to the hair shaft near the scalp, visible as white or yellowish specks embedded in the tangled mass. The scalp may be obscured by the bulk of the hair, making the skin surface difficult to assess without thorough combing.

Key visual indicators of this condition include:

Thick, interwoven clumps that cannot be brushed apart with a regular comb.
Visible nits attached close to the scalp, often clustered in the same region as the matting.
A coating of fine debris, sometimes referred to as “lice dandruff,” that gives the hair a dusty or greasy sheen.
Areas where the hair appears darker or discolored due to accumulated excrement and dead insects.

These characteristics together create a unmistakable picture of a scalp overwhelmed by lice, with hair that has lost its natural texture and freedom of movement.

Secondary Bacterial Infections

A scalp densely populated with lice appears as a tangled mass of hair interspersed with tiny, grayish insects and their nits clinging to shafts. The irritation caused by constant biting often leads to excoriation, creating breaches in the epidermis that serve as entry points for bacteria. The most common secondary pathogens are Staphylococcus aureus and Streptococcus pyogenes, which exploit the compromised skin barrier.

Typical manifestations of bacterial superinfection include:

Red, swollen patches that enlarge beyond the immediate area of scratching.
Pus‑filled lesions or crusted sores (impetigo‑type lesions).
Foul odor emanating from the affected region.
Fever, chills, or malaise when infection spreads systemically.

If left untreated, the infection may progress to cellulitis, characterized by diffuse warmth, tenderness, and rapid expansion of erythema. In severe cases, bacterial toxins can trigger toxic shock syndrome, presenting with hypotension, rash, and multi‑organ involvement.

Management requires:

Immediate removal of lice and nits through fine‑toothed combing or medicated shampoos.
Topical or oral antibiotics targeting gram‑positive organisms; clindamycin or dicloxacillin are first‑line choices.
Wound care with gentle cleansing and sterile dressings to prevent further contamination.
Monitoring for systemic signs; hospitalization is warranted for rapid spread or systemic toxicity.

Prompt eradication of the ectoparasite and aggressive treatment of bacterial complications reduce the risk of scarring and systemic illness.

Enlarged Lymph Nodes

A scalp infested with lice often presents with visible nits attached to hair shafts, a gritty sensation when the hair is moved, and frequent scratching. The irritation can trigger a localized immune response that enlarges the cervical and occipital lymph nodes. These nodes become palpable, firm, and may be tender to pressure.

Enlarged lymph nodes associated with a lice infestation typically exhibit the following characteristics:

Size exceeding 1 cm in short axis
Soft to moderately firm consistency
Mobility over underlying structures
Tenderness that diminishes as the infestation resolves

The underlying mechanism involves antigenic stimulation from lice saliva and bacterial superinfection of scratched lesions. This prompts proliferation of lymphoid tissue in the regional nodes, producing the observed swelling.

Management focuses on eradicating the ectoparasite and addressing secondary infection. Effective measures include:

Topical pediculicides applied according to manufacturer instructions
Mechanical removal of nits with fine-toothed combs
Antiseptic cleansing of the scalp
Antibiotic therapy if bacterial cellulitis is confirmed

Resolution of the infestation usually leads to gradual reduction of node size within weeks. Persistent enlargement beyond this period warrants further evaluation for alternative causes.

Factors Influencing Appearance

Hair Type and Color

Hair texture determines how lice and their eggs are observed on an infested scalp. Straight hair allows nits to lie flat against each shaft, creating a uniform, silvery line that is easy to spot. Wavy hair produces a slightly irregular pattern, with nits clustering in bends where the filament is thicker. Curly and coily hair forms tighter spirals; nits often hide within loops, making detection more difficult and giving the scalp a patchy, speckled appearance as lice move among the curls.

Color influences visual contrast between the head and the parasites. Light‑colored hair (blond, white, or gray) highlights the dark brown or black bodies of adult lice and the translucent sheen of nits, producing a stark, noticeable contrast. Dark hair (brown, black, or deep red) reduces contrast; lice blend with the shaft, and nits appear as faint, pale dots that may be missed without magnification. Red or dyed hair adds an additional hue that can either mask or accentuate the parasites, depending on the dye’s opacity.

Key observations for different hair types and colors:

Straight, light hair: clear, linear rows of nits; adult lice easily visible.
Straight, dark hair: reduced contrast; nits appear as subtle specks.
Wavy, light hair: irregular nit clusters along bends; lice move visibly.
Wavy, dark hair: patchy speckling; detection requires close inspection.
Curly/coily, any color: nits hidden in loops; adult lice may be seen crawling between curls, but overall visibility is lower.

Understanding how texture and pigmentation affect the visual presentation of a lice‑infested scalp enables accurate identification and targeted treatment.

Severity and Duration of Infestation

A head heavily infested with lice exhibits a progression that correlates with both the intensity of the parasite load and the length of time the infestation has persisted.

Mild infestation – a few live lice and nits visible near the scalp; hair appears slightly disheveled, occasional itching.
Moderate infestation – dozens of lice moving across the scalp, clusters of nits attached to hair shafts; hair may look clumped, scalp redness and frequent scratching are common.
Severe infestation – hundreds of lice, dense layers of nits covering the majority of strands; hair appears matted, scalp shows extensive irritation, possible secondary infection, and noticeable debris resembling grayish powder.

The visual state evolves as the infestation endures. In the first one to two weeks, live lice are present but nits are sparse; the scalp may show only mild irritation. Between three and four weeks, the reproductive cycle produces a rapid increase in nits, and hair becomes visibly coated with egg cases, intensifying itching and redness. Beyond a month, the buildup of dead lice, shed skins, and fecal matter creates a thick, grayish coating that obscures the hair’s natural texture, while chronic scratching can lead to excoriations and secondary bacterial infection.

Individual Reaction to Bites

Individuals who discover a scalp infested with lice often focus on the immediate physical response to the insect bites. The reaction varies according to personal sensitivity, overall health, and previous exposure to similar parasites.

Typical manifestations include:

Small, red papules that appear shortly after a bite, often clustered near the hairline or behind the ears.
Intense itching that intensifies after a few hours, sometimes leading to scratching and secondary skin irritation.
Swelling of the affected area, which may be localized or spread across a larger portion of the scalp.
A burning or stinging sensation that persists for several minutes to an hour.

Less common responses involve:

Hives or urticarial plaques that develop beyond the scalp, indicating a systemic allergic component.
Dermatitis with crusted lesions caused by repeated scratching, increasing the risk of bacterial infection.
Hyperpigmentation or scarring in severe cases where the skin has been damaged repeatedly.

Factors influencing severity:

Age – children often exhibit stronger itching due to thinner skin and heightened immune reactivity.
Immune status – immunocompromised individuals may develop larger inflammatory zones.
Previous sensitization – repeated exposure can either amplify or diminish the rash, depending on the person’s immunologic memory.

Management strategies focus on symptom control and preventing further infestation. Antihistamines reduce itching, topical corticosteroids alleviate inflammation, and thorough lice removal eliminates the source of bites. Prompt treatment minimizes skin damage and curtails the spread of the parasite.

Differentiating from Other Conditions

Dandruff

A scalp infested with lice often displays visible flakes that are frequently mistaken for dandruff. Dandruff consists of dead skin cells that detach from the scalp surface, creating white or yellowish particles that cling to hair strands and fall onto clothing. Unlike the live insects and their eggs, dandruff does not move and does not cause itching from mechanical irritation, although a dry scalp may be itchy.

Key visual and tactile differences:

Size: dandruff flakes range from 0.2 mm to 1 mm; lice nits are larger and oval‑shaped.
Mobility: dandruff remains static; lice can crawl and shift when the head is touched.
Distribution: dandruff appears evenly across the scalp; lice concentrate around the hairline, behind the ears, and near the neck.
Odor: dandruff lacks a distinct smell; lice may emit a faint, unpleasant odor when present in large numbers.

Recognizing these characteristics helps distinguish simple scalp flaking from an active lice infestation, allowing appropriate treatment.

Dry Scalp

A head infested with lice often presents a combination of visual and tactile cues. The scalp may feel rough and exhibit noticeable flaking. Dryness appears as fine, white or grayish scales that detach easily when brushed. The loss of natural moisture can make the skin appear dull and slightly discolored, sometimes with faint erythema around attachment sites. Scratching intensifies dehydration, exposing small fissures that can bleed minimally.

Typical observable features include:

Numerous live lice moving quickly across hair shafts.
Nits attached firmly to the base of each strand, appearing as tiny, oval, yellow‑brown bodies.
Persistent itching that leads to excessive scratching.
Visible dandruff‑like flakes that are larger and dryer than ordinary dandruff.
Localized redness or mild inflammation surrounding clusters of insects.

Dry scalp in this context is not merely a cosmetic issue; it reflects the scalp’s compromised barrier function caused by the mechanical irritation of lice and the host’s inflammatory response. Managing the infestation promptly reduces scratching, restores moisture balance, and minimizes the characteristic dry, flaky appearance.

Other Skin Conditions

A head infested with lice displays live insects moving among hair shafts, numerous white or brown nits firmly attached close to the scalp, and intense pruritus that worsens after heat exposure. The scalp may appear reddened, but the primary visual cue is the presence of the parasites and their eggs.

Other dermatological conditions can produce similar symptoms or be mistaken for an infestation. Recognizing distinguishing features prevents misdiagnosis.

Seborrheic dermatitis – greasy, yellowish scales on the scalp, often extending to the eyebrows and nasolabial folds; no nits or live insects.
Psoriasis – well‑defined, silvery plaques with underlying erythema; lesions are typically thicker and may involve elbows and knees.
Atopic eczema – dry, flaky skin with occasional excoriations; itching is chronic, and hair shafts remain free of nits.
Tinea capitis – fungal infection causing patchy hair loss, black dots where hair shafts break, and scaly borders; microscopy reveals hyphae, not lice.
Folliculitis – pustules centered around hair follicles; may produce mild itching but lacks the characteristic nits.
Allergic contact dermatitis – localized erythema and edema after exposure to irritants; symptoms resolve when the irritant is removed, and no lice are present.
Scabies (rare on scalp in adults) – burrowed tracks and intense nocturnal itching; skin scrapings reveal mites, not lice.

Differentiation relies on direct observation and adjunct tests. Dermoscopy can confirm moving lice and nits, while skin scrapings, fungal cultures, or KOH preparations identify fungal or mite involvement. Absence of nits, presence of scale type, lesion distribution, and laboratory findings guide accurate diagnosis and appropriate treatment.