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Ce booklet for pdffrom Mosby's Department of Continuing Education and Training Mosby ContinuingEducation and Training is accredited as a provider of continuing education innursing by the AmericanNurses Credential Center’s Commission onAccreditation (ANCC- Biology, Diagnosis, and Management COA) and is also a certi-fied provider of nursing continuing education in California (provider number CEP3257). Mosby recognizes this activity as continuing education Department of Dermatology and Cutaneous Surgery approves or endorses anyproduct included in the This course is sponsored in service of the public health by: HairClean™®
The natural, non-chemical solution 754 Washington Street Eugene, Oregon 97401 Additional educational materials for nurses, familiesand students are available free of charge.
Fig 3. Viable head louse egg(lower left) andhatched empty egg(above).
louse nymph com-pared to a period atthe end of a sentence.
Fig 5. “Hair muff,” or artifact often mistaken Physical DescriptionThe head louse is a bloodsucking, wingless insect with a hard exoskeleton. Like all insects, it has three pairs of legs. Each leg the participant should be able to: ends in a claw with which the louse grasps the hair shaft. Antennaelocated in front of the eyes enable the louse to detect odor, humidity, ■ describe the head louse and its life cycle; temperature, and, possibly, other information not yet known. ■ diagnose pediculosis capitis (infestation Head lice tend to adapt their color to their surroundings. Therefore,lice found on dark-haired, dark-skinned individuals are darker than those found on people with lighter skin and/or blonde hair.1 The exoskeleton of lice also darkens in color with increased tem- perature and sunlight.1 Thus, lice in warmer climates tend to be darker in color than those found in cooler regions. An adult head louse is usually 2 to 3 mm long, or about the size of a sesame seed. Females are generally longer and wider than males ■ describe the various courses of treatment and have a more rounded abdomen (Fig. 1). The rear portion of the female abdomen ends in two protrusions, or “gonopods,” ■ discuss head lice resistance to pediculicides which form a V-shape the width of a human hair.1 The gonopods are supportive structures that enable the female to clamp the hairshaft while laying eggs. ■ describe measures to prevent reinfestation; ■ educate teachers, parents, and children Male lice have distinguishable brown bands across their backs (Fig. 1). The rear portion of the male exoskeleton is rounded andtilts upward, with the anal and sexual organs located on the louse’s ■ conduct a school-wide head lice screening.
back. This arrangement enables the male louse to crawl beneaththe female for the purpose of copulation.
Twenty-four hours after mating, the female head louse lays her Pediculosis, the infestation of humans by lice, has been document- eggs, more commonly referred to as “nits.” Under optimum condi- ed for thousands of years. Head lice and nits have been found on tions, a healthy female will lay approximately 140 eggs during her human mummies, and lice are mentioned in ancient writings, lifetime of about 30 days. The eggs are coated with a fixative that including the Bible. Not all civilizations have viewed these para- cements them to the hair shaft (see Fig. 2). Because the chemical sites in a negative light. The Aztecs, for example, collected their structure of this fixative substance is very similar to that of the hair lice in bags and offered them to their emperor as a token of shaft, researchers have yet to develop a product that will dissolve respect. Young women in northern Siberia once threw lice at men as a sign of affection, as if to say, “My louse is thy louse.”1 The location of the nits on the hair shaft may vary depending on Today, most westernized societies consider lice undesirable and climate and temperature. Because nits are incubated by human expend billions of dollars on head lice treatment and control.
body heat, it is commonly thought that most eggs are laid close to Despite the efforts of parents, health providers, and school authori- the scalp and that the distance of a nit from the scalp may be used ties, however, infestation with head lice is a persistent and growing to judge the nit’s viability. In warm climates, however, the top of problem. Head lice affect up to 25% of school-aged children in the the head is often too warm for optimal incubation, and viable nits United States,2 and incidence appears to be on the rise, with lice may be found 6 or more inches down the hair shaft.3 becoming increasingly resistant to many commonly-used pediculi-cide products.3 Newly-laid, viable eggs are plump and shiny and have a tan or coffee color. Eggs that have hatched are clear, white, or light in color and may appear shrunken or indented (Fig. 3). On the end The head louse, Pediculus capitis, is one of three species of lice that of the nit facing away from the scalp is the “operculum,” a tiny infest humans. The other two are Pediculus humanus, the body or cap with several holes in it that allow air and moisture into the egg clothing louse, and Pthirus pubis, the pubic or “crab” louse.
Unfortunately, body lice, which are associated with poor hygiene,have given all lice a bad reputation. Body lice live on clothing and After a 7- to 10-day incubation period, the baby louse, commonly go to the body only to feed. Therefore, they are most commonly referred to as a “nymph” or “instar,” uses its mouth parts to cut a found among refugees, victims of disaster or war, homeless individ- hole in the operculum. The nymph then sucks in air and rapidly uals, and others who are unable to wash or change their clothes.
expels it, causing the operculum to pop off. The newly-emerged Head lice, in contrast, spend their entire lives on the human scalp, nymph closely resembles an adult louse but is much smaller and clinging to the hair while feeding, mating, and laying eggs. They not yet capable of reproducing. It is flesh-colored and no larger are not linked to poor living conditions and are most commonly than a pinhead, making it almost impossible to see with the naked found in individuals with good hygiene and grooming habits. eye (Fig. 4). The nymph emerges from the egg active and mobile and must feed on human blood shortly after hatching, or it will bites, the infested individual may be feverish and feel tired and irri- rapidly succumb to dehydration and starvation.
table due to lack of sleep, hence the term “feeling lousy.” The nymph goes through three stages of development, or “instar Although the body louse is notorious as a carrier of typhus, stages.” Each instar stage lasts 3 to 4 days and terminates when research has not shown the head louse to be a vector of serious the nymph molts, casting off its exoskeleton to reveal a new one.
disease. Some head louse professionals believe, however, that the The sex is not determined until the final molt, which occurs any- head louse has not been studied long enough or closely enough to where from 9 to 12 days after hatching. At this point, the louse is rule out its potential for transmitting typhus and other louse-borne a full-sized sexually-mature adult. The adult female must take a diseases. Head lice have been shown to transmit Staphylococcus blood meal before copulating, and her first eggs are laid within aureus and Group A Streptococcus pyogenes,1 resulting in infec- tions of the scalp. Chronic scalp infections are not uncommon inindividuals with active head lice infestations, especially in tropical Unlike many ectoparasites (external parasites) that can endure star- climates or when daily hygiene is difficult to maintain. vation and extremes of temperature, lice and their eggs can surviveonly under a relatively narrow set of environmental conditions.
From their first blood meal to their last, lice prefer to feed every The definitive diagnosis of head lice infestation occurs when a live 4 to 6 hours and cannot survive if they miss several consecutive louse or viable egg is found on the scalp or hair. The scalp should meals. Also, lice require a temperature of 87°F (30.6°C) to 95°F be examined in sunlight or under bright artificial light (e.g., fluo- (35°C) for continued survival, and prolonged temperatures below rescent light). The hair should be parted, with individual strands 65°F (18°C) or above 97°F (38°C) are fatal to the egg. Therefore, checked for nits. Magnifying reading glasses (2x or greater) avail- although a louse may fall or climb onto other surfaces, it cannot able in pharmacies can aid in visual detection. live on these and must return to a human head within 24 hours ifit is to survive. Because lice are fast, avoid light, and often blend in with the skinor hair, making them difficult to see, finding nits is the most effec- tive way of diagnosing an infestation. Nits are most predictablyfound on hairs at the nape of the neck and behind the ears, where they are protected from extremes of light and temperature. However, they may be laid anywhere on the hair (see Fig. 2), especially in warm weather, and the entire head should be examined. Viable nits can be distinguished from non-viable nits with the use of a 10x hand-held magnifier. Because the light-colored non-viable nits are often more noticeable than “camouflaged” viable nits, it is not uncommon to find more nits a day or two after treatment than The appearance of a nit is often confused with that of a flake ofdandruff or a dried particle of hairspray or gel. A distinguishingfeature is that dandruff and hair products can be easily combed off the hair or removed with the fingers, while nits cannot. Nits are firmly glued to the hair and must be removed with a fine-toothedcomb or fingernails, or snipped off with a scissors.
Signs and symptoms Although the feeding bite of the louse is painless, louse saliva Another artifact commonly mistaken for an egg is the “hair muff” contains a vasodilator and an anticoagulant that cause an allergic (Fig. 5). Without a good light and a magnifier, even an expert may reaction in most individuals. The vasodilator causes the capillaries mistake hair muffs for nits. Hair muffs consist of dried skin cells to expand, while the anticoagulant prevents clotting of the blood, (desquamated epithelial cells, or dec) and oil from the hair follicle producing red marks and itching at the site of the bite. The severity that surrounds the hair shaft, creating the illusion of a nit. They of the host reaction depends on host sensitivity and the number are especially common in individuals who have been treated many of prior exposures. Initial infestation may produce no signs or times with pediculicides, which may dry the scalp and clog the symptoms for 4 to 6 weeks. Subsequent infestations may produce sebaceous glands. Schoolchildren are often mistakenly sent home itching within 24 to 48 hours. Therefore, first-time infestations are with this condition and then retreated with pediculicides, creating often asymptomatic, and severe itching usually indicates an infesta- tion that has been present for several weeks. Some individuals canremain asymptomatic and never itch; these individuals can be con- Finally, although individual feeding sites may be difficult to see, sidered “carriers.” The existence of asymptomatic head lice carriers red marks, scratches, scaling, rash, and sores, including pyodermas, may account for the high rate of reinfestation among individuals may be present in infested individuals. These symptoms should be distinguished from contact or seborrheic dermatitis, insect bites,eczema, psoriasis, and piedra (a harmless fungal infection of the Intense itching at the site of the bite compels the host to scratch, hair), all of which can give a false-positive diagnosis for pediculo- often breaking the skin. The open scratches, in turn, create an sis. Also, repeated treatment with pediculicides can in itself cause entryway for germs and lice feces and may lead to secondary infec- irritation to the scalp with scaling, rash, and itching. These side- tions and swollen glands in the neck. With a large number of lice effects should not be confused with signs of an active infestation. Most pediculicide products currently available in the US kill lice Essentially everyone with hair on his or her scalp is susceptible to but do not kill all eggs. Therefore, all topical pediculicides should head lice infestation. Some groups, however, are more susceptible be applied two times, one week apart. The second application is than others. The group most likely to get head lice is children aged necessary to kill any nymphs that may have hatched from eggs 3 to 11 years.1,4,5 The relatively high incidence of head lice in this group is probably related to head-to-head and body contact duringplay and the sharing of objects to which lice can cling, e.g., combs, There has been a continuing struggle to find new pediculicidal brushes, hats, barrettes, helmets, head phones, and other head gear. agents ever since head lice developed resistance to DDT in Englandin 1949. In the past, it seemed as though investigators were always Most studies, including those conducted in the United States, show one step ahead of the louse with a new treatment, but now it that infestations are more common in girls than in boys, but others appears that lice are developing resistance to lice-killing products show no association between infestation and gender.3 In most cul- faster than new ones are being developed. The active ingredients of tures, girls tend to have longer hair than boys. This may account the pediculicidal products currently available in the United States for the gender differences in some studies; researchers in Israel include lindane, malathion, natural pyrethrins, and permethrin.
found that children with long and medium-length hair were more These and other alternative head lice treatments are discussed in likely to be infested than children with short hair.6 Also, girls may be more likely than boys to share brushes, combs, and hair acces-sories. Length, texture, and color of the hair and gender of the host Regardless of the pediculicidal product used, it is important to have not been shown to be significant factors in host preference.1 stress to the patient or parent that pediculicides are insecticides andshould be used according to instructions. To ensure that there are Head lice can infest all levels of society and most racial and ethnic no language, hearing, or reading problems, it is always advisable groups. They can be found on the heads of whites, Asians, to have the patient repeat the instructions verbally. Also, because Hispanics, and North, Central and South American Indians. Race several pediculicide products decrease in efficacy after being has been shown to be a factor in infestation in only one instance— opened, pediculicides should be discarded after the second treat- head lice are so uncommon among African Americans that it is ment. They should never be stored in a medicine cabinet, where recommended that this group be excluded when estimating preva- they may be confused with cough syrup or other medications lence.1,7 It is believed that the head louse indigenous to this part several months after the infestation.
of the world is not well adapted to grip the oval-shaped hair shaft characteristic of the hair found in the black population.
Nevertheless, cases of North American head lice in blacks (e.g.,African Americans, Jamaicans, Haitians) occasionally do occur Currently, lindane is one of two prescription products that havebeen approved by the Food and Drug Administration (FDA) for the treatment of pediculosis (the other, 0.5% malathion, is dis- Because lice are very host-specific, the lice that affect humans can- cussed below). Lindane is in the class of chemical insecticides not be transmitted to or from pets or other animals. Head lice are called organochlorines, which also includes DDT. It has been avail- transmitted from person to person, either directly or indirectly.
able as a 1% shampoo for the treatment of head lice and a 1%lotion for the treatment of scabies for more than 50 years. The Direct transmission may occur during children’s play or other lotion is FDA-approved for scabies only and is potentially toxic if activities in which individuals come into close physical contact with each other. Contrary to common belief, lice cannot jump (like fleas)
or fly (like gnats). However, head lice that are warm and well-fed
Lindane shampoo has a short application time (4 minutes) and is can move fairly quickly from hair to hair and scalp to scalp.
relatively easy to use, but it also has some significant drawbacks.
First, lindane may be stored in human tissue and will accumulate Indirect transmission may occur through contact with lice-carrying in the body with repeated use.8 If overused, misused, or accidental- objects. Lice may cling to a long list of objects, including brushes, ly ingested, lindane may be toxic to the central nervous system.
combs, hats, clothing, costumes, athletic gear, and towels.
Clinical symptoms of central nervous system toxicity relating to Although lice cannot survive for long on such objects, they can lindane poisoning may include: nausea, vomiting, headache, dizzi- move readily from them to another scalp. Thus, it is not uncom- ness, restlessness or hyperactive behavior, apprehension, tremors, mon to trace an outbreak of head lice to a single, shared object, weakness, increased excitability, disorientation, convulsions, respi- such as a batting helmet or a set of language lab headphones.
ratory failure, twitching of eyelids, coma, and occasionally death.8Lindane overuse also may result in “delusions of parasitosis,” or the mistaken belief that one is infested with parasites. Delusions of Common measures to mechanically remove lice and nits from the parasitosis often arise from altered neurological sensations, which hair, such as brushing, combing with a good nit comb, shampoo- patients have described as a sharp sting or pain, increased itching, ing, and towel- or blow-drying, play a role in reducing the number or a “biting” or “crawling” sensation. Although these feelings are of viable lice and eggs on the head, but are insufficient to cure an real to the patient, they are not due to a continued infestation, but active infestation. Effective treatment involves the application of are instead manifestations of lindane toxicity. Believing that they a pediculicide to kill lice and nits followed by manual nit removal are infested with “bugs,” patients experiencing these sensations may use lindane repeatedly, thus creating a dangerous cycle.3,9Due to its potential for toxicity, lindane should not be left on for longer than the prescribed time and should not be used more than two times one week apart. Prescriptions should not be refilled. Ivermectin is perhaps best known as a safe and effective treatmentfor onchocerciasis, or “river blindness” caused by the parasitic Another major drawback of lindane is its relatively poor pediculi- worm Onchocerca volvulus. A single oral dose of 150 to 200 µg/kg cidal and ovicidal (nit-killing) activity. Because lindane resistance body weight given semiannually in a 6 mg tablet is effective against in lice has developed in the US and other countries,3 lindane has this disfiguring and blinding disease. Worldwide, an estimated 18 a relatively high treatment failure rate, compared with several million children and adults are treated with ivermectin each year. over-the-counter (OTC) pyrethrin and permethrin products (see“Pyrethrins” and “Permethrin” below). Moreover, even in non- In the early 1990s, anecdotal reports that ivermectin resolved resistant lice, lindane is a slow-killing pesticide. Lice exposed to ectoparasitic infections in patients with onchocerciasis prompted lindane 1% shampoo may take many hours to die,10 during which studies of the effectiveness of this drug for the treatment of scabies time they shake and squirm, often causing increased itching and and head lice. In studies using ivermectin against onchocerciasis, individuals who had received ivermectin tended to have significantlyfewer head lice than individuals who had not received this drug.12 Finally, lindane 1% shampoo leaves the hair with a straw-like texture that makes it almost impossible to comb out, even with While the FDA has approved ivermectin for the treatment of a wide-toothed comb. The use of a non-pesticide creme rinse or onchocerciasis and strongyloides, another internal parasitic infec- detangler may facilitate nit removal following lindane use. Other- tion, this drug does not have an FDA-approved indication for the wise, it is a tedious and painful experience for both parent and child.
treatment of head lice. However, ivermectin has been used “offlabel” for pediculosis treatment when all other treatments have In view of the many negative aspects of this pediculicide, it is difficult failed. A public health official in the US prescribed this treatment to see the advantage of future lindane use, particularly because sev- for pediculosis when grade schools in parts of Washington state eral other equally-effective and less-toxic treatments are available.1 were closed due to outbreaks of “resistant head lice.” Ivermectin If the patient or parent prefers a prescription product for financial delivered orally at 200 µg/kg seemed to cure most individuals, but reasons, 0.5% malathion lotion, ivermectin, or 5% permethrin follow-up was difficult, and some people required a second dose cream (discussed below) are safer and more efficacious options. the next day to kill surviving lice.13 Clinical trials are necessary todetermine the optimum dose. MalathionAlcoholic 0.5% malathion lotion was approved by the FDA Products Available Over the Counter (OTC) around 20 years ago, but has been marketed in the US only inter-mittently. In 1999 it became available by prescription under the brand name Ovide® (Medicis, Scottsdale, AZ). Ovide® is the The flower heads of Chrysanthemum cinerariaefolium (pyrethrum) quickest-acting and most ovicidal of any pediculicide developed in yield a mixture of natural botanical extracts called pyrethrins.1 the last 30 years.1,10 Ironically, despite its quick action, this prod- These pyrethrins, which have insecticidal properties, have been uct has a relatively long recommended application time. Because formulated into various lotions, shampoos, foam mousses, and the original malathion studies for FDA approval involved an 8 to gels for the treatment of head lice. Trade names include RID® 12 hour application, this became the recommended treatment pro- (Bayer, Leverkusen, Germany), A-200® (Hogil, Purchase, NY), tocol. There is evidence, however, that Ovide® is highly effective Clear Lice System® (Care Technologies, Darien, CT), and Pronto® against lice and nits in less than 10 minutes.10 Clinical trials should (Del Laboratories, Uniondale, NY). Generic pyrethrin products be conducted to establish the optimum application time. The high content of isopropyl alcohol (78%), pine needle oil, and Most pyrethrin products combine natural pyrethrins with piper- turpineol in this product make it quite flammable, if accidentally onyl butoxide (PBO), which has insecticidal properties of its own.1 ignited. Furthermore, the odor is quite objectionable, and inhaling PBO is a synergist that greatly enhances the activity of pyrethrins the fumes can result in headaches when the product is applied for and seems to play a role in preventing or slowing down the devel- the recommended 8 to 12 hours. A 10-minute application does not Natural pyrethrins demonstrate low toxicity in mammals. However, Illnesses linked to agricultural use of malathion have raised con- the active components in pyrethrin pediculicides are extracted with cerns about its toxicity in humans. However, the high grade of kerosene or petroleum distillates that may cause eye or scalp irrita- malathion used for the treatment of human pediculosis is very dif- tion.1 Also, because pyrethrins are natural botanical extracts, all ferent from the grade used for agricultural or veterinary purposes.
pyrethrin products carry a warning of possible allergic reaction in Based on extensive toxicity studies for an 8 to 12 hour application patients who are sensitive to ragweed or flowers, but these reac- time, the FDA has approved 0.5% malathion alcoholic lotion for pediculosis treatment, and this product is believed to be safe whenused as directed. Natural pyrethrin products suffer from instability to heat and light,and they have no residual activity once they have been rinsed off.
Malathion resistance in head lice has been documented in England,11 Furthermore, none of the natural pyrethrin pediculicides are totally but so far, there are no documented cases of resistance in the ovicidal.10 Twenty to 80% of the nits remain viable after treatment.
United States. Lice in the US may have remained sensitive to Therefore, a second treatment is necessary 7 to 10 days after the malathion because this product is not as readily available here as it is in the UK, where it can be purchased over the counter. Although there is no published documentation of pyrethrin resis-tance in the United States, recently there has been an increase in reports of treatment failures. Further research is necessary to determine whether these reports represent cases of resistant lice.
Because outbreaks of pediculosis frequently occur in the summer months, when the temperature is warm and children come By synthesizing and modifying the molecular structure of natural together at camps and sleepovers, a schoolwide screening for pyrethrins, chemists were able to develop compounds called pediculosis should be held soon after school starts in the fall. synthetic pyrethroids. Permethrin, one of the first heat- and light- A second screening is recommended in mid-January, when chil- stable synthetic pyrethroids, is highly toxic to insects and other dren are returning from holiday vacation. The following plan arthropods but is one of the least toxic insecticides to mammals.8 can maximize the efficiency of the screening process.
Based on oral studies in animals, permethrin is about 3 times less toxic than natural pyrethrins and approximately 36 times less toxic ■ Obtain permission for the screening from the school administrator.
■ Arrange for one trained volunteer per 200 students to help with Permethrin is available by prescription as a 5% cream (Elimite®, ■ Gather supplies, including a fluorescent lamp, a 10x hand-held Allergan, Irvine, CA; Acticin®, Penederm, Foster City, CA) or over magnifier, screening sticks to part the hair, and disposable gloves.
the counter as a 1% crème rinse with the trademark Nix® (Pfizer, Disposable gloves should be used to maintain proper hygiene NY, NY). The 5% permethrin cream, commonly prescribed for the treatment of scabies, does not have an FDA-approved indication for the treatment of head lice but is recommended by some doctors ■ Prepare and send a letter signed by the school nurse and admin- because it is safe for an 8 to 14 hour application in children as istrator to the parents informing them of the date and time of young as 2 months. The 1% permethrin crème rinse Nix® has the upcoming screening. Include suggestions that will help par- been approved by the FDA for the treatment of pediculosis since ents check their children and the surrounding household for 1986. This product has undergone more clinical trials and toxicol- signs of lice and nits. Offer suggestions for treatment.
ogy studies than any other pediculicide on the US market. Like the natural pyrethrin products, Nix® is not completely ovici- ■ Provide teachers with a schedule that includes the date and time dal; approximately 20% to 40% of viable eggs hatch after treat- ■ Encourage teachers to discuss the upcoming screening with their ment. Also, although residual permethrin on the hair once killed nymphs soon after they hatched, this is no longer the case. Thedecrease in the residual activity of Nix® suggests that permethrin levels that were lethal in the past may be sublethal today. ■ Beginning with the youngest class, have each class line up in Since 1994, it has become clear that permethrin is no longer as ■ On the roster, indicate which children are infested. Use one nota- effective as it had been previously. Data from researchers in tion for children who have viable lice and nits and another nota- England, France, the Czech Republic, and Israel show that head tion for those who have nothing but hatched, non-viable nits. lice have become resistant to permethrin.3 Recent studies in the US ■ At the end of the day, have the teacher gather the students that have not only confirmed the existence of permethrin resistance,14 are infested. Hand each student involved an envelope with a let-ter and suggestions to the parent for treatment of the child. but also traced this resistance to specific genetic mutations in lice.15 ■ Children with viable lice and nits should be given a letter recom- mending treatment with a pediculicide followed by combing to HairClean 1-2-3® (Quantum, Eugene OR), an FDA-approved lice ■ Children with nothing but hatched, non-viable nits should be removal system consisting of a hair hygiene treatment and a nit given a letter recommending combing to remove the nit casings. comb, is available in drug and health food stores. This product con- ■ Have trained, designated volunteers contact parents by phone to tains no chemical pesticides, making it an attractive alternative for ensure proper treatment and answer any questions they may individuals who are opposed to using chemical products on the head.
have. Many parents will be angry about the situation. Such The hair hygiene treatment consists of all natural ingredients, includ- anger most likely represents underlying embarrassment or guilt.
ing anise oil, ylang ylang oil, coconut oil, and isopropyl alcohol. Therefore, head lice should always be discussed with a con-cerned but unemotional attitude, the way a head cold or fever In studies conducted in South Florida, HairClean 1-2-3® appeared might be discussed. An attitude of calm, professional concern, to be a safe and highly-effective pediculicide. HairClean 1-2-3® sympathy, and reassurance will do much to defuse feelings of killed all lice and nits in 98% (51/52) of study participants. By comparison, Nix® showed a treatment success rate of 89% (17/19). No adverse experiences were reported.3 ■ Make sure each teacher and parent clearly understands that infested children are not to re-enter the classroom without There are no known reports of resistance to HairClean 1-2-3®, a visit to the health office for a clearance by a school nurse.
making this product a viable alternative in cases of resistant lice.
■ Schedule a trained and designated volunteer to be available for Also, because the hair hygiene treatment prompts lice to leave the the next two days to help examine returning children and pro- scalp and run to the tips of the hair, use of this product may aid vide any additional support required for families still infested.
ing nits, the possible psychological damage done by such shearing Reluctant to continue applying pesticides to children’s heads, many desperate and frustrated parents and health professionals are turn-ing to alternative therapies to battle head lice. Many individuals claim to have successfully cured their infestations by using inexpen- sive, non-pesticide products including petroleum jelly, hair pomade, After individual treatment, the second step in pediculosis control olive oil, mayonnaise, vegetable shortening, vinegar, mineral oil, is to treat other individuals to whom lice may have spread. All and essential oils sold at health food stores. household members should be checked for lice and nits—adults There is no doubt that oily alternatives such as petroleum jelly, as well as children. Additionally, anyone with whom the infested olive oil, or mayonnaise slow down the lice, making them easier to individual has recently had physical contact or possibly shared lice- find and comb out, and even killing some. Unfortunately, because carrying objects should be checked. This may include classmates, they are not as effective as the currently available pediculicide playmates, and babysitters in the case of children; and co-workers products, they usually require repeated overnight treatments and and acquaintances in the case of adults. If these individuals are many hours of painstaking combing. The need for repeated found to have lice or nits, their families and friends should in turn overnight treatments, in turn, can delay a child’s return to school.
be notified, and so on. It is only by attempting to eliminate theentire chain of transmission that the cycle of infestation and rein- It is common practice to comb or “nit pick” through the hair aftertreatment to remove lice and nits. Nit removal is important for two main reasons. First, it removes an outwardly visible sign of The third step in controlling pediculosis and preventing reinfesta- head lice infestation, thus preventing stigmatization. Second, tion is to thoroughly clean all objects of potential transmission. because no pediculicide product kills 100% of eggs, manual nit In order to remove all lice and nits from the environment, the removal is recommended to eliminate any nits that may have sur- ■ All clothing, bedding, and linens that the infested individual may Many school officials insist on a “no nit” policy to ensure freedom have worn or handled within two days of diagnosis should bewashed in hot water (150°F) and dried on “high” for 20 minutes.
from infestation and proof of adequate treatment. Because this policy fails to differentiate between viable and non-viable nits, it ■ Brushes, combs, and hair accessories should be soaked in either tends to have an overreaching effect, keeping children who pose rubbing alcohol or hot (150°F) soapy water. no threat of transmitting lice from attending school. The “no nit” policy also places a substantial burden on parents, who must go through the time-consuming process of removing all nits from the hair. For many working parents, this may mean missing consider- permethrin vs. lindane for the treatment of scabies [editorial]. Arch Dermatol Team, University of Miami, FL) for her editorial assistance and Lidia Serrano (Lice Source Services, Plantation, FL) and Kathy Combing the hair with a wide-toothed comb does not suffice for nit removal. Nit removal is a slow and careful process of examin- ing individual hairs from root to tip and completely removing all nits with a special fine-toothed comb. The process is made easier Eberle MW. Comparative efficacy of treat- ments for pediculosis capitis infestations.
when the hair is parted and combed in sections, and use of a detangler or hair conditioner may facilitate combing. Plastic nit 11. Downs AM, Stafford KA, Coles GC.
combs that come with pediculicide products often are not as and insecticide resistance. Parasitol Today good as metal combs purchased separately. Both the LiceMeister® available in the United States through the National Pediculosis 2. Friedlander SF. What’s new in cutaneous infection? Presented at the Second Annual Association, and the Quantum Lice Comb (Quantum, Eugene, OR) JAG. A field study of the effects of iver- Infectious Diseases in Children Symposium seem to work well. The Quantum Lice Comb is particularly easy to grasp and manipulate and is less expensive than the LiceMeister. 13. Brettman A. Untested pill kills lice fast, dozens of local parents say. The Daily Because eggs scraped off the hair are caught in the teeth of the nit News (Longview, WA) 1997 Jul 10.
comb, the comb should be treated or discarded after use. An old 14. Pollack RJ, Kiszewski A, Armstrong P, CN. Ectoparasitic diseases in dermatology: toothbrush or dental floss can be used to dislodge the nits. Metal- reassessment of scabies and pediculosis.
toothed combs should be soaked in rubbing alcohol or pediculi- Advances in Dermatol 1999;15:67-108.
Differential permethrin susceptibility of cide. Plastic combs should be sealed in plastic and thrown away.
5. Mumcuoglu KY, Klaus S, Kafka D, et al.
head lice sampled in the United States and Clinical observation related to head lice Following treatment and manual nit-removal, the infested individ- ual should be checked for lice and nits daily for 14 days to ensure 6. Mumcuoglu KY, Miller J, Gofin R, et al.
that he or she has not become reinfested. It is not necessary to Epidemiological studies on head lice infesta- Devonshire AL, Clark JM. Moleculartion in Israel, I: parasitological examination analysis of kdr-like resistance in perme- cut long hair or shave the head to manage a head lice infestation.
of children. Intl J Dermatol, 1990;29:502-06.
thrin-resistant strains of head lice, Pediculus While such measures may ease the task of looking for and remov- capitis. Pesticide Biochem & Physiol tations and insect bites. New York: MarcelDekker; 1985.
■ Carpets, rugs, and upholstered furniture should be thoroughly vacuumed, and the vacuum bag should be carefully removed No single approach is likely to be effective in eradicating head lice.
Due to the development of lice that are resistant to many existingpediculicides, infestations are increasingly difficult to treat.
■ Spraying classrooms or homes with insecticides is not recom-
mended for cases of head louse infestation. In fact, it is strongly Moreover, while currently available pediculicides kill lice with discouraged by many health professionals, including those at the varying degrees of success, none of these products kills all eggs.
National Pediculosis Association and the Centers for Disease Therefore, treatment with pediculicides is an imperfect solution to Control. Because washing and vacuuming are adequate protection the head lice problem and should be accompanied by preventive if done properly, the potential health risk of spraying or fumiga- efforts. Preventing the transmission of head lice involves not only tion is unwarranted. Also, insecticides intended for veterinarian treating infested individuals, but also eliminating lice from the or agricultural use should never be used on people or on house-
environment, raising the awareness of school officials and health hold objects such as furniture or stuffed animals. professionals, and, most importantly, educating children and their ■ In taking measures to avoid reinfestation, it is helpful to recall parents about head lice infestations and their control. ■ that head lice cannot live more than 24 hours off the host at normal room temperature or higher. Eggs attached to hairs may This course is based on an article by the author that originally appeared in Current Problemsin Dermatology, 1999;11 1999 Mosby, Inc.
remain viable for up to 10 days after treatment, but the nymphmust find a blood meal within hours of hatching, or it will die. c) lindane is not as effective as several 5. In the United States, head lice infesta- tions are least common among:
2. Viable eggs differ from eggs that have a) a viable egg has a tan to coffee color, comb after treatment with a pediculicide: 3. Which of the following is not a poten-
or symptom of infestation with head lice? Department of Continuing
Education & Training
11830 Westline Industrial Dr.
St. Louis, MO 63146
Sponsored by HairClean 1-2-3 Lice RemoverQuantum, Inc. 1-877-LICE-877 (1-877-542-3877) www.quantumhealth.com
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