Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Real life
- Wendy Taylor (9 November 2001)
-
Head lice treatment and pesticides: another perspective
- Andrew Watterson (10 November 2001)
-
Re: Real life
- Nigel Hill (13 November 2001)
-
The economics of combating pesticide resistance in head lice
- Joanna Wickenden de Ibarra (13 November 2001)
-
Premature to abandon wet combing for head lice infestation.
- Robert Bunney (13 November 2001)
-
The real facts
- Janet Barrass (13 November 2001)
-
Don't let it go to your head
- Colin Dewar (14 November 2001)
-
Headlice in real life.
- C H Kimberley (14 November 2001)
-
Any evidence for electronic combs?
- Gary Jackson (14 November 2001)
-
Conditioner should be applied to dry hair
- Phillip J Colquitt (17 November 2001)
-
Re: Any evidence for electronic combs?
- Joanna Ibarra, Jane Leseley Smith, Frances Fry (17 November 2001)
-
Re: Any evidence for electronic combs?
- Joanna Ibarra, Jane Leseley Smith, Frances Fry (17 November 2001)
-
Simian-style grooming can work
- Rowan H Harwood (23 November 2001)
-
Practical advice
- John Charlton (24 November 2001)
-
Control of head lice - advice misleading
- Nigel Hill (27 November 2001)
-
Which head lice treatments are likely to be effective in the UK?
- Richard J Roberts (30 November 2001)
-
Effective management of head lice requires further research
- Rodger Charlton (6 December 2001)
-
Health professionals lack of knowledge of effective control measures contributes to poor outcomes
- H V Duggal, B Olowokure, M Beaumont (7 December 2001)
-
Re: Health professionals lack of knowledge of effective control measures contributes to poor outcomes
- Tamas Grubaum (18 August 2003)
-
Safe removal of lice
- Mary Ryan, 49534 (26 March 2008)
|
|
|||
|
Wendy Taylor, ConsultantNeuroradiologist NHNN/GOS
Send response to journal:
|
I read with interest the review of head lice treatment. I am writing in my capacity of a mother of three children, attending three different schools and who has encountered mmultiple infestations of head lice over the years. The simplest treatment for eradication of head lice without doubt, is a simple shampoo of Tea Tree followed by extraction of the nits with ordinary conditioner with a lice comb. This should be repeated ( depending on the number of nits and drowning lice extractd with the lice comb, every two/ three days for a period of a week or so. I have tried all the proprietary brands of chemicals and do not find them any more effective than this.No nasty chemicals are required. Interestingly, now my children are moving into adolescence, we have far less of a problem! Any ideas why this should be so? |
|||
|
|
|||
|
Andrew Watterson, Professor of Health Effectiveness University of Stirling
Send response to journal:
|
Treatment of head lice raises questions about why to treat, how to treat and with what effects. All the risks and benefits of treatment methods should be considered. Treatments choices for parents and those advising them will not simply depend on local patterns of lice resistance to pesticides although such knowledge will undoubtedly be useful (1). It is dangerous to base arguments about preferred chemical treatments of parasites without providing data on risk assessments for humans exposed to such pesticides. Commercial companies may view this as unproblematic for synthetic pyrethroid lice treatments; others do not (2). The development of widespread resistance by pests to pesticides litters pesticide history. The phenomenon is entirely predictable and, if pesticides are viewed as the only tool available, it simply benefits pharmaceutical and chemical companies (3). These companies will then have perpetual markets for an endless series of new products to combat resistance. This is the pesticide 'treadmill' that is never ending and presents established and serious challenges for public health (3). Organochlorine, organophosphate and synthetic pyrethroid pediculicides are all established human health hazards and do involve unknown human health risks because evidence is lacking about longer term low levels exposures, low level mixtures and so on. Newer products are also often less well researched than older lice products The problem described by Dodd is one of 'an essentially harmless parasitic infestation' that may cause psychological distress (1). Hence strategies could be used to address the knowledge base that parents have about lice as well as the respective risks and benefits of chemical and non-chemical treatments, better and earlier detection and improved monitoring. These strategies have been widely discussed and, although some are touched on by Dodd, their relevance to reduced chemical usage is neglected (4). However, the editorial's coverage of treatment methods now available appears to be somewhat unbalanced. For instance the Roberts study cited that looked at combing versus malathion lice treatment is presented as 'showing combing to be ineffective'(1). What the paper states is that malathion was twice as effective as combing: a very different finding with combing giving a cure rate of 38% and malathion 78% (5). Hill noted that other studies - cited by Dodd but in a very different context - found malathion usage in Bath to have only a 36% success rate, worse than combing (6) . So, in areas where pesticide resistance may operate and perhaps in other settings too, combing would be the preferred pest control method over malathion. It is unfortunate that Dodd did not flag up in her editorial the pertinent criticisms made of the methodologies and findings of the Roberts study that bear directly on her own conclusions. The debate is still as much about chemical versus 'integrated' or other pest control methods for head lice as it is about local resistance problems in the context of a total human risk assessment (7)(8). (1) Dodd C. Treatment of head lice. BMJ 2001;323:1084 (2) Diel F, Horr B, Borck H, Savtchenko H, Mitsche T, Diel E. Pyrethroids and piperonyl-butoxide affect human T-lymphocytes in vitro. Toxicol Lett 1999; 107(1-3):65-74 (3) Hansen M. Escape from the pesticides treadmill. 1987. IOCU, Washington. (4) Olkowski W, Daar S, Olkowski G. Common-sense Pest Control: least toxic solutions. 1991. Taunton press, Newtown, Connecticut (5) Roberts RJ, Casey D, Morgan DA, Petrovic M. Comparison of wet combing with malathion for treatment of headlice in the UK: a pragmatic randomised controlled trial. Lancet 2000; 356:540-4 (6) Hill N. Treatment of head lice. Lancet 2000; 356:2007 (7) Ibarra J, Fry F, Wickenden C. Treatment of head lice. Lancet 2000; 356:2007 (8) Richards SM. Treatment of head lice. Lancet 2000; 356:2007 |
|||
|
|
|||
|
Nigel Hill, Medical Entomologist London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT.
Send response to journal:
|
The reply by Wendy Taylor to Dodd's Editorial on head lice control is one no doubt echoed by many. Even many pharmacists in the UK frequently advocate Tea Tree oil as a "cure" for lice. However, most are unaware that, volume for volume, Tea Tree oil is more toxic to mammals than the organophosphate pediculocide malathion, yet many see it as a "safe" alternative (see Hill.N, Nursing in Practice, Autumn 2001). It is my view that those who are happy using Tea Tree shampoo plus a fine tooth comb would have just as much success using any shampoo / conditioner plus a fine tooth comb. |
|||
|
|
|||
|
Joanna Wickenden de Ibarra, Programme Co-ordinator Community Hygiene Concern, Manor Gardens Centre, 6-9 Manor Gardens, London N7 6LA
Send response to journal:
|
It was surprising to find the Cochrane reviewer of treatment for head lice, Ciara Dodd (1) attributing an unfamiliar statement to an article of mine. (2) The inaccuracy, of little significance in itself, nevertheless prompts questions about supporting evidence for other statements, that head lice are only caught by relatively prolonged head to head contact, for instance. Downplaying the reality that families face multiple episodes of infestation leads her to centre on a treatment choice solely between pesticides. Yet she acknowledges a failure rate as high as 87% and 64% for permethrin and malathion respectively, reported in 1999 (3) and the Cochrane review rejects on the grounds that they are flawed, the clinical trials of the two other active ingredients available,phenothrin and carbaryl. (4) The chances of treatment failure,especially against eggs, which may remain unnoticed until after the hatching lice have spread, appears to be high indeed. The trial, reported in 2000, comparing two applications of malathion with use of the 1996 bug buster kit for wet combing did, in fact show a cure rate of 78% and 38% respectively; sustainability was not addressed. (5) Product costs when each new case requires two doses must be considered in comparison with a single kit for the whole family, reusable for detection and, as demonstrated by a fair number of families, cure. Continued dependance on pesticides inevitably raises insect population resistance, whereas skill with wet combing increases with practice, and introduction of the new bug buster comb has simplified acquisition of this skill. Families who check using the bug busting method 3 to 5 days after treating with a pediculicide which claims to kill the egg, will detect the first and second instar nymphs which indicate that the product did not work, before the lice can spread. Advising families to follow this procedure, clearly explained on the demonstration video, is an economical rapid response to an everyday situation, which should be supported by periodic investment in the expensive testing required to establish the pesticide resistance status of local head lice. Community Hygiene Concern is non-profit making, a registered charity,and produces the bug buster kit; its work on head lice is grant funded by the UK Department of Health and Community Fund. References 1 Dodd C. Treatment of head lice. BMJ 2001; 323: 1084. 2 Wickenden J. Head lice, schools, teachers and parents. Health at School 1985; 1: 18-19. 3 Downs AMR, Stafford KA, Harvey I, Coles GC. Evidence for double resistance to permethrin and malathion in head lice. British Journal of Dermatology 1999; 141:508-511. 4 Dodd CS. Interventions for treating head lice. Cochrane Library 2001;(3):CD001165. 5 Roberts RJ, Casey D, Morgan DA, Petrovic M. Comparison of wet combing with malathion for treatment of head lice in the UK: a pragmatic randomised controlled trial. The Lancet 2000; 356: 540-544. |
|||
|
|
|||
|
Robert Bunney, GP Brannam Medical Centre,Barnstaple,North Devon. EX32 8GP
Send response to journal:
|
Dodd states that wet combing is ineffective as a treatment for head lice but the trial she refers to found 36% of children allocated this treatment to be free of lice at 14 days (1) .I am unaware of lice clearing without any treatment and although the Malathion group showed twice the clearance rate I feel it is premature to discard wet combing. Our own children repeatedly required treatment for lice during the late 1990s and although the infestations usually responded to various pediculicides the children soon became reinfected requiring repeated applications until in exasperation we turned to wet combing . Presumably we managed to acquire the technique used by the successful 36% as we found it possible to clear infestations and by repeated combing keep the children clear until the epidemic waned. Presumably even when pediculicides have a success rate of 20% the children bearing resistant lice are likely to reinfect the successfully treated children so that a resistant epidemic soon ocurrs. Although initially seeming to have less success it is likely that during the more typical outbreak of several months duration the combing method will at least retain or even increase it’s effectiveness as parent’s become more skilled in its use encouraged by the finding that resistance can’t ocurr. Surely a longer trial of several months duration in areas of both high and low resistance is required before definitive recommendations can confidently be made. 1 Roberts RJ, Casey D, Morgan DA, Petrovic M. Comparison of wet combing with malathion for treatment of head lice in the UK: a pragmatic randomised controlled trial. Lancet 2000;356:540-544 |
|||
|
|
|||
|
Janet Barrass, Personal Medical Secretary/mum
Send response to journal:
|
Sir, In my opinion it is all well and good trialing new drugs to combat headlice when in fact more headlice is seen now than when I was a child (60s/70s)because the government deemed it necessary to do away with the 'Nitty' nurse. Being a mother of two, one of whom is still in primary school, I have found that one effective treatment to try to reduce my daughter contracting headlice has been the use of simple conditioner on her hair after washing every morning whilst in the shower. This has markedly reduced the number of occasions she has come home from school with headlice. Before this treatment I could guarantee clearing her head of lice over a weekend or during school holidays only to find that after one day at school she has the lice present and within the week is covered in eggs as well at itching. My daughter suffers from excema and therefore the use of chemicals to combat headlice is kept to a minimum. I feel that the health professionals and government should re- introduce the school nurse to looking at childrens heads on a regular basis. My daughters school seems to have had trouble with headlice since the day she started 5 years ago and before when my son was there. At one point I actually called the school to find that at least 3 classes were infected. Letters were sent home but unless the parents do somthing the problem won't go away. Maybe its time to use the 'shame' factor by calling the nurse, writing to the parents and then the nurse rechecking after a week. If the problem persists with particular children then ask the parents to call in to the school or suspending the children until the problem is solved. These chemical solutions are not cheap, and this could be a factor as to why some parents don't bother, but its a problem that needs a solution and I feel that the NURSE is that solution. Yours Janet Barrass |
|||
|
|
|||
|
Colin Dewar, Research Psychiatrist Larkfield Centre
Send response to journal:
|
Don't let it go to your head. Having read Dodd's contribution to the subject of Head Lice, I can throw in my modest experience on the same subject. I had head lice once. The Child Psychiatry inpatient unit where I worked was the only possible point of contact and to strengthen the case there was an infestation of head lice at the time. Yet I was far too morose to have had any physical contact with the children there. I therefore assumed that I must have picked up the lice while leaning back against a sofa where one of the children had sat a few minutes earlier. I recollected long trips on third world buses when I had sat behind people and observed numerous head lice moving around their hair. Occasionally one would drop off onto the back of the seat and continue to move around for a while. Yet a lot of people believe and it is stated in this article "that it is possible to contract head lice only by relatively prolonged contact head to head with an infected person". Perhaps they don't flourish away from the human body but nor do they die instantly and if another person comes along a few minutes later then they are sure to take advantage of a new host. As for cure, I can recommend none better than an extremely short haircut, so short that it will still be short in six weeks time, followed by a refreshing sponge over the scalp with methylated spirits. It is not well known that neat alcohol is highly toxic to arthropods, without causing any damage to the skin of humans when used on an occasional basis and well away from naked flames. An ordinary wash with water afterwards can remove any lingering fragrance of alcohol. Dodd C. Treatment of head lice. BMJ 2001;7321:1084. |
|||
|
|
|||
|
C H Kimberley, GP Partner Catshill Vilage Surgery, Bromsgrove. B61 0PU
Send response to journal:
|
Editor - I turned with hope to the recent editorial (1), and was disappointed. We are regularly told (I have just received a copy of our Health Authority's guidelines) that headlice only transfer on prolonged head to head contact, that headlice off the head lose their infectiveness and that wet-combing is an ineffective treatment. Is there any evidence for these assertions? My son brought us headlice home from school (live lice seen). We all used a permethrin lotion, following the manufacturer's instructions. It failed (live lice continued to be seen). We used wet combing with louse comb and conditioner, which succeded (no more live lice seen). In the process I observed lice removed from my son's head, transferred from comb to tissue paper for easy observation. As they dried out they became increasingly active and mobile. Why should I think they could not climb aboard a convenient head of hair? Experience shows that the same families return repeatedly for prescriptions of pediculicide (pesticide) lotion. The reason may be pest resistance, incorrect application, or reinfestation. In any case, pesticides do not seem to be the answer. Wet combing worked for us. Even if pesticides do work they do not guard against reinfestation. Common sense funnels down to regular bug-busting while you are at risk in your community. Bug busting needs to be done correctly, but then so would application of pesticides. A charity called Community Hygiene Concern (www.chc.org/bugbusting) - I have no connection with them - provides suitable kits and instructions at a very reasonable cost. What do other people think? |
|||
|
|
|||
|
Gary Jackson, Public Health Physician Counties Manukau District Health Board
Send response to journal:
|
I would have liked to have seen some discussion on the electronic comb, Robi Comb. Originally from Israel, it seems to be selling like hotcakes here in New Zealand, and if the web is anything to go by, around the world. For those who haven't seen this device, it is powered by a single AA battery. The Robi Comb makes a humming sound until it finds a louse. When that happens, the louse is "zapped" and the humming stops, telling you a louse has been found and killed. You then clean the teeth with the small brush, the humming starts again, and you continue combing until the lice are gone. I haven't seen any evidence of it's effectiveness published - is anyone working on this? On an anecdotal level I can certainly vouch for it in the case of my own children. And that zapping sound when you hit a louse is immensely satisfying! |
|||
|
|
|||
|
Phillip J Colquitt, Independent Technical Advisor
Send response to journal:
|
According to an article found on a Queensland Government website <www.health.qld.gov.au/phs/shpu/9169_doc.pdf>, and titled "HEAD LICE IN PRIMARY SCHOOLS", "The conditioner and combing technique is the most effective way of finding head lice and is effective in treating them." The article goes on to say, "Apply hair conditioner to dry hair. Use enough conditioner to thoroughly cover the whole scalp and all hair from the roots to the tips." The article recommends white hair conditioner be used. This 'conditioner to DRY hair' technique, isn't dealt with by Dodd[1]. Nor is it dealt with by the above responses. Is the technique well known and/or effective? 1. Dodd, C. Head Lice. BMJ 2001;323:1084 Phillip J Colquitt, New Farm, Queensland, Australia, Nov.15,2001 |
|||
|
|
|||
|
Joanna Ibarra, Programme Co-ordinator, Project Worker, Development Worker Community Hygiene Concern, Manor Gardens Centre, 6-9 Manor Gardens, London N7 6LA, Jane Leseley Smith, Frances Fry
Send response to journal:
|
Our observations found the main drawback with electronic combs is that head lice move rapidly away from disturbance in dry hair, evading the teeth. This finding is corroborated by Burgess, an advocate of fine-tooth detection combing in dry hair, who describes the effect on lice; he recommends “placing a thumb over any suspect object before the comb is withdrawn from the hair. This prevents lice from being lost before they are identified.”(1) With an electronic comb, not only a louse, but any scalp debris caught in the teeth cuts off the current, allowing the escape of any other lice in the vicinity while cleaning proceeds. Combing dry hair causes static electricity to build up, producing pain if there are sore patches, which is likely in head infestation. The electronic comb must be used in dry hair for safety reasons. If the hair is only slightly damp from scalp perspiration the current running though the teeth causes shocks. The thickness of the handle above short teeth obstructs easy insertion at the roots of the hair where viable lice tend to be found. The comb is difficult to use without causing considerable distress in anything other than short straight hair. It often misses eggs and therefore must be applied repeatedly over the hatching period of 10 days to attempt a cure. Users may inadvertently spread lice meanwhile. And it is expensive! Community Hygiene Concern is non-profit making and a registered charity; its work investigating mechanical methods of head louse detection and elimination is grant funded by the UK Department of Health and Community Fund. |
|||
|
|
|||
|
Joanna Ibarra, Programme Co-ordinator, Project Worker, Development Worker Community Hygiene Concern, Manor Gardens Centre, 6-9 Manor Gardens, London N7 6LA, Jane Leseley Smith, Frances Fry
Send response to journal:
|
SECOND SUBMISSION, WITH REFERENCE DETAILS! Our observations found the main drawback with electronic combs is that head lice move rapidly away from disturbance in dry hair, evading the teeth. This finding is corroborated by Burgess, an advocate of fine-tooth detection combing in dry hair, who describes the effect on lice; he recommends “placing a thumb over any suspect object before the comb is withdrawn from the hair. This prevents lice from being lost before they are identified.”(1) With an electronic comb, not only a louse, but any scalp debris caught in the teeth cuts off the current, allowing the escape of any other lice in the vicinity while cleaning proceeds. Combing dry hair causes static electricity to build up, producing pain if there are sore patches, which is likely in head infestation. The electronic comb must be used in dry hair for safety reasons. If the hair is only slightly damp from scalp perspiration the current running though the teeth causes shocks. The thickness of the handle above short teeth obstructs easy insertion at the roots of the hair where viable lice tend to be found. The comb is difficult to use without causing considerable distress in anything other than short straight hair. It often misses eggs and therefore must be applied repeatedly over the hatching period of 10 days to attempt a cure. Users may inadvertently spread lice meanwhile. And it is expensive! Community Hygiene Concern is non-profit making and a registered charity; its work investigating mechanical methods of head louse detection and elimination is grant funded by the UK Department of Health and Community Fund. Reference (1) Burgess, IF. The management of headlice infections. Surgery OTC Review October 1997; i-iii |
|||
|
|
|||
|
Rowan H Harwood, consultant geriarician QMC Nottingham NG7 2UH
Send response to journal:
|
Two of my children, aged 5 and 7, were visted by head lice this summer. Two applications each of phenothrin and permethrin were ineffective, although this did seem to kill the adults. We were also unimpressed by the combing and conditioner regimen, especially for the one with long hair. I resorted picking out the juvenile lice by hand. They are just visible to the (bespectacled) naked eye, lurking around the hair roots. They can then be crushed between finger nails. At this point the exoskeleton becomes obvious, confirming that you have got your quarry. It takes some forbearance on the part of the children, especially as on the first day I retrieved 42 lice from one head. The retrieval rate decreased exponentially thereafter, and by day 7 no more lice were appearing. What is more, they have stayed away. The answer to the question about why adolescents become immune, is, I think, sebum. Elderly peole with dry, oil-less hair, become prone to lice again. |
|||
|
|
|||
|
John Charlton, General Practitioner Derby DE3 5EB
Send response to journal:
|
As a GP and a parent I have confronted the blighters on numerous occasions. All ages give them refuge.. recently we have had patients in their 90's... we think the same hairdresser! A medical secretary asked me recently why the betnovate scalp lotion was not helping. Some people (parents) ingore them despite all protestations. Most parents are frantic and camp outside the chemist. Most of the patients we see are either in need of a free script or the "lotion has failed Dr". In our family the lotion depleted the population and the anxiety levels but combing is to be frank the only answer. The few with electric combs I have seen have failed miserably. If the parents comb (everyone)three times a day it works. And if compliance is good... always works. Wet preferably (thou not practical) and with some conditioner (so that the claws are less effective). Logic suggests that combing thrice a day, each time ferreting out say 90% each time, will work. I was once told (by a medical student) that combing breaks the back legs so they cannot lay eggs (or it it realated to intercourse) ! An observation should be made re the replies and author... about as far from a 'Nit nurse' or humble GP as one could imagine. John Charlton |
|||
|
|
|||
|
Nigel Hill, Medical Entomologist Disease Control & Vector Biology Unit, London School of Hygiene & Tropical Medicine, London,WC1E 7HT
Send response to journal:
|
Whilst it is always pleasing to see unglamorous issues such as head lice being discussed in leading medical journals it is unfortunate that the editorial by Dodd (1) appears so misleading in the way it interprets results of other's work. To state the study by Roberts et al. (2) shows wet combing "to be ineffective" is untrue, as it eradicated lice in 38% of cases. If the author considers this to be the definition of an ineffective treatment then the study by Downs et al. (3) also sited, with efficacy of permethrin and malathion at 13% and 36% respectively, should be equally dismissive of pediculocides. It is also very misleading for the author to state that malathion and permethrin resistance in the UK "may be as high as 87% and 64% respectively", after all, these figures are based on real data (3) and elsewhere resistance is just as likely to be higher as lower ! We would also question 2 other rather ambiguous statements made. Whilst it is true to say there is no published evidence that resistance has developed to carbamates, there is equally none to say it is effective, particularly as many insects develop cross-resistance between these compounds and organophosphates, which have an identical mode of action. Finally, whilst it is true that the Cochrane review (4) "found no evidence that no one pediculocide had greater effect than another", that is because the author (again Dodd) had surprising omitted the crucial study in Bath & Bristol (3) which clearly shows malathion far superior to permethrin. With so little high quality research published in this field it is very important that what does appear is both balanced and fully representative of all pertinent data. References 1) Dodd, C. Treatment of head lice. BMJ 2001;323:1084. 2) Roberts RJ, Casey D, Morgan DA, Petrovic M. Comparison of wet combing with malathion for control of head lice in the UK: a pragmatic randomised controlled trial. The Lancet 2000;356:540-544. 3) Downs AMR, Stafford KA, Harvey I, Coles GC. Evidence for double resistance to permethrin and malathion in headlice. B. J. Dermatol. 1999;141:508-511. 4) Dodd CS. Interventions for treating head lice. Cochrane Library 2001;3:CD001165. |
|||
|
|
|||
|
Richard J Roberts, Consultant in Public Health Medicine North Wales Health Authority, Mold, Flintshire, CH7 1PZ, UK
Send response to journal:
|
Sir, The Editorial on treatment of head lice (1) made many useful points but inaccurately reported the results of our clinical trial (2). We actually found wet combing 38% effective in children, and we deplete our limited armoury of treatments if we dismiss wet combing. The author also gave undue emphasis to a finding of 64% resistance to malathion (i.e. 36% effective), suggesting this result applied to “some areas” of the United Kingdom. In fact, that figure is based on treatment of 14 infested children identified by screening three class rooms in a non -randomly selected school in Bath (3). Similar comments apply to the figure of 87% resistance to permethrin. We screened 4037 children from 24 randomly selected schools in two counties (population 238,000) with proven intermediate resistance to malathion (2,4), and found malathion lotion 78% effective when applied by parents. This finding is more likely to be representative of effectiveness elsewhere. Finally, it is a counsel of perfection to base choice of treatment on local resistance patterns, as most areas have no surveys of resistance. I believe it is possible, based on somewhat limited published data and expert opinion, to offer useful guidance about which treatments are likely to be broadly effective in the UK (Table).
Table: Estimated effectiveness of head lice treatments in the UK
Treatment Availability Safety Effectiveness
Carbaryl Carylderm(POM) Intermediate* Good
Malathion Derbac-M,
Quellada M† Good (aqueous)
Intermediate
Suleo-M,
Prioderm† Intermediate
(alcoholic)*
Pyrethroids Full Marks,
(permethrin Lyclear Good Poor
and phenothrin)
Wet Combing Bug Buster Kit Good Poor
Key:
* alcoholic lotions are flammable when wet(5)
† lotion (shampoo not recommended)
POM = prescription only medicine
References 1. Dodd C. Treatment of head lice. BMJ 2001;323:1084. 2. Roberts RJ, Casey D, Morgan DA, Petrovic M. Comparison of wet combing with malathion for treatment of head lice in the UK: a pragmatic randomised controlled trial. Lancet 2000:356:540-44. 3. Downs AMR, Stafford KA, Harvey I, Coles GC. Evidence for double resistance to permethrin and malathion in head lice. Br J Dermatol 1999;141:508-511. 4. Linnane E, Roberts RJ, Casey D. The use of field testing to produce rational treatment protocols for the eradication of Pediculus humanus capitis. In: Bartlett C, McEvoy M, Reacher M, Stuart J, Fitch V, editors. Proceedings of the Conference on the Epidemiology and Control of Communicable Diseases and Environmental Hazards; 1999 Nov 1-3; London. London: PHLS, 1999:24-25. 5. Choudhary S. Burns due to anti-lice lotion. Burns 1999;25:184-5. |
|||
|
|
|||
|
Rodger Charlton, GP and senior lecturer Centre for Primary Health Care Studies, University of Warwick.
Send response to journal:
|
We write in reply to this editorial and associated electronic correspondence and a recently conducted head lice survey at a local primary school of 220 children (59% response rate). This involved mailing a questionnaire to parents asking about family demographics and activities relating to washing and hair care. We found that 45% of the children had experienced head lice with 19% being infested three or more times. Of those families who had experienced head lice, 29% washed their children's hair in the bath only, 19% in the shower only and 52% in either compared with 62%, 0% and 38% in those families who had not experienced head lice. Shampoo type appears to have no influence. In addition, neither does the sharing of a brush or comb with friends and family suggesting that actual contact between the heads of the children is needed to transfer the louse. Families with only one child of primary school age have a lesser incidence of head lice (36%) in comparison with those who had a brother or sister of that age.(57%) This study highlights that the management of head lice has research issues other than treatment with pediculicides and wet-combing. (Acknowledgement to Martyn Lewis, Statistician, Keele University for data analysis) Dr Rodger Charlton, GP & Senior Lecturer, Centre for Primary Health Care Studies, University of Warwick, Coventry CV4 7AL. (Email: rodger.charlton@warwick.ac.uk) Gary Smith, Research Assistant, The Surgery, Hampton-in-Arden, Solihull B92 0AH. |
|||
|
|
|||
|
H V Duggal, Consultant Communicable Disease Control Department of Public Health and Health Strategy, South Staffordshire Health Authority, Stafford ST16, B Olowokure, M Beaumont
Send response to journal:
|
The editorial by Dodd (1) and the resulting electronic correspondence is a timely reminder that the head lice debate has centred on individual treatment rather than population control. Much has been made of the effectiveness, or perceived lack of effectiveness, of various types of treatment and local resistance patterns. However, there is little information on the knowledge and practice of healthcare professionals in relation to the control of head lice. In 1998 the Public Health Medicine Environment Group produced national guidance on the control of head lice. (2) This was adapted for local use in South Staffordshire and disseminated among local health professionals (general practitioners, practice nurses, health visitors, community paediatricians, school nurses and pharmacists) in 1999. (3) Eighteen months after dissemination of the local guidelines we undertook a survey of their use and the knowledge of local healthcare professionals regarding the treatment and prevention of head lice. A self-administered postal questionnaire based on the guidelines was sent to all local health professionals. Preliminary analysis of responses to two questions, one on the treatment of head lice and the other on prevention were scored on a three-point Likert scale (‘full’, ‘some’ or ‘no’ knowledge) is presented here. The overall response rate was 48% (235/487) and this ranged from 24% to 63% across the different categories of health professional. The policy was well disseminated, 76% (173/228) of respondents indicated that they referred to it. When describing preventive measures for head lice, 63% (123/194) of respondents appeared to have ‘full’ knowledge. However, when describing treatment for head lice, only 5% (10/191) appeared to have ‘full knowledge’. This difference was highly significant (p<0.0001). Most respondents failed to mention contact tracing while others did not mention that a live louse must be seen before treatment. Our results suggest that health professionals may contribute to propagation of head lice through lack of knowledge of effective control measures despite a large proportion claiming that they consult local guidelines. This is supported by reports of general practitioners prescribing treatment for head lice without seeing the patient. (4) This means that unnecessary treatment may be given thereby increasing louse resistance and may account in part for differential geographic resistance patterns. Improved education of health professionals and their communities will help promote understanding of the condition, dispel myths and enhance effective control measures. More work needs to be done with frontline staff to address the recognised problems of incorporating guidelines into clinical practice. (5) Harsh V Duggal
Babatunde Olowokure
Mandy Beaumont
Clinical Nurse Specialist, Infection Control
Department of Public Health and Health Strategy, South Staffordshire Health Authority, Stafford ST16 3SR REFERENCES 1 Dodd C. Treatment of head lice. BMJ 2001; 323: 1084. 2 Aston R, Duggal H, Simpson J. Head Lice: A report for Consultants in Communicable Disease Control (CCDCs). The Public Health Medicine Environmental Group, 1998. 3 South Staffordshire Health Authority. The control of head lice. Stafford: South Staffordshire Health Authority, 1999. 4 Ibarra J. Head lice: changing the costly chemotherapy culture. Br J Community Nurs 2001; 6: 146-151. 5 Feder G, Eccles M, Grol R et al. Using clinical guidelines. BMJ 2001; 318: 728-730. |
|||
|
|
|||
|
Tamas Grubaum, Vascular Technologist Mar Immaculate Hospital 153-11 89th AveJamaicaa New York
Send response to journal:
|
I realize that this response is a couple years after the publishing of the original article, however I believe that such questions about competency in treatment are still very relevent, especially when it comes to treatment of skin parasites. Although head lice remain a significant problem, my main concern is with scabies (sarcoptic scabea) which I am encountering more and more on a clinical setting. In addition I have personally had a problem with this parasite. The pertinence of scabies to the above mentioned article has to do with physician knowledge and appropriate treatment. If a patient presents anything but a textbook case of scabies to dermatologist it will be most likely misdiagnosed. Scabies burrows can be dismissed as scratches and dermatologists are too eager to practice psychology by dismissing the patients symptoms as delusions of parasitosis. In addition even if scabies are correctly diagnosed. The recognition of resistent scabies to 5% permethryn or 10% crotamiton goes largely unrecognized. One dermatologist refered to a 5%permethrin cream as the atomic bomb of scabicides. He ensured me that I was cured. Yet the next morning after having intimate contact the night before, my girlfriend complained of fealing "dust mites" in her bed. Then I new for sure that I wasn't cured. I instructed her to was the sheets in hot water. But I knew that I cannot have any intimate contact until I was completely cured based on my symptoms and not just told so by my Dr. To get back to my main point. The above article hopefully shed some light on the practicle knowldge of doctors treating head lice. I think a similar survey would be very useful to asses physician knowledge of the proper diagnosis and treatment of scabies. Competing interests: None declared |
|||
|
|
|||
|
Mary Ryan, Nutrition educator Merry Nutrition, 49534
Send response to journal:
|
Check out www.thebestcontrol2.com by Steve Tvedten. This is a free ebook containing over 2000 pages on pests and how to control them naturally in a non toxic manner. Chapter 16 is about head lice. There are several companies that sell the patented enzymes that are registered with the USFDA as a medical device to remove lice. They are mentioned in the book as Licenex and Lice R Gone. Competing interests: None declared |
|||