Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Treatment of head lice
- Paramoo Sudevan (6 June 2003)
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Electrocuting the b******s
- Ian Pennell (6 June 2003)
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Neem oil kills headlice
- Rachel M Calam (6 June 2003)
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Head Lice: A Disruptive Social Problem
- Martin. G. Buckley (6 June 2003)
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endorse the finetooth comb
- M D Dominic Bell (6 June 2003)
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Treating head lice--view from the battlefield
- Sylva Dolenska (7 June 2003)
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Re: endorse the finetooth comb
- Sylva Dolenska, TN24 0LZ (7 June 2003)
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Herbs in the Treatment of Headlice
- Cindy L Jones (8 June 2003)
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Natuarl history should dictate management of head lice
- Surinder Bakhshi (8 June 2003)
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lengthn of time for permethrin application and other queries
- John sharvill (8 June 2003)
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Of lice and men
- Anthony M R Downs (9 June 2003)
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Web data and information
- David de Berker (9 June 2003)
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another method for treating headlice
- anita m houghton (9 June 2003)
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Re: Neem oil kills headlice
- James McKenzie (9 June 2003)
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Bug Zapper
- Irene M Peat (10 June 2003)
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Head Lice
- Rosemary A Smart (11 June 2003)
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Re: Natuarl history should dictate management of head lice
- Sylva Dolenska, Ashford, Kent TN24 0LZ (11 June 2003)
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Electrocuting headlice
- Waqas Anwar, Seamus P. Mac Suibhne (13 June 2003)
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Re: Neem oil kills headlice
- dawa alejandro, children hosspital buenos aires (13 June 2003)
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Contact tracing and insecticide resistance matter
- Martin S Schweiger (14 June 2003)
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Doctors as patients: an oral history of effective louse elimination.
- Mair E M Thomas, Anna Eleri Livingstone (15 June 2003)
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Collective treatment
- Paulo Roberto de Madureira (17 June 2003)
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Too much head lice, too little evidence, too many reviews.
- Robert H Vander Stichele, Lapeere Hilde (26 June 2003)
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Re: Re: Natuarl history should dictate management of head lice
- Maddalena C Feliciello (26 June 2003)
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Combing is effective in headlice-treatment, and nessessary for lice-check.
- Asbjørn Høegholm, Alice Olsen (1 July 2003)
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The natural way to keep head lice at bay?
- Tracey Jones (2 July 2003)
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Advise users of flammability of lotions
- Paula McDonald (13 July 2003)
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Contact tracing should not be ignored.
- Joanna Harris, Dr Sally Millership (14 July 2003)
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Lindane should be banned!!!
- Pam A LaBrake (2 August 2003)
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more treatments
- douglas n salmon (10 October 2003)
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Paramoo Sudevan, Vice Principal,UEIMS, Vyttila, Cochin 682 019
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It is seen that the nits remain attached the hair even after successful treatment for head lice. These can be removed manually using a special type of comb which is an elongated instrument made of wood. It can be used in the same way as the usual coombs are used . The toothed portion of this comb is inserted into the hair close to the scalp and pressure is applied on both sides of the comb with index finger and thumb and the comb is draged to the end of the hair. Nits will be removed easily by this method Competing interests: None declared |
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Ian Pennell, consultant psychiatrist GL5 2JG
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One treatment which has not been mentioned and which was repeatedly effective in my own personal family patient group (N=1), is the comb which zaps the lice with a small electric charge. It costs about the same as 3 courses of insecticide, is painfree, chemical free and entirely safe (for the host). Treatment resistance does not develop. You can hear the little things frying between the teeth of the comb, which is most satisfying to the sufferer. Experts may argue that this method is the same as plain combing, but I am not convinced. I am suprised this device is not more widely known and used, as it must be preferable to coating the scalps of our young children with powerful insecticides. Competing interests: None declared |
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Rachel M Calam, Senior Lecturer in Clinical Psychology University of Manchester M23 9LT
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I've had experience of both older and newer approaches to head lice. 15 years ago, lice gave up more easily. More recently, having tried a series of recommended preparations and bug busting techniques, I finally found a neem based louse shampoo in a health food shop. This worked within a couple of applications, killing off "superbugs" that had hung on with remarkable determination. Competing interests: None declared |
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Martin. G. Buckley, Lecturer/ Research Fellow Diabetes Centre, Bolton Hospitals NHS Trust, Chorley Street, Bolton, BL1 4AL.
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Editor-I have read with great interest the recent series of articles regarding head lice and treatment1. In the past I have had repeated problems with my children coming home from primary school with repeated infections from head lice. Over one period of time my daughter was re- infected with adult head lice five times in 2 weeks. Although we treated her each time with products containing Malathion and meticulously combed and cleared her hair each time before sending her back to school. It was obvious re-infection was being introduced on an almost daily basis from another close source at school (presumably an untreated pupil). This caused tremendous disruption in our own household since every night my wife who is a nurse checked everyone’s hair (including myself and two other children) meticulously combing and treating taking up to 2-3 hours per night. Furthermore, my second youngest daughter who suffers from bronchiolitis was affected by the pungent smell produced by the product, which needs to be left on several hours overnight. I wrote to the headmaster of my daughters school to complain about the constant re- infestations. He wrote back and told me that the school could do nothing about it, since it was Local Education Authority (LEA) policy not to send out individual letters to children of parents informing them their children had head lice and needed treating. In the end I became so sick to the teeth of responsibly treating my own child, and sending her back to school to be re-infected. I informed the headmaster my daughter was to be seated elsewhere in the class, or she would be kept off school indefinitely. The headmaster duly did this and the repeated re-infections with head lice stopped as if turning off a tap! Head lice are a disruptive social problem and repeated chemical use is harmful to the child. However, what is also needed is intelligent and sensible policies implemented by the LEA and Local Health Authorities to identify infected children, inform parents of infected children directly and ensure that infected children are treated accordingly. 1. Nash B. Treating head lice BMJ 2003; 326: 1256-8. Competing interests: None declared |
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M D Dominic Bell, Consultant in Intensive Care/Anaesthesia The General Infirmary at Leeds LS1 3EX
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Editor, the clinical review on the management of head lice (1) has simply identified the problems rather than reached a conclusion on an effective strategy that the individual parent, school or broader community can adopt. The available options are clearly chemical, mechanical or ‘alternative’. The chemical agents may be ineffective due to resistance or inappropriate application and do not prevent re infestation if the source or secondary hosts have not been simultaneously treated. Identifying drug sensitivities, disseminating information and ensuring co- ordinated treatment is a major public health exercise, with less than 100% compliance rendering the exercise questionable, due to inevitable resistance problems and subsequently re-infestation. Such weaknesses must be considered in the light of the potential cumulative toxicity of these agents. The ‘alternative’ agents are, as Nash notes, not proven to be either effective or free from toxicity. Although unfashionably manual and time-consuming, the finetooth comb appears to be not only a treatment strategy free from side-effects, but the only mechanism for potential prevention or early identification of infestation and satisfactory endpoint for elimination. The distress related by the parent at the lack of effective advice from paediatrician, school and pharmacy indicates a need not only for a more open and rational approach to this problem, but more explicit and prescriptive directions. Schools should have a policy placing a duty on parents or carers to notify when their children are found to be infested, of informing all parents when a case is identified within the school, and of recommending appropriate management. Recommendations would include the importance of regular finetooth combing at least at weekly intervals for the non-symptomatic child and daily for at least three weeks if lice or nits are found until the head is clear, as defined by three successive clear comb cycles. Advice would also be included on using conditioner, particularly for curly or prone-to-tangle hair. The emphasis would therefore become prevention of infestation rather than random, uncoordinated, difficult, protracted or potentially toxic treatment once infestation was established and symptomatic. There is a strong case furthermore for reintroduction of a peripatetic nit nurse to target those schools with an infestation problem to encourage parental compliance and to directly manage those pupils whose parents of carers are unable to comply with best possible treatment, thereby avoiding exclusion which clearly does not address the primary infestation. The public can rightly expect a more co-ordinated approach to an inevitably recurrent and distressing problem, however ‘boring for doctors’. 1. Clinical Review. Treating head lice. BMJ 2003; 326: 1256-7 Competing interests: potential embarrassment of daughters who may clearly be identified as previous sufferers by virtue of this communication |
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Sylva Dolenska, Consultant William Harvey Hospital, Ashford, Kent TN24 0LZ
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The comparison of the various proprietary preparations is useful. Also, the article points out that the alternative therapies, which are relied on by many mothers, are untested. However,I strongly disagree with some of the statements in the "Misconceptions about head lice: what does the research really show?" section. Where is the research that shows that "there is no evidence to support the cleaning of sheets and clothing", or that "cutting hair....may increase the incidence of infestation"? It is not quoted and my experience directly contradicts these statements. Also, dismissing the head lice removed from the head as "effectively dead" is not quite true: they continue to live on for a number of hours and can infest several heads through sharing of hair brushes, hats etc. Over the last year I had 10 months' continuous infestation in my daughter, and I devoted considerable amount of time and energy to studying the infestation and how it is spread. I have written a full letter to Beth Nash, and also to the editor, or if interested in what I have to say, please mail me for a copy. Most mothers' attitude to head lice is "do not worry, it is not a problem". This sort of attitude, reinforced by unproven statements as those above, does not help to keep a check on the pest which may be harmless but is extremely unpleasant. Dr. Sylva Dolenska dolenska@yahoo.co.uk Competing interests: None declared |
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Sylva Dolenska, Consultant Anaesthetist William Harvey Hospital, Ashford, Kent, TN24 0LZ
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I fully agree with the author of this repsonse. Please see my response to the original article. I forgot to mention that recommending abandoning the "no nits" policies is rather counterproductive. Obviously children with eggs cannot be kept off school. However, children who are repeatedly scratching should have their head checked and sent home if live lice are found for treatment. If the child's home is unable to deal with a repeated source of primary infestation (such as in the case of Dr. Buckley's child's school firend), then the school must deal with it. Local education authority policies are incredibly lenient and the parents should exert pressure on the authority to amend them. In the end, however, isolating the child from the primary source does indeed do the trick. (Some other poor soul then has to suffer the pest. It would seem far more sensible for the scool nurse to talk to the mother of the poor primary source and perhaps supervise some initial treatment. Competing interests: None declared |
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Cindy L Jones, President Sagescript Consulting
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While it may be true that no double-blind, placebo-controlled clinical trials have been done on the efficacy of herbs in treating headlice, there is much evidence to support their use. A quick search of Medline brings up papers indicating that essential oils from a number of botanicals is deadly to headlice. These include lippia, aniseed, cinnamon leaf, red thyme and tea tree. There are probably many others as well since the phenols in these oils are widespread. Do to the irritant and neurotoxic properties of some of the drugs used to treat headlice I would encourage research to further determine the efficacy of some of these essential oils for the treatment of headlice. Competing interests: None declared |
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Surinder Bakhshi, Consultant in Communicable Disease Control (Retired) 48 Vernon Avenue, Handsworth Wood, Birmingham, B20 1DF
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The review and the accompanying commentaries of treating head lice is another rehash of failure of treatment and the unhappy triage of parents, doctors and teachers (1). In Birmingham, we accept that head lice are a hazard to nursery and primary school age children. Head lice are not problem at a latter age. Controlling rather than fruitless attempts at eradicating head lice makes sense during the period of acute infestation. Birmingham city council (2) in collaboration with NHS public and community health agencies has produced an attractive handbook for teachers which advocates combing of wet shampooed and conditioned hair with an ordinary plastic fine tooth comb, when head lice are suspected, and the process repeated as often as required. This action keeps the infestation at an acceptable and invisible level until such time as head lice disappear - and they certainly do - from the head in the natural course of their history. Making a naturally occurring, self-limiting infestation a matter for medical diagnosis (difficult) and treatment (impossible) makes little sense. It is unethical and even criminal to subject children to toxic drugs and parents to often prohibitive expense. No doubt to the delight of drug firms, pharmacists, head lice 'experts' and medical journalists but of little benefit to children and their parents. References 1. Beth Nash. Clinical review –Treating Head lice. BMJ 2003; 326:1256 –1257 2. Birmingham City Council, Birmingham Health Authority, Birmingham Specialist Community Health NHS Trust. Head lice guidance for Educational establishments. Birmingham City Council Education Service 0November 2000) Competing interests: None declared |
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John sharvill, gp ct14 7au deal kent
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At some stage in my career I was advised that for permethrin to work it needs to be left on overnight like malathion. (Certainly when treating sabies with the 5% cream it is left on for 8 hours so toxicity should not be a problem.)Then repeat after 1 week. Where is the evidence that pronolged physical contact is needed for transmission. If one collects a live louse and put it in a pot it stays happily alive for quite some time. Most parents especially of boys dont go for this theory of catching. Tea tree oil is at present going through a phase of cure all including for head lice. Is there any evidence? Competing interests: None declared |
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Anthony M R Downs, consultant dermatologist Taunton & Somerset NHS Trust, Somerset, TA1 5DA
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The snippets and editorial concerning head lice were read with much interest and no boredom given my research interest in ectoparasites and lack of desire to don the RCP presidential robes.1 Your readers may wish to note that lindane was withdrawn (voluntarily) many years ago and so it is not available in the UK. The genetic mechanism (termed super-kdr) for synthetic pyrethroids and natural pyrethrum resistance has been isolated to a recessive mutation in the pyrethroid/DDT binding site in samples of head lice from the USA, Europe and throughout England.2,3 Wherever we have taken head lice samples for resistance testing to malathion, permethrin and phenothrin, we have found very few susceptible headlice.4 Carbaryl, however, shows no significant clinical lack of efficacy.4 It is available on prescription only and should be used where combing, pyrethroids and malathion have all failed to work. Clinical resistance to malathion in the UK is patchy. Firstly, biochemical assays have revealed several different resistance mechanisms of varied effectiveness from different locations in England;4 and secondly, some malathion products have monoterpenoides (e.g. alpha terpeneol) as an additional insecticide.5 We may wish to berate the suppliers of natural medicinal insecticides for their lack of safety data, yet we have completely ignored the fact that one such biologically active agent has slipped in (almost) unnoticed into more than one licensed head louse product. 1. Editor’s Choice & Extracts of Best Treatments: Treating Head Lice. BMJ 2003; 326:1256-58. 2. Lee SI, Yoon KS, Williamson MS et al. Molecular analysis of kdr-like resistance in permethrin resistant stains of head lice, Pediculus capitis. Pest Biochem & Physiol 2000; 66:130-43. 3. Downs AMR, Williamson MS, Stafford KA et al. A common mechanism of resistance to pyrethroids in head lice. Br J Dermatol 2002; 147(S62):49. 4. Downs AMR, Stafford KA, Hunt LP et al. Widespread insecticide resistance in head lice to the over-the-counter pediculocides in England, and the emergence of carbaryl resistance. Br J Dermatol; 2002; 146:88-93. 5. Downs AMR, Stafford KA, Coles GC. Monoterpenoides and tetralin as pediculocides. Acta Derm Venereol 1999; 79:1-2. Competing interests: None declared |
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David de Berker, Consultant Dermatologist Bristol Royal Infirmary, BS2 8HW
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Sir, Your clinical review of head lice was oddly off balance and idiosyncratic. It had the impression of being put together by cut and paste from poorly informed foreign websites by someone who did not know much about head lice. The usual controversies remain and are covered, but there are simply some big howlers. These are not backed up by references which are only available to those with on-line access and so the flavour comes across as a version of Woman's weekly journalise. For instance, who in the UK, much of Europe and California will be using Lindane on the scalp of children with head lice? It has been banned in many places for years and will not be found in the British National Formulary. Why is Carbaryl not mentioned - the only agent on prescription in the UK and retaining a good record of low biological resistance? Why is hair cutting dismissed as ineffective where the manifest logic is that if you have no hair shafts for a nit to adhere to, the louse can not reproduce? Conversely, long hair prevents access of all treatments to the scalp surface where the lice live. I have seen 8 year olds (nit free) use the web for writing projects and at that level it is a fair method. But the BMJ should be informing the web with well-researched reviews written by authors familiar with the topic. Competing interests: None declared |
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anita m houghton, doctor London
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I have recently discovered a very effective method of eliminating headlice that was not mentioned in your articles on the subject. I’m afraid the evidence comes from a trial of N= only 4, nevertheless I’m sure that many desperate people will be prepared to take the chance. Following a report from my daughter’s school that a member of her class had headlice, a thorough check revealed nothing. When I finally realised several weeks later, that lice were in fact present, a single wet comb venture yielded 80 – 100 lice at varying stages of development. Having tried wet-combing as a treatment on previous occasions, and found that this method is really only for mothers with absolutely nothing to do, and children with the docility of a soft toy, I went straight for the only treatment that has ever worked before – malathion. Alas it did not work, even after repeating. Remembering vaguely that a medical friend of mine had had a similar experience, and had eventually resorted to an electric comb, I rang her to get the low-down. I bought this magical instrument from a high street chemist's at a high, but well worth it cost of £25. (It’s worth noting that a bottle of malathion for a family of four costs £11.) After a week of daily combing, and a further week of combing on alternative days, the entire family was free of lice. The advantages of this method over wet-combing are: - It takes considerably less time to comb through the hair. - The hair does not need to be wet before, or to be rinsed afterwards. - It is therefore much more acceptable to both parent and child. - The high pitched whine of the comb stops when you encounter a louse, making it easier to use on oneself, and easier if one’s eyesight is not what it was. - It has worked for all four people I know who have used it. The possibility that there is an effective method that avoids both unpleasant chemicals and laborious combing methods must surely be investigated! Dr Anita Houghton
Competing interests: None declared |
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James McKenzie, Clinical Fellow Orthopaedics Bristol BS2 8BJ
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Though thoroughly anecdotal I have also had first hand experience of Neem oil as an effective de-louser. I do not know the best formula or Neem oil's toxicity but if drug resistance is a possiblilty then it may be worth trying. Competing interests: None declared |
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Irene M Peat, Consultant Oncologist Leicester Royal Infirmary LE1 5WW
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Dear Sir, I was suprised that your article 'Treating Head Lice' omitted mention of the 'bug-zapper' (devices available at good chemists), which kill lice by electrocution with a satisfying blipping sound. This proved 100% effective in two teenagers with waist length hair, used daily for three weeks. When I rang one manufacturer, I was told there was no clinical evidence base, but entymological data only. The clinical trial is just waiting to be done, and the manufacturers more than happy to supply the units. Yours faithfully,
Competing interests: None declared |
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Rosemary A Smart, NP GP SWPCT WR4 9RW
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I was interested to read in this article that it is still thought that the head louse can only be transmitted from head to head by direct contact. My experience as a mother is otherwise. 20 years ago, my small daughter was continuously infected by head lice despite rigorous treatment. In desperation , I removed one head louse from her scalp and put it in a scew topped jar at about 7 PM . The next morning I took it to my local microbiology department where it was examined. The first thing that was noted was that the louse was still alive and its identity was confirmed by microscopy. My deduction was that her school felt hat was the reason for reinfection and therefore I cooked it at an appropriate temperature in the oven. This action broke the cycle of reinfection. I should be interested therefore to hear of any recent research that has been done on the viability of the head louse away from the scalp. Competing interests: None declared |
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Sylva Dolenska, Consultant Anaesthetist William Harvey Hospital, Ashford, Kent TN24 0LZ
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It is interesting to note that of all the repsonses, this is the only one which advocates abandoning medical treatment in favour of mechianical approach. As a parent who suffered repeated infestations from her children, the last bout being 10 months, I disagree with the "no treatment" policy. In my children and me, the lice, even when kept at an "invisible and acceptable " level caused itching, and subsequent scratching produced ulcers on my daugters head. To label as "criminal" the use of treatment which is licensed is perhaps a little too strong, and I would say irresponsible. I too worried about the toxicity of the products that I used but in fact was rather reassured by the review, as regards malathion and pyrethrin products. Furthermore, as the researcher above points out, carbaryl was not included in the review, whereas lindane (the really toxic drug) was withdrawn some time ago. I would suggest that cautiious use of treatment where mechanical and "natural" treatments failed (which is in more than 50% cases) has its place. I too accept that healice are not going to be eradicated but that does not mean I will tolerate them on my or my children's heads. Competing interests: None declared |
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Waqas Anwar, Registrar, Dermatology Mater Misericordiae Hospital, Eccles Street, Dublin 7., Seamus P. Mac Suibhne
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Contrary to some correspondents above, electrical treatment for headlice is not entirely free of potential adverse effects. Electric current may destroy hair follicles (as can electrolysis) We would be grateful if some one could tell us the name of the manufacturer! Competing interests: None declared |
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dawa alejandro, chief clinical pediatrics 1425, children hosspital buenos aires
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I need to know if you use oil in treating lice thank you and do you know about tea tree oil and its toxicity? Competing interests: no competing interests |
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Martin S Schweiger, Consultant in Communicable Disease Control Health Protection Agency, 7a Woodhouse Cliff, Leeds, LS6 2HF
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Health Protection Agency Sycamore Lodge 7a Woodhouse Cliff Leeds LS6 2HF
The Editor British Medical Journal BMA House Tavistock Square London WC1H 9JR
Dear Editor Headlice and their management The attention headlice received in a series of short articles published in the British Medical Journal on 7th June 2003 is welcome. We agree with much of what was said, but regret that little attention was paid to the importance of managing contacts. We suggest that mechanical removal of headlice can be made more successful across a population than the BMJ articles suggested. Failure to identify, examine and when required treat both adult and child contacts results in re-infection, what ever treatment method is chosen. We know that headlice in Leeds have a high degree of resistance to the commonly available insecticides, because we maintain a resistance monitoring programme. The resistance monitoring system was set up in collaboration with Ian Burgess, one of the authors of the BMJ articles. Sample headlice collected during the first quarter of 2003 died when exposed to carbaryl, but remained viable for a prolonged period when exposed to malathion and permethrin. These findings reflect clinical observation of resistance. It is probably that the more insecticides we use the worse the resistance problem becomes. We may well be exposing children to potentially toxic compounds for no therapeutic benefit. Our understanding is that Lindane is no longer available in the UK because of its toxicity. In Leeds a headlice working party has developed and maintains a policy of encouraging contact tracing and combing as the first option in managing headlice, (http://www.leeds.nhs.uk/dynamic/docman/docman.php?list=headlice) . There has been regular investment in staff training, working with nurseries and schools public education with leaflets, posters and videos, a referral clinic for problematic cases together with a good and accessible supply of appropriate combs. The financial cost of this approach has been more that met by the reduction in the use of insecticides. We cannot claim that Leeds is a lice free zone, but the situation appears to be more under control than when the “try combing first” policy was introduced in 1996. Yours sincerely
Katrina Kay, Specialist Nurse Martin Schweiger, CCDC Competing interests: Both of us are employed in work that involves managing headlice. We have taken part in trials of headlice treatments but have no pecuniary interest in the results and received no payments or inducemnents for being involved. |
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Mair E M Thomas, retired epidemiologist n.a., Anna Eleri Livingstone
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The uncertainties in management revealed by the review of head lice treatment made us feel we should contribute anecdotal evidence: MT: My grandmother, minister's wife and former schoolmistress in west Wales, born in 1853, had a keen eye for infestations. She got rid of head lice from her children and family by the following method. I remember her treating me regularly in the nineteen twenties. Step 1: she placed a two foot square of well-washed old white Welsh blanket on the table. Step 2: she employed a metal small toothcomb, to display the lively mature lice and their population density on the blanket. Step 3: a small pottery jug was filled with domestic paraffin (used for lamps) and applied to hair and scalp of the infested person. Step 4: a round waterproof elasticated 'bathing cap' was put over all the hair, a small rubber sheet was placed on the pillow and the individual was told to go to sleep. Step 5: next morning the hair was washed with soap and water, toothcombed, toweled dry, and the child sent to school. This whole procedure was repeated for three successive nights. Precautionary toothcombing was continued daily for longer but we never found lice. My grandmother poured boiling water over all hair brushes and combs in a tin basin. Caps and berets were all thoroughly washed in hot water. Ordinary bedding wasn't changed. Meanwhile everyone in the household was subjected to exploratory toothcombing over a square of white blanket. Any with lice were treated. None of us enjoyed the strict regime though we were glad to be rid of the lice. MT and AL: A strong metal toothcomb was an essential part of Mary Morgan's armamentarium. We do not feel as confident in plastic successors which can distort. The rigor of repeated investigation and elimination of hatched lice with tooth comb of index case and contacts and repeat treatments was memorable and probably essential to efficacy. Did the paraffin worked by suffocation or poisoning of the lice? This could be further investigated in developing treatments for resistant infestations. Could a repeatedly and thoroughly applied non toxic paraffin product deprive hatching nits of oxygen? Incidentally, we have seen very active lice walking across clothing in public transport and seen them jumping above the head of a child heavily infested with resistant lice. We think infestation may occur by proximity rather exclusively by close contact. Dr Mair E M Thomas Retired epidemiologist Dr Anna Eleri Livingstone General practitioner 61 Chesterton Road Plaistow London E13 8BD 1 Nash B, Treating head lice Extracts from “BestTreatments” BMJ 2003;326:1256-8 Competing interests: None declared |
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Paulo Roberto de Madureira, Preventive and Social Medicine Professor Universidade Estadual de Campinas (UNICAMP), SP, Brasil.
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Dear Sir, Here in Brazil we have the same problem with head lice infestation that is described by the Commentary and the Editor's choice of BMJ. We don't have any pediculicides with Malathion or Carbaryl in our country but only Permethrim rinse cream or Deltamethrim shampoo, and a lot of strains of head lice resistant against both products. The review, the letters and the editorial were very interesting, but I think that there was not emphasis on the importance of the treatment against head lice, which must be collective with all infested children treated at the same time to avoid reinfestation and a second treatment 10 days later to kill the nymphs emerged from the nits that remained alive on the first treatment. Competing interests: None declared |
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Robert H Vander Stichele, MD Heymans Institute of Pharmacology, University Ghent, Belgium, Lapeere Hilde
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Sir, The BMJ of June 7th focused on head lice with a cover picture, an editorial, a clinical review and comments. [1-3] This clinical review is another addition to the long list of reviews on head lice treatment [4-10], while over the past decade very few new randomised clinical trials of topical treatment have been published. All these reviews have their own fragmented evaluation of a selection of the old and not always high quality knowledge base in this field. The latest BMJ review ignores the original literature and only builds upon Clinical Evidence. [8] The section on head lice in Clinical Evidence is mainly based on two systematic reviews, one by Vander Stichele et al. published in the BMJ in 1995 and on a Cochrane review by C. Dodd, published in 1991 and revised in 2001. The conclusions from these two reviews are conflicting but yet the section in Clinical Evidence is a combination of both. These two reviews were based on the same knowledge base but come to different, conflicting conclusions. The Cochrane Review on head lice treatment set out with an impressive list of objectives, identified 70 existing trials (not necessarily randomised clinical trials), accepted only 3 trials as valid, and recommended malathion, permethrin and pyrethrins for treatment. [9] The BMJ review identified 28 randomised clinical trials, 14 of which were considered valid, and 7 suitable for pooling of results. On that basis, the authors recommended permethrin, malathion and carbaryl for treatment (in specific doses, with specific vehicles, and specific application times). [10] A criticism on this review was published in the BMJ calling for more rigorous assessment of trial quality. [11] In the Cochrane review the evidence base was trimmed down to three studies. A placebo controlled trial of malathion, a lab test of malathion and a small trial of permethrin versus pyrethrins. [12] The main criterion that led the Cochrane reviewers to eliminate so many potentially valuable trials was that the method section should explicitly mention that the inclusion criterion was 'living lice, not just eggs' and not 'living lice and/or (viable) nits. Trials by reputed scientists with valuable information were eliminated only on this formalistic criterion. This harshness was in sharp contrast with the benevolence towards the only selected comparative trial. Furthermore, the review did not solve the problem of publication bias that was exposed by the BMJ review. Traces were discovered of 11 unpublished trials by Wellcome, where malathion was compared to permethrin. The results were kept from publication by the company, as malathion(the comparator) was found to be equally efficacious as permethrin. The Cochrane Review has led to erroneous conclusions and to flawed subsequent reviews. The clinical review in the June 7th issue of BMJ is just another example of the dangers of uncritical re-chewing of derivative literature. Based on too little evidence, it recommends treatments with a high failure rate (such as pyrethrins) and it condemns other treatments (like bug-busting). The clinical review is silent about carbaryl but still discusses lindane, notoriously ineffective and banned in many countries because of safety and environmental issues. It is a pity that the BMJ gave such a prominent place to a substandard review that is not going to help local communities to deal effectively with epidemic outbreaks of head lice. Robert H Vander Stichele, Heymans Institute of Pharmacology, University of Ghent Conflict of interest : None H. Lapeere MD, Department of Dermatology, University of Ghent. Supported by a BOF grant from the Ghent University, BOF2002/DRMAN/007 Conflict of interest : None References 1. Smith R. Editor’s choice. Head Lice: boring for doctors, important to patients. BMJ 2003;326. 2. Nash B. Treating head lice. BMJ 2003;326:1256-7. 3. Burgess I. Commentary: how to advise a patient when over the counter products have failed. BMJ 2003;326:1257. 4. Chosidow O. Scabies and pediculosis. Lancet 2000; 355:819-26. 5. Roberts RJ. Clinical Practice. Head lice. N Engl J Med 2002;346:1645-50. 6. Frankowski BL, Weiner LB. Clinical report. Head lice. Pediatrics 2002;110(3):638-43. 7. Eichenfield LF, Colon-Fontanez F. Treatment of head lice. Pediatr Inf Dis J 1998;17:419-20. 8. Burgess IF. Head Lice. Clin Evid 2002;7:1508-12. 9. Dodd CS. Interventions for treating head lice. The Cochrane Library 2002, issue 3. 10. Vander Stichele RH, Dezeure EM, Bogaert M. Systematic review of clinical efficacy of topical treatments for head lice. BMJ 1995;311:604-8. 11. Burgess IF. Authors differ on assessment of flaws in trials. BMJ 1995;311:1369. 12. Burgess IF, Brown CM, Burgess NA. Synergised pyrethrin mousse, a new approach to head lice eradication: efficacy in field an laboratory studies. Clin Ther 1994;16:57-64. Competing interests: None declared |
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Maddalena C Feliciello, parent Leeds
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To take up the proposition offered by Sylva Dolenska on the intervention of the school nurse, it might be of interest to her that in the early 80's there was a changeover in policy here in sunny 'ol West Yorks which meant that the routine rounds of the beloved "Nit-Nurse" no longer took place. Now this in conjunction with the perhaps locally held belief that lice were associated with poverty and lack of grooming led to an underground and often unrecognised explosion of the little dears in our schools and amongst families that could not conceive of such an infestation touching their family. The perceived social stigma encouraged lack of communication of individual cases by parents to the school or by the school to other parents. Lack of appropriate information or experience quite often led to a complete inability to detect them at the early stage. I feel a whole generation of children grew up with parents and if I might say so, GPs' unable to recognise a louse unless the little darlings were at the positively teeming stage hence more likely to be passed on. So Malathion, Permethrin etc were thrown at them with alarming frequency and no obvious benefit as re-infestation was almost a certainty, the source was unlikely to make itself known and the merry-go-round would begin again. There is good reason to suppose that this was in part within the family itself as often parents would not treat themselves for a variety of reasons but would quite happily hurtle to the nearest chemist and liberally dose the child in their organo-phosphate of choice. The welcome stance taken by Leeds in the past few years might prove effective in other areas if the "dirty" image were well and truly laid to rest by more active campaigning by schools and local health practices including education of parents and children by frank discussion in the school and home. Though as has been noted, it should be stressed that while Lice are not life threatening, the potential for scalp irritation and secondary infections could be highlighted lending added weight to the argument that they need to be dealt with. The thorough wet combing of every family members hair as a norm at EVERY bathing whether needed or not should be actively encouraged, breaking the lifecycle of the blessed things, no special shampoo or conditioner is needed, though the alleged anti-bacterial properties of some essential oils seem to help with minor scalp irritation. As a nation we spend millions on hair products but spend so little time on this basic preventative measure. Though I actively loathed my Nonna and her vicious metal comb as a child, the culture and tradition is one that I’m grateful for. As for my observation being well researched (?) I can only cite experience of my own four children and being all too often called in by neighbours, friends (and in some cases people I was barely acquainted with) on the verge of tears to come and inspect their childrens’ hair as they hadn’t a clue what to look for. There’s a lot to be said for communal grooming sessions, coming down from the trees is optional. Regards MCF Competing interests: None declared |
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Asbjørn Høegholm, Consultant Medical department, Næstved University Hospital, 4700 Næstved, Denmark, Alice Olsen
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Editor. The coverage in BMJ 7.june of head lice treatment (1) reinforces the generally accepted preference of the chemical agents – Malathion, Lindane, Permethrin and Pyrethrins. Combing, typically wetcombing, is ranked secondary and this is logical in view of the few data available from regular trials. However the finding of only 38% effectivenes of ‘bug busting’ (2) is a clear underestimation of what is achievable with combing. Fact is that combing as well as chemical treatment is extremely operator dependent. We have recently had the opportunity to test a newly developed method; ‘vacuum-combing’ in which the comb is mounted into a special vacuum cleaner mouthpiece and caught lice can be directly inspected in a filter. From the press we had recruited 23 lice infested persons (age 12.3 years (3-43), one boy, length of hair average 32.2 cm (3-60). Scheduled treatments were given 5 times with 3-4 days intervals so that the treatment was finished after 14 days. Twenty person were licefree after the planned course, while three needed prolonged treatment, one of them because she had not followed the treatment plan. We caught an average of 22.7 lice (1-150). So in this test 87% of the participants were lice free after a standard treatment, but all were cured after maximum 5 extra treatments. None of the participants reported lice during the following 8 weeks. At the moment we are performing study which compares ‘vacuum combing’ and ‘bug busting’. The preliminary results shows that the two methods seem equally effective and most likely the efficacy is in the same order as mentioned above. In these two studies we did ourselves perform the combing, we had obtained routine, we were wellinstructed, we had the time and we were of course motivated to follow the treatment plan. These are factors that are extremely important to be successful in the treatment of headlice. Based on our own experience we are confident that combing is an effective way to treat head lice. Further studies comparing chemical agents and different methods of combing are badly needed, but we are convinced that properly performed combing can easily compete with the chemical methods. (1) BMJ 2003;326:1256-8 (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., 2000, Lancet. 356(9229):540-4, 2000 Aug 12 Alice Olsen, MS, Biologist
Asbjørn Høegholm, MD, MDSci.
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Tracey Jones, retired pharmacokineticist, pharmaceutical R&D Self employed SA14 8BA
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There is no doubt in my mind that the chemical pesticides are proving increasingly ineffective locally (S.W. Wales). This is hardly surprising as many parents are unaware that they should not use these chemicals unless active infestation is found. Indeed, those dreaded school letters, informing parents of head lice in the class, may actually be perpetuating the problem. Why have there not been any new, more efficacious, less toxic topical treatments been developed over the last few decades? Market forces are clearly a huge driving force, plus the fact that, as your article points out, head lice are not life threatening. But, as a parent, with a background in pharmaceutical research, I became curious when my 3 year old contracted head lice and I discovered a apparently pesticide resistant head lice population. Your article alludes to the possible need for repeat treatments. My understanding is that no treatment is 100% ovicidal, so repeat treatments are imperative, yet sale of single treatments continue. You refer to little evidence for efficacy of herbal remedies. Indeed, although my background would tell me that double blind placebo controlled studies are necessary to prove both safety and efficacy of such treatments, my frustration led me to test out 'natural remedies' on my family (I already had an interest in essential oils). I was quite amazed by my findings. In short, after considerable reading, some hand-on experience and many second-hand reports I would contend that 1) coating lice in any viscous oil will block their spiracles, effectively suffocating them, 2)utilising essential oils at an appropriate dilution will disorientate most of the lice and even kill a good proportion, 3) treating with neem oil (or leaf extract) at an appropriate dilution will disrupt the breeding cycle and development process, hence ultimately prove fatal to the lice. Head lice are not of huge concern for pharmaceutical companies, but are terribly frustrating for a large number of parents, many of whom continue to waste their money on ineffective OTC treatments. When will it stop? Competing interests: None declared |
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Paula McDonald, GP returner Ellesmere Practice,262 Stockport Road, Chesdle heath, Stockport,SK3 ORQ
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Like many reviews of treating head lice, the review by Beth Nash discussed the potential toxicity of chemical treatments, but does not mention a more immediate risk: the fact that alcohol-based head lice lotions are flammable. A few years ago, North West media reported the case of two siblings who were badly burnt when the lotion which had just been applied to their hair was ignited by a nearby gas fire. The manufacturer's instructions clearly state that the lotion is flammable, but busy parents may not find the time to read the instructions, and in any case seven million adults in England have poor literacy skills. [1] All doctors, nurses and pharmacists prescribing or selling alcohol- based head lice lotions should make users aware of this potential risk. [1] Skills for life: the national strategy for improving adult literacy sklls. DfEE London 2000. Competing interests: None declared |
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Joanna Harris, Community Infection Control Nurse Essex Local Health Protection Unit, Collingwood Road, Witham, Essex. CM8 2TT., Dr Sally Millership
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Editor - We felt there were a number of fundamental omissions and errors in this article. This was an excerpt from an American resource ‘Best Treatment’. The ‘Treatments that are likely to work’ were listed as malathion, lindane, permethrin and pyrethrins. The author did not list carbaryl, which is a useful prescription-only medication frequently used in the United Kingdom, especially when resistance to the other pediculocides is suspected. Malathion is generally very effective if correctly applied, and although shampoo preparations requiring only a 5-minute contact time are available in the UK, we would generally recommend the use of lotion or liquid with a 12-hour contact time. Phenothrin (marketed in the UK as Full MarksÒ) and Permethrin (LyclearÒ) are both pyrethroids. Again a 12-hour contact formulation is preferable. In the UK a repellent spray known as RappellÒ is available, but its’ efficacy is uncertain (BNF). Lindane is not included in the British National Formulary When discussing the lack of evidence to support ‘bug busting’ as a control measure the article cites a study which compared the use of malathion to combing, stating that malathion was more effective. The sample size for each study group was very small and would have made interpretation of the findings difficult to validate. The reference for this study was not given. It is certainly true that many combs that are available will not be effective as the teeth are too short to penetrate the full thickness of the hair at each stroke. We would agree that further study is needed to fully evaluate the efficacy of the various headlouse combs available to the public at the current time. Many are little more than expensive gimmicks. The article states that headlice away from the head are non-viable. Our own experience is rather different from this and we believe the issue needs further research. We have circumstantial evidence indicating that headlice may, rarely, be transmitted via fomites such as hairdressing equipment. We have observed during detection combing that headlice at all stages of maturity, removed from a scalp during combing can orientate themselves and ascend towards the head. A headlouse that, having been forcibly removed from one head (eg during detection combing), is placed at waist level on another person will move towards the head and we have found it can re-establish its’ lifestyle. Chunge et al.1 showed that headlice removed from children’s heads survived at room temperature for an average of 21.3± SD 12.1 hours although the ability to re-establish the life cycle was not examined. Headlouse infestation causes a high degree of anxiety, humiliation and frustration to families across the UK. The parents’ commentary accompanying the article barely touched on the issues that impinge on the management of this ‘common harmless condition’. We would challenge the statement that it is a ‘harmless’ condition when it affects parents’ relationships with their children, their partners, and health and education professionals. Children who have ongoing headlouse infestation may have poor concentration at school if they are not sleeping at night due to scalp irritation or secondary bacterial infection. They will frequently be bullied or socially isolated at school when peers are aware of their heavy headlouse infestation. In rare cases, ongoing headlouse infestation may be an indicator of more fundamental parenting issues and may be a component of other clinical scenarios such as psychiatric disorder affecting the child’s carer. It is also important for the health professional to recognise that a few families will not consider headlouse infestation as abnormal. None of the papers mentioned the fundamental importance that effective contact tracing has on the management of headlouse infestation. The application of an insecticidal lotion will have no deterrent action, so the problem will recur unless the source of the infestation is identified and effectively treated. For this reason we always advise the full detection combing of all close contacts when a person is identified as having headlice. This can be very complex in some families, especially if there are communication problems between the main carers. Ideally any affected people must be treated using the same type of lotion within the same 24-hour period. Once a person has been identified as having headlice, carers should be aware that reinfestation may occur. For this reason, detection combing we believe should be built into the regular grooming routine. Ideally detection combing should be done 2-3 times a week. If a few mature headlice are found, the frequency of combing should increase to daily. If all mature headlice are removed, lotions are not necessary, but continued combing is – to ensure the removal of newly hatched lice before they reach maturity. Combing must be continued until no more lice are found. We have noted that the general public have attributed erroneous properties to the conditioners used to facilitate regular combing. Some parents allow the conditioner to dry on the hair believing it to have repellent properties. This should be discouraged, as dermatitis or trichological problems may ensue. The successful treatment of headlouse infestation relies on commitment. Whether infestation is treated by the use of lotions or by frequent combing, ongoing vigilance is necessary in order to facilitate the early detection and treatment of reinfestation when it occurs. 1. Chunge et al. A pilot study to investigate the transmission of headlice. Can J Public Health 1991;82:207-8) Competing interests: None declared |
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Pam A LaBrake, mother Schenectady 12309
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Your article stated it is not to be used in pregnancy or while breastfeeding, or only once while pregnant. The FDA has new guidelines, saying Lindane should be used with caution in anyone under 110 lbs. and only if other treatments have failed. Children are being neurologically damaged from Lindane and is also found to cause aplastic anemia and cancer causing. My son has been neurologically damaged from Lindane, and I'm hoping in the near future that it is banned in the United States as it is in many other countries. Competing interests: None declared |
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douglas n salmon, gp birmingham b20 3he
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more treatments as suggested by patients; 1.Oils eg olive or corn oil; method - saturate hair and wash out; theory - non toxic oils safe, but asphyxiates the lice. 2.Saunas; method - Scandinavian style sauna for 20 minutes or longer; theory - lice are heat sensitive and are killed by scalp temp of 40 celsius or more. 3.Granny holiday; method - send child to grandparents with nit comb for ten days; theory - Granny has time, authority and motivation for repeated intensive nit combing. "Kitchen sink science " demonstrates rapid cessation of all movement in freshly caught lice immersed in oil compared to water immersed lice, so the oil treatment seems likely to be effective, but messy. Two case reports of the effectiveness of Granny holiday. Competing interests: small child in house |
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