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CLINICAL REVIEW: Michael J Sladden and Graham A Johnston More common skin infections in children BMJ 2005; 330: 1194-1198 [Full text]

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Does shaving cure headlice?

James A Dickinson   (20 May 2005)

Shaving is safer for head lice than insecticides

Anthony Lwegaba   (22 May 2005)

Scabies

JK Anand   (23 May 2005)

Common skin infections in children - author's response

Michael J Sladden   (28 May 2005)

Practicalities of treatment

Anne Holmes   (31 May 2005)

Head lice: Accurate knowledge of the life-cycle is essential to achieve control

Joanna Ibarra, Frances Fry, Clarice Wickenden, Jane L. Smith   (16 June 2005)

Does shaving cure headlice? 20 May 2005
James A Dickinson, Prof of Family Medicine Dept of Family Medicine, UCMC North Hill, Calgary, AB T2N 1M7 Send response to journal: Re: Does shaving cure headlice?	The article about skin infections describes the uncertain state of treatments for headlice. Many parents are dubious about using insecticides on the heads of their children. In historical times, I understand that shaving was the recommended treatment, and led to the fashion of wearing wigs to cover the naked scalp. Would this be an effective non-chemical treatment that could be offered to such patients? Competing interests: None declared
Shaving is safer for head lice than insecticides 22 May 2005
Anthony Lwegaba, lecturer in Public Health, SCMR, University of West Indies, Cave Hill, Barbados Send response to journal: Re: Shaving is safer for head lice than insecticides	I would like to thank Slodden MJ and Johnson GA for their clinical reviews on common skin infections in children in BMJ 2004; 329: 95-99 and BMJ 2005; 330: 1994-1998. The life cycle of head lice (pediculosis capitis) was well described and is similar to pubic lice. I worked in chronic emergencies in Somalia in 1993 and Sudan 1996-97 among internally displaced populations and in the nomadic Karimajong of Uganda in 1998-99, whose poor hygiene would be good breeding ground for head lice. However, head lice was never a clinical problem, because those populations simple as they may be, know how to interrupt its life cycle very well and shave off the hair, the only place where the eggs (nits) are ancored and glued close to the skin. As it was rightly pointed out lice outside the hair is not transmissible and does not cause infestation. I recall that in one institution for the mentally handicapped children in Uganda in the 1970s, there was massive poisoning and some deaths because children licked their insecticide treated hair! In March 2005, I mentioned to surprised colleagues that hair shaving is a good riddance of both pubic and head lice, who disagreed and preferred the treatment with insecticide with all their attendant poisonous risk as outlined. Shaving off hair in many communities has become a fashion propagated by famous sports stars. It was and is common practice for schools, military, prisons to encourage short hair or shaving. In my consultations for postnatal, family planning and genitourinary patients; the majority especially females have cleanly shaven pubic hair. Shaving is therefore not distasteful. But none of the treatment and control advice on the major websites US Centre for Disease Control and Prevention, NIH and World Health Organisation mentions shaving. Is it because a doctor’s powerful role includes prescribing medicines, in this case poisonous insecticides? Given the obvious facts about the lifecycle do we need to do a randomized controlled study on shaving to recommend it? Is there an alternative place for eggs to anchor after hair has been shaved off? Yes, there are may be some people that may not wish to shave; but wishes could be out weighed by the burden of the infestation, such as pururitus. Competing interests: None declared
Scabies 23 May 2005
JK Anand, Retired public health physician N/A Send response to journal: Re: Scabies	I thank Drs Sladden and Johnston for a succint review (21 May, pp1194 -8). Could they please also tell us the number of cases each year seen by them in Leicester in the past few years, in the context of their catchment population? There are no national statistics, I presume. Also, perhaps many cases are treated by the general practitioners and do not get linked to the hospital data. Secondly, was there any good pharmacological reason why sulphur ointment (the only reliable treatment in my youth) was ditched? I know it causes sensitivity sometimes and also it is rather unpleasant. However, its "toxicity" surely is not in the same league as that of the newer drugs. Dr JK Anand Competing interests: None declared
Common skin infections in children - author's response 28 May 2005
Michael J Sladden, SpR Dermatology Leicester, LE15WW Send response to journal: Re: Common skin infections in children - author's response	Many thanks for the interest in our recent article. Shaving the head would be extremely effective at eliminating head lice. No hair, no home for the lice, therefore no lice. Shaving will be acceptable in some cultures, but not others. I am not usually successful at persuading patients to cut infested-hair, let alone shave it all off. Certainly in some communities, people shave their heads to raise money for charity or to copy fashionable sports stars. Thus, shaving is a badge of honour, as my friend and mentor (JAD) points out. Presumably, it was the reason for military crew cuts, and for nuns being shaved under their cowls in the old days (JAD). Personally, if I got head lice, I would shave my head and not use insecticides. I found one article on Medline which suggested that shaving is unsafe / inappropriate. However, this was not based on any clear evidence and I would give the article little credence. As far as scabies is concerned, we do not record the number of cases, and I expect there are no national figures. Most cases are treated appropriately, effectively and excellently by GPs, and we would only see a small percentage of cases. The issue about using sulphur ointment is very interesting. We have not treated scabies with sulphur ointment. I am not sure about its historical use or why it was ‘ditched’. There are some reports on Medline suggesting that it might be safe and effective. However, it is not recommended in any of the national guidelines located during our literature search. Mike Sladden Competing interests: None declared
Practicalities of treatment 31 May 2005
Anne Holmes, GP Tithebarn Medical Centre, Stockton on Tees, TS19 8RH Send response to journal: Re: Practicalities of treatment	Whilst I welcome articles about common conditions, I too wonder about the experience of the authors. The phrase 'under medical supervision' is used in the treatment of scabies and head lice. what does this mean in practical terms or is it a reflection of the pharmacists inability to sell the product in these circumstances? I cannot envisage any useful or practical form of direct supervision of treatment The use of wet combing is dismissed due to lack of evidence but as a parent whose children were reinfested frequently its use with conditioner was a pragmatic alternative to shaving the head or repeated doses of treatment. Finally, you suggest that parents should liaise with the school. As a GP and parent, I am aware that head lice infestation is an emotive topic and schools have little ability to do anything other than send a letter. You might become aware that the head teacher is tearing their own hair out. Competing interests: None declared
Head lice: Accurate knowledge of the life-cycle is essential to achieve control 16 June 2005
Joanna Ibarra, Programme Co-ordinator Community Hygiene Concern, Manor Gardens Centre, 6-9 Manor Gardens, London N7 6LA, Frances Fry, Clarice Wickenden, Jane L. Smith Send response to journal: Re: Head lice: Accurate knowledge of the life-cycle is essential to achieve control	We are concerned that, in common with numerous publications offering guidance on treatment, Sladden and Johnston, (1) give incorrect information on the duration of the egg stage of Pediculus capitis. Hatching may occur later than the seven days stated, to at least ten days post laying. This fact, which has important implications for treatment advice, was recorded by Buxton in 1947 in a masterly reference work on the lice which infest humans (2). We are not aware of any robust research which challenges this; indeed, our own investigations developing the Bug Busting wet combing method confirm that the incubation period often lasts ten days. It follows that two doses of a product that may not kill the egg, applied a week apart (i.e. on day 1 and 8) will not reliably eradicate an infestation because some lice may hatch after the second application. The information provided by Sladden and Johnston about mechanical measures is also confused and misleading. Meinking and colleagues (3) did not report on wet combing, which is intended to comb out hatched lice, but on the unreliability of combing to remove eggs as an adjunctive after using insecticide treatment to kill lice. Bug Busting wet combing is a precise method using specific combs supplied with full instructions in a Bug Buster Kit. This product is reusable for detection and eradication. It works with ordinary shampoo and conditioner. No insecticide, synthetic or natural is involved. Combing sessions should be administered on days 1,5, 9 and 13 to break the life-cycle on the basis of removing lice. At a fifth session, post day 13, no lice should be found, unless re-infestation has occurred during the Bug Busting period. Full-grown lice move between heads. The instructions teach users to distinguish this stage from the smaller nymphal stages. Although initially seeming to have less success than insecticide treatment, Bug Busting wet combing will retain or even increase its effectiveness as parents become more skilled in using the Bug Buster Kit (4). Louse resistance cannot occur and it is more economical than using two or more applications of formula per infestation. Only one Bug Buster Kit per family is required. Community Hygiene Concern is a registered charity. Our work investigating mechanical methods of head louse detection and elimination is grant funded by the UK Department of Health and Community Fund. We supply the Bug Buster Kit (which is available on NHS prescription) on a non-profit making basis. Joanna Ibarra, Programme Co-ordinator, Frances Fry, Development Worker, Clarice Wickenden, Project Co-ordinator, Jane Leseley Smith, Project Worker Community Hygiene Concern, Reg charity 801371 Manor Gardens Centre 6-9 Manor Gardens London N7 6LA www.chc.org bugbusters2k@yahoo.co.uk References 1 Sladden MJ, Johnston GA. More common skin infections in children. BMJ 2005;330:1194-8. 2 Buxton P A. The Louse. An account of the lice which infest man, their medical importance and control. London: Edward Arnold & Co, 1947. 3 Meinking TL, Clineschmidt CM, Chen C, Kolber MA, Tipping RW, Furtek CI, et al. An observer-blinded study of 1% permethrin creme rinse with and without adjunctive combing in patients with head lice. J Pediatr. 2002; 141:665-70. 4 Crossan L. Experience based treatment of head lice. BMJ 2002;324:1220. Competing interests: Community Hygiene Concern is part-funded by sales of the Bug Buster Kit on a non-profit making basis.