Head lice: boring for doctors, important to patients

Doctors don't become famous through working on head lice. Presidents of royal colleges are never experts on head lice. Nobody dies of head lice. Nobody even gets very sick. Head lice are boring to doctors. But head lice matter a lot to patients and can cause great distress. “I felt lost and hysterical,” writes a mother who has head lice, along with her two daughters (p 1258). “My older daughter was humiliated by the way the school nurse treated her… My paediatrician (who I really like) had no suggestions.”

A cluster of short pieces beginning on p 1256 considers what we know and don't know about head lice. They come from Best Treatments, a website for patients and healthcare workers based on Clinical Evidence that the BMJ Publishing Group has developed together with United Healthcare. The material on head lice is available on bmj.com, but most of the site—which will cover some 60 conditions by the end of the year—is available only to members of United Healthcare plans in the United States. We hope to find ways to make it available in other countries, including Britain.

Most of the conditions covered by Best Treatments are the chronic conditions like heart failure and depression that are the major causes of mortality and morbidity. But we try to respond to signals from patients on conditions that matter greatly to them. Hence head lice.

One problem with head lice is that many people think their children have them when they don't. Reliably identifying live lice is not easy, and, writes Ian Burgess, “nobody can reliably identify viable eggs, even with the aid of a microscope, unless the young louse can be seen moving inside the shell.” This is one of the reasons why school “no-nits” policies (banning children with nits (hatched egg shells) until all nits are removed) don't make sense. Further, less than a fifth of school children with nits go on to develop infestation within 14 days, and infection is spread only by prolonged head to head contact.

Initial treatment often fails. “Bug busting” (wet combing with conditioner) works in only about a third of people and is often uncomfortable for children. Over the counter remedies fail because not enough of the product is used or because it isn't repeated after 7–10 days. Treatment also “fails” because patients weren't infected in the first place. An increasingly common reason for failure is insecticide resistance. If a patient has adequately applied over the counter products but still has lice, the most reliable prescription is malathion (despite resistance being reported in Britain and France). But it's smelly and hard to apply.

It's easy to see why doctors are irritated by head lice and patients very bothered by them. Next week's issue of the BMJ will be different from normal and will try to look forward to a world where doctors and patients work much more in partnership than they do now.