Treatment for head lice
BMJ 1999; 318 doi: https://doi.org/10.1136/bmj.318.7180.385 (Published 06 February 1999) Cite this as: BMJ 1999;318:385
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Head Lice Treatment Needs Primary Care Research
EDITOR- We would like to add to the discussion generated by the
interesting article by Dawes et al describing their search for the
evidence base on effective head lice treatment.(1)
As has already been highlighted in the e-correspondence since the
original article was published, Dawes et al concentrated on the chemical
methods of eradication, but did not mention the DOH endorsed method of Bug
Busting.(2) We believe that including non-chemical methods would have
provided a more comprehensive answer to the question posed: "in children
attending primary care with nits what is the most effective treatment for
eradication?
Well conducted studies on mechanical removal of head lice are
lacking. Advice to primary care is conflicting. The Stafford report for
Consultants in Communicable Disease Control says "do not recommend or
support any mass action, including wet combing campaigns,” but does advise
that mechanical removal might be tried for individual cases and their
families.(3)
Although at present, there is insufficiently robust evidence to
support the wet combing method as a mass treatment option, the lack of
such evidence should not cause us to discount the non-chemical methods.
Rather, this interesting alternative management of head lice needs to be
highlighted and the evidence gap addressed. We are pleased to report that
Suffolk Health Authority is developing a project to address this issue.
One author(4)has undertaken a pilot study to investigate using a
systematic wet combing campaign in an attempt to reduce the head lice in a
whole school population. The project used Community Hygiene Concern
educational material(2)
In this study, point prevalence before and after a two week 'Bug
Busting' intervention, demonstrated a reduction of head lice by
approximately a third(29%). The other important health gain was to raise
awareness of the problem in a de--stigmatising way, empowering children
and their families to cope with, and effectively treat head lice
themselves without pesticides.
The next stage is to undertake a randomised field trial comparing six
head lice treatment options based on the Isle of Wight Protocol(5), to
include chemical, non-chemical and tea tree treatment methods, to be
carried out in the primary care setting, by members of the team.
Michael McCullagh
General Practitioner
Kathy Cubitt
Practice Nurse
Orchard Medical Practice
Orchard St Health Centre
Ipswich. IP4 2PU.
Tel: 01473 - 213261
Fax: 01473 - 287741
E-mail: MMcCullagh@msn. Com
References
1.Dawes N, Hicks NP, Fleminger M, Goldman D, Hamling J, Hicks LJ.
Evidence based case report: Treatment for head lice. BMJ 1999; 318: 385-
6.
2.Bug Busting; the Teaching Pack, method and Kit were developed by
Community Hygiene Concern (1996) CHC, 160, Inderwick Rd, London N8 9JT.
National Helpline Tel: 0181-341-7167
3.Stafford Group Report. Jan. 10 (1999). Head lice: a report for
Consultants in Communicable Disease Control (CCDCs), http://www.fam-
english.demon.co.uk/phmeghl.htm
4. Cubitt, K. (1998) Control by Combing: testing a strategy for head
lice control. Paper in preparation.
5.Bingham, P. et al (1998) A pilot RCT of the effectiveness of the
bug busting against a single application insecticide product of head louse
treatment. Paper in preparation.
Competing interests: No competing interests
I was very interested to read the paper by Dawes et al on Treatment
for head lice (BMJ 1999;318:385-386.
Head Lice are a very time-consuming condition for all those
professionals involved in child care, and are the one of the most frequent
conditions for which advice is sought from Consultants in Communicable
Disease Control by other professionals and members of the public. Over
£10,000,000 is spent in the U.K. on treatment each year. It is therefore
heartening to see an article in the BMJ on this topic. There are however
four points I would like to make.
1. One of the major problems in this field is that there has been
very little quality research on the epidemiology and treatment of head
lice. This has allowed treatment strategies both chemical and mechanical
removal, to be used with little evidence of their efficacy as the article
showed. This deficit needs to be remedied as it adds to the confusion. The
"Stafford Group" report of which I was one of the authors is an attempt at
a consistent approach to management.
2. Resistance is a problem with all insecticides and does vary
around the country in both extent and which insecticide is most affected.
It is therefore useful to test local lice for their resistance pattern as
this will aid treatment by allow8ing the use of the most effective
preperation.
3. Nits are the spent egg cases of lice. It is therefore very
important to make sure that there is a current infection of live lice.
thsi is best performed by detection combing. Treatment of nits alone will
only result in increased risk of insecticide toxicity.
Competing interests: No competing interests
Editor,
I read with interest the recent case report1 in the BMJ, recounting the
experiences of GP's at an Oxford practice. They appear to have conducted a
thorough search to obtain evidence to determine the most effective
treatment.
The advice obtained from the Medical Entomology Centre has been mis-
interpreted in a number of instances. A certain level of resistance has
developed to pyrethroid pediculicides in the UK which occurs over a
geographically widespread area. Within each district resistance arises in
localised pockets, but permethrin can still be used effectively in some
locations. Resistance to pyrethroid pediculicides in the UK is more
widely distributed than to malathion and carbaryl.
The spread of head lice by symptomless carriers is controversial as
there is currently no evidence to support this. Many people infected with
head lice show no symptoms and therefore the existence of such carriers
within the suggested age groups may be open to discussion. Direct head to
head contact is the only way in which head lice are transmitted regardless
of whether the infected individual exhibits any symptoms. Secondary
infections associated with head lice are dermatitis and impetigo of the
scalp.
A course of treatment for the eradication of head lice should consist
of two applications of the same insecticide spaced seven days apart. If
the first product fails to control the infection by day 14 then treatment
should be continued using a different pediculicide from a another
insecticidal group. This regime is recommended to ensure eradication of
any lice hatched from eggs surviving the first treatment. Up until day
seven any lice that have hatched will not have reached a stage of
development that will enable the infection to be transferred to another
host.
Head lice should never be referred to as "nits", as nits are hatched
empty egg cases indicative of a past or ongoing infection. Viable
embryonated eggs are called eggs or ova.
The systematic review by Vander Stichele2, recommending permethrin
as the treatment of choice has been criticised in a number of
publications, 3 4 and even Vander Stichele5 agreed that stricter criteria
would have been appropriate. The subsequent Cochrane Systematic Review4
applied such criteria resulting in no overall recommendations being made
regarding the treatment of choice.
Both reviews had to rely on trials conducted some years ago. As
resistance has developed to some pediculicides recommendations made by
such papers should be viewed with caution.
CIARA S DODD
Scientific Officer
Medical Entomology Centre
Cambridge Road, Fulbourn
Cambridge CB1 5EL.
References
1. Dawes M, Hicks NR, Fleminger M, Goldman D, Hamling J, Hicks LJ.
Treatment for head lice. BMJ 1999;318:385-386.
2. Vander Stichele RH, Dezeure EM, Bogaert MG. Systematic review of
clinical efficacy of topical treatments for head lice. BMJ 1995;311:604-
608.
3. Burgess IF. Clinical efficacy of treatment for head lice: Authors
differ on assessment of flaws in trials. BMJ 1995;311:1369.
4. Dodd CS. Interventions for the treatment of head lice. Cochrane
Database of Systematic Reviews. The Cochrane Library. Cochrane
Collaboration 1999, Issue 2. Oxford: Update Software. (In press)
5. Vander Stichele RH. Clinical efficacy of treatment for head lice:
Authors' reply. BMJ 1995;311:1369.
Competing interests: No competing interests
The readers of the BMJ were allowed to peak over the shoulders of
Dawes et al. while they were searching for evidence on the treatment of
head lice1.
Dawes et al. stumbled on our 1995 systematic review of the evidence for
topical treatments for head lice2, through a Medline search (with the
wrong keywords), through the Bandolier service on the Internet and through
the Cochrane Library. In addition, Dawes et al. got conflicting advice
from the Oxford Textbook of Medicine, from the British National Formulary,
from the NHS Information Service, and the Medical Entomology Centre in
Cambridge.
We are happy that our review withstood the systematic critical appraisal,
but we are not happy with the lack of agreement between information
sources and with the persistent poorness of the available evi dence. Four
years after our review, not one new randomized clinical trial on topical
treatment has been published, and 11 unpublished comparative trials of
permethrine versus malathion remain unpublished, despite an extended
amnesty for unpublished trials3.
Wet combing4 has been proposed as an alternative treatment, but the
efficacy of this approach has not yet been formally tested. There were
unsubstantiated media crises on the safety of carbaryl and malathion, and
anecdotical reports on pesticide resistance, but without systematic
monitoring. Meanwhile, companies continue to sell ineffective, underdosed
or dangerous products, with information sheets that push for prophylactic
and repeated use, without any evidence.
A new Cochrane Collaboration review on this subject has been announced.5
We hope it will bring new insights, although little new original research
is available. It is plain to see for every practitioner that in this
field we engage in lousy practice and that we lack evidence. We can only
hope that adequate research funding will be provided to select a few
efficient topical treatments and some sensible infestation control
measures for the benign but resource consuming problem of head lice.
1. Dawes M, Hicks NR, Fleminger M. Evidence based case
report:treatment for head lice. BMJ 1999;318:385-386.
2. Vander Stichele RH, Dezeure EM, Bogaert MG. Systematic review of
topical treatments for head lice. BMJ 1995;311:605-8
3. Roberts I. An amnesty for unpublished trials. BMJ 1998;317:763-4.
4. Ibarra J, Hill N. Towards the establishment of bug busting in the
public health calender. London: Report to the Kings' Fund, 1994.
5. Dodd, C. Head Lice treatment [Protocol] Cochrane Library 4, Oxford:
Update Software, 1998.
Vander Stichele RH, Bogaert MG
Heymans Institute of Pharmacology, University of Gent, Depintelaan, 185, B
-9000 Gent, Belgium.
Competing interests: No competing interests
Dawes et al are to be congratulated on their assiduous attempts to
locate the evidence on their topic of head lice treatment. I am sure that
many a general practitioner, upon reading this article, will feel that the
steps taken go beyond those practicable for the variety of cases that they
are likely to encounter in their day to day practice. This is where the
importance of critical appraisal digests (CAD) comes to the fore.
Coincidentally, as a senior health information professional, I have
just completed a quest for evidence for a CAD on head lice to appear in
the first issue of the Journal of Clinical Excellence (to be published in
Spring 1999 by Radcliffe Medical Press). The conclusions of my search
which took about eight hours and which followed an evidence seeking
protocol (http://www.shef.ac.uk/~scharr/ir/proto.html) are very similar to
those of Dawes and colleagues. However, several additional pieces of
evidence may serve to augment, if not to confound, the picture.
First, in 1995, following reports of possible carcinogenicity from
laboratory studies the government restricted the availability of carbaryl
(1). Soon after this a health information leaflet, issued by the
Department of Health recommended the "bugbusting" regime which several
correspondents have subsequently mentioned (2). However there appears to
be no published evidence to support the government's policy in this
regard. Nevertheless, this continues to be the recommended advice for
enquirers to NHS health information services primarily because it is both
cheap and has no unwanted side effects. Somewhat unfortunately,
particularly in the context of availability of evidence, Dawes et al do
not appear to have had access to information on either the existence of a
Drug and Therapeutics Bulletin on this topic (3) nor, even more
significantly, to a protocol on the Cochrane Library signalling a
forthcoming review (4). Ironically this latter item appears to be being
conducted by the Medical Entomology Unit to which they refer. Other items
to populate the debate include a full text information leaflet from the
Health Education Board for Scotland (5), an unreferenced report from The
Stafford Group of Consultants in Communicable Disease Control (6) and
Guidelines from Canadian family practice (7). In this connection the
Internet is revealed as a valuable source of such primary materials to
support evidence based practice.
What may we conclude? Certainly although there are many benefits for
general practitioners from the process of evidence seeking it is clearly
not desirable to produce local outcomes that will inevitably be duplicated
elsewhere. Perhaps the answer lies in having information professionals,
trained in the production of critical appraisal digests, delivering
updateable summaries via the proposed National Electronic Library for
Health. In Trent Region the Programme for Encouraging Clinically
Effective Practice in Trent (PRECEPT) has been the first in this country
to extend critical appraisal skills training for librarians specifically
to include the production of such digests. Perhaps the end is in sight
for the perpetuation of "lice, damned lice and statistics"!
1. Scowen P. Government restricts the use of carbaryl for head lice.
Professional Care of Mother and Child 1995; 5 (6):163, 165.
2. Department of Health. The Prevention and Treatment of Head Lice. 1996.
[Health education leaflet available from DoH, PO Box 410, Wetherby LS23
7LN. (Fax: 01937 845381)]
3. Treating head louse infections. Drug Ther Bull 1998; 36 (6): 45-46.
4. Dodd, C. Head Lice treatment [Protocol] Cochrane Library 4, Oxford:
Update Software, 1998.
5. Health Education Board for Scotland. Head lice - getting rid of a
nuisance: a guide for parents. http://www.hebs.scot.nhs.uk
6. The Stafford Group. Head Lice: a report for Consultants in Communicable
Disease Control (CCDCs). http://www.fam-english.demon.co.uk/phmeghl.htm
7. MacDonald N. The facts of lice. CMAJ 1997; 157: 747
Competing interests: No competing interests
Editor,
We were impressed by the way in which Dawes et al. have sifted
through the evidence to identify the most appropriate treatment for head
lice1. Sadly the evidence base may not always identify ‘best practice'.
Randomised controlled trials rarely compare the patient's own labours with
the use of drugs. For head lice, personal experience suggests that the
repeated, painstaking combing out of lice and their eggs is an effective
treatment. It costs only the price of a decent comb and the parents' time.
The lice do not develop resistance even if the child may!
Yours faithfully,
Amanda Rowlatt
Economist, London SW13 0NN
Tim Heymann
Consultant Physician, Kingston Hospital, Surrey KT2 7QB
1 Dawes M, Hicks NR, Fleminger M, Goldman D, Hamling J, Hicks LJ.
Treatment for head lice. BMJ (1999) 318 385 - 386
Competing interests: No competing interests
Dawes et al should be congratulated for underlining the lack of an
evidence base on the treatment of head lice with insecticide, a condition
that is common and causes considerable parental anxiety, The authors
stress the importance of using lotion correctly and discuss resistance but
do not mention reinfestation.
Reinfestation can lead to repeated applications of insecticide and
concerns about side effects. Reinfestation can occur if family members
and close contacts have not been effectively screened before treatment
starts or if more distant contacts with head lice are not being treated.
Unfortunately an evidence base for an effective screening technique is
also lacking.
Bug Busting, a standardised method of wet combing, can be used for
screening for head lice and for treatment. Unfortunately although the
charity that promotes Bug Busting instances reports supporting the value
of the method when properly applied, no randomised trial has been
conducted. One of us has recently undertaken a pilot for a trial but
obtaining funding for a full trial has been problematic.In our
experience, insecticide and Bug Busting can both work and in the absence
of evidence we would suggest that parents should be offered a choice.
Parents should be made aware that if insecticide is chosen, this does not
negate the need to screen close contacts with an effective combing
technique or the need to check for clearance following treatment.
A firmer evidence base for the treatment of head lice is badly needed
and in view of the parental concern that it generates, this topic should
have greater priority for funding.
Yours sincerely
DR PAUL BINGHAM
Consultant in Public Health Medicine
Isle of Wight Health Authority
Whitecroft
Sandy Lane
Newport
Isle of Wight PO30 3ED
DR PETER OLD
Director of Strategy & Public Health
1 Dawes M, Hicks N R, Fleminger M, Goldman D, Hamling J, Hicks LJ.
Treatment for head lice. BMJ 1999; 318 : 385-6
2 Figueroa J, Hall S, Ibarra J, Primary Health Care Guide to Common
UK Parasitic Diseases. London: Community Hygiene Concern, 1998: 1-16
3 Bingham P et al. A pilot RCT of the effectiveness of the bug
busting method against as single application insecticide product for head
louse treatment. Paper in preparation.
Competing interests: No competing interests
EDITOR -
Dawes et al's article about treatment for headlice (1) was
interesting as an exercise in evidence searching but it failed to ask the
right question in the first place. Pragmatically, a more useful research
question would have been ' In children atending primary care with
headlice,
what is the most effective intervention that will keep the problem under
control?'
Headlice are most prevalent in primary school children and the
average number of adult lice per child is only 8-10. (2)
This does not constitute a major health hazardand there is little evidence
of an association with impetigo as quoted in the article. If used
correctly, insecticide lotions are effective in killing off headlice but
what is the point of using repeated applications of chemicals on school
children? Their heads may be cleared of headlice by insecticide lotion one
day, only for them to be reinfected on their return to school the
following day. Extensive and expensive campaigns in the past where entire
communities have been treated with insecticide lotion have shown that
headlice reinfection from outside sources will occur very quickly.
The technique of 'wet combing' (combing through wet, well conditioned
hair with a fine-toothed nit comb), if done correctly and repeated every
three days, will control the problem by physical removal of the lice.(3) A
plastic nit comb, a short teaching session with the Community Hygiene
Concern training video (4) and support from the health professionals will
enable parents to take control of the problem of headlice in their
children. In the long term, surely this is more effective and
environmentally friendly
than repeat prescibing of insecticide lotion?
Gill Lewendon
Senior Clinical Medical Officer
South and West Devon Health Authority
Dartington TQ9 6JE
1. Dawes M, Hicks NR, Fleminger M. Evidence based case
report:Treatment for head lice.BMJ 1999; 318: 385-386
2. Mellanby K. Natural population of the head louse on infected children
in England. Parasitology 1942: 34: 180-4
3.Elizabeth S. Can purchasers adopt the innovations offered by the
voluntary sector? Kings fund news 1994;17:8
4.Community Hygiene Concern, 160 Inderwick Rd, London N8 9JT
Competing interests: No competing interests
Use of tea tree oil in the treatment of head lice.
Editor - The management of Pediculus humanus capitis, or head lice,
is becoming increasingly contentious due to the reluctance of many people
to use pharmaceutical insecticide preparations. The emergence of
resistance to many over-the-counter and prescription products further
confounds the issue.1, 2 Anecdotal and in vitro evidence suggest that the
essential oil of Melaleuca alternifolia (tea tree oil) and some of its
components may be useful in the treatment of head lice.3-5
Tea tree oil
is an increasingly popular home remedy with a broad spectrum of
antimicrobial activity.6 Preliminary data from usage trials in which
thirty-two schoolchildren in two classes of a remote, rural school
community were provided with tea tree oil shampoo (1% v/v) and conditioner
(2% v/v) for twice weekly use at home (Sunday and Wednesday evenings) are
reported here. Each child's hair was also sprayed with 3% tea tree oil
solution at the beginning of every school day. Not all students in the
classes or school were treated. Informed consent was obtained from
guardians for all participating students. Students were examined twice
weekly (Monday and Thursday mornings) for 4 weeks by a school health nurse
for infestation, defined as the presence of eggs or lice. Students who
missed more than one of the eight evaluations were omitted from data
analysis (n=6). Infestation was recorded after each examination. The
cumulative number of observations of infestation was determined for each
week.
Overall, levels of infestation declined throughout the usage time.
Of the 26 evaluable students, the cumulative scores of infestation for
week one through four were 18, 13, 11 and 6, respectively. The overall
level of infestation fell amongst students after application of the tea
tree oil products suggesting that their use warrants further
investigation.
References
1 Brainerd E. From eradication to resistance: Five continuing
concerns about pediculosis. J Sch Health 1998;68:146-50.
2 Dawes M, Hicks NR, Fleminger M, Goldman D, Hamling J, Hicks LJ.
Evidence based case report. Treatment for head lice. BMJ 1999;318:385-6.
3 Veal L. The potential effectiveness of essential oils as a
treatment for headlice, Pediculus humanus capitis. Comp Ther Nurs Mid
1996;2:97-101.
4 Weston SE, Burgess I, Williamson EM. Evaluation of essential oils
and some of their component terpenoids as pediculocides for the treatment
of human lice. J Pharm Pharmacol 1997;49(suppl 4):120.
5 Downs AMR, Stafford KA, Coles GC. Monoterpenoids and tetralin as
pediculocides. Acta Derm Venereol 1999;80:69-70
6 Carson CF, Riley TV. Antimicrobial activity of the essential oil
of Melaleuca alternifolia. Lett Appl Microbiol 1993;16:49-55.
D. Chapman
Ord River Tea Tree Oil Pty. Ltd.
Cedar Suite,
Winchester Road,
Alresford,
Hampshire SO24 9EZ
Competing interests: No competing interests