More common skin infections in children
BMJ 2005; 330 doi: https://doi.org/10.1136/bmj.330.7501.1194 (Published 19 May 2005) Cite this as: BMJ 2005;330:1194
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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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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.
Competing interests: No competing interests