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Eradicating Lice: Myths and Facts

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getting rid of lice..... kutu


Pediculosis humanus capitis, most commonly referred to as head lice, affects approximately 6 million to 12 million children aged 3 to 12 annually.1 Reporting of head lice outbreaks is thought to be underestimated, however, due to the fact that specific reporting criteria are not required by state or government agencies such as the Centers for Disease Control and Preventon. Lice infestation is a common cause of emotional, social, physical, and financial burden for children and their families.2 Emotional and social consequences can arise due to missed school days, anxiety, or embarrassment. Physical complications of a lice infestation include excessive itching, which can lead to scalp infections. Treating a lice infestation also can have a financial impact, stemming from the need for multiple treatments due to resistance.

Description of the Organism

Pediculosis humanus capitis is an ectoparasite that requires human blood for survival.3 After mating, an adult female louse will lay approximately 6 to 10 eggs (referred to as nits) daily, and the female will die after 1 month of laying eggs. The warmth of the scalp is an ideal setting for the nits to develop and hatch. Nits are laid by the female on the hair shaft close to the scalp, where they remain attached by a water-insoluble, glue-like substance called chitin. After 6 to 10 days, the nits will hatch and become adults and continue the cycle. Once the nits become adults, they only can survive without a feeding for a maximum of 1 to 2 days.

An adult louse is 2 to 3 mm long and differs in color, depending on current feeding status. Immediately after feedings, lice appear to be a darker brown to red color; other times they are white gray. During feedings, which occur every few hours, the lice inject saliva under the skin of the scalp in exchange for blood. The saliva is responsible for the pruritus that occurs as the presenting symptom prior to diagnosis. This sensitivity reaction, which causes the itching, may take 4 to 6 weeks to develop, signifying that the patient may be infested for 1 to 2 months prior to diagnosis.

Diagnosis

Case

1. A teacher notices a few students in the classroom itching their scalps frequently during the day. After discussing it with another teacher, they decide to report it to the nurse's office. What steps should be taken at this point?

  1. Send a note home to the parents asking them to check for head lice
  2. The teachers should inspect the children in their classrooms
  3. The school nurse should inspect the individual children who show signs of lice and then evaluate the rest of the class if necessary
  4. Teach the children it is not polite to scratch their heads in public

Answer below

Diagnosis of head lice typically occurs in the school setting.4 Ideally, school nurses should be the personnel screening children for lice, but in many cases, health care providers are not the individuals conducting the screenings, eg, parents or teachers may be conducting the initial screenings. Diagnosing lice includes visualization of nits or adult lice either by the naked eye, hand lens, or light microscope (black light). Other items, such as desquamated epithelial cells, dandruff, sand, knotted hair, or dried hairspray, can be misdiagnosed as lice. Distinguishing lice or nits from these items can be done by checking the adherence to the hair shaft.5

Nits are not easily removed, due to the chitin, whereas the other items are easily removed. Misdiagnosis can occur because of the above items seen on the hair or scalp. Nits that do not contain live embryos or nonviable/dead lice also are not diagnostic for an infestation. Viable lice and nits will be no farther than 1 cm away from the scalp.6 It is important to note that combs and other diagnostic materials that come into contact with the child's scalp or hair should be cleaned between inspections to assure lice are not spread from one child to the next.

Transmission and Prevention

Transmission is predominantly via direct head-to-head contact.7 Transmission through sharing hats also can occur, but this route is less common. Typically, transmission will occur when children are at rest and not vigorous play. This is due to the hair being stationary and parallel.7 Prevention is important to discuss with children, especially if a recent outbreak has occurred in a school or day care setting. Steps taken to prevent lice transmission include teaching children to not share combs, hats, or hair accessories.1 Parents and school personnel should be educated on the signs and symptoms of head lice to ensure prompt treatment of children.

No-Nit Policies

The National Pediculosis Association (NPA) recommends a "no-nit" policy for school administrators to follow.8 The policy supports the recommendation that children not be allowed to return to school until no evidence of nits appears in the child's hair. This policy has met resistance from some parents and administrators, who argue that children are kept out of school for extended periods unnecessarily. The rationale of the no-nit policy is to minimize head lice infestations as a public health problem and to keep children in school, lice and nit free.

Case (cont.)

2. The entire class was screened, and 5 of 40 students were diagnosed with head lice. The children's parents were called and instructed to treat their children that evening, and they could return to classes the next day. Which of the following is an appropriate counseling point to discuss with the parents?

  1. The children should be segregated from any other children in the house until no nits/lice are seen on inspection
  2. The children should be instructed to wash more thoroughly when bathing at night to prevent future outbreaks
  3. The pets in the house should be screened for lice as well
  4. Other family members do not need to be treated unless they are also diagnosed with head lice

Answer below

By implementing this policy, the school administrators put more responsibility on the parents to ensure head lice are taken care of immediately. Current resistance problems with chemical treatments increase the likelihood of repeat infestation and further transmission. The overall message for parents is not only to treat the child with chemical treatments, but also to use lice combs to further eliminate the lice infestation.

Recent publications challenging no-nit policies highlight the fact that many cases of head lice are overdiagnosed, leading to unnecessary treatment and burden to children and their families.9 The authors point out that approximately 60% of schools in the United States still abide by the no-nit policy, and changes to allow children back into the classroom earlier should be made to decrease unnecessary missed days of school for children.

Myth Versus Fact

Many myths accompany head lice infestations (Table 1).7 The most common misconception regarding head lice is the assumption of a higher risk in lower socioeconomic classes.7 Head lice infestations occur similarly regardless of status. Risk factors include day care centers, schools, and females. A decreased risk has been reported in the African American population due to differences in the hair shaft. Infestations occur in both developed and undeveloped countries, and the most common mode of transmission is direct head-to-head contact.


Table 1
Table 1

Noninsecticidal Topical Treatments

If lice infestation is diagnosed, noninsecticidal topical treatment options, such as occlusion therapy, nit-combing, and hair removal, have been used.10 The most effective and appropriate of the aforementioned is nit-combing, in combination with topical pharmacologic therapy.

Occlusion Therapy
Occlusion therapy has not been proven to be effective because lice have spiracles that they can use to breathe when suffocation is attempted. Occlusion therapy agents that have been used in the past include kerosene, mayonnaise, Cetaphil Gentle Skin Cleanser, and petroleum jelly.10 Occlusion therapy is not recommended, especially products such as kerosene which is flammable. A study published in 2004 assessed the effectiveness of home remedies, such as vinegar, isopropyl alcohol, olive oil, mayonnaise, melted butter, and petroleum jelly, which showed no effectiveness in killing lice.11 Although many parents are hesitant to use the available pharmacologic therapies, it is important to counsel patients on avoiding delaying therapy by trying any of the above options.

Case (cont.)

3. The pharmacist is approached by one of the parents of the affected children who is hesitant to use the comb. What counseling point should be explained to the parent to help ease his or her concerns?

  1. The child can sit on the couch and watch a movie while the parent is using the nit comb. The parent can turn off the lights to relax the child because lighting is not an issue when using the nit comb.
  2. Use a well-lit area in the house and comb individual sections of the head. Explain to the child that it will take awhile to do the entire head, but it is the best treatment available.
  3. Tell the parent to buy the cheapest comb available; it does not matter if it is plastic or metal
  4. Comb the hair lightly; if the child claims one section hurts, skip that area

Nit Combs
Two different types of nit combs are available: plastic and metal.12 Of the 2 different types of combs, metal combs have been shown to be superior to plastic combs for nit removal. In a study by Speare et al, metal combs were shown to remove more nits than plastic combs in 96% of participants.12

The NPA recommends removing nits while seated under good lighting.8 Hair should first be combed or brushed, so it is free of tangles, and then the hair should be gathered into sections. The person removing the nits should work on one section at a time, making sure to comb from the scalp to the ends of the hair. After the comb is passed through the hair once, it can be wiped on a paper towel or dipped in a cup of water to remove any lice or nits from the comb.

The entire head should be combed and inspected for lice and nits. Nit-combing is labor-intensive and difficult because nymphs and adult lice can quickly move away from areas of the scalp that are being searched, and nits are particularly well-camouflaged in lighter-colored hair. Nit-combing is often overlooked and not used because of the time involved, and children may find it painful. Although it is not a pleasant experience for children or their parents, it is an important aspect of proper treatment of lice. Product information for pediculicides all recommend use of nit-combing with treatment to increase effectiveness.8 Pediculicidal products do not kill nits; therefore, combing is an essential adjunct to therapy.

Hot Air Therapy
Hot air therapy has been studied to assess the effectiveness of different types of delivery methods and length of time for treatments.13 A study performed at the University of Utah assessed the effectiveness of 6 types of hot air therapy, including a bonnet-style hair dryer, a handheld blow dryer (diffuse heating), a handheld blow dryer (directed heating), a wall-mounted dryer, the LouseBuster with sections, and the LouseBuster with hand piece (the LouseBuster is a hair dryer–like device used to dry out lice and nits). The level of heat used was no greater than a normal hair dryer, and the length of time heat therapy was administered with the LouseBuster was approximately 30 minutes.

Overall, mortality effectiveness against eggs was >88%, whereas mortality effectiveness against live lice ranged from 10% to 80%. The conventional blow dryer methods had lower effectiveness rates when compared with the LouseBuster, but currently the device is not commercially available. At this time, hot air therapy has not been studied in comparison with pharmacologic therapy and is not a recommended treatment. It does, however, open possibilities for future investigations of mechanisms of actions to eradicate head lice.

Topical Pharmacologic Therapy

Several different topical pharmacologic options are FDA-approved to treat head lice, such as pyrethroids, malathion, and lindane (Table 2).1,6,10,14 Treatments can be classified as pediculicidal, ovicidal, or both. Pediculicidal agents kill nymphs and adult lice but do not affect nits. Ovicidal agents kill nits but do not affect nymphs or adult lice. Each topical product has specific application directions that must be followed carefully. Refer to Table 3 for a summary of application instructions.1,6,10,14


Table 2
Table 2

Malathion
Malathion is a prescription insecticide and is both ovicidal and pediculicidal.10,15 This product exerts its mechanism of action by causing hyperexcitability and inhibition of acetylcholinesterase, thereby rendering lice unable to feed. Malathion also contains isopropyl alcohol and terpineol, which is a tea tree oil extract. Both of these components may help with the efficacy; isopropyl alcohol may work by denaturing proteins, whereas terpineol also may inhibit acetylcholinesterase. Malathion has a strong odor, and it can cause stinging and burning of the skin and eyes.7 Concerns regarding flammability have been raised, because it contains isopropyl alcohol, and, thus should be used with caution. The American Academy of Pediatrics recommendations in 2002 placed malathion as second-line therapy, but increasing resistance has moved malathion to first-line therapy in more recent reviews.1,6,10

If malathion is chosen, patients should be counseled to apply the product to dry hair.15 Patients should not wash or wet their hair first. Patients should use whatever quantity of lotion is necessary just to wet their hair; if necessary, a second bottle may be used if patients have longer hair. After application of the lotion, hair should be air dried and the lotion left on for 8 to 12 hours. Do not use a hair dryer, and do not cover the hair. After the recommended application time, the hair should be shampooed and rinsed, and then a fine-tooth comb should be used to remove any lice or nits. Treatment may be repeated in 7 to 9 days if lice are still present.

Lindane
Lindane is another prescription pediculicide, with ovicidal properties.10,16 Lindane inhibits the gamma-amino butyric acid (GABA) receptors, causing hyperexcitability, thus rendering the lice unable to feed. Lindane has been designated a second-line treatment by the FDA and has a boxed warning regarding potential neurotoxicity in patients weighing <110>7 Lindane shampoo is contraindicated in premature infants and patients with any uncontrolled seizure disorder.16 A medication guide is required to be dispensed with each prescription of lindane, and the package size to be dispensed is limited to a maximum of 2 oz.17

Lindane shampoo should be applied to clean, dry hair.16 Patients should be counseled to leave the shampoo on for 4 minutes and then to add water immediately, work into a lather, and rinse out. Application of the shampoo for longer than 4 minutes can lead to increased neurotoxicity. Patients also should be advised not to use >2 oz in a single application; usually just 1 oz of the shampoo will suffice. Furthermore, treatment should not be repeated, due to the potential for neurotoxicity.

In September 2000, California banned the use of lindane as treatment for head lice, and the ban went into effect on January 1, 2002.17 The State of California was concerned primarily with contamination of groundwater with the chemical and the resulting harmful exposure to its citizens. Although lindane is still available in other states, it is not used as first-line therapy for the treatment of lice. Lindane also has been completely banned in Australia, New Zealand, Germany, and Switzerland.

Pyrethroids
Pyrethroids were extremely efficacious when they were first introduced in 1986, but resistance has become widespread in the United States.6,10,14 This may be due either to genetic mutations in head lice, improper use of pyrethroids, or a combination of both. Pyrethroids are OTC insecticides that are pediculicidal, and they are divided into 2 classes: permethrin and pyrethrin. Pyrethroids are not ovicidal and do not affect nits; therefore, treatment with these products must be repeated 1 week later. Pyrethroids attack the nervous system of lice, causing overstimulation of the nervous system by delayed repolarization of voltage-gated sodium channels.

Pyrethrins are extracted from chrysanthemums, and therefore they should not be used in patients who are allergic to chrysanthemums or ragweed. When using pyrethrins, patients should be advised to apply the product to dry hair and massage the product into the scalp until all the hair is wet.14 Patients should not wash or wet their hair first. After the product has been in the hair for 10 minutes, patients should then rinse the product out and wash their hair with regular shampoo. Finally, the patient's hair should be combed with a fine-tooth comb to remove any dead lice or nits. Treatment should be repeated in 7 to 10 days to remove any lice that may have hatched.

Permethrin is a synthetic derivative of pyrethrin and can be used cautiously in patients with chrysanthemum or ragweed allergies. A test dose may be used to see if patients develop an allergic reaction to permethrin. If patients choose to use a product with permethrin, they should be counseled to shampoo their hair first and towel dry, as opposed to keeping the hair dry with the pyrethrin products.6,10,14 After the hair is shampooed and towel dried, enough of the product should be applied to wet the hair and scalp. If the patient has long hair, a second bottle may be used to ensure that all of the hair is saturated. The product should be left on for 10 minutes and then rinsed off. The patient's hair should then be combed with a fine-tooth comb to remove any dead lice or nits. Treatment may need to be repeated if live lice are seen after 7 days. One application of permethrin may be effective, due to the residual activity that is present for at least 14 days.18


Table 3
Table 3

Non-FDA-approved Pharmacologic Therapies
Because of the issue of resistant Pediculus capitis, 2 non-FDA-approved, oral medications also have been used off label in the treatment of head lice: ivermectin and trimethoprim/sulfamethoxazole (TMX/SMX).10

Ivermectin works on neuronal membranes in lice and causes paralysis, rendering them unable to feed.1 It is pediculicidal only. The usual dose is 200 µg/kg/dose given orally for 1 dose and repeated in 7 to 10 days. Caution should be used when using ivermectin in children who weigh <15>19,20 This may be a product of the future to add to the armamentarium for head lice.

TMX/SMX works by eliminating symbiotic bacteria that live in the gut of lice; without this bacteria, lice theoretically cannot live.21,22 The louse must feed on the human to ingest the antibiotic from the blood, and thus this agent is only pediculicidal. In one study, TMX/SMX was compared with permethrin 1% crème rinse or both agents used together.23 The authors concluded that the combination of oral TMX/SMX plus permethrin 1% topical was more effective than either treatment alone. The dose used was 10 mg/kg/day, based on the trimethoprim component, and given in 2 divided doses for 10 days.23 No repeat dosing of TMX/ SMX was prescribed, unless treatment failure was observed at the scheduled 2- and 4-week follow-up appointments. All treatment arms were well tolerated, but caution needs to be exercised when recommending TMX/SMX due to the potential skin reactions that can occur, including Stevens-Johnson syndrome. Patients also should be screened for any sulfa allergies prior to use.

Another agent, crotamiton has been used for the treatment of Pediculosis capitis, but the safety and efficacy has not been established for the indication of head lice.1 Preliminary studies indicate that crotamiton 10% lotion can be used for the treatment of head lice; it should be applied to the scalp and left on for 24 hours before being washed off. More studies are needed, however, to determine safety and efficacy before its use in head lice is recommended. It currently is not approved by the FDA for the treatment of head lice.1

Alternative Therapies

Although the topical therapies reviewed have their place in treating head lice, resistance does appear to be increasing, and many families do not like the thought of using pesticides on their child's head. Thus, many alternative therapies have been tried. Little to no data supporting the proper use, safety, or efficacy of these products exist, however.

One study looked at a variety of oil preparations applied in vitro, including tea tree oil, lavender, coconut, and peppermint, and compared them with N, N-diethyl-3-methylbenazamide (DEET).24 A lubricant gel was used as a control. The authors conducted 3 varying experiments looking at transmission of lice to a treated hair (repellant effect), behavior of the louse placed onto a treated hair (irritancy of the louse was assessed based on 4 responses: avoidance, hesitation, speed of walking, and confusion), and overall avoidance of a treated area.

In the first experiment, tea tree oil did perform better overall as a repellant compared with the other oils used, and a combination of tea tree oil, coconut, and lavender may prove to be somewhat effective as a repellant and have less odor than tea tree oil alone. The lubricant gel also aided in decreasing transmission of the louse to the treated hair, probably because it made the hair slippery. Thus, the repellant nature of the product used may not be important. One caution that the authors note, though, is that any repellant used may just spread the louse to other hosts and cause more of an outbreak, so treatment of all close contacts may be necessary to prevent the dispersal of lice.

None of the products appeared to irritate the louse much except coconut oil, and when looking at the last experiment, lice avoided the peppermint and tea tree oil–treated areas, decreasing the amount of blood feeding time. Based on the overall results of the 3 experiments, it was concluded that none of the substances showed superior efficacy, including DEET.

Another product reviewed in the literature is paw paw herbal shampoo.25 This product is a combination of thymol, paw paw extract, and tea tree oil. Varying concentrations and application times were studied, and a final formulation was recommended that should be applied for 1 hour and repeated as directed. The product was commercially available online until recently. Now if families wish to use this product, they must use the recipe that is online using paw paw capsules, thyme essential oil, and tea tree oil.26

One other product recently brought to market in the United States is a dimeticone- based shampoo.27 This product is considered chemical free and apparently works by coating the hair, making the hair slippery and not allowing the louse to move properly. One study done in the United Kingdom (UK) compared a 4% dimeticone lotion with phenothrin, a pesticide used in the UK.28 The dimeticone treatment was less irritating than the pesticide treatment and both agents were comparable in efficacy. Of note, patients were asked not to use any lice combs to aid in the removal of nits or lice. The authors noted that dimeticone is not absorbed transdermally, and because of its physical mechanism of action, dimeticone should not be affected by the ongoing concern of resistance.

A final product recently marketed in 2008 as a pesticide-free formulation is Nix PF.29 This product is labeled as a comb and combing aid product. The metal comb is 2-sided, with 1 side having larger teeth to help detangle the hair and the other side being a finer-toothed comb to aid in removing lice and nits. The spray contains anise and coconut oil, isopropyl alcohol and ylang ylang (a flower oil).30 The product is to be sprayed on the hair and rubbed into the scalp and hair. The spray should be left on the hair for 15 minutes and then rinsed off with warm water. The comb should then be used to detangle the hair and remove the nits and lice. Upon completion of the combing, the hair should be washed with regular shampoo. This process should be repeated in 7 days to eliminate all of the lice. The product is approved for all ages; however, if the patient is pregnant or breast-feeding, the health care provider should be contacted prior to use.29 This product may be irritating if spilled in the eyes or directly onto the skin. If this occurs, flush the eyes with water for 15 minutes and wash off the skin with soap and water. Finally, since this product may be flammable if exposed to direct heat, store away from heat or flame.30

The bottom line with alternative therapies for head lice is that none are curative or FDA-approved for prevention or treatment. The OTC and prescription products described within this review should remain primary therapies for the treatment of head lice until further data are available on the safe and effective use of herbal therapies.

Household Interventions

Lice only can live 1 to 2 days off of a human head; thus, household interventions do not need to be extremely stringent. At the time of treatment of an infested person, all items that touched the affected person's head should be cleaned. This may include clothing, bedding, furniture, car upholstery, or carpeting. Clothing and bedding can be washed in water that is at least 130°F in order to kill any nits or lice that may be present. If it is preferred, the clothing and bedding simply may be dried at temperatures >130°F. For furniture, car upholstery, or carpeting, vacuuming will suffice.31-34

Although pediculicidal sprays specifically indicated for the treatment of furniture and carpeting are commercially available, these are not recommended because their use can lead to unnecessary exposure to the pediculicidal chemicals. Another common household intervention is to place items that cannot be washed into plastic bags for 2 weeks. This is typically not necessary or recommended, but is a potential strategy that may help avoid reinfestation.34

Drug Resistance

Drug resistance is an issue that has been reported all over the world.35 Resistance is thought to be due to local factors, including improper treatment (eg, foregoing second applications of products) and prescribing recommendations of local dermatologists or pharmacists. In many cases, resistance has to be weighed against the possibility of other explanations, including misdiagnosis, nonadherence to previous treatments, or a new reinfestation.1

One thought to consider is alternating treatment recommendations. This theory has not been proven but is used in many communities. To avoid resistance, children and their parents must be counseled extensively on proper use and reapplication of products. Malathion is the only product in the United States that has not shown resistance, but due to concerns over its use and increased cost compared with OTC products, it is not commonly administered.10

Patient Counseling

When educating families on treating head lice, a few facts should be relayed to the caregiver.36 First, be sure that lice are present. Commonly, dandruff and other debris can be misdiagnosed as lice. Second, remember that lice are a common infestation. Lice do not carry disease, but they can persist and reinfest for many months. Thus, it is extremely important to read and follow specific product instructions.

First-line therapy continues to be permethrin-containing, OTC products (Table 2). This is a safe and effective therapy in most cases; however, resistance has been documented, so careful adherence to instructions, reapplication, and combing are important. If reinfestation occurs after a second application, consult a physician to determine if a prescription product is necessary. Many times, the reinfestation is simply due to improper use of the product (eg, not enough applied to the scalp and hair) or forgetting to reapply in 7 to 10 days as instructed. It is important to remember that OTC products are only pediculicidal; in order to kill the nits that will hatch in 7 to 10 days, another application is required.31-33 Permethrin does not always require a second application; however, if live lice are seen after 7 days of the first application, another treatment should be done. Treating an entire family (or a school, for that matter) has not been proven efficacious. Screening close contacts is important, though, once someone has been confirmed as having head lice.34

Combing, in addition to medication applied topically, can be effective; combing alone is usually not effective, simply due to the fact that it is so tedious and requires a lot of patience. Combing wet hair is usually easier, and some researchers recommend applying olive oil first to aid in removing nits and eggs.31-33

Because many parents will ask for alternative therapies, it is extremely important that the pharmacist understand that little to no data exist to support the use of any complementary, herbal, or alternative therapy for head lice. The essential oils that were discussed in this review should not be used in addition to the commercially available pesticides, because oils can increase the absorption of the pesticide, increasing the potential for toxicity.17 Also, many of the occlusion therapies are not safe (eg, kerosene) and are cosmetically unacceptable to most patients (eg, mayonnaise). Other methods for suffocating the lice that should not be recommended include placing a plastic bag over the child's hair at night. Not only could this lead to accidental suffocation of the child, but if used in combination with pesticides, the topical irritation could be increased.

Finally, keep in mind that children and families diagnosed with head lice may be humiliated and embarrassed. Empathy and offering counseling will encourage the family to use a safe and effective product properly. Providing additional resources and guidance such as the NPA Web site (www.headlice.org) will give families continued support after leaving the pharmacy.

Conclusion

Overall, education and proper counseling of the parent and child are the most important aspects of treatment. Parents should understand the importance of immediate treatment and understand how to use the products and combs. For optimal treatment, chemical products and nit combs should be used in combination.

References

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Mitzi Wasik, PharmD, BCPS is a Clinical Assistant Professor, University of Illinois at Chicago-College of Pharmacy

Nancy Paek is a PharmD Candidate 2008 at the University of Illinois at Chicago-College of Pharmacy

Leslie Briars, PharmD is a Clinical Assistant Professor, University of Illinois at Chicago-College of Pharmacy

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