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Pediatrics John Ciuppa ➼ Between 6 million and 12 million infestations of head lice occur every year in the United States. 1 Children between the ages of 3 and 11 are the most often affected, with occurrence more frequently in girls. 1 Although head lice pose no public health threat or transmission of disease, they are an expensive nuisance. Treatments, lost wages and school expenses total an estimated $1 billion annually — an amount almost three times the estimated expenditure in the 1990s. 2 The direct and indirect costs of treatment could be reduced by ending the “no-nit” policies enforced by most school systems and by delivering efficacious treatments. Current Issues Pediculus humanus capitus is a six-legged parasite that grows no larger than 2 mm or 3 mm. Each leg has claws that allow the organism to grasp a hair follicle. Head lice survive by feeding off human blood every 3 to 6 hours. In optimal conditions, adult lice can survive more than 3 weeks. Pruritus of the scalp is the most common symptom of an infestation, a result of localized allergic reaction to the louse bites. An infestation may be present for 6 weeks before symptoms become evident. The female lice lay eggs, or nits, within ¼ inch of the scalp. These hatch in 5 to 10 days. The adult stage is reached about 10 days after hatching. 1,3 Head lice infestation has historically been associated with lack of personal hygiene, lack of cleanliness in the home environment and (erroneously) lower The direct and indirect costs of treatment could be reduced by ending the “no-nit” policies enforced by most school systems and by delivering efficacious treatments. socioeconomic status. The truth is that head lice infestations affect 5% to 10% of school-age children across all facets of life; rates of infestations among black children are lower. 1,2 Head lice are most commonly transmitted through direct contact with the hair of an infected person. Environments in which direct contact often occurs include school, home, sporting practices/events, camps and slumber parties. Although parents and schools have long recommended that children avoid sharing hats, scarves, coats, combs, brushes and bed linens to prevent head lice spread, these are uncommon forms of transmission. 1,2 In an attempt to curtail the transmission of head lice, the National Pediculosis Association advocates a “no nit” policy: 4 screening children for head lice to identify any evidence of lice or nits and immediately removing students with nits or lice from class until a re-examination proves clearance. Given the $1 billion burden associated with treating head lice and missing school and work, is this the best policy The American Academy of Pediatrics, the National Association of School Nurses and the Centers for Disease Control and Prevention recommend that children return to class as soon as treatment has been provided. 1,2,4 The CDC goes a step Kara L. Caruthers is an assistant professor in the physician assistant program at the University of Alabama at Birmingham and works clinically in emergency medicine. Patricia R. Jennings is director of the physician assistant program at the University of Alabama at Birmingham and also serves as a professor. She works clinically in the Division of Infectious Diseases at the University of Alabama Medical Center and the Birmingham Veterans Affairs Medical Center. The authors have completed disclosure statements and report no relationships related to this article. further by stating that children should not be immediately dismissed from school after a positive lice finding; instead, they should be allowed to complete the school day. 1 Head lice do not fly, hop or jump. They crawl through the head, staying close to the scalp for both warmth and access to their food source (blood). They usually do not survive longer than 48 hours when away from the host. 1,3 Nits cannot hatch and usually die within 7 days if the temperature is not comparable to that of the scalp. 1 These facts support recommendations for discontinuing nonit policies. The cost of unnecessary absenteeism exceeds the risks associated with head lice. Permethrin The longstanding pharmacologic treatment of choice for head lice infestation is permethrin 1% lotion. 5 Permethrin (Nix) is a pediculicide that has reported secondary ovicidal properties. It is indicated for patients older than 2 months. Permethrin lotion was introduced in 1986 and has been available over the counter since 1990. 2 It is associated with low levels of toxicity. 2 Before using permethrin, hair must be washed with a nonconditioning shampoo and towel dried. A sufficient amount of lotion must be applied to saturate the hair and scalp; it should be rinsed off after 10 minutes. Current labeling for the product recommends a routine second treatment 7 to 10 days later. 2 In recent years, reports of treatment failure with this therapy have surfaced throughout the world. Experts initially believed that the treatment failures were due to user error (nonadherence or failure to properly comb out nits), but in the United States, treatment failure is mostly attributed to increased resistance as a result of overuse and formula changes. 4,6 Malathion Malathion 0.5% (Ovide), an organophosphate, is a prescription pediculicide with ovicidal properties. It is available in a lotion or gel, and studies show it is more ADVANCE for NP & PAs 13
Pediatrics The most obvious drawback for the preferred utilization of malathion is cost, since it requires both an office visit and a prescription. efficacious that permethrin 1%. 4-7 No reports of resistance have been associated with the current U.S. formulation of this drug. 6 Malathion 0.5% lotion is safe to use on patients older than 6, and the gel formulation is safe to use on patients older than 2. To deliver this treatment, the lotion or gel is applied to dry hair and allowed to air dry. The lotion remains on the hair for 8 to 12 hours; the gel preparation remains on the hair for 30 minutes. The gel is associated with fewer odors, easier application and less likelihood of eye irritation because of diminished dripping. Studies show that the gel formulation is as effective as the lotion formulation, with similar rates of retreatment. 2,5,7 The most obvious drawback for the preferred utilization of malathion is cost, since it requires both an office visit and a prescription. Potential side effects must also be considered. Because malathion is a cholinesterase inhibitor, the potential for respiratory depression with ingestion is concerning. The potential risk of inadvertent ingestion by young children in the home should be considered. 2 No such cases have been reported, however. Newer Agents Three other pharmacologic agents have been introduced over the last 3 years to address emerging resistance. Benzyl alcohol 5% (Ulesfia) lotion was approved in 2009 for use as a prescribed pediculicide for the treatment of head lice in patients older than 6 months and in pregnant women. The lotion is touted as nontoxic because it does not contain pesticides; malathion 0.5% and permethrin 1% do. Ulesfia has a unique mechanism of asphyxiating lice by “stunning” their external breathing component. 8 Ulesfia lotion should be applied in sufficient quantity to cover all lice on the hair and scalp. The application is rinsed off after 10 minutes and must be repeated in 7 days. In clinical trials, head inspection 1 day after the second dose showed clearance rates of 92% or higher. 5,8 Development of resistance is thought to be unlikely with Ulesfia since the mechanism of action opens the external breathing pathway of the louse. Spinosad 0.9% (Natroba) is a cream rinse for patients older than 4; it was approved in 2011. This product is a prescribed pediculicide that targets the nicotinic receptor of acetylcholine and the gamma aminobutyric (GABA) gated chloride channel of the louse, causing paralysis. The hair and scalp should be saturated with Natroba and left on for 10 minutes. In clinical trials, most patients only needed one treatment. A second treatment can be given in 7 days if live lice are still present. Eighty-five percent of patients were lice-free 14 days after the final treatment. While spinosad 0.9% is neurotoxic to lice, it is thought to have fewer side effects than permethrin. 5 Ivermectin lotion 0.5% (Sklice) is a lice treatment for patients older than 6 months; it was approved in February 2012. This lotion is a prescribed pediculicide that also works on the GABA chloride channels, causing paralysis and resulting in death of the louse. The lotion is applied to dry hair and to the scalp. The contents of the entire 4-gram tube should be applied. The product should remain on the hair and scalp for 10 minutes before being rinsed out. The current recommendation is for use as a one-time treatment. Two trials of ivermectin lotion demonstrated 71% to 76% lice eradication 14 days after a single treatment. 9 Oral ivermectin has been used off label for the treatment of head lice for some time. Safety concerns exist about crossing Head Lice Through the Years ➼ find our archived coverage of head lice by entering the term in our Search box at www.advanceweb.com/NPPA. the blood–brain barrier and potential for neural transmission interruption in younger patients. 2 Rethinking Policy Head lice infestations in school systems across the United States are a public health nuisance and an economic burden on families. Prolonged absenteeism from both school and work are unnecessary considering the lifespan and patterns of the human head louse. Several health organizations recommend an end to “no nit” policies in American school systems. Children should be allowed to return to the classroom once treatment has been initiated. Permethrin is still considered the treatment of choice for head lice, but increasing pesticide resistance warrants consideration of other treatment modalities. Malathion, benzyl alcohol, spinosad and ivermectin should be considered for head lice treatment since these therapies can be more efficacious than permethrin. While copayments and prescriptions are burdensome for some, these costs may be worth it when weighed against the potential for prolonged absence from school and work. 4 ■ References 1. Centers for Disease Control and Prevention. Parasites-Lice-Headlice. www.cdc.gov/parasites/lice/ head/index.htm. 2. Frankowski BL, Bocchini JA. Head Lice. Pediatrics. 2010;126(2):392-403. 3. Texas A&M University. Louse. http://insects. tamu.edu/fieldguide/aimg37.html. 4. Gur I, Schneeweiss R. Head lice treatments and school policies in the US in an era of emerging resistance: a cost-effectiveness analysis. J Pharmacoeconomics. 2009;27(9):725-734. 5. Keller E, Tomecki K. Cutaneous infections and infestations: new therapies. J Clin Aesthet Dermatol. 2011;4(12):18-24. 6. Meinking TL, et al. Comparative in vitro pediculicidal efficacy of treatments in a resistant head lice population in the United States. Arch Dermatol. 2002;138:220-224. 7. Meinking TL, et al. A randomized, investigatorblinded, time-ranging study of the comparative efficacy of 0.5% malathion gel versus Ovide Lotion (0.5% malathion) or Nix Crème Rinse (1% permethrin) used as labeled, for the treatment of head lice. Pediatr Dermatol. 2007;24(4):405-411. 8. Meinking TL, et al. The clinical trials supporting benzyl alcohol lotion 5% (Ulesfia): a safe and effective topical treatment for head lice (pediculosis humanus capitis). Pediatr Dermatol. 2010;27(1);19-24. 9. Sanofi. Sklice Lotion prescribing information. http://products.sanofi.us/Sklice/Sklice.pdf 14 ADVANCE for NP & PAs
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