Going to School on Head Lice

New Approaches to an Old Nemesis

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Key Points to Cover Today!

1. Head Lice: Getting to Know You2. The Key Role of the Clinician in Head Lice

Diagnosis and Treatment3. The School Nurse’s Pivotal Roles

in Head Lice Management4. Strategies for School Nurses:

When Lice Go to the Head of the Class5. Background Information on Approved

Head Lice Products

2

Head Lice: Getting to Know You

Head Lice Infestation: A Common Pediatric Condition

• Pediculosis is the most prevalentparasitic infestation among humans1

• Head lice infestations are pervasiveamong school-age children in theUnited States2,3

• ~6-12 million infestations occur eachyear in children 3-11 years of age3

– More common in females4 • All socioeconomic groups are affected2,4,5

– Contrary to myth, “head lice prefer clean, healthy hosts”4

References: 1. Hodgdon HE, et al. Pest Manag Sci. 2010;66(9):1031-1040. 2. Frankowski BL, et al. Pediatrics. 2010;126(2):392-403.3. Centers for Disease Control and Prevention (CDC). Head lice. Epidemiology & risk factors. http://www.cdc.gov/parasites/lice/head/epi.html. Accessed January 13, 2013. 4. Meinking T, et al. Infestations. In: Schachner LA, Hansen RC, eds. Pediatric Dermatology. 4th ed. Mosby Elsevier; 2011:1535-1583. 5. Meinking TL, et al. Int J Dermatol. 2013;52(1):106-112.

Getty Images/Peter Dazeley.

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Common Myths About Head Lice1

Reference: 1. Pontius DJ. NASN Sch Nurse. 2011;26(6):356-362. 5

MYTH: Head lice can fly or jump from head to headFACT: Head lice have no wings and can only crawl.

MYTH: Head lice are a health hazard and are more common in people with poor hygiene.FACT: Head lice prefer a clean, healthy head; they are not a health hazard and do not transmit disease.

MYTH: Transmission of head lice in the classroom is common.FACT: Classroom transmission is considered rare.

MYTH: You can get head lice from a house pet.FACT: Dogs, cats, and other house pets do not play arole in head lice transmission.

CDC. Dr. Dennis D. Juranek.

The Head Louse:A Closer Look

• The adult louse is 2-3mm long (aboutthe size of a sesame seed)1

• Usually pale gray; color may vary1

– Red when engorged with blood– May adapt color to surroundings

• The louse feeds by injecting smallamounts of saliva and taking tinyamounts of blood from the scalpevery few hours1

• Lice usually survive less than 24-48 hours away from the scalp at room temperature1,2

• Lice that fall off the head are usually dead or dying• Must find a host to survive • Eggs need warm temperatures (like those near the scalp) to hatch

References: 1. Frankowski BL, et al. Pediatrics. 2010;126(2):392-403. 2. CDC. Head lice. Prevention and control. http://www.cdc.gov/parasites/lice/head/prevent.html. Accessed March 26, 2013. 6

CDC.

Female lives 3-4 weeks

Lays up to 10 eggs per day

Eggs tightly attached to hair,

close to scalp

Eggs hatch in 7-12 days

Female lays 1st egg 1-2 days after mating

Without treatment, the cycle may repeat

every 3 weeks

Become adults 9-12 days after

hatching

3 nymph stages

1

2

3

References: 1. Frankowski BL, et al. Pediatrics. 2010;126(2):392-403. 2. Meinking TL, et al. Infestations. In: Schachner LA,Hansen RC, eds. Pediatric Dermatology. 4th ed. Mosby Elsevier; 2011:1535-1583. 7

Illustration by Penumbra Design Inc.

The Life Cycle of the Head Louse1,2

Know Your Nits!

• Nits are tiny, teardrop-shaped eggs attached to 1 sideof the hair shaft with a waterproof, glue-like substance1-4

– Often found on nape of the neck and behind the ears5

• Viable nits with an egg inside may be tan to coffee-colored or darker1

• Nonviable nits are white or yellowishshells, or casings1

• Nits attached >1cm from the scalpare usually not viable2

– In some warmer climates, viable nitsmay be found several inches from the scalp3

– Close inspection is needed4References: 1. Meinking TL, et al. Infestations. In: Schachner LA, Hansen RC, eds. Pediatric Dermatology. 4th ed. Mosby Elsevier; 2011:1535-1583. 2. Frankowski BL, et al. Pediatrics. 2010;126(2):392-403. 3. Paller AS, Mancini AJ, eds. Hurwitz Clinical Pediatric Dermatology. A Textbook of Skin Disorders of Childhood and Adolescence, 4th ed. New York, Elsevier Saunders; 2011:424-427. 4. CDC. Head lice. Diagnosis. http://www.cdc.gov/.parasites/lice/head/diagnosis.html. Accessed January 13, 2013. 5. American Academy of Pediatrics. Pediculosis capitis (head lice). In: Red Book. 2012 Report of the Committee on Infectious Diseases. Pickering LK, ed. 29th ed. Elk Grove Village, IL, American Academy of Pediatrics; 2012:543-546. 6. Franca K, et al. Int J Trichology. 2011;3(2):121-122.

Nits may be confused with:• Dandruff1-5 • Dirt and other debris2,4,5

• Droplets of hair spray, gel2-4

• Hair casts (pseudonits) encircling the hair shaft1,3,5,6

• Plugs of skin cells5

• Fungal infection of the hair (piedra)1,3,5

• Psoriasis1,3

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CDC/Dr. Dennis D. Juranek.

Head Lice: The Truth About Transmission1-3

• Transmission of lice typically occursby direct head-to-head contact withan infested individual

• Children can get head lice anytimethey come in close contact withothers—during play at home orschool, slumber parties, sportsactivities, or camp

• Indirect spread by contact withpersonal items (combs, brushes,hats, headgear) is less likely butcan occur

References: 1. Frankowski BL, et al. Pediatrics. 2010;126(2):392-403. 2. CDC. Head lice. Epidemiology & risk factors. http://www.cdc.gov/parasites/lice/head/epi.html. Accessed January 13, 2013. 3. Meinking TL, et al. Infestations. In: Schachner LA, Hansen RC, eds. Pediatric Dermatology. 4th ed. Mosby Elsevier; 2011:1535-1583.

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Getty Images/Jamie Grill.

Typical Symptoms of Head Lice Infestation

• Itching is the most common symptom1-3

– Caused by an allergic reaction to louse saliva• If someone is infested for the first time,

itching may take 4-6 weeks to develop1

– If a person has had previous head liceepisodes, itching may develop within48 hours3

• Irritability, difficulty sleeping1

– Lice are more active in the dark• Sores, crusting, secondary bacterial infection

on the scalp1-3

– Not common; caused by excessive scratching• In some cases, no symptoms are present3

Getty Images/Westend61.

References: 1. CDC. Head lice. Disease. http://www.cdc.gov/parasites/lice/head/disease.html. Accessed March 28, 2013. 2. Frankowski BL, et al. Pediatrics. 2010;126(2):392-403. 3. Meinking TL, et al. Infestations. In: Schachner LA, Hansen RC, eds. Pediatric Dermatology. 4th ed. Mosby Elsevier; 2011:1535-1583. 10

Gordon SC. Dermatology Nursing. 2010;22(4):18-20. Reprinted with

permission of Jannetti Publications, Inc.

The Key Role of theClinician in Head Lice Diagnosis

and Treatment

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The Traditional Approachto Head Lice1,a

• Desire to avoid delay• Easy access to over-the-

counter (OTC) products • Limited parent knowledge

of Rx choices

Treat On Their Own Contact a Health Care Provider

70%of Households

30%of Households

Reference: 1. Sanofi Pasteur Inc., Data on file (ICR Research; Excel Omnibus Studies H8824-26, I8823). July 2009. MKT26505. 12

Head lice suspected

• Office may treat “over the phone” by recommending an OTC option or calling in a prescription treatment

a Independent market research conducted in the US; data shown are based on responses from 201 households.

A New Approach: Getting Clinicians More

Involved1

• The American Academy of Pediatrics (AAP) calls fora new approach to diagnosis and treatment of head lice

• The rationale:– Self-diagnosis by families, plus easy availability of OTC

products, have removed clinicians from the treatment process

– The potential for misdiagnosis leading to improper use of pediculicides raises concerns about unsafe use of these products, especially when no lice are present or when products are used excessively

– Emergence of resistance to some head lice products and introduction of new products call for increased provider involvement in the diagnosis and treatment of head lice

Reference: 1. Frankowski BL, et al. Pediatrics. 2010;126(2):392-403. 13

A New Approach: Getting Clinicians More Involved (cont)

• According to the AAP, clinicians should:– Be knowledgeable about head lice infestations and the

range of treatment options, both OTC and Rx1

– Take an active role as information resources for families, schools, and community agencies1

– Take time to instruct families in the proper use of head lice products1

• The AAP and National Association of School Nurses (NASN) support collaborative efforts to educate communities and develop sensible, evidence-based approaches1,2

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References: 1. Frankowski BA, et al. Pediatrics. 2010;126(2):392-403. 2. Pontius D, Teskey C. Pediculosis management in the school setting. NASN position statement, 2011. http://www.nasn.org. Accessed March 28, 2013.

An Alternative to Self-Treatment

Diagnosisconfirmed by clinician

Treatment choices made

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School nurse identifies head lice,

communicates with family

Family contacts their health care provider

Rx and OTC

options discussed

Instruction given on

proper use of product

Treatmentunsuccessful

Treatment successful

Who Needs to be Treated?• Treatment should never be initiated without a clear

diagnosis of head lice1,2

• Definitive diagnosis is made by finding a live louse or nymphon the scalp or head2,3

• Misdiagnosis is common3-5

• If no nymphs or adults are seen, and the only nits are >1/4 inch from the scalp, infestation is probably old and no longer active3,a

• When 1 member of a household is diagnosed, everyone in the household—and other close contacts—should be checked1

– Anyone with evidence of active infestation should be treated – All such persons should be treated at the same time

a Some authorities use a guideline of >1cm from the scalp.2

References: 1. CDC. Head lice. Treatment. http://www.cdc.gov/parasites/lice/head/treatment.html. Accessed March 26, 2013. 2. Frankowski BL, et al. Pediatrics. 2010;126(2):392-403. 3. CDC. Head lice. Diagnosis. http://www.cdc.gov/parasites/lice/head/diagnosis.html. Accessed April 4, 2013. 4. Pollack RJ, et al. Pediatr Infect Dis J. 2000;19(8):689-693. 5. Burkhart CG. Mayo Clin Proc. 2004;79(5):661-666. 16

Guidance on Managing Infestations

• In recommending treatment, the clinician should considerthe product’s:1

Effectiveness Safety Ease of use Cost Local patterns of resistance (if known)

• There is no scientific evidence that home remedies are effective1,2

– Remedies not based in science can be expensive and frustrating, leaving the child and family ineffectively treated

– Treatment recommendations should be evidence-based and come from medical, public health, and nursing experts rather than anecdotal experience or commercial advertisements3

References: 1. Frankowski BL, et al. Pediatrics. 2010;126(2):392-403. 2. Takano-Lee M, et al. J Pediatr Nurs. 2004;19(6):393-398.3. Pontius D, Teskey C. Pediculosis management in the school setting. NASN position statement, 2011. http://www.nasn.org. Accessed March 28, 2013. 17

Guidance on Managing Infestations (cont)

• Resistance to some head lice products has been reported, but the prevalence is not known1

• According to the AAP, 1% permethrin or pyrethrins(OTC products) can be used to treat active infestations—unless resistance has been noted in the community1

• If a treatment does not seem to be working, possible causes include incorrect use of the product or resistance2

• Newer prescription treatment options are availableto help families resolve head lice episodes

References: 1. Frankowski BL, et al. Pediatrics. 2010;126(2):392-403. 2. CDC. Head lice. Treatment. http://www.cdc.gov/parasites/lice/head/treatment.html. Accessed March 28, 2013.

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Careful Instruction: Key to Avoiding Misuse, Overuse• The clinician should offer families careful instruction

in the proper use of head lice products1

– Need for second treatment? Use of nit comb?• Products vary; families should be advised to follow

the specific instructions that accompany the product• Parents should not use extra amounts of any lice

medication unless instructed to do so by their health care provider2

– Drugs used to treat head lice can be dangerous if misusedor overused

• An infested person should not be treated more than 2-3 timeswith the same medication if it does not seem to be working2

– In such situations, it is important to seek the advice of a health care provider, who may recommend an alternative medication

References: 1. Frankowski BL, et al. Pediatrics. 2010;126(2):392-403. 2. CDC. Head lice. Treatment. http://www.cdc.gov/parasites/lice/head/treatment.html. Accessed March 28, 2013.

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Getty Images/Photodisc.

Cleaning Up: What’s Really Needed?1

• Use of pediculicides is part of an overall approachto head lice management that may also include:– Wash in hot water or dry-clean all clothing, hats,

bed linens, and towels used by an infested personduring the 2 days prior to treatment

– Wash personal care items such as combs,brushes, and hair clips in hot water

– Vacuum floors and furniture, especially where the infested person sat or lay

• Fumigant sprays or fogs are not needed tocontrol head lice– These products can be toxic if inhaled or absorbed

through the skin

Reference: 1. CDC. Head lice. Prevention & control. http://www.cdc.gov/parasites/lice/head/prevent.html. Accessed March 26, 2013.

Shutterstock.

Photos.com.

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The School Nurse’s Pivotal Roles in

Head Lice Management

The School Nurse: First Responder to Head Lice

Infestation• School nurses are often the first to assess a child

for the presence of head lice1

• The NASN encourages parents to talk to their school nurse about head lice

• When a case of head lice is suspected, school nurses should– Provide accurate information to families and – Encourage them to contact their physician or other

health care provider to confirm the diagnosis and discuss treatment options

Reference: 1. Schoessler SZ. Am J Manag Care. 2004;10(9 Suppl):S273-S276. 22

The School Nurse: Educator

• School nurses play an essential role in educating families, teachers, and school officials about head lice1

– Calming fears– Dispelling myths and stigmas regarding pediculosis– Maintaining student privacy and confidentiality– Building awareness of effective head lice

management“School nurses are in a pivotal position to dispel myths and stigmas regarding pediculosis by providing education on the life cycle of the louse, methods of transmission, treatment options, and care of the environment to the student’s family, school, and community at large.” —NASN1

Reference: 1. Pontius D, Teskey C. Pediculosis management in the school setting. NASN position statement, 2011. http://www.nasn.org. Accessed March 28, 2013. 23

The School Nurse: Advocate• School district policies on head lice

management vary widely1-3

– Not always based on science• School nurses can be instrumental

in championing evidence-basedpolicies in their school districtsand communities1-5

References: 1. Weisberg L. Nasnewsletter. 2009;24(4):165-166. 2. Sciscione P, et al. J Sch Nurs. 2007;23(1):13-20. 3. Pontius DJ. NASN Sch Nurse. 2011;36(6):356-362. 4. Pontius D, Teskey C. Pediculosis management in the school setting. NASN position statement, 2011. http://www.nasn.org. Accessed March 28, 2013. 5. Schoessler SZ. Am J Manag Care. 2004;10(9 Suppl):S273-S276. 24

“The school nurse is the key health professional to provide education and anticipatory guidance to the school community regarding best practice guidance in the management of pediculosis.”4

Getty Images/Ariel Skelley.

The School Nurse: First Responder, Educator, Advocate

• The school nurse thus has a vital role to play in: Facilitating an accurate assessment of the

problem1,2

Containing head lice infestations1,2

Safeguarding family privacy and confidentiality1,2

Advising affected students and families to contact their physician or other health care provider to discuss available treatment options3

Preventing overexposure to potentially hazardous chemicals1,2

Minimizing school absences1,2

References: 1. Pontius D, Teskey C. Pediculosis management in the school setting. NASN position statement, 2011. http://www.nasn.org. Accessed March 28, 2013. 2. Schoessler SZ. Am J Manag Care. 2004;10(9 Suppl):S273-S276. 3. Burkhart CG. Mayo Clin Proc. 2004;79(5):661-666.

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Strategies for School:When Lice

Go to the Head of the Class

Managing Infestations in the School:NASN Guidance

If a child in school has live head lice, he or she shouldremain in class but be discouraged from close direct head contact with others

The school nurse should contact the parents to discuss treating the child at the end of the school day

It is vital to prevent stigmatizing and maintain the student’s privacy and the family’s right to confidentiality

It may be appropriate to screen others who have had closehead-to-head contact with a student who has an active infestation– Classroom-wide or school-wide screening is not merited

Students with nits only should not be excluded from school; however, it is appropriate to monitor for signs of activere-infestation

Reference: 1. Pontius D, Teskey C. Pediculosis management in the school setting. NASN position statement, 2011. http://www.nasn.org. Accessed March 26, 2013. 27

Helping Kids Stay in School

• The AAP and NASN state: No healthy child should be allowed tomiss school time because of head lice1,2

• “No-nit” policies for return to school should be abandoned1,2

• School-based head lice screeningprograms have not had a significanteffect on incidence of head lice inschools and are not cost-effective2

References: 1. Pontius D, Teskey C. Pediculosis management in the school setting. NASN position statement, 2011. http://www.nasn.org. Accessed January 13, 2013. 2. Frankowski BL, et al. Pediatrics. 2010;126(2):392-403.

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iStockphoto.

Easing the Stigma

• Head lice infestations can take a high emotional and psychological toll on some children and parents1-3

People with head lice may feel:– Disgust, horror, panic, anger;

feelings of being dirty or contaminated– Excluded from school and social activities

• Head lice infestations can be an emotional issuein schools– Parents may panic when they are told their child has head lice– Students may feel isolated

• Parents should rely on the experience and judgment of school nurses and other health professionals who are equipped to provide accurate information and recommend or prescribe treatment options

References: 1. Gordon SC. J School Nurs. 2007;23(5):283-292. 2. Parison J, et al. Int J Dermatol. 2013;52(2):169-171. 3. Parison J, Canyon DV. Head lice and the impact of knowledge, attitudes and practices—a social science overview. In: Heukelbach J, ed. Management and Control of Head Lice Infestations. UNI-MED, Bremen, Germany; 2010:103-109. 29

Supporting Families

• The school nurse can help students and families cope with the anxiety and stress of head lice episodes1,2

• The nurse has an opportunity to establish ongoing relationships with students and families

– Often perceived as an ally• Offer support and encouragement through:

– Fact-to-face conversations with families– Frequent phone contact– Written materials sent home with the student

• Nurse can serve as case manager– Educating families and providing helpful resources for dealing with infestations – Directing them to their physician or other health care provider to discuss

treatment options– Following up with families

References: 1. Gordon SC. J School Nurs. 2007;23(5):283-292. 2. Schoessler SZ. Am J Manag Care. 2004;10(9 Suppl):S273-S276. 30

The School Nurse: Champion for Evidence-Based Policies

• School nurses can be successful in persuading school districtsto adopt evidence-based approaches:1-4

• Case in point: Lovelock, Nevada2

– School nurse used incremental approach to achieve change• Individual conversations with teachers, administrators• “Lice 101” presentation to school board• Educational letters to parents; fact sheets on myths

• Case in point: 5 school districts in an Iowa county3

• School nurses were called upon to serve as “catalysts for change”– Disseminated information on evidence-based approaches to key stakeholders– Helped develop pediculosis toolkit—“best practice guideline” rather than “policy”– Enlisted local public health department as a key partner

References: 1. Pontius D, Teskey C. Pediculosis management in the school setting. Position statement, NASN, 2011. http://www.nasn.org. Accessed March 28, 2013. 2. Pontius DJ. NASN Sch Nurse. 2011;26(6):356-362. 3. Andresen K, McCarthy AM. J Sch Nurs. 2009;25(6):407-416. 4. Weisberg L. Nasnewsletter. 2009;24(4):165-166.

“The school nurse, as a student advocate and nursing expert, should be included in school district-community planning, implementation, and evaluation of vector control programs for the school setting.”1 —NASN

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Getty Images/joSon.

Summary

• School nurses are important first responders to head lice infestations

• They play a key strategic role in supporting children and families, ensuring privacy, and combating myths and stigma associated with head lice

• School nurses can work collaboratively with parents, physicians, and other health care providers to help manage head lice outbreaks in a calm and professional manner

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Summary (cont)

• School nurses can help their communities by advocating for evidence-based policies and encouraging an end tono-nit policies for school re-entry

• Professional associations such as the AAP are urging pediatricians and other clinicians to become more involved in head lice management and family education

• School nurses can support the AAP guidance by directing students and families to first contact their physician to discuss treatment options

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For More Information …

Selected References• NASN. Pediculosis management in the school setting, 2011 NASN

position statement. http://www.NASN.org• Pontius DJ. Hats off to success: changing head lice policy. NASN Sch

Nurse. 2011;26(6):356-362.• Frankowski BL, Bocchini JA Jr, AAP Council on School Health and

Committee on Infectious Diseases. Clinical report—head lice. Pediatrics. 2010;126(2):392-403.

• Weisberg L. The goal of evidence-based pediculosis guidelines. Nasnewsletter. 2009;24(4):165-166.

• Gordon SC. Shared vulnerability: a theory of caring for children with persistent head lice. J School Nurs. 2007;23(5):283-292.

• Andresen K, McCarthy AM. A policy change strategy for head lice management. J Sch Nurs. 2009;25(6):407-416.

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Visit the Lice Lessons resources area at http://www.NASN.org

Background Information on Approved

Head Lice Products

OTC Prescription

Nix®,a (permethrin, 1%) Lindanec 1% shampoo

RID®,b et al (pyrethrins with piperonyl butoxide)

Ovide®,d (malathion, 0.5% lotion)

Ulesfia®,e (benzyl alcohol,5% lotion)

Natroba®,f (spinosad,0.9% suspension) Sklice®,g (ivermectin,0.5% lotion)

Treating Head Lice: Many Choices

a Nix® is a registered trademark of Insight Pharmaceuticals, LLC. b RID® is a registered trademark of Bayer HealthCare, LLC. c Lindane is manufactured by Morton Grove Pharmaceuticals. d Ovide® is a registered trademark of Taro Pharmaceuticals, U.S.A., Inc. e Ulesfia® is a registered trademark of Shionogi, Inc. f Natroba® is a registered trademark of ParaPRO LLC. g Sklice Lotion® is a registered trademark of Sanofi Pasteur Inc. 36

Please see Important Safety Information for Sklice Lotion at the end of this presentation. Full Prescribing Information for Sklice Lotion will be provided at this session.

Important Safety Information for Sklice LotionThe most common adverse reactions for Sklice (<1%) are conjunctivitis, ocular hyperemia, eye irritation, dandruff, dry skin, and skin burning sensation.

Prescription Lice ProductsLindane, 1%1 Malathion, 0.5%

(Ovide)2Benzyl

alcohol, 5% (Ulesfia)3

Spinosad, 0.9%

(Natroba)4

Ivermectin, 0.5%

(Sklice Lotion)5

Age indication

Use with caution in those <110lb

Safety not shown <6 y

≥6 mo ≥4 y ≥6 mo

Dosage 1-2oz depending on hair length and density

2-oz bottles; apply enough to wet hair

and scalp

4-48oz (varies with hair

length)

Up to 120mL (1 bottle)

depending on hair length

Up to 120mL ( 4-oz tube)

Time of application

4 min; do not re-treat

8–12 hr; repeattreatment in

7-9 d if lice present

10 min; repeat treatment after 7 d

10 min; repeat treatment in

7 d if lice present

10 min; tube is intended for single use only; consult

health care provider prior to

re-treatment

References: 1. Lindane [Prescribing Information]. Morton Grove, IL: Morton Grove Pharmaceuticals; 2005. 2. Ovide [Prescribing Information]. Hawthorne, NY: Taro Pharmaceuticals; 2011. 3. Ulesfia [Prescribing Information]. Florham Park, NJ: Shionogi Inc.; 2012. 4. Natroba [Prescribing Information]. Carmel, IN:ParaPRO, 2011. 5. Sklice Lotion [Prescribing Information]. Swiftwater, PA: Sanofi Pasteur Inc.; 2012. 37

The comparison of product information has not been established in head-to-head trials. The clinical significance of this information has not been established.

Please see Important Safety Information for Sklice Lotion at the end of this presentation. Full Prescribing Information for Sklice Lotion will be provided at this session.

Important Safety Information for Sklice Lotion

IndicationSklice Lotion is a pediculicide indicated for the topical treatment of head lice infestations in patients 6 months of age and older.

Adjunctive MeasuresSklice Lotion should be used in the context of an overall lice management program:Wash (in hot water) or dry clean all recently worn clothing, hats, used beddingand towels.Wash personal care items such as combs, brushes and hair clips in hot water.A fine tooth comb or special nit comb may be used to remove dead lice and nits.

Important Safety Information for Sklice LotionIn order to prevent accidental ingestion, Sklice Lotion should only be administered to pediatric patients under the direct supervision of an adult.The most common adverse reactions (incidence <1%) were conjunctivitis, ocular hyperemia, eye irritation, dandruff, dry skin, and skin burning sensation.

Before administering Sklice Lotion, please see the full Prescribing Information provided at this session.

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