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HEAD LICE: What to Do? A Guide to the Pediatric Patient
US.IVE.13.01.021
Faculty
MODERATOR Bernard A. Cohen, MD Professor of Dermatology and Pediatrics Johns Hopkins University School of Medicine Director of Pediatric Dermatology and Cutaneous Laser Center Johns Hopkins Children’s Center Baltimore, Maryland FACULTY Frank R. Roemisch, MD, FAAP Parkside Pediatrics, S.C Park Ridge, Illinois Wendy L. Wright, MS, APRN, FNP, FAANP Wright & Associates Family Healthcare, PLLC Amherst, New Hampshire Anderson Family Healthcare Concord, New Hampshire
HEAD LICE: What to Do?
A Guide to the Pediatric Patient
Moderator: Bernard Cohen, MD Director of Pediatric Dermatology Johns Hopkins Children’s Center
Dermatlas.org
Head Lice: What to Do? A Guide to the Pediatric Patient
Practical, evidence-based guidance to help you…
Become more involved in the diagnosis and management of head lice
Educate affected families by dispelling the many myths and stigmas surrounding this commonly misunderstood problem
Enhance your clinical understanding of head lice infestations and treatment options
Head Lice Eating You?
Social stigma1
Anxiety, paranoia
Families spend at least $250,000,000/year2
Products range from $10-28/person/Rx
Most recommend 2 Rx/person
Harvard Panel 19993
References: 1. Gordon SC. J School Nurs. 2007;23(5):283-292. 2. Hansen RC, O'Haver J. Clin Pediatr. 2004;43(6):523-527. 3. Pollack RJ, et al. Pediatr Infect Dis J. 2000; 19(8):689-693.
Pediculus capitis plush toy…
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Lice—Historical Perspective
Lice in existence for several million years1
Documented in writing for several thousand2
560 species of blood-sucking lice—only in mammals3
Insects in order Anoplura, only 2 genera infest humans: Pthirus, Pediculus2
3 species in humans: P humanus capitis, P humanus humanus, Pthirus pubis2
References: 1. Meinking T, et al. Infestations. In: Schachner LA, Hansen RC, eds. Pediatric Dermatology.
4th ed. Mosby Elsevier;2011:1535-1583. 2. Lice (pediculosis). In: 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. 3. Huynh TH, et al. Derm Clin. 2004;22(1):7-11.
Head Lice—Historical Perspective
Exodus 8:17: Aaron “stretched out his hand with his rod and smote the dust of the earth, and it became lice in men and beast”
Identified in Egyptian, N. American Indian mummies
Aztecs offered to gods
Young women in Siberia threw at men as sign of affection
Tonga—catching and eating of parents’ lice sign of respect
Medieval Swedes used lice to select mayor
Head Lice—A Cultural Perspective
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Why do we care?
Transient local reactions from saliva1
Papular urticaria1
Scratching and resultant inoculation of fecal material1
Vectors2
– Head/pubic lice: Staph/Strep
– ????HIV, other viruses
References: 1. Meinking T, et al. Infestations. In: Schachner LA, Hansen RC, eds. Pediatric Dermatology. 4th ed. Mosby Elsevier;2011:1535-1583. 2. Lebwohl M, et al. Therapy for head lice based on life cycle, resistance, and safety considerations. Pediatrics. 2007;119(5):965-974.
Head Lice—Presentation
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Closer Examination
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Gravid Females
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Head Lice—Epidemiology
Underestimate of prevalence1
Undeveloped world >90%2
Endemic in US; incidence may be rising
No area free of infestation3
Highest in 3-11 y-o3,4
All races—African-Americans not spared (adaptations of claws or egg-laying anatomy in African organism?)1
Fomites an issue in tropical climates1
References: 1. Meinking T, et al. Infestations. In: Schachner LA, Hansen RC, eds. Pediatric Dermatology. 4th ed. Mosby Elsevier;2011:1535-1583. 2. Gratz NG. Document WHO/CTD/WHOPES/97.8. Geneva:World Health Organization; 1997. 3. Frankowski BL, et al. Pediatrics. 2010;126(2):392-403. 4. CDC. Head lice: epidemiology and risk factors. http://www.cdc.gov/parasites.lice/head.epi.html. Accessed June 30, 2012.
Head Lice—More on Epidemiology
Risk factors: brown, red hair; female?; length not a factor1,2
Girls>boys>women>men1-3
Preference for certain blood types? 2
Reference: 1. CDC. Head lice. Epidemiology & risk factors. http://www.cdc.gov/parasites/lice/head/epi.html. Accessed July 16, 2012. 2. Meinking T, et al. Infestations. In: Schachner LA, Hansen RC, eds. Pediatric Dermatology. 4th ed. Mosby Elsevier;2011:1535-1583. 3. Amirkhani MA, et al. Iran Red Crescent Med J. 2011;13(3):167-170.
Head Lice—Our Study
Learned how to collect critters
Bioassay for crawlers (knockdown time)
Technique for studying nits
Infrastructure for accessing students
Decreased sensitivity to various components of pediculicide
– There have been reports of resistance to both over- the-counter and prescription products; however, the prevalence of resistance is not well studied
Body louse model not adequate
Harvard Panel—19991
Transmission occurs more often at home than at school
No-nit policy is disruptive
Home grooming and exams are essential
Second treatment may be necessary
Reference: 1. Pollack RJ, et al. Pediatr Infect Dis J. 2000; 19(8):689-693.
Head Lice Treatment Clinical Diagnosis
& Treatment
Frank Roemisch, MD, FAAP Parkside Pediatrics, S.C.
Park Ridge, Illinois
Pediculus Humanus Capitis: A Closer Look at the Critter1
The adult louse is 2-3 mm long (size of a sesame seed)
– Usually pale gray; color may vary (red when engorged with blood)
The louse feeds by injecting small amounts of saliva and taking tiny amounts of blood from the scalp every few hours
Lice usually survive less than 1 day away from the scalp at room temperature
References: 1. Frankowski BL, et al. Pediatrics. 2010;126(2):392-403.
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The Life Cycle Of The Head Louse1,2
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.
Female lives 3-4 weeks
Lays ≤10 eggs/day
Eggs tightly attached to hair,
close to scalp
Eggs hatch in 7 – 12 days
Female lays 1st egg 1 or 2 days
after mating
Without treatment, the cycle may repeat every
3 weeks
Become adults 9 -12 days
after hatching
3 nymph stages
1
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Transmission: Think Head-to-Head1,2
Transmission of lice typically occurs by direct head-to-head contact with an infested individual1,2
Indirect spread via contact with personal items (combs, brushes, hats) is less likely but can occur1,2
Itching is the most common symptom
– It may take 4-6 weeks for itching to develop in someone infested for the first time1
• In someone with previous episodes, itching may develop within 48 hours3
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 July 16, 2012. 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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Infection: An Uncommon Consequence1
Although uncommon in the US, secondary bacterial infection may result from pruritus and excoriations associated with head lice infestation. The photo here shows a case of streptococcal-staphylococcal pyoderma.
It is important to note that decreases in the prevalence and severity of scalp pyoderma have been noted following treatment for head lice, even without the use of antibiotics.
Reference: 1. Meinking TL, et al. Infestations. In: Schachner LA, Hansen RC, eds. Pediatric Dermatology. 4th ed. Mosby Elsevier; 2011:1535-1583.
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Careful Inspection Needed For Proper Diagnosis1
A 10-year-old girl complained of scalp pruritus for several weeks. Nits (within white circle) were visible on hairs above the ear. Note the brown scaly fecal material below the hair line (black circle).
Unhatched egg of a head louse, firmly cemented to hair shaft. P
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Reference: 1. Frankowski BL, et al. Pediatrics. 2010;126(2):392-403.
Nymphs, Eggs, and Knowing What To Do
Definitive diagnosis is made by finding a live louse or nymph on the scalp or head1,2
Eggs attached >1 cm from the scalp are usually non-viable1
– In some warmer climates, viable eggs may be found several inches from the scalp3
– Close inspection is needed
Eggs & nits may be confused with dandruff, fibers, scabs, hair casts, droplets of hair spray, plugs of desquamated cells, or particles of dirt1,3,4
References: 1. Frankowski BL, et al. Pediatrics. 2010;126(2):392-403. 2. CDC. Head lice. Diagnosis. http://www.cdc.gov/parasites/lice/head/diagnosis.html. Accessed July 16, 2012. 3. Lice (pediculosis). In: 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. 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.
Guidance On Managing Infestations
Never initiate treatment without a clear diagnosis of head lice1
– Check all household members, other close contacts, and treat if active infestation is found2
In recommending treatment products, consider:1
– Effectiveness
– Safety
– Ease of use
If treatment does not seem to be working, it may be caused by incorrect use or by resistance2
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 June 28, 2012.
– Cost
– Local patterns of resistance (if known)
Other Approaches
Home remedies and “natural” products1
– Essential oils, plant extracts
– Occlusive agents: Mayonnaise, petroleum jelly, tub margarine, Cetaphil cleanser
– Vinegar and vinegar-based products
Removal of nits and lice
– Products containing citric acid, isopropanol, other ingredients
Nit-picking salons
Reference: 1. Frankowski BL, et al. Pediatrics. 2010;126(2):392-403.
Nit-picking Salons: An Emerging Phenomenon
Nit-picking salons have gained favor in certain parts of the US (California, Florida, Texas, Northeastern states) with some franchises1,2
– Advertise a “natural” or “chemical-free” approach to lice and nit removal
– $100 per hour for a “comb-out” is a common fee1,2
Treatments may also include various applications of controlled hot air1,3
References: 1. LiceLifters. http://www.licelifters.com. Accessed July 16, 2012. 2. Texas Lice Squad. http://www.texaslicesquad.com. Accessed July 16, 2012. 3. Goates B, et al. Pediatrics. 2006;118(5):1962-1967.
OTC Pediculicides1,2
Plant-based and synthetic chemical pesticides
– Decreased efficacy of older agents
– Require >1 application and nit combing
– Restrictions in youngest patients
References: 1. Stough D, et al. Pediatrics. 2009;124(3):e389-e395. 2. Burkhart CG. Mayo Clin Proc. 2004;79(5):661-666.
Prescription Pediculicides
Available: 3 products approved since 2009, and 2 decades-old agents
Check the label
– Application times range from 4 minutes to 8–12 hours
– Some require nit combing
– Multiple applications required for some
– Safety considerations and age/weight restrictions
Why Some Cases May Persist After Treatment
1. Misdiagnosis (no active infestation or misidentification)1-3
– Non-lice, non-nit debris may be mistaken for infestation2
– Other conditions may be mistaken for head lice3
• Contact or seborrheic dermatitis, eczema, psoriasis, insect bites, piedra
2. Lack of adherence to the treatment regimen (such as not using enough product to saturate the hair)
3. Reinfestation1
4. Lack of ovicidal or residual killing properties of the product1
5. Resistance of lice to the pediculicide1
References: 1. Frankowski BL, et al. Pediatrics. 2010;126(2):392-403. 2. CDC. Parasites-lice. http://www.cdc.gov/parasites/lice/head/diagnosis.html. Accessed July 16, 2012. 3. Meinking TL, et al. Infestations. In: Schachner LA, Hansen RC, eds. Pediatric Dermatology. 4th ed. Mosby Elsevier; 2011:1535-1583.
Keeping Kids In School
The AAP and National Association of School Nurses state: No healthy child should be allowed to miss school time because of head lice1,2
“No-nit” policies for return to school should be abandoned1,2
School-based head lice screening programs have not had a significant effect on incidence of head lice in schools and are not cost-effective2
School nurses in concert with other health care providers should become involved in helping school districts develop evidence-based policies1
References: 1. Pontius D, Teskey C. Pediculosis management in the school setting, position statement, National Association of School Nurses, 2011. http://www.nasn.org/PolicyAdvocacy/PositionPapersandReports/ NASNPositionStatementsFullView/tabid/462/ArticleId/40/Pediculosis-Management-in-the-School-Setting-Revised-2011. Accessed July 16, 2012. 2. Frankowski BL, et al. Pediatrics. 2010;126(2):392-403.
AAP Issues A Call—Get More Involved In Head Lice Treatment1
Historically, diagnosis of infestations by parents and other non-health care personnel, combined with easy availability of OTC pediculicides, essentially removed the HCP from the treatment process
Treatment failures may result from misdiagnosis, lack of adherence to the treatment regimen, reinfestation, lack of the product’s ovicidal or residual killing properties, and resistance to the pediculicide; these call for increased provider involvement in the diagnosis and treatment of head lice
Health care providers should be knowledgeable about head lice infestations and treatments
– They should take an active role as information resources for families, schools, other community agencies
– Instructions on the proper use of products should be carefully communicated
Reference: 1. Frankowski BL, et al. Pediatrics. 2010;126(2):392-403.
HEAD LICE: What to Do? A Guide to the Pediatric Patient
PATIENT EDUCATION AND COUNSELING
Wendy L. Wright, MS, RN, APRN, FNP, FAANP Adult/Family Nurse Practitioner
Owner, Wright & Associates Family Healthcare, Amherst, NH
Owner, Wright & Associates Family Healthcare, Concord, NH
Objectives
Upon completion of this presentation, the participant will be able to:
– Dispel common myths regarding head lice
– Discuss the role of health care professionals in educating families and colleagues re: head lice
– Provide practical information for families
– Identify strategies for countering the psychosocial impact of infestation
– Share important resources for health care professionals and families
Facts and Myths Regarding Head Lice
Facts:
– Pediculosis is the most prevalent parasitic infestation among humans1
– Head lice infestations are pervasive among school-age children in the United States2,3
– More common in females4
Myth: Head lice affect lower socioeconomic groups
– Fact: All socioeconomic groups are affected2,3
Myth: Head lice are only seen in “dirty individuals”
– Fact: “Head lice prefer clean, healthy hosts”4
References: 1. Hodgdon HE, et al. Pest Manag Sci. 2010;66(9):1031-1040. 2. Roberts RJ. N Engl J Med. 2002;346(21):1645-1650. 3. Centers for Disease Control and Prevention (CDC). Head lice. Epidemiology & risk factors. http://www.cdc.gov/parasites/lice/head/epi.html. Accessed January 4, 2013. 4. Meinking T, et al. Infestations. In: Schachner LA, Hansen RC, eds. Pediatric Dermatology, 4th ed. Mosby Elsevier; 2011:1535-1583.
Myth
Lice can live for days off the human host
– Fact: The louse feeds by injecting small amounts of saliva and taking tiny amounts of blood from the scalp every few hours1
– Fact: Lice usually survive less than 1 day away from the scalp at room temperature1
Reference: 1. Frankowski BL, et al. Pediatrics. 2010;126(2):392-403.
Myth
Lice can be transmitted easily from one person to another
– Fact: Transmission of lice typically occurs by direct head-to-head contact with an infested individual1-3
– Indirect spread via contact with personal items (combs, brushes, hats) is less likely but can occur1-3
References: 1. Meinking T, et al. Infestations. In: Schachner LA, Hansen RC, eds. Pediatric Dermatology. 4th ed. Mosby Elsevier; 2011:1535-1583. 2. Lice (pediculosis). In: Paller AS, Mancini AJ, eds. Hurwitz Clinical Pediatric Dermatology. 4th ed. New York, Elsevier Saunders, 2011:424-427. 3. Frankowski BL, et al. Pediatrics. 2010:126(2):392-403.
Myth
Head Lice are associated with bacterial infections, including MRSAa
– Fact: In the United States, secondary infections from head lice are very rare1
Reference: 1. AAP. Pediculosis capitis (head lice). In: Red Book. Pickering LK, ed. 29th ed. Elk Grove Village, IL, AAP, 2012:543-546.
a MRSA = Methicillin-resistant Staphylococcus aureus
Role of the Health Care Professional1
Health care professionals are essential in head lice diagnosis, treatment, prevention, and education
Key role in diagnosis
– Head lice are often confused by laypersons— and even health care providers—with dandruff, seborrhea, and other skin conditions
Vital role in education
– Education of co-workers, colleagues, families, and patients
Reference: 1. Frankowski BL, et al. Pediatrics. 2010:126(2):392-403.
Diagnosis
Should encourage health care providers to bring individuals into the office for diagnosis
Refrain from phone diagnosis to avoid over-utilization of treatment options
Home Remedies
Very little science exists in many of the “Internet-based” recommendations1
Avoid recommendations for treatments not scientifically based
– Expensive options
Contribute to frustration and leave child or family ineffectively treated
Some of these treatments can be very dangerous to the individual’s health
Reference: 1. Frankowski BL, et al. Pediatrics. 2010;126(2):392-403.
Important Education
Health care providers need to familiarize themselves with the range of treatment options
Whatever treatment is recommended, the health care provider should offer instructions on proper use – If product information calls for repeat treatment in
2 weeks, this should be performed
– If nit picking is recommended, it should be conducted
Educate families about potential for treatment failure with certain products – Treatment failures may result from misdiagnosis, lack of
adherence to the treatment regimen, reinfestation, lack of ovicidal or residual killing properties of the product, and resistance of the lice to the pediculicide1
– Resistance patterns for particular products can be regional; actual prevalence of resistance is not known1
Reference: 1. Frankowski BL, et al. Pediatrics. 2010;126(2):392-403.
Removing “No-Nit Policies”
The American Academy of Pediatrics and National Association of School Nurses state:
– No healthy child should be allowed to miss school time because of head lice1,2
“No-nit” policies for return to school should be abandoned1,2
School nurses, in concert with other health care providers, should become involved in helping school districts develop evidence-based policies1
References: 1. Frankowski BL, et al. Pediatrics. 2010;126(2):392-403. 2. Pontius DJ. Pediculosis Management in the School Setting. National Association of School Nurses (NASN). 2011 Position Statement. http://www.nasn.org. Accessed January 7, 2013.
Social Stigma1,2
A study published in 2007 in The Journal of School Nursing looked at 20 parents in southeast Florida caring for ≥1 school-age child with persistent head lice (defined as ≥3 active infestations in a 6-week period)1
Primary stigma
– Stigma faced by persons with an undesirable characteristic or health condition
– “Spoiled social identity”
Courtesy stigma
– Stigma faced by unaffected persons due to association with a person who bears a stigma
References: 1. Gordon SC. J Sch Nurs. 2007;23(5):283-292. 2. Goffman E. Stigma: Notes on the Management of Spoiled Identity. New York, NY, Simon & Schuster, Inc., 1963.
Caregiver Strain1
Caring for children with persistent head lice may produce “caregiver strain,” as parents/caregivers share vulnerability to social stigma with their child
Stigmatizing characteristics may include:
– Presence of live lice
– Presence of nits (viable and nonviable)
– Observable itching
Feelings of stigma associated with head lice may persist long after successful treatment
Reference: 1. Gordon SC. J Sch Nurse. 2007;23(5):283-292.
Role of Health Care Providers
Educate affected families in order to dispel myths about head lice
Affirm correct diagnosis of head lice
Recommend appropriate treatment, as needed
Resources for Health Care Providers, Educators, and Parents
Centers for Disease Control and Prevention – http://www.cdc.gov/parasites/
National Association of School Nurses, 2011 policy statement – http://www.nasn.org/PolicyAdvocacy/PositionPapersandReports/
NASNPositionStatementsFullView/tabid/462/ArticleId/40/ Pediculosis-Management-in-the-School-Setting-Revised-2011
American Academy of Pediatrics, Clinical report—head lice – Frankowski BL, et al. Pediatrics. 2010;126(2):392-403.
American School Health Association, 2005 policy statement – http://www.ashaweb.org/files/public/Resolutions/Pediculosis.pdf
American Academy of Dermatology, parent resources – http://www.kidsskinhealth.org/grownups/lice.html
Web MD, Head lice slideshow: What parents should know – http://children.webmd.com/ss/slideshow-lice-overview