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Lice detectives

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Lice detectives

With the new school term on the horizon, parents will be concerned about the increased risk of head lice and are likely to turn to the pharmacy for advice on preventing and managing infestations

Most people will have had experience of head lice. But despite being a common condition – particularly among schoolchildren aged seven to 11 – many people remain unsure about how to detect and treat lice. Pharmacy teams can play an important role in encouraging parents and carers to keep an eye out for signs of head lice, as well as advising on the different treatment options. 

However, Ian Burgess, lice expert and president of the International Society of Phthirapterists (phthiraptera are lice), says if parents leave thinking about lice until the new term they are already too late. “Lice have a great time over the summer when people’s minds are on other things, children meet other children and lice meet new heads,” he says. “Of course, all those new infestations coming into contact with others can increase the number of cases, but actually the only reason lice figures go up – and sales of louse products go up – in September is because people suddenly think about them and the companies gear their advertising to that time to gain maximum effect.” 

Playing detective

So what do you need to tell customers about detecting head lice? Hedrin brand manager Caroline Wheeler says the place to start is by advising them to check their child’s hair regularly using a fine-toothed comb with teeth no more than 0.3mm apart. “Combing hair when wet or with a conditioner can make this more comfortable,” says Caroline. “Parents are looking for a live louse, which could range in size from a pin head to four millimetres in length, and if these are discovered then treatment is required.” 

Treatment pros and cons

Caroline says there is strong evidence that the head louse population has and is continuing to develop resistance to a number of traditional pesticides, particularly permethrin. This is partly due to inappropriate and overuse of these agents over a long period, she explains. Because of this, Ian says: “Nobody in their right mind uses an insecticide-based product these days because there is too much resistance about – and why use pesticides when there are plenty of alternatives?” Similarly, he says there is not much point using herbal treatments as none of these have been clinically tested in rigorous clinical trials. “Using a normal tea tree shampoo might reduce dandruff, but it only makes lice cleaner and smell different,” he says. “Anyway, many essential oils have the same mode of action as the pesticides, so they are often affected by resistance.” 

The other options are physically acting chemicals, primarily synthetic oils of some sort, and mechanical removal through combing. Ian says mechanical removal is “theoretically OK and does work if you put in enough effort, but many people use the wrong kit and most do not do it with enough intensity”. To get it right, Ian advises using a detection comb at least every three to four days for a minimum of two weeks. He warns: “The main problem people encounter is removing a few lice, thinking they have done a good job and then stopping. You really have to do a thorough job of getting right down to the skin with the comb (not scratching it) and making repeated strokes of the comb over the same area. However, there are some children – especially blonde children with very fine hair – on whom it is very difficult because the lice have adjusted to the environment and sit so close to the skin that you cannot get the comb underneath them.” 

As for the physically acting chemical products – mostly silicone based, some other synthetic oils, and one wetting agent (1,2-octanediol) – Ian advises ‘buyer beware’ as not all products have published clinical evidence to support the claims made for them. 

Tackling treatment failure

If treatment does appear to fail, user error or the wrong choice of product are two of the most common factors. In order to avoid this, Ian says users should check that: 

  • The product has evidence of efficacy
  • Enough of the product was used – girls with long, thick hair often need more than one bottle
  • It was applied thoroughly and spread through the hair right down to the scalp with a comb
  • A second application was given if required. 

“Also, it is wise to detection comb a couple of days after a treatment to check that there are no surviving lice,” says Ian, “and if problems persist, change to a different product or method to see if that solves the problem.” 

Caroline says pharmacy staff also need to check that parents understand what to expect from treatment:

  • Does it need a second application to deal with hatchlings or has the product been shown to work with one application?
  • If it is a physical killer that doesn’t work by poisoning, then it needs to cover the hair completely
  • Empty or dead eggs (nits) left on the hair after treatment need to be removed physically. Their presence is not a sign that treatment hasn’t worked
  • Children may still feel itchy after treatment, but don’t assume that the product hasn’t worked – use a detection comb to check.

Is prevention possible? 

Ian says that preventing lice infestations is not easy, and customers shouldn’t be swayed by untested treatments: “There are repellents around, but nobody has produced any evidence they are effective – they all rely on in vitro test results. There are also some ‘quack’ products about like impregnated hair bands – how could they possibly work?”

It’s important to remember that the whole family should be checked to guard against the problem of re-infestation. “One common issue is that someone in the house who may have had lice was overlooked,” says Ian. “I’ve had mums who said ‘Oh the boy never gets them’ but when you check, he has thousands, and also I’ve encountered mums who say they have not got them themselves ‘because they check’, but actually they have more than the kids, so these people are passing them back.”

Unwanted visitors

Children – and adults – can fall prey to other common parasitic and fungal infections, so it’s important to know what to advise: 

Threadworm

A common infection, particularly in children under 10 years, threadworms are tiny, white parasitic worms that infect the large intestine and lay their eggs around an infected person’s anus, usually at night. Along with the eggs, the worm secretes a mucus that causes itching. If the eggs get stuck on the person’s fingertips when they scratch, they can be transferred to their mouth or onto surfaces and clothes. If other people touch an infected surface, they can then transfer the eggs to their mouth. Threadworms only infect humans. 

Treatment: Mebendazole is the main medication used and is available over the counter (OTC) as chewable tablets or liquid. It works by preventing threadworms absorbing sugar, so they die within a few days. All household members must be treated, even if they don’t have any symptoms. Although extremely effective at killing threadworms, mebendazole doesn’t kill their eggs, so hygiene measures such as regular vacuuming and thoroughly washing bathrooms and kitchens should also be followed for six weeks to avoid spreading the eggs.

When to refer: Customers should see their GP if they think they have threadworms and are pregnant or breastfeeding, or have a child under two years of age with threadworms, as the recommended treatment is usually different. People should also see their GP if the infection continues two weeks after treatment, as they may need a second dose of medication.

Ringworm

Ringworm is a common fungal infection (not actually a worm) that can cause a red or silvery ring-like rash on the skin that may be scaly, inflamed and itchy. Although not serious, it is contagious and easily spread.

Treatment: Most ringworm infections are mild and can be treated using an antifungal cream. Scalp infections can be treated with antifungal tablets – available on prescription – sometimes combined with an antifungal shampoo.

When to refer: If the skin is irritated or broken, it can lead to other bacterial infections, which may need treatment with antibiotics. Customers don’t need to see a doctor unless the condition persists, although it can be worth advising that children see a GP to confirm a diagnosis.

Scabies 

Scabies is a contagious skin condition caused by tiny mites that burrow into the skin. The main symptom is intense itching that’s worse at night. It also causes a skin rash on areas where the mites have burrowed.

Treatment: Scabies is usually serious and needs immediate treatment. The two most widely used treatments are permethrin and malathion, which are available OTC, and both contain insecticides that kill the scabies mite. Permethrin 5% cream is usually recommended as the first treatment. Malathion 0.5% lotion is used if permethrin is ineffective. GPs can prescribe treatments such as a mild steroid cream to reduce the itchiness, but pharmacy also has products that can help. Menthol cream or gel can relieve itchy skin, and oral sedative antihistamines can control itching and give a better night’s sleep. Non-sedating antihistamines do not help relieve the itching of scabies.

Bed bugs 

Bedbugs are small blood-sucking insects that live in cracks and crevices in and around beds and crawl out at night to bite exposed skin and feed on blood, like mosquitoes. After being bitten, some people develop itchy red bumps which appear in straight lines on the face, neck, hand or arm and can last for several days. Although bedbugs can be upsetting to find, they aren’t dangerous and don’t transmit any human diseases. Most people don’t develop any serious skin reaction. However, action should be taken straight away to prevent the spread of an infestation.

Treatment: Once in the home, bedbugs are hard to get rid of, and the advice from NHS England is to contact your local council or a pest control firm, who will use insecticide, a steamer or a rapid freeze system to get rid of the bugs. To tackle the bugs themselves, customers should wash clothes or bed linen at 60°C or put in a tumble dryer on a hot setting for 30 minutes to kill them, dismantle furniture and thoroughly vacuum it, disposing of the contents in a sealed bag. Insecticide spray for bedbugs can be used to kill remaining bugs, but should not be used on clothing, linen or mattresses.

Parents are looking for a live louse, which could range in size from a pin head to four millimetres in length

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