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The summer holidays and the new school year often see an increase in parasite infections. This is an area where parents will welcome your advice

While parents and children are enjoying the summer break from school, now is the time for you to prepare for the new school year, which brings an influx of parasite infections, from head lice and threadworm to scabies and bed bugs. It’s important to be aware of head lice during the holidays too, says Christine Brown, ex-school nurse and consultant to the Medical Entymology Centre. “Families are on holiday and meeting new people for short periods and head lice are often taken on holiday too,” she says.

“Families also visit relatives who they might not see at other times. Focusing just on school ensures that parents don’t think they are likely to get them outside of term-time and they don’t think it’s necessary to check, yet more product for head lice is sold during the holidays. Sleepovers and parties are the head louse’s best social get-togethers.”

There are varying figures on the incidence of head lice in the UK. A Welsh study of 31 primary schools found an incidence of 8.3 per cent, another found that one in 10 children have head lice at any one time, while a poll in 2011 found that 48 per cent of four to 11-year-olds had experienced them in the past year.

A recent Which? survey found that 49 per cent of children aged seven to nine have had head lice in the last two years. The peak age for infection is seven to eight years. A couple of recent studies blame the ‘selfie’ trend for an increasing number of teens affected by head lice.

“This may be a factor, but lice will only spread from one head to another if heads are put together for a considerable length of time,” says head lice expert Joanna Ibarra, programme adviser at Community Hygiene Concern.

Signs of infection

Head lice are notoriously difficult to spot and often there are no symptoms. “Discourage parents from relying on an itchy head before they check for lice and also just checking through with their fingers – neither are reliable,” says Joanna.

Itching often doesn’t develop for weeks or months after an infection takes hold and can persist for weeks after treatment. Parents may spot a rash behind the ears or at the back of the neck, caused by a reaction to lice droppings.

How to detect head lice effectively

As there are often no obvious signs of infection, the only way to detect head lice is with an effective checking method. “Regular checks for the at-risk group are important in identifying infestation at the earliest stage. However, many people don’t know how to do it, use the wrong type of comb to check and parents often forget to check themselves too,” says Ian Burgess, head lice expert at the Medical Entymology Centre, Insect Research & Development.

The highest risk group are children under 12, girls, families with four or more children and those with long hair. Joanna also stresses the importance of checking heads regularly. “Encourage customers to use the three national bug busting days each year, which means everyone checks at the same time.”

The days are: 31 January, 15 June and 31 October each year. Christine advises parents to check for lice once a week. “It’s really important to check the whole family weekly, especially when there are cases at school,” she says. Detection combing is the most reliable method.

It can be done on wet or dry hair, though wet combing is more reliable as lice are motionless when wet so are easier to spot and remove. Customers will need a fine toothed detection comb with teeth spacing of 0.2-0.3mm to trap lice. Suggest the following method:

  • Wash hair using ordinary shampoo. Apply plenty of conditioner
  • Use a wide toothed comb to untangle hair
  • Take a detection comb and carefully comb through hair from roots to ends
  • Remove any lice by rinsing or wiping the comb
  • Work through section by section so the whole head is thoroughly combed through
  • Rinse off the conditioner and repeat the combing on wet hair.

If customers are not sure if they have found lice, get them to attach any they find to sticky tape and bring them into the pharmacy for confirmation.

 

The lice life cycle

The head louse has three stages of development:

  1. The female louse lays eggs close to the scalp. The eggs are pinhead sized and hard to spot. Unhatched eggs look dull and are well camouflaged
  2. Eggs hatch in seven to 10 days. Unless removed, the empty eggshells (nits) remain stuck to the hair shaft. The nits glisten and become easier to spot as hair growth carries them further from scalp
  3. The lice take nine to 10 days to mature and are 3mm long. They usually only crawl from head to head once fully grown and feed on blood. A female louse can start laying eggs from nine days after hatching, so to break the cycle and stop lice spreading, they need to be removed before then. Lice lay six to eight eggs a day and about 150 during their 30-day life span.

How are lice spread?

Head lice can’t jump, swim or fly, but they can climb quickly between hair shafts and between heads when there is prolonged contact. They are unlikely to spread via hats, combs or pillows. Once removed from the head, lice will die within one to two days if unable to feed on human blood.

Treating head lice

Advise customers that treatment is only needed if live lice are found. In the past, head lice were usually treated with insecticides alone, but lice have developed resistance to many of these. Most of the treatments used today have a physical action and are silicone or oil-based. Parents can treat lice using wet combing alone or together with a head lice treatment product.

Wet combing method

Similar to detection combing, the wet combing method of treatment can be used to remove head lice. “If you want to wet comb effectively, you need to spend a lot of time and effort and repeat, repeat, repeat,” says Ian. “It’s important to recommend the right type of comb too.” Teeth should be spaced 0.2-0.3mm apart.

  • Wash hair with shampoo and apply lots of conditioner
  • Use a wide toothed comb to untangle hair
  • Once the comb runs through easily, switch to a fine toothed comb
  • Draw the comb slowly through hair from roots to tips
  • Check the comb for lice after every stroke
  • Remove lice by rinsing and wiping the comb
  • Rinse out conditioner
  • Repeat combing process
  • Repeat on days three, six, nine, 12 and 15 to remove young lice as they hatch.

Medicated treatments

There are two types of treatments available: physical and chemical. Physical treatments work by blocking the oxygen supply of the lice. Chemical treatments act by poisoning or paralysing the nervous system of the lice.

Physical products contain dimeticone or isopropyl and cyclomethicone. The only chemical treatment currently recommended contains malathion. Permethrin is no longer recommended by the BNF.

Treatments should be used according to instructions and applied twice with seven days between applications. Why has treatment failed? A common complaint that pharmacy staff hear is that “head lice treatments don’t work”.

One reason is that many customers don’t repeat the treatment as advised, believing once is enough. Another reason is trying to economise with the product. It’s also important to repeat the detection process after treatment to ensure it has been successful.

It is always possible that re-infection has occurred. “Not following instructions carefully is a key reason for failure. It can be hard to remove all lice in just one treatment, which is why most products advise two treatments,” says Christine.

It’s also worth noting that some parents will seek treatment for head lice infection when itching is in fact caused by eczema or impetigo. Remind customers that itching can persist for several weeks after an infection has cleared up.

Other common parasites

Threadworm

Common among children under 10, these tiny parasitic worms hatch eggs in the large intestine. They look like tiny pieces of white thread and parents may notice them in the child’s stools or around their bottom. A common symptom is itching around the anus or vagina, which can be worse at night and disturb sleep.

Severe or persistent cases can cause loss of appetite, weight loss, skin infection and sleep difficulties. The important thing to remember is that all household members need to be treated, even if they have no symptoms, as the risk of the infection spreading is very high. Mebendazole is the main medication used and works by preventing the threadworms from absorbing sugar, which causes them to die within a few days, and is 90-100 per cent effective.

However, it doesn’t kill eggs, so strict hygiene measures should be followed for six weeks. Mebendazole isn’t recommended for pregnant or breastfeeding women or children under two – refer these patients to the pharmacist for advice. Hygiene measures to recommend include:

  • Wash all night clothes, bed linen, towels and soft toys when first diagnosed
  • Thoroughly vacuum the whole house, especially bedrooms
  • Damp dust kitchens and bathrooms regularly
  • Keep fingernails short and discourage nail-biting/sucking fingers
  • Wash hands frequently and scrub under nails
  • Wear close fitting underwear at night
  • Bath or shower each morning
  • Don’t share towels/flannels
  • Keep toothbrushes in a cupboard and rinse before use.

Scabies

This contagious skin condition is caused by tiny mites that burrow into the skin. It is spread by direct physical contact.

The main symptom is intense itching, especially at night. You’ll notice a rash of tiny red spots all over the body and burrow marks can be found anywhere on the body – these are short, wavy, silver-coloured lines with a tiny black dot at one end. All family members should be treated as well as sexual partners.

Permethrin 5% cream is usually recommended as the first treatment and malathion 0.5% lotion if this isn’t effective. The cream or lotion should be applied all over the skin and left on for eight to 24 hours (depending on which treatment is used) before washing off. Advise customers to wash bed linen, nightwear and towels after the first application and repeat the treatment process seven days after the first application.

Bed bugs

These small, blood-sucking insects live in the cracks and crevices around beds. At night, they bite exposed skin and feed on blood. Some people develop itchy red bumps after being bitten that last several days.

Bites are usually found on the face, neck, hands or arms, often in straight lines. Adult bed bugs look like small lentils, and are flat, oval shaped and up to 5mm long. They spread easily from room to room.

Bites can be treated with antihistamine cream or cream containing steroids to relieve itching. Customers should be advised to contact their local council or a pest control firm to get rid of bed bugs. A specialist may use a heat and steam treatment rather than insecticide, as bugs have developed resistance to some of these.

Ticks

These tiny spider-like insects are found mainly in woodland and heath areas. They feed on animal and human blood and can carry the bacteria that cause Lyme disease. There are about 2,000 to 3,000 new cases of Lyme disease in England and Wales each year.

Many people with early stage Lyme disease develop a circular rash at the site of the tick bite around three to 30 days after being bitten, but one in three people won’t develop a rash. Some people experience flu-like symptoms in the early stages. If left untreated, more serious symptoms can develop months or even years later, including swollen joints, problems affecting the nervous system, heart problems and meningitis.

Any customer who thinks they may have been bitten by a tick (with or without a rash) should be referred to the pharmacist. The customer may need to see a GP who should prescribe antibiotics and then a blood test for Lyme disease. This may need to be repeated, as early tests often come back negative.

If a tick is found on the skin, gently remove by gripping it as close to the skin as possible, using fine tweezers. Pull steadily without crushing the tick. Apply antiseptic cream after removal. To avoid being bitten by a tick, advise customers to:

  • Avoid walking through long grass
  • Wear trousers and long sleeves when walking in tick-infested areas such as woodland and heaths
  • Use insect repellent on exposed skin
  • Inspect skin for ticks and promptly remove any if found
  • Check that pets do not bring ticks indoors on their fur.

 

Myth busting

  • “Wet combing doesn’t work”: Not true – it does work if the right type of comb and a methodical method is used
  • “Lice can jump between heads”: Not true – they can only crawl from head to head
  • “Head lice like dirty hair”: Not true – having lice has nothing to do with hygiene
  • “Pets can carry lice”: Not true – head lice only live on human heads
  • “Itching is a sure sign of lice”: Not true – it normally takes weeks for an infection to cause itching, and some people never itch
  • “Head lice are the same as nits”: Not true – nits are just empty eggshells
  • “Head lice only affect children”: It’s true that most cases are in under-16s, but about 20 per cent are in other age groups.

 It can be hard to remove all lice in just one treatment, which is why most products advise two treatments

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