Intended for healthcare professionals

Letters

Experience based treatment of head lice

BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7347.1220 (Published 18 May 2002) Cite this as: BMJ 2002;324:1220
  1. Liz Crossan, freelance technical editor

    EDITOR—Head lice are a familiar problem to most doctors, but especially to general practitioners and those who have children. Ten of the 17 responses to Dodd's editorial were from doctors, and all but four were from the United Kingdom. 1 2 Many respondents enthusiastically described the strategies that had worked for their children, most favouring variations on the theme of wet combing, a strategy deemed ineffective in the editorial.

    Robert Bunney, one of four general practitioners responding, reports that his children repeatedly required treatment, and although the infestations usually responded to various pediculicides, the children soon became reinfected. In exasperation he turned to wet combing and kept them clear until the epidemic waned. The combing method, he adds, although initially seeming to have less success than pediculicides, will at least retain or even increase its effectiveness as parents become more skilled in using it and realise that resistance can't occur.

    C H Kimberley, another general practitioner, says: “We are regularly told that head lice only transfer on prolonged head to head contact, that head lice off the head lose their infectiveness, and that wet combing is ineffective. My son brought head lice home from school. We all used a permethrin lotion, following the manufacturer's instructions. It failed. We used wet combing with louse comb and conditioner, which succeeded…. Common sense suggests that regular bug busting (which, like the application of pesticides, needs to be done correctly) should be used.”

    Community Hygiene Concern (www.chc.org/bugbusting) provides kits and instructions at a reasonable cost. Product costs must be considered, writes Joanna Ibarra, programme coordinator for the charity. If chemicals are used each new case requires two doses. In contrast, a single bug buster can be used for the whole family, is reusable, and often leads to cure.

    Dry combing with conditioner is advocated as the most effective way of finding and treating head lice in primary schoolchildren on Australian government website found by Phillip Colquitt (www.health.qld.gov.au/phs/shpu/9169_doc.pdf). “Use enough conditioner to thoroughly cover the whole scalp and all hair from the roots to the tips.”

    Rowan Harwood, a consultant geriatrician, confirms that two applications each of phenothrin and permethrin to lice on his children's heads were ineffective, although they did seem to kill the adults. He was, however, unimpressed by the combing and conditioner regimen, especially in long hair, and resorted to picking out the juvenile lice by hand. “They are just visible to the naked eye and can be crushed between finger nails. It takes some forbearance on the part of the children”—on day 1 he retrieved 42 lice from one head, but by day 7 no more lice were appearing.

    Jenny Muiry extols the virtues of using a fine tooth comb. But buyers beware: many combs are ineffective as they can extract only adult lice, and so nit combing is seen as ineffective. She has successfully used a two-piece comb (ITAX; Gadimex) that has barely any space between the teeth and can extract the smallest juvenile lice. She applies a simple protocol (wash hair and apply conditioner; brush and then comb hair thoroughly; rinse) every four days while there are still signs of nits (at least two weeks).


    Embedded Image

    Some variant of wet combing may yet be the best way to zap me and mine

    (Credit: http://www.headlice.org/)

    Gary Jackson, a public health doctor from New Zealand, urges discussion of the electronic comb, Robi Comb, which is powered by a battery and proved effective for his children. It makes a humming sound until it finds a louse, at which point the louse is “zapped” and the humming stops. After the comb's teeth are cleaned the humming starts again and you can look for more lice.

    No effectiveness trials for the electric comb are available yet, but at least one general practitioner, John Charlton, says that the few electric combs he has seen have failed miserably and are not a patch on combing (everyone) three times a day. Ms Ibarra and colleagues explain that their main drawback is that they must be used on dry hair for safety reasons and head lice move rapidly away from any disturbance in dry hair, thus evading the teeth. In addition, anything caught in the teeth, including scalp debris, will cut off the current, allowing lice in the vicinity to escape while the comb is cleaned.

    The simplest and most effective treatment found by Wendy Taylor, a consultant neuroradiologist and veteran of multiple infestations in her three children, is a shampoo of tea tree oil followed by extraction of the nits with ordinary conditioner and a lice comb. “This should be repeated every two or three days for a week or so.” Nigel Hill, a medical entomologist in London, has a word of warning, though. “Although many pharmacists advocate tea tree oil as a cure for lice, most are unaware that, volume for volume, it is more toxic to mammals than malathion.”

    Finally, Colin Dewar, a research psychiatrist, recommends an extremely short haircut, followed by a sponge over the scalp with methylated spirits. “Neat alcohol is highly toxic to arthropods, without causing any damage to the skin of humans when used occasionally.” So not much has changed then since the shaved heads, shame, and nit picking of around 100 years ago.

    References

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