Faculty Discussion: Definitive Management of Head Lice in the Era of Pediculicide Resistance

The following are highlights from a teleconferenceamong the faculty that took place on May 26, 2004.Elliot F. Ellis, MD, affiliate professor of internalmedicine at the University of South Florida, St.Petersburg, moderated the discussion.

Ms Meinking: My first comment is about DrWest's statement that schools can losefunding when children are absent becauseof no-nit policies. From our research, we areaware of schools in poor districts that werelosing millions of dollars in state fundingbecause of absenteeism from lice infestations.After discovering that infestations werenot being controlled, putting schools at continualfinancial risks, the state is no longerpenalizing schools and is simply ignoring no-nitpolicies.

In the regions where we have done ourresearch, lice infestations are so bad thatpeople use veterinary products. Ivermectin,which is a systemic option to failed topicaltreatment, has been used in this populationvery effectively and safely. We have used itto treat children and have had very goodoutcomes. Another topical option is HairClean 1-2-3, which is an OTC [over-the-counter]product. It has a 15-minute applicationtime and produces good results.

Dr Hansen: It's also flammable, isn't it, MsMeinking?

Ms Meinking: Yes, it is flammable becauseit has a high alcohol content. One reasonwe investigated this product is becausepeople use all kinds of occlusive products,such as mayonnaise or olive oil. We heardreports of children getting food poisoningbecause mayonnaise was applied to theirhair and left on overnight. We decided toreview alternative therapies, includingocclusive agents and Hair Clean 1-2-3. Theproblem with food items such as mayonnaiseis that they become a growth mediumfor bacteria. Also, they are messy; when theyreach body temperature, they begin to dripdown the neck. Unfortunately, they have noeffect on lice. When we removed the mayonnaisefrom our patients' heads, the licewere unaffected and were able to crawl. Sothe idea that mayonnaise immobilizes liceisn't true. Another product that is marketedOTC and claims to kill both lice and eggson contact is Lice Freee!, a sodium chlorideproduct. I was hired by a company thatwanted to purchase this product and askedme to evaluate its efficacy. Another evaluationwas performed by David Taplin. Weboth found that the product did not work.Since Lice Freee! has such impressiveadvertising and packaging, I called the FDA[Food and Drug Administration] to ask howthe manufacturers could make claims thatthe product killed on contact when it doesnot. The FDA responded that the product isconsidered to be holistic, so it is not regulatedas closely as pharmaceutical products,for example.

Dr Ellis: Yes, many nutritional stores andtheir products are exempt from certain FDAregulations.

Ms Meinking: Another product that wasmentioned is the shampoo with tea treeextract. You can also purchase tea tree oiland put it into shampoo, although it isexpensive. It can be an irritant. Outside theUnited States, I have found it packaged witha skull-and-crossbones label.

Dr Hansen: Ms Meinking, would you tell usmore about Hair Clean 1-2-3? I think that'sone product that many practitioners aren'tas familiar with as school nurses are. Ihaven't been able to find it in nutritionstores.

Ms Meinking: It is made by a company inEugene, Oregon, called Quantum. At onetime it was carried by Walgreens, Eckerd,and many chain drugstores. But it did notsell very well and was removed from theshelves. It's now available at some healthfood stores.

Dr Hansen: And you believe it probably hasan efficacy rate of over 70%? Are 2 applicationsused?

Ms Meinking: Yes. There is a 15-minuteapplication period, and it's a nonaerosolspray. It has good ovicidal properties and efficacyof more than 70%. It should be appliedtwice. I have reviewed the product data andwas impressed by it. But this product is 40%alcohol and is flammable, although it doesn'thave a flammability label on it.

Dr Hansen: I spent 10 years in pediatricsbefore I went into dermatology, and I wasvery concerned about organophosphates. Allof these products are insecticides, and Iunderstand why pediatricians shy awayfrom them. But there's been no toxicity withmalathion. Frankly, even field exposure toaerosolized malathion produces less mammaliantoxicity than many other insecticides.The liquid formulation really is so safewhen used as directed. I don't think theorganophosphate part of it is even an issue.The flammability is, but if it is used asdirected, and if you use a shortened applicationtime….

Ms Meinking: Yes. For 20 minutes. Youcould have a child sit for 20 minutes andwatch him. You could put on a video to keephim entertained.

Dr Hansen: Most children could sit still for20 minutes. You want to be careful.

Dr Frankowski: Right, but can the mothernot smoke a cigarette for 20 minutes?

Dr Hansen: The product is labeled withan international sign with a flame. Sincemalathion is a prescription product, patientsreceive instructions from the pharmacist.There's only so much you can do. MsMeinking's new data says all of the live licewere killed in 10 minutes. You could treattwice using 10-minute applications.

Ms Meinking: Yes, I followed a child who hadonly an 8-minute application of malathion,and she had no lice after 2 weeks.

Dr Hansen: But you're trying to kill the nits,really. Your study was aimed at a 20-minuteperiod. That's not very long, really, and takescare of the flammability issue. I think pediatriciansare still alarmed by the labelingregarding flammability.

Ms Meinking: Yes, I do, too. I think 10 minuteswould work [to kill the nits]. I conducteda study in Panama where everyone livedin a thatched hut. They had their cookingfires inside the thatched huts. Malathion wasapplied and left on overnight and with noshower cap or head covering. But as I wasapplying it, for the 10 minutes or so that ittook to saturate hair, I could actually see thenits just collapse. Malathion just dehydratesthem.

Dr West: There are several things that wouldhelp us control the treatment. If you shortenthe treatment time and supervise patients,then you can use a product that has a fastand high kill rate.

Dr Frankowski: If physicians begin to prescribeshorter application times for malathionand supervise treatment, so morepeople begin to feel comfortable using it,what are the chances of malathion resistanceoccurring?

Ms Meinking: Lice shouldn't becomeresistant to malathion with the shortapplication and its fast action. Also severalother ingredients in OVIDE havepediculicidal properties. Malathion resistancehas been documented elsewhere in theworld, but resistance to OVIDE has not beendocumented.

Dr Hansen: So there's malathion resistanceelsewhere but no OVIDE resistance in NorthAmerica?

Dr Frankowski: Because of the vehicle?

Ms Meinking: Exactly. The terpineol anddipentene are active ingredients.

Dr Hansen: Yes, but the problem with promotingshort application times is that thelabeling has not been changed. I've beenprescribing short application of malathionfor my patients for 3 years. But the pharmacistwon't tell patients they can do thatbecause it is an off-label use. It would take alot of money to conduct new studies for theFDA to support a labeling change. Thatwould be the sensible thing to do, though, toeliminate pediatricians' worries aboutabsorption and flammability. Those disappearif you're only applying it for 20 minutes.

Dr Frankowski: Right, that would make abig difference.

Dr Hansen: That's what we should bedoing–using shorter applications. If youuse malathion for only short periods, thenit would not be necessary to use systemicagents. As a pediatrician, I have a basicproblem with giving systemic agents liketrimethoprim/sulfamethoxazole, or even ivermectin,to treat an ectoparasite. You have tobuild it up in the child's bloodstream so feedingon the blood kills the louse. It works, butI think it's the wrong model for treatingectoparasites. It's different if you're treatingcrusted scabies, which is a morbid disease.But to give ivermectin to every child in thecountry with head lice seems to me an oddmodel for treatment.

Dr Frankowski: I'd like to highlight MsSchoessler's comments that school nursescan act as case managers for families thathave persistent problems. Then we could beselective about using these other products.Otherwise, everyone wants the easy, first linetreatment. If the school nurse can performselective screenings of symptomaticchildren, rather than school-wide screenings,that would be really helpful.

When the AAP [American Academy ofPediatrics] statement came out against no-nitpolicies, school nurses were outraged.They thought no-nit policies were the bestcourse of action. But there was a case of achild who had long-term head lice fromkindergarten on and had never been lice-free.The school nurses realized that thechild would be home all of the time, so theybegan to act as case managers for her. Anurse would come in every morning, 10minutes before school, and comb out thechild's hair and eliminate the lice theyfound. No other child was infested becausethe nurses managed the case so thoroughly.Interestingly, everyone assumed the girl hadresistant lice. But she was eventually sent tofoster parents who were able to followinstructions for an OTC pediculicide, andthe child was lice-free after only 1 week.

Ms Schoessler: Yes, family plays a pivotalrole. The school nurse or teacher can have adifficult time trying to figure out if the problemis because of resistant lice or treatmentfailure. That's a huge issue in the school.Unfortunately, the school nurse can't gohome with every child to see what the familyis doing.

Dr Hansen: But you could apply themalathion for 20 minutes at school.

Ms Schoessler: Well, that becomes an interestingissue because most school nurses arenot based at health clinics. We also need tobe aware of the legalities of scope of practicefor school nurses.

Dr Hansen: Ms Schoessler, what percentageof the school districts in the country do youthink have a no-nit policy?

Ms Schoessler: I don't have that information,but I have begun to see schools moveaway from no-nit policies.

Dr Hansen: If I'm not mistaken, almost 4years ago in California, about the time theybanned lindane, they also instituted a no-nitpolicy for the whole state.

Ms Schoessler: States may adopt policiesbased on the prevalence of infestations inthe state. I live in a northern state, so thedecline in no-nit policies may have somethingto do with a lower prevalence of infestations.Some nurses that I speak to who livein southern states deal with the head liceissue differently than we do in the northernareas.

Dr Hansen: I think that someday no-nitpolicies will be tested for legality. Schoolhealth law generally requires a compellingreason to exclude a child from school. Theremust be a public health interest. That is whya child who is HIV-positive cannot beexcluded; the disease cannot be easily transmitted,so there is no public health risk.Attending school is actually a property right.Excluding a child is like taking away a car, ahouse, the child's educational future. It'smoney out of the child's future if they sendhim home from school without a compellingpublic health reason. That's why we don'texclude children for viruses that cause muchgreater morbidity than head lice. Even juvenileswho have been incarcerated have theright to come back to school.

There is no compelling public health reasonto exclude a child from school because oflice. The National Pediculosis Associationhas influenced everyone to adopt no-nit policies.They were well intentioned, but theywere wrong. I don't think these policieswould stand legal testing. A lawsuit is theonly way we're going to get it changed at apolicy level. Otherwise, it's going to be schooldistrict by school district. As you said in yourpresentation, Ms Schoessler, the administratorscome under pressure, and then theypressure school nurses and teachers.

Ms Schoessler: The National Association ofSchool Nurses [NASN] published a positionstatement against no-nit policies in 1999,and it's being updated now. The statementcontinues to support the point that nit-freepolicies disrupt the educational process.

Dr Hansen: But some nurses at the locallevel still feel the pressure.

Ms Schoessler: It's a highly charged subject.If I call parents to tell them that their childhas strep throat, where there still are complicationsin this day and age, I get a completelydifferent reaction than if I call to say,"Your child has head lice." It's so emotionallycharged.

Ms Meinking: It can have serious consequences.I've seen parents lose their jobsbecause they missed work to care for theirchild who was sent home from school. If achild has repeated infestations, some parentsare reported to Health and HumanServices by the school.

Dr Frankowski: I think, too, this speaks tothe importance of the AAP partnering withthe NASN to make sure that we have soundpolicies and procedures for people to follow.We need to be able to say to parents who areangry, "Let me show you what the guidelinessay." It's very valuable to have procedures inprint and to be able to calmly and rationallysay, "Let's look at this, let's keep everybody'sdignity and everybody's best interestat heart, but this reflects the best interests ofall students."

Dr Hansen: I can't agree with that more.The Academy's position has been in placesince 1972, and the NASN policy has beenavailable since 1999. But I think mostschool districts in the country still have no-nitpolicies.

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