Supplements Definitive Management of Head Lice in the Era of Pediculicide Resistance
Faculty Discussion: Definitive Management of Head Lice in the Era of Pediculicide Resistance
The following are highlights from a teleconference
among the faculty that took place on May 26, 2004.
Elliot F. Ellis, MD, affiliate professor of internal
medicine at the University of South Florida, St.
Petersburg, moderated the discussion.
Ms Meinking: My first comment is about Dr
West's statement that schools can lose
funding when children are absent because
of no-nit policies. From our research, we are
aware of schools in poor districts that were
losing millions of dollars in state funding
because of absenteeism from lice infestations.
After discovering that infestations were
not being controlled, putting schools at continual
financial risks, the state is no longer
penalizing schools and is simply ignoring no-nit
In the regions where we have done our
research, lice infestations are so bad that
people use veterinary products. Ivermectin,
which is a systemic option to failed topical
treatment, has been used in this population
very effectively and safely. We have used it
to treat children and have had very good
outcomes. Another topical option is Hair
Clean 1-2-3, which is an OTC [over-the-counter]
product. It has a 15-minute application
time and produces good results.
Dr Hansen: It's also flammable, isn't it, Ms
Ms Meinking: Yes, it is flammable because
it has a high alcohol content. One reason
we investigated this product is because
people use all kinds of occlusive products,
such as mayonnaise or olive oil. We heard
reports of children getting food poisoning
because mayonnaise was applied to their
hair and left on overnight. We decided to
review alternative therapies, including
occlusive agents and Hair Clean 1-2-3. The
problem with food items such as mayonnaise
is that they become a growth medium
for bacteria. Also, they are messy; when they
reach body temperature, they begin to drip
down the neck. Unfortunately, they have no
effect on lice. When we removed the mayonnaise
from our patients' heads, the lice
were unaffected and were able to crawl. So
the idea that mayonnaise immobilizes lice
isn't true. Another product that is marketed
OTC and claims to kill both lice and eggs
on contact is Lice Freee!, a sodium chloride
product. I was hired by a company that
wanted to purchase this product and asked
me to evaluate its efficacy. Another evaluation
was performed by David Taplin. We
both found that the product did not work.
Since Lice Freee! has such impressive
advertising and packaging, I called the FDA
[Food and Drug Administration] to ask how
the manufacturers could make claims that
the product killed on contact when it does
not. The FDA responded that the product is
considered to be holistic, so it is not regulated
as closely as pharmaceutical products,
Dr Ellis: Yes, many nutritional stores and
their products are exempt from certain FDA
Ms Meinking: Another product that was
mentioned is the shampoo with tea tree
extract. You can also purchase tea tree oil
and put it into shampoo, although it is
expensive. It can be an irritant. Outside the
United States, I have found it packaged with
a skull-and-crossbones label.
Dr Hansen: Ms Meinking, would you tell us
more about Hair Clean 1-2-3? I think that's
one product that many practitioners aren't
as familiar with as school nurses are. I
haven't been able to find it in nutrition
Ms Meinking: It is made by a company in
Eugene, Oregon, called Quantum. At one
time it was carried by Walgreens, Eckerd,
and many chain drugstores. But it did not
sell very well and was removed from the
shelves. It's now available at some health
Dr Hansen: And you believe it probably has
an efficacy rate of over 70%? Are 2 applications
Ms Meinking: Yes. There is a 15-minute
application period, and it's a nonaerosol
spray. It has good ovicidal properties and efficacy
of more than 70%. It should be applied
twice. I have reviewed the product data and
was impressed by it. But this product is 40%
alcohol and is flammable, although it doesn't
have a flammability label on it.
Dr Hansen: I spent 10 years in pediatrics
before I went into dermatology, and I was
very concerned about organophosphates. All
of these products are insecticides, and I
understand why pediatricians shy away
from them. But there's been no toxicity with
malathion. Frankly, even field exposure to
aerosolized malathion produces less mammalian
toxicity than many other insecticides.
The liquid formulation really is so safe
when used as directed. I don't think the
organophosphate part of it is even an issue.
The flammability is, but if it is used as
directed, and if you use a shortened application
Ms Meinking: Yes. For 20 minutes. You
could have a child sit for 20 minutes and
watch him. You could put on a video to keep
Dr Hansen: Most children could sit still for
20 minutes. You want to be careful.
Dr Frankowski: Right, but can the mother
not smoke a cigarette for 20 minutes?
Dr Hansen: The product is labeled with
an international sign with a flame. Since
malathion is a prescription product, patients
receive instructions from the pharmacist.
There's only so much you can do. Ms
Meinking's new data says all of the live lice
were killed in 10 minutes. You could treat
twice using 10-minute applications.
Ms Meinking: Yes, I followed a child who had
only 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-minute
period. That's not very long, really, and takes
care of the flammability issue. I think pediatricians
are still alarmed by the labeling
Ms Meinking: Yes, I do, too. I think 10 minutes
would work [to kill the nits]. I conducted
a study in Panama where everyone lived
in a thatched hut. They had their cooking
fires inside the thatched huts. Malathion was
applied and left on overnight and with no
shower cap or head covering. But as I was
applying it, for the 10 minutes or so that it
took to saturate hair, I could actually see the
nits just collapse. Malathion just dehydrates
Dr West: There are several things that would
help us control the treatment. If you shorten
the treatment time and supervise patients,
then you can use a product that has a fast
and high kill rate.
Dr Frankowski: If physicians begin to prescribe
shorter application times for malathion
and supervise treatment, so more
people begin to feel comfortable using it,
what are the chances of malathion resistance
Ms Meinking: Lice shouldn't become
resistant to malathion with the short
application and its fast action. Also several
other ingredients in OVIDE have
pediculicidal properties. Malathion resistance
has been documented elsewhere in the
world, but resistance to OVIDE has not been
Dr Hansen: So there's malathion resistance
elsewhere but no OVIDE resistance in North
Dr Frankowski: Because of the vehicle?
Ms Meinking: Exactly. The terpineol and
dipentene are active ingredients.
Dr Hansen: Yes, but the problem with promoting
short application times is that the
labeling has not been changed. I've been
prescribing short application of malathion
for my patients for 3 years. But the pharmacist
won't tell patients they can do that
because it is an off-label use. It would take a
lot of money to conduct new studies for the
FDA to support a labeling change. That
would be the sensible thing to do, though, to
eliminate pediatricians' worries about
absorption and flammability. Those disappear
if you're only applying it for 20 minutes.
Dr Frankowski: Right, that would make a
Dr Hansen: That's what we should be
doing–using shorter applications. If you
use malathion for only short periods, then
it would not be necessary to use systemic
agents. As a pediatrician, I have a basic
problem with giving systemic agents like
trimethoprim/sulfamethoxazole, or even ivermectin,
to treat an ectoparasite. You have to
build it up in the child's bloodstream so feeding
on the blood kills the louse. It works, but
I think it's the wrong model for treating
ectoparasites. It's different if you're treating
crusted scabies, which is a morbid disease.
But to give ivermectin to every child in the
country with head lice seems to me an odd
model for treatment.
Dr Frankowski: I'd like to highlight Ms
Schoessler's comments that school nurses
can act as case managers for families that
have persistent problems. Then we could be
selective about using these other products.
Otherwise, everyone wants the easy, first line
treatment. If the school nurse can perform
selective screenings of symptomatic
children, rather than school-wide screenings,
that would be really helpful.
When the AAP [American Academy of
Pediatrics] statement came out against no-nit
policies, school nurses were outraged.
They thought no-nit policies were the best
course of action. But there was a case of a
child who had long-term head lice from
kindergarten on and had never been lice-free.
The school nurses realized that the
child would be home all of the time, so they
began to act as case managers for her. A
nurse would come in every morning, 10
minutes before school, and comb out the
child's hair and eliminate the lice they
found. No other child was infested because
the nurses managed the case so thoroughly.
Interestingly, everyone assumed the girl had
resistant lice. But she was eventually sent to
foster parents who were able to follow
instructions for an OTC pediculicide, and
the child was lice-free after only 1 week.
Ms Schoessler: Yes, family plays a pivotal
role. The school nurse or teacher can have a
difficult time trying to figure out if the problem
is because of resistant lice or treatment
failure. That's a huge issue in the school.
Unfortunately, the school nurse can't go
home with every child to see what the family
Dr Hansen: But you could apply the
malathion for 20 minutes at school.
Ms Schoessler: Well, that becomes an interesting
issue because most school nurses are
not based at health clinics. We also need to
be aware of the legalities of scope of practice
for school nurses.
Dr Hansen: Ms Schoessler, what percentage
of the school districts in the country do you
think have a no-nit policy?
Ms Schoessler: I don't have that information,
but I have begun to see schools move
away from no-nit policies.
Dr Hansen: If I'm not mistaken, almost 4
years ago in California, about the time they
banned lindane, they also instituted a no-nit
policy for the whole state.