what makes one louse able to survive treatment with permethrin and another louse unable to survive?
Dtsch Arztebl Int. 2016 Nov; 113(45): 763–772.
Continuing Medical Education
Head Lice
Epidemiology, Biology, Diagnosis, and Treatment
Falk Ochsendorf
oneSection of Dermatology, Venereology and Allergology, University Infirmary Frankfurt/Primary
Received 2016 Feb xviii; Accepted 2016 Aug 16.
Abstract
Groundwork
Alien information about the proper treatment of head lice has given rise to dubiety among patients and treating personnel. For example, the reported efficacy of permethrin roughshod from 97% in the 1990s to thirty% in 2010.
Methods
Review of the literature based on a selective search of PubMed.
Results
In Germany, outbreaks of head lice mainly occur among v- to 13-year-olds returning to school after the summer vacation. Nymphs hatch from eggs later an average of viii days and become sexually mature lice over the ensuing 9 days. The main route of transmission is direct head-to-head contact; transmission via inanimate objects is of no relevance. Symptoms arise 4–6 weeks later on an initial infestation; many affected persons accept no symptoms at all. Wet combing is the most sensitive method of establishing the diagnosis and monitoring treatment. Resistance to neurotoxic pediculocidal drugs is increasing around the world. Dimethicones are the treatment of option, with 97% efficacy. Outbreaks must be managed with the synchronous handling of all infested persons to break the chain of infestation. If the agent used is non ovicidal, the treatment must be repeated in 8–10 days and sometimes in a further 7 days every bit well.
Decision
Outbreaks of head lice can be successfully terminated by synchronous treatment with ovicidal dimethicones.
Normally, the prevalence of head lice in the general population of industrialized countries is low. Infestations occur virtually exclusively in vulnerable groups: schoolhouse children, homeless people, refugees, and slum dwellers (prevalence 0.7% to 61% [1, 2]). In the USA it is estimated that vi to 12 one thousand thousand head lice infestations occur every twelvemonth (e1). Having head lice is usually associated with negative feelings and tin atomic number 82 to negative consequences such as quarantine, overtreatment, or postponement of surgery (iii, 4). Since treatment resistance is on the increase, probably due to the large-scale employ of neurotoxic pediculicides (v), this article is intended to provide an account of the present land of knowledge. Farther bones information will exist institute in review articles (half dozen– nine, e2).
A selective literature search of PubMed was carried out using the search terms "head lice" OR "pediculosis capitis." As the final review on this topic in Deutsches Ärzteblatt was published in 2005 (half-dozen), the search was restricted to the fourth dimension menses subsequently this date. The search filter "randomized controlled trial" was employed in compiling the Tabular array.
Tabular array
Randomized controlled studies on treatment for head lice infestation using substances licensed as topical therapeutic agents in Germany (all evidence level B, publication engagement 2003 or later)
| Author/yr/ reference | Study location | Number of probands | Plant-based topical treatments | |
| Burgess IF et al. 2010 (e28) | United Kingdom | 100 children | Substance A | Coconut and anise spray |
| Cure rate | 83% | |||
| Unwanted drug effects | Itching and burning awareness | |||
| Substance B | Permethrin 0.5% | |||
| Cure rate | 44% | |||
| Unwanted drug effects | Itching and called-for awareness | |||
| Mumcuoglu KY et al. 2004 (e29) | Jerusalem | 198 children/adolescents | Substance A | iii.7% citronella solution |
| Cure rate | 88% | |||
| Unwanted drug furnishings | Itching, unpleasant smell | |||
| Substance B | Placebo | |||
| Cure rate | l% | |||
| Unwanted drug furnishings | No information | |||
| Writer/year/reference | Report location | Number of probands | Topical handling with dimethicone | |
| Burgess IF et al 2005 (e30) | U.k. | 253 children/adults | Substance A | Dimethicone |
| Cure rate | 70% | |||
| Unwanted drug effects | No information | |||
| Substance B | Phenothrin 0.v% | |||
| Cure rate | 75% | |||
| Unwanted drug furnishings | No information | |||
| Heukelbach J et al. 2008 (e21) | Brazil | 145 children | Substance A | 2-stage dimethicone |
| Cure rate | 97% | |||
| Unwanted drug effects | Ocular irritation | |||
| Substance B | Permethrin one% | |||
| Cure rate | 67% | |||
| Unwanted drug effects | None | |||
| Kurt O et al. 2009 (e22) | Turkey | 72 children/adults | Substance A | Dimethicone |
| Cure rate | 92% | |||
| Unwanted drug effects | No information apart from "no adverse events" | |||
| Substance B | Dimethicone + nerolidol two% | |||
| Cure rate | 86% | |||
| Unwanted drug furnishings | No information autonomously from "no adverse events" | |||
| Burgess IF et al. 2013 (e31) | Uk | 90 children/adults | Substance A | Dimethicone |
| Cure rate | 77% | |||
| Unwanted drug furnishings | Dry skin | |||
| Substance B | Permethrin ane% | |||
| Cure rate | 16% | |||
| Unwanted drug effects | Rash | |||
| Writer/twelvemonth/reference | Study location | Number of probands | Topical treatment with permethrin and phenothrin | |
| Tanyuksel M et al. 2003 (e32) | Turkey | 566 | Substance A | Permethrin i% |
| Cure rate | 94% | |||
| Unwanted drug furnishings | No information | |||
| Substance B | D-Phenothrin 0.iv% | |||
| Cure rate | 76% | |||
| Unwanted drug furnishings | No data | |||
| Author/year/ reference | Written report location | Number of probands | Moisture combing | |
| Loma Due north et al.2005 (e24) | Great britain | 126 children/adolescents | Cloth A | Louse detection comb |
| Cure rate | 57% | |||
| Unwanted drug effects | No information | |||
| Substance A | Malathion 0.v% | |||
| Cure charge per unit | 17% | |||
| Unwanted drug effects | No data | |||
| Substance B | Permethrin i% | |||
| Cure rate | 10% | |||
| Unwanted drug effects | No information | |||
Evidence level B: lower-quality randomized clinical studies (e.thousand., single-blinded, intention-to-treat analysis non used)
Learning goals
After reading this article, the reader will exist competent to treat head lice infestation effectively; he or she will be able to
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explain the life bicycle and manual routes of head lice,
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explicate how to diagnose an infestation, and
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give recommendations for treatment.
Epidemiology
The spread of head lice depends on spatial and temporal factors, including the number of susceptible hosts, the elapsing of the infestation, and the elapsing and nature of "hair-to-hair" contact. The event is the occurrence of outbreaks of head lice infestation in kindergartens and schools (10). At that place are no population studies on incidence. Prevalence studies from many parts of the earth exist, but they are not directly comparable because:
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Diagnostic methods vary in sensitivity. Compared with wet combing, visual inspection of v predilection sites underestimated prevalence by a factor of iii.5 (xi).
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In Germany, head lice infestations bear witness a seasonal rhythm, with a peak between the middle of September and the end of Oct (later the summer holidays) (12).
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Prevalence varies from region to region fifty-fifty within one country (10).
Prevalence studies practice not, therefore, reflect the true prevalence of this parasitosis in the population (e3).
Those most frequently afflicted are children between the ages of iv and 12. A screening program in Braunschweig (Brunswick) carried out between Oct 2006 and July 2007, in which 1890 children starting school for the first fourth dimension (aged v to vi years) had their heads visually inspected for head lice and nits, resulted in an estimated incidence of 598/10 000 (point prevalence 0.7%) (13). In a questionnaire-based study in Norway, a point prevalence of i.six% was found in a chief school, but in one out of iii households surveyed head lice infestation had occurred in the past. It emerged that more than densely populated areas showed a college prevalence of previous head lice infestation than less densely populated areas. Prevalence was also dependent on the number of children in a household (x), or, every bit was shown in another written report, increased when the number of persons in the household went above 6 (14).
In i large report in Belgium, in which 6169 kindergarten and school children (anile 2.5 to 12 years) were examined using the sensitive "wet combing" method, a point prevalence of 8.9% was shown (and 4.six% of children examined had nits, indicating a previous infestation) (14). The schoolhouse or class visited had a stronger influence on prevalence than individual characteristics of the children. Infestation risk was higher for children with lower socio-economical status, more children in the family unit, longer hair, and brown hair. Xiv days afterward the screening examination, despite appropriate treatment recommendations, head lice were still demonstrated in 41% of children (14). The reason for this was probably lack of handling, wrong treatment, or lack of synchronized treatment. Inadequate personal hygiene was not mentioned as a gamble factor in any report.
Depending on the endemic region, girls were more than often affected by head lice than boys (ratio in Turkey 12:1, in Australia 2:1) (e3, e4). Lice and nits remain undetected for longer in girls' longer hair, and are harder to treat in that location (8). Having short hair halved the risk (15). The college prevalence in girls can be explained by this and past gender-typical behaviors (girls grouping together more closely, boys are but briefly in contact during play); it is not a reflection of any biologically determined increased susceptibility in girls. Merely pilus length and the hair colors "dark-brown" (xiv) or "brown and red" (e5) were identified as independent risk factors for head lice infestation. It was assumed that lice can remain undetected for longer in hair of these colors because of their own coloring.
Caput lice infestation was associated with densely populated areas, more children or people in i household, longer hair, female person sex, and dark-brown hair colour.
Biology of the head louse
It is thought that sucking lice of primates co-evolved with their hosts over a catamenia of at least 25 million years. Around ii million years ago, human lice differentiated into three different groups with different geographic distributions (five).
The development bike of head lice is shown in Figure 1. The time taken by a head louse to develop has implications for handling.
Life cycle of the head louse adapted from(16, 17, e6)
Eggs are glued to the base of the hairs, immediately next to the scalp. From egg lay to hatching of the first nymphs takes an average of 8 days. A recent report indicated that this interval was up to 13 days in 1.2% of samples examined. Variations are probably due to differences in hair density, temperature, and moisture on different parts of the scalp (17). Egg lay occurs preferentially at the temples, backside the ears, and at the back of the cervix (e7). Female lice produce an average of five eggs per twenty-four hours (e8, 18). Caput lice live for nigh 21 days (18). Even first-generation nymphs are mobile, although they move significantly more than slowly than full-grown lice (19). The egg cases (nits) plant on growing hair >ane cm away from the scalp are empty and are not a sign of active infestation.
In Cardinal Europe, commonly fewer than 10 lice per head are establish (5). In Australia, the number plant in one study was significantly college [mean n = thirty/head (20)].
Near head lice dice without ingesting more blood within 30 hours later on the terminal feed (18). In terms of infection epidemiology, still, all that is relevant is how long they remain infectious. It may be causeless that, as a consequence of dehydration, caput lice not in contact with heads are unable to produce saliva, feed on blood, and hence transmit infection (21). Although there are no data near the survival rate of eggs laid off-host, information technology is unlikely that nymphs can hatch from dehydrated eggs (21). Recommendations for x-24-hour interval quarantine of rooms used by people in whom head lice accept been found (e9) thus have no rational basis. Thus, the key to infection command is to treat the infested heads, not the environment (21).
The immune system of the head louse has a smaller chapters for phagocytosis than that of the body louse (e10). All the same, it has been shown that caput lice tin carry Rickettsia prowazekii (the causative amanuensis of classical typhus) and Bartonella quintana (which causes trench fever, also known equally Wolhynia fever), and probably all infectious pathogens reported for torso lice (e11). In rural Federal democratic republic of ethiopia, B. quintana was found in 7% of head lice (e12) and Borrelia recurrentis (the causative amanuensis of relapsing fever) in 23% (22). In the context of the large migrations currently occurring, relapsing fever has been diagnosed in African refugees (23). And then far, however, information technology remains unclear what role may actually take been played by head lice in the transmission of these diseases, but they are regarded every bit unimportant compared to torso lice since, because there are fewer of them, less saliva is transferred (v).
Transmission routes
Pediculosis humanus capitis, the human head louse, is a highly specialized parasite of the human scalp. The main manual route for head lice is therefore close caput-to-head contact. The main place where this occurs is in children during play. Manual via objects is a rare exception and is epidemiologically irrelevant (e13).
This is withal a contentious issue, with proponents on both sides (for: [e9]; against: [21]). Although the "pro" side adduces show from in vitro studies that do not lucifer atmospheric condition in nature, such every bit manual through the utilise of a hair dryer or combing or toweling pilus, and egg lay on constructed textiles among other things (19), the "contra" side has large quantities of data from clinical field studies to draw on. These include, for instance, the fact that not a single head louse was establish in 1000 caput coverings of schoolchildren with head lice (north = 5500 lice found on their heads) (e14). Likewise, no head lice were constitute on the floors of classrooms in a school with a head lice epidemic (20). Simply for a few individuals with high-intensity infestation were a few nymphs found on their pillow the following morn, then that a pocket-sized, negligible risk of infestation exists, which can be further reduced past washing the pillow case (24). Transmission through the use of a shared hairbrush is likewise strictly possible, but unlikely (21). In vitro, caput lice survived for up to 20 minutes in water, irrespective of what kind of water information technology was (25 °C, deionized water, ocean water (100%), salt solutions (30, 60, 120, 240 g/L), and chlorinated water (0.2, two und v mg/L). During this time they were completely immobilized. During a 30 minute experimental swim in a pool, neither developed lice nor older nymphs were lost from hair. This makes transmission in swimming pools unlikely (25).
The time to infestation varies depending on where the louse is at the time of contact. Probably it is in the order of a few minutes. The man caput louse can move along a pilus model at a speed ranging from 9.5 ± 1 (19) to up to 23 cm/min (e9). No in vivo data are bachelor on this point. Transmission depends on temporal and spatial factors. For example, lice migrated more than easily to a neighboring hair when it was presented slowly, from behind, and parallel to their torso axis. At an angle of 90°, no transmission took place (26).
Manual is dependent on the life bicycle of the louse. Synchronized treatment is therefore essential to prevent a serial of overlapping infestations within a group.
Clinical aspects
The most tangible symptom of a head lice infestation is itching. This is caused by an allergic reaction to louse saliva and for this reason does not occur immediately with a start-time infestation, but just afterwards four to 6 weeks when sensitization has taken place. On reinfestation, itching starts afterwards only 2 days.
At the back of the neck the excoriated "head lice rash" is seen, which can be subject to secondary infection with Staphylococcus aureus or streptococci. The hairs go encrusted and stuck together, and the cervical lymph nodes may peachy. However, not everybody affected by head lice experiences itching (just 14% to 36%); frequently it is only the lice themselves, discovered incidentally, that lead to the diagnosis (13, 27, e15). Just when an infestation is really heavy could anemia become a possibility (28, 29).
Diagnosis
Inspection lonely does not suffice for diagnosis, fifty-fifty if the entire head is examined (30). In an Israeli study of 7- to 10-year-erstwhile schoolchildren, direct inspection plant head lice in simply 6%, compared to 25% when a nit rummage was used (e17). Active infestation is therefore all-time identified using the "moisture combing" technique (box) using a nit detection comb (tooth spacing 0.2 mm) (11). Metal nit combs appear to remove more than lice, eggs, and nits from the hair (up to three times more) than do plastic nit combs (31). If one wishes only to make up one's mind an infestation that is already over, i.e. to detect only nits and unviable eggs, visual inspection is superior to moisture combing (eight).
One live louse is enough to make the diagnosis (5). However, misinterpretations are frequent. In the The states, only 59% of all samples sent to an expert center contained typical lice or eggs. In 35% of re-examined samples, dandruff had been incorrectly interpreted equally lice, and in 5% other arthropods had been similarly misinterpreted. Only 53% of material that had been interpreted every bit living actually showed the relevant living parasite phase. Accordingly, 62% of patients had been incorrectly "overtreated" with potentially unsafe substances (32).
Treatment
The Table shows the results of randomized controlled trials of topical agents licensed for employ in Germany against head lice.
Neurotoxic topical agents
Overuse of neurotoxic pediculicides (organophosphates: malathion, carbamate [carbaryl], pyrethrin [chrysanthemum extract]) or pyrethroids (synthetic derivatives: permethrin, phenothrin, deltamethrin) has resulted in resistant populations of head lice on all continents (e18, 33).
Double and cross-resistances take been shown, underlying which was a indicate mutation in the region of the alpha subunit of the neuronal sodium channels (kdr gene) (34, e19). The efficacy of permethrin fell from 97% in the 1990s to 30% in 2010 (e20).
As a rule, neurotoxic substances are well tolerated. However, they have been criticized because of the possibility of resorption, hypersensitivity, and neurological complications later accidental swallowing, and a potentially increased risk of leukemia (v).
Topical treatment with dimethicones
In direct comparisons, dimethicones were more effective than permethrin (e21). Dimethicones are constructed silicone oils. They spread very well on surfaces and work in a purely mechanical mode past sealing the spiracles (animate pores) of the caput lice. In that location is therefore no reason to anticipate the development of resistance. They are not toxic (35).
With 4% dimethicone and 96% cyclomethicone, 70% to 92% efficacy was achieved, depending on the number of head lice (e22). A mixture of ii dimethicones showed an efficacy of 97% irrespective of the severity of the infestation (e21).
In vitro, this mixture even killed off young and mature eggs (95% and 100% respectively), whereas the monopreparation and neurotoxic drugs were ineffective (36). When ovicidal substances were likewise used, a single treatment appears to be normally sufficient.
Dimethicones, especially cyclomethicone, are combustible. For this reason, contact with potential sources of burn down, such as cigarettes or hair dryers, should be avoided during treatment.
Systemic treatment
The efficacy of ivermectin has been well documented in several clinical studies. The dosage is 200 µg per kilogram body weight (2 × in a seven-day menses). The cure charge per unit is upwards to about 97% (37, 38, e23). Ivermectin is not licensed for the treatment of head lice in Germany, simply may be considered for apply on an private footing, e.thou. in a patient with concurrent scabies. It is contraindicated in persons with a trunk weight of less than 15 kg, and in meaning or breastfeeding women.
Culling treatment options
Repeated moisture combing (box) is likewise effective. Co-ordinate to one study in the Uk, mechanical removal with a detection comb (no information was given about how often information technology was used) was fifty-fifty more effective than a single application of a pediculicide (e24). The optimum procedure is to comb every 3 days until after four successive combings no more than head lice are found.
This approach is recommended peculiarly for significant and nursing mothers, babies, patients with open up wounds on the scalp, patients with asthma, and any who have reservations most using chemical substances (39).
Cleansing the environment after a head lice infestation
If parents wish, they can thoroughly cleanse combs and pilus brushes in hot soap solution, even though the gamble of transmission is negligible. Head lice in pillows are killed past washing at >60 °C or drying for 15 minutes in a dryer at 60 °C. Cold washing and hanging up to dry were ineffective (24). Treatment of furniture upholstery and carpets is not necessary since the lice, as already described, only survive for a brusque fourth dimension away from their host, so that transmission via textiles is irrelevant in terms of infection epidemiology (21). In improver, no studies exist about whether the washing of wear prevents reinfestation or small-scale outbreaks.
Studies accept shown that lice can only exist removed with normal commercially bachelor vacuum cleaners for floors; so-called table or handheld vacuum cleaners are inadequate for louse removal (19). In the lay media, the recommendation is repeatedly seen to go on all nonwashable textiles, underwear, bed linen, and soft toys in closed plastic bags for 3 days. This recommendation has no ground in science.
Handling failure
The efficacy of treatments as shown in in vitro or controlled studies is non usually achieved in practise. This may be due to wrong application: the exposure time is too curt, too lilliputian of the substance is applied, it is unevenly applied, or the solution is too weak once it is applied to hair that is dripping wet.
Another mode of failure is when echo treatment fails. Unless an ovicide is used, the treatment must be repeated on twenty-four hour period 8 (day ane = get-go day of treatment) so as to eliminate the nymphs that were protected inside eggs at the fourth dimension of the first treatment before they are sexually mature and can lay new eggs (Figure 2). Studies have shown that afterward egg lay some nymphs may hatch afterwards, after 13 days (17). In the worst case, therefore, nymphs that survived the commencement repeat treatment undamaged inside the egg may not hatch until the 13th day. The only way to eliminate these would exist a third treatment on day 15 (Effigy 2). Ovicides, on the other hand, only demand to be applied once.
Treatment for caput lice Form over time of therapeutic interventions in the life cycle of the caput louse
Moreover, asymptomatic individuals, specially children, can be undetected carriers. This explains recurrent minor outbreaks (e25), and is the reason why potentially infested contact persons, such as family unit and play group, must all be treated at the same time ("synchronized treatment"). Mathematical modeling has shown this to be effectual (40). When safe pediculicides such as dimethicone are used, this can as well be given equally a "blind" recommendation, when it is non possible to perform diagnostic wet combing.
Legal requirements
In Germany, the presence of head lice is not a notifiable illness- or pathogen-specific condition nether the Infection Protection Human activity (IfSG, Infektionsschutzgesetz). However, co-ordinate to paragraph 34, section 6, of the IfSG, senior managers of community facilities must notify the relevant health authority immediately if an outbreak of head lice occurs in either members of the public or personnel (e26). The notification must name the persons affected. Consequently, the parents of children affected past head lice are under an obligation to inform the management of the public facility (school) so that the management tin can inform the health authority. In the instance of an outbreak of head lice, information technology may exist assumed that after competent treatment using appropriate means, farther spread of the outbreak is very unlikely. Consequently, any person who has been treated may return to the building (e.yard., school) on the mean solar day subsequently treatment. The Infection Protection Deed does non require that a doctor'due south certificate be obtained.
Acknowledgments
Translated from the original High german by Kersti Wagstaff, M.A.
Footnotes
Conflict of interest statement
The authors declare that no conflict of involvement exists.
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