The Pharmaceutical Journal Vol 267 No 7164 p317
8 September 2001

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Pharmacy-based head lice management

With children returning to school this month, pharmacists are an ideal first port of call for parents to get advice on head lice management. Community pharmacy head lice management schemes are being set up across Britain. Zoë Gross reports

Sources of information

Head lice are transmitted by direct, head-to-head contact with an infected person. They are primarily a problem for the community as a whole rather than just for schools and can present both during term time and school holidays. Both children and adults can catch head lice but those most at risk are pre-school and primary school children and their families. So pharmacists need to be able to teach parents the technique of detection combing and be prepared to advise on appropriate treatment.

Head lice management schemes are being set up in community pharmacies across Britain. One such scheme is in operation in Sunderland and 50 community pharmacies in the area now offer a head lice service. The Sunderland scheme is based on a National Pharmaceutical Association pilot project for managing head lice in Nottingham. It was developed by a team of pharmacists, doctors and nurses and provides evidence based health care advice.

Similar schemes are now in place in County Durham, Glasgow and Cambridge. A further scheme is expected to start up in Calderdale and Kirklees next week. To provide the service pharmacists must have received additional training and accreditation. Accreditation enables them to be paid both a dispensing fee and a fee for counselling patients. It also allows them to supply certain lotions for head lice on prescription to those exempt from prescription charges, and to be reimbursed.

As part of the service in Sunderland pharmacists first have to identify whether the patient actually has head lice. Patients are counselled on how to detect head lice, supplied a detection comb free of charge and given a contact trace sheet. They are asked to check all people living in the same household and told to return to the pharmacy with any lice found, stuck to a leaflet provided by the pharmacist, within seven days. Infected patients are then supplied an appropriate product, as recommended in the scheme, and counselled by the pharmacist on its use. Only those family members who are infected are treated.

Matthew Shaw, NPA professional development co-ordinator for northern England, involved in running the Sunderland scheme, told The Journal that in Sunderland Suleo M (malathion in a terpene containing alcohol base) has proved to be the most appropriate treatment and is used as first-line therapy. He said that aqueous formulations, although not as effective as alcohol preparations, are recommended for patients with asthma, those with eczema or other skin conditions and in young children. A pyrethroid preparation is used as second-line therapy and carbaryl preparations are recommended for any lice found to be resistant to both malathion and permethrin. Pregnant women are referred to their GP for treatment.

Treatment options

Each infected patient receives two 50ml bottles of lotion to be used seven days apart and is advised to use the whole bottle for each application. Three days after the second application has been used, it is recommended that patients use a detection comb again to ensure that the lotion has worked. If head lice are still present, wet combing daily for two weeks is recommended and a second-line treatment used thereafter. Pharmacists need to make sure that the reason for the infection still being present is due to treatment failure rather than compliance problems. Mr Shaw commented that “as pharmacists we should be promoting the concept of ‘use what we know works’.” Head lice have not been eradicated in Sunderland but the service has helped to reduce the panic that parents fell when their children have head lice.

In terms of preventing head lice, Mr Shaw said: “Good grooming is the key to managing head lice infections. It is difficult to persuade people that they should comb every day and use a detection comb once a week.”

Judith Wells, a community pharmacist who is also involved in the Sunderland scheme, said that few people had so far reported treatment failure. She also said that the greatest number of people presenting with head lice last year was in August when children were away from school.

Mrs Wells recommends that if all pharmacists give the advice that is given as part of the Sunderland scheme and initiate treatment only if they see a louse then there will be less treatment failure. She also commented that using a conditioner to assist with the method of wet combing to remove lice is not the best option.

Ian Burgess, director, Medical Entomology Centre, Cambridge, agreed with Mrs Wells. Wet combing with a conditioner results in “foam and slime” and makes it difficult to see the lice, he said. Conditioners also contain components such as panthenol and surfactants which may lead to adverse reactions. He suggested using olive oil or grape seed oil as a lubricant instead. “Olive oil is used as an emollient for scalp conditions and grape seed oil has some insecticidal activity.” Commenting on wet combing, he said that the problem is not that it does not work but that people do not know how to do it. “You need to appreciate what you are doing and why and to continue until you find no more lice,” he said. He recommended that, if necessary, wet combing needs to be continued for up to two hours at a time, depending on the number of lice found and the thickness of the hair, and carried out four times over a period of at least two weeks. This period may need to be extended until all lice have been removed.

Treatment failure

Resistance to individual products, selecting the wrong product and applying the product incorrectly can lead to treatment failure. The British National Formulary recommends that a course of treatment for head lice should be two applications of product seven days apart to prevent lice emerging from eggs that survive the first application. If a course of treatment fails to cure the infection, a different insecticide should be used for the next course of treatment to overcome resistance from developing (BNF 41, p551). Mr Burgess commented that a high failure rate is also a result of people using alternative treatments and devices, and resistance may occur with both natural products and insecticides. “If aromatherapy is not toxic to humans then it is definitely not toxic to lice,” he said.

For patients in whom first-line treatment options have failed, he advised that pharmacists should refer them to their GP. These patients should be given a note, for their GP, saying that the infection has not been successfully treated and that a carbaryl product should be prescribed. For treating asthmatic patients, Mr Burgess said that, depending on the severity of asthma, alcohol-based lotions could be used as long as they are applied at least two hours before going to bed, close to the scalp and in the open air. Combing is a better option for those not wanting to use alcohol-based products.

To prevent head lice infection a suitable plastic detection comb should ideally be used at least once weekly, Mr Burgess said.

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Zoë Gross is on the staff of The Pharmaceutical Journal