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This article was originally published in Advances in Dermatology, Volume 1, 1986.
The unfortunate reality is that 17 years later there are still many health
professionals who prefer to dismiss lice as a serious health concern for the
people who have them. The NPA continues to emphasize an informed and
responsible approach to pediculosis management, putting education and prevention
in advance of outbreaks.
When Dr. Rasmussen begins his article, "Pediculosis:
Treatment and Resistance," with the statement that "infestation with
head lice is not a particularly interesting issue." he reveals a common
bias within the medical community that has contributed to the chaotic state of
pediculosis management in the United States. The low priority assigned to
this widespread parasitic infestation has created a climate in which there is no
collective will to address it.
Bearing the burden of this scenario are young children and their
parents, for whom the incidence of pediculosis in our society is
unacceptable. For them, pediculosis ranks very high on the priority
scale. One Connecticut general practitioner recently wrote that
"pediculosis leads to more anxiety out of proportion to the disease than
anything else in office practice," and compared its impact with that of
venereal disease.1 His appreciation of
the problem was unusual, because physicians facing more serious and
"interesting" disease entities tend to regard head lice as the
"nuisance" factor in their practices. However, the existence of
more dangerous medical conditions does not justify a laissez-faire approach to a
public health problem where those populations most likely to contract the
infestation are also most vulnerable to the adverse effects of its pesticidal
treatment.
Unfortunately, this relative indifference of the medical
community "trickles down" and permeates the attitudes of health
professionals at every level. These include the front-line, hand-on
people, such as school and infection control nurses, whose information and
methodology are crucial to the effective control of head lice. Looking to
physicians for guidance or authorization, they find either a maze of conflicting
opinions or an approach based on outworn traditional wisdoms. More
constructive would be the development of a mutual agenda focused on: (1)
accurate diagnosis, (2) effective treatment, (3) safe product application, (4)
prevention of recurrence, and (5) development of standardized policies and
procedures. Such an agenda would have to take into consideration the fact
that policies cannot continue to be based solely on the use of
commercially-available remedies (and their exaggerated advertising
claims). Until we work together to devise this agenda, pediculosis
management will remain in the hit-or-miss, crisis intervention state it is in
now.
Dr. Rasmussen's review of treatments, with information on
chemistry side-effects, and resistance, is helpful but is only a starting
point. In a recent interview, Dr. Marc. Roberts, Professor of Health
Policy at the Harvard School of Public Health, noted that "the consequences
of treatment are multi-dimensional and must take into account the values and
preferences of the patient."2 In
pediculosis treatment, the numerous factors must be considered by the physician
when recommending lice products. As in every other medication
situation, it is important to ask the right questions of the patient once lice
diagnosis has been made -- not only for the protection of the individual -- but
also of the person applying the treatment and ultimately of the entire
community. This is especially true since the "medication" is a
pesticide.
Some of the factors impinging on treatment choice include: (1)
the ages/size of the child; (2) whether the mother applying the product is
pregnant or nursing; (3) whether there are several infested family members to be
treated by one parent; (4) whether the case is semi-isolated or part of a larger
community outbreak; (5) the duration/extent of the child's infestation and how
many times he may have already been treated; and (6) the perceived ability of
the person to follow directions accurately. Pediculicidal preparations
possess varying degrees of toxicity, absorption potential, ovicidal capability,
and efficacy. We therefore discourage the continual reliance on one
treatment of choice. It is far more productive to fit one's product
recommendation to the specific needs of the patient, his family, and his
community.
The critical reexamination of products is only a logical first
step toward a safer and more effective program of pediculosis control.
Other areas which must be addressed by the medical community include: (1) the
unnecessary marketing of personal and environmental sprays in tandem with lice
shampoos and lotions (The use stands with the Centers for Disease Control in
discouraging the use of these high risk, questionable benefit products which
take advantage of parental entomophobia); (2) the importance of nit removal as
an integral component of treatment (As with pediculicides, nit combing tools
vary widely in their efficacy.); (3) encouragement of further research and
development of safer, more effective lice treatments; (4) consideration of
record-keeping by public and private health care providers to obtain the kind of
hard data necessary for policy planning; and (5) the need to support programs of
public education and awareness.
Many diseases affect our child population today, but few are as
communicable and as widespread as pediculosis capitis, and few involve the
repeated direct exposure of young children to pesticides. Pediculosis has
been referred to as "an infestation in search of a disease."3
Would we be prepared to deal with the consequences of our attitudes should the
potential of head lice to act as disease vectors be realized?
This question, and many others related to pediculosis remain
unanswered, largely because the politics of lice have decreed it
"uninteresting" and of low priority. Consequently, it is an
arena where there is much room for improvement. Parents, schools and other
health professionals will continue to look to the medical community for
leadership. The quality of pediculosis management programs throughout the
country will depend on your ability to respond.
Deborah Z. Altschuler
Leslie R. Kenney
From Advances in Dermatology, Volume 1, 1986
REFERENCES
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Einstein E.: Personal communication, 1984.
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Roberts M: Safety as a political and social concept. Harvard
Medical Area Focus, April 11, 1985.
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Parish L. C. Witkowski J. A.: Pediculosis: An infestation in
search of a disease. Int. J. Dermatol. 19(7):387, 1980.
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