Head Lice: a report for Consultants in Communicable Disease Control (CCDCs)

Headlice: notes and guidance for community pharmacists

General

• Please read the attached statement carefully.
• Head louse infection is not primarily a problem of schools but of the wider community.
• Pharmacists are an important source of advice on the management of head louse infection. They should be knowledgeable and competent on the subject, be able to teach patients the technique of detection combing, and be prepared to advise appropriate treatment.
• Pharmacists have an especially important role in limiting chemical treatment to true cases of infection, reducing unnecessary and inappropriate treatment, and thereby reducing the risk of further development of resistant strains of lice.
• Health professionals should make sure that they are able to identify a louse at all stages of its development. It helps to have a magnifying glass to hand.
• Patients should be made aware that head lice are only transmitted by direct, prolonged, head-to-head contact.

Specific

• Do consider nominating a member of staff to be responsible for advising patients on head louse problems.
• Do consider asking the Consultant in Communicable Disease Control to arrange training for nominated staff from local pharmacies.
• Do liaise, as appropriate, with your local family practices, school nurses, health visitors, head teachers, infection control nurses, and Consultant in Communicable Disease Control. Only a concerted approach can be effective.
• Do not refer patients to the School Nurse.
• Do adhere to the following principles of control:
  • definite diagnosis; a living, moving louse found by detection combing
  • listing and examination of contacts
  • simultaneous thorough and adequate treatment of all confirmed cases with one of the standard chemical insecticidal lotions
  • repeat of the treatment after seven days
• Do make sure that the patients are provided with information, advice and support. At a first consultation, it may be sufficient to ensure that they know how to undertake detection combing and what to do if there are head lice present (See Appendix 5: have you got head lice? - notes for families, Appendix 6: how to treat head lice - notes for families, and Appendix 7: head lice; the truth and the myths - notes for families.)
• Do not assume a patient has head lice unless you yourself have seen a living, moving louse, or you have physical evidence from the patients; ask them to stick one of the lice on a piece of paper with clear sticky tape and bring it in.
• Do be aware that patients are often mistaken when they believe they have lice. Recurrent scalp problems may go undiagnosed if it is simply assumed without evidence that lice are the cause.
• Do make every effort to discourage unnecessary or inappropriate treatment with insecticides.
• Do not ever recommend treatment unless a louse has been clearly identified (as described above). If you do recommend treatment, ensure that it is done adequately for the case and infected contacts.
• Do make sure that patients know that the correct use of insecticidal lotions is the scientifically confirmed way to treat head louse infections.
• Do follow the British National Formulary’s recommendation of two applications seven days apart.
• Do not assume that "reinfections" or "treatment failures" are truly infections. Make sure that a louse is found or produced.
• Do not ever recommend retreatment without first of all establishing that living, moving lice are still present after two applications of lotion seven days apart and after a full professional assessment as to the ways in which the family may not have complied carefully with the first attempt.
• Do resist the temptation to agree with parents’ suggestions that a first course of treatment has failed, that "it must be a resistant strain", and a that further course of treatment should be given. There is no substitute for a proper professional assessment.
• Do seek the advice of the local Consultant in Communicable Disease Control on appropriate insecticidal lotions. Generally, malathion or one of the pyrethroids is considered as first line treatment, and carbaryl as second line treatment. There is little resistance so far to carbaryl, but it is available only on prescription.
• Do bear in mind that different formulations of the same active ingredient may have different efficacies. When a first treatment has definitely failed, it may be useful to try the same agent in a different formulation.
• Do not generally recommend "wet combing" techniques claimed to prevent or control head lice, as their effectiveness in the community has not to date been supported by any authoritative scientific research. They may, however, have a place for individual families if, for example, they are not prepared to use an insecticidal preparation.
• Do not support the use of electronic combs, repellent sprays, or chemical agents not specifically licensed for the treatment of head louse infections.
• Do ensure that you provide patients with an effective detection comb. This will have rigid plastic teeth set not more than 0.3mm apart.

(This document was originally appendix 2 of Head Lice: a report for Consultants in Communicable Disease Control (CCDCs).)