Every year the boards here at allnurses are abundant with the same question, what do we do? In this article I'm going to identify your enemy, give objective and factual options for treatments, and attempt to address the special challenges about controlling and treating lice infestation in the camp setting.
What are Lice?
The head louse, Pediculus Humanis Capitis, is a wingless insect that spends its entire life cycle on the human scalp feeding on blood. Unlike body lice, head lice are not vectors for disease. They cannot fly, jump, or even walk on flat surfaces. They rely almost entirely on casual head-to-head contact, but can be transmitted on combs, hats, and clothing, (although these are much less commonly the source of infestation.) They show no preference for socioeconomic or hygiene status. Eighty percent of infestations occur in children ages three and twelve, with studies showing that approximately 8% of school aged children are infested with lice each year. Millions of dollars and countless hours are spent by families, institutions, and healthcare providers in attempts to control or eliminate lice infestations. Similar efforts are put into funding drug research or developing and marketing patented medicines to treat head lice. Despite all these efforts, the head louse has been, and continues to be, a formidable foe; evolving defenses against and eluding our best efforts at elimination. Summer camps join the ranks of other institutions such as schools, residential living, prisons, and the military in an endless struggle to control lice.
Lice Control in Camp Environments
Many camps have taken a proactive approach to louse control, some utilizing a head check process in attempt to keep lice out of camp. The theory being that if no lice come into the camp community, then by nature camp will remain lice-free as there is limited contact with the outside population. However, a study conducted in 2000 found that traditional scalp inspection produced 30% false positives, and failed to catch 10% of lice infestations, making the dry scalp inspection clinically ineffective. The study found wet combing to be much more effective in correctly identifying infestation. Wet combing is done using a standard comb followed by a lice comb on hair moistened with water, wiping the comb off on a paper towel in between each swipe, and looking for nits and live louse on the towel. Studies have also shown itching to be a late indication of infestation and as such a poor screening tool. The scalp will not develop a reaction to the lice saliva for 4-6 weeks after the infestation is established. Most persons complaining of head itching are stuffing form dandruff or even simply anxiety over having lice rather than a genuine infestation.
Another attempt to keep camp lice free is the "no nit policy." Once a mainstay of policy in public schools and private institutions, it has fallen from favor in recent years. The presence of nits, especially more than 1/4 of an inch from the scalp, does not necessarily indicate infestation. A2001 study concluded that only 18% of children identified as having nits subsequently develop a lice infestation. It is now almost universally known at the presence of nits is not a sufficient basis for the exclusion of a child from education.
How to Treat Lice?
Treatment of lice infestation is divided into two types of methods: manual removal/physical impedance and chemical/pesticide. Below are brief descriptions and some available statistics for each method.
Mechanical removal/physical impedance techniques use combs to physically remove lice, or various materials to coat the hair to suffocate them. These methods are gaining in popularity as the concerns over the use of pesticides on children's scalps increase and as lice develop resistance to many over the counter chemical treatments.
Wet combing (Bug Busting) - simply use a wet comb and conditioner, followed by a repeat combing. Once conditioner is rinsed out, it removes live lice every 3-4 days for a period of 14 days. Immature lice cannot reproduce until seven to ten days after hatching, and have a difficult time moving from host to host, so combing every 3-4 days removes the immature lice preventing them from mating and laying more nits. After 14 days all nits should have hatched, and if no live lice are present, the infestation is eradicated. A 2005 study of 133 children showed this method effective 57% of the time compared to 13% of the participants provided with a permethrin shampoo. While these success rates may seem low compared to other techniques discussed later, remember that the study was conducted with lay persons providing the treatment in the community setting so it reflects an actual use, rather than perfect use results.
Household items - a common technique is to coat the hair in oil, mayonnaise, petroleum jelly, or other materials. These items generally attempt to suffocate the louse. The hair is coated in the material of choice before bed and rinsed in the morning. Often this treatment option is less effective as the material dries or shifts and exposes some hair leaving live lice after treatment. As with all mechanical treatments, household remedies are only effective against live louse, so treatments must be repeated every seven to ten days until clear. Studies have shown no home ready treatment is 100% effective. Petroleum jelly was found to be most effective, however no human trials have been conducted and the inconstancy in materials and technique means results will vary.
Hot air (Louse Buster) - the application of hot air to control lice was studied in 2006. The results varied widely. Commercially available products, mainly the louse buster with hand attachment, boasted an impressive 80% louse mortality, and 98% nit mortality. However, more commonly available methods such as a hand or bonnet style dryer killed only 10% of lice and 89% of nits.
Cetaphil (Nuvo Method) - uses the common skin lotion Cetaphil to coat the hair completely. The lotion is then dried with a hair drier, encasing the hair, effectively suffocating live lice. The treatment must be left on for 8 hours, generally overnight, and then is washed out. It is recommended the treatment be repeated every week for three weeks. The inventor of this method claims 96% effectiveness and is non toxic. Although it is time consuming as Cetaphil-covered hair takes two to three times as long to blow dry as untreated hair.
Dimethicone (LiceMD) - used extensively in shampoos,other hair products, and also as an industrial lubricant,dimethicone works by suffocating live louse and makes combing out nits easier. A 2005 study showed it to be 70% effective. Product literature seems to indicate this is a onetime treatment, and that combing is required to complete treatment.
Benzyl alcohol (Ulesfia) - this prescription treatment works by suffocation but is quicker, requiring only 30 minutes of application time and no combing. It is effective only against live lice and not against nits, so it requires reapplication 7 days after first use. It's non-toxic and has been shown to be 75% effective.
Treatment with chemicals known as pediculicides has been the treatment of choice for decades. Many treatments are falling out of favor as they have become less effective as time progresses, and as concerns about chemical exposure increase. However, chemical treatments remain a common treatment option and are easily available over the counter. In the past few years,new products have appeared on the market that are highly effective but may be prohibitively expensive. These new treatment options are unfamiliar to many nurses and physicians and should be thoroughly reviewed before use.
Permethrin/Phenothrin (rid/nix) - this first line pediculicide has been in heavy use for decades. It is the most common over the counter treatment. It is applied to dry hair, sets for 10 minutes, and must be rinsed out. This is followed by the hair being combed out. The treatment is repeated in 7-10 days. A 2005 study found 70% effectiveness. However a 2014 study found most lice in North America are resistant to permethrins, casting doubts on the effectiveness of this long standing treatment.
Lindane (Kwell) - is still available as a shampoo or lotion by prescription. It is not generally used as a first-line treatment, only being used after treatment with Permethrin has failed. It's more commonly used for scabies and body lice. It has caused seizures; however generally only in cases of repeated treatment or misuse, and some accusations of permanent disability have been reported. It also has a long list of restrictions as to who may not use it, including woman who are pregnant and persons who are immune compromised. It is reported to be effective against louse and nit, and generally only requires one application.
Malathion (Ovide) - a prescription topical treatment, again generally only used when first line treatments have failed. It has been associated with neurological side effects and overdoses have occurred even with careful use. It is also flammable and should not be used near any heat source. It is applied and left in for eight to twelve hours, and rinsed out. It is 97% effective, killing both louse and nit.
Spinosad (Natroba) - a new prescription treatment derived from bacteria, giving it a unique mechanism of action. It has been tested on children as young as six months. A single application is placed on dry hair, left in for ten minutes, and rinsed. It is 86% effective at 14 days after treatment.
Ivermectin (Sklice) - a newly approved prescription treatment that kills both lice and some nits. One treatment with 4oz of lotion applied to the scalp for 10 minutes and then rinsed out. No combing required or recommended. Effectiveness was 74% at 15 days. It is reported to be very safe with minimal side effects and is recommended for children as young as six months. At this time, treatment with oral ivermectin is off label although thought to be safe.
Presently many organic and natural products are marketed for lice treatment. They make a variety of claims. Some claim to repel lice, others will weaken the glue that binds the nits to the hair. At present all are untested, but have many users who will swear by them. They often work by mechanical means either by suffocation of live lice, or simply facilitating easy removal with combing. They are generally more pleasant to use than other methods, as they smell pleasant, and often put parents' minds at ease with their all natural ingredients. Many camps have found them to be successful; however as with many such products actual quality research is generally not available.
After treatment has been initiated the environment needs be cleaned to prevent live lice from re-infesting the scalp. Combs must be changed out, soaked in alcohol, or washed in hot water greater than 140 degrees. Bedding should be placed in a dryer on high for 15-30 minutes. It is generally not necessary to vacuum furniture or carpets. No treatment is required for stuffed animals or other objects that have incidental contact with the child, as lice cannot survive more than two days without a host.
Treating lice in the camp setting comes with a unique set of challenges. The communal living situation and prevalence of activities create abundant opportunities for close casual contact and clothes sharing. It is practically assured that if one case of lice is found in a bunk, it is present in other members of the bunk. With bunk sizes between eight and thirty, and the labor intensive task of using almost any removal technique, the job of treating an outbreak quickly becomes daunting. Social concerns must also factor in to your considerations, children with lice may feel singled out or become the victim of teasing. The nurse must work quickly to coordinate with the counselors to try and keep the bunk moral positive.
Camps using chemical methods of removal exclusively, especially over the counter premetherin, quickly encounter the concern that the lack luster success rate may result in re-infestation of the bunk. Also many parents wish to avoid chemical use on their children, which results in ma many parents refusing specific treatments or requesting their favored brand of OTC shampoo. This increases confusion, and may contribute to treatment mistakes.
Concerns Regarding Chemical Treatments
The concerns regarding chemical treatments have lead many camps to use exclusively manual removal techniques. These are more time consuming the course of treatment may span over several weeks. The longer treatment times will quickly overwhelm the health staff, and the perfect technique required to achieve best results becomes challenging as the length of treatment drags on. Although the success rate of many manual methods is often not significantly higher success rate than the chemical methods, parents are often more comfortable with them.
Due to the unsatisfactory success rates of both chemical and manual methods, and the desire of many camps to treat entire bunks or living units as a preventative measure generally leads to the use of a combination of methods. Usually chemical methods are being reserved for confirmed infestations, and manual methods used on the exposed bunk mates. Alternatively, prescription treatments for confirmed cases and less effective methods for exposed bunk mates, is a common choice.
However you choose to address your camps lice issue, you will quickly find it a labor intensive and often overwhelming process. Often the nursing department is the only one to handle this task. It's very important to stress to your camps management that if they want the issue dealt with correctly, and believe me they do, they will need to assign extra staff to assist. Simply expressing your needs in terms of man hours may be helpful. If we have 8 campers with lice and treatment will take an hour each, there is no way one department has eight additional man hours to dedicate to this task today. Reassignment of volunteers to assist, or hiring outside community assistance may be options to assist.
Also letters and calls home will quickly raise alarms in the community of camp parents, who will undoubtedly call camp with vigorous concern and generally one resounding sentiment of "don't send them home with lice!" Working with your camp director to get ahead of the rumor mill is quite helpful; mass emails and a script for the office to read will help keep parental hysteria under control.
Many camps realizing that their health department cannot address lice outbreaks to the satisfaction of the clientele have outsourced lice screening and treatment to outside companies. These companies can take the time to do through lice checks, and will arrive at camp with staff dedicated exclusively to addressing the lice infestation. These companies often offer lice-free guarantees and will retreat the child in their home if the lice infestation persists, much to the relief of the families.
Key to Success ... Plan Ahead
As with most camp crises, it is important to plan ahead. A quick conversation with your director about screening and treatment options is critical. Laying-in supplies to treat at least one bunk of campers is very helpful. If you're in an area that is heavy with summer camps, don't rely on Walmart to have an endless supply of combs and other essentials, another camp with the same problem may have beat you to all the supplies. Speaking to your local pharmacy to make sure they can acquire your prescription treatment of choice is an important step, especially if forms have been sent to parents authorizing a particular treatment. Get all the health staff on board with the plan, the last thing you need is a debate on what to do when the first cases start to roll in. Even if you're not a Boy Scout camp, "be prepared" is always good advice.
Below are the sources used for this article. Please pursue your own information, as new products and studies are always coming out.
Head lice - NHS Choices
News - Heads Up Nitpickers
3 New Head Lice Drugs Could Change How Lice Are Treated - Forbes
FAQs - Nontoxic Head Lice Treatment
The clinical trials supporting benzyl alcohol lotion 5% (Ulesfia): a safe and effective topical treatment for head lice (pediculosis humanus capitis) - PubMed - NCBI