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Head Lice Treatment Head Lice Treatment New Options for an Ancient Adversary US.IVE.12.03.005 Presentation Outline I. Head Lice Are With Us II. Approaches to Head Lice Treatment III. The Role of Health-Care Providers (HCP) in Head Lice Management IV. Sklice (Ivermectin) Lotion, 0.5% V. Educational Resources Full Prescribing Information for Sklice Lotion will be provided. 2 Head Lice Are With Us “Lice occur wherever there are humans.”1 atology 1 CDC/Dr. Dennis D.Juranek Reference: 1. Lice (pediculosis). In: Paller AS, Mancini AJ, eds. Hurwitz Clinical Pediatric Dermatology. A Textbook of Skin Disorders of Childhood and Adolescence, 4th ed. New York, Elsevier Saunders, 2011:424-427. 3 Head Lice Infestation: A Common Pediatric Condition • Pediculosis is the most prevalent parasitic infestation among humans1 • Head lice infestations are pervasive among school-age children in the United States2,3 • ~6-12 million infestations occur each Photo Researchers year in children 3 to 11 years of age3 – More common in females4 • All socioeconomic groups are affected2-4 – Contrary to myth, “head lice prefer clean, healthy hosts”4 Getty Images/Peter Dazeley References: 1. Hodgdon HE, et al. Pest Manag Sci. 2010;66(9):1031-1040. 2. Frankowski BL, et al. Pediatrics. 2010;126(2):392-403. 3. Centers for Disease Control and Prevention (CDC). Head lice. Epidemiology & risk factors. http://www.cdc.gov/parasites/lice/head/epi.html. Accessed July 16, 2012. 4. Meinking T, et al. Infestations. In: Schachner LA, Hansen RC, eds. Pediatric Dermatology. 4th ed. Mosby Elsevier; 2011:1525-1583. 4 Pediculus Humanus Capitis: A Closer Look at the Critter1 • The adult louse is 2-3 mm long (size of a sesame seed) – Usually pale gray; color may vary (red when engorged K.S.Yoon, F. Collins, PhD. CDC. J. Strycharz, PhD; with blood) Head louse family portrait, left to right: nymph stages 1, 2, and 3; adult male, • The louse feeds by injecting adult female.2 small amounts of saliva and taking tiny amounts of blood from the scalp every few hours • Lice usually survive less than 1 day away from the scalp at room temperature CDC. References: 1. Frankowski BL, et al. Pediatrics. 2010;126(2):392-403. 2. Meinking TL, et al. Infestations. In: Schachner LA, Hansen RC, eds. Pediatric Dermatology. 4th ed. Mosby Elsevier; 2011:1525-1583. 5 The Life Cycle of the Head Louse1,2 Female lays 1st Become adults egg 1 or 2 days 9 -12 days after after mating hatching 3 Lays ≤10 eggs/day Female lives 3-4 weeks Without treatment, the cycle may Eggs tightly repeat every attached to hair, 3 weeks close to scalp 2 3 nymph Eggs hatch in stages 7 – 12 days 1 Illustration by Penumbra Design Inc. References: 1. Frankowski BL, et al. Pediatrics. 2010;126(2):392-403. 2. Meinking TL, et al. Infestations. In: Schachner LA, Hansen RC, eds. Pediatric Dermatology. 4th ed. Mosby Elsevier; 2011:1525-1583. 6 Transmission: Think Head-to-Head1,2 • Transmission of lice typically occurs by direct head-to-head contact with an infested individual1,2 • Indirect spread via contact with personal items (combs, brushes, hats) is 1,2 less likely but can occur Getty Images/Westend61 • Itching is the most common symptom – It may take 4-6 weeks for itching to develop in someone infested for the first time1 • In someone with previous episodes, itching may develop within 48 hours3 – Excoriation, crusting, secondary bacterial 1-3 infection may result from scratching Getty Images/Photodisc References: 1. Frankowski BL, et al. Pediatrics. 2010;126(2):392-403. 2. CDC. Head lice. Epidemiology & risk factors. http://www.cdc.gov/parasites/lice/head/epi.html. Accessed July 16, 2012. 3. Meinking TL, et al. Infestations. In: Schachner LA, Hansen RC, eds. Pediatric Dermatology. 4th ed. Mosby Elsevier; 2011:1525-1583. 7 Careful Inspection Needed for Proper Diagnosis CDC/Dr. Dennis D. Juranek. Unhatched nit of a head louse, firmly cemented to hair shaft. A 10-year-old girl complained of scalp pruritus for several weeks. Nits (within white circle) were visible on hairs above the ear. Note the brown scaly fecal material below the hair line (black circle). Photo © Bernard Cohen, MD. DermAtlas; http://www.dermatlas.org. 8 Infection: An Uncommon Consequence Although uncommon in the US, secondary bacterial infection may result from pruritus and excoriations associated with head lice infestation. The photo here shows a case of streptococcal-staphylococcal pyoderma. It is important to note that decreases in the prevalence and severity of scalp pyoderma have been noted following treatment for head lice, even without the use of antibiotics. Reproduced with permission from Meinking TL, et al.1 © Elsevier 2011. Reference: 1. Meinking TL, et al. Infestations. In: Schachner LA, Hansen RC, eds. Pediatric Dermatology. 4th ed. Mosby Elsevier; 2011:1525-1583. 9 Nymphs, Nits, and Knowing What to Do • Definitive diagnosis is made by finding a live louse or nymph on the scalp or head1,2 • Nits attached >1 cm from the scalp are usually non-viable1 – In some warmer climates, viable nits may be found several inches from the scalp3 – Close inspection is needed • Nits may be confused with dandruff, fibers, scabs, hair casts, droplets of hair spray, plugs of desquamated cells, or particles of dirt1,3,4 References: 1. Frankowski BL, et al. Pediatrics. 2010;126(2):392-403. 2. CDC. Head lice. Diagnosis. http://www.cdc.gov/.parasites/lice/head/diagnosis.html. Accessed July 16, 2012. 3. Lice (pediculosis). In: Paller AS, Mancini AJ, eds. Hurwitz Clinical Pediatric Dermatology. A Textbook of Skin Disorders of Childhood and Adolescence, 4th ed. New York, Elsevier Saunders, 2011:424-427. 4. American Academy of Pediatrics. Pediculosis capitis (head lice). In: Red Book. 2012 Report of the Committee on Infectious Diseases. Pickering LK, ed. 29th ed. Elk Grove Village, IL, American Academy of Pediatrics, 2012, 543-546. 10 Approaches to Head Lice Treatment 11 Current Treatment Paradigm for Head Lice1 Diagnosis: often by school nurse, parent, or caregiver 00 72% 28% of Households of Households (n = 133) (n = 68) Treat On Their Own Contact Health Care • Availability and awareness of Provider OTCa products; limited parent knowledge, poor perception of Rx choices • Immediate access to OTC 46% are 54% receive a products (avoid delay in treating) instructed to prescription for • Access to “trusted advisors”: try OTC first an OTC product school nurse, pharmacist or traditional Rx a OTC = Over-the-counter. Reference: 1. Sanofi Pasteur Inc., Data on file. Excel Omnibus Studies. 12 Treating Head Lice: Many Choices OTC Prescription Nix®,a (permethrin, 1%) Lindanec 1% shampoo RID®,b et al (pyrethrins Ovide®,d (malathion, 0.5% lotion) with piperonyl butoxide) Ulesfia®,e (benzyl alcohol, 5% lotion) Natroba®,f (spinosad, 0.9% suspension) Sklice®,g (ivermectin, 0.5% lotion) Important Safety Information for Sklice Lotion The most common adverse reactions for Sklice (<1%) are conjunctivitis, ocular hyperemia, eye irritation, dandruff, dry skin, and skin burning sensation. Full Prescribing Information for Sklice Lotion will be provided. a Nix® is a registered trademark of Insight Pharmaceuticals, LLC. b RID® is a registered trademark of Bayer HealthCare, LLC. c Lindane is manufactured by Morton Grove Pharmaceuticals. d Ovide® is a registered trademark of Taro Pharmaceuticals, U.S.A., Inc. e Ulesfia® is a registered trademark of Shionogi Pharma, Inc. f Natroba® is a registered trademark of ParaPRO LLC. g Sklice is a registered trademark of Sanofi Pasteur Inc. 13 Other Approaches • Home remedies and ”natural” products1 – Essential oils, plant extracts – Occlusive agents: Mayonnaise, petroleum jelly, tub margarine, Cetaphil cleanser – Vinegar and vinegar-based products • Removal of nits and lice – Products such as dimethicone gel (LiceMD®,a) and gel containing citric acid, isopropanol, other ingredients (Lycelle®,b) • Nitpicking salons a LiceMD® is a registered trademark of Quantum Pharmaceuticals. b Lycelle ® is a registered trademark of Mission Pharmacal Company. Reference: 1. Frankowski BL, et al. Pediatrics. 2010;126(2):392-403. 14 Nitpicking Salons: An Emerging Phenomenon • Nitpicking salons have gained favor in certain parts of the US (California, Florida, Texas, Northeastern states) with some franchises1,2 – Advertise a “natural” or “chemical-free” approach to lice and nit removal – $100 per hour for a “comb-out” is a common fee1,2 • Treatments may also include various applications of controlled hot air1,3 References: 1. LiceLifters. http://www.licelifters.com. Accessed July 16, 2012. 2. Texas Lice Squad. http://www.texaslicesquad.com. Accessed July 16, 2012. 3. Goates B, et al. Pediatrics. 2006;118(5):1962-1967. 15 How Head Lice Cases Are Treated Today1 Nit Don’t Know Combing Factors contributing to Lice/Nit 10% 6% OTC use include consumer Removal awareness, ease of access, Service and recommendations by 1% groups such as the American Academy of Pediatrics (AAP).2 Rx 10% Home Remedies/ OTC Natural Products 57% 16% References: 1. Sanofi Pasteur Inc., Data on file. Excel Omnibus Studies. 2. Frankowski BL, et al. Pediatrics. 2010;126(2):392-403. 16 Prescription Lice Products Benzyl Malathion, 0.5% Spinosad, Ivermectin, Lindane, alcohol, 5% (Ovide)2 0.9% 0.5% 1%5 (Ulesfia)1 (Natroba)3 (Sklice Lotion)4 Age ≥6 mo Safety not shown ≥4 y ≥6 mo Use w/caution indication <6 y in those <110 lb Dosage 4-48 oz 2-oz bottles; Up to 120 mL Up to 120 mL 1-2 oz (varies with apply enough to (1 bottle) ( 4-oz tube) depending on hair length) wet hair and depending on hair length and scalp hair length density Time of 10 min; 8–12 hrs; repeat 10 minutes; 10 minutes; tube 4 min; application repeat treatment in repeat is intended for do not re-treat treatment 7-9 d if lice treatment in single use only; after 7 d present 7 d if lice consult HCP present prior to re-treatment The clinical significance of this information has not been established.
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