Patient Presentation
A 2 1/2-year-old female came to clinic with head lice. She and her family had been treated multiple times with Nix®, mayonnaise, using cream rinse daily and combing with a metal nit comb and multiple cleanings of the house. The family was frustrated as was the resident. When the resident talked with her staff, the attending said that he had just heard of a new medication at a professional meeting that suffocated the lice with benzyl alcohol, but he hadn’t tried it yet. He also had read that another new medication had just been approved by the Federal Drug Administration (FDA) but wasn’t in pharmacies yet. They decided to try the benzyl alcohol medication and gave verbal and written instructions for cleaning the home and the babysitter’s home also. They also asked the family to call back in 2 weeks to tell them how well this medicine had worked.
Discussion
Head lice (Pediculosis capitus) is a common problem for worldwide. Multiple treatments are available with mixed success because of the life cycle of the parasite, the parasites’ ability to be transmitted between objects and persons, and the difficulty to clean the environment to rid the infestation. A previous review of lice can be found here that contains descriptions of the organism, other treatments and instructions for environmental cleaning.
Learning Point
In 2009, Ulesfia® was approved by the FDA. It is a 5% benzyl alcohol lotion that suffocates the lice; it is not directly ovicidal. It is approved for infants and children older than 6 months of age to age 60 years. It cannot be used in infants less than 6 months because of the potential for neonatal gasping syndrome which is characterized by “…central nervous depression, metabolic acidosis, gasping respirations, and high levels of benzyl alcohol and its metabolites.” Ulsefia is applied to the dry scalp, left on for 10 minutes and then washed off. A second application is recommended at 7 days. More than one bottle may be needed for the length of hair and an Internet search of cost was ~$65 for an 8 ounce bottle. Ulsefia’s main side effects include pruritis and erythema of the scalp. Ocular irritation also occurs in some patients. Parents should be warned not to have fire or other heated items around the patient as the product is flammable.
The FDA reviewed Ulsefia in 8/2010 and found that ~9000 prescriptions had been written and only 19 instances of problems were reported. These problems were expected such as pruritis.
Natroba® was approved by the FDA on January 18, 2011. It contains 0.9% spinosad and some benzyl alcohol. It is approved for children more than 4 years of age. It is applied to scalp and hair for 10 minutes, and if live lice are seen one week later, patients should be re-treated. In a study of 552 individuals, 86% were lice free after 14 days compared to 44% for the control group. Natroba should be available in pharmacies in the first 6 months of 2011.
Questions for Further Discussion
1. How far out on the hair shaft can live lice live?
2. How long can lice live in the environment?
Related Cases
- Disease: Head Lice | Parasitic Diseases
- Symptom/Presentation: Health Maintenance and Disease Prevention
- Specialty: Infectious Diseases | Pharmacology / Toxicology | Preventive Medicine and Health Maintenance
- Age: Toddler
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Head Lice and Parasitic Diseases
and at Pediatric Common Questions, Quick Answers for this topic: Head Lice
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
FDA. FDA Approves Head Lice Treatment for Children and Adults.
Available from the Internet at http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm240302.htm (rev. 1/18/2011, cited 2/4/2011).
FDA. Ulesfia After Market Evaluation.
Available from the Internet at http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/PediatricAdvisoryCommittee/UCM234373.pdf (rev. 8/18/2011, cited 2/4/2011).
RxList. Ulesfia. eMedicine.
Available from the Internet at http://www.rxlist.com/ulesfia-drug.htm (rev. 2011, cited 2/4/11).
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
8. Health care services aimed at preventing health problems or maintaining health ar
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
16. Learning of students and other health care professionals is facilitated.
19. The health professional works effectively with others as a member or leader of a health care team or other professional group.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
Pediatric Education 