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Addressing A Common Bias

Indifference to Head Lice in The Medical Community


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


  1. Einstein E.: Personal communication, 1984.

  2. Roberts M: Safety as a political and social concept.  Harvard Medical Area Focus, April 11, 1985.

  3. 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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