Clinics in Dermatology (2010) 28, 511–518

Treatment of scabies and pediculosis:

Facts and controversies
Ronni Wolf, MD ⁎, Batya Davidovici, MD
The Dermatology Unit, Kaplan Medical Center (affiliated to the Hebrew University—Hadassah Medical School, Jerusalem,
Israel), 76100 Rechovot, Israel

Abstract Unlike many other skin diseases, success or failure of therapy of ectoparasitic infestation
depends much more on how to use the topical preparation and whom we treat than on which scabicide
or pediculicides to use. The diagnosis of scabies should no longer rely on the rather uncommon and
unpractical sign of finding a burrow or the number of parasites per infected patient. Most infested
individuals have been shown to have several-fold more acari than the oft-quoted average of 12 adult
acari per infected patient that appears in most of our textbooks (stemming from Mellanby's work).
Contrary to what Mellanby taught us, we know that indirect transmission (ie, without personal contact)
does occur. As to which agent to use, the winner remains undeclared at present. Although indirect
contact transmission of hair lice has been clarified after thousands of years of infestation, there are still
numerous questions, uncertainties, disagreements, and controversies on the subject; for example, we
know that lice survive immersion in water but are probably not transmitted in swimming pools. There is
no consensus on the best or most correct way to diagnose lice, nor is the problem of resistance resolved.
We do not recommend a “no-nit” policy.
© 2010 Elsevier Inc. All rights reserved.

Scabies which of the asymptomatic family members and physical

contacts also need to be treated must be determined, and
Scabies—the dread of nursing homes for the elderly, above all, patients need to know how to deal with their
prisons, and extended care facilities, the demon that haunts environment, including clothes, linens, towels, floors,
teenagers and parents alike—is on the march again. We have mattresses, laundry baskets, etc. Success or failure of therapy
indeed eliminated smallpox, but scabies is still here to stay, of this annoying infestation depends much more on how to
and with a vengeance. Treating scabies is sometimes no less use the topical preparation and whom we treat than on which
of a challenge than diagnosing it, and as we all know, scabicide to use. This contribution will deal with these
diagnosing this infestation can sometimes be a very issues, highlighting the many controversies, myths, and
demanding task. misconceptions associated with them and trying to reach the
Unlike many other skin infections, prescribing the correct appropriate no-nonsense recommendations.
drug is only the first step in its treatment. Patients need step-
by-step instructions on how to use the specific therapy, Mellanby's work

⁎ Corresponding author. Fax: +972 9 9560978. A discussion of the epidemiology and treatment of scabies
E-mail address: [email protected] (R. Wolf). is incomplete without mentioning Kenneth Mellanby, who

0738-081X/$ – see front matter © 2010 Elsevier Inc. All rights reserved.
doi:10.1016/j.clindermatol.2010.03.008
512 R. Wolf, B. Davidovici

was considered for years the doyen of this disease. Mellanby Mellanby was resolutely against organized research,
was born in 1908. He was a British entomologist who spent saying “in research inspiration and organization by no
much of World War II studying scabies, and his contribution means always go hand in hand.”4 We leave it for you to
to our understanding and knowledge of this infestation is decide if we can and should believe the man and trust his
invaluable. He was the first to demonstrate that the itching experimental data.
sensation does not begin until about 4 weeks after the initial
infestation. He gave an exact description of the dermatitis, The diagnosis
which is not limited to the sites of the mites on the body and
which is attributed the eruption to a true sensitization. He Mellanby diagnosed scabies by extracting the mites out of
also provided extensive data on the epidemiology and their burrow. In one of his contributions, he presented the
transmission of the disease. results of the extraction of more than 9000 mites from more
The enormously important findings and interpretations of than 800 infested men. Although this is glowing testimony to
Mellanby, summarized in his book,1 have been cited in the extent of his dedication and skills, it is hardly a practice
almost all dermatologic textbooks and have been faithfully that we recommend to our colleagues. In our experience and
copied from one textbook edition to the next, and from one that of others, the pathognomonic burrow from which
contribution to another, over decades, without anyone having Mellanby extracted the mite is very rarely noticed today.
attempted to challenge them by repeating his trials. The This may be because dermatologists today are no longer
reason for this is rather extraordinary: it is very unlikely that familiar with this sign or they lack the time and patience to
any contemporary ethics committee would authorize a look for it. It is more likely, though, that the scabietic
similar opportunity for human experimentation under the burrows occur less frequently than they did in the past,
conditions and on the scale of Mellanby's experiments! possibly due to far more scrubbing with soap as part of the
Mellanby studied pacifists who objected to serving in the contemporary lifestyle. Whatever the explanation, the
Royal Army for reasons of conscience. Nearly all of them diagnosis of scabies should no longer rely on this rather
had appeared before tribunals and were allowed to volunteer uncommon clinical sign, even if it is pathognomonic.
for the experiments as an alternative to military service.2 If clinical signs are insufficient for arriving at a diagnosis,
According to one description: verification should be made by demonstration of the mite or
mite products, or both, by skin scrapings and direct
. . .they submitted bravely to a variety of experiments
designed to infest them with mites from contaminated microscopic examination. Preparation of the scrapings is
bedding and underclothes. Some even felt guilty when also controversial and deserves mention. Although potassi-
they did not catch the disease, though several remained um hydroxide preparation gives a clear, high-quality
infested for months, sometimes running round naked at visualization of the mite, it dissolves most of the fecal
night in an attempt to cool their skins and so stop the material, which is the most common positive finding and
mites moving.3 sometimes the only sign of scabies infestation. For this
reason, many physicians and laboratory workers prefer using
Here was the first of his misconceptions: Mellanby mineral oil or saline on skin scrapings. We use tap water.5
believed that itching results from “true sensitization” to the
mites' antigens—even after the mites were dead. If so, how
The number of parasites per infected individual
is this reconciled with the theory that itching was associated
with movement of the parasites and how does it explain
The oft-quoted average number of 12 adult acari per
nocturnal itching by the mites being more active under the
infected patient that appears in most of our textbooks has been
warmth of blankets? Given that many other immunologic
shown to be several-fold more in most infested individuals.6
skin diseases (most notably atopic dermatitis) behave the
One of us (R. W.) extracted mites from an infested man by
same way, however, the credibility of the “movement
skin scrapings from various areas and counted 20 under the
theory” is de facto reduced to zero.
microscope before giving up. Interestingly, one of Mellan-
We shall now briefly update, reassess, and with all due
by's volunteers testified that “My five mites had multiplied to
respect, refute some of Mellanby's original conclusions,
59 before they were cleared off.” 7
mostly those directly related to the treatment of affected
patients. Before doing so, one last comment on Mellanby and
his findings. He was sent as a medical reporter for the British Treatment of the household and what to advise the
Medical Journal to cover the Nuremberg trials in 1946. sexual contacts of the patient with scabies
Despite later claims that he brought German records on
human experimentation back to Britain, none has ever been Older dermatologists surely remember that during their
discovered. In addition, he and others used some of the residency, it was common practice to treat asymptomatic
material he had then collected in Germany with considerable contacts and, of course, the sexual partners of a patient with
personal advantage, but as it turns out, with little or no profit scabies. Although the matter still has not been settled, the
to science.4 current trend is to treat only the patient and to avoid
Treatment of scabies and pediculosis 513

prescribing medications for others who have not been and blankets of scabies patients, thus saving the country
examined. We believe this approach stems more from millions of pounds sterling.3,8 In contrast to the inaccura-
motives associated with practicing defensive medicine and cies in Mellanby's findings and suggestions concerning the
from ethical and medicolegal motives than from well thought academic issues of reinfestation and the number of
out professional ones. Laws and good clinical practice do parasites per patient, this recommendation has far-reaching
indeed require an established physician-patient relationship practical consequences.
before a medication is prescribed, and treating “blindly” Today, we know with certainty that scabies can be passed
without examining a patient might be considered malpractice on between individuals indirectly by fomite transmission.
or even negligence. We must take exception to this approach Likewise, reinfestation from clothes, linen, and towels is,
for a number of reasons: indeed, possible. There is now evidence that mites can easily
live off the skin surface, that they have host-seeking behavior,
1. Individuals in close physical contact with infested and that they exist alive on inanimate objects: in other words,
patients have a high likelihood of sharing the people can be infested by them. Away from their hosts, mites
infestation. When we first see a patient with scabies, are able to survive and remain capable of infestation for 24 to
his or her contacts are often asymptomatic and 36 hours at 21°C and 40% to 80% relative humidity.9 In
negative on examination simply because the mites addition, lower temperatures and higher humidities prolong
are still in the incubation phase of the disease, which is their survival. For example, at 10°C and 97% relative
about 4 weeks. It follows, then, that there is no point in humidity, mites remain capable of infestation for about 1
examining contacts, because we do not expect them to week, but at temperatures below 20°C, they are unable to
have any sign of the disease. move and cannot penetrate the skin. The mite's infectivity
2. The level of risk of retreatment to the patient is greater decreases the longer it is off the host.10 Studies have
than any risk associated with the initial treatment. Not documented the existence of live mites in the bedding, floors,
preventing unnecessary morbidity in family members mattresses, curtain, laundry baskets, and other objects from
and not avoiding “ping-pong” transmission that would scabietic patients in homes and nursing homes.6
lead to retreatment is no less problematic than treating Contrary to what Mellanby taught, we now know that
unaffected contacts. indirect transmission, without personal contact, does occur.
3. The currently available drugs are reasonably safe, and Indeed, it is our experience that fomites are more involved in
eradicating the disease with the first treatment far the transmission of scabies than direct contact, and even
outweighs the potential risk of a drug's side effects in more so in reinfestation after the success of therapy and
uninfected contacts. full recovery.
4. There are many contagious diseases for which we give
prophylactic treatment to asymptomatic contacts. If we Where does that leave us? What should we
routinely treat the partners in all sexually transmitted recommend to our patients?
diseases without examining them, why should scabies
be an exception? The importance of eliminating the potential of reinfesta-
tion lies not only in avoiding repeated applications of the
Having said that, we do not recommend blindly treating antiscabietic preparation but also has another no less
all household members and contacts. Our advice is first to important effect. Symptomatic pruritus can easily persist
assess the likelihood that they are infected, according to the for 2 to 4 weeks after successful elimination of all parasites,
infected patient's living conditions, sexual habits, and so on. and even worsen. The physician has no way to differentiate
We still, however, follow the rule of thumb—“If there is any between the often-occurring immunologic reaction to the
doubt, then there is no doubt—treat!” mite's products, a treatment failure, or reinfestation. A skin
scraping will not provide the answer in most cases. We, thus,
Fomite transmission have one equation with many unknowns, and so it makes
good sense to get rid of as many of these unknowns as
A fomite is any inanimate object or substance capable of possible—and one that is possible is that of making
carrying infectious organisms and transferring them from absolutely sure the likelihood of reinfestation is reduced
one individual to another. The word fomite is a back- to zero.
formation from the plural fomites, which was originally the This can be done by the following strategy: Although
Latin plural of the singular fomes, literally meaning most of the patients will be rid of their reinfestation by one
touchwood or tinder. simple treatment of any antiscabietic preparation, some will
Mellanby's observations indicated that almost no not; therefore, our policy is to overtreat all patients, their
transmission of scabies occurred by bed linens and surroundings, their belongings, and their contacts. Our
clothing. On the basis of his findings, the Ministry of recommendation to all of our patients is that they wash all
Health of the United Kingdom recommended that it was clothing, including everything in the closet; linens, towels,
reasonable to dispense with the disinfection of the clothing etc. in hot water (at least 60°C). Nonwashable articles should
514 R. Wolf, B. Davidovici

be isolated for 2 weeks in sealed plastic bags with the Other potential candidates are herbal treatments. There is
expectation that the mites will die within a few days. less scientific information about the antiscabietic activity of
these treatments and their clinical and pharmacologic
Which medication? characteristics compared with conventional treatments,
which means more controversy and uncertainty about their
Surprisingly, few controlled studies have been done to use. Tea tree oil is perhaps the most studied preparation. Data
compare the effectiveness of commercially available topical of two in vitro studies of tea tree oil for treating scabies14,16
compounds. As a result, treatment recommendations vary revealed that it might be an effective novel agent, as
from one country to another, and the selection of a drug is demonstrated by the rapid in vitro killing time that was
often based on the personal preference of the physician, local observed. The therapeutic role of herbs awaits future studies.
availability, and cost, rather than on medical evidence.11,12
Lindane had been the mainstay of antiscabietic treatment
for more than 40 years; however, reported toxic effects have
Controversies regarding ivermectin
prompted debate over its use since the 1970s. Its use was
further limited by the emergence of lindane-resistant scabies, Ivermectin was a revolutionary drug in the 1980s, the
which became a major and common problem in most parts of forerunner of a new group of antiparasitic agents with
the world. activity against parasitic nematodes and arthropods. It was
Permethrin was first approved for human use in 1986 in initially marketed for veterinary use by Merck & Company
the United States of America (USA) for the treatment of Inc, and was used largely for nematode control in cattle,
head lice. Due to its wide usage, resistance to the drug has horses, pigs, and dogs. Ivermectin become the standard for
rapidly developed, and head lice resistant to permethrin are control of the ectoparasitic disease scabies, and the injectable
now widespread.13 In contrast, 5% permethrin has been cattle formulation, Ivomec, became the world's most
standard treatment for scabies for more than 20 years, with profitable veterinary drug.17
little or no apparent evidence of clinical resistance.14 Ivermectin, which was approved for human use in 1988,
Although no cases of scabies resistant to permethrin have has become essential role in the control and eradication of
been documented, several controlled studies have revealed filarial infection in humans. It is presently being used in two
diminished sensitivity to this insecticide.15 An in vitro global disease elimination programs, as part of one of the
acaricide efficacy study suggested that scabies mites are largest drug donation programs in history.17 As its discoverer
becoming increasingly tolerant to permethrin16: 35% of Satoshi Omura of the Kitasato Institute in Tokyo, Japan,
mites exposed to 5% permethrin were still alive after 18 to 22 recently stated,
hours. These results and the experience of others have raised
This remarkable compound has improved the lives and
concerns about the development of acaricide resistance in productivity of billions of humans, livestock and pets
the future. around the globe, and promises to help consign to the
Five trials have compared 5% topical permethrin with 1% history books two devastating and disfiguring diseases
topical lindane.12 Two trials found permethrin was superior, that have plagued people throughout the tropics for
one trial found fewer treatment failures in the lindane group, generations—while new uses for it are continually
and two studies found no significant difference between the being found.18
groups. The trials' combined estimate showed no significant
difference between permethrin and lindane, but there was Anecdotal reports began to circulate in the 1980s about
some statistical heterogeneity.12 the curative potential of ivermectin for scabies when used in
Which drug should we recommend our patients? At the treatment or prophylaxis of onchocerciasis. A random-
present, the winner remains undeclared, although permethrin ized placebo-controlled study in Mexico of 55 patients
has a minor advantage over other topical treatments in terms demonstrated its efficacy in 1993, with a 79% cure rate after
of efficacy and toxicity. We currently use both lindane and 1 week in the ivermectin group vs 15% in the placebo
permethrin day after day. For our resistant or massively group.19 Another study published in the same year compared
infected patients, we recommend 4 consecutive days of ivermectin at a lower dose than recommended (100 μg/kg)
treatment, consisting of alternating the use of lindane and with oral therapy and topical 10% benzyl benzoate, and the
permethrin so that each medication is applied twice. results showed no difference in outcome.20 Soon after its
Although it is generally accepted that one cannot overcome introduction for the treatment of scabies (off-label), iver-
drug resistance with higher doses or repeated treatments of mectin was expected to be the drug of the future for this
the same drug, this is not our practical experience with disease, and some authors even predicted that topical
scabies, and we can say with confidence that this method treatments were headed for extinction.21 Indeed, several
does work in the field. We have followed this protocol for a controlled trials have proven its efficacy for the treatment
number of years, and no patients have encountered any of scabies.12,22
serious adverse effects, except for occasional and transient Proof of efficacy notwithstanding, it was soon realized
skin irritation. that ivermectin was not a wonder drug that would make all
Treatment of scabies and pediculosis 515

other therapies obsolete, although it definitely has its place in are transferred from one host to another. There are several
the therapeutic armamentarium. Ivermectin provides numer- mechanisms by which louse transmission is assumed to
ous advantages compared with local treatments. It is occur: direct host-to-host contact, by way of inanimate
effective, simple, fast-acting, safe, and well-tolerated, all objects, through fallen hairs containing lice or nits, wind
features that result in better compliance. It does not have movement, static movement, or contact with dislodged lice
some of the disadvantages of local therapy, which depend on crawling on the floor. More controversial than whether these
compliance, clinical form, and possible resistance, as mechanisms of transfer might or do take place are the
described for lindane. In addition, to be effective, local questions of to what extent and what is the main mechanism
treatments must cover the entire integument and may cause of transfer. No less controversial is the question of at which
adverse side effects, such as a burning sensation and irritative stages of their life cycle are lice most likely to disperse. The
dermatitis, unlike systemic therapy with ivermectin. ongoing debate continues because of the lack of hard data for
We, like others,10,22,23 believe it should be routine therapy quantifying the role of the various routes of transmission.
for patients who have no response to a topical scabicide (in The importance of this issue is not merely academic but
cases of crusted scabies and in immunocompromised patients), rather highly practical and associated with controlling the
and it may be the appropriate first choice for the elderly, spread of the infestation and recurrences.
patients with generalized eczema, atopic dermatitis, and others There is a general agreement that physical contact of one
who may be unable to tolerate or comply with topical therapy. head to another (head-to-head) can pass the infestation. The
Ivermectin is particularly useful in institutional outbreaks of disagreement concerns the route of fomite transmission, and
scabies and has been used to control scabies in the community although not supported by hard data, several studies and
and to reduce associated morbidity in developing countries.10 arguments substantiate head-to-head as being the major route.
The role of ivermectin in the treatment of ordinary scabies A study of the epidemiology of head lice in a primary
remains to be determined, however. school showed a clustering of pediculosis by class and less
Other controversies and uncertainties regarding the strongly by family. 26 According to the authors, this
treatment of scabies with ivermectin include the regimen to suggested that close contact was strongly associated with
be used, for example, dosage (200 to 250 or 400 μg/kg), one transmission.27 This weakened the argument supporting the
or more courses, and interval between courses. Other aspects significance of wind-borne transmission because clustering
that have yet to be determined are the manner of treatment of would be unlikely by that route. Transmission from
asymptomatic contact individuals, efficacy in treating classroom floors could be a possible explanation of
nodular scabies, reinfestation or relapse rate, and risk of clustering of pediculosis by class, but the same authors
resistance. So far, resistance to oral ivermectin has been found no lice on examination of classroom carpets during
reported in two patients. They had received 30 and 58 doses daylight hours in primary schools and day care centers,
of the drug during a 4-year period, indicating that resistance whereas 14,033 lice were collected from the heads of the
can be induced by repetitive treatment.24 children. The authors concluded that classroom floors are not
instrumental in the transmission of head lice.28
Several epidemiologic studies29,30 showed no association
between head lice and the sharing of combs, brushes, towels,
Pediculosis capitis scarves, hats, and clothes. No head lice were found in 1000
hats, whereas more than 5500 head lice were present on the
Head lice have been unwelcome companions of the human students' heads in four schools.27
species since antiquity and remain an unabating nuisance in Contrasting with these findings are the results from
our society. They are a major irritant to children and their convincing studies and arguments that support fomite
parents around the world, with millions of cases occurring transmission of head lice, although confirmatory hard data
annually, including 6 to 12 million cases per year in the USA are lacking here as well. Lice can typically survive 1 to 2
alone.25 Although head lice do not produce an illness per se, days away from the scalp, and under favorable conditions,
they are physically and psychologically unpleasant for the survival up to 4 days away from the scalp has been reported.
child and an exasperating problem for parents and school Nits can survive for up to 10 days away from the scalp.31
authorities. This section will focus on the various controver- Under natural conditions, head lice can travel at 23 cm/min.
sies connected with this infestation, such as transmission and The fastest lice are third instar nymphs and young adults,
fomite transmission, diagnosis of active infestation, preven- suggesting that they may be in the best physiologic state for
tive measures, the “no-nit policy,” treatment modalities, and migration.32,33 Thus, head lice can move rapidly away from
chemical, physical, and resistance to treatment. any perceived threat, either to hide or to escape from the
host's hair. This response has been designated “the flea
Fomite transmission response” in which the louse traverses to the periphery of a
hair ready to drop off if the perceived danger warrants
Even today, after years of studies and hundreds of evacuation. Several in vitro and field studies have shown that
publications, it remains unknown and controversial how lice the flea response is a viable mode of transmission.32,33
516 R. Wolf, B. Davidovici

Lice can walk across linens, clothing, and carpets, and can in which louse combs were used to examine more 15,000
even attach to hand and arm hairs without difficulty. This children, and 11% to 19% of the children were infested with
passive transfer also supports the movement of lice to living lice and eggs, and another 22% to 30% had nits only.41
numerous objects, including hats, headphones, and pillow- Approximately 80% of these children had nits that were 2 to
cases, thus posing a risk of not only fomite transmission but 5 cm away from the scalp, which was indirect evidence of
also of reinfestation.34 successfully treated infestations during the previous 2 to 5
One recent experimental study showed that lice could be months. The authors concluded that when the diagnosis of
blown about in the air.35 Head lice were consistently head louse infestation is based on the presence of nits, one to
dislodged by using a hair dryer set at low and high settings two out of three children are sent home for treatment without
as well as by using a normal comb. Lice fell to the ground or justification. According to the international guidelines for
remained on the comb. Lice were also easily transferred from effective control of head louse infestations:
wet hair to a towel. Approximately 27% of lice passively if no living lice are detected using an accurate method of
transferred from hairs to adjacent fabric within 5 minutes, but detection, the child should be considered negative for
hot air currents and combing were more likely to dislodge head louse infestation. Nobody should be treated with a
lice than toweling. Head lice could be ejected from the head formulated product unless a thorough investigation
by the static electric charge built up by combing.36 This may reveals living lice in the hair.39
have accounted for the failure of a controlled trial of combing
that was conducted in a school in Victoria, Australia, where One accepted authority in this field believes diagnosing
the combing class finished the term with a higher prevalence head lice only when one finds a live louse is not
of head lice than the control noncombing class.37 If combing reasonable.42 “No study has ever been performed by using
is not done in class, static electricity is unlikely to be these standards. The sensitivity of such testing would be too
significant in everyday life.27 low. It is very difficult to find live lice in the vast majority of
In conclusion, although indirect contact transmission has patients.” A search for lice with the help of a lice comb takes
been clarified after thousands of years of infestation, there at least 15 minutes, and he concludes, “Nits are much easier
are still numerous questions, uncertainties, disagreements, to see, and this is the standard for all health professionals.”
and controversies on the subject. Modern medicine still seeks a consensus on the best or most
Finally, the $64,000 question: Do head lice spread in correct way to diagnose head lice.
swimming pools? Head lice will easily survive immersion in
water, washing of hair, mechanical manipulation (such as “No-nit” policies in schools
combing and brushing), and hair treatments with the use of
various chemicals. It would, therefore, be only logical to Should children with nits be excluded from school? To
assume that lice can survive the conditions of swimming ensure more efficient control of lice infestations in the
pools and thus be transmitted from one person to another. A community, approximately 60% of schools and childcare
very recent in vitro experiment and field trial38 shed light on centers in the USA have adopted “no-nit” policies that
this issue and won the prize: head lice survived immersion exclude children from school until they are free of nits.43,44
for 20 minutes in tap water, sea water, salt solutions, and Most experts believe there is no scientific evidence to justify
chlorinated water comparable to that found in swimming the no-nit policy.44-46 The American Academy of Pediatrics
pools, and they fully recovered after removal from the liquid; (AAP) issued a position statement discouraging no-nit
however, experiments with naturally infested children policies in schools.47 Some consumer organizations, how-
showed that lice did not leave the children's heads during ever, strongly support and promote a no-nit policy, including
30 minutes of vigorous swimming.38 When they become the National Pediculosis Association. (http://www.headlice.
immersed, head lice become stationary and clasp firmly onto org/downloads/nonitpolicy.htm).
the hair to which they were attached at the time of A very convincing recent review article46 by experts from
immersion. This reflex, called “sham death,” is the Israel, United States, and Canada presented compelling
explanation of why although lice survive immersion they arguments against the no-nit approach. The authors state that
are not transmitted in swimming pools. it has been repeatedly shown that only a small number of
children who have nits on their scalp are also infested with
Diagnosis of active infestation living lice. Accordingly, 4 to 8 million children in the USA
alone are treated unnecessarily for head lice annually, which
Surprisingly, the optimal way to diagnose such an old amounts to 64% of all lice treatments. In addition, 12 to 24
infestation with visible parasites is still controversial. The million school days are lost annually along with a $4 to $8
main disagreement lies in the question of whether only living billion loss owing to missed workdays by parents who have
lice found on the scalp indicate active infestation. The to stay home with their children. Furthermore, lice are
supporters of this approach believe that the presence of nits usually detected only 1 to 2 months after the child has
alone is not an accurate indicator of an active head louse become infested, and so keeping the child in school for a few
infestation.39,40 To strengthen their case, they present a study more hours will not make any significant difference.
Treatment of scabies and pediculosis 517

According to the authors, “the no-nit policy is imprudent and Conclusions

unjust, as it is based on intolerance, hysteria and misinfor-
mation rather than on objective healthcare.” We tried to highlight the many controversies, myths,
and misconceptions associated with diagnosing and
Insecticide efficacy and the problem of resistance treating two common infestations, scabies and pediculosis,
and to reach, as much as possible, the appropriate no-
There is general agreement that widespread resistance of nonsense recommendations.
head lice to lindane, pyrethrin, and permethrin does occur,
whereas the situation concerning the organophosphate,
malathion, is still controversial. References
Lindane has been considered a primary treatment for head
lice for more than 50 years, but poor efficacy and serious
1. Mallanby K. Scabies. Middlesex, England: Classey, Hampton; 1972.
adverse events have resulted in restrictions of its use. A
2. Pemberton J. Medical experiments carried out in Sheffield on
recent study compared the ability of lindane, malathion, conscientious objectors to military service during the 1939-45 war.
pyrethrin, and permethrin to rid treatment-sensitive and Int J Epidemiol 2006;35:556-8.
treatment-resistant lice collected from a patient population in 3. Savin JA. Mellanby on scabies. Clin Exp Dermatol 2002;27:86-7.
Florida. The slowest and least effective product was 1% 4. Weindling P. Human guinea pigs and the ethics of experimentation: the
BMJ’s correspondent at the Nuremberg medical trial. BMJ 1996;313:
lindane, apparently killing no lice after 10 minutes, the
1467-70.
recommended application time for lindane shampoo. After 3 5. Wolf R, Avigad J, Brenner S. Scabies: the diagnosis of atypical cases.
hours' exposure, only 17% of lice were dead.48 Cutis 1995;55:370-1.
Permethrin was introduced in 1986 and showed a very high 6. Burkhart CG, Burkhart CN, Burkhart KM. An epidemiologic and
efficacy of 97% to 100% in the first years of usage.49-51 Its therapeutic reassessment of scabies. Cutis 2000;65:233-40.
7. Commentary: guinea-pigs’ private war. Int J Epidemiol 2006;35:558-60.
efficacy has been constantly waning, however, and high levels
8. Jackson R. Scabies by Kenneth Mellanby. J Cutan Med Surg 2004;8:
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