OTC Case Study Presentation - Head Lice

OTC Case Study Presentation:Head Lice

Presented by Dave Porter

Presentation Outline

• Case Study– Case study text

– Patient overview

• Pathophysiology– Lice life cycle

– Disease state overview

• OTC Pharmacological Options

• Nonpharmacological Options

• Prevention of Reoccurrence

• Conclusion

Case Study Overview

The Case

A mother comes to our pharmacy asking questions about eradicating lice in her seven-year-old daughter’s long hair. Her mother says her daughter is very itchy. There is a younger daughter and an older brother in the household as well.

What are some products we offer and what are the counseling points that should be discussed with this patient and her mother concerning these products?

The Patient

• Seven year old female with long hair• HPI/CC

– Head lice in hair– Itching– In otherwise good health

• FH– Mother, father, older brother and younger sister

• All in good health

• PMH non contributory– No known drug allergies

• SH noncontributory• No current medications

Pathophysiology

Species of Lice

• Pediculus humanus capitis

– Organism of interest

– Size of a sesame seed

• Pediculus humanus corporis

• Phthirus pubis

http://livingwithinsects.files.wordpress.com/2010/11/lice1199.jpg

http://www.naturalliceandmitebuster.ie/uploads/images/head-lice-top.jpg

http://www.headlicetreatmentworld.com/wp-content/uploads/2011/05/nits_and_lice_life_cycle1.gif

Life Cycle

• Mature lice can lay 50-150 eggs during life

– Lifespan of 30 days while on host

• Takes 7-10 days for the eggs (nits) to hatch

• Developing lice (nymphs) take about 21 days to mature and lay eggs

• Lice are parasitic insects

– Must live on host to live, feed and breed

• Transmissible through direct contact!

Nits, Nymphs and Lice

http://www.liceremovallosangeles.com/nits1.jpg

Nits, Nymphs and Lice

http://www.headlice.org/images/louses.jpg http://www.redorbit.com/media/uploads/2004/10/40_32d5ec9b3b2b3a93445c4765251bcd9b.jpg

http://upload.wikimedia.org/wikipedia/commons/f/fe/Pediculus_humanus_capitis_CDC9217.png

Signs and Symptoms

• Intense Itching– Possible allergic reaction to the saliva that lice inject

during feeding results in itching and redness on the scalp, neck and shoulders• Not always experienced during the first infection

– Irritation due to feeding

• Adult lice in hair and on scalp– Usually located behind ears and back of neck

• Lice eggs– Often mistaken for dandruff– Directly attached to hair

• Cannot be removed easily by brushing hair

http://www.mayoclinic.com/health/head-lice/ds00953/dsection=symptoms

Signs and Symptoms

• Patients may not experience any symptoms until weeks or even months after the lice establish infection

• Oftentimes, the first symptom noticed are the lice themselves

Diagnosing Our Case

• Information

– Adult lice visually confirmed on daughter’s hair

– Itching present

• Conclusion

– Lice infestation has been established

• Recommendations

– Pharmacological intervention

– Nonpharmacological prevention

OTC Pharmacologic Treatment Options

1. Nix® Creme Rinse

2. Rid® Complete Lice Elimination Kit

3. LiceMD™

4. A-200 Lice Killing Shampoo®

Nix® Creme Rinse

• Ingredients

– Permethrin 1% shampoo

• Application

– Applied to dry hair, nape of neck and behind ears until saturated and left on for 10 minutes, then worked into a lather and rinsed with water

– 97-99% cure rate after 1 application

– Patient may repeat if lice present after 7-10 days

– Use nit comb daily and wash in hot water

http://www.clinicalpharmacology-ip.com/Forms/drugoptions.aspx?cpnum=1506&n=Permethrin

Nix® Creme Rinse

• MOA

– Permethrin

• Disrupts sodium channels on nerve cells, preventing or delaying repolarization causing paralysis and death of lice

• Affects eggs

• ADRs/Interactions

– Generally well tolerated

• Mild stinging and itching with OTC strength

– No documented drug interactions

http://www.clinicalpharmacology-ip.com/Forms/drugoptions.aspx?cpnum=1506&n=Permethrin

Nix® Creme Rinse

• Additional counseling points

– Shake well before applying

– Do not self-treat if lice are present on eyebrows or eyelashes

– Avoid getting Nix® in your eyes, nose or mouth

– For external use only

– Should not be used by patients with a ragweed or chrysanthemum allergy

http://c1.soap.com/images/products/p/zj/zj-001_1z.jpg

Rid® Complete Lice Elimination Kit

• Ingredients– Pyrethrins 0.33%

– Piperonyl butoxide 4%

• Application– Applied to dry hair, nape of neck and behind ears until

saturated, left for 10 minutes, worked into a lather then rinsed off with water

– Towel dry and apply the Lice and Egg Comb-Out Gel to one section of hair at a time, then comb out nits• Use nit comb daily and wash in hot water

– Patient must repeat in 7-10 days

http://www.clinicalpharmacology-ip.com/Forms/drugoptions.aspx?cpnum=2528&n=Rid+Pediculicide

• MOA– Pyrethrins

• Disrupts sodium channels on nerve cells, preventing or delaying repolarization, causing paralysis and death

• Does not affect eggs

– Piperonyl butoxide• inhibits metabolism of pyrethrins by lice and thus enhances

the effects of the pyrethrins• Also reduces risk of pyrethrin resistance in lice

• ADRs/Interactions– Generally well tolerated

• Mild localized itching, redness and swelling




• Additional Counseling Points– Shake well before use if using the mousse– Not ovicidal

• 20-30% of eggs will remain after the initial application• Must repeat application in 7-10 days

– Do not self-treat if lice are present on eyebrows or eyelashes

– Avoid getting Rid® in your eyes, nose or mouth– Pyrethrin products may be flammable– External use only– Should not be used by patients with a ragweed or

chrysanthemum allergy



http://ridlicepro.com/static/media/images/upload/RID_COMPLETE_LICE_ELIMINATION_KIT_Front_Top_Lo_Resolution_150_dpi.jpg

LiceMD™ Lice and Eggs Removal Kit

• Ingredients

– Dimethicone 4%

• Application

– Apply behind ears, to nape of neck and throughout hair and massage until wet and leave on for 10 minutes

• Apply to dry hair only

– While hair is still wet, comb out nits

– May repeat as needed for 10 days

– For long hair, use 4 ounces per application

LiceMD™ Lice and Eggs Removal Kit

• MOA– Coats the lice, nymphs and eggs and irreversibly

immobilizes them

– Allows for easier removal with nit comb

• ADRs/Interactions– No ADRs


• Additional Counseling Points– Keep out of eyes

– External use only

http://www.rbnainfo.com/ppmsds_uploaddata/images/productline/09941-62200-00348-00-BTY.jpg

A-200 Lice Killing Shampoo®

• Ingredients– Pyrethrins 0.33%

– Piperonyl butoxide 3%

• Same application directions, MOA and ADRs as Rid®– Only difference is a 3%

concentration of piperonyl butoxide

– Wegmans does not carry this


http://ep.yimg.com/ca/I/physlabs_2205_227793075

Additional Notes

• Nix® and Rid® products are equally effective if used properly– Rid® application must be repeated

• Contact MD if there are still lice or eggs remaining after 2 applications of either Nix® or Rid®– Prescription options are available (Ovide®)

• Contact MD if severe skin reaction or allergy occurs

• LiceMD™ may be used by patients who have a known allergy to chrysanthemums or ragweed or those with very sensitive skin

Nonpharmacological Treatment Options

1. Cetaphil® Gentle Skin Cleanser

2. Tea Tree Oil

3. Home Remedies

Cetaphil® Gentle Skin Cleanser

• Suffocation-based pediculicide treatment

• Method

– Apply Cetaphil® to scalp, using enough to coat thoroughly

– Comb out excess lotion

– Blow dry hair with hair drier

• Dried lotion coats any lice in a shrink-wrap-like layer, preventing movement and respiration

– The dry lotion must remain on the hair and scalp for at least 8 hours

• Leave in place until bathing or showering the following day

http://www.nuvoforheadlice.com/method_explained.htm

http://www.meijer.com/assets/product_images/styles/xlarge/1000947_509216_A_400.jpg

Tea Tree Oil

• Proposed MOA– Inhibits acetylcholinesterase enzyme in lice– May also act as a repellent

• Application– Do not take orally!– Add 10 drops of tea tree oil to 4 tablespoons of

vegetable or olive oil– Coat hair thoroughly with the oil mixture and leave on

for 3 hours– Comb the dead lice and the nits out with a nit comb– Wash the hair with a regular shampoo to remove the oil

http://headlicecenter.com/tea-tree-oil-lice-treatment/

http://acphs.naturalstandard.com/databases/herbssupplements/teatreeoil.asp

Tea Tree Oil

• ADR/Interactions– Drying, redness, stinging, burning of the skin

– May interact with topical antibiotics and antifungals

– If absorbed systemically, may increase effectiveness of antihistamines, NSAIDs and antihelminthics

– May increase drying effects of tretinoin

• Additional Counseling Points– No significant clinical trials have been done, not a

recommended treatment

– Often used with lavender oil to diminish bloodsucking

– Store in a dark place

http://acphs.naturalstandard.com/databases/herbssupplements/teatreeoil.asp

http://myultimatetips.com/wp-content/uploads/2012/01/tea-tree-oil-definition-what-is-tea-tree-oil.jpg

http://turbyandjohn.com/files/2010/08/41mzhY5jz5L._SL500_AA300_.jpg

Some Home Remedies

• Petroleum jelly or mayonnaise– Supposedly decreases respiration but

really decreases the mobility of lice

– Poor efficacy

• Coconut oil– No evidence of efficacy

• Vinegar– No evidence of efficacy

– Offensive smell

• Gasoline or kerosene– Extremely dangerous, ADRs likely

Preventative Measures

Prevention of Reoccurrence

• Use nit comb regularly

• Vacuum living areas regularly during treatment– Includes furniture and especially anything with cloth

• Wash bed sheets, clothes, towels, hair brushes, combs and stuffed animals in hot water– > 130°F

• Objects unable to be washed should be stored in plastic bag for 2 weeks– If eggs are present, they will hatch and the nymph will

die• Must feed within 24 hours

Conclusion

• Case Study– 7 year old female with head lice and itching

• Recommendations– Rid® Complete Lice Elimination Kit*

• Apply once as directed, repeat in 7-10 days if needed

– Use nit comb regularly

– Wash patients clothes and linens separately in >130°F water

– Vacuum living areas regularly

– If desired, use Rid® Home Lice, Bed Bug and Dust Mite Spray

Monitoring Criteria

• After application of pediculicide agent and combing out nits, check daily for new lice and new nits on the patient’s hair, linens and clothing

– Check daily

– Return to or call the pharmacy after a week to discuss progress

• If lice keep appearing after treatment, contact the pharmacy or the patient’s pediatrician

– If at any time they begin infesting the eyebrows or eyelashes, contact MD

http://graygame205.files.wordpress.com/2011/04/any-questions.jpg

OTC Case Study Presentation - Head Lice

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