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Detection combing

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VOL: 98, ISSUE: 46, PAGE NO: 55

Detection Finding lice is relatively difficult (Pollack et al 2000). The insects mostly remain close to the skin, often aligned with hairs, and have sufficient camouflage coloration so that they are difficult to see.

Detection Finding lice is relatively difficult (Pollack et al 2000). The insects mostly remain close to the skin, often aligned with hairs, and have sufficient camouflage coloration so that they are difficult to see.

Louse eggs are even more difficult to see because they are smaller, closely attached to hairs near the scalp, and act like a lens to refract the colour of their surroundings when newly laid. As they develop they take on a coloration of their own, and even this often blends with their background. Only the empty eggshell - the nit - that remains after the nymph has emerged is relatively easy to see, because reflection of light from each of the surfaces of the shell makes it appear white to the naked eye.

However, it is a poor diagnostic guide simply because it may persist for months after all lice have gone, and many children have been treated unnecessarily merely because a few eggshells remain on the hairs (Pollack et al, 2000; Williams et al, 2001). Regardless of any other evidence, it is only if you find living lice that you can be sure that an infestation is active.

Finding lice by the traditional method of parting the hair and looking at the scalp is not particularly efficient and likely to miss a high proportion of infections (De Maeseneer et al, 2000).

At present the most effective approach is to use a detection comb, but whether to use it on dry hair or with a lubricant - such as water, oil or conditioner - is a matter of debate. The disadvantage of dry combing is generation of static that can cause lice to be repelled from the comb as it is withdrawn from the hair. However, the advent of antistatic combs means that this problem can now be overcome.

The disadvantage of using conditioner is that small lice can be more easily overlooked in among the material combed from the head, and some people can develop allergic sensitivities to components of conditioning rinses.

Regardless of these factors, detection combing is a systematic examination of the hair, from the scalp outwards, using a fine-toothed plastic comb with flat-faced teeth 0.2-0.3mm apart. Combs with teeth like this are capable of trapping and lifting out even the smallest lice.

Treatment Once lice are found, treatment needs to be instituted. How this is achieved is largely a matter of personal preference, but whatever is done should be carried out thoroughly and consistently, and failures arise as much from not doing the job properly as from the lice acquiring resistance to treatment,

There is little clinical evidence for any form of treatment. Virtually all clinical trials have serious flaws, and in term of giving advice to the public on effectiveness of treatment our clinical evidence library currently has only one study.

In various parts of the country pharmacist-prescribing schemes are now providing advice on diagnosis and treatment. In most cases, two applications of an insecticide are used as the first line of approach. However, it is important to stress that some products are likely to fail due to resistance, especially those that have shorter application times or those that are water-based. If the insecticide fails, combing should be explored for treatment and used for follow-up in all cases to ensure that treatment has been successful.

This approach takes pressure off primary care providers, especially GPs, and offers an immediately available resource for people who need help with treatment. Nevertheless, it is not intended as a replacement for other professional services, and the traditional role of nurses in providing advice and support for families in dealing with lice remains. This is especially important where resistance to insecticide influences treatment outcomes and where people lack competence in using combs or do not understand the level of commitment required if they choose them as a treatment option.

It is important to stress that currently there is no clinical evidence or safety data for any of the alternative therapy approaches to treating head lice, including electrically powered devices.

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