Alan A. Ayers, MBA, MAcc is Practice Management Editor of JUCM, The Journal of Urgent Care Medicine, a member of the Board of Directors of the Urgent Care Association of America, and Vice President of Strategic Initiatives for Practice Velocity.

URGENT MESSAGE: Twenty-five states are now seeing head lice that are resistant to most common over-the-counter remedies, creating a nuisance for parents and a potential business opportunity for urgent care.
Between 6 and 12 million children age 3-11 become infested with head lice every year, and parents spend about $350 million per year on permethrin-laced over-the-counter and prescription treatments.1 While permethrin has been an effective weapon against mosquitos, bedbugs, head lice, and other biting insects since its introduction in the early 1990s, 25 states are now seeing some lice populations that do not respond to the drug.

Worse, Arizona, California, the Carolinas, Connecticut, Florida, Georgia, Illinois, Maine, Massachusetts, Texas, and Virginia all have lice that have developed what researchers refer to as “knock-down resistant mutations,” a triple whammy of genetic alterations that render lice completely immune to over-the-counter permethrin treatments.1

These findings might not be a surprise in light of the fact that more powerful insecticides have been taken off the market over the years. DDT was withdrawn in the 1970s because of environmental concerns, and organophosphates, which are neurotoxic, were restricted after 9/11 because the federal government feared their use by terrorists. Consequently, lice, scabies, bedbugs, fleas, and other biting insects have been constantly exposed to the most commonly used chemical left: permethrin.

Just as incorrect use of oral antibiotics has led to multidrug-resistant bacteria, incorrectly using OTC products containing permethrin might be a factor in head lice developing resistance to treatment.

Permethrin only kills the active lice; the nits or eggs remain to hatch later. Many people ignore recommendations to repeat the treatment in seven to 10 days, as recommended to kill any remaining lice. In a classic example of how an organism becomes resistant to a specific drug, constant exposure to permethrin has caused head lice to develop self-protective genetic mutations that render the once powerful and effective insecticide useless.

The U.S. Centers for Disease Control and Prevention (CDC) does not require health providers, schools, or public health departments to report lice infestations because the insects do not spread diseases, so it’s hard to pin down when the resistance trend really took hold. To this day, because statistics are not systematically collected, there is no definitive statement on what percentage of lice have developed immunity to OTC treatments. Also, the parasitic pests circulating in one region of the country could be more (or less) resistant than those in other regions.2 For example, lice tested in New Jersey, New Mexico, New York, and Oregon have developed partial immunity, while lice in Michigan have developed no resistance at all.

While a physician’s evaluation of the scalp and a prescription written for a diagnosis of pediculosis is typically reimbursable by insurance in urgent care, lice removal services generally are not covered. Patients can pay cash or use their health reimbursement/ health savings accounts to pay for lice removal services, tax-free.

Prescription Remedies for Head Lice
Prescription medications that do not contain permethrin are still effective against head lice. These contain powerful agents such as benzyl alcohol, ivermectinmalathion, and spinosad. Lindane shampoo is another alternative for difficult-to-treat cases. While these drugs are more expensive than OTC treatments, the fact that they require a prescription creates an opportunity for urgent care. Head lice represent an episodic medical need that fits the urgent care model perfectly: infestation requires immediate attention, but is clearly not a medical emergency. Evaluation of a patient leading to a diagnosis of pediculosis may be reimbursed as an urgent care or office visit. Referrals can come through relationships with school nurses or by raising awareness in the community via advertising and public relations efforts.

Unfortunately, not all prescription alternatives are safe for everyone. Medications may have side effects or carry warnings, and the nonprescription treatments are safer for younger children, typically (though ivermectin has been approved by the FDA for use in children 6 months of age and older). Malathion can sting if the scalp is irritated from scratching. It’s also flammable, so it is important to stay away from heat sources (including hair dryers) or flames for the 8 to 12 hours that the malathion is on the hair. Lindane can cause seizures if used incorrectly and should not be used in small children or women who are pregnant or breastfeeding. Providers should be familiar with each of these prescription alternatives, including their indications and side effects.

Providers should also become familiar with local school policies, which vary by district. Sample policies range from requiring that all lice and nits be removed before the child can return to school, to allowing return to school after treatment with a special shampoo or rinse, or return to school with minimal numbers of nits or lice. In professional circles, there is widespread disagreement as to when a child may return to school because, technically, a lice infestation is not dangerous or infectious. Some doctors and school nurses argue that by the time the lice infestation is discovered, classmates would likely have been exposed.

The National Pediculosis Association is against allowing children with nits back into schools, as these nits will eventually hatch into lice. The American Academy of Pediatrics, on the other hand, encourages the discontinuation of “no-nit” policies, as nits cement themselves to hair shafts and are tough to remove. And the position of the National Association of School Nurses is that children with live head lice should continue to go to class (but avoid direct head contact with others).3

Lice infestations are often misdiagnosed based on parents’ reporting of symptoms. However, parents who suspect that a child has lice might be wrong, and an urgent care provider should rule out other causes such as dandruff or ringworm of the scalp.

The bottom line is that considered, aggressive treatments are needed when a child is miserable from itching and scratching, but this does not necessarily involve going straight for the prescription-strength treatments for head lice infestation.

Nonmedical Lice Removal Services
A growing number of entrepreneurs, such as Lice Lifters in Dallas (http://liceliftersdfw.com) and The Hair Angels in Los Angeles (http://www.thehairangels.com) see profit potential in the drug-resistant lice epidemic and parents’ need for treatment. These services are provided in a salon-like environment using natural, nonchemical remedies that remove all lice and nits, making follow-up visits unnecessary. One chain, Lice Clinics of America, uses a device that floods the scalp with warm air, drying out and killing lice. Combing out of nits is still necessary, although less so than without the dehydration process.

While such lice removal services are not covered by health insurance, typically, they can be paid for using a health savings account or flexible savings account.
Of course, most treatments require that other steps be taken to get rid of a head lice infestation.4 After two treatments, the use of a very fine-toothed comb is required to get rid of the nits that could still be clinging to the hair shaft. It’s also recommended that all family members be checked and/or treated. Patients and parents should be counseled to not share grooming tools, hats, scarves, or other articles of clothing that were worn by someone with a known infestation. Further, all items that have come into contact with the head and hair need to be cleaned. Combs and brushes should also be cleaned well by soaking them in a disinfectant such as Lysol or Clorox. Hats, scarves, towels, and bed sheets should be washed in hot water and dried in a hot dryer. Contaminated clothing that cannot be washed or dry cleaned should be sealed in a plastic bag for two weeks, as lice can live for only a few days off the patient’s body. Sometimes people are advised to buy a special lice insecticide spray to use on furniture. However, careful vacuuming may be as effective in most cases. Pets do not need to be treated.

Conclusion
Just like the overuse of antibiotics has helped create so-called “superbugs,” the use of over-the-counter lice treatments over the years has made head lice resistant to some chemicals. Researchers have been saying for years that this was a likely scenario. Although growing drug resistance can make getting rid of lice a real pain, it’s not cause for too much concern. That’s because lice are not dangerous. They don’t spread any diseases. They’re just an incredibly annoying problem for both parents and kids. Fortunately, urgent care can be part of the solution.
The relevance to urgent and primary care physicians is that they already have a trusted medical relationship with parents who may look to them to solve any and every medical problem the family encounters. Urgent and primary care practices can make a side, cash business by providing or referring to lice removal services—particularly if an epidemic occurs in the local schools.

References
1. Mose A. Head lice resistant to common meds in 25 states. WebMD News. Available at: http://www.webmd.com/skin-problems-and-treatments/news/20150818/head-lice-now-resistant-to-common-meds-in-25-states. Accessed September 14, 2015.
2. Sisson P. Head lice are getting tougher to treat. San Diego Union Tribune. Available at: http://www.sandiegouniontribune.com/news/2015/aug/30/lice-san-diego/. Accessed September 14, 2015.
3. FastMed Urgent Care. Triad, NC. Parents: Be Prepared for Head Lice! Available at: http://www.fastmed.com/health-resources/nc-local-resources/triad-nc-parents-be-prepared-for-head-lice. Accessed September 14, 2015.
4. Reddy Urgent Care Centers. Head lice symptoms and information. Available at: http://www.reddyurgentcarecenters.com/health-information/head-lice/. Accessed September 14, 2015.

Drug-Resistant Lice: A Nuisance or an Opportunity for Urgent Care?

Alan A. Ayers, MBA, MAcc

Chief Executive Officer of Velocity Urgent Care, LLC and is Practice Management Editor of The Journal of Urgent Care Medicine
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