WHAT’S EATING YOU?

1. WHAT’S EATING YOU? By Joe R. Monroe, MPAS, PA

3. TICKS CAN BE DISEASE VECTORS BUT DON’T LIVE ON OR MULTIPLY ON HUMANS PERFECT EXAMPLE OF THE “ICK” FACTOR BUT NOT A REASON TO PANIC

4. ECTOPARASITES • SCABIES • HEAD LICE • CHIGGERS • CHICKEN MITES, HAY MITES ARE CARRIED BY WIND • AND ONLY SCABIES AND LICE RESIDE OR MULTIPLY ON HUMANS

5. “WHO KNOWS WHAT I MIGHT HAVE?” ANSWER: YOU DO (OR SHOULD) BUT PATIENTS IMAGINE MUCH, AND SOMETIMES “SEE” CREATURES WHICH AREN’T THERE E.g.: MORGELLON’S DISEASE, aka delusions of parasitosis (DOP)

6. OUTSIDE THE US MANY ECTOPARASITES EXIST WHICH ARE NOT (YET) HERE EG, DERMATOBIA HOMINIS (FROM BELIZE) OR CUTANEOUS LARVA MIGRANS (MOSTLY FROM TROPICAL AREAS) AFRICA, SOUTH AMERICA

7. SCABIES SCABIES SARCOPTEI, VAR. HUMANUS MICROSCOPIC ID NECESSARY FOR DX TREATMENT “FAILURES” ARE COMMON OFTEN = STD IN YOUNG ADULTS

8. SCABIES HUMAN TO HUMAN ONLY LIKES TENDER SKIN, BABIES HATES HAIR, THICK SKIN 24/7 ITCHING, SCRATCHING BETWEEN FINGERS, VOLAR WRIST VASTLY OVERDIAGNOSED TREATMENT = PROBLEMATIC

9. SCABIES cont’d PETS CAN’T GET OR GIVE IT DOESN’T LIVE IN THE SOFA, RUG SNIFF TEST POSITIVE? INSTITUTIONAL SETTINGS = A NIGHTMARE, AFFECTING STAFF, PATIENTS, FAMILIES ESPECIALLY PROBLEMATIC IN IMMOBILE PATIENTS

10. SCABIES cont’d MUST CONFIRM MICROSCOPICALLY LOOKING FOR “SCABETIC ELEMENTS” (eggs, adults, droppings) USING #10 BP BLADE, SCRAPE TINY VESICLES WITH GUSTO, SMEAR ON SLIDE, ADD KOH 10 – 20%, PLUS COVERSLIP EXAMINE UNDER 10X

14. SCABIES TREATMENT PERMETHRIN CREAM, ALL OVER EXCEPT ABOVE NECK LEAVE ON OVERNIGHT, WASH OFF IN A.M., REPEAT IN 10 DAYS ADD IVERMECTIN P.O.? HAVE TO ID, TREAT OR AVOID POTENTIAL CONTACTS ITCH ALWAYS PERSISTS > TX

15. TREATMENT FAILURE MISDIAGNOSED = # 1 PATIENT COMPLIANCE = # 2 FAILURE TO CONFRONT/TREAT OR AVOID CONTACTS HAVE TO TREAT TWICE, 10 DAYS APART (ELIMITE ONLY) ADD IVERMECTIN (200 ug/kg)?

16. HEAD LICE PEDICULOSIS CAPITIS GIRLS >> BOYS HEAD TO HEAD TRANSMISSION NITS ½ INCH FROM SCALP PROVOKES A GREAT DEAL OF IRRATIONALITY HEAD LICE CANNOT TRANSMIT DISEASE

17. HEAD LICE PREFER WELL-WASHED, WELL-NOURISHED VICTIM HAPPEN IN THE BEST OF FAMILIES LICE CANNOT FLY OR JUMP HAVE BEEN AROUND SINCE MANKIND

20. PEDICULOSIS CAPITIS 2-3 MM LONG, PALE GRAY COLOR INJECT SALIVA INTO SCALP, INGEST BLOOD MEAL EVERY FEW HOURS ONLY LIVE FOR A DAY OR SO OFF THE BODY LAY EGGS ¼ INCH FROM SCALP OR LESS, ABOUT 10 AT A TIME NITS ADHERENT TO HAIR SHAFT

26. HEAD LICE NO NEED TO CALL ORKIN DO CHECK FAMILY MEMBERS MUST ID AND AVOID SOURCE(S) RX MEDS VASTLY SUPERIOR TO “NATURAL” TREATMENTS NIX/RID ARE FINE AS ROUTINE TX BUT MUST BE USED WITH NIT COMB

27. HEAD LICE IT CAN TAKE WEEKS AFTER INITIAL INFESTATION BEFORE ITCHING BEGINS, UNLESS PATIENT HAS HAD HEAD LICE BEFORE ACTUAL ALLERGIC REACTION THINK HEAD TO HEAD TRANSIMISSION COMBS, BRUSHES, HATS ARE FAR LESS IMPORTANT IN TRANSMISSION

28. HEAD LICE VIABLE NITS WILL BE CLOSE TO SCALP & ADHERENT TO SHAFT MAY SEE BROWN SCALY FECAL MATERIAL ON SCALP, EVEN OUTSIDE HAIR LINE NEW, SUPERIOR TREATMENT NOW AVAILABLE, ONLY ON RX

29. HEAD LICE TREATMENT THE PROBLEM: 70% TREATED IRRATIONALLY, ONLY 30% BY MEDICAL PROVIDER PROVIDER OFFICE ADVISES OTC ALMOST HALF THE TIME, RX’S THE OTHER HALF BUT USUALLY WITH OTC OR TRADITIONAL RX COMPLICATED BY HYSTERIA

30. HEAD LICE TREATMENT MANY PARENTS GO ONLINE, WHICH SERVES TO MAKE THINGS EVEN MORE CONFUSING MANY, MANY PRODUCTS, SERVICES EG “PROFESSIONAL NIT PICKERS” LINDANE, MALATHION NOT TERRIBLY EFFECTIVE AND POTENTIALLY TOXIC

31. HEAD LICE TREATMENT ONLY 10% OF HEAD LICE PATIENTS GET RX OFTEN AFFECTS OTHER FAMILY MEMBERS, FRIENDS, MAKING TREATMENT PROBLEMATIC HEAD LICE IS OFTEN OVERDIAGNOSED BY ANXIOUS PARENTS, TEACHERS, NURSES

32. HEAD LICE TREATMENT DIAGNOSIS AND EFFECTIVE TREATMENT NEED INVOLVEMENT OF HEALTH CARE PROVIDER IN TERMS OF DX/RX OF EFFECTIVE MEDS AND THEIR CORRECT USAGE AMERICAN ACADEMY OF PEDIATRICS URGES MORE ACTIVE PCP INVOLVEMENT

33. HEAD LICE TREATMENT 1% PERMETHRIN CAN BE USED IN UNCOMPLICATED CASES + COMB BUT ONLY AFTER VISUAL CONFIRMATION OF VIABLE NITS OR ADULTS LOCAL PATTERNS OF RESISTANCE ARE BECOMING A PROBLEM

34. NIT COMBING 2 WEEKS OF DAILY NIT COMBING ADVISED WHEN PERMETHRIN IS USED SPECIAL COMB NEEDED NIT COMBING = ESSENTIAL COMPONENT OF HEAD LICE TREATMENT

35. HEAD LICE TREATMENT AAP AND SCHOOL NURSES ASSOCIATION SAYS: “NO REASON TO KEEP CHILDREN OUT OF SCHOOL FOR HEAD LICE…..AND NO REASON TO ENFORCE A NO-NIT POLICY FOR A RETURN TO SCHOOL.” BOTH ON RECORD FOR SUPPORTING ADOPTION OF EVIDENCE-BASED TX

36. IVERMECTIN USED ORALLY FOR MANY YEARS FOR VARIOUS PARASITES IN HUMANS AND ANIMALS LONG RECORD OF SAFETY USED ORALLY FOR SCABIES, WITH GREAT SUCCESS NOW AVAILABLE IN TOPICAL FORM FOR HEAD LICE (SKLICE) ONLY

37. TOPICAL IVERMECTIN CALLED “SKLICE”, IN LOTION FORM, WITH 5MG IVERMECTIN/GRAM OF LOTION DERIVED FROM FERMENTATION OF STREPTOMYCES AVERMITILIS, A SOIL BACTERIA CLINICAL TRIALS IN HUMANS FOR SKLICE BEGAN IN 2005, APPROVED IN 2-12

38. SKLICE (ivermectin lotion) APPROVED FOR AGE 6 MONTHS AND UP AS A ONE-TIME TREATMENT APPLY TO HAIR AND SCALP, LEAVE ON 10 MINUTES, RINSE OUT > 70% EFFECTIVE IN TRIALS AS ONE-TIME TREATMENT NIT COMBS OK, BUT NOT NECESSARY – KILLS NITS TOO

39. IVERMECTIN LOTION TRADE NAME = SKLICE REPRESENTS A TOTALLY NEW AND UNIQUELY EFFECTIVE TREATMENT FOR HEAD LICE SAFE FOR 6 MONTHS AND UP RX ONLY, ONE-TIME TREATMENT, LEFT ON 10 MINUTES NO NIT COMBING REQUIRED

40. HEAD LICE TREATMENT COMMON SENSE MEASURES STILL NEEDED ID CONTACTS, URGE TREATMENT BUT FIRST, CONFIRM DIAGNOSIS URGE CALM

41. ECTOPARASITES SCABIES ON THE BODY, HEAD LICE IN THE SCALP = WHOLE STORY BENIGN BUT MUCH HYSTERIA PETS CAN’T GET/GIVE EITHER ONE PERMETHRIN+/- ORAL IVERMECTIN FOR SCABIES TOPICAL PERMETHRIN, OR TOPICAL IVERMECTIN (SKLICE) FOR SCALP