7/22/2018. Big Bites: the Summertime Bug Blues. Disclaimers. Objectives. Camp Lice Policy. F015: What s Hot in Pediatric Dermatology

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1 F015: What s Hot in Pediatric Dermatology Big Bites: the Summertime Bug Blues DISCLOSURE OF RELATIONSHIPS WITH INDUSTRY Raegan D. Hunt, MD, PhD Assistant Professor of Dermatology & Pediatrics Chief, Pediatric Dermatology Texas Children s Hospital Baylor College of Medicine Raegan Hunt, MD, PhD F015: What s Hot in Pediatric Dermatology DISCLOSURES Pfizer: Advisory Board Consulting Fee Objectives Disclaimers Describe treatment resistance trends among head lice Diagnose and treat skin infestations and bite reactions Develop effective insect repellant strategies for children Trade names will be listed in parenthesis alongside generic medication names but not used Off label medication may be discussed Camp Lice Policy 60% of summer camps report head lice as a significant problem 34 % of summer camps have a no nit policy < 20% of children with nits or lice are allowed to stay at camp Of children treated at camp with over the counter treatments, only 40 % received a second treatment as recommended DeHudy A, et al American Academy of Pediatrics National Conference & Exhibition Head lice: pediculosis capitis CDC estimates 6 12 million head lice infestations annually in the US Most headlice infestations are among ages 3 11 years More common among girls than boys Occurs in all ethnic groups Estimated economic burden of lice ~ $1 billion/ year (2004) Other impacts of head lice infestation Scalp itch and irritation Secondary infection associated with scratching Missed school/work Social disruption Embarrassment 1

The Facts of Lice Head lice die in 1 2 days without feeding Nits die within a week and cannot hatch if they are not near scalp Pediculosis capitis: Super lice Pyrethroid resistant over the counter

hot water ( 130 F) for 5 minutes Vacuum floor and furniture around where infested person sits/sleeps Counsel patients not to share hair accessories Red states: 100% of tested lice resistant Orange

2 The Facts of Lice Head lice die in 1 2 days without feeding Nits die within a week and cannot hatch if they are not near scalp Pediculosis capitis: Super lice Pyrethroid resistant over the counter treatments ineffective Hygiene recommendations Machine wash and dry clothing and bed linens worn 2 days before treatment Seal un washable items in plastic bag for 2 weeks Soak combs and brushes in hot water ( 130 F) for 5 minutes Vacuum floor and furniture around where infested person sits/sleeps Counsel patients not to share hair accessories Red states: 100% of tested lice resistant Orange states: 50 90% of tested lice resistant Yellow state: 0 % of tested lice resistant White states: data not analyzed yet Blue states: data not collected yet Yoon, et al. American Chemical Society, August 2015 Pyrethroid resistant head lice Knockdown resistance: (kdr) mutations Point mutations in voltage sensitive sodium channel (VSSC) create nerve insensitivity 138 lice collection sites in 48 U.S. states from Not tested: Alaska, West Virginia 132/138 sites (95.6%) had a mean % resistance allele frequency (RAF) of 100% Five sites (3.7%) had intermediate values Only a single site had no mutations (0.0%) Michigan Forty two states (88%) mean RAF 100% Gellatly KJ, et al. J Med Entomol, Mar 2016 Pyrethroids Over the counter: lice treatments Pyrethrins (Rid, A 200, Pronto, R&C, Triple X, Licide) pyrethroid extracts from the chrysanthemum flower Not ovicidal; repeat treatment on day 9 Avoid use in people allergic to chrysanthemum or ragweed Approved ages 2 years Permethrin lotion 1% (Nix) synthetic pyrethroid similar to naturally occurring pyrethrins Not ovicidal; repeat treatment on day 9 Approved ages 2 months Malathion lotion 0.5% (Ovide) FDA approval 1999 Organophosphate pesticide Inhibits cholinesterase activity Partially ovicidal Single application + nit combing adequate for most patients Apply to dry hair Leave on 8 12 hours then rinse May be irritating Flammable Approved for 6 years of age Malathion resistance reported among head lice in UK Spinosad 0.9% topical suspension (Natroba) FDA approved 2011 Biochemical insecticide produced by soil bacteria bacterial species Saccharopolyspora spinose Found in crushed sugar cane Neurotoxic to lice Targets nicotinic acetylcholine receptors of the insect nervous system resulting in hyperactivation Ovicidal Apply to dry hair, leave on scalp 10 min Effective as a single application on dry hair without nit combing Re treatment typically not needed (re treat if live lice seen in 1 week) Approved for children 6 months 2

3 Ivermectin lotion 0.5% (Sklice) FDA approval 2012 Neurotoxic to lice Activates glutamate gated chloride channels in nerves Death by cell hyperpolarization and paralysis Not ovicidal Kills nymphs! (newly hatched lice) Apply to dry hair, leave on 10 min then rinse nit picking optional Typically effective as a single application on dry hair without nit combing Approved for children 6 months Benzyl alcohol lotion 5% (Ulesfia) FDA approved 2009 Aromatic alcohol Kills lice via asphyxiation Non neurotoxic pesticide Not ovicidal Apply to dry hair, leave on 10 min Nit comb REPEAT treatment on day 9 Approved for ages 6 months 60 years Meinking TL, et al. Pediatr Dermatol Jan Feb;27(1):19 24 Benzyl alcohol lotion 5% (Ulefsia) Active ingredient Malathion 0.5% lotion Spinosad 0.9% suspension Name Class/mechanism Ovicidal? Retreatment Potential side effects/fda Cost (approximate) brand Need? approval Ovide Organophosphate Partially, Yes Not Flammable! (8 12 hours $ (60 ml) usually * on scalp) Irritating! Approved age 6 years Natroba Antimicrobial biochemical YES! NO! * Approved 6 months $ (120 ml) produced by soil bacteria; neurotoxic to lice Ivermectin 0.5% lotion Sklice Anti parasitic; neurotoxic to lice No, but kills nymphs NO! * Approved 6 months $ (120 ml) Benzyl alcohol 5% lotion Ulefsia Alcohol Not a neurotoxic pesticide No YES Approved 6 months $ (8 fl oz bottle) may need 1 6 bottles depending on hair length Pyrethrins Rid (OTC) Pyrethroid extract from No YES Avoid if allergic to $6 16 ( ml) crysanthemum chrysanthemums or ragweed Approved 2 years Permethrin 1% Nix (OTC) synthetic pyrethroid similar No YES Approved 2 months $8 14 ( ml) lotion to naturally occurring pyrethrins Lindane 1% Lindane Organochloride No YES Black Box warning $125 (60 ml) shampoo/lotion Kwell Second line due to risk of neurotoxicity Emerging therapies for head lice More Natural Approaches? Abametapir lotion, 0.74% Effective in phase 3 clinical trial Inhibits metalloproteinases critical for louse survival Apply to dry hair, rinse in 10 min No nit picking No repeat treatment 6 months and older Bowles, et al. Pediatr Dermatol Jul 12 3

4 Nit picking Professional nit picking Cost range ~$75 100/hour Estimated 3 total treatments needed Treatments ~1 1.5 hours each Estimated minimum: $225 AND 3 hours of family time Louse calls Discrete in home concierge nit picking Some Health Flex savings accounts cover nit picking Home nit picking Instructions for families on Headlice.org hosted by the National Pediculosis Association (non for profit) Modern male head lice have smaller claws compared to ancient specimens Nit picking practices may have resulted in selective advantage to smaller grip Nunez H, et al. Micron Apr;95:31 34 FDA approved device for lice treatment AirAllé Lice Treatment Heated air Cooler temperature & faster flow than hair drier Estimated 1 hour treatment 30 minutes with device 30 minutes of nit picking One treatment needed Cost approximately $170 FDA approved for ages 4 years Essential Oil Alternatives? Eucalyptus oil lemon tee tree oil Eucalyptis oil: Leptospermum petersonii (EO/LP) blend vs. pyrethrin:piperonyl butoxide EO/LP twice as effective (83% vs 36%, P < ) EO/LP 100% pediculocidal with 1 application EO/LP 100% of lice and eggs in vitro Adverse events: transient burning, itching, stinging Greive KA and TM Barnes, Australas J Dermatol Mar 7 Pediculosis capitis re cap Super head lice! In most of the U.S., head lice show 100% resistance to pyrethroids now Several FDA approved head lice medications available Malathion 0.5% lotion Ivermectin 0.5% lotion Spinosad 0.9% suspension Benzyl alcohol 5% lotion Nit picking FDA approved head lice air treatment device AirAllé History No fever No pain + intense itch Early lesions start as bumps same thing happened last year No mucosal involvement 4

5 Diagnostic clues Very itchy! Bullous arthropod bite reaction Localized preferentially on extremities Happened before around 1 year ago (e.g. the same season of year ) Goodheart HP, MD. Goodheart's Photoguide of Common Skin Disorders, 2nd Edition. Philadelphia: Lippincott Williams & Wilkins, 2003 Bullous arthropod Treatment Antihistamines Cool compresses High potency topical steroid applied twice daily to itchy bumps Prevention Protective clothing Insect repellant Bullous arthropod Cannot distinguish the offending insect from skin findings Bullous bite reaction to bed bugs Mosquitos Fleas Ants Bed bugs Midges Leverkus M, et al. Bullous Allergic Hypersensitivity to Bed Bug Bites Mediated by IgE against Salivary Nitrophorin. Journal of Investigative Dermatology (2006) 126, Biting midges Bullous arthropod bite reaction Bullous arthropod bite reactions have been noted in adults with Chronic Lymphocytic Leukemia (CLL) Reaction may be secondary to the underlying lymphoproliferative disorder Rosen, LB et al, JAAD, 1986, Krakoski, A. J Pediatr Jul;163(1):298 Mayes RC, et al, Am J Trop Med Hyg. Sep 2010; 83(3): 447 5

6 Bullous Insect Bite Reaction Pearls: Itchy! Location: on exposed skin, extremities History of recurrence annually with season change Parents find diagnosis hard to accept! Treatment: Antihistamines, high-potency topical steroid, cool compresses Prevention: protective clothing, insect repellant In adults, consider underlying diagnosis of CLL N,N diethyl m toluamide (DEET) Gold standard insect repellent Registered for public use in 1957 Protects against ticks, mosquitos, biting flies, biting midges DEET concentration influences duration 10% approximately 2 hours 20% approximately 4 hours 24% approximately 5 hours > 50% DEET not more effective High doses: concern for neurotoxicity (prolonged exposure or ingestion) CDC recommendations for children DEET concentration 20 30% to exposed skin Picaridin IR3535 (3 [N butyl Nacetyl] amino propionic acidethylester) Sold in US since % picaridin is ~ equivalent to 20% DEET Protects against ticks, mosquitos, biting flies, biting midges No strong odor Possible skin irritation No damage to plastics, synthetics Less long term safety data Registered in US in 1999 (used in Europe >20 years) Protects against: Mosquitoes, deer ticks, body lice, and biting flies similar protection as DEET against most species of mosquitoes DEET is more effective against the Anopheles species of mosquitoes, which carry malaria, encephalitis and dengue fever very effective at repelling deer ticks 7.5% not effective, need higher concentration (available 5 20%) Shorter duration Up to 2 hours mosquitos Up to 3 hours ticks May irritate eyes May damage or dissolve plastics content/uploads/2015/04/picaridin Research.pdf Oil of lemon eucalyptus (OLE) (p menthane 3,8 diol) Infants < 2 months of age: insect repellent not recommended stroller netting recommended Available in natural or synthetic versions (PMD) Lemon Eucalyptus Oil (64% PMD) is not Oil of Lemon Eucalyptus Not for children < 3 years of age poor repellency against the Aedes aegypti zika fever, dengue fever, chikungunya, yellow fever 6

Protective clothing Sunscreen and Insect Repellant Combination products are not recommended Permethrin treated clothing ticks,

5% permethrin Pretreated EPA approved for 70 washes Sunscreen needs to be applied in larger amounts re applied more frequently Risk

sunscreen is applied CDC recommends: Apply sunscreen first, then apply the repellent Montemarano, AD, et al. Lancet, 349 (1997), pp.

Ultrasonic insect repellent devices Off label Mosquito Spray Methyl dihydrojasmonate Plant derived fragrant compound Lilial synthetic

7 Protective clothing Sunscreen and Insect Repellant Combination products are not recommended Permethrin treated clothing ticks, chiggers, mites and mosquitoes Home treat: hours before Lasts ~6 washes Odorless ~0.5% permethrin Pretreated EPA approved for 70 washes Sunscreen needs to be applied in larger amounts re applied more frequently Risk of one third decrease in the sun protection factor (SPF) of sunscreens when DEET containing insect repellents are used after a sunscreen is applied CDC recommends: Apply sunscreen first, then apply the repellent Montemarano, AD, et al. Lancet, 349 (1997), pp Ineffective Insect Repellants Wristbands soaked in chemical repellents Garlic or vitamin B1 oral supplements Tea tree oil Ultrasonic insect repellent devices Off label Mosquito Spray Methyl dihydrojasmonate Plant derived fragrant compound Lilial synthetic aromatic aldehyde commonly used in cosmetics Activate CquiOR136 mosquito odorant receptor Not recommended as an alternative to DEET Zeng F, et al. PLoS One Jun 19;13(6) THANK YOU THANK YOU 7

8 + 9 Drowned Head Lice 8

Treat the infested person(s): Requires using an Over-the-counter (OTC) or prescription medication.

Treat the infested person(s): Requires using an Over-the-counter (OTC) or prescription medication. Pursuant to Texas Education Code, Section 38.031, this notice regarding head lice is being provided to parents. CDC Head Lice Treatment General Guidelines Treatment for head lice is recommended for persons