Spinosad has a broad spectrum of activity against insects, including many species of lice. Activity appears to be both ovicidal and pediculicidal by disrupting neuronal activity and lingering long enough to exert its effect on the developing larvae until they form an intact nervous system. 37 Superiority of spinosad over permethrin has been demonstrated with treatment success rates of 84% to 87% as compared with 43% to 45%. 38 Adverse reactions described include application site erythema (3%), ocular erythema (2%), and application site irritation (1%). 38 – 40 Spinosad is available by prescription and should be applied to dry hair by saturating the scalp and working outward to the ends of the hair, which may require a whole bottle. Spinosad should be rinsed 10 minutes after application. A second treatment is given at 7 days if live lice are seen. Safety in children younger than 4 years has not been established. Ivermectin (0.5%) Ivermectin (Sklice; Sano fi Pasteur, Swiftwater, PA ) , a widely used anthelmintic agent, was approved in a lotion form by the FDA in 2012 for children 6 months or older for head lice. This medication increases the chloride ion permeability of muscle cells, resulting in hyperpolarization, paralysis, and death of the lice. 41 Combined data from 2 multisite, randomized, double-blinded studies comparing a single application of 0.5% ivermectin lotion with a vehicle control found that signi fi cantly more patients receiving ivermectin were louse free on day 2 as compared with the control (94.9% vs 31.1%), day 8 (85.2% vs 20.8%), and day 15 (73.8% vs 17.6%; P , .001 for each comparison). 41 Topical ivermectin lotion is available by prescription, is applied to dry hair and scalp, and is rinsed after 10 minutes. Only 1 application is required, because when the treated eggs hatch, the lice are not able to feed as a result of pharyngeal muscle paralysis and, therefore, are not viable. 42 Adverse effects are rare and include skin or eye irritation and erythema, burning, or dryness. 41 Lindane (1%) Lindane is no longer recommended by the American Academy of Pediatrics or the Medical Letter for use as treatment of pediculosis capitis. Removal of Topical Pediculicides All topical pediculicides should be rinsed from the hair over a sink rather than in the shower or bath to limit skin exposure, and with warm rather than hot water to minimize absorption attributable to vasodilation. 43 Topical Reactions Itching or mild burning of the scalp caused by in ﬂ ammation of the skin in response to topical pharmaceutical agents can persist for many days after lice are killed and is not a reason for retreatment. Topical corticosteroids and oral antihistamines may be bene fi cial for relieving these signs and symptoms. e1358 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on May 3, 2015 pediatrics.aappublications.org Downloaded from
Scabicides Used Off-Label for Lice Permethrin (5%) Permethrin 5% is not currently approved by the FDA for use as a pediculicide. Five percent permethrin (Elimite; Prestium Pharma, Inc, Newton, PA) is available by prescription only as a cream,
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