Could it be this simple?

Personal Health; The real problem with children’s scalp ills.

By Jane E. Brody

Published: Wednesday, November 9, 1994  NOTE THE DATE

WITH school in full swing, lice and ringworm have once again gone to the heads of the class. But while the families of affected children are most distressed by what they regard as embarrassing if not repulsive infestations, dermatologists say the real problems lie in misdiagnosis and inappropriate and sometimes hazardous treatments.

Ringworm Re-Emerges

A half-century ago, ringworm, a fungal infection that most often attacks the scalp, was a common scourge among school-aged children. And while it lapsed into relative obscurity for decades, ringworm is now back in a more insidious form that is harder to recognize and trickier to treat. In its previous incarnation, ringworm mainly affected Caucasian children and could be detected easily because the fungus that caused it fluoresced under ultraviolet light. The current form of the disease most often attacks African-American children and must be diagnosed by taking scrapings of the scalp and culturing the fungus. Although primarily a disease of school-age children, it is becoming increasingly common among adults and infants, according to Dr. Ilona J. Frieden and Dr. Renee Howard, dermatologists at the University of California in San Francisco.

Ringworm is a misnomer, since the new infection does not form a ring and neither resembles nor is caused by a worm. This fungal infection, known medically as tinea capitis, can be present for months or years before subtle but widely distributed hair loss and inflammation become apparent. Children with ringworm in its early stages may complain about itching and flaking of the scalp, which is often mistaken for dandruff and treated futilely with over-the-counter medicated shampoos. As the infection progresses, a closer look should reveal tiny black dots on the scalp at the hairline; the dots are the remnants of hairs that have broken off within the follicle as a result of the infection. “Misdiagnosis and delays in diagnosis have allowed ringworm to spread unchecked in classrooms, day-care centers and within families,” said Dr. Rebat M. Halder, chairman of the department of dermatology at Howard University Hospital in Washington. The infection is easily transmitted through shared combs, brushes, caps, hair ribbons, barrettes and the like, although simply washing such items in hot soapy water is all that is needed to get rid of the fungus, Dr. Halder said. It can also be acquired from contact with telephone receivers and seat backs that have been contaminated by a previous user.

Children from 3 to 9 years old are most likely to pick it up. While it is more common in inner cities, every school-age child — poor or rich — is a potential target. Genetic factors and certain hair-care practices like tight hair braiding and the use of pomades and oily hair dressings are believed to increase the vulnerability of black children.

The fungus at first attacks nonhairy skin; tight braids can leave parts of the scalp exposed and unprotected, and gluey hair dressings can give the fungus a better opportunity to adhere to the scalp and invade. The current culprit is a fungus known as Trichophyton tonsurans, which is estimated to cause 90 percent of cases in this country.

Unlike the ringworm fungus of yore, this one does not respond to topical treatments, because the organism grows within the hair shaft so that substances applied directly to the scalp cannot eradicate it. Rather, T. tonsurans infections must be treated with oral medication, typically an antifungal agent called griseofulvin taken daily for at least six weeks.

Since many adults are symptomless carriers of the fungus, to reduce the chances of reinfection, when one person in a family is found to be infected, all members of the household should be tested and treated if necessary. Epidemics of Head Lice In the last 15 years, outbreaks of head lice have become commonplace in schools and show little respect for education, social class or degree of cleanliness. Every school year, more than six million cases come to light, a significant share of them representing repeated attacks by these tiny, wingless insects that feed on human blood. Head lice are uncommon among black children. Dr. Mervyn Elgart, chairman of dermatology at George Washington University Medical School in Washington, describes head lice as “more of a psychological problem than a real medical problem.”

Parents understandably cringe when their well-cared-for children are invaded by creepy, crawling creatures. But head lice can become a medical problem if the wrong substances are used to treat the condition or if the appropriate substances are overused.

Because remedies are sold over-the-counter as shampoos, creams and lotions, many parents fail to appreciate the fact that they contain potent insecticides that can become highly toxic if misused. Particularly risky are products that contain lindane, which can sometimes cause seizures or convulsions and brain damage, especially in very young children, even when used according to directions. Although the best-known lindane product, Kwell, is no longer being manufactured, generic forms of lindane are still available.

Louse bites can cause severe itching, and those who scratch for relief can sometimes develop secondary infections. Most commonly, it is not the insects themselves but their oval, yellowish-white eggs, or nits, that are noticed by parents. Undisturbed, the female louse lays three to five eggs a day for about a month. The eggs are attached to the base of hairs, often on eyelashes and eyebrows as well as on the head.

They spread easily from person to person, usually through direct head-to-head contact. But contaminated clothing, bedding, grooming items and headphones can spread them as well, for example, when several children’s coats are hung together on the same hook.

Getting rid of lice requires simultaneous treatment of all infected individuals who are in close contact. Although there is considerable controversy about the best and safest products, most dermatologists now recommend a cream rinse called Nix, which contains permethrin, a pesticide minimally toxic to mammals. A one-time treatment kills only the adult lice, but the chemical remains active on the hair and scalp for 10 days or longer (even if you shampoo and swim daily) and can kill adult lice that emerge later from the impervious eggs.

Deborah Altschuler, president of the National Pediculosis Association in Boston, said there were problems with all the available products, with none living up to manufacturers’ claims for effectiveness.

Dr. Elgart said that keeping potentially contaminated clothing and furnishings away from people for about five days spells death to head lice, which can live only as parasites. “You don’t have to boil or dry-clean everything in sight,” he insisted.

http://www.nytimes.com/1994/11/09/us/personal-health-the-real-problem-with-children-s-scalp-ills.html