|Year : 2017 | Volume
| Issue : 2 | Page : 33-42
Prevalence of pediculosis capitis among primary school students at Sharkia Governorate by using dermoscopy
Manal M El-Sayed1, Mohammed A Toama1, Ahmed S Abdelshafy1, Abdulla M Esawy1, Safaa A El-Naggar2
1 Department of Dermatology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
2 Department of Industrial Medicine and Occupational Health, Faculty of Medicine, Zagazig University, Zagazig, Egypt
|Date of Submission||01-Sep-2016|
|Date of Acceptance||15-Feb-2017|
|Date of Web Publication||4-Aug-2017|
Abdulla M Esawy
Lecturer of Dermatology and Venereology Faculty of Medicine, Zagazig University, Zagazig, 44519
Source of Support: None, Conflict of Interest: None
Pediculosis capitis is the infestation of human hair and scalp by head lice. Dermoscopy was used to improve the health of students in Sharkia Governorate by decreasing the prevalence of pediculosis capitis among them.
The aim of the present study was to determine the prevalence of pediculosis capitis among primary school students in Sharkia Governorate, find the risk factors associated with this infestation, and to compare the traditional methods in diagnosis of pediculosis capitis with dermoscopy.
Participants and methods
This study was conducted on 242 students in Sharkia Governorate. Clinical and dermoscopic examinations were carried out for all children.
Dermoscopic examination of the studied children was as follows: 44.6% of them were free of infestation or dandruff, 17.8% were also free of infestation but showed dandruff, which may be misdiagnosed as nits, and 4.1% showed empty nits only. Thus, the total negative was 162 (66.9%). Only 0.4% of them showed empty nits with dandruff. About 7.4% of them were with empty and filled nits, 21.9% were with filled nits only, and 0.4% of them showed mobile lice. Hence, the prevalence of pediculosis capitis was 33.0% by using dermoscopic examination.
Prevalence of pediculosis capitis among primary school students in Sharkia Governorate was 33.0% by using dermoscopic examination. Pediculosis capitis was found to be affected by some sociodemographic characteristics as sex, residence, social class, father’s and mother’s education, and some behaviors as combing of hair and sharing tools; moreover, hair length was shown to increase infestation. Overall, dermoscopy was found to be better in diagnosis pediculosis capitis compared with visual examination.
Keywords: dermoscopy, Pediculosis capitis, prevalence
|How to cite this article:|
El-Sayed MM, Toama MA, Abdelshafy AS, Esawy AM, El-Naggar SA. Prevalence of pediculosis capitis among primary school students at Sharkia Governorate by using dermoscopy. Egypt J Dermatol Venerol 2017;37:33-42
|How to cite this URL:|
El-Sayed MM, Toama MA, Abdelshafy AS, Esawy AM, El-Naggar SA. Prevalence of pediculosis capitis among primary school students at Sharkia Governorate by using dermoscopy. Egypt J Dermatol Venerol [serial online] 2017 [cited 2017 Nov 18];37:33-42. Available from: http://www.ejdv.eg.net/text.asp?2017/37/2/33/212101
| Introduction|| |
Head lice infestation − also known as pediculosis capitis − is the infestation of human hair and scalp caused by head louse (Pediculus humanus capitis) . Head lice are obligate blood-feeding human ectoparasites. They are connected to human hosts during all of their life stages and feed on only human blood, do not have wings, and cannot jump . However, head lice generally spread through direct transmission through head-to-head contact with an infected person, which is the major route, or indirect transmission by sharing clothing, hair brushes, hats, towels, or other personal items of a person already infected. Head lice infestation is usually detected by three types of evidence − itching and inflammation of the scalp and neck, sighting of lice, and detection of eggs attached to hair shafts ,.
The clinical spectrum of head lice infestation includes pruritus, scalp infection, lymphadenopathy, conjunctivitis, and allergic reaction. Chronic heavy infestation among school children may lead to anemia. In addition, head lice infestation causes not only physical symptoms but also psychological stress because children believe that head lice infestation is a result of being dirty . However, head lice are a common infection in school-aged children worldwide. In high-income countries, school children aged 3–11 years are the most frequently affected population despite therapeutic advances . Millions of cases occur annually, and it has been estimated that children in the USA miss 12–24 million days of school per year because of head lice . The high levels of lice infestations have also been reported from all over the world, varying from 1.6 to 87% . The variation of infestation rate may be due to several factors including the eradication methods, number of head-to-head contacts, diagnostic techniques, school head lice policy (no-nit policy), pesticide resistance, and knowledge regarding head lice .
In Egypt, head lice infestation was found to be most common among primary school children. The prevalence of head lice infestation among primary school children in 2004 in Beni Suef was reported by Essam and Nada AandSoha  as 15.98%. In 2007, Ali and Amir  reported the infestation rate of head lice among primary school children in Assuit city to be 13.4%. According to the national pediculosis association of USA, which defines head lice infestation rate more than 5% as an epidemic, the status of primary school children in Egypt is an epidemic condition .
Dermoscopy is a noninvasive technique allowing rapid and magnified (×10) in-vivo observation of the skin, with the visualization of morphologic features often imperceptible to the naked eye. In the last few years many studies have utilized it for the diagnosis of hair and scalp disorders . Diagnosis of pediculosis capitis is generally based upon the detection of lice or nits; however, because the louse moves quickly and avoids light, it is often invisible to the naked eye. Dermoscopy differentiates lice egg containing the nymph from the empty cases of hatched parasites and from amorphous pseudonits and hair casts .
| Aim|| |
The aim of the study was determining the prevalence of pediculosis capitis among primary school students in Sharkia Governorate, finding the risk factors associated with this infestation, and comparing the traditional methods in the diagnosis of pediculosis capitis with dermoscopy.
| Participants and methods|| |
This study was conducted on 242 primary school students in Sharkia Governorate. The sample frame was all students of primary school in Sharkia Governorate. The sample size was calculated through Epi-Info (Epidemiological Information Package) software version 6.1 (Centers for Disease Control and Prevention, Atlanta, GA), according to the following collected data. The prevalence of pediculosis capitis among primary school students in Sohag Governorate was 15.98% . At a confidence interval of 95%, the power of the study 70%, the estimated sample size was calculated to be 242 school students. A sample from primary school students was selected using the multistage random sampling technique as follows:
- The primary sampling unit: two districts were chosen randomly from all districts in Sharkia Governorate (Zagazig and Menia El Kamh). We selected Zagazig to represent the urban part of Sharkia and Menia El Kamh to represent the rural part.
- The second sampling unit: Zagazig district contains 223 schools (11 private and 212 governmental schools); the total number of primary school students were 111 162+9380=120 542. We selected randomly one private and one governmental school. Finally, we selected 145 students. Menia El Kamh district contains 121 schools, which has 74 253 students; 97 students were selected from them randomly.
- The third sampling unit: one class from each grade was chosen randomly. The desired number of students was selected by using the stratified random sample according to sex. A structured questionnaire was used to collect information from all participants about the following. Part 1 included questions about personal and sociodemographic data (e.g. name, age, sex, residence, school achievements, family size, number of rooms, education of the mother and father, job of the mother and father, and bathing facilities in the house). Part 2 included questions about risk factors and symptoms of pediculosis capitis infestation (e.g. hair wash rate, hair wash method, combing rate per day, sharing of the bed and tools, previous complain of pruritis, class area and number of students in class, and crowding index of the class, which was calculated according to the instructions of the ministry of education, which determined the ideal area for each child equals 1.2 m). Part 3 included the character of hair and results of visual examination and also of dermoscopy.
Before the start of the study, the predesigned questionnaire was tested on 15 of the students to explore whether any essential modifications were needed. The questionnaire was tested several times to ensure that the wording, format, length, and sequencing of questions were appropriate. During each successive test, feedback obtained helped to refine the quality of the questionnaire. All students of the pilot were excluded from the study. The study design was cross-sectional.
- Clinical examinations were performed for all students in the form of visual examination, and grading of the students were as follows. The following were the four degrees of parasitism. (0) Children with signs of past infestation: they only showed nits more than 1 cm of the scalp (old nits, more than 30 days). No mobile lice or nits were found and considered negative. (1) Children with recent infestation and low probability of an active parasitism: they showed up to 10 nits less than 1 cm from the scalp. No mobile lice were observed. As nits that are at less than 1 cm from the scalp were less than 30 days old, these children were considered as ‘recently infested children’, with low probability of having a future active parasitism. (2) Children with recent infestation and high probability of an active parasitism (suspected active pediculosis): they showed more than 10 nits less than 1 cm from the scalp, with no mobile lice observed. And (3) children with an active parasitism (demonstrated active pediculosis): mobile lice and nits close to the scalp were observed .
- The examinations were repeated by using dermoscopy (Dermlite 3gen II pro HR, San Juan Capistrano, CA, USA) and grading of the cases was as follows: 0, meaning no infestation detected and thus considered negative; pseudonits, meaning no infestation detected but there may be dandruff, hair cast, or gel, and also considered negative; empty nits, meaning there were nits with no nymph (past infestation) and were considered negative; filled nits, meaning there were nits with nymph (recently infested) and thus considered positive ; and lice, meaning there were mobile lice.
- Health education about pediculosis capitis infestation was done.
- Treatment of pediculosis capitis was explained to all infested students.
Official permissions were obtained from the Dermatology and Venereology Department, Faculty of Medicine, Zagazig University. The scientific ethical committee of the college was respected. Official permissions were obtained from the Director of Education, Sharkia Governorate. The study group was informed about the nature and the purpose of the study and verbal consent was taken before interview. The study group was not exposed to any harm or risk and confidentiality of data were ensured.
The collected data were computerized and statistically analyzed using statistical package for the social sciences program, version 16.0 (SPSS; SPSS Inc., Chicago, Illinois, USA). Crowding index of classes was calculated according to instructions of the ministry of education, which considers the ideal crowding index as 120 cm2 or more. For the statistical calculations data were coded. Qualitative data were represented as frequencies and percentages. The χ2-test for trend and odds ratio were carried out for testing the association between the qualitative data whenever possible. In addition, binary logistic regression was performed. The test results were considered significant when P-value less than 0.05.
| Results|| |
As regards sociodemographic characteristics of the studied primary school students, 59.9% of them were girls and 40.1% were boys. More than one-half of them (52.1%) lived in urban areas. The majority of them (95.5%) studied at governmental schools, and the level of education of the fathers of 45.9% was up to higher education and that of mothers of 40.9% was up to higher education. Only 24.4% of students were considered of low social class. As regards the risk factors and symptoms of pediculosis capitis infestation among the studied primary school students, more than 70% washed their hair two times per week (77.3%). Moreover, about 85.1% of them used shampoo and combed their hair every day. About two-thirds shared bed (63.2%) and 48.8% shared tools. Majority of them (95.5%) were educated in crowded classes, according to the instructions of the ministry of education, which determined the ideal area for each child equals 120 cm2, as shown in [Table 1].
|Table 1 Risk factors and symptoms of pediculosis capitis infestation among the studied primary school students|
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[Table 2] shows the results of clinical examination of the studied primary school students. Nearly 37.2% of them suffered from pruritus, with only 5.4% having impetigo and 0.4% having lymphadenopathy. About 66.1% were free of infestation (no nits or lice at all), 19.0% were with old infestation (nonviable lice or nits were more than 10 cm away from the scalp), 5.8% were with recent infestation (<10 nits were found <10 cm from the scalp), 8.3% were with suspected active pediculosis (>10 nits were found <10 cm from the scalp), and only 0.8% were with demonstrated active pediculosis (lice were found), as shown in [Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5],[Figure 6],[Figure 7],[Figure 8]. Hence, the prevalence of pediculosis capitis was 14.9% by using visual examination as 0 and +0 were considered as negative.
|Table 2 Results of clinical examination of the studied primary school students|
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|Figure 1 Male student. (a) By visual examination: may be dandruff or nits; (b) by dermoscopic examination: peudonits|
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|Figure 2 Female student. (a) By visual examination: multiple nits near and away from the scalp (new–old); (b) by dermoscopic examination: filled nits; (c) by dermoscopic examination: hatching nymph|
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|Figure 3 Female student. (a) By visual examination: nits; (b) by dermoscopic examination: empty nit (hatched–treated–old)|
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|Figure 4 Female student. (a) By visual examination: multiple nits; (b) by visual examination: dandruff; (c) by dermoscopic examination: filled nits|
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|Figure 5 Female student. (a) By visual examination: multiple nits or maybe dandruff; (b) by dermoscopic examination: empty nits|
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|Figure 6 Male student. (a) By visual examination: dandruff or nits; (b) by dermoscopic examination: empty nits|
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|Figure 7 Female student. (a) By visual examination: heavy infestation (multiple nits); (b) by dermoscopic examination: filled nits|
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|Figure 8 Female student. (a) By visual examination: heavy infestation (multiple nits); (b) by dermoscopic examination: empty nits (old–treated–hatched)|
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[Table 3] shows the results of dermoscopic examination of the studied primary school students. Overall, 44.6% of them were free of infestation or dandruff, 17.8% also were free of infestation but showed dandruff, which may be misdiagnosed as nits, and 4.1% showed empty nits only; therefore, the total negative was 162 (66.9%). Only 0.4% of them showed empty nits with dandruff. About 7.4% were with empty and filled nits, 21.9% were with filled nits only, as shown in [Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5],[Figure 6],[Figure 7],[Figure 8],[Figure 9],[Figure 10], and 0.4% showed mobile lice, as shown in [Figure 10]. Therefore, the prevalence of pediculosis capitis was 33.0% by dermoscopic examination.
|Figure 9 (a) By dermoscopic examination: nymph; (b) by dermoscopic examination: filled nit|
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[Table 4] shows the relation between visual and dermoscopic examination. According to McNemar’s χ2-test, the P-value was 0.000; thus, there was a disagreement between visual and dermoscopic examinations, and dermoscopy was found to be better in diagnosis compared with visual examination. Using a dermoscope diagnosed 80 cases, and only 32 cases were diagnosed by using visual examination.
| Discussion|| |
In Egypt, head lice infestation was found to be most common among primary school children. According to the national pediculosis association of USA, which defines head lice infestation rate, more than 5% has been considered to be epidemic ; therefore, the status of primary school children in Egypt is an epidemic condition, as was shown in our study. This study was, as far as we know, the first one in Egypt that addressed this important public health problem in our locality by using a new accurate method of diagnosis (dermoscopy). We also compared this method with visual examination of infestation.
The rate of infestation in our study was about 33% by using a dermoscope, but only 14.9% by using visual inspection among primary school children at Sharkia Governorate. Low rates were reported in the city of Aran and Bidgol (Iran) (0.47%)  but it was very low as it was performed in an elementary school. In the UK, the prevalence was found to be 2% , in Assuit city, Egypt, it was 3.8% , in Korea it was 4.1% , in Mali it was 4.7% , in Belgium it was 8.9% , and finally, it was 9.6% in Saudi Arabia . Moderate rates of infestation were reported among primary school children in Yemen (13.3%) , in Australia (13%) , in China (14%) , in Sohag (Egypt) (15.98%) , and finally in Izmir (Turkey) (16.6%) . Higher rates of infestation were reported in Beni Suef (48.2%) , in Minofiya (32.2%) , in Argentina (29.7%) , and finally in Cairo (about 22%) .
The prevalence of pediculosis in the present study was near to that reported by the majority of studies done in Egypt by using visual examination. However, by using dermoscopy it was doubled and this can be attributed to dermoscopic accuracy. Higher rates reported in Minofiya and Beni Suef may be due to variable habits, different climates, and overcrowded schools and dwellings. Lower rates reported in Assuit city may be due to the fact that this study was performed only in urban areas, whereas our study performed in both urban and rural areas.
The variation of infestation rate may be due to several factors such as age, residence, the school head lice policy, eradication methods, numbers of head-to-head contact, personal hygiene, overcrowded dwellings, economic condition, family income, and attitude of less concern about head lice infestation.
In our study, there was a highly significant difference between prevalence of pediculosis capitis infestation determined by using visual examination and its prevalence determined by using dermoscopy (P=0.000). Dermoscopy helps us to differentiate true nits, pseudonits infestation from dandruff respectively and this will lead to decrease rates of false diagnosis. Dermoscopy also compares filled nits with empty nits, which indicates recent and old infestation or treated and untreated cases, respectively. These results were in agreement with the study conducted by Di Stefani et al. .
Our study was conducted among children aged 6–13 years, with higher rates of infestation among those 10–13 years old (about 36.9%) compared with among those 6–9 years old (25.6%). It may be attributed to the fact that children 6–9 years old depend on their mothers for washing their heads and combing, but others are self-dependent in that regard. This difference between the two age groups shows no significant association between age and pediculosis capitis infestation, as P-value was 0.070, which was similarly to that reported by El-Rifaie et al. , El-Shafie and El-Shazly , Zabihi et al. , and Abbas et al. .
The influence of age on infestation rate was very prominent in the study conducted in Sohag  as pupils 10 years of age and older had a significantly higher rates compared with younger ones (P=0.0004). On the other hand, Paredes et al.  and Morsy et al.  found that younger pupils (6–8 years old) had much higher rates compared with older ones.
The current study indicated that girls showed higher rates of infestation than did boys (43.4 and 17.5%, respectively); the correlation between sex and head lice was highly significant, with a P-value of 0.000. Similarly, studies in Assuit, Beni Suef, Cairo, and in Minofiya it was shown that the prevalence of head lice in girls was greater than that in boys , ,  . This was in agreement with the results of a number of other studies , , , , , .
Probably one of the main factors contributing to higher rates of infestation in girls is the length of their hair. However, it was believed that the amount of head louse infestation does not depend on the length of hair. Special behaviors in girls, such as close contact in a friendlier manner, might have affected transmission rates of head louse infestation. But these behaviors are different in boys. As the transmission of head lice occur through close contact, possibly children’s play and frequent contact of their head or use of scarves, hats, combs, hair brush, and other accessories can transmit head lice.
In the present study, there was a highly significant correlation between residence and pediculosis capitis infestation (P=0.000). The prevalence was 45.7% in rural areas compared with 21.4% in urban areas. It was similar to the studies performed in Sohag , Sharkia , and Beni Suef . This can be explained by the cultural and hygienic differences between rural and urban inhabitants.
This study showed no significant correlation between school type and prevalence of infestation (P=0.080).
The present study showed that as the prevalence of infestation increases the school achievement decreases. It may be due to the fact that severe infestation may cause anemia and also uncomfortable night sleeping, which may have an effect on the child’s concentration and achievement.
In this study as the level of father’s education decreased, the prevalence of infestation increased. Illiterate fathers’ children had 11 times higher risk for developing infestation. Mother’s education showed a statistical association with the prevalence of infestation. Illiterate mothers’ children had more than five times the risk for developing infestation. This was in agreement with the study conducted in Assuit . It seems reasonable to assume that the higher level of parents education leads to more appropriate health behavior in the family.
The study in Aran and Bidgol showed no significant correlation between father’s education and prevalence of infestation; however, a significant correlation between mother’s education level and infestation rate was observed . On the other hand, Shayeghi et al.  reported no significant relationship between the parents’ education and infestation rate in Khajeh.
The present study showed that the higher the social class, the lower the prevalence of infestation (P=0.002). The impact of socioeconomic status and the infestation rate was detected also in other studies carried out in Sohag , Beni Suef , Sharkia , Assuit , and finally, in Minofiya .
Improvements in socioeconomic and cultural conditions may reduce the prevalence of pediculosis capitis as education and income are intimately related to housing, nutrition, personal hygiene, attitudes toward life, and the way the family income is spent.
The current study showed that hair wash rate does not affect the prevalence of infestation (P=0.480). This was in agreement with the studies performed in Sohag , Beni Suef , and in Sharkia .
No significant association between methods of hair wash and rates of infestation was found in the current study (P=0.160). Barbara et al.  reported that head lice infestation is not significantly influenced by shampooing. The present study showed that daily combing of hair helps in decreasing the prevalence of infestation, with a P-value of 0.006. It may be attributed to early detection of head lice, which leads to early treatment. A study in Angola recommended a regular use of a louse comb as one of the best measures to protect against head lice infestation . However, it is also a common practice for black African girls and women to leave their hair unwashed for some weeks after braiding , and it has been suggested that mothers should examine the hair of their girls more frequently and more thoroughly than the hair of boys .
The present study showed no significant relationship between sharing of bed and prevalence of infestation (P=0.07). However, there was a significant correlation between sharing of tools and prevalence of infestation (P=0.001).
A study in Angola reported that more than two-thirds of school children infested with head lice did not share a bed, suggesting that transmission may have been more through social contacts at home or at school .
The present study showed that class-crowding index has a non-significant association with rates of infestation (P=0.08). Index is measured through dividing the number of students by the class’s surface area. The ideal class-crowding index mentioned by the Ministry of Education was 1.2 m2 or more.
The results of our study revealed a highly significant association between hair length and prevalence of infestation, with a P-value of 0.000. However, no significant association was found between hair color and type and prevalence of infestation. This result was in agreement with the results of a previous study conducted in Sharkia .
In a study in Sohag pupils with medium-length hair were found to be more susceptible to infestation than both those with short hair and long hair; furthermore, those with black hair were found to be at a higher risk of infestation compared with those with lighter hair, with a statistically significant difference (P=0.005).
The results of the present study indicated that a higher percentage of infested students had pruritis and impetigo (50 and10%, respectively) compared with those not infested (30.8 and 3%, respectively); the differences were statistically significant but a very small number of infested students had lymphadenopathy. In a study in Sohag, scalp pruritus was represented with a statistically significant difference (P=0.001), and impetigo, on the other hand, also had a statistically significant difference (P=0.003) . In their study conducted in Cairo, Morsy et al.  mentioned some of those associated clinical manifestations, scalp pruritus in 14% and enlarged lymph nodes in 28.1%.
Logistic regression analysis
Finally, our results from logistic regression analysis revealed that the significance risk factors for pediculosis capitis were rural residence, sharing tools, and length of hair.
| Conclusion|| |
The results from this study show that the prevalence of pediculosis capitis among primary school students at Sharkia Governorate was (33.0%) by using dermoscopy. Pediculosis capitis was affected by some sociodemographic characteristics as sex, residence, social class, father’s and mother’s education, and some behaviors as combing of hair and sharing tools; moreover, hair length was shown to increase infestation. There was disagreement between visual and dermoscopic examination. Dermoscopy was shown to be better in diagnosis compared with visual examination.
As dermoscope diagnosed 80 cases, and only 32 cases of them were diagnosed by using visual examination, we recommend using dermoscopy in the diagnosis and treatment monitoring of pediculosis capitis infestation. We recommend further studies with larger number of patients and different stages of the disease activity.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
[Table 1], [Table 2], [Table 3], [Table 4]