Back to school means new classes, new teachers, hectic schedules and the less than exciting opportunity for your child to bring home a contagious infection or infestation. Lice, scabies, and tinea capitis (a fungal infection of the scalp), are quite prevalent and highly contagious in the early school year. Viral and bacterial infections provide the added risk of surprise skin rashes. Be aware and be prepared for this year's crop of critters.

A COUGH, A KISS, AND A RASH

Not all back-to-school infections have legs. Here is a partial list of the various infectious conditions that plague our schools every year and may result in surprise rashes for you and your child:

• Chicken Pox (No surprise here)
• Echo-Coxsacckie Viruses (A large family of viruses that cause cold and flu-like symptoms)
• Fifth's Disease (AKA "slapped cheek" disease)
• Gianotti-Crosti Disease (May or may not be associated with hepatitis)
• Hand,Foot & Mouth Disease (The name says it all)
• Herpangina (A virus causing severe temporary ulcerations in the mouth)
• Herpes Simplex (Cold sores)
• Impetigo (Due to Staph or Strep)
• Kawasaki's Disease (Strawberry-tongue disease, may be associated with heart symptoms)
• Molluscum Contagiosum (Soft warts that are highly contagious in young children)
• Mononucleosis (Notoriously referred to as the "kissing" disease)
• Rubella (not as common now due to vaccinations)
• Scarlet Fever (Post strep throat)
• Warts (They are more likely to spread than go away. Get them treated!)

Now for the creepy crawlies that you need to be on the alert for.

LICE

Lice are tiny parasitic insects that may live on the scalp and hair, causing tremendous itching. Pediculosis capitis is one of those infestations we all dread. Lice live off of us, piercing our skin and then receiving nourishment from the blood of the affected body part. There are different forms of lice that live on the scalp versus those that live on the body (body louse - Pediculus humanus humanus, or pubic louse aka crabs - Pthirus pubis). Those on the scalp (Pediculus capitis) are usually the ones you need to worry about finding on your children.

Typically, the itching is worse at the nape of the neck. Your child may complain about itching there, especially at night. It is unusual to find the actual live lice crawling around, but the eggs are a tell-tale sign of infestation. Nits are the eggs of the lice that are attached to the strand of hair. They are tiny white hard bumps that seem to hang off of the hair, like dandruff, but don't come off easily. It is usually more difficult to visualize the adult lice. Lice don't fly nor do they burrow into the skin.

Eradication of the organism is usually attempted with a medicated shampoo. There are 2 basic active agents that help kill lice. One is a prescription product lindane (generic name) that is best known by the brand name Kwell Shampoo. However, the active ingredient in Kwell, can be toxic to small children and result in neurological problems if overused. It is important to follow the instructions carefully and not repeat the use without the directions of your physician. Kwell kills the living lice but doesn't penetrate the eggs that hatch in 7-10 days. Therefore, it must be reused 7-10 days after the initial treatment. Kwell should not be used more than twice without discussing this with your doctor. Nor should it be used on the pets.

The second active agent is one you can do on your own known as Permethrin. This ingredient is available in a variety of OTC shampoos such as RID or Nix. Permethrin does not have neurological toxicity so it is much safer to use on young school aged children. While it is more likely to kill the eggs, follow the directions closely on the package. Also, permethrin coats the hair and helps prevent reinfestation for up to two weeks after the treatment. This is good for any nits that survive and hatch. The follow-up treatment is not a bad idea, particularly as there have been reports of resistant strains of lice.

It is important to try to physically remove the nits from the hair with a fine-toothed comb. One is typically included in your lice kit. All hats, bedding, combs, brushes, recently worn clothing must be washed to remove the remnant nits and lice so that reinfestation doesn't occur. Soaking the combs and brushes in a dilute ammonia or bleach solution is very effective. Make sure you rinse these well so that the chemical doesn't have the opportunity to contact the skin.

A helpful OTC product for treatment of head lice is called RID Lice & Egg Comb-Out Kit. This product is used to dissolve the remaining nits after use of the shampoo. RID Lice & Egg Comb-Out Kit comes in a 2 oz. tube or in a combination pack called Rid Advanced Removal System. It can make your life a lot easier when it comes to trying to comb out your child's hair.

Another treatment for lice is a new prescription product called Ovide, made by Medicis. Ovide contains 0.5% Malathion in a lotion formulation. It is applied to DRY hair and scalp and allowed to remain there for 8-12 hours. It is then shampooed out and the dead lice and nits are removed by a nit comb. Product should be reused if lice are still present after 7-9 days. Typically, no further treatment will then be required. This product was not tested on children less than 6 years of age. Ovide lotion is FLAMMABLE and should be used with caution. I have to tell you, that after reading the prescribing information, I would be somewhat concerned about selecting this as a first line agent. Certainly, with resistant strains I would consider using this product if need be.

SCABIES

Scabies is a parasite that burrows under the skin. Clinical symptoms of generalized itching occur approximately 30 days after exposure to the organism. This is why it is crucial that all family members be treated at the same time, even if they are do not exhibit symptoms. Patients complain about overwhelming itching, often keeping them up at night. For all of the discomfort that scabies can cause, only 10-20 organisms are alive at any one time! The "rash" of scabies is often overwhelming scratch marks and open small sores that are the result of scratching. A small red bumpy eruption can sometimes be seen as well. Areas most commonly affected are the soft portions of the wrist, finger and toe webs, belly button, groin and buttock regions. This is because the mite lives on the cooler portions of the body. Infants can have eruptions on their scalp, and other areas atypical for adults. Although textbooks describe linear burrows that can be seen on the skin, I can count the number of times I've seen this appearance on one hand, despite the hundreds of scabies patients I have seen. Unrestricted scratching can occasionally lead to secondary bacterial infection.

My favorite prescription product is Elimite cream. It also contains premethrin, in a prescription strength that is safer to use than Kwell lotion. Also, it is only used one time as it kills the living mite along with the eggs. Elimite is applied from the neck down at bedtime and washed off in the morning. It is important not to continually repeat the use of Elimite as it will cause irritation. All clothing from the previous day, pajamas and bedding down to the mattress should be washed and dried for an hour in a hot dryer. Any materials that are unable to be cleaned in this way should be placed in a closed plastic bag for two weeks as the eggs will hatch in about 10 days. Living scabies are unable to live off of human skin for more than 24 hours and will die. This is why it is not necessary to treat fomites (inanimate objects such as the sofa), or fog the house.

The good news is that scabies is easily treatable. The bad news is that you may itch for up to 6 weeks post treatment. The reaction to the presence of the infestation is an allergic reaction and can last for as long as 6 weeks after the scabies have been killed. That means you do NOT continue to use scabies-killing agents during this time frame. The bug and eggs are long dead. All you will do is create massive skin irritation. Scabies is one skin disorder that I see where so many patients have tried every conceivable home remedy, including some very unsafe ones to try to "kill the scabies that didn't die from the medicine" that their primary doctor gave them. That is why in addition to treating a patient's scabies, it is equally important that their symptoms of discomfort be addressed as well. I will prescribe an oral antihistamine such as Atarax (generic is hydroxyzine) in a small dose of 10mg that can be titrated to a patient's needs without making them excessively drowsy. You can also take OTC Benadryl such as Children's ZYRTEC Allergy Grape Chewables to help alleviate these symptoms. In addition, topical prescription-strength mid potency steroid is applied twice daily. The treatment of open wounds with hydrogen peroxide and an antibiotic ointment like Polysporin First Aid Antibiotic Ointment will help prevent a bacterial infection from developing on top of your scabies. If there are signs of secondary infection, such as golden crusts, I will also prescribe an oral antibiotic. Recently, I have seen my first case of resistant scabies, and an oral medication, Ivermectin,, prescribed as a one-time dose was required.

THERE'S A FUNGUS AMONG US!

Tinea capitis, tinea pedis (athlete's foot), tinea cruris (jock itch), and tinea corporis (ring worm) are variations on a theme of fungal infections that may affect various areas of the body. Interestingly enough, they do have some age specifications. For instance, typically as soon as a child goes through puberty, their hormones prevent the development of scalp infections due to fungi. And while we do not normally associate the presence of jock itch with small children (never say never to any skin condition), it is conversely more often associated with teens.

An amazingly contagious problem frequently brought home by school age every fall is tinea capitis, a fungal infection of the scalp. Children may experience profuse crusting, itching, hair loss and sometimes a large domed lesion called a kerion. If caught early, and before too much inflammation can cause scar formation, hair loss will usually regrow. Tinea capitis can result from a number of members of the fungal family, but they are all treated with oral medication. Topical antifungal products and shampoos can't penetrate the hair shaft where the majority of the fungus resides. It used to take 4-6 weeks of treatment with Grifulvin V syrup for complete resolution when I trained in residency, however, the fungi have become resistant to therapy. It is not uncommon to see treatment last 3 months or even as long as 6 months. New treatments with oral Lamisil and Sporonox have been tried in an attempt to reduce the time frame for therapy. However, there can be side effects such as a depression of the blood cells and liver problems possibly more frequently than seen with the Grifulvin V syrup. For all of the children I have treated in the past 14 years, despite the potential for risk, I have fortunately never seen a complication for a child with use of the Grifulvin V syrup. The use of shampoos such as Nizoral A-D Shampoo can provide some relief from itching, but it is not capable of penetrating the hair and killing the baseline fungal infection.

The treatment of fungal infections affecting the body, whether the feet, groin or body can often be dealt with by using an excellent antifungal cream. Lamisil AT Cream for Athlete's Foot was my favorite prescription treatment for these issues and has gone OTC, allowing you to access this therapy on your own. Remember that if the rash is not resolving or is spreading, you should check with your dermatologist. Sometimes oral antifungal therapy, such as mentioned above may need to be used for difficult cases. Keep moist areas like the feet and groin dry. Have your older children who are frequenting school locker rooms, showers, etc., wear protective foot wear and they may want to powder up these areas with non-corn starch containing products. Corn starch acts as food for yeast, fungi and bacteria, so do not use it! Also, encourage children to wear canvas athletic shoes as much as possible instead of leather as they breathe better. This can help reduce the issues with athlete's foot.

PREVENTION:

Prevention is important. Good hygiene will help prevent a lot of headaches. Educate your children appropriately based upon their age and social activities.

• Remind your children not to share combs, brushes, or wear each other's hats or clothing. These articles are a great way to pass head lice throughout the classroom.

• Encourage frequent hand washing. Nothing stops germs like washing them down the drain. Make this the first stop when coming home from school. Keep on hand an antibacterial soap that the kids will enjoy and educate them about how germs are spread.

• Discourage towel sharing, including at home. Towel sharing creates a marvelous method of spreading soft warts known as molluscum contagiosum.

• Periodically disinfect combs and brushes. This is a good practice to minimize the spread of lice from items that got shared at school despite your warnings to the contrary.

• Encourage wearing swim shoes or sandals poolside and in the gym locker room. Helps to minimize picking up athlete's foot and warts.

• Make sure your preschool and kindergarten dress-up clothing are periodically cleaned. Lice and scabies can be transmitted throughout the classroom. While I would not want to eliminate the creative play of children, at least keep the clothing cleaned throughout the school year.

• Educate children about herpes cold sores and how they are transmitted by sharing glasses or kissing. Not to mention a whole host of other easily transmittable infections.

• Educate teens and college students about the risk of genital warts and the importance of condoms in minimizing the spread of various diseases. The spread of genital warts every early school year has become epidemic. (These have been implicated in causing cervical cancer in women). You cannot imagine the numbers of college students with this infection that I see annually. While I agree that abstinence would be a better idea, reality dictates that your child should be knowledgeable.

Enjoy getting the children off to school, but be aware that if they start to complain of itching, you need to take it seriouslybefore everyone at home itches, too!

Thank you for taking the time to read my newsletter. I hope you have found it informative.

Audrey Kunin, M.D.

(Any topic discussed in this article is not intended as medical advice. If you have a medical concern, please check with your doctor.)

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