Chapter 74 - Common childhood infectious diseases (including skin eruptions)

The physical signs of measles are nearly the same as those of smallpox, but nausea and inflammation is more severe. The rash of measles usually appears at once, but the rash of smallpox spot after spot...

Avicenna (980-1037)

Children are subject to a variety of infectious diseases, mainly causing acute skin eruptions. Fortunately, many of these diseases, such as scarlet fever, measles and rubella, are being seen less frequently by the family doctor.Reye syndrome and aspirinThe concern about the ingestion of aspirin for febrile illness in children is the suspected causal relationship between it andReye syndrome, particularly in children with varicella and influenza infections. However, there is some controversy about the connection. Orlowski and colleagues at the Children's Hospital in Sydney found no association between aspirin use and Reye syndrome from 1973-1985. 1 It is possible that the connection is coincidental or at least confounded with other factors.Despite these doubts, aspirin should not be recommended for the treatment of fever in young children in view of our knowledge of the beneficial effects of fever on the immune response and the availability of a safe alternative antipyretic such as paracetamol.Reye syndromeClinical features:

A rare complication of influenza, chickenpox and other viral diseases, e.g. Coxsackie virus Rapid development of:encephalopathy (seizures and coma) hepatic failure (seizures and coma) hypoglycaemia (seizures and coma)30% fatality rate and significant morbidityTreatment is supportive and directed at cerebral oedema

Varicella (chickenpox)Varicella, a common and highly infectious disease, affects people mainly during childhood, especially between 2 and 8 years,but no age is exempt. The characteristic crops of small vesicles have a central distribution (face, scalp and trunk). It is caused by the varicella zoster virus, one of the human herpes viruses, which remains latent after infection. Clinical reactivation later in life results in herpes zoster.EpidemiologyVaricella has a worldwide distribution, causing endemic (occasionally epidemic) disease, with little clear evidence of seasonalincidence in temperate climates. About 75% of people in urban communities have had the infection by 15 years of age and at least 90% by young adulthood.It is one of the most easily transmitted viruses, probably by airborne spread, usually via a person with chickenpox (occasionally with herpes zoster). Varicella is contagious only while the patient has symptoms and vesicles remain; drying of the vesicles indicates that infectivity has stopped. The scabs are not infectious.The incubation period is 10-21 days (usually 15-16). Laboratory diagnosis is by serology 2 or immunofluorescence of vesicular fluid.Clinical featuresThe clinical features of varicella are shown in Table 74.1 and the complications in Table 74.2 . Children are not normally verysick but tend to be lethargic and have a mild fever. Adults have an influenza-like illness. The typical distribution is shown inFigure 74.1 .Table 74.1 Clinical features in varicella

Onset Children: no prodrome Adults: prodrome (myalgia, fever, headaches) for 2-3 days

Rash

General Practice, Chapter 74

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Centripetal distribution, including oral mucosa Scalp lesions can become infected 'Cropping' phenomenon: vesicles, papules, crusting lesions present together Pruritic

Degrees of severity Number of vesicles can vary from fewer than ten to thousands Mild cases can be missed More severe in adults, especially the immunocompromised Viral pneumonia rare in children, uncommon in adults Death rare except in the immunocompromised and neonates with congenital varicella

Table 74.2 Complications of varicella

Common

Bacterial infection of cutaneous lesions (usually staphylococcal or streptococcal); can take form of cellulitis or bullous impetigo

Can leave pitted scars

Uncommon

Viral pneumonia

Thrombocytopenia

Acute cerebellitis (ataxia, normal mental state)

Rare

Meningoencephalitis

Purpura fulminans

TreatmentTreatment is symptomatic and usually no specific therapy is required. Many people worry about scarring but the lesionsinvariably heal, leaving normal skin, unless they become infected.

Fig. 74.1 Chickenpox: typical distribution

Advice to parents

The patient should rest until feeling well.Give paracetamol for the fever (avoid aspirin).Daub calamine or a similar soothing lotion to relieve itching, although the itch is usually not severe. Avoid scratching; clean and cut the fingernails of children short. Provide cotton mittens if necessary. Keep the diet simple. Drink ample fluids, including orange juice and lemonade.Daily bathing is advisable, with the addition of mild antiseptic or sodium bicarbonate if pruritic (half a cup to the bath water). Pat dry with a clean, soft towel; do not rub.

MedicationAntihistamines can be prescribed for itching. Aciclovir or similar agents can be life-saving in the immunocompromised host. Antibiotics (e.g. flucloxacillin/dicloxacillin) are reserved for bacterial skin infection.Use of antiviral agents for varicellaThe antiviral agents, aciclovir and others, have an important place in the management of severe chickenpox. Although generally used in adolescents and adults with a severe eruption or the likelihood of a severe eruption, there is no set age for the use of an antiviral agent. It should be commenced during the first 3 days of the eruption (preferably day 1) and can be introduced in a contact (often the second case in a family) experiencing a severe prodromal syndrome.In general, it is not used in the very young, or in those with a mild/short prodrome, and in those who are not ill, do not have many spots and are not compromised.Exclusion from schoolExclusion is recommended until full recovery, usually for 7 days. A few remaining scabs are not an indication to continueexclusion. Except for immunocompromised children, contacts should not be excluded from school. Exclusion and incubation times are given in Table 74.3 .Table 74.3 Basic childhood infectious diseases: incubation periods, minimum exclusion periods fromschool, preschool and child care centres (times in days)

Incubation period (days)

Patient exclusion (least time from onset rash or symptoms) (days)

Contact exclusion (days)

Measles10-14514 in non-immunised

Mononucleosis?30-50NilNil

Mumps14-219Nil

Pertussis7-145 (after starting antibiotics)14 in non-immunised

Parvovirus (erythema infectiosum)

4-14 NilNil

Rubella14-215Nil

Varicella and zoster10-217Only those immune deficient

HepatitisA B C

15-4540-18014-180

7 or recovery NilNil

Nil Nil Nil

Infective diarrhoeavariesuntil cessation diarrhoeaNilBased on NHMRC recommendations

PreventionPrevention in contacts who are immunocompromised, or premature infants in contact with varicella, is possible with zosterimmune globulin. An attenuated live virus vaccine is available in some countries.Measles

Measles (rubeola) is a highly contagious disease caused by an RNA paramyxovirus. It presents as an acute febrile exanthematous illness with characteristic lesions on the buccal mucosa called Koplik's spots (tiny white spots like grains of salt).The disease is endemic throughout the world and complications are usually respiratory in nature. If an acute exanthematous illness is not accompanied by a dry cough and red eyes, it is unlikely to be measles. Laboratory diagnosis is by serology, nasopharyngeal aspirate immunofluorescence and culture. 2EpidemiologyMeasles is transmitted by patient-to-patient contact through oropharyngeal and nasopharyngeal droplets expelled duringcoughing and sneezing.The incubation period is 10-14 days and the patient is infectious for about 5 days, but especially just before the appearance of the rash. Morbidity and mortality are high in countries with substandard living conditions and poor nutrition.Immunity appears to be lifelong after infection. Measles, like smallpox, could be eradicated with public health measures.Clinical featuresThe clinical presentation can be considered in three stages.

1. Prodromal stage. This usually lasts 3-4 days. It is marked by fever, malaise, anorexia, diarrhoea, and 'the three Cs': cough, coryza and conjunctivitis. Sometimes a non-specific rash appears a day before the Koplik's spots (opposite the molars).2. Exanthema (rash) stage. Identified by a typically blotchy, bright red maculopapular eruption; this stage lasts 4-5 days.The rash begins behind the ears and on the first day spreads to the face, the next day to the trunk and later to the limbs. It may become confluent and blanches under pressure. The patient's fever usually subsides within 5 days of the onset of the rash Fig 74.2 .3. Convalescent stage. The rash fades, leaving a temporary brownish 'staining'. The patient's cough may persist for days, but usually good health and appetite return quickly.

Fig. 74.2 Measles: typical symptoms. Note the 3C's: cough, coryza, conjunctivitis

ComplicationsRespiratoryThe patient could develop secondary bacterial otitis media or sinusitis. If pneumonia develops it is more likely to be bacterial superinfection than viral. Laryngotracheobronchitis (croup) is a common complication of measles.Central nervous systemEncephalitis has an incidence of one in 1500 and although the mortality rate is low there is significant CNS morbidity. Febrile convulsions are another common complication.Late complicationsTwo rare complications are bronchiectasis and subacute sclerosing panencephalitis.TreatmentThere is no specific treatment although some symptoms can be relieved, e.g. a linctus for the cough, paracetamol for fever.The patient should rest quietly, avoid bright lights and stay in bed until the fever subsides.The management of complications is determined by their nature and severity. Children should be kept away from school until they have recovered or for at least 5 days from the onset of the rash.PreventionVaccination programs have been most successful. Live attenuated measles virus vaccinations combined with mumps andrubella (MMR) are recommended at the age of 12 months and then 10-16 years. Consider normal immunoglobulin for infants less than 12 months and the immunocompromised when MMR is contraindicated, given as soon as possible after exposure.RubellaRubella (German measles) is a viral exanthema caused by a togavirus. Because of immunisation programs it is seen lessfrequently now in family practice. It is a minor illness in children and adults, but devastating when transmitted in utero.

Congenital rubella is still the most important cause of blindness and deafness in the neonate. It is completely preventable.EpidemiologyRubella has been reported from virtually every country and is endemic in heavily populated communities. Epidemics occurevery 6-9 years in non-immunised populations, the disease being spread by droplets from the nose and throat. It is not as communicable as varicella and measles. Intrauterine infection occurs via the placenta.Approximately one-third of infections are asymptomatic (subclinical). Infection usually confers lifelong immunity. Infection is proved either by virus culture or by specific serology. Incubation period: 14-21 days.Clinical featuresThe clinical features of rubella are presented in Table 74.4 and Figure 74.3 and the complications in Table 74.5 .Table 74.4 Clinical features of rubella

There is no prodrome.

A generalised, maculopapular rash, sometimes pruritic, may be the only evidence of infection.

Other symptoms are usually mild and short-lived.

There is often a reddened pharynx but sore throats are unusual. An exudate may be seen as well as palatal exanthem.

Fever is usually absent or low-grade.

Other features: headache, myalgia, conjunctivitis and polyarthritis (small joints).

Lymphadenopathy may be noted; usually postauricular, suboccipital and postcervical.

The patient is infectious for up to 10 days from onset of rash (this aspect is often not appreciated as the patient is asymptomatic by that time).

The rash

A discrete pale pink maculopapular rash (not confluent as in measles).

Starts on the face and neckspreads to the trunk and extremities.

Variable severity: may be absent in subclinical infection.

Exaggerated on skin exposed to sun.

Brief durationusually fades on the third day.

No staining or desquamation.

Fig. 74.3 Rubella: typical symptoms

Congenital rubellaInfection of the mother in the first trimester can lead to abortion or stillbirth, or to foetal malformation, including congenital heartdisease, deafness and blindness (cataract or glaucoma). It can also produce lesions (such as microcephaly), mental retardation,

retarded growth, thrombocytopenic purpura (with a 30% mortality rate), jaundice/hepatosplenomegaly and bone abnormalities.Table 74.5 Complications of rubella

Encephalitis (one in 5000)

Polyarthritis, espcially in adult women (this complication abates spontaneously)

Thrombocytopenia with bleeding (one in 3000)

Congenital rubella

Rubella in pregnancyIdeally all women of child-bearing age should know their rubella immune status by having serology performed. A history ofimmunisation is not good enough evidence of immunity. However, in Victoria, Australia, almost 95% of women aged 15-40 are immune. 3If the immune status is not known, then serology testing should be ordered at the first antenatal visit. Rubella vaccine, while not shown to be embryopathic, should not be given during pregnancy. If maternal rubella antibodies are in adequate titre, there is no risk to the foetus from rubella infection.TreatmentTreatment is symptomatic, especially as rubella is a mild disease. Patients should rest quietly until they feel well and take paracetamol for fever and aching joints. Prevention is by vaccine, recommended at 12 months and 10-16 years.School exclusionThe child is usually excluded until fully recovered or for at least 5 days from the onset of the rash.Viral exanthema (fourth disease)This mild childhood infection may be caused by a number of viruses, especially the enteroviruses, and produces a rubella-likerash which may be misdiagnosed as rubella. The rash, which is usually non-pruritic and mainly confined to the trunk, does not desquamate and often fades within 48 hours. The child may appear quite well or can have mild constitutional symptoms including diarrhoea.Erythema infectiosum (fifth disease)Erythema infectiosum, also known as 'slapped face' syndrome or fifth disease, is a childhood exanthem caused by parvovirusB19. It occurs typically in young school-aged children. Incubation period is 4-14 days. The bright macular rash erupts on the face first then, after a day or so, a maculopapular rash appears on the limbs. 4 The rash lasts for only a few days but may recur for several weeks.Clinical features

mild fever (30%) and malaisepossible lymphadenopathy (esp. cervical) The rash Fig 74.4 :bright red flushed cheeks with circumoral pallor for 2-3 days maculopapular rash on limbs (especially) and trunk (sparse) reticular appearance on fadingmay be pruritic

Typically, the cheeks become reddened again for the next few weeks on exposure to sunlight or wind or after a hot bath. 2 Erythema infectiosum is a mild illness but, if the parvovirus infection occurs during pregnancy, foetal complications including death in utero can occur. 3 Adults can be infected and the side effects, especially arthritis, can be quite severe. Diagnosis is by serology. Treatment is symptomatic.

Fig. 74.4 Erythema infectiosum: typical distribution of rash

Roseola infantum (exanthema subitum or sixth disease) Roseola infantum is a viral infection (human herpes virus6) of infancy, affecting children at the age of 6-18 months; it is rare after this time. Constitutional symptoms are generally mild.Clinical features

high fever (up to 40) runny nosetemperature falls after 3 days (or so) thenred macular or maculopapular rash appears The rash:largely confined to trunk usually spares face and limbs appears as fever subsides disappears within 2 daysno desquamationmild cervical lymphadenopathy

The infection runs a benign course, although a febrile convulsion can occur. Diagnosis is by serology and treatment is symptomatic.Scarlet feverScarlet fever results when a Group A Streptococcus pyogenes organism produces erythrogenic toxin. The prodromal symptomsprior to the acute exanthem comprise about 2 days of malaise, sore throat, fever (may be rigors) and vomiting.Features of the rash

appears on second day of illness first appears on neckrapidly generalised punctuate and red blanches on pressureprominent on neck, in axillae, groin, skinfolds Fig 74.5absent or sparse on face, palms and soles circumoral pallorfeels like fine sandpaper lasts about 5 daysfine desquamation

Fig. 74.5 Scarlet fever: typical presentation of rash

TreatmentPhenoxymethylpenicillin (dose according to age) with rapid resolution of symptoms.Kawasaki's disease (mucocutaneous lymph node syndrome)This is an uncommon acute multisystemic disorder in children, characterised by an acute onset of fever of 5 days or more and accompanied by the following features:

bilateral conjunctivitis maculopapular polymorphous rash cervical lymphadenopathy > 1.5 cm dryness, redness and cracking of the lips erythema of the oral cavityerythema of palms and soles with induration and oedema desquamation of fingertips (a characteristic)tender mass in right hypochondrium

Kawasaki's disease can be elusive as there are variations with incomplete manifestations. There is no specific test but the ESR is usually elevated.The disease is generally benign and self-limiting but it is important to make an early diagnosis because early treatment may prevent complications. The major complication is vasculitis, which causes coronary aneurysms in 17-31% of cases, with an overall case fatality rate of 0.5-2.8% 5 due to the aneurysm that usually develops between the second week and the second month of the illness. Early treatment with immunoglobulin and aspirin has been shown to be effective in reducing the prevalence of coronary artery abnormalities. Echocardiography is indicated to detect these aneurysms and determine prognosis. Avoid corticosteroids in these patients.Mumps (epidemic parotitis)Mumps is an acute infectious disease caused by a paramyxovirus, with an affinity for the salivary glands and meninges.Although it most often affects children (90% present before adolescence), no one is exempt. 3Mumps has a worldwide prevalence. Most adults have antibodies to it, whether or not they have had the clinical infection. Because the antibody crosses the placenta in pregnancy, the infant will be immune for the first 6-9 months of life. One episode of the illness is sufficient to confer permanent immunity.The patient is most infective during the prodrome, less so by the time the parotid glands are enlarged. Spread of infection is by aerosol droplets from the saliva and nasopharynx and can be rapid in school classrooms and throughout a household.Mumps in a woman in early pregnancy occasionally causes abortion or foetal abnormalities.General course and symptomsThe incubation period is 2-3 weeks.The patient might be free of symptoms but a high fever, headache and malaise, for 5-7 days (occasionally 2-3 weeks), is usual. Involvement of the salivary glands is common. Dry mouth and discomfort on eating or opening the mouth occur.

Major manifestationsUnilateral or bilateral inflammation of the parotid gland is usual: one parotid gland swells first and in 70% of cases the oppositeside swells after 1-2 days. The submandibular and sublingual glands are less commonly involved. About 6% of patients will have presternal oedema resembling cellulitis of the neck.ComplicationsThe complications are summarised in Table 74.6 .Orchitis, usually unilateral, occurs in 25% of postpubertal males, developing 3-4 days after parotitis. Subsequent sterility is rare, even if both testes are affected.Aseptic meningitis is common but benign. Many patients suffer transient abdominal pain and vomiting: severe pancreatitis is a rare complication.Table 74.6 Complications of mumps

Common Orchitis Aseptic meningitis (benign) Abdominal pain (transient)

Rare Ophoritis Encephalitis Arthritis (one or several joints) Deafness (usually transient) Pancreatitis

Clinical diagnosisEnlargement of the cervical lymph glands can be mistaken for parotitis but the correct diagnosis is indicated by the anatomy ofthis area. Lymph nodes are posteroinferior to the ear lobe; the parotid gland is anterior and, when enlarged, obscures the angle of the mandible.Bacterial (suppurative) parotitis is associated with toxaemia and results in a high leucocyte count. The skin over the parotid gland is tense and shiny and Stensen's duct might discharge pus.Rare disorders such as Sjgren's syndrome can be misdiagnosed as mumps.Virological diagnosisThe diagnosis of mumps is usually clinical; virological confirmation is rarely required but the virus can be isolated from thenasopharynx or saliva during the acute illness (and from cerebrospinal fluid in mumps meningitis). A serological test for antibodies is available.ManagementTreatment is symptomatic. Paracetamol may be prescribed for fever, meningitis and orchitis. Ample fluid intake and a bland dietis advisable. Bed rest should be taken only according to the symptoms: it does not seem to have an influence on the development of complications. 3Children should not return to school until the symptoms subside but contacts need not be excluded.The patient with orchitis should use supportive underwear. Steroids may be prescribed to relieve severe pain but will have no other effect; nor will they reduce the risk of testicular atrophy.PreventionIsolation is generally ineffective. The best protection is immunisation of all children.Epstein-Barr mononucleosisAlthough glandular fever is more common in adolescents and young adults, it can occur in young children but is oftenasymptomatic or atypical. The differential diagnosis includes cytomegalovirus infection and acute lymphatic leukaemia. Diagnosis is confirmed by the Paul-Bunnell test or the Monospot test.PertussisPertussis (whooping cough) is a respiratory infection caused by Bordetella pertussis and occurs worldwide. The incidence ofthis infectious disease has diminished because of immunisation programs and improvements in standards of living, but the infection is still seen frequently, often modified by partial immunity.Pertussis is predominantly an illness of infants under two years of age (up to 50% of all cases). Approximately 70% of unimmunised children will eventually develop pertussis, the majority by their fifth birthday. 3 However, no age is exempt. The source of infection is older children or young adults who have relatively mild disease.

The illness is characterised by three stages: catarrhal, paroxysmal and convalescent, with the person being most infectious during the catarrhal stage.Suspect pertussis in an illness lasting 2 weeks or more with one of:

paroxysms of coughing orinspiratory 'whoop' without other apparent causes orpost-tussive vomiting

Clinical features

Incubation period 7-14 days Catarrhal stage (7-14 days)anorexia rhinorrhoeaconjunctivitis/lacrimation dry coughParoxysmal stage (about 4 weeks)paroxysms of severe coughing with inspiratory 'whoop' vomiting (at end of coughing bout)coughing mainly at night lymphocytosis (almost absolute)Convalescent stagecoughing (less severe)

Note: Physical findings are minimal or absent.DiagnosisThe diagnosis is basically a clinical onevirtually no other acute infectious illness in children causes a cough that lasts 4-8weeks. 3 Confirmed by culture of nasopharyngeal aspirate (within 1 week from onset of cough) or Ig A serology (late in disease), although this can be misleading. High-grade lymphocytosis (12-25 x 109/L) on an FBE is strongly suggestive of pertussis. New methods include immunofluorescence, PCR and ELISA techniques. 6Differential diagnosisViral pneumonia, acute bronchitis, influenza. Chlamydia respiratory infection can cause a 'pseudopertussis' type of illness in infants.ComplicationsThese include asphyxia, hypoxia, convulsions and cerebral haemorrhage. Also pulmonary complications, e.g. atelectasis,pneumonia, pneumothorax.TreatmentErythromycin estolate for 10 days may help reduce the period of communicability (but not the symptoms) if given early (coughless than 3 weeks). There is no evidence that antibiotics produce an improvement in the patient. 7 Cough mixtures are ineffective. 3 Good ventilation is important: avoid dust and smoke, and also emotional excitement and overfeeding during the paroxysmal phase.Almost all infants under 6 months and some who are older require admission to hospital. 2 School exclusion until at least 5 days of antibiotics.PreventionActive immunisation with pertussis vaccine.ProphylaxisA 10 day course of erythromycin (cotrimoxazole if contraindicated) is recommended for household and other close contacts,regardless of immunisation status, commenced within 3 weeks of onset of cough in the patient. 6Herpes simplexHerpes simplex virus infection is common and widespread. Primary HSV infection is basically a disease of childhood,presenting as severe acute gingivostomatitis. However, the infection may be subclinical in children; based on antibody studies, approximately 90% of the population acquire herpes simplex infection before the age of 4 or 5 years. 5The primary infectionTypical clinical features:

children 1-3 yearsfever and refusal to feed

ulcers on gums, tongue and palate prone to dehydrationmay be lesions on face and conjunctivae resolution over 7-10 days

These children are generally very miserable and ill, and some may require hospitalisation for intravenous therapy to correct fluid and electrolyte loss. Treatment is usually symptomatic, e.g. oral lignocaine gel. Careful nursing and prevention of secondary infection is important. The latter includes gentle mouth toilets. Children with severe infections, those who are immunosuppressed and those with eczema herpeticum can have aciclovir IV or orally.Serious complications:

encephalitis can develop in otherwise healthy childreneczema herpeticumchildren with eczema can get widespread herpetic lesions disseminated HSV infection in neonates

Herpes zosterHerpes zoster (shingles) is caused by reactivation of varicella zoster virus (acquired from the primary infection of chickenpox) inthe dorsal root ganglion. It occurs at all ages and can occur in children, including infants, who have been exposed to varicellain utero. 3Recurrences are uncommon except in immunocompromised patients. The diagnosis is a clinical one but can pose difficulties, especially as it is not so common in childhood and may present with only a few vesicles.ImpetigoImpetigo (school sores) is a contagious superficial bacterial skin infection caused by Streptococcus pyogenes orStaphylococcus aureus or a combination of these two virulent organisms. There are two common forms:

1. vesiculopustular with honey-coloured crusts (either Strep or Staph)2. bullous type, usually Staph aureusEcthyma is a deeper form of impetigo, usually on the legs and other covered areas. If mild with small lesions and a limited area:Topical antiseptic cleansing with gentle removal of crusts, using antibacterial soap, chlorhexidine or povidone-iodine. Then mupirocin (Bactroban), a small amount tds for 10 days. Topical antibiotics other than mupirocin (Bactroban) are not recommended. 7

If extensive and causing systemic symptoms: 7

Cephalexin 6.25 mg/kg up to adult dose (250 mg) (o) 6 hourly for 10 days (first choice) orFlucloxacillin/dicloxacillin 6.25 mg/kg up to adult dose (250 mg) (o) 6 hourly for 10 days orErythromycin 10 mg/kg up to adult dose (500 mg) (o) 12 hourly for 10 days

Boils (furunculosis) and carbunclessame treatment as impetigo.The child should be excluded from childcare settings until sores have healed fully.Head liceHead lice is an infestation caused by the louse Pediculus humanus capitis. The female louse lays eggs (or 'nits') which areglued to the hairs; they hatch within 6 days, mature into adults in about 10 days and live for about a month. Head lice spread from person to person by direct contact, such as sitting and working very close to one another. They can also spread by the sharing of combs, brushes and headwear, especially within the family. Children are the ones usually affected, but people of all ages and from all walks of life can be infested. It is more common in overcrowded living conditions.Clinical features

asymptomatic or itching of scalpwhite spots of nits can be mistaken for dandruff unlike dandruff, the nits cannot be brushed off diagnosis by finding lice (or 'nits')

Treatment

pyrethrins/piperonyl foam or shampoo, e.g. Lyban foam

MethodMassage well into wet hair, leave for at least 10 minutes but preferably overnight, then wash off thoroughly. Repeat treatment at one week.Treat household child contacts at the same time.

Note: The hair does not have to be cut short. All members of the family must be treated whether or not lice, or nits, can be found. There is no need to treat clothing, pillows or other items. School exclusion should not be necessary after proper treatment. For eyelash involvement, apply petrolatum bd for 8 days and then pluck off remaining nits.

References

1. Jarman R. A word about aspirin in children. Aust Ped Review, 1991; 1(6):2.2. Efron D. Paediatric handbook (5th edn). Melbourne: Blackwell Science, 1996, 69.3. Robinson MJ. Practical paediatrics (2nd edn). Melbourne: Churchill Livingstone, 1990, 217-227.4. Mansfield F. Erythema infectiosum. Slapped face disease. Aust Fam Physician, 1988; 17:737-738.5. Wilson JD et al. Harrison's principles of internal medicine (12th edn). New York: McGraw-Hill, 1991, 1462-1463.6. Golledge C. A case of persistent cough. Aust Fam Physician, 1997; 26:1219.7. Mashford ML. Antibiotic guidelines (9th edn). Melbourne: Victorian Medical Postgraduate Foundation, 1996-97, 106-136.8. Tierney LM et al. Current medical diagnosis and treatment. Stamford: Appleton & Lange, 1996, 113-114.