Creepy crawlies can really get under your skin

Bernard Cohen of Johns Hopkins examines hair samples of a child with ringworm, a fungus often diagnosed as athlete's foot.
Bernard Cohen of Johns Hopkins examines hair samples of a child with ringworm, a fungus often diagnosed as athlete's foot. (Sarah L. Voisin/The Washington Post)
By Laura Hambleton
Special to The Washington Post
Tuesday, January 26, 2010

Carla Sguigna laid her daughter's head in her lap as they watched a movie in their basement family room in her North Bethesda home. Sguigna methodically combed through her 4-year-old's hair, strand by strand, fingering each shaft down to her scalp.

She was hunting for nits, the little eggs laid by lice that cement themselves to hair. Sguigna's own hair was infested and itchy, too -- a girlfriend later nitpicked her head at her kitchen table -- but Sguigna shrugged at this dual invasion. It's a rite of childhood passage: H1N1 and seasonal flu may be the stuff of headlines right now, but pint-size parasites and fungi and the miseries they cause are a constant for Sguigna and other pediatricians all the time.

"I get a fair amount of calls about lice all year long, and I treat to a lesser extent pinworm and ringworm," said Sguigna, whose office is in Rockville. "When I tell parents" what their child has, she said, "sometimes they recoil."

Lice, scabies, pinworm and fungi such ringworm lurk in the environment, attaching themselves to new hosts every day, from grown-ups to little children. Each can be contagious, especially when people find themselves cooped up inside in the winter or sitting cheek by jowl in circle time at preschool.

"They're out there all the time; they're endemic regardless of socioeconomic class," said Bernard Cohen, head of dermatology at Johns Hopkins Children's Center in Baltimore. "Some people think scabies [caused by mites that tunnel under the skin,] for one, are from medieval times, but they're not."

More challenging

Cohen has been studying bugs and fungi for 25 years. In fact, he collects creatures such as the scabby mite, bedbugs, body lice and ringworm and displays them in cups, bottles and glass slides in his office. "They are pretty harmless pets," he added. Pets may be how Cohen views them; many consider them uninvited guests with huge social downsides. Consider how these creatures have influenced our very language and culture, said Chevy Chase dermatologist Richard Castiello. "We call people a louse. We look for things with a fine-tooth comb and we call people nitpickers," he said. "Military haircuts came about because of lice."

These bugs and fungi are unpredictable. "They seem to go in epidemics," Castiello said. "I won't see something for a few years. In the late '70s I saw scabies every day. It was on an upswing. Now it has settled down."

Yet doctors worry that these bugs, especially lice, and fungi including ringworm are becoming more challenging to treat. "The scary thing about head lice and scabies is that the agents we use to treat them are not as effective as they once were," Cohen said. "So there's still research going on."

Treatments have changed. Lindane, an agricultural pesticide, once was widely used to treat lice. The Food and Drug Administration still allows it, by prescription, in shampoos but says it should be a choice of last resort because of its toxicity. Said Sguigna, "Lindane, which is a neurotoxin, is fairly toxic." Cohen said he prefers to avoid it. "I have not used it for 20 years because there are safer alternatives, and I advise physicians to use alternatives as well."

Washington pediatrician Howard Bennett cautions that it is difficult to know how much any outbreak of, say, lice is the result of resistance to treatment or just a normal recurrence. It's also possible, said Cohen, that the bugs have been misdiagnosed as lice. He has devised a method for determining if a particularly bothersome itch is caused by a bug, a hypersensitivity to a bug bite or just a rash.

Often when a child picks up a bug infestation, parents go hush, which can make the outbreak worse. They know their child's peers and those children's parents will withdraw, and principals will shoo their children home until the parasites are cleaned out. Bugs create stigma.

Unfairly so. "It isn't about being clean or dirty," said Karen Franco, who picks lice nits out of hair professionally. She has an office in Kensington. "It has actually become a rich-man's problem. Our kids have so many extracurricular activities from ballet to gymnastics. There is so much cross-population."

What to do

So what do you do when your child comes home itching like crazy?

If it's head lice, sometimes it takes a few painstaking tries to kill them, since they go from nit to nymph to adult in about one to two weeks. Franco advised brushing the hair before shampooing to try to knock off some lice. Some area doctors recommend over-the-counter treatments such as Nix or Rid, although parents complain they don't work very well. Some doctors will prescribe shampoos or creams with insecticides in them. Sguigna likes pesticide-free "LiceMD, which suffocates them. It is a thick, gooey stuff. You work it on the hair and let it sit there."

Franco also suggests something that isn't an insecticide at all: "Ulesfia, which is a benzyl alcohol product that is supposed to paralyze the breathing pores of the lice so that they stay open, and the bugs succumb to the combination of oil and alcohol." The FDA approved the lotion last April.

But, she said, "all lice treatments should include fine-tooth combing on a regular basis since there is always the potential for product failure and human error, which is combated with repetitious combing. The best way to get rid of lice is through manual labor." Special nit combs are available at pharmacies, online and at pet stores (as flea combs). Finally, all bedding, stuffed animals and clothing must be washed or at least put in the dryer at a hot setting for 10 minutes.

Scabies mites -- tiny, eight-legged creatures that creep along under the skin -- leave elongated bumps in a trail, "much like pearls on a necklace," Bennett said. The bumps itch and can be as maddening as chickenpox, especially at night. Scabies is spread by direct contact. "Kids give it to each other, like a gift," Cohen said. There is also a dog version of this itch mite that can infect people. The treatment is the same. "It doesn't hurt," Bennett said. "But they are living on you. They feed on you. They leave excretory produce on you. They lay eggs on you. The itchy rash is your body's allergic reaction. You can get red spots and sometimes pus bumps."

The mites can burrow everywhere, even under the fingernails, said Sterling pediatrician William Incatasciato. Often dermatologists take skin scrapings to look at them under a microscope to conclusively diagnose scabies.

Most doctors will prescribe Elimite, a topical cream containing permethrin, a synthetic form of chrysanthemums classified by the Environmental Protection Agency as a likely human carcinogen, to get rid of scabies. The infected person must smear the cream over their body, to make sure any wayward mites are killed, then sleep with the treatment on. This process may have to be repeated a few times. This skin cream has been used to combat lice as well. As with lice, bedding and clothes of people with scabies need be thoroughly washed in hot water.

Ringworm is not a worm at all. It is a fungus, which forms scaly, red circles, or rings, on the skin. "It's like plants that grow on the surface," said Castiello. "Ringworm grows on the outer layer of skin like fungi, like a plant."

Ringworm comes in many forms and can be present in locker rooms, on wrestling and gymnastic mats, on goggles and bathing caps. It is spread on the body by scratching and between people by skin-to-skin contact. Some children get it in their scalps. Teenagers and adults often get it between toes -- so-called athlete's foot -- while others find it in more private areas.

"True ringworm is usually picked up from animals, especially kittens and puppies," Castiello said. "To get rid of it, apply topical antifungal medicine. Or take an oral [prescription] antifungal pill" if the ringworm has spread.

Pinworm, in contrast, is a true worm, and one that pediatricians say particularly alarms parents. Tiny, white worms about an inch long, pinworms take up residence in the body's intestines and squiggle out through the anus at night to lay eggs on a child's skin. Once they've established themselves, pinworms cause extreme itching around the anus, and parents may find the worms in a child's bowel movements. Pinworms spread easily: An egg may lodge under a child's fingernail when he or she scratches the itch and then be spread by that child to others.

"Pinworms are more common in preschool, day cares and sandboxes," Incatasciato said. "Kids scratch themselves, put hands in their mouths or touch a friend." Children with ringworm often complain of itchy bottoms at night but seem fine in the morning.

The old-fashioned but effective way of detecting the worms is to go into a child's room at night, armed with a flashlight, and look at the child's bottom. Or take a stool sample to the doctor. Two doses of a prescription anti-parasitic pill take care of the worms. Plus laundering pajamas, clothes and bedding.

Hambleton is a freelance writer and documentary filmmaker in Chevy Chase.

© 2010 The Washington Post Company