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A further finding of our survey is that nearly 50 of pediatricians who prescribe a conventional topical pediculicide as first line therapy, administrate the same treatment in children under 24 months of age. As a matter of fact, about 40 of pediatricians choice malathion as first line treatment, and suggest this product also in children under 24 months. In general, conventional pediculicides are not recommended in children younger than 2 years 2729. Furthermore, malathion is not recommended in children younger than 6 years, because there are not enough studies to support its safety, and it is moreover contraindicated in children younger than 2 years 21. It is also of note that about one fifth of pediatricians prescribe dimethicone as first line treatment and only 40.1 prescribe it in children under 24 months. In fact, in this age group, dimethicone could be an excellent therapeutic tool, since it is odourless, nontoxic and generally well tolerated by children from 6 months of age 1517. It acts by coating the lice and causing suffocation and has neither pediculocide nor ovocidal activity. A study in the United Kingdom reported a cure rate of nearly 70 30, a study in Turkey reported cure rates of 92 31, and another large randomized trial conducted in Brazil 32, in which a different formulation of dimethicone was used 92 dimethicone, reported a 97 cure rate. Maybe it is a new product, there are few studies all from the same authors, and Italian pediatriciansFancelli et al. Italian Journal of Pediatrics 2013, 3962 httpwww.ijponline.netcontent39162Page 5 of 6prescribe it less than older pediculocides. Therefore, even if 2012 UK guidelines suggest di dimethicone as first line treatment, we believe that more studies are needed to assest efficacy and safety for young children. Furthermore, only 11 of pediatricians suggest only mechanical removal for children younger than 24 months. Wet combing is the preferred treatment for children younger than 2 years 27 and it also should be considered if parents prefer not use a pediculocide on their child. Wet combing is commonly suggested in association with topical pediculocides, in order to improve their efficacy. However, an observerblinded study by Meinking TL, has investigated the use of 1 permethrin creme with and without adjunctive combing and it has demonstrated the failure of nit removal combing when made by nonprofessional caregivers 33. Maybe, when pediatricians suggest the use of the comb, they should train parents to use the comb as appropriate 25. Finally, very few 3 pediatricians suggest a treatment with oils or other herbal products their safety and efficacy are currently unknown and they are not recommended 21. Our survey also shows that oral pediculocides Ivermectin and SulfamethoxazoleTrimethoprim are, correctly, very rarely prescribed. Recently February 2012, topical ivermectin lotion Sklice was approved by the FDA. It is indicated for the treatment of head lice in children aged 6 months and older it shows good therapeutic perspectives 34,35. Another result of our study is that the majority of pediatrician interviewed 72 recommend routine retreatment for all topical pediculocides, preferably on day 79, as well as many experts suggest 21. Improper timing of second application of pediculicides should be considered an important cause of treatment failure. In literature there is a lack of data about the real incidence of treatment failure in children. The majority of pediatricians interviewed 65 report a frequence of 10 or less of short term recidives 2 months from treatment, while nearly one third reports a frequence rate between 30 and 50. The majority of them believe that recidives are attributable to a reinfestation in the childhood community. More important, the ongoing presence of nits or itch is not a sign of treatment failure, since nits could be not alived. Only the finding of live lice, using a detection comb, two or three days after completing a course treatment two applications of treatment 7 days apart should be considered a sign of treatment failure 25. The persistence of living head lice after the use of pediculocides may have several causes, such as lack of adherence of the patient to the treatment protocol inadequate dosis or duration of treatment reinfestation lice reacquired after treatment and resistance of lice to pediculocides. Several studies report an increasing rate of lice resistance to topical pediculicides in the last years13,36,37. There are three main patterns of resistance genetic resistance the presence of polymorphisms in genes associated with resistance clinical resistance persistence of live lice after a cycle of application parassitologic resistance in vivo resistance of lice to pediculocide compounds. As Durand R describes in a recent review, permethrinresistant phenotypes are mostly associated with a recessive kdr trait, while no genetical mechanism has been formally reported for malathion 26. Now, resistance rather than a lack of compliance with treatment should be considered the main cause of a treatment failure 38. Currently, several strategies have been proposed to overcome a possible treatment failure. One of the strategies is the application of a product for a fullcourse treatment and, in case of failure, the use pediculocide with a different resistance profile 17,25. Only 37 of pediatricians interviewed used this type of therapeutic approach. Probably, the restriction of pediculocides availability only with medical prescription, the administration of these drugs at the right dose and with a correct timing may help in prevent treatment failure. The main limit of our study is that over 40 of pediatricians attending the conference did not respond to our questionnaire and nonresponders may be less updated on national guidelines as compared to responders pediatricians. Globally, the Italian pediatricians surveyed proved to be quite informed on head lice management. Moreover, pediatricians should advise parents that head lice infestation should be diagnosed and treated under the supervision of a physician. In fact, proper education of parents, other than continuous updating of pediatricians, may contribute to a better management of head lice in the community.Additional fileAdditional file 1 Questionnaire on the management and treatment of head lice for the pediatrician. Competing interests The authors declare that they have no competing interests. Authors contributions CF, MP, LG, MdM conceived of the study, performed the statistical analysis and drafted the manuscript. MP, PB, CM, EC participated in the design of the study and helped to draft the manuscript. All authors read and approved the manuscript. Received 27 April 2013 Accepted 15 September 2013 Published 3 October 2013 References 1. Gelmetti C, Veraldi S, Scanni G Head lice proposal for therapeutic guidelines. Italian J Dermat Vener 2004, 13914. 2. Ciftci IH, Karaca S, Dogruo O Prevalence of pediculosis and scabies in preschool nursery children of Afyon, Turkey. Korean J Parasitol 2006, 449598. 3. Kokturk A, Baz K, Bugdayci R The prevalence of pediculosis capitis in schoolchildren in Mersin, Turkey. Int J Dermatol 2003, 42694698.Fancelli et al. 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Can Fam Physician 2012, 58839841.doi10.1186182472883962 Cite this article as Fancelli et al. Survey assessment on pediatricians attitudes on head lice management. Italian Journal of Pediatrics 2013 3962.Submit your next manuscript to BioMed Central and take full advantage of Convenient online submission Thorough peer review No space constraints or color figure charges Immediate publication on acceptance Inclusion in PubMed, CAS, Scopus and Google Scholar Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.comsubmit