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ORIGINAL ARTICLE
Year : 2021  |  Volume : 22  |  Issue : 3  |  Page : 220-225

Assessment of impact on quality of life in children attending skin outpatient department with pediculosis capitis: A study in Western Rajasthan


1 Department of Skin and VD, Dr. SNMC, Jodhpur, Rajasthan, India
2 Department of Skin and VD, NMCH, Kota, Rajasthan, India
3 Department of Preventive and Social Medicine, Sardar Patel Medical College, Bikaner, Rajasthan, India

Date of Submission25-Apr-2020
Date of Decision07-May-2020
Date of Acceptance30-Mar-2021
Date of Web Publication30-Jun-2021

Correspondence Address:
Aditi Agrawal
Department of Skin and VD, NMCH, Kota, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpd.IJPD_70_20

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  Abstract 


Background: Pediculosis capitis is an endemic infestation prevalent worldwide and common among primary school girls with low socioeconomic background. Aims and Objectives: The objective of this study is to determine the various risk factors associated with pediculosis, Children's Dermatology Life Quality Index (CDLQI), and its correlation with the various risk factors. Materials and Methods: Sixty-one children of age group of 6–12 years who were clinically diagnosed with pediculosis capitis at our outpatient clinic were included in this study. Demographic details and risk factors along with CDLQI were obtained from the patients on a preformed written pro forma. Statistical Analysis: It was performed on the SPSS software version 22 using the Mann–Whitney U and ANOVA test; P < 0.05 was considered statistically significant. Results: Of 61 patients, all were female with a moderate impact on quality-of-life children. Mean CDLQI was 9.8 ± 6.04 and most common affected domain was of symptoms and feelings with a mean of 3.53 ± 1.45. Other domains affected were sleep and treatment-seeking difficulties with a mean of 1.69 ± 1.03 and 1.64 ± 0.81, respectively. Girls of the rural community with longer hairs, poor hygiene, and lower socioeconomic class, i.e., class 5 had a higher impact on their lives as compared to others with a mean CDLQI of 14.83 ± 6.08, 10.36 ± 5.43, 15.06 ± 6.51, and 13.42 ± 6.74, respectively. Conclusion: Community-based health programs and delousing campaigns are needed to create the awareness among people so that good hygiene practices can act as a primary preventive measure against pediculosis capitis and prevent any deleterious impact on the lives of children.

Keywords: Child Dermatology Life Quality Index, impact on life, pediculosis capitis, risk factors


How to cite this article:
Kumar A, Mohta A, Agrawal A, Mohta A. Assessment of impact on quality of life in children attending skin outpatient department with pediculosis capitis: A study in Western Rajasthan. Indian J Paediatr Dermatol 2021;22:220-5

How to cite this URL:
Kumar A, Mohta A, Agrawal A, Mohta A. Assessment of impact on quality of life in children attending skin outpatient department with pediculosis capitis: A study in Western Rajasthan. Indian J Paediatr Dermatol [serial online] 2021 [cited 2021 Aug 5];22:220-5. Available from: https://www.ijpd.in/text.asp?2021/22/3/220/319951




  Introduction Top


Pediculosis capitis is caused by a louse Pediculus humanus capitis, a common social problem, and is of a great health concern, especially among school-aged children.[1],[2] Human lice are a permanent and specific human blood-sucking ectoparasites. Close physical contact, poor socioeconomic status (SES), sharing of articles such as comb, hats, scarves, and hair hygiene are the major risk factors for the transmission and establishment of hair lice.[3],[4] It is mainly characterized by itching which is caused as a result of saliva injected at the time of sucking of blood. In neglected cases, it may result in secondary infection, lymphadenopathy, fever, and focal loss of hair. Although not associated with major health risks, head lice infestation can lead to social stigma, discomfort, embarrassment to the child, and absenteeism from school and work. A child may become an object of laughter and ridicule among their peer group causing psychological distress and may hinder learning performance of the children because of the social stigma associated with it.[5]

The present study was conducted to determine the risk factors, assess the quality of life of children infested with head louse or pediculous humanus capitis, and its correlation with the various risk factors responsible for acquisition of infestation.

To our knowledge, this is the first study evaluating the quality of life in children affected with pediculosis capitis.


  Materials and Methods Top


Ethical approvals

We took a formal permission from Professor Andrew Y Finlay, Department of Dermatology, Cardiff University School of Medicine, Health Park, Cardiff, UK, to use the validated Hindi version of CDLQI questionnaire.[5] Hindi version of the questionnaire was validated by Dr. Sheena Goyal, Department of Dermatology, Venereology and Leprology, Era's Lucknow Medical College, Lucknow, UP, India by doing twice forward translation and then their corresponding back translation. In addition, the study was approved by the Institutional Ethical Committee. Written informed consent was obtained from the patient's parents and before enrolling them into the study.

Patient

Our study was a hospital-based cross-sectional study done in a tertiary care hospital. The cases of pediculosis capitis were selected from Skin and Venereal Disease Out Patient Department (OPD) between September 2019 and February 2020.

Sixty-one consecutive children of age 6–12 years who presented with a clinical diagnosis of pediculous capitis were enrolled in the study. Diagnosis was made after careful visual examination of scalp and hairs in adequate day light for the presence of adult lice, nymphs, or viable nits. Age, sex, residence, mother's occupation, socioeconomic class, hair washing habit, sharing of articles, and hair length were obtained on a preformed written pro forma.

Socioeconomic class was taken as per the Modified Kuppuswamy Scale[6] which included 5 Classes [I-V]. The Modified Kuppuswamy Scale is commonly used to measure SES in the urban and rural areas. This scale was devised by Kuppuswamy in 1976 and consists of a composite score which includes the education and occupation of the family head along with income per month of the family, which yields a score of 1–29. Class I is upper class with a total score of 26–29, Class II is upper middle with a total score of 16–25, Class III is lower middle with a score of 11–15, Class IV and V are upper lower and lower with a score of 5–10, and 01–04, respectively.

All new cases clinically diagnosed with pediculosis capitis were included in the study, whereas immunocompromised children, those with age <6 years, and those who were unable to comprehend were excluded from the study [Figure 1] and [Figure 2].
Figure 1: An 8-year-old female presented with nits (yellow arrow)

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Figure 2: (a) An 9-year-old female presented with lice and nits. (b) Same female presenting with focal hair loss due to secondary infection

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Statistical analysis

Statistical analysis was performed on the Statistical Package for the Social Sciences V22.0 (IBM, Armonk, NY) using the Mann–Whitney U and ANOVA test; P < 0.05 was considered statistically significant.

CDLQI questionnaire was given to each patient in Hindi containing 10 questions and each question was scored from 0 to 3, 0 - not at all or not relevant or unanswered, (1) a little, (2) lot, and (3) very much or prevented from work or studying.

After summing up the total score, it was interpreted as follows:

Dermatology life quality index score interpretation

  • 0–1 no effect at all on patient's life
  • 2–5 small effect on patient's life
  • 6–10 moderate effect on patient's life
  • 11–20 very large effect on patient's life
  • 21–30 extremely large effect on patient's life.


The Child Dermatology Life Quality Index (CDLQI) was analyzed under 6 headings-

  1. Symptoms and feelings – questions 1 and 2
  2. Leisure – questions 4, 5, and 6
  3. School or holidays – question 7
  4. Personal relationships – questions 3 and 8
  5. Sleep – question 9
  6. Treatment – question 10.



  Results Top


In our study, we took 61 children who were in the age group of 6–12 years attending skin OPD with clinically diagnosed pediculosis capitis. All patients who presented to us with pediculosis were females.

Forty-nine patients (80.33%) belonged to the urban community and rest to the rural area. Out of 61children, 35 patients (57.38%) had medium length of hair, i.e., >3 cm to shoulder level, 19 (31.15%) children had long hairs (>shoulder level), and 7 or 11.48% of them had short length of hairs (<3 cm) [Table 1].
Table 1: Exposure variables associated with pediculosis

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Regarding mother's employment, 44 (72.13%) were employed outside home, 12 of them were dead (19.67%), and 5 stayed at home [Table 1].

Frequency of hair washing was 1/week in 32 patients (52.46%), <1/week in 16 patients (26.23%), and 2/week in 13 patients (21.31%) [Table 1].

The maximum number of patients (18.03%) was in the age group of 12 years, followed by 6, 8 and 9 years of age group (14.75%) [Table 2].
Table 2: Age distribution of patients

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We found in our study that maximum patients belonged to class 3, 4, and 5 with maximum patients belonging to class 4, i.e., 54.10% [Table 3].
Table 3: Socioeconomic class of patients

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Mean Children's DLQI was 9.8 ± 6.04 and the most common affected domain was of symptoms and feelings with a mean CDLQI of 3.53 ± 1.45 followed by domain which covered sleep and troubles dealt while seeking treatment with a mean CDLQI of 1.69 ± 1.03 and 1.64 ± 0.81, respectively. Next in line was the domain which affected academics/holidays and leisure activities and the mean CDLQI was 0.85 ± 1.08 and 0.84 ± 1.08, respectively [Table 4].
Table 4: CDLQI score according to various domains of life

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Twenty-four patients (39.34%) had moderate impact on quality of life; 29.51% and 21.31% had small and very large effect on quality of life, respectively [Table 5].
Table 5: CDLQI distribution of study subjects

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Mean Children's DLQI of the rural community was 14.83 ± 6.08 greater than that of urban community, i.e., 8.57 ± 5.40 with significant P = 0.004 [Table 6].
Table 6: Mean CDLQI and its exposure variables

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Mean CDLQI of children whose mother were dead had a higher mean CDLQI of 13.91 ± 6.12 followed by children whose mothers stayed outside home for work with a mean CDLQI of 9.02 ± 5.86 [Table 6].

Children with long and medium hairs had a higher mean CDLQI of 10.36 ± 5.43 and 10.17 ± 6.63, respectively, while those with short hairs had mean CDLQI of 6.42 ± 3.40. Furthermore, children with long hairs experienced more symptoms and disturbance in sleep as compared to others with significant P = 0.002 and 0.003, respectively [Table 6].

Children who washed their hairs <1 time in a week had a mean CDLQI of 15.06 ± 6.51 while those who washed once and twice per weekly had a mean CDLQI of 7.87 ± 5.49 and 8.07 ± 1.18, respectively, with significant P = <0.0001 [Table 6].

Children with higher age group had a higher CDLQI as compared to those with lower age group and maximum impact on quality of life was on 9 years of age group, i.e., 13.22 ± 7.13. [Table 6]. Correlation coefficient between age and CDLQI was 0.183.

CDLQI was more in children with more number of family members, 17.75 ± 5.90 with 8, 10.92 ± 6.48 with 9 and 12 ± 4.24 with 10 family members, respectively, [Table 6 ] with a correlation coefficient of 0.13.

Children who belonged to lowest socioeconomic class or class 5 had larger impact on quality of life with a mean CDLQI of 13.42 ± 6.74 as compared to others [Table 6]. Children with long(10.36±5.43) and medium hairs (10.17±6.63) had a higher CDLQI as compared to those with short hairs (6.42±3.40) [Table 7].
Table 7: Hair length affecting CDLQI scoring

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  Discussion Top


Pediculosis capitis, a lice infestation of scalp hairs, is common among school-aged children and is a cause of great morbidity among them affecting their quality of life.

The affected children not only experience symptoms like severe itching but also social embarrassment, disturbances in sleep, schooling, and friendship thus affecting their quality of life.

This results in the negative impact on children's mental health and emotional status.

All children were females in our study as boys have shorter hairs and lice find it difficult to establish themselves in short hairs.

Our study exhibited moderate effect on the quality of life.

Mean CDLQI in our study was 9.8 ± 6.04 and most common affected domain of life was symptoms and feelings. Patients experienced severe itching and discomfort as well as pain, malaise, and fever in those who presented with secondary infection. Severe pruritus due to infestation leads to the disturbances in sleep and difficulty in concentrating in their academics and playful activities. Visibility of lice and their nits along with continuous itching which forces children to scratch their scalp in front of their pupils leading to their low self-esteem, stigmatization, and social isolation.

We found in our study that CDLQI was directly proportional to the degree of lice infestation which in turn is directly proportional to its various determinants or risk factors.

Mean CDLQI of the rural community was significantly greater than that of urban community and it can be explained by carelessness of people, poor availability of resources, difficulty in seeking treatment, and less affection for female child in Indian rural setting, which results in increase in burden of infestation and hence its consequences thus decreasing quality of life of patients. This was in consistent with the studies done by Gulgun et al.[7] and Amirkhani et al.[8] where the prevalence of pediculosis was more in the rural areas.

Children with medium and long hairs had a higher mean CDLQI as longer hairs not only require daily hair do and cleanliness but also provide adequate environment for the establishment of lice. Furthermore, studies done by AlBashtawy and Hasna.[9] and Khamaiseh[10] suggest that pediculosis was more prevalent in children with long and medium length hairs.

Mean CDLQI of children whose mothers were dead or worked outside was higher implying that mother's cannot pay attention to their children as compared to those whose mothers stayed at home. This was in concordant with the study done by Ghofleh Maramazi et al.[11] where 90.9% mothers were unemployed or stayed at home.

Children who washed their hairs less often were more heavily infested with poorer quality of life as substandard hygiene practices increases the infestation rate as opposed to the study done by Maramazi et al.[11] where 84.7% patients maintained standard hygiene practices.

Our study suggests that mean CDLQI was directly correlated to the number of family members. Possible explanations could be increased overcrowding, increase in person to person contact, sharing of articles, and decreased personal care and was in concordance with the study done by AlBashtawy and Hasna.[9] Comparison of our study with different other studies are as shown in [Table 8].
Table 8: Comparison between different studies

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Thus, more is the burden of infestation due to the above-mentioned risk factors, more is the impact on the lives of children affecting their day to day activities, emotional and mental well-being, their relationship with peer group and self-esteem.

Limitations

The major limitation in our study was the differences in the age group of children and their understanding regarding cleanliness and hygienic practices which might have resulted in the variation in their answers. Furthermore, due to the lack of follow-up after treatment, we were not able to compare the quality of life before and after the intervention. Other limitations were small sample size, the absence of a disease specific quality of life indexing, the absence of control group, and the differences in psychological status of children unaffected with pediculosis capitis.


  Conclusion Top


Pediculosis capitis, which is a public health problem, is still an undervalued disease affecting mental and physical results of children. A constant itching in front of peers results in social anxiety and high psychological impact on being secluded from peers. The trend of westernization in our society has made young children more conscious about how their peers perceive them even, and hence, we need a community-based pragmatic and sensible approach promoting education, hygiene practices, and primary prevention strategies.[14]

Acknowledgment

The authors would like to thank Gratitude to Professor Andrew Y Finlay, Department of Dermatology, Cardiff University School of Medicine, for giving us permission to use CDLQI.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Orkin M, Maibach HI. Cutaneous Infestations and Insect Bites. New York, Basel: Marcel Dekker Inc; 1981. p. 175-87.  Back to cited text no. 1
    
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Bloomfield D. Head lice. Pediatr Rev 2002;23:34-5.  Back to cited text no. 2
    
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Willems S, Lapeere H, Haedens N, Pasteels I, Naeyaert JM, De Maeseneer J. The importance of socio-economic status and individual characteristics on the prevalence of head lice in schoolchildren. Eur J Dermatol 2005;15:387-92.  Back to cited text no. 3
    
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Roberts RJ. Clinical practice. Head lice. N Engl J Med 2002;346:1645-50.  Back to cited text no. 4
    
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Finlay AY, Khan GK. Dermatology life quality index (DLQI) – A simple practical measure for routine clinical use. Clin Exp Dermatol 1994;19:210-6.  Back to cited text no. 5
    
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Wani RT. Socioeconomic status scales-modified Kuppuswamy and Udai Pareekh's scale updated for 2019. J Family Med Prim Care 2019;8:1846-9.  Back to cited text no. 6
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Gulgun M, Balci E, Karaoğlu A, Babacan O, Türker T. Pediculosis capitis: Prevalence and its associated factors in primary school children living in rural and urban areas in Kayseri, Turkey. Cent Eur J Public Health 2013;21:104-8.  Back to cited text no. 7
    
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Amirkhani MA, Alavian SM, Maesoumi H, Aminaie T, Dashti M, Ardalan G, et al. A nationwide survey of prevalence of pediculosis in children and adolescents in iran. Iran Red Crescent Med J 2011;13:167-70.  Back to cited text no. 8
    
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AlBashtawy M, Hasna F. Pediculosis capitis among primary-school children in Mafraq Governorate, Jordan. East Mediterr Health J 2012;18:43-8.  Back to cited text no. 9
    
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Khamaiseh AM. Head lice among governmental primary school students in Southern Jordan: Prevalence and risk factors. J Glob Infect Dis 2018;10:11-5.  Back to cited text no. 10
    
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Ghofleh Maramazi H, Sharififard M, Jahanifard E, Maraghi E, Mahmoodi Sourestani M, Saki Malehi A, et al. Pediculosis humanus capitis prevalence as a health problem in girl's elementary schools, southwest of Iran (2017-2018). J Res Health Sci 2019;19:e00446.  Back to cited text no. 11
    
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Buczek A, Markowska-Gosik D, Widomska D, Kawa IM. Pediculosis capitis among schoolchildren in urban and rural areas of eastern Poland. Eur J Epidemiol 2004;19:491-5.  Back to cited text no. 12
    
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Saraswat N, Shankar P, Chopra A, Mitra B, Kumar S. Risk factors associated with head lice infestation in rural pediatric patients. Indian Dermatol Online J 2020;11:25-8.  Back to cited text no. 13
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Nejati J, Keyhani A, Tavakoli Kareshk A, Mahmoudvand H, Saghafipour A, Khoraminasab M, et al. Prevalence and risk factors of pediculosis in primary school children in South West of Iran. Iran J Public Health 2018;47:1923-9.  Back to cited text no. 14
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

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