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Infections and infestations Sexual health Skin and nail

Pubic lice

Last revised in February 2023

Pubic lice infestation is caused by the louse Phthirus pubis.Pubic lice are blood-sucking insects, and are obligate parasites of humans.

Pubic lice: Summary

  • Pubic lice infestation (pediculosis pubis) is caused by Phthirus pubis, an obligate, blood-sucking ectoparasite.
  • Transmission is usually through sexual contact. Occasionally, it may be spread by close personal contact or contact with articles, such as clothing, bedding, and towels that have been used by an infested person.
  • Pubic lice are usually found on pubic and perianal hairs, but they may occasionally be found on other coarse body hair, such as hair on the legs, armpits, chest, forearms, and face (including eyelashes). Lice found on the head are generally head lice, not pubic lice.
  • Complications of pubic lice infestation include:
    • Excoriation and infection of the skin (due to scratching).
    • Lichenification and hyperpigmentation of skin (in chronic infestation).
    • Blepharitis, conjunctivitis, or corneal epithelial keratitis (if the eyelashes are involved).
  • Pubic lice infestation commonly presents as genital itching, which is worse at night.
  • The diagnosis is confirmed if visible pubic lice ('crab'-shaped, tan to greyish-white in colour, and about 2 mm in length) or eggs (yellow-white in colour and smaller than a pinhead) are found on examination.
    • Small, blue macules (maculae cerulae) or red papules may be seen at feeding sites.
    • Rust-coloured flecks of faecal material deposited by the lice may be seen on the skin and underwear.
  • Management of pubic lice infestation in primary care involves:
    • Treating with an insecticide (permethrin or malathion).
    • Providing appropriate information and advice, including a detailed explanation of the condition, clear and accurate written information on applying the treatment, and information on measures to prevent transmission (such as decontamination of clothing and bedding and avoiding close body contact until treatment is successfully completed).
    • Considering the need for referral to a genito-urinary medicine (GUM) clinic for contact tracing and screening for other sexually transmitted infections.
    • Considering the possibility of sexual abuse in children with pubic lice. The presence of pubic lice in children is not necessarily an indicator of sexual abuse as they can be transmitted by non-genital bodily contact between close living companions. 
  • Follow up should be arranged 1 week after completion of treatment to ensure clearance of infestation.
    • If pubic lice infestation is unresponsive to initial insecticide treatment and the correct application technique has been used, an alternative insecticide should be used.
  • Advice should be sought from a specialist if:
    • Treatment fails despite the use of an alternative insecticide.
    • There is uncertainty about treatment.
    • The clinical picture is atypical or there is doubt about the diagnosis. 

Have I got the right topic?

From age 6 months onwards.

This CKS topic covers the diagnosis and management of pubic lice infestation in primary care.

There are separate CKS topics on Head lice and Scabies.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

February 2023 — reviewed. A literature search was conducted in December 2022 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. No major changes to the recommendations have been made.

Previous changes

February 2018 — reviewed. A literature search was conducted in November 2017 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials (RCTs) published since the last revision of this topic. No major changes to the recommendations have been made.

December 2011 — reviewed. A literature search was conducted in October 2011 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. This identified the United Kingdom National Guideline in the Management of Phthirus pubis infestation (2007) produced by the British Association of Sexual Health and HIV. Recommendations within this guideline are consistent with the current CKS topic; therefore, no changes to recommendations have been made. 

March 2011 — topic structure revised to ensure consistency across CKS topics. No changes to clinical recommendations have been made.

December 2007 — minor update to text. Malathion is now licensed for a second application after 7 days. (The recommendation for a second application of insecticide 7 days after the first is unlicensed for permethrin, and is different to the information supplied by the manufacturers: their package inserts state that a single application is sufficient.) 

February to May 2007 — converted from CKS guidance to CKS topic structure. The evidence base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence. There are no major changes to the recommendations.

August 2003 — reviewed. Validated in December 2003 and issued in February 2004.

November 2000 — rewritten. Validated in March 2001 and issued in June 2001.

June 1998 — reviewed.

September 1997 — written.

Update

New evidence

Evidence-based guidelines

No evidence-based guidelines since 1 December 2022.

HTAs (Health Technology Assessments)

No new HTAs since 1 December 2022.

Economic appraisals

No new economic appraisals relevant to England since 1 December 2022.

Systematic reviews and meta-analyses

No new systematic review or meta-analysis since 1 December 2022.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 December 2022.

New policies

No new national policies or guidelines since 1 December 2022.

New safety alerts

No new safety alerts since 1 December 2022.

Changes in product availability

No changes in product availability since 1 December 2022.

Goals and outcome measures

Goals

To support primary healthcare professionals to:

  • Identify pubic lice infestation.
  • Appropriately manage pubic lice infestation.
  • Give advice to prevent transmission of pubic lice to others.
  • Recognise the possibility of coexisting sexually transmitted infections and manage appropriately.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

No NICE quality standards were found during the review of this topic.

Background information

What is it?

  • Pubic lice infestation (pediculosis pubis) is caused by Phthirus pubis, an obligate, blood-sucking ectoparasite [Salavastru, 2017; Gunning, 2019; PCDS, 2021].
    • Pubic lice have three forms: egg (or nit), nymph, and adult [CDC, 2019; CDC, 2020]:
      • Eggs are laid on a hair shaft (by female lice) and take about 6–10 days to hatch. The eggs are oval-shaped, yellow-white in colour, and smaller than a pinhead. 
      • Nymphs are immature lice that hatch from eggs. After hatching, the nymphs undergo three moults before becoming adults; this takes about 2–3 weeks. Empty egg shells remain tightly attached to the hair.
      • Adult pubic lice are about 2 mm long, grey-white in colour, and have six legs. They are found only on the human host and require human blood to survive. If a louse falls off a person, it dies within 24–48 hours.
    • Pubic lice are usually found on pubic and perianal hairs, but they may occasionally be found on other coarse body hair, such as hair on the legs, armpits, chest, forearms, and face (including eyelashes). Lice found on the head are generally head lice, not pubic lice [CDC, 2020].
    • Pubic lice are also known as crab lice because of their 'crab'-like shape and the pincer-like claws on their second and third pair of legs (with which they attach to body hair) [NHS inform, 2022].
  • Pubic lice are usually spread through sexual contact. Occasionally, they may be spread by close personal contact or contact with articles, such as clothing, bedding, and towels that have been used by an infested person [CDC, 2019; CDC, 2021].  
    • Pubic lice move by crawling; they cannot hop or fly. 
    • Pets do not play a role in the transmission of human pubic lice.
    • Pubic lice do not transmit disease.

How common is it?

  • Pubic lice infestation is found worldwide and occurs in all races and ethnic groups and in all levels of society [CDC, 2019]. 
  • The incidence of pubic lice infestation has been estimated at 1.3–4.6% with an average of 2% worldwide [Dholakia, 2014].
  • Pubic hair removal has been associated with atypical patterns of pubic lice infestations and decreasing incidence of infection (due to the destruction of the natural habitat of the parasite) [Dholakia, 2014; CDC, 2021; PCDS, 2021].

What are the complications of pubic lice infestation?

  • Complications of pubic lice infestation include:
    • Excoriation and secondary bacterial skin infection (due to scratching).
    • Lichenification and hyperpigmentation of pruritic areas (in chronic infestation).
    • Conjunctivitis, blepharitis, or corneal epithelial keratitis (if the infestation involves the eyelashes).

[CDC, 2019; Gunning, 2019]

What is the prognosis?

  • Resolution of infestation is unlikely without active management.
    • A prospective cohort study (n = 8955) of people attending a sexually transmitted infections unit in Spain found that 7.6% had reinfestation following treatment. Reinfestations were more common in males than females [Varela, 2003].

Diagnosis of pubic lice

How should I assess a person with suspected pubic lice infestation?

  • Take a history.
    • Ask about the symptoms experienced.
      • Pubic lice infestation commonly presents as genital itching, which is worse at night.
      • The diagnosis is confirmed if visible pubic lice and/or eggs are found on examination.
    • Ascertain whether the infestation was acquired via sexual or non-sexual contact. If the infestation is thought to have been acquired through sexual contact, refer the person to a genito-urinary medicine (GUM) clinic (unless facilities and appropriate expertise are available locally) for:
  • Examine the person.
    • Look for:
      • Live lice ('crab'-shaped, grey-brown in colour, and about 2 mm in length) or eggs (yellow-white in colour and smaller than a pinhead). A dermatoscope, magnifying lens, or fine-toothed comb may aid identification.
      • Other clinical signs of infestation, such as small blue macules (maculae cerulae) and red papules at feeding sites.
      • Signs of secondary infections of the skin, such as impetigo or cellulitis.
      • Signs of chronic infestation, such as thickened or hyperpigmented skin.
      • Lice faeces (often visible as rust-coloured specks) on skin and underwear.
    • Examine other hairy areas of the body, as lice may colonize the eyebrows, eyelashes, beard, axillae, areolar hair, and scalp margins. In more severe cases, the hair on the trunk and limbs may also be affected.

Basis for recommendation

These recommendations are based on the United Kingdom National Guideline on the Management of Phthirus pubis infestation (2007) published by British Association of Sexual Health and HIV (BASHH) [BASHH, 2007], Sexually transmitted infections in primary care, a joint guideline by the Royal College of General Practitioners (RCGP) and BASHH [RCGP, 2013], the European guideline for the management of pediculosis pubis [Salavastru, 2017], the Centers for Disease Control and Prevention (CDC) publications Parasites: Pubic 'crab' lice [CDC, 2019] and Sexually transmitted diseases treatment guidelines, 2021. Ectoparasitic infections: pediculosis pubis [CDC, 2021], Pubic lice (syn. pediculosis pubis) published by the Primary Care Dermatology Society (PCDS) [PCDS, 2021], and on expert opinion in a review article [Gunning, 2019].

  • The itching associated with pubic lice infestation is a delayed hypersensitivity reaction, which may take 4–6 weeks to develop after the first exposure, with future exposures resulting in itching within 1–2 days [Gunning, 2019].

What else might it be?

Basis for recommendation

Information on the differential diagnoses of pubic lice is based on expert opinion in review articles [Chosidow, 2000; Flinders, 2004; Markova, 2014; Dadabhoy, 2015].

Management

Scenario: Management of pubic lice

From age 6 months onwards.

How is pubic lice infestation managed in primary care?

  • Prescribe a topical insecticide.
    • For lice on body areas other than the eyelashes, treat with permethrin 5% cream or malathion 0.5% aqueous solution.
    • For lice on eyelashes, treat with an inert occlusive ophthalmic ointment (such as simple eye ointment BP) or paraffin eye ointment, twice a day for 8–10 days. Alternatively, permethrin 1% lotion should be applied to the eyelashes, keeping the eyes closed during the application, and washed off after 10 minutes.
      • An inert occlusive ophthalmic ointment or paraffin eye ointment should be used for people under the age of 18 years and for those who are pregnant or breastfeeding.
      • Regular petrolatum (for example Vaseline®) should not be used because it can irritate the eyes.
  • Provide appropriate information and advice.
    • Give a detailed explanation of the condition and how it is transmitted. Patient information on pubic lice infestation is available from the NHS A-Z website.
    • Give clear and accurate written information on how to apply the treatment.
      • Ensure that the person is aware that treatment may fail if treatment instructions are not closely followed.
      • Explain that itching may persist for several days or weeks after treatment, especially if the skin is excoriated.
    • Advise on measures to prevent transmission, such as:
      • Decontamination of clothing and bedding by washing them in hot water (50oC or more). Items that cannot be laundered can be dry cleaned or stored in a sealed plastic bag for 2 weeks to kill the lice.
      • Avoiding close body contact and sharing of clothes, beddings, and personal hygiene products until the person (and their partner[s]) have successfully completed treatment.
  • If the infestation is thought to have been acquired through sexual contact, refer the person to a genito-urinary medicine (GUM) clinic (unless facilities and appropriate expertise are available locally) for:
  • Consider the possibility of sexual abuse in children with pubic lice. 
    • The presence of pubic lice in children is not necessarily an indicator of sexual abuse as they can be transmitted by non-genital bodily contact between close living companions. However, the possibility of sexual abuse should be considered and managed appropriately. For more information, see the CKS topic on Child maltreatment - recognition and management.
  • Re-examine the person 1 week after completion of treatment to ensure that all lice have been killed.
    • If live lice are seen at follow up, confirm whether the correct treatment technique has been used.
      • If the correct technique has not been used, repeat the previous treatment with the correct technique.
      • If the current technique has been used, treat with the alternative insecticide.
    • Note that dead nits can remain attached to hairs; this does not indicate treatment failure. Nits can be removed with a fine-tooth ‘nit’ comb.
  • Refer to (or discuss with) a GUM specialist if:
    • Treatment fails despite the use of an alternative regimen.
    • There is uncertainty about treatment.
    • The clinical picture is atypical or there is doubt about the diagnosis. 

Basis for recommendation

These recommendations are largely based on the United Kingdom National Guideline on the Management of Phthirus pubis infestation (2007) published by British Association of Sexual Health and HIV (BASHH) [BASHH, 2007], Sexually transmitted infections in primary care, a joint guideline by the Royal College of General Practitioners (RCGP) and BASHH [RCGP, 2013], the European guideline for the management of pediculosis pubis published by the European Academy of Dermatology and Venereology (EADV) [Salavastru, 2017], the Centers for Disease Control and Prevention (CDC) publications Parasites: Pubic 'crab' lice [CDC, 2019] and Sexually transmitted diseases treatment guidelines, 2021. Ectoparasitic infections: pediculosis pubis [CDC, 2021], Pubic lice (syn. pediculosis pubis) published by the Primary Care Dermatology Society (PCDS) [PCDS, 2021], and on expert opinion in a review article [Gunning, 2019].

Topical treatments
  • Permethrin 5% cream is licensed for the treatment of crab louse infestations in adults and children aged over 2 months of age [IPHA, 2021; BNF, 2023].
  • Malathion 0.5% aqueous solution is licensed for the treatment of crab louse infestation in adults and children aged 6 months and over [BNF, 2023].
  • Permethrin and malathion are widely recommended in the literature for the treatment of crab louse infestation. The EADV guideline recommends permethrin first line and malathion second line EADV [Salavastru, 2017].
Pregnancy and breastfeeding 
  • The UK Medicines Information (UKMi) recommends that malathion or permethrin topical preparations may be used to treat pubic lice infestations in breastfeeding mothers of full-term healthy infants. According to UKMi [UKMi, 2015]: 
    • Percutaneous absorption of malathion is about 4%, and it is rapidly destroyed by plasma cholinesterases.
    • Percutaneous absorption of permethrin is less than 2%, and it is rapidly metabolized to inactive metabolites and excreted in the urine.
    • The amount of either drug passing into milk after topical application would be too low to present a hazard to the breastfeeding infant.
  • The UK Teratology Information Service (UKTIS) reviewed the available pregnancy safety data on the use of malathion or permethrin for the treatment of scabies in pregnancy [UKTIS, 2018]. 
    • There was no evidence that either product posed an increased risk to the fetus; however, the data was too limited to state that there is no risk.
    • UKTIS concluded that:
      • Treatment of scabies should not be withheld due to pregnancy.
      • Exposure to topical malathion or permethrin at any stage in pregnancy would not usually be regarded as medical grounds for termination of pregnancy or any additional foetal monitoring.
      • Other risk factors may be present in individual cases which may independently increase the risk of adverse pregnancy outcome. Clinicians should consider such factors when performing case-specific risk assessments.
  • Clinical guidelines from BASHH [BASHH, 2007], the CDC [CDC, 2021], and the EADV [Salavastru, 2017] state that permethrin can be used in pregnancy and breastfeeding.
Treatment of lice on eyelashes
  • The BASHH, RCGP/BASHH, EADV, and PCDS guidelines recommend an inert occlusive ophthalmic ointment (such as simple eye ointment BP), paraffin eye ointment, or permethrin 1% lotion for infestations of the eyelashes [BASHH, 2007; RCGP, 2013; Salavastru, 2017; PCDS, 2021].
  • The CDC guidelines do not recommend permethrin 1% lotion but state that infestations of the eyelashes should be treated by applying occlusive ophthalmic ointment or ophthalmic-grade petrolatum ointment to the eyelid margins [CDC, 2019; CDC, 2021].
  • The British National Formulary (BNF) states that Lyclear® Creme Rinse (Permethrin 1% w/w) is 'less suitable for prescribing' [BNF, 2023].
  • Paraffin eye ointment works by suffocating adult lice and nymphs [RCGP, 2013; Salavastru, 2017].
    • An inert ophthalmic ointment with a white or yellow soft paraffin base provides a suitable consistency to produce this effect.
    • Inert ophthalmic ointments are preferred over topical ointments that are not formulated for use in the eyes because there is no risk of adverse effects should the ointment spread to the eye. In addition, ophthalmic ointments are sterile prior to use, reducing risk of eye infection.
    • Regular petrolatum (for example, Vaseline®) should not be used because it can irritate the eyes if applied [CDC, 2019].
Reapplying treatment 7–10 days of initial treatment
  • Persistent infestation is found in 40% of people 10 days after treatment and nit combing. Reapplication of treatment after 7–10 days can kill adult lice emerging from eggs that have survived the initial treatment [Salavastru, 2017].
Refer to genito-urinary medicine (GUM) if the infestation is thought to have been acquired through sexual contact
  • The CDC guidelines recommend treating sexual partners from the previous month [CDC, 2019; CDC, 2021], but the RCGP/BASHH, EADV, and PCDS guidelines recommend treating partners from the previous 3 months [RCGP, 2013; Salavastru, 2017; PCDS, 2021]. CKS recommends 3 months as it covers both recommendations.
  • Screening for other sexually transmitted infections (STIs), including HIV, is strongly recommended in people with pubic lice as concomitant STIs are present in 30% of infested individuals [Salavastru, 2017]. 
Considering sexual abuse in children with pubic lice infestation
  • The presence of pubic lice in children is not necessarily an indicator of sexual abuse as they can be transmitted by non-genital bodily contact between close living companions. However, the possibility of sexual abuse should be considered and managed appropriately [Salavastru, 2017].
Managing persistent infestation
  • Reported resistance to pediculicides (permethrin and pyrethrins) has been increasing and is widespread [CDC, 2021].
  • The RCGP/BASHH, EADV, and CDC guidelines recommend retreatment with an alternative regimen if live lice are seen at the 1 week follow up [RCGP, 2013; Salavastru, 2017; CDC, 2021].
  • However, the PCDS guideline recommends that if the initial treatment is unsuccesful, the previous treatment should be repeated with the correct technique (rather than switching to a different treatment). If insecticide resistance is suspected, an alternative insecticide (malathion or permethrin) should be used [PCDS, 2021].

Prescribing information

Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) or the British National Formulary (BNF).

Permethrin 5% cream

Licensed indication

  • Permethrin 5% cream is indicated for the treatment of crab louse infestations in adults and children aged over 2 months of age.

[ABPI, 2021a; BNF, 2023]

Contraindications and cautions

  • Children aged under 18 years should seek medical advice before using this product for the treatment of crab lice.
  • People aged over 70 years should be treated under medical supervision.
  • Contact with the eyes should be avoided.
  • The treatment:
    • Should not be used on broken or secondarily infected skin.
    • Should be used with caution during pregnancy and breastfeeding. See the section on Pregnancy and breastfeeding for more information.

[ABPI, 2021b; BNF, 2023]

Adverse effects

  • Common — paraesthesias, skin burning sensation, itching, erythema, and dry skin.
  • Very rare — skin hypopigmentation, excoriation, folliculitis, dyspnoea (in people with allergies/sensitivities).
  • Frequency unknown — urticaria.

[ABPI, 2021a; BNF, 2023]

Application technique

  • The cream should be applied over the whole body, allowed to dry naturally, and washed off after 8–12 hours or after leaving on overnight. 
  • Sufficient cream should be applied to cover the pubic region, peri-anal area, inner thighs down to the knees, and any hair on the trunk, which extends to the pubic area.
  • Any facial hair, except the eyelashes and eyebrows, should also be treated if found to be infested with lice or their eggs. See the section on Management for information on managing lice on eyelashes.
  • The treatment should be reapplied 7 days after initial application to ensure that lice emerging from surviving eggs are eradicated.
  • Lice eggs (nits) should be removed with a fine-tooth ‘nit’ comb.

[ABPI, 2021a; BNF, 2023]

Malathion 0.5% aqueous solution

Licensed indication

  • Malathion 0.5% aqueous solution is licensed for the treatment of crab louse infestation in adults and children aged 6 months and over.

[BNF, 2023]

Contraindications and cautions

  • Contact with the eyes should be avoided.
  • Exposure to heat (including hair dryers) should be avoided, as malathion products are potentially flammable.
  • The treatment:
    • Should not be used on broken or secondarily infected skin.
    • Should not be used more than once a week for 3 consecutive weeks.
    • Should be used with caution during pregnancy and breastfeeding. See the section on Pregnancy and breastfeeding for more information.

[BNF, 2023]

Adverse effects

  • Angioedema.
  • Eye swelling.
  • Hypersensitivity.
  • Skin reactions.

[BNF, 2023]

Application technique

  • The treatment should be applied over the whole body, allowed to dry naturally, and washed off after 12 hours or overnight.
  • Sufficient cream should be applied to cover the pubic region, peri-anal area, inner thighs down to the knees, and any hair on the trunk which extends to the pubic area Salavastru, 2017.
  • Any facial hair, except the eyelashes and eyebrows, should also be treated if found to be infested with lice or their eggs. See the section on Management for information on managing lice on eyelashes.
  •  The treatment should be reapplied 7 days after initial application to ensure that lice emerging from surviving eggs are eradicated.
  • Lice eggs (nits) should be removed with a fine-tooth ‘nit’ comb.

[BNF, 2023]

Supporting evidence

This CKS topic is largely based on the United Kingdom National Guideline on the Management of Phthirus pubis infestation (2007) published by the British Association of Sexual Health and HIV (BASHH) [BASHH, 2007], Sexually transmitted infections in primary care, a joint guideline by the Royal College of General Practitioners (RCGP) and BASHH [RCGP, 2013], the European guideline for the management of pediculosis pubis published by the European Academy of Dermatology and Venereology (EADV) [Salavastru, 2017], the Centers for Disease Control and Prevention (CDC) publications Parasites: Pubic 'crab' lice [CDC, 2019] and Sexually transmitted diseases treatment guidelines, 2021. Ectoparasitic infections: pediculosis pubis [CDC, 2021], and Pubic lice (syn. pediculosis pubis) published by the Primary Care Dermatology Society (PCDS) [PCDS, 2021].

The rationale for the primary care assessment and management of pubic lice infestation is discussed in the relevant basis for recommendation sections.

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of pubic lice.

Search dates

November 2017 - December 2022

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

  • exp Lice infestations/, exp Phthirus/, public lice.tw., phthirus pubis.tw.

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
  • Consistency with other providers of clinical knowledge for primary care.
  • Accuracy of implementation of national guidance (in particular NICE guidelines).
  • Usability.

Principles of the consultation process

  • The process is inclusive and any individual may participate.
  • To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
  • Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
  • Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
  • External reviewers are not paid for commenting on the draft topics.
  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
  • All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
  • All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

  • Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
  • Stakeholders identified from the following groups are invited to review draft topics:
    • Experts in the topic area.
    • Professional organizations and societies (for example, Royal Colleges).
    • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
    • Guideline development groups where the topic is an implementation of a guideline.
    • The British National Formulary team.
    • The editorial team that develop MeReC Publications.
  • Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

  • Topic selection
  • Scoping of topic
  • Selection of clinical scenarios
  • First draft internal review
  • Second draft internal review
  • External review
  • Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
    • Likely uptake of new intervention or recommendation
    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
  • Personal family interest
  • Personal non-financial interest
  • Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

References

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  • ABPI (2021b) SPC for Permethrin 5% w/w Cream. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
  • BASHH (2007) United Kingdom national guideline on the management of Phthirus pubis infestation (2007). British Association of Sexual Health and HIV, Clinical Effectiveness Group. http://www.bashh.org [Free Full-text]
  • BNF (2023) British National Formulary. National Institute for Health and Care Excellence. https://bnf.nice.org.uk
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  • CDC (2020) Parasites: Pubic 'crab' lice - Frequently Asked Questions (FAQs). Centers for Disease Control and Prevention. http://www.cdc.gov [Free Full-text]
  • CDC (2021) Sexually Transmitted Infections Treatment Guidelines, 2021: Pediculosis Pubis. Centers for Disease Control and Prevention. http://www.cdc.gov [Free Full-text]
  • Chosidow, O. (2000) Scabies and pediculosis. Lancet 355(9206), 819-826. [Abstract]
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  • Flinders, D.C. and De Schweinitz, P. (2004) Pediculosis and scabies. American Family Physician 69(2), 341-350. [Abstract]
  • Gunning, K., Kiraly, B. and Pippitt, K (2019) Lice and scabies: treatment update. American Family Physician 99(10), 635-642. [Abstract]
  • IPHA (2021) SPC for Lyclear 5% w/w Dermal Cream. Medicines.ie. http://www.medicines.ie [Free Full-text]
  • Markova, A., Kam, S.A., Miller, D.D. and Lichtman, M.K. (2014) In the Clinic. Common cutaneous parasites. Annals of Internal Medicine 161(5). [Abstract]
  • NHS inform (2022) Pubic lice. NHS inform. http://www.nhsinform.scot [Free Full-text]
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  • RCGP (2013) Sexually transmitted infections in primary care. Royal College of General Practitioners. http://www.rcgp.org.uk [Free Full-text]
  • Salavastru, C.M., Chosidow, O., Janier, M. and Tiplica, G.S. (2017) European guideline for the management of pediculosis pubis. Journal of the European Academy of Dermatology and Venereology 31(9), 1425-1428. [Abstract]
  • UKMi (2015) How should pubic lice be treated in a breastfeeding mother. UK Medicines Information Service. [Free Full-text]
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  • Varela JA, Otero L, Espinosa E, Sánchez C, Junquera ML, Vázquez F (2003) Phthirus pubis in a sexually transmitted diseases unit: a study of 14 years. Sexually Transmitted Disease 30(4), 292-296.
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