We found one systematic review that evaluated louse removal by combing compared with insecticide treatment, but none evaluating nit combing to remove eggs. Three studies compared the effectiveness of insecticide treatments and wet combing with conditioner. The first, a community-based pragmatic RCT (72 people) included in the systematic review, compared "bug-busting" (wet combing with conditioner) with two applications of 0-5% malathion 7 days apart.20 Seven days after treatment, fewer people using malathion had lice compared with those using "bug-busting" (9/40 (23%) versus 20/32 (63%); RR 1-27, CI 0-2-0-7; NNT 3, CI 2-5). A second small RCT, in which a trained hairdresser performed the first combing treatment or applied the insecticide product, compared a single application of permethrin (1% crème rinse) with "bug-busting".21 After 14 days more people treated with permethrin still had lice

(8/11 (73%) versus 8/14 (57%); RR 1-27, CI 0-7-2-3; NNT 6, CI 0-4-1-4). An unpublished community-based pragmatic RCT (275 people), (SSL International, personal communication, 1998) compared single applications of phenothrin 0-2% lotion with both phenothrin 0-5% mousse and "bug-busting" in an area where resistance to pyrethroid insecticides was subsequently identified. Insecticide treatments were assessed at 4, 7, 10 and 14 days, with the primary endpoint determined at 14 days, and combing was assessed at 14, 21 and 28 days with the primary endpoint determined either after 28 days or if lice were discovered earlier. Fewer people treated with phenothrin lotion still had lice when compared with those treated with phenothrin mousse (77/107 (72%) versus 84/105 (80%); RR 0-9, CI 0-8-1-0; NNT 12, CI 1-1-3) and those using "bug-busting" (77/107 (72%) versus 49/63 (78%); RR 0-9, CI 0-8-1-1; NNT 17, CI 0-9-1-3). Analysis of ovicidal failure showed that if a second application of insecticide had been given after 7 days the effectiveness of the lotion would have increased compared with both mousse (45/107 (42%) versus 74/105 (71%); RR 0-6, CI 0-5-0-8; NNT 4, CI 1-3-2-2) and "bug-busting" (45/107 (42%) versus 49/63 (78%); RR 0-54, CI 0-4-0-7; NNT 3, CI 1-4-2-4). We found four RCTs comparing different pediculicides in combination with nit combing, but only one included a non-combing control group and none included a combing-only group.22-24 All had significant methodological flaws.

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