ORIGINAL STUDY
Pubic Lice: An Endangered Species? Shamik Dholakia, Jonathan Buckler, John Paul Jeans, Andrew Pillai, Natasha Eagles, and Shruti Dholakia Abstract: The incidence of pubic lice infestations is estimated to be between 1.3% and 4.6%, with an average incidence of 2% worldwide. It is also estimated that 70% to 80% of adults now remove pubic hair in part or entirety, using a variety of methods. It is hypothesized that the destruction of this pubic hair habitat may account for the falling incidence of pubic lice and may possibly lead to its eradication or atypical presentation. Aim: To report the changing incidence of pubic lice infestation from our unit over the last 10 years and assess its association, if any, with pubic hair removal of any kind. Methods: Assessment of medical records and questionnaires were used to identify the incidence of hair removal and pubic lice infestation over a 10-year period. Data were anonymized and analyzed to identify any correlation. Results: A significant and strong correlation between the falling incidence of pubic lice infections and increase in pubic hair removal was observed, with a Pearson correlation r value of 0.9686 (95% confidence intervals, 0.88Y0.992). The P value is less than 0.0001. Conclusions: The increased incidence of hair removal may lead to atypical patterns of pubic lice infestations or its complete eradication as the natural habitat of this parasite is destroyed.
P
hthirus pubis infestations commonly known as ‘‘crabs’’ are found worldwide. Pubic lice usually are spread through sexual contact but occasionally may be spread by close personal contact or contact with articles such as clothing, bed linens, and towels that have been used by an infected person.1,2 Typically, pubic lice cause itching in the area covered by pubic hair, which can develop into erythematous sore lesions due to scratching of bites. Similar to head lice, these egg-laying blood-sucking lice are effectively treated with permethrin and deep cleaning of all materials to eliminate any egg stores. When pubic lice are unable to find a suitable place to lay eggs, it ends their lifecycle.3 The incidence of pubic lice infestations is estimated to be between 1.3% and 4.6%, with an average incidence of 2% worldwide.4,5 It is estimated that 70% to 80% of adults now remove pubic hair in part or entirety.5Y7 There are various methods and degrees of hair removal available, thought to offer comfort and cleanliness to its users. There is also some evidence to suggest that the destruction of this pubic hair habitat may account for the falling incidence From the Milton Keynes General Hospital, Standing Way, Eaglestone, Milton Keynes, Buckinghamshire, UK.
All authors collected data. S.D. wrote the first draft of the manuscript. All authors contributed to the manuscript. Local ethics approval was given; patients gave written consent to data being used, which was all anonymized. No funding was necessary, and we declare no competing interests. Correspondence: Shamik Dholakia, MRCS, MBBS, BSc, Milton Keynes General Hospital, Standing, Way Eaglestone, Milton Keynes, Buckinghamshire, UK. E-mail: [email protected]. Received for publication February 1, 2014, and accepted April 9, 2014. DOI: 10.1097/OLQ.0000000000000142 Copyright * 2014 American Sexually Transmitted Diseases Association All rights reserved.
388
of pubic lice and may possibly lead to its eradication or atypical presentation.8Y10
AIM To report the changing incidence of pubic lice infestation from our unit over the last 10 years and assess its association if any with pubic hair removal of any kind.
METHODS Medical records of patients with confirmed pubic lice infestation were reviewed from our unit. All data were anonymized and local ethics approval was granted. The date range August 2003 to August 2013 was selected. Five hundred randomly allocated anonymous questionnaires were sent out to all clinic visitors regardless of diagnosis, from each year to ascertain whether they had any pubic hair removal. In total, 5000 questionnaires over the 10-year period were sent out. Four questions were asked: 1. Do you or did you ever remove any of your pubic hair? 1. Yes 2. No 2. How much is removed? 1. Total 2. Partial 3. None but trimmed 4. None 3. What was the reason for this? 1. Cosmesis 2. Hygiene 3. Religious reasons 4. Other 4. What method of hair removal do you use Y you can select more than one? 1. Shaving 2. Trimming 3. Waxing 4. Laser 5. Chemical Cream/Gel 6. Other
STATISTICAL ANALYSIS IBM SPSS Statistics 22.0 was used for statistical analysis to compare the changing incidence of pubic lice infestation and hair removal using Pearson rank correlation coefficient and appropriate W2 tests.
DEMOGRAPHICS For demographic data, refer to Tables 1 and 2.
RESULTS Seventy-seven percent (3850) of our patients returned questionnaire of the 5000 initially sent out. When reviewing the incidence rates over the 10-year period, we found that the incidence of pubic lice has continually fallen from 1.82% to 0.07% (Fig. 1). When comparing the incidence of infection between 2003 and 2013, using the W2 test for association with Yates correction, we found a P value less than 0.001, suggesting a strongly significant decrease in incidence. Among patients who had confirmed pubic lice infections, when reviewing their records, we found that 94.21% of these patients had documented records suggesting no pubic hair removal. We also observed that the overall incidence of pubic hair removal has increased from 33.2% to 87.1% over the same 10-year
Sexually Transmitted Diseases
&
Volume 41, Number 6, June 2014
Copyright © 2014 by the American Sexually Transmitted Diseases Association. Unauthorized reproduction of this article is prohibited.
Pubic Lice: An Endangered Species?
TABLE 1.
Showing Demographics
Median patient age (range), t Sex (male/female), % Ethnicity (white/European:Asian: African/Afro-Caribbean), %
24.32 (14.87Y52.14) 47.24:52.76 78.34:6.82:14.84
period (Fig. 2). When comparing the hair removal incidence between 2003 and 2013, using the same W2 test with Yates correction, we found a P value less than 0.001, suggesting, again, a significant increase. The comparison of these 2 observations is shown in Figure 3, where we can clearly identify a highly significant and strong correlation between the falling incidence of pubic lice infections and increase in pubic hair removal. Pearson correlation gives an r value of 0.9686 (95% confidence intervals, 0.88Y0.992) and has a P value less than 0.0001. Our questionnaire aimed to identify reasons and methods of hair removal. Figure 4 shows that the reasons for hair removal from our population were only identified as follows: hygiene and cosmesis. The Pearson correlation coefficient r values were 0.9719 (95% confidence intervals, 0.953Y0.992) for cosmesis and 0.9781 (95% confidence intervals, 0.932Y0.9813) for hygiene, both of these correlations have been shown to be significant, with P value less than 0.001. Our population suggests that shaving remains the most common method of hair removal (mean, 70.36%). Waxing and laser hair removal have become increasingly popular, whereas trimming and chemical methods are less popular, as seen in Figure 6. The pattern of hair removal has also changed during our observed period. In 2003, 56.38% of patients had no hair removal, which dropped to 12.45% in 2013. The incidence of both total hair removal and partial hair removal has increased from 19.21% to 31.23% and from 23.57% to 56.32%, respectively (Fig. 6). The Pearson correlation coefficients were used to identify the strength of linear relationships when charting the amount of hair removal. Total hair removal has a Pearson correlation coefficient r value of 0.966 (95% confidence intervals, 0.913Y0.972), with a P value less than 0.0001. Partial hair removal has a Pearson correlation coefficient r value of 0.918 (95% confidence intervals, 0.892Y0.926), with a P value of 0.001. No hair removal has a Pearson correlation coefficient r value of 0.910 (95% confidence intervals, 0.903Y0.928), with a P value less than 0.0001,
TABLE 2.
Figure 1. The changing incidence of patients affected with confirmed pubic lice infections over the 10-year period.
and finally, trimmed pubic hair has a Pearson correlation coefficient r value of 0.536 (95% confidence, intervals 0.523Y0.541), with a P value of 0.721.
DISCUSSION Over the examined 10-year period, we have found a clear and significant decrease in the incidence of pubic lice infestation from our unit. Figure 1 shows the incidence falling from 1.82% in 2003 to 0.07% in 2013 (P G 0.001). During that same period, Figure 2 highlights a significant increase in the incidence of pubic hair removal, increasing from 33.2% in 2003 to 87.1% in 2013 (P G 0.001). Figure 3 demonstrates a strongly significant linear correlation between these 2 variables, with a Pearson correlation r value of 0.9686 (95% confidence intervals, 0.88 to 0.992) and a P value less than 0.0001. These results support the hypothesis that increased incidence in pubic hair removal is associated with the falling incidence of pubic lice infections and expands on the work of previous studies that have drawn similar conclusions that without pubic hair being present, it is difficult to establish infection.9,10 The reasons for pubic hair removal are many; however, within our sample, cosmesis and hygiene were the only 2 reasons identified (see Fig. 4). Cosmesis over the 10-year period has shown a strong positive correlation, having an r value of 0.9719 (95% confidence intervals, 0.953Y0.992) and a P value less than 0.001.
Absolute Numbers of Cases and Male/Female
Ratios (M:F)
Year
Total No. Pediculosis Pubis Cases Identified (M:F)
No. Identified Pubic Depilation Cases Based on Annual Sample (M:F)
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Total
453 (215:238) 421 (216:205) 407 (213:194) 331 (184:147) 217 (135:82) 145 (101:44) 51 (37:14) 33 (27:6) 27 (25:2) 22 (18:4) 17 (14:3) 2124 (1185:939)
127 (16:111) 196 (34:162) 214 (40:174) 244 (57:187) 282 (73:209) 293 (78:215) 295 (88:207) 298 (78:220) 310 (93:217) 328 (102:226) 335 (107:228) 2922 (766:2156)
Sexually Transmitted Diseases
&
Figure 2. The changing incidence of hair removal within our patient group.
Volume 41, Number 6, June 2014
389
Copyright © 2014 by the American Sexually Transmitted Diseases Association. Unauthorized reproduction of this article is prohibited.
Dholakia et al.
Figure 3. Correlation between pubic lice infection and pubic hair removal.
Figure 5. The changing pattern of hair removal.
We can hypothesize that the reason for this may be due to the increased media coverage. The use of magazines, celebrities, and chat shows, promoting openness of pubic hair removal, has made it fashionable. With numerous patterns and styles being advertised, it is clear that it has gained in popularity.7 The mean age of patients within our sample was 24.32 years. We hypothesize that this age group of people is composed of those who are most influenced by what society may regard as ‘‘cool’’ and so are likely to be influenced by these media campaigns regarding pubic hair removal. This is supported by the increase in both total hair removal (r = 0.966 [95% confidence intervals, 0.913Y0.972; P G 0.0001) and partial hair removal (r = 0.918 [95% confidence intervals, 0.892Y0.926; P = 0.001) over this period (see Fig. 5). The incidence of no hair removal has also shown a strong negative linear correlation over the same period, with an r value of 0.910 (95% confidence intervals, 0.903Y0.928; P G 0.0001), suggesting that it is significantly less popular. Throughout all the years, our data suggest that pubic hair removal remains more common in women than in men, although the proportion of men undertaking some sort of hair removal is increasing. We also noted that although overall pubic lice infections reduced, there was a shift from it being relatively
evenly distributed between the sexes to it becoming more prevalent in men (see Table 2). This may be due to the reduced amount of hair removal proportionally when compared with women, again supporting the hypotheses and previous work.9,10 Figure 6 shows the several methods of hair removal identified from our study population. The most popular of these remains shaving, with a mean 70.36% of patients using this method. Despite the increasing incidence of waxing and laser use, we believe that the popularity of shaving is due to the costeffectiveness offered by this method. Specific cost analysis was out of the scope of this study, but it is an important factor that may influence the method chosen to remove pubic hair. The limitations of our study are that we have used correlations to show associations and so are limited because these do not prove that casual relationships exist between our variables. However, the correlations are very strong and have narrow confidence intervals, and so we feel that there may be a significant relationship between hair removal and incidence of lice infection if further studies were done. The second limitation is that of recall bias regarding hair removal, as we were reliant on the answers provided by our questionnaires, which may not be truly representative. This must also be considered in the context of a wider population, as our
Figure 4. The reasons for hair removal.
Figure 6. Methods of hair removal.
390
Sexually Transmitted Diseases
&
Volume 41, Number 6, June 2014
Copyright © 2014 by the American Sexually Transmitted Diseases Association. Unauthorized reproduction of this article is prohibited.
Pubic Lice: An Endangered Species?
sample was mainly a young white group, and so our conclusions may not hold true in areas where this is not the case. The exact causal relationship would be better demonstrated using a case-control study. However, this study logistically provides more challenges because it, too, is also prone to recall bias and can have difficulty in establishing a temporal relationship between exposure and outcome.
CONCLUSIONS Pubic lice infestations are in decline, and there is a growing body of evidence that it is associated with the increased incidence in removal of pubic hair. As culture and practice changes, we may see a changing atypical pattern of pubic lice infestations, as they try to colonize other habitats such as chest or eyebrow hair. We may even see its complete eradication and no longer have patients presenting with pubic lice, within the sexual health setting. REFERENCES 1. Burkhart CN, Burkhart CG, Morrell DS. Infestations. In: Bolognia JL, Jorizzo JL, Schaffer JV, et al., eds. Dermatology. 3rd ed. Philadelphia, Pa: Mosby Elsevier, 2012:chap 84.
Sexually Transmitted Diseases
&
2. Centers for Disease Control and Prevention. Factsheet on Parasites, Pubic LiceVSeptember 2013. 3. Diaz JH. Lice (pediculosis). In: Mandell GL, Bennett JE, Dolin R, editors. Mendell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases. 7th ed. Philadelphia, PA: Churchill Livingstone Elsevier, 2009:chap 293. 4. Bignell C. Lice and scabies. Medicine 2005; 33:76Y77. 5. Varela JA, Otero L, Espinosa E, et al. Phthirus pubis in a sexually transmitted diseases unit: A study of 14 years. Sex Transm Dis 2003; 30:292Y296. 6. Bercaw-Pratt JL, Santos XM, Sanchez J, et al. The incidence, attitudes and practices of the removal of pubic hair as a body modification. J Pediatr Adolesc Gynecol 2012; 25:12Y14. 7. Smolak L, Murnen S. Gender, self-objection and pubic hair removal. Sex Roles 2011; 65:506Y517. 8. Gale J, Pettypiece S. Brazilian bikini waxes make crab lice endangered species. Bloomburg News 2013. 9. Armstrong NR, Wilson JD. Did the Brazilian kill the pubic louse. Sex Trans Infect 2006; 82:265Y266. 10. Portman M. The Brazilian Hasn’t Killed the Pubic LouseIBut It’s A Close Shave. Leeds, UK.
Volume 41, Number 6, June 2014
391
Copyright © 2014 by the American Sexually Transmitted Diseases Association. Unauthorized reproduction of this article is prohibited.
Pubic Lice: An Endangered Species? Shamik Dholakia, Jonathan Buckler, John Paul Jeans, Andrew Pillai, Natasha Eagles, and Shruti Dholakia Abstract: The incidence of pubic lice infestations is estimated to be between 1.3% and 4.6%, with an average incidence of 2% worldwide. It is also estimated that 70% to 80% of adults now remove pubic hair in part or entirety, using a variety of methods. It is hypothesized that the destruction of this pubic hair habitat may account for the falling incidence of pubic lice and may possibly lead to its eradication or atypical presentation. Aim: To report the changing incidence of pubic lice infestation from our unit over the last 10 years and assess its association, if any, with pubic hair removal of any kind. Methods: Assessment of medical records and questionnaires were used to identify the incidence of hair removal and pubic lice infestation over a 10-year period. Data were anonymized and analyzed to identify any correlation. Results: A significant and strong correlation between the falling incidence of pubic lice infections and increase in pubic hair removal was observed, with a Pearson correlation r value of 0.9686 (95% confidence intervals, 0.88Y0.992). The P value is less than 0.0001. Conclusions: The increased incidence of hair removal may lead to atypical patterns of pubic lice infestations or its complete eradication as the natural habitat of this parasite is destroyed.
P
hthirus pubis infestations commonly known as ‘‘crabs’’ are found worldwide. Pubic lice usually are spread through sexual contact but occasionally may be spread by close personal contact or contact with articles such as clothing, bed linens, and towels that have been used by an infected person.1,2 Typically, pubic lice cause itching in the area covered by pubic hair, which can develop into erythematous sore lesions due to scratching of bites. Similar to head lice, these egg-laying blood-sucking lice are effectively treated with permethrin and deep cleaning of all materials to eliminate any egg stores. When pubic lice are unable to find a suitable place to lay eggs, it ends their lifecycle.3 The incidence of pubic lice infestations is estimated to be between 1.3% and 4.6%, with an average incidence of 2% worldwide.4,5 It is estimated that 70% to 80% of adults now remove pubic hair in part or entirety.5Y7 There are various methods and degrees of hair removal available, thought to offer comfort and cleanliness to its users. There is also some evidence to suggest that the destruction of this pubic hair habitat may account for the falling incidence From the Milton Keynes General Hospital, Standing Way, Eaglestone, Milton Keynes, Buckinghamshire, UK.
All authors collected data. S.D. wrote the first draft of the manuscript. All authors contributed to the manuscript. Local ethics approval was given; patients gave written consent to data being used, which was all anonymized. No funding was necessary, and we declare no competing interests. Correspondence: Shamik Dholakia, MRCS, MBBS, BSc, Milton Keynes General Hospital, Standing, Way Eaglestone, Milton Keynes, Buckinghamshire, UK. E-mail: [email protected]. Received for publication February 1, 2014, and accepted April 9, 2014. DOI: 10.1097/OLQ.0000000000000142 Copyright * 2014 American Sexually Transmitted Diseases Association All rights reserved.
388
of pubic lice and may possibly lead to its eradication or atypical presentation.8Y10
AIM To report the changing incidence of pubic lice infestation from our unit over the last 10 years and assess its association if any with pubic hair removal of any kind.
METHODS Medical records of patients with confirmed pubic lice infestation were reviewed from our unit. All data were anonymized and local ethics approval was granted. The date range August 2003 to August 2013 was selected. Five hundred randomly allocated anonymous questionnaires were sent out to all clinic visitors regardless of diagnosis, from each year to ascertain whether they had any pubic hair removal. In total, 5000 questionnaires over the 10-year period were sent out. Four questions were asked: 1. Do you or did you ever remove any of your pubic hair? 1. Yes 2. No 2. How much is removed? 1. Total 2. Partial 3. None but trimmed 4. None 3. What was the reason for this? 1. Cosmesis 2. Hygiene 3. Religious reasons 4. Other 4. What method of hair removal do you use Y you can select more than one? 1. Shaving 2. Trimming 3. Waxing 4. Laser 5. Chemical Cream/Gel 6. Other
STATISTICAL ANALYSIS IBM SPSS Statistics 22.0 was used for statistical analysis to compare the changing incidence of pubic lice infestation and hair removal using Pearson rank correlation coefficient and appropriate W2 tests.
DEMOGRAPHICS For demographic data, refer to Tables 1 and 2.
RESULTS Seventy-seven percent (3850) of our patients returned questionnaire of the 5000 initially sent out. When reviewing the incidence rates over the 10-year period, we found that the incidence of pubic lice has continually fallen from 1.82% to 0.07% (Fig. 1). When comparing the incidence of infection between 2003 and 2013, using the W2 test for association with Yates correction, we found a P value less than 0.001, suggesting a strongly significant decrease in incidence. Among patients who had confirmed pubic lice infections, when reviewing their records, we found that 94.21% of these patients had documented records suggesting no pubic hair removal. We also observed that the overall incidence of pubic hair removal has increased from 33.2% to 87.1% over the same 10-year
Sexually Transmitted Diseases
&
Volume 41, Number 6, June 2014
Copyright © 2014 by the American Sexually Transmitted Diseases Association. Unauthorized reproduction of this article is prohibited.
Pubic Lice: An Endangered Species?
TABLE 1.
Showing Demographics
Median patient age (range), t Sex (male/female), % Ethnicity (white/European:Asian: African/Afro-Caribbean), %
24.32 (14.87Y52.14) 47.24:52.76 78.34:6.82:14.84
period (Fig. 2). When comparing the hair removal incidence between 2003 and 2013, using the same W2 test with Yates correction, we found a P value less than 0.001, suggesting, again, a significant increase. The comparison of these 2 observations is shown in Figure 3, where we can clearly identify a highly significant and strong correlation between the falling incidence of pubic lice infections and increase in pubic hair removal. Pearson correlation gives an r value of 0.9686 (95% confidence intervals, 0.88Y0.992) and has a P value less than 0.0001. Our questionnaire aimed to identify reasons and methods of hair removal. Figure 4 shows that the reasons for hair removal from our population were only identified as follows: hygiene and cosmesis. The Pearson correlation coefficient r values were 0.9719 (95% confidence intervals, 0.953Y0.992) for cosmesis and 0.9781 (95% confidence intervals, 0.932Y0.9813) for hygiene, both of these correlations have been shown to be significant, with P value less than 0.001. Our population suggests that shaving remains the most common method of hair removal (mean, 70.36%). Waxing and laser hair removal have become increasingly popular, whereas trimming and chemical methods are less popular, as seen in Figure 6. The pattern of hair removal has also changed during our observed period. In 2003, 56.38% of patients had no hair removal, which dropped to 12.45% in 2013. The incidence of both total hair removal and partial hair removal has increased from 19.21% to 31.23% and from 23.57% to 56.32%, respectively (Fig. 6). The Pearson correlation coefficients were used to identify the strength of linear relationships when charting the amount of hair removal. Total hair removal has a Pearson correlation coefficient r value of 0.966 (95% confidence intervals, 0.913Y0.972), with a P value less than 0.0001. Partial hair removal has a Pearson correlation coefficient r value of 0.918 (95% confidence intervals, 0.892Y0.926), with a P value of 0.001. No hair removal has a Pearson correlation coefficient r value of 0.910 (95% confidence intervals, 0.903Y0.928), with a P value less than 0.0001,
TABLE 2.
Figure 1. The changing incidence of patients affected with confirmed pubic lice infections over the 10-year period.
and finally, trimmed pubic hair has a Pearson correlation coefficient r value of 0.536 (95% confidence, intervals 0.523Y0.541), with a P value of 0.721.
DISCUSSION Over the examined 10-year period, we have found a clear and significant decrease in the incidence of pubic lice infestation from our unit. Figure 1 shows the incidence falling from 1.82% in 2003 to 0.07% in 2013 (P G 0.001). During that same period, Figure 2 highlights a significant increase in the incidence of pubic hair removal, increasing from 33.2% in 2003 to 87.1% in 2013 (P G 0.001). Figure 3 demonstrates a strongly significant linear correlation between these 2 variables, with a Pearson correlation r value of 0.9686 (95% confidence intervals, 0.88 to 0.992) and a P value less than 0.0001. These results support the hypothesis that increased incidence in pubic hair removal is associated with the falling incidence of pubic lice infections and expands on the work of previous studies that have drawn similar conclusions that without pubic hair being present, it is difficult to establish infection.9,10 The reasons for pubic hair removal are many; however, within our sample, cosmesis and hygiene were the only 2 reasons identified (see Fig. 4). Cosmesis over the 10-year period has shown a strong positive correlation, having an r value of 0.9719 (95% confidence intervals, 0.953Y0.992) and a P value less than 0.001.
Absolute Numbers of Cases and Male/Female
Ratios (M:F)
Year
Total No. Pediculosis Pubis Cases Identified (M:F)
No. Identified Pubic Depilation Cases Based on Annual Sample (M:F)
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Total
453 (215:238) 421 (216:205) 407 (213:194) 331 (184:147) 217 (135:82) 145 (101:44) 51 (37:14) 33 (27:6) 27 (25:2) 22 (18:4) 17 (14:3) 2124 (1185:939)
127 (16:111) 196 (34:162) 214 (40:174) 244 (57:187) 282 (73:209) 293 (78:215) 295 (88:207) 298 (78:220) 310 (93:217) 328 (102:226) 335 (107:228) 2922 (766:2156)
Sexually Transmitted Diseases
&
Figure 2. The changing incidence of hair removal within our patient group.
Volume 41, Number 6, June 2014
389
Copyright © 2014 by the American Sexually Transmitted Diseases Association. Unauthorized reproduction of this article is prohibited.
Dholakia et al.
Figure 3. Correlation between pubic lice infection and pubic hair removal.
Figure 5. The changing pattern of hair removal.
We can hypothesize that the reason for this may be due to the increased media coverage. The use of magazines, celebrities, and chat shows, promoting openness of pubic hair removal, has made it fashionable. With numerous patterns and styles being advertised, it is clear that it has gained in popularity.7 The mean age of patients within our sample was 24.32 years. We hypothesize that this age group of people is composed of those who are most influenced by what society may regard as ‘‘cool’’ and so are likely to be influenced by these media campaigns regarding pubic hair removal. This is supported by the increase in both total hair removal (r = 0.966 [95% confidence intervals, 0.913Y0.972; P G 0.0001) and partial hair removal (r = 0.918 [95% confidence intervals, 0.892Y0.926; P = 0.001) over this period (see Fig. 5). The incidence of no hair removal has also shown a strong negative linear correlation over the same period, with an r value of 0.910 (95% confidence intervals, 0.903Y0.928; P G 0.0001), suggesting that it is significantly less popular. Throughout all the years, our data suggest that pubic hair removal remains more common in women than in men, although the proportion of men undertaking some sort of hair removal is increasing. We also noted that although overall pubic lice infections reduced, there was a shift from it being relatively
evenly distributed between the sexes to it becoming more prevalent in men (see Table 2). This may be due to the reduced amount of hair removal proportionally when compared with women, again supporting the hypotheses and previous work.9,10 Figure 6 shows the several methods of hair removal identified from our study population. The most popular of these remains shaving, with a mean 70.36% of patients using this method. Despite the increasing incidence of waxing and laser use, we believe that the popularity of shaving is due to the costeffectiveness offered by this method. Specific cost analysis was out of the scope of this study, but it is an important factor that may influence the method chosen to remove pubic hair. The limitations of our study are that we have used correlations to show associations and so are limited because these do not prove that casual relationships exist between our variables. However, the correlations are very strong and have narrow confidence intervals, and so we feel that there may be a significant relationship between hair removal and incidence of lice infection if further studies were done. The second limitation is that of recall bias regarding hair removal, as we were reliant on the answers provided by our questionnaires, which may not be truly representative. This must also be considered in the context of a wider population, as our
Figure 4. The reasons for hair removal.
Figure 6. Methods of hair removal.
390
Sexually Transmitted Diseases
&
Volume 41, Number 6, June 2014
Copyright © 2014 by the American Sexually Transmitted Diseases Association. Unauthorized reproduction of this article is prohibited.
Pubic Lice: An Endangered Species?
sample was mainly a young white group, and so our conclusions may not hold true in areas where this is not the case. The exact causal relationship would be better demonstrated using a case-control study. However, this study logistically provides more challenges because it, too, is also prone to recall bias and can have difficulty in establishing a temporal relationship between exposure and outcome.
CONCLUSIONS Pubic lice infestations are in decline, and there is a growing body of evidence that it is associated with the increased incidence in removal of pubic hair. As culture and practice changes, we may see a changing atypical pattern of pubic lice infestations, as they try to colonize other habitats such as chest or eyebrow hair. We may even see its complete eradication and no longer have patients presenting with pubic lice, within the sexual health setting. REFERENCES 1. Burkhart CN, Burkhart CG, Morrell DS. Infestations. In: Bolognia JL, Jorizzo JL, Schaffer JV, et al., eds. Dermatology. 3rd ed. Philadelphia, Pa: Mosby Elsevier, 2012:chap 84.
Sexually Transmitted Diseases
&
2. Centers for Disease Control and Prevention. Factsheet on Parasites, Pubic LiceVSeptember 2013. 3. Diaz JH. Lice (pediculosis). In: Mandell GL, Bennett JE, Dolin R, editors. Mendell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases. 7th ed. Philadelphia, PA: Churchill Livingstone Elsevier, 2009:chap 293. 4. Bignell C. Lice and scabies. Medicine 2005; 33:76Y77. 5. Varela JA, Otero L, Espinosa E, et al. Phthirus pubis in a sexually transmitted diseases unit: A study of 14 years. Sex Transm Dis 2003; 30:292Y296. 6. Bercaw-Pratt JL, Santos XM, Sanchez J, et al. The incidence, attitudes and practices of the removal of pubic hair as a body modification. J Pediatr Adolesc Gynecol 2012; 25:12Y14. 7. Smolak L, Murnen S. Gender, self-objection and pubic hair removal. Sex Roles 2011; 65:506Y517. 8. Gale J, Pettypiece S. Brazilian bikini waxes make crab lice endangered species. Bloomburg News 2013. 9. Armstrong NR, Wilson JD. Did the Brazilian kill the pubic louse. Sex Trans Infect 2006; 82:265Y266. 10. Portman M. The Brazilian Hasn’t Killed the Pubic LouseIBut It’s A Close Shave. Leeds, UK.
Volume 41, Number 6, June 2014
391
Copyright © 2014 by the American Sexually Transmitted Diseases Association. Unauthorized reproduction of this article is prohibited.
