There comes a time in your professional life when you need to learn new skills. Coaching your patients through effective insect bite prevention is something every travel medicine provider must master.
But how can you become adept at providing insect repellent advice when they never covered it in your training program?
You know that it’s much more than saying: “If you don’t get bit by insects, you won’t contract the diseases they carry.”
But what do you say? And will your patients follow your recommendations?
How many times have you given advice in the office, only to find out that it wasn’t heeded? Even when you are ‘right’ and ‘know what is best’ for your patients– they don’t always see it that way.
My own son was a skeptic.
I sent him to Recife, Brazil to visit some friends. He gave me the ol’ “yeah, yeah” as I reviewed Dengue prevention etc. By his attitude I was sure he’d never use repellents I tucked into his suitcase. Imagine my surprise when I received the following text:
I did a quiet little happy dance knowing that he was actually using the repellents. He came home healthy, with great stories but no mosquito bites.
Diseases spread by insects can be exotic such as Dengue, Zika, Malaria, Japanese Encephalitis or as commonplace as Lyme and West Nile Virus.
Preventing insect bites is an essential part of anticipatory guidance for travelers, yet rarely taught in training programs.
You might think, how hard can it be?
Just put on some DEET and forget it.
If only it was that easy.
Patients have a lot of objections
If you don’t address their objections they really won’t be protected. But, if you show sensitivity to their concerns, and find easy-to-use products, you’ll be able to really help your patients stay safe. And your patients will appreciate your insights into a vexing problem.
The top three complaints I hear from travelers include:
- I don’t want to use products that aren’t natural
- I don’t want to smell all ‘chemically’
- I don’t have time to put on repellent every couple of hours
First and foremost, debunk the ‘natural’ myth.
Clinically effective insect repellent is a manufactured product. The ‘all natural’ products do not work well as shown by scientific studies. The Centers for Disease Control (CDC) is clear about this.
Remind your patients these diseases will make them very sick or possibly kill them. This is not the time to fool around with wristbands, herbal lotions, vitamin supplements, dryer sheets and the like. Of course, you’ll say it more gently. But be firm and clear.
Instead, suggest easy-to-use effective insect repellents. You’ll likely win them over when they learn more about them from you.
My two personal favorites are 20% Picaridin or 30% DEET in a long-acting liposomal formulation.
Why? Because you only have to apply them every 10-12 hours. And they don’t smell bad.
Which is reasonable for travelers.
There are other formulations that work, but to be effective, they have to be applied more frequently, smell bad, or are sticky.
It’s important that you review proper use with your patients, including washing hands before eating and avoiding spraying insect repellent on the face where it can be inhaled.
All areas of exposed skin should be protected. You can recommend that your travelers apply it on top of sunscreen, in the morning, as they are getting ready for the day, and again in the late afternoon if night-biting insects are a concern. Of course they will want to wash off the repellent with soap and water daily.
What do you need to know about 20% Picaridin?
This is a favorite with many travelers. They choose it because it doesn’t smell bad and it’s not DEET. Many people, in my experience, will not wear a product that smells like a chemical factory. No matter how much you warn them of the dangers of malaria or dengue etc. they simply won’t wear a repellent that smells bad.
Picaridin is a mimic for piperine, a compound found in black pepper plants. It creates a barrier that prevents ticks, mosquitos, chiggers and the like from locating their prey (your patient). It does not affect the insect at all.
In the USA there are two main brands- Sawyer and Natrapel. They are widely available at sporting goods and discount stores and online. Have your patients turn the bottle over and make sure they are purchasing the 20% concentration. Lesser concentrations are not reliable.
It comes in either a spray or a lotion. Both work well. Warn your patients that there is a light smell to the product when you sniff the bottle, but not after you apply it. Otherwise they won’t believe you that it doesn’t smell. It’s non-sticky and comfortable to wear even in tropical heat.
Despite the fact the chemical is related to black pepper, it is not irritating to skin and considered non-toxic if accidentally inhaled.
The main problem with Picaridin is the packaging. The lotion comes in 4-oz bottles. Sadly, these bottles are too large for carry-on luggage. However the spray comes in a handy 3-oz. size.
What do you need to know about long-acting 30% DEET?
A client used this on a hunting trip and was wowed by its effectiveness. He was sick and tired of tick and mosquito bites every time he was out in the woods. Of course he had tried others, but could never be bothered to reapply them in the recommended 2-3 hours.
Only a long-acting formulation actually worked for him, because of the ease of application.
DEET works by turning off receptors on the antennae of insects that are used to locate prey. This makes your patient ‘invisible’ to insects and thus prevents bites.
DEET’s effectiveness is related to its concentration. The stronger the concentration the longer it lasts. 10% DEET lasts 1-½ hours while 100% DEET lasts 10 hours. But the higher concentration can be irritating and it smells really bad, making it unacceptable to many travelers.
When 30% DEET was placed into liposomes, little bubbles made of phospholipids, they found that the protective effect lasts 11-12 hours, resists sweating and is non-irritating to skin. You have an effective product with the stickiness and smell DEET almost completely removed.
All of this means you patient will actually use this product.
Commonly used brands are Ultrathon and Sawyer. They are available at sporting goods and discount stores and online. It comes in a non-greasy lotion which is applied on top of sunblock.
Be specific about the formulation: 30% DEET is not the same as 30% liposomal DEET. Again your patients may have to turn over the bottle and read the ingredients. Fortunately it comes in 3-oz. bottles, handy for those who like to carry-on their luggage.
It’s true, you can get the same effective duration from 100% DEET but in my experience it is rarely properly applied. It’s also an unappealing greasy liquid with a strong odor. Additionally it’s a plasticizer, which means that it can make performance clothing or the soft grips on cameras permanently sticky. Yuck.
Contrary to what many people believe, DEET is safe. The American Academy of Pediatrics recommends using up to 30% DEET for children older than 2 months.
There have been widely circulated reports of DEET toxicity in the lay press. When you look closely these events they occurred when excessive quantities were incorrectly applied.
What do you need to know about Permethrin for clothing?
When your patients have more than casual exposure to insect bites recommend Permethrin treatment for clothing, sleeping bags and bed nets. It gives added protection with minimal fuss.
You may want to recommend this to your travelers who are outdoor enthusiasts and anyone spending time in areas of dengue or malaria exposure without screens on the windows. It is designed for clothing that is washable; avoid using on dry-clean only fabrics.
It does not replace Picaridin or DEET, it is used in addition to topical insect repellent.
You may be familiar with a prescription cream with 5% permethrin. The clothing treatment is 0.5% and comes as a wash or a spray. It is applied prior to traveling and lasts for 6 washings or 40 days of sunlight, whichever is shorter.
Permethrin is a synthetic version of a chemical found in chrysanthemums. When an insect comes into contact with it their nervous systems freezes up and they die. It turns clothing into a protective shield.
Apply the spray in quantities heavy enough to soak the clothing to allow the chemical to bind with the fibers of the clothing. Sometimes you need to spray both the inside and outside of the clothing to assure good coverage. Only the outer pieces of clothing need to be treated. Similar to the products above, once it dries it is odorless.
In the USA permethrin is widely available at sporting goods and discount stores and online. Ask your patients to read the label carefully before purchasing as some aerosolized products only last 2 weeks while others, such as Sawyer, last 6 weeks.
Provide the right insect repellent advice
Your patients are counting on you to keep the safe and healthy when they travel. Often this involves preventing insect bites (and the diseases they carry).
Just as you would for any treatment, you need to learn how insect repellents work, how to apply them, and tips to make sure your patients are purchasing the right products. Picaridin, DEET and Permethrin are all safe and effective.
You know from experience not all advice is helpful or actionable. When you learn to use three (3) simple and effective insect repellents you are taking the first step in the path to providing excellent travel advice. You are providing your patients with easy to follow, effective recommendations.
You will keep your patients healthy and happy when they travel. You will be doctor your patients trust.
What type of insect repellent do you recommend for your patients? Which ones do you use when you travel? Add your comments to the discussion below: