Widespread insecticide resistance in head lice to the over-the-counter pediculocides in England, and the emergence of carbaryl resistance

Bioactive Compound-Loaded Nanocarriers for Hair Growth Promotion: Current Status and Future Perspectives

Hair loss (alopecia) has a multitude of causes, and the problem is still poorly defined. For curing alopecia, therapies are available in both natural and synthetic forms; however, natural remedies are gaining popularity due to the multiple effects of complex phytoconstituents on the scalp with fewer side effects. Evidence-based hair growth promotion by some plants has been reported for both traditional and advanced treatment approaches. Nanoarchitectonics may have the ability to evolve in the field of hair- and scalp-altering products and treatments, giving new qualities to hair that can be an effective protective layer or a technique to recover lost hair. This review will provide insights into several plant and herbal formulations that have been reported for the prevention of hair loss and stimulation of new hair growth. This review also focuses on the molecular mechanisms of hair growth/loss, several isolated phytoconstituents with hair growth-promoting properties, patents, in vivo evaluation of hair growth-promoting activity, and recent nanoarchitectonic technologies that have been explored for hair growth.

Pediculosis humanus capitis in 6-7 years old schoolchildren in Valencia, Spain

OBJECTIVES

Pediculosis humanus capitis is a worldwide public health concern that affects mostly school-aged children. The aim of this study is to determine the rate of pediculosis and to determine possible risk factors in a group of primary school children in Valencia, Spain; 227 children, 6-7 years old, were selected from 7 schools.

METHODS

A self-reported questionnaire completed by the parents/guardians about the presence of pediculosis in their children and their knowledge about pediculosis. The results recorded in the questionnaire were analysed by SPSS® software.

RESULTS

30.4% of the children had pediculosis. The results showed significant variation (p < 0.05) in prevalence depending on the following factors: sex, hair length, level of parental education, family size, presence of affected family member in the home, and frequency of hair washing. Less than half of parents/guardians showed an appropriate level of knowledge on pediculosis. Pediculosis remains a health problem in Valencian schoolchildren. The family size and existence of another member with pediculosis were shown to be the main potentiating factors.

CONCLUSIONS

Parents are not sufficiently informed about pediculosis and adopt inappropriate practices. There is a need to promote studies with the objective of determining risk factors for pediculosis as well as the need for actions to increase the knowledge of parents and healthcare professionals on this parasitosis to prevent outbreaks in the community, assure correct treatment and maintain effective epidemiological surveillance.

Head lice: an inexpensive bioassay for use as guidance for healthcare workers monitoring treatment failures for insecticide resistance (1994-1999)

Head lice, Pediculus humanus capitis De Geer (Psocodea: Pediculidae) that failed to respond to pyrethroid insecticide-based treatment products were first identified in London and Cambridge, UK, in 1993 after which reports of treatment failure arose throughout the UK. There was a need amongst healthcare workers for a rapid detection method for resistance that could be used at the community level. A laboratory service was set up so that health professionals could send lice by overnight post for bioassay testing for resistance. In addition, test kits were provided so that testing could either be conducted on site or lice could be shipped to the laboratory on pre-treated test papers so that insecticide exposure could proceed while lice were in transit to the laboratory. Between 1994 and 1999, over 350 samples from 145 locations were tested and during this time populations of lice resistant to pyrethroids, malathion, and carbaryl were identified from all parts of the country, both urban and rural. In some areas, lice were only resistant to one of the insecticides available but in other places lice showed tolerance to all three insecticides used at the time.

Physically Acting Treatments for Head Lice—Can We Still Claim They Are ‘Resistance Proof’?

Head lice worldwide have developed resistance to insecticides, prompting the introduction of a range of alternative treatments including plant extracts and natural and synthetic oils. Clinical studies of physically acting treatments showed them to be highly effective when first introduced, and a widely held, but unsubstantiated, belief is that lice are unlikely to develop resistance to them. However, this ignores possibilities for natural selection of traits enabling lice to survive exposure. More recent investigations of some physically acting products have shown reduced efficacy, suggesting either changes of behavior, physical structure, or physiology of some louse populations. In addition, the activity of surfactants and similar compounds, acting as solubilizing agents of insect cuticular lipids, can be compromised by the widespread use of toiletry products containing similar substances. Hitherto, most clinical investigations have provided “best case” data resulting from investigator application of treatments. In the few studies involving participant application, the effectiveness was reduced, suggesting that consumer use allows some insects to survive, which could then be selected for tolerance. Unlike neurotoxic insecticides, there is no straightforward method to test for the activity of physically acting chemicals other than by clinical investigations, which need to be rigorous to eliminate poorly effective products as a way of ensuring the continued effectiveness of those treatments that are successful in eliminating infestation.

Pyrethroid-linked resistance allelic mutations by molecular analysis in wild human head louse (Phthiraptera: Pediculidae) populations from schoolgirls of South Iran

Background

Human head louse, Pediculus humanus capitis De Geer, 1767 (Anoplura: Pediculidae), is one of the most frequent ectoparasites infesting Homo sapiens worldwide. Reduced sensitivity to treatment due to genetic mutations, in particular knockdown resistance (kdr) (or target site insensitivity) allele, has led to this infestation prevalence. Molecular characterization of this resistance has a crucial impact on selecting appropriate treatment protocol. The aim of this study was to investigate kdr gene mutations on voltage-sensitive sodium channel (VSSC) among wild head lice samples from Fars province, southern Iran.

Methods

Head lice were collected using plastic detection combs on girls enrolled in public schools from 10 counties in Fars province. The specimens were screened in 10 pools (each pool per county containing 35 specimens), with three pools (30%) being positive. Following species identification with valid entomological keys, 350 (68%) out of 514 randomly collected adult head lice were analyzed after their somatic genomic DNA extraction using Sinaclon kit. Samples were investigated by polymerase chain reactions (PCR), and the amplicon was subsequently sequenced.

Results

Sequence analysis showed that the sodium channel genes in the pooled ectoparasites had two intron and three exon regions. Single (L840F), double (I836L, E837K), and triple novel point mutations (V875L, Q876P, S879V); the last involving two concomitant allelic substitutions; were discovered in the second and third exon regions of head louse DNA on chromosome II from three (30%) counties. Other exon or intron regions remained non-mutated from the remaining seven counties.

Conclusions

The detection of six amino acid substitutions from 30% of examined head lice among infested schoolgirls reveal that mutants are minutely developing. These findings provide further incentive to recapitulate the legitimacy of current control measures and resolve dynamics of resistance in human head louse populations.

Detection of permethrin resistance and phylogenetic clustering of turkish head lice (Pediculus humanus capitis; De Geer, 1767 populations

Head lice infestation caused by Pediculus humanus capitis De Geer, 1767 is one of the most common public health problems. The relationship between humans and head lice dates back millions of years ago that differentiated into different phylogenetic clades. Treatment of head lice infestation usually based on insecticide-based products, which promotes the resistance in the head lice populations. In the present study, we aimed to screen the presence of permethrin resistance among collected P. h. capitis specimens in Turkey. Three mutation sites (T917I, L920F, and M815I) were screened using real-time PCR and resistance was identified by melt analysis. Of the studied specimens, resistance allele frequency (RAF) was found 0.98 for T917I, 0.99 for L920F, and 1.00 for M815I. The phylogenetic study revealed that Clade A and Clade B are present and overlap in Turkey. The present study is first to screen the resistance among Turkish head lice specimens. To not stimulate the pyrethroids resistance in head lice populations, early detection of resistance is crucial and will help the health professionals to choose suitable formula in the treatment. We suggest that the resistance status needs to be screened in randomly selected populations before any treatment application is given.

Evolution of Hair Treatment and Care: Prospects of Nanotube-Based Formulations

A new approach for hair treatment through coating with nanotubes loaded with drugs or dyes for coloring is suggested. This coating is produced by nanotube self-assembly, resulting in stable 2-3 µm thick layers. For medical treatment such formulations allow for sustained long-lasting drug delivery directly on the hair surface, also enhanced in the cuticle openings. For coloring, this process allows avoiding a direct hair contact with dye encased inside the clay nanotubes and provides a possibility to load water insoluble dyes from an organic solvent, store the formulation for a long time in dried form, and then apply to hair as an aqueous nanotube suspension. The described technique works with human and other mammal hairs and halloysite nanoclay coating is resilient against multiple shampoo washing. The most promising, halloysite tubule clay, is a biocompatible natural material which may be loaded with basic red, blue, and yellow dyes for optimized hair color, and also with drugs (e.g., antilice care-permethrin) to enhance the treatment efficiency with sustained release. This functionalized nanotube coating may have applications in human medical and beauty formulations, as well as veterinary applications.

Identification of Novel Voltage-Gated Sodium Channel Mutations in Human Head and Body Lice (Phthiraptera: Pediculidae)

In recent years, the increase of head louse infestation in Iran (7.4%) and especially in West-Azerbaijan Province (248%) has raised the hypothesis of insecticide resistance development. There are different mechanisms of resistance to various groups of insecticides, and knockdown resistance (kdr) is a prominent mechanism of resistance to pyrethroids, an insecticide group which is used conventionally for pediculosis control. For detection of kdr-type well-known amino acid substitutions (M815I-T917I-L920F) and additional sodium channel mutations potentially associated with kdr resistance in head and body lice, louse populations were collected from West-Azerbaijan and Zanjan Provinces of Iran. Six novel mutations were found to be located in the IIS1-2 extracellular loop (H813P) and IIS5 (I927F, L928A, R929V, L930M, and L932M) of the α-subunit. Genotyping results showed that all specimens (100%) have at least one of these or the well-known mutations. Therefore, the presence of kdr-related and novel mutations in the sodium channel is likely to be the reason for the frequent use of pyrethroid insecticides due to treatment failure against lice. Further studies are now required to evaluate the prevalence of the kdr-like mutant allele for monitoring of insecticide resistance and the management of head and body lice in other provinces of the country.

Management of Head Louse Infestations in the United States-A Literature Review

Head lice are a source of scalp irritation, social disruption, and loss of school time. Health care providers need authoritative information to help avoid the costs and risks of ineffective treatment. A review was completed to provide relevant information on infestation treatments available in the United States. Three major biomedical databases were searched from 1985, when current products were first available, to 2014, focusing on U.S.

REPORTS

A total of 579 references remained after duplicates were removed. A search of the U.S. Food and Drug Administration website and labels of approved products were reviewed. A marked decline in the effectiveness of permethrin and synergized pyrethrins was found, probably because of resistance arising from widespread and indiscriminate use, and the emergence of knockdown resistance mutations. The potential toxicity of lindane in the setting of readily available, safer, and more effective alternatives, should limit its use. Prescription products shown to be safe and effective with a single application, without nit combing, are topical ivermectin, malathion, and spinosad, whereas benzyl alcohol requires two applications. Home remedies such as mayonnaise, and essential oils, have not been demonstrated to be safe or effective, and may carry potential for severe adverse events. The high risk of failure of over-the-counter treatments in eliminating head louse infestations drives a need for health care provider recognition of the limitations of current treatments and for judicious use of treatments that remain effective.

[Randomised clinical trial to evaluate the efficacy and safety of a new pediculicide made with saponified olive oil in the eradication of Pediculus humanus capitis]

INTRODUCTION

The aim of the study was to evaluate the efficacy and safety of a new pediculicide in the eradication of Pediculus humanus capitis infestation.

MATERIAL AND METHODS

A randomised clinical trial was designed, in which children aged between 5 and 15 years diagnosed with pediculosis were selected. Treatment was administered on days 1 and 7 after selection, and they were evaluated in 4 visits (day 2, 7, 9, and 14). The product under evaluation with saponified olive oil was Inex Pediculicide Soap^®, which was compared with Paranix^®, with a similar mechanism of action. The primary efficacy endpoint was the eradication of the parasite by day 14 (louse-free rate), using an intention to treat analysis.

RESULTS

Six paediatricians from 5 Primary Health Care centres in the Community of Madrid (Spain) and one private clinic participated in the study. A total of 45 children were included, of which 75.6% were girls (n=34). The mean age was 7.1 years (95% CI 6.3-7.9). The large majority (80%) were middle class, and 82.2% had a history of previous pediculosis. The efficacy at 14 days was 76.2% (95% CI 52.8-91.8) in the group treated with Inex Pediculicide Soap^® group, and 79.2% (95% CI 57.9-92.9) in Paranix^® group (NNT=33.3). No adverse effects were observed with treatment.

CONCLUSIONS

The 2 products were effective and safe in the eradication therapy Pediculus humanus capitis, with no statistical differences.

Lice update: new solutions to an old problem

An estimated 6 to 12 million children are affected by lice annually in the United States.(1) Knowledge of the various treatment options for this diagnosis is essential. This paper aims to provide an overview of the myriad therapeutic options available for lice infestations in children. U.S. Food and Drug Administration-approved drugs, off-label drug therapies, over-the counter-products, and herbal remedies are all discussed in detail. Clinicians may use this information to teach patients and families about the latest available care for the eradication of head lice in pediatric patients.

Assessment of the efficacy and safety of a new treatment for head lice

Infestation with head lice is a widespread, persistent, and recurring issue leading to serious health problems if untreated. We are facing resistance phenomena to usual pediculicides and questions about their direct or cumulative toxicity. The aim of this trial was to assess the efficacy of a new product, free of chemical insecticides but with a physical effect. This product contains components whose antilice efficacy has already been demonstrated, as well as Andiroba oil which asphyxiates the lice and Quassia vinegar which dissolves the chitin of the nits (they are then inactivated). 30 patients with head lice infestation, aged 3–39 years, applied the treatment one to three times, 5 days apart. Cure was defined as the absence of live lice after 5, 10, or 14 days, and symptoms are usually associated with infestation. Easiness and safety of the treatment were assessed by the patients and/or their parents. Overall cure rates were 20% on D5 after one treatment, 37% on D10 after two treatments, and 90% on D14 after three treatments. Symptoms such as itch, scalp dryness, redness, and flakiness rapidly diminished. This treatment seems to be a beneficial addition or a valuable alternative to existing treatments, considering the total absence of chemical insecticides, the absence of drug-resistance induction in head lice, the absence of major toxicological risks compared with usual pediculicides, and the favourable patient use instructions.

Insecticide resistance in head lice: clinical, parasitological and genetic aspects

Insecticide treatment resistance is considered to be a major factor in the increasing number of infestations by head lice. The large insecticide selection pressure induced by conventional topical pediculicides has led to the emergence and spread of resistance in many parts of the world. Possible mechanisms of resistance include accelerated detoxification of insecticides by enzyme-mediated reduction, esterification, oxidation that may be overcome by synergistic agents such as piperonyl butoxide, alteration of the binding site, e.g. altered acetylcholinesterase or altered nerve voltage-gated sodium channel, and knockdown resistance (kdr). Clinical, parasitological and molecular data on resistance to conventional topical pediculicides show that treatments with neurotoxic insecticides have suffered considerable loss of activity worldwide. In particular, resistance to synthetic pyrethroids has become prominent, probably because of their extensive use. As other treatment options, including non-insecticidal pediculicides such as dimeticone, are now available, the use of older insecticides, such as lindane and carbaryl, should be minimized, owing to their loss of efficacy and safety concerns. The organophosphorus insecticide malathion remains effective, except in the UK, mostly in formulations that include terpineol.

Safety and efficacy of a non-pesticide-based head lice treatment: results of a randomised comparative trial in children

BACKGROUND/OBJECTIVES

Increasing resistance to pesticide-based head lice treatments has resulted in the need for alternative products to treat head lice infestations, but there are few clinical studies that have adequately tested these products. This multicentre, randomised, assessor-blind, parallel-group phase IV trial compared the safety and efficacy of a non-pesticide-based head lice shampoo with malathion foam in children.

METHODS

This trial used strict entry criteria, standardised treatment and assessment regimes, sibling control and a primary efficacy end-point defined as the absence of live head lice 21 days after initiating treatment. Repeat insult patch tests were performed to further assess the safety of the non-pesticide-based shampoo. In vitro tests were used to assess its ovicidal and pediculicidal efficacy.

RESULTS

A total of 216 children were enrolled, of whom 172 were per-protocol. The non-pesticide-based shampoo was significantly more effective than malathion foam for the intent-to-treat population (62.3 vs 40.4% louse-free, unadjusted P = 0.002; adjusted P = 0.003), as well as for the per-protocol population (67.8 vs 43.0% louse-free, unadjusted P = 0.001; adjusted P = 0.004). Adverse events were limited to itching or stinging. Patch testing with the non-pesticide-based shampoo resulted in no adverse reactions. In vitro tests using body lice demonstrated that the non-pesticide-based shampoo is ovicidal and pediculicidal.

CONCLUSION

The non-pesticide-based shampoo is significantly more effective in eliminating head lice than malathion foam in children, while being associated with a low incidence of mild, transient adverse events.

Permethrin and malathion resistance in head lice: results of ex vivo and molecular assays

BACKGROUND

Treatment of head lice infestation relies on the application of topical insecticides. Overuse of these products has led to the emergence of resistance to pyrethroids and malathion worldwide. Permethrin resistance in head lice is mostly conferred by the knockdown resistance (kdr) trait.

OBJECTIVE

To evaluate the occurrence of permethrin- and malathion-resistant head lice in Paris.

METHODS

A prospective survey was conducted in 74 elementary schools. Live lice collected on schoolchildren were randomly selected and submitted to ex vivo bioassays or underwent individual DNA extraction. A fragment of kdr-like gene was amplified and compared with wild-type sequences.

RESULTS

Live head lice were detected in 574 children. Ex vivo assays showed no surviving lice after a 1-hour contact with malathion while most lice died after a 1-hour exposure to permethrin and piperonyl butoxide (85.7%, 95% confidence interval [CI]: 83.9-87.5). Among the 670 lice with workable DNA sequences, 661 lice (98.7%, 95% CI 97.7-99.3) had homozygous kdr mutations.

LIMITATIONS

The findings of this large-scale survey of the occurrence of insecticide-resistant head lice indicated a major insecticide pressure in the study population, but it was not sufficient to draw conclusions about other populations. The presence of T917I-L920F mutations in kdr gene may not correlate with treatment failure in prospective studies.

CONCLUSION

The high occurrence of kdr mutant allele suggests that insecticide resistance was already strongly established in the studied population. This finding must be interpreted with caution as it may not be predictive of treatment failure.

1,2-Octanediol, a novel surfactant, for treating head louse infestation: identification of activity, formulation, and randomised, controlled trials

BACKGROUND

Interest in developing physically active pediculicides has identified new active substances. The objective was to evaluate a new treatment for clinical efficacy.

METHODS AND FINDINGS

We describe the selection of 1,2-octanediol as a potential pediculicide. Clinical studies were community based. The main outcome measure was no live lice, after two treatments, with follow up visits over 14 days. Study 1 was a proof of concept with 18/20 (90%) participants cured. Study 2 was a multicentre, parallel, randomised, observer-blind study (520 participants) that compared 0.5% malathion liquid with 1,2-octanediol lotion (20% alcohol) applied 2-2.5 hours or 8 hours/overnight. 1,2-octanediol lotion was significantly (p<0.0005) more effective with success for 124/175 (70.9%) RR = 1.50 (97.5% CI, 1.22 to 1.85) for 2-2.5 hours, and 153/174 (87.9%) RR = 1.86 (97.5% CI, 1.54 to 2.26) for 8 hours/overnight compared with 81/171 (47.4%) for malathion. Study 3, a two centre, parallel, randomised, observer-blind study (121 participants), compared 1,2-octanediol lotion, 2-2.5 hours with 1,2-octanediol alcohol free mousse applied for 2-2.5 hours or 8 hours/overnight. The mousse applied for 8 hours/overnight cured 31/40 (77.5%), compared with 24/40 (60.0%) for lotion (RR = 1.29, 95% CI, 0.95 to 1.75; NNT = 5.7) but mousse applied for 2-2.5 hours 17/41 (41.5%) was less effective than lotion (RR = 0.69, 95% CI, 0.44 to 1.08). Adverse events were more common using 1,2-octanediol lotion at both 2-2.5 hours (12.0%, p = 0.001) and 8 hours/overnight (14.9%, p<0.0005), compared with 0.5% malathion (2.3%). Similar reactions were more frequent (p<0.045) using lotion compared with mousse.

CONCLUSIONS

1,2-octanediol was found to eliminate head louse infestation. It is believed to disrupt the insect's cuticular lipid, resulting in dehydration. The alcohol free mousse is more acceptable exhibiting significantly fewer adverse reactions.

TRIAL REGISTRATIONS

Controlled-Trials.com ISRCTN66611560, ISRCTN91870666, ISRCTN28722846.

In vitro comparison of four treatments which discourage infestation by head lice

Products which discourage the transmission of head lice are appealing; however, few studies have tested this concept. This study aims to test the efficacy of four commercial products which claim to discourage infestation by head lice; MOOV Head Lice Defence Spray (MOOV), Wild Child Quit Nits Head Lice Defence Spray (Wild Child), 100% Natural Head Lice Beater (Lice Beater) or Lysout Natural Anti-Lice Spray (Lysout). An in vitro challenge test was used. Briefly, one half of a filter paper lining the base of a petri dish was treated with the test product. Lice were then introduced to the centre of the dish, which was covered and placed in the dark at 20°C for 30 min. The number of lice on the treated and untreated sides of the filter paper was then counted after 2, 4 and 8 h post-application. MOOV was significantly more effective at discouraging the transmission of lice than the water control (p < 0.01), while Wild Child and Lysout were not at all time points. Lice Beater was significantly worse than the water control after 2 h (p < 0.01), while there was no difference after 4 and 8 h. MOOV was found to perform significantly better than Wild Child (p < 0.05) and Lice Beater (p < 0.05) at all time points. It also performed significantly better than Lysout at 2 (p < 0.05) and 8 h (p < 0.05), but not 4 h. MOOV offers the best efficacy and consistency of performance of the four products tested to discourage the transmission of head lice.

A randomized, assessor-blind, parallel-group, multicentre, phase IV comparative trial of a suffocant compared with malathion in the treatment of head lice in children

BACKGROUND/OBJECTIVES

There are concerns about the effectiveness of head lice treatments because of increasing resistance and safety. This trial compared the safety and efficacy of a suffocant-based head lice treatment to malathion in children.

METHODS

The trial used strict entry criteria, standardized treatment and assessment regimens, sibling treatment where appropriate and a primary efficacy end-point defined as the absence of live head lice.

RESULTS

A total of 216 children were enrolled. One hundred and sixty-nine were per-protocol. The suffocant was significantly more effective than malathion for the intention-to-treat population (53.9% vs 40.4% louse-free, unadjusted P = 0.052; adjusted P = 0.024), as well as for the per-protocol population (57.8% vs 43.0% louse-free, unadjusted P = 0.054; adjusted P = 0.045). Adverse events were limited to itching or stinging and there were no serious or systemic adverse events. Repeat insult patch testing with the suffocant resulted in no adverse reactions. In vitro tests confirmed that the suffocant is a potent ovicide and pediculicide with 100% mortality of eggs and lice following a 20-min contact time.

CONCLUSIONS

The suffocant is shown to be significantly more effective in eliminating head lice than malathion in children, while being associated with a low incidence of mild, transient adverse events.

Efficacy of chemical and botanical over-the-counter pediculicides available in Brazil, and off-label treatments, against head lice ex vivo

BACKGROUND

There is a lack of reliable data on the efficacy of over-the-counter (OTC) pediculicides in Brazil.

METHODS

We performed ex vivo assays of eight marketed pediculicides: 1% permethrin (Kwell, Clean Hair, Keltrina, Nedax), 0.02% deltamethrin (Deltacid, Pediderm), and two "natural" products (Piolho e Lêndea, Pilogenio). We also tested 5% permethrin (Keltrina Plus), traditional home remedies and an ivermectin-based product used in veterinary medicine. Head lice (49-52 per group) were immersed in the compound for 3 min and washed after 20 min to simulate the typical in vivo treatment protocol. Lice were examined for activity up to 24 h using stringent criteria for survival.

RESULTS

Of the permethrin containing products, highest mortality was observed with Kwell and Clean Hair (97.9 and 90.2% after 4 h). Keltrina, Nedax, Keltrina Plus, and the two deltamethrin-based products showed only a low efficacy of <60% after 4 h. With exception of pure coconut oil (80% mortality after 4 h), home remedies showed a very low efficacy, and both marketed products killed few lice. The ivermectin-based product caused a mortality of 100% after 4 h.

CONCLUSIONS

Most Brazilian OTC products did not show a satisfactory efficacy against head lice. Resistance may be present. Ivermectin and coconut oil are promising compounds for topical treatment. Laboratory-based tests should be used to assess resistance patterns and to identify formulations of the active ingredient that increase the efficacy. Standardized testing should be performed before a product is licensed for head lice treatment.

The clinical trials supporting benzyl alcohol lotion 5% (Ulesfia): a safe and effective topical treatment for head lice (pediculosis humanus capitis)

Benzyl alcohol lotion 5% (BAL 5%) is a non-neurotoxic topical head lice treatment that is safe and effective in children as young as 6 months of age. The safety and efficacy of this pediculicide has been studied in 695 (confirm number) subjects in all phases of clinical development. Scanning electron micrographs (SEM) demonstrated that the active agent appears to stun the breathing spiracles open, enabling the vehicle to penetrate the respiratory mechanism (spiracles), therefore asphyxiating the lice. Initial phase II trials compared this novel product to RID using identical volumes of treatment (4 oz/application) and yielding, almost, identical efficacy. This outcome pointed to the significant importance of completely saturating the hair with the product in order to achieve maximum treatment success. A second phase II trial, which allowed the use of sufficient product to saturate the hair, resulted in 100% efficacy after both 10 and 30 minute treatments. A third phase II trial verified an effective dose. Phase III trials compared BAL 5% to vehicle placebo for two 10-minute applications. It proved to be safe and effective (p < 0.001) for treatment of head lice and is the first FDA-approved non-neurotoxic lice treatment, now available in the United States as Ulesfia lotion.

Head lice treatments and school policies in the US in an era of emerging resistance: a cost-effectiveness analysis

BACKGROUND

Head lice are a common infection in school-age children worldwide. Several authorities in the US have recommended different treatments and school policies in order to control this disease. Recent concerns of emerging lice resistance worldwide raise the necessity to reassess the current recommendations.

OBJECTIVES

To perform a cost-effectiveness analysis (from the US caregiver perspective) of three head lice treatments commonly used in the US, permethrin 1%, malathion 0.5% and the lice comb, in order to evaluate the cost effectiveness of different treatments in the current era, and to explore the effect of different factors in this analysis.

METHODS

We used a decision-tree model to represent the costs and effectiveness of the different treatment strategies. A patient/caregiver perspective was applied, with a time horizon of 2 weeks. Probabilities of treatment success or failure of the three treatments were based on the literature. Effectiveness was measured as the successful eradication of head lice, and costs - including the costs of the treatment, the physician co-pay and the costs of days out of school - were calculated. One-way and multi-way analyses were performed using decision analysis software (Treeage Pro Healthcare 2008).

RESULTS

Combing was dominated by permethrin 1%. The incremental cost-effectiveness ratio of malathion 0.5% versus permethrin 1% was $US161.75 per cure. For caregivers whose willingness to pay is <$US161.75 per cure, permethrin 1% is the most cost-effective option. For those with a willingness to pay of > or =$US161.75 per cure malathion 1% may offer the highest net monetary benefit. Twenty percent of the uncertainty in the model is due to variation in permethrin 1% resistance, and approximately 73% of the total variability of the model is attributed to the number of days the student has to be out of school because of the school's policy.

CONCLUSIONS

Our study suggests that permethrin 1% was the most cost-effective treatment for those with a willingness to pay of <$US162 per cure. Sensitivity of lice to permethrin and the specific school head lice policy had major effects on the model. Thus, informing communities in a given geographical area about the degree of head lice resistance and sensitivity is necessary in order for the public to make a rational decision regarding treatment. Schools' head lice policies have a major effect on the cost of head lice treatments.

Epidemiological aspects of Pediculosis capitis and treatment evaluation in primary-school children in Iran

This study was undertaken to assess the prevalence of and epidemiological factors associated with, head lice infections in Iranian primary schools in 2006 and evaluate data on the therapeutic efficacy of lindane shampoo. A total of 40586 children (19774 boys (48.72%) and 20812 girls (51.28%)] from 198 Governmentprimary schools in Kerman, were screened for head lice between March and June 2006. The diagnosis of head lice infestation was confirmed by clinical inspection of scalp and hair for the presence of adult lice nymphal stage, or eggs (nit) by line-toothed head lice comb. All children infested with lice were treated with lindane shampoo (1% gamma benzene hexachloride). The overall prevalence of head lice infestation was 1.8%. The prevalence of infestation was significantly higher in girls (2.9%) than in boys (0.6%) (p = 0.000). The infestation rate was greater among pupils who were living in rural areas (4.6%) than in urban areas (1.5%). Of the 721 children with a positive examination result, 424 pupils (58.8%) were reported as having been infested with head lice in the previous 6 months. Mother's education level was a significant risk factor in this model (p < 0.05). At 2 weeks after the primary treatment, the success rates of treatment were 49%. Comprehensive survey in our work showed the better future of the disease and related factors. Education campaigns by health care officials, physicians and teachers are expected to be helpful for head lice control. It is essential that governments should be supported form cooperation between the school authorities and public health centers to successful control head lice infestation in primary school. Also there is an urgent need to identify safe, novel insecticides for proved efficacy.

A highly efficacious pediculicide based on dimeticone: randomized observer blinded comparative trial

Background

Infestation with the human head louse (Pediculus humanus capitis) occurs worldwide. Existing treatment options are limited, and reports of resistance to commonly used pediculicides have been increasing. In this trial we assessed the efficacy of a product containing a high (92%) concentration of the silicone oil dimeticone (identical in composition to NYDA^®), as compared to a 1% permethrin lotion.

Methods

Randomized, controlled, observer blinded clinical trial. Participants were recruited from a poor urban neighbourhood in Brazil where pediculosis capitis was highly prevalent. To minimize reinfestation during the trial, participants (145 children aged 5–15 years with head lice infestations) were transferred to a holiday resort outside the endemic area for a period of 9 days. Two applications of dimeticone or 1% permethrin were done, seven days apart. Outcome measures were defined as cure (absence of vital head lice) after first application and before and after second applications, degree of itching, cosmetic acceptability, and clinical pathology.

Results

Overall cure rates were: day 2 – dimeticone 94.5% (95% CI: 86.6% – 98.5%) and permethrin 66.7% (95% CI: 54.6% – 77.3%; p < 0.0001); day 7 – dimeticone 64.4% (95% CI: 53.3% – 75.3%) and permethrin 59.7% (95% CI: 47.5% – 71.1%; p = 0.5); day 9 – dimeticone 97.2% (95% CI: 90.3% – 99.7%) and permethrin 67.6% (95% CI: 55.4%-78.2%); p < 0.0001). Itching was reduced similarly in both groups. Cosmetic acceptability was significantly better in the dimeticone group as compared to the permethrin group (p = 0.01). Two mild product-related incidents occurred in the dimeticone group.

Conclusion

The dimeticone product is a safe and highly efficacious pediculicide. Due to its physical mode of action (interruption of the lice's oxygen supply of the central nervous system), development of resistance is unlikely.

Trial registration

Current Controlled Trials ISRCTN15117709.

In vitro efficacy of over-the-counter botanical pediculicides against the head louse Pediculus humanus var capitis based on a stringent standard for mortality assessment

Infestation of the head louse Pediculus humanus var capitis DeGeer (Phthiraptera: Pediculidae) is an important public health problem in Australia, with up to a third of children infested in some primary schools. Insecticide resistance and inadequate attention to the application instructions of topical pediculicides are common reasons for treatment failure. This study evaluated six popular Australian over-the-counter products against head lice, primarily comprised of different botanical extracts, and compared them with permethrin 1% (Quellada) and a non-treatment control in order to assess their in vitro efficacy. We also assessed commonly used criteria for evaluating pediculicide efficacy in vitro. All tested products failed to demonstrate high levels of efficacy with the exception of Tea Tree Gel((R)), which outperformed 1% permethrin. Permethrin had a high level of efficacy, but using stringent criteria 18% of lice were not dead at 3 h, indicating some resistance to Quellada. Commonly used less stringent criteria were shown to overestimate mortality of head lice as a result of the protective phenomenon of stasis or sham death observed in exposed lice that may recover after some time. Using two different levels of stringency resulted in different rankings of efficacy for most products, with the exception of the first ranked product, Tea Tree Gel. Rankings of efficacy also varied over time, even within the different assessment criteria. Government regulatory agencies should require standard in vitro tests using stringent mortality criteria, with an observation period of >or= 6 h, to determine the efficacy of new pediculicides, and only products that cause a minimum mortality rate (e.g. 80%) in head lice collected from the target population should be licensed for sale.

High in vitro efficacy of Nyda L, a pediculicide containing dimeticone

BACKGROUND

The therapy of pediculosis remains a common problem in clinical practice. As resistance to commonly used chemical pediculicides is constantly increasing, there is a need for new effective compounds.

STUDY DESIGN

The efficacy of Nyda L, a new pediculicide containing a high concentration of dimeticone, was assessed in an in vitro trial and compared with three reference products (Hedrin containing 4% dimeticone, Lyclear containing 1% permethrin, and Prioderm containing 1% malathion) and a negative control group. Head lice were collected from heavily infested patients in a resource-poor community in Northeast Brazil, where no resistance against pediculicides has been reported thus far. In each of the five groups, 50 adult fully vital lice were tested. We used a dip test (immersing head lice in the undiluted products for 3 min, washing off products after 20 min). Using predefined criteria for mortality, the lice were monitored at different points in time, for a period of 24 h.

RESULTS

Nyda L and Prioderm killed all head lice already after 5 min. The efficacy of Nyda L was better than of Lyclear. Lice treated with Hedrin resurrected after several hours and did not show a significantly higher mortality compared with the control group after 24 h.

CONCLUSION

Nyda L can be regarded as a very efficacious pediculicidal compound, killing all lice in vitro within 5 min.

Overcoming health inequalities by using the Bug Busting 'whole-school approach' to eradicate head lice

AIMS AND OBJECTIVES

The aim of this paper was to illustrate the socially inclusive nature of the Bug Busting 'whole-school approach' to head louse eradication.

BACKGROUND

In the UK, Belgium and Denmark, persistent head lice in families of all socio-economic status (SES) is a problem. Since 1995 in the UK and 1998 elsewhere, an educational programme intended to teach families how to detect and treat head lice by using the Bug Busting wet combing method has been organized in some areas. Local schools lead this community strategy for prevention, known as a 'whole-school approach' (UK).

DESIGN AND METHODS

We describe five studies applying the Bug Busting approach, four set in districts where some disadvantaged families live (UK and Belgium) and a fifth set in Denmark. Feasibility and consumer satisfaction are examined. One UK study analyses data on area prescribing for head lice and the impact in a deprived locality of raising the profile of Bug Busting.

RESULTS

We find parental education in Bug Busting enables families of all SES to participate in a 'whole-school approach' to head lice. Best results are obtained when each family has a Bug Buster Kit. This provides all the combs necessary with full instructions on their use with ordinary shampoo and conditioner to detect lice, eradicate an infestation mechanically, or to check the success of any treatment. In the UK, the promotion of the Bug Busting approach is reducing primary care expenditure on treatment for head lice and professional time spent with worried parents. As a result, healthcare providers can give time to the few families who require one-to-one guidance.

RELEVANCE TO CLINICAL PRACTICE

Incorporation of the Bug Busting approach to head lice into clinical practice in school communities contributes to sustainable control whilst overcoming health inequalities in participating families.

Effectiveness of lotions based on essential oils from aromatic plants against permethrin resistant Pediculus humanus capitis

In Argentina, field populations of the head louse Pediculus humanus capitis De Geer (Phthiraptera: Pediculidae) have developed resistance to permethrin and other pyrethroids. Thus, the aim of this work was the development of a lotion containing essential oils from plants and an alcoholic coadjuvant to improve biological effect. Ethanol + isopropanol (1 + 1 in volume) 50% in water and ethanol 96% were taken as bases for preparation of experimental lotions containing essential oils from plants. We found that experimental lotions containing lavender, peppermint and eucalyptus oils in a 5% composition and the combination of eucalyptus and peppermint in a total concentration of 10%, dissolved in 50% ethanol + isopropanol (1 + 1) in water, showed the best knockdown effect. On the other side, lotion containing peppermint oil and eucalyptus oil (1 + 1) 10%, dissolved in ethanol 96%, showed to be as effective as the best commercial lotion now available in Argentina. Furthermore, addition of 1-dodecanol in all cases increased the effectiveness of all the experimental lotions. This difference is significantly important for 1-dodecanol concentration of 10%, reaching a toxic activity compared to the best commercial lotion available in the market.

In vitro pediculicidal and ovicidal activity of an extract and oil from fruits of Melia azedarach L

BACKGROUND

Head louse infestation is difficult to control because of increasing lice resistance to synthetic pediculicidal drugs.

OBJECTIVE

To test the activity of extract and oil obtained from fruits of Melia azedarach L. against the head louse Pediculus humanus capitis.

METHODS

A filter paper diffusion bioassay was carried out in order to determine the pediculicidal and ovicidal activity of extract and oil from M azedarach L. fruits.

RESULTS

Both vegetable products, tested either individually or in combinations, showed high levels of mortality on adult lice, with values ranging between 62.9% and 96.5%. The highest mortality rate was obtained with a combination of 20% ripe fruit extract with 10% ripe fruit oil. A formulation made with both extract and oil at 10% plus the addition of emulsifier and preserving agents showed 92.3% pediculicidal activity. The products were also successful in delaying or inhibiting nymph emergence, with the formulation being the most effective, with a complete inhibition of emergence.

LIMITATIONS

Because adult lice are sensitive to starvation and therefore control mortalities are often higher than 20% in tests with field specimens, the results may not reflect the direct effect of the extract.

CONCLUSIONS

These results demonstrate the possibility of using Melia products for controlling head lice, which are difficult to control because of their resistance to the currently used anti-louse agents.

Control of head lice: past, present and future

Pediculosis capitis is common among children. Rapid and accurate detection is an underlying principle of effective control and the use of a fine-tooth comb in wet, conditioned hair is most sensitive. However, none of the available treatments are fully effective. Of the current pediculicides available over the counter in the UK, those based on malathion are more effective than pyrethroids. Carbaryl is likely to be the most effective insecticide but is only available on prescription. Wet combing with conditioner has proven to be as effective as some over-the-counter lotions for unsupervised use in the home. There are several promising candidates for new insecticidal actives that are likely to be highly effective for a new generation of pediculicides, as well as a variety of unconventional novel treatments.

Molecular characterization of two acetylcholinesterase cDNAs in Pediculus human lice

Two cDNA sequences encoding Drosophila Ace-orthologous and -paralogous acetylcholinesterase precursors (AO- and AP-AChE precursors, respectively), were identified from the body louse, Pediculus humanus humanus L. In vitro inhibition studies with an insecticide-susceptible body louse strain exhibited a simplex inhibitory response of AChE. The I50 values of fenitroxon and carbaryl were estimated to be 2.2 and 1.9 microM for the susceptible lice, respectively. The mRNA level of AP-AChE gene was 3.1- and 9.3-fold higher than that of AO-AChE gene in the abdomen and the combined parts of the head and thorax, respectively, suggesting, due to its abundance, the potential significance of the AP-AChE isoform in Pediculus human lice in association with the efficacy of AChE-targeting pediculicides.

Surveillance of insecticide resistance in head lice using biochemical and molecular methods

Treatment of head louse infection is primarily through topical insecticides. However, there is growing evidence of resistance. A representative population sample was tested using biochemical and molecular methods; it was shown that, in Wales, treatments containing pyrethroids are likely to be less effective in controlling head louse infection than those containing organophosphates.

A new shampoo based on neem (Azadirachta indica) is highly effective against head lice in vitro

Because topical compounds based on insecticidal chemicals are the mainstay of head lice treatment, but resistance is increasing, alternatives, such as herbs and oils are being sold to treat head lice. To test a commercial shampoo based on seed extract of Azadirachta indica (neem tree) for its in vitro effect, head lice (n=17) were collected from school children in Australia and immersed in Wash-Away Louse shampoo (Alpha-Biocare GmbH, Germany). Vitality was evaluated for more than 3 h by examination under a dissecting microscope. Positive and negative controls were a commercially available head lice treatment containing permethrin 1% (n=19) and no treatment (n=14). All lice treated with the neem shampoo did not show any vital signs from the initial examination after immersion at 5-30 min; after 3 h, only a single louse showed minor signs of life, indicated by gut movements, a mortality of 94%. In the permethrin group, mortality was 20% at 5 min, 50% at 15 min, and 74% after 3 h. All 14 head lice of the negative control group survived during the observation period. Our data show that Wash-Away Louse is highly effective in vitro against head lice. The neem shampoo was more effective than the permethrin-based product. We speculate that complex plant-based compounds will replace the well-defined chemical pediculicides if resistance to the commonly used products further increases.

Safety and efficacy of pediculicides for head lice

Head lice infestation is a common and growing problem, primarily affecting school-aged children. There are growing numbers of treatment failures due to the emergence of treatment-resistant lice to the popular over-the-counter products that have been used for the past several decades. Resistance has also decreased the efficacy of lindane, a prescription pediculicide that has been commonly used for several generations. Malathion, recently reintroduced in the US as a prescription pediculicide, has been associated with some treatment resistance depending upon its formulation. Other insecticidal treatments, such as ivermectin, will have to be developed further, given the limited options presently available for the treatment of head lice. Given the number of anecdotal and market-driven reported studies on head lice, assessment of topical lice therapies requires standardised in vitro testing. Based on concerns about safety and decreasing efficacy due to resistance, a reassessment of the general topic of pediculicides for head lice is warranted.

Identification of sodium channel mutations in human head louse (Anoplura: Pediculidae) from Denmark

The presence of the two mutations T9291-L932F in the voltage-sensitive sodium channel gene associated with permethrin resistance (kdr-like) was shown in head louse, Pediculus humanus capitis De Geer, populations in Denmark. The existence of one susceptible and one T929I-L932F haplotype based on the limited single nucleotide polymorphism (SNP) of these sequences was established. One louse had an SNP causing a G943A substitution in the trans-membrane segment five of domain II on the sodium channel, which has not been identified in other insect species. A polymerase chain reaction-restriction endonuclease method using genomic DNA to discriminate between resistant and susceptible alleles in head lice was developed and implemented. The SNP that results in the T9291 substitution also creates a cutting site for the restriction endonuclease SspI, and the presence of one or two SspI cutting sites in head lice is diagnostic for the T9291-L932F haplotype.

Single blind, randomised, comparative study of the Bug Buster kit and over the counter pediculicide treatments against head lice in the United Kingdom

OBJECTIVE

To compare the effectiveness of the Bug Buster kit with a single treatment of over the counter pediculicides for eliminating head lice.

DESIGN

Single blind, multicentre, randomised, comparative clinical study.

SETTING

Four counties in England and one county in Scotland.

PARTICIPANTS

133 young people aged 2-15 years with head louse infestation: 56 were allocated to the Bug Buster kit and 70 to pediculicide treatment.

INTERVENTIONS

Home use of proprietary pediculicides (organophosphate or pyrethroid) or the Bug Buster kit.

MAIN OUTCOME MEASURE

Presence of head lice 2-4 days after end of treatment: day 5 for the pediculicides and day 15 for the Bug Buster kit.

RESULTS

The cure rate using the Bug Buster kit was significantly greater than that for the pediculicides (57% v 13%; relative risk 4.4, 95% confidence interval 2.3 to 8.5). Number needed to treat for the Bug Buster kit compared with the pediculicides was 2.26.

CONCLUSION

The Bug Buster kit was the most effective over the counter treatment for head louse infestation in the community when compared with pediculicides.