A new two-phase dimeticone pediculicide shows high efficacy in a comparative bioassay
© Heukelbach et al; licensee BioMed Central Ltd. 2009
Received: 20 July 2009
Accepted: 14 December 2009
Published: 14 December 2009
Dimeticones kill head lice by physical means. Here we assessed in a comparative bioassay the ex vivo efficacy of "NYDA® sensitiv", a new two-phase dimeticone-based pediculicide similar to a product established on the market, but without fragrances.
We compared efficacy of the new product to a positive dimeticone control group, a sample of four other insecticidal and natural head lice products marketed in Germany, and an untreated control. In a bioassay, lice were exposed ex vivo to products and examined for activity for up to 24 hours, following a standard protocol.
After 6 and 24 hours, 13.7 and 88.5% of untreated control lice did not show major vital signs. In contrast, no lice showed major vital signs 5 minutes after treatment with the new product or the control dimeticone group (NYDA®). This effect persisted at all observation points (100% efficacy). Efficacy of 0.5% permethrin (Infectopedicul®) ranged between 76 and 96% in evaluations between 5 min and 6 hours. All lice treated with a coconut-based compound (mosquito® Läuseshampoo) did not show major vital signs after 5 min, but mortality was only 58% after one hour. Pyrethrum extract (Goldgeist® forte) showed an efficacy of 22 - 52% between 5 min and 3 hours after treatment; after 6 hours, 76% of lice were judged dead. An oxyphthirine®-based compound (Liberalice DUO LP-PRO®) killed 22 - 54% of lice in the first 6 hours.
The two-phase dimeticone compound NYDA® sensitiv is highly efficacious. The removal of fragrances as compared to an established dimeticone product did not affect in vitro efficacy.
Head lice infestations are widespread and occur in all socio-economic strata in low, middle and high-income countries [1–3]. Anecdotal evidence suggests an increasing prevalence of head lice in many countries. In addition, as a result of the extensive use of neurotoxic insecticides, such as permethrin and malathion, reports of resistances to these pediculicides have increased in the recent years [4–8].
However, many over-the-counter head lice products are still not tested adequately for their efficacy - neither before nor after licensing - and, unfortunately, lack efficacy. For example, we recently reported that only one of six plant-based head lice products marketed in Australia showed a considerable degree of efficacy against adult head lice . Thus, there is a clear need for standardized assessment of alternative head lice treatments. In fact, there is now a trend for a more evidence-based approach, and there have been several promising reports of clinical trials and bioassays testing new topical head lice compounds [10–19].
The trends for product development in some countries have changed from neurotoxic insecticides to products containing substances acting by physical means . These compounds, such as silicones, are of particular interest for head lice control: they are considered non-toxic to humans, and due to their mode of action development of resistance is not expected [12, 20–22]. The silicone oil dimeticone coats the louse surface and enters the respiratory tract, thereby blocking spiracles and tracheae [20, 22]. Böckeler & Richling (2008) showed that a two-phase product containing a mixture of two dimeticones of different viscosity (NYDA®) was capable of entering the tracheal system, subsequently asphyxiating lice . We have previously shown in a clinical trial and in an ex vivo study that this two-phase dimeticone (marketed in Germany, Austria, the UK, France, Denmark, Finland, Greece, The Netherlands, Turkey and several other countries) is highly efficacious against head lice [12, 13]. Here we report efficacy of a similar formulation, but without fragrances, and compare it to several other products.
Details of products tested against head lice.
92% dimeticone, medium-chain triglycerides, jojoba wax
Solution in plastic bottle
G. Pohl-Boskamp GmbH o KG, Hohenlockstedt (Germany)
92% dimeticone, medium-chain triglycerides, jojoba wax, fragrances
Solution in glass bottle
G. Pohl-Boskamp GmbH o KG, Hohenlockstedt (Germany)
Liberalice DUO LP-PRO®
Oxyphthirine® (triglycerides and lipid esters)*
Lotion in plastic bottle
Duhot S.A., Limal (Belgium)
0.5% permethrin, ethanol (39 vol. %), 2-propanol, purified water, propylene glycol, sodium dihydrogen phosphate
Solution in glass bottle
InfectoPharm Arzneimittel und Consilium GmbH, Heppenheim (Germany)
Pyrethrum extract (0,3%), piperonyl butoxide, chlorocresol, diethylene glycol
Solution in glass bottle
Eduard Gerlach GmbH, Lübbecke (Germany)
Soybean oil, coconut oil derivatives, purified water, sodium laureth sulphate, cocamidopropyl betaine, glycine soya, hydrolysed collagen, glycosphingolipids, geranium
Wepa Apothekenbedarf GmbH o. KG, Hillscheid (Germany)
The new product differs from the established dimeticone product by the absence of fragrances. As a consequence, concentrations of dimeticones are slightly changed. The compound without fragrances contains a mixture of two dimeticones of different viscosity, in a total concentration of 92.4%, as compared to 92.0% in the product with fragrances. Fragrances used in NYDA® are α-terpineol and Eucalyptus citriodora oil. The remaining difference in concentration between both dimeticone formulations was substituted by middle-chain triglycerides, which is another ingredient of both products.
Head lice used
Adult head lice (Pediculus capitis) were obtained by dry combing with a fine toothed comb, from children living in a community in the city of Fortaleza (northeast Brazil), where head lice are endemic. Children had not treated their infestations with topical compounds or taken any antibiotics/antiparasitic drugs in the previous four weeks. We examined lice for activity and physical integrity and used fully active adult insects within 60 min after collection. Female and male lice were used.
A previously published standardized method for ex vivo assessment of efficacy of pediculicidal products was used [9, 13]: Lice attached to hair strands were immersed completely in undiluted products for 3 min and then placed with hairs onto Whatman filter paper in 5 cm Petri dishes. To prevent lice from desiccation, the filter paper was moistened by 200 μl tap water. After placing lice on filter paper, obvious pools of the products were wiped from the lice by a jeweller's forceps directed under a dissecting microscope. Lice were washed after 20 min by immersing the strands into water for one minute. Hair strands and lice were agitated using a jeweller's forceps, and then placed on new Petri dishes with filter paper. Lice of the untreated control group were washed after 20 min without any further treatment.
The number of parasites tested was 50 in each treatment and 131 in the control group. Lice were tested in batches of nine to eleven insects, and results were then pooled.
The lice were examined for activity under a dissecting microscope after 5, 10, 20, 30, 60, 120 and 180 min, as well as after 6 hours. A final assessment was made after 24 hours - however, a high mortality in the control group was expected, as lice desiccate without regular feeding.
Pre-defined criteria for evaluation of survival of lice were used, based on activity, ataxic signs, ability to stay on hair, as well as gut and leg movements. As the exact time point of death of an insect is difficult to define, we defined strict criteria for the determination of "mortality": Lice were judged as "dead" if there were no vital signs or minor vital signs present (merely internal gut movements, movements of antennae, minimal leg movements with or without stimulation by a forceps). Lice showing major vital signs such as inability to walk in a progressive fashion or no righting reflex when rolled onto the back - considered as dead in many other bioassays  - were judged as alive.
A single observer performed all examinations to prevent inter-observer variation. Due to differences in color and odor of products, complete blinding was impossible. All lice were maintained at 27-29°C and not fed during testing.
Data were entered using Excel spreadsheets and checked for entry-related errors. Binomial confidence intervals of mortality rates were calculated using STATA® software version 8.2 (Stata corporation, College Station, USA). The significance of the difference of relative frequencies was compared by applying Fisher's exact test.
The study was done in collaboration with local community leaders and approved by the Ethical Review Board of the Federal University of Ceará (Fortaleza, Brazil). Prior to combing, study objectives were explained, and informed written consent was obtained from children and their guardians. All children and their families involved were treated against head lice and other parasitic diseases with oral ivermectin (Revectina®; 200 μg/kg body weight, repeated after 10 days), or in the case of contra-indications, with a 1% permethrin-based lotion available over the counter in Brazil (Kwell®). In Brazil, oral ivermectin is registered for treatment of pediculosis and has been shown to be effective against a variety of parasitic diseases .
In the untreated control group, all lice survived for up to one hour. After six hours 13.7% of lice were dead, and after 24 hours 88.5% (Figure 1).
The two-phase dimeticones performed significantly better than Infectopedicul® at observations after 5 min (p = 0.003), 10 min (p < 0.001), 20 min (p = 0.006) and 2 h (p = 0.001); better than mosquito® at observations after 20 min (p = 0.003), 30 min, 1 h, 2 h, 3 h and 6 h (all p < 0.001); and better than Liberalice DUO LP-PRO® and Goldgeist® forte at all observations in the first six hours after exposure to products (all p < 0.001). At other observation points, differences between products tested were not statistically significant.
Our data show that a new dimeticone-based head lice product without fragrances is highly efficacious in a standardized pediculicidal bioassay. The removal of α-terpineol and Eucalyptus citriodora did not affect efficacy, as compared to the established two-phase dimeticone product NYDA®.
Several recent studies have shown the efficacy of products containing silicone oils. In clinical trials, preparations based on silicones have shown a high efficacy as compared to neurotoxic insecticides [11, 12, 14, 24, 25]. In a recent comparative clinical trial, efficacy of two-phase dimeticone was 97% after 9 days, as compared to 68% efficacy of 1% permethrin . Considering the similar ex vivo efficacy of both two-phase dimeticones used in the present study, it can be assumed that clinical efficacy of the product without fragrances will be similar. In addition, an in vitro ovicidal assay has shown that the two-phase dimeticone reveals almost 100% efficacy against head lice eggs .
In a previous comparative bioassay we observed 100% efficacy of NYDA® and 1% malathion (Prioderm®), compared to 90% efficacy of 1% permethrin creme rinse (Lyclear®) . Lice treated with 4% dimeticone/96% cyclomethicone (Hedrin®) showed a similar efficacy to two-phase dimeticone in the first three hours after exposure, but a considerable number of lice recovered after 6 hours .
In the present study, an alcoholic solution of 0.5% permethrin showed an efficacy ranging between 72 and 96% in the first six hours after exposure. Similar results applying an identical methodology were found with permethrin-based products from Australia, the UK and Brazil [9, 13, 27]. The pyrethrum extract Goldgeist® forte showed a low efficacy in our study.
Liberalice DUO LP-PRO® contains a compound called oxyphthirine®, which is based on triglycerides and lipid esters. Lice are claimed to be killed by asphyxiation, but no adequate in vitro or clinical data are published confirming this assumption. In our assay, efficacy of this product was low, indicating that a single topical application, as recommended by the producer, is not sufficient to eradicate lice. Resistance is an unlikely cause for the low efficacy, as the assays were performed in Brazil where the product is not commercialized yet and thus lice were most likely naïve regarding exposure to oxyphthirine®.
A considerable number of lice exposed to the plant-based product mosquito® recovered of sham death after some time. Resistance may develop also against plant extracts, but similar to permethrin we cannot conclude on resistance patterns. In fact, death of insects is difficult to define, and lice in particular have the ability to shut down their metabolism and go into stasis; they may later recover from an apparently morbid state [28, 29]. Thus, in the evaluation of head lice treatments, the end-point "death" can only be determined by microscopy and by observing the insects for a prolonged period, as done in our study. Some authors have highlighted the need for an extended observation period of at least 6 hours to confirm death [13, 27, 28, 30]. From the design of above cited studies and data presented in this study, it cannot be concluded if resistance is the cause for incomplete efficacy of pyrethroids and plant products. This should be the focus of future studies. Resistance of the Brazilian lice tested has not yet been described.
Since our study was performed, another product (50% isopropyl myristate, a fatty acid ester, and 50% cylcomethicone) claimed killing lice by physical means has entered the German market. Clinical trials have shown efficacy of this compound [14, 25].
Different house remedies such as application of mayonnaise or olive oil have erroneously been reported to be efficacious. In reality, these substances cause a transient period of stasis, and lice usually are not observed during a prolonged period. Interestingly, the majority of "resurrected" lice after exposure to mosquito® recovered from "no vital signs" (data not shown).
Many in vitro studies used the inability to walk in a progressive fashion or loss of righting reflex when rolled over as criteria for mortality . We believe that the more stringent criteria used in the present bioassay are adequate, if lice are observed for a period of six hours or more. In fact, mortality usually remains relatively constant after 3-6 hours of observation [13, 27] and our study confirmed this finding. Other authors used "no vital signs", including complete cessation of gut peristalsis, as criterion for mortality .
Even in control lice mortality increased considerably after 3 - 6 hours , owing to dehydration. A longer observation period would considerably bias efficacies of tested products. Thus, we observed lice up to 6 hours with an additional final assessment after 24 hours to assess mortality in control group not exposed to pediculicides. Clearly, the increased "efficacy" of some products after 6 hours of observation should be interpreted with caution, due to increasing mortality in the control group.
Permethrin and malathion are generally considered safe, when used correctly, but an increased awareness that neurotoxical products may be harmful has been influencing head lice therapy in the last years . In some cases these insecticides may cause adverse events such as skin irritation, paraesthesia, exacerbation of asthma and allergic reactions. Incorrect use may cause more severe adverse events. For example, a patient developed neck dystonia for 24 hours after applying 5% permethrin and not washing for 10 hours . One case control study found an OR of 1.9 (95% CI: 1.1-3.3) for acute leukaemia in childhood, if insecticidal pediculicides were used in the past . Clearly, further studies are needed to prove causal relationship of this association, but in general care should be taken when using neurotoxic pediculicides. In countries where safe alternatives are available with efficacy proven in well-designed studies, we recommend to avoid the use of topical neurotoxic insecticides.
We have shown in a standardized bioassay that a two-phase dimeticone product is a highly efficacious product against head lice. The removal of fragrances as compared to NYDA® did not affect efficacy. Permethrin showed a satisfactory efficacy, but the majority of lice treated with pyrethrum survived for a prolonged period. Highly concentrated dimeticone products can be seen as an alternative to neurotoxic pediculicides.
JH is research fellow from the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq/Brazil). FAO was supported by DAAD-CAPES PROBRAL program for academic interchange between Germany and Brazil. AA and OL were supported by the DAAD-CAPES UNIBRAL program. This article is part of a medical thesis of AA.
- Falagas ME, Matthaiou DK, Rafailidis PI, Panos G, Pappas G: Worldwide prevalence of head lice. Emerg Infect Dis 2008,14(9):1493–1494. 10.3201/eid1409.080368View ArticlePubMedPubMed CentralGoogle Scholar
- Heukelbach J, Wilcke T, Winter B, Feldmeier H: Epidemiology and morbidity of scabies and pediculosis capitis in resource-poor communities in Brazil. Br J Dermatol 2005,153(1):150–156. 10.1111/j.1365-2133.2005.06591.xView ArticlePubMedGoogle Scholar
- Willems S, Lapeere H, Haedens N, Pasteels I, Naeyaert JM, De Maeseneer J: The importance of socio-economic status and individual characteristics on the prevalence of head lice in schoolchildren. Eur J Dermatol 2005,15(5):387–392.PubMedGoogle Scholar
- Kasai S, Ishii N, Natsuaki M, Fukutomi H, Komagata O, Kobayashi M, Tomita T: Prevalence of kdr-like mutations associated with pyrethroid resistance in human head louse populations in Japan. J Med Entomol 2009,46(1):77–82. 10.1603/033.046.0110View ArticlePubMedGoogle Scholar
- Thomas DR, McCarroll L, Roberts R, Karunaratne P, Roberts C, Casey D, Morgan S, Touhig K, Morgan J, Collins F, et al.: Surveillance of insecticide resistance in head lice using biochemical and molecular methods. Arch Dis Child 2006,91(9):777–778. 10.1136/adc.2005.091280View ArticlePubMedPubMed CentralGoogle Scholar
- Kristensen M, Knorr M, Rasmussen AM, Jespersen JB: Survey of permethrin and malathion resistance in human head lice populations from Denmark. J Med Entomol 2006,43(3):533–538. 10.1603/0022-2585(2006)43[533:SOPAMR]2.0.CO;2View ArticlePubMedGoogle Scholar
- Vassena CV, Mougabure Cueto G, Gonzalez Audino P, Alzogaray RA, Zerba EN, Picollo MI: Prevalence and levels of permethrin resistance in Pediculus humanus capitis De Geer (Anoplura: Pediculidae) from Buenos Aires, Argentina. J Med Entomol 2003,40(4):447–450. 10.1603/0022-2585-40.4.447View ArticlePubMedGoogle Scholar
- Durand R, Millard B, Bouges-Michel C, Bruel C, Bouvresse S, Izri A: Detection of pyrethroid resistance gene in head lice in schoolchildren from Bobigny, France. J Med Entomol 2007,44(5):796–798. 10.1603/0022-2585(2007)44[796:DOPRGI]2.0.CO;2PubMedGoogle Scholar
- Heukelbach J, Canyon DV, Oliveira FA, Muller R, Speare R: 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. Med Vet Entomol 2008,22(3):264–272. 10.1111/j.1365-2915.2008.00738.xView ArticlePubMedGoogle Scholar
- Mougabure CG, Zerba EN, Picollo MI: Permethrin-resistant head lice (Anoplura: Pediculidae) in Argentina are susceptible to spinosad. J Med Entomol 2006,43(3):634–635. 10.1603/0022-2585(2006)43[634:PHLAPI]2.0.CO;2Google Scholar
- Burgess IF, Lee PN, Matlock G: Randomised, controlled, assessor blind trial comparing 4% dimeticone lotion with 0.5% malathion liquid for head louse infestation. PLoS ONE 2007,2(11):e1127. 10.1371/journal.pone.0001127View ArticlePubMedPubMed CentralGoogle Scholar
- Heukelbach J, Pilger D, Oliveira FA, Khakban A, Ariza L, Feldmeier H: A highly efficacious pediculicide based on dimeticone: randomized observer blinded comparative trial. BMC Infect Dis 2008, 8: 115. 10.1186/1471-2334-8-115View ArticlePubMedPubMed CentralGoogle Scholar
- Oliveira FA, Speare R, Heukelbach J: High in vitro efficacy of Nyda ® L, a pediculicide containing dimeticone. J Eur Acad Dermatol Venereol 2007,21(10):1325–1329. 10.1111/j.1468-3083.2007.02258.xView ArticlePubMedGoogle Scholar
- Burgess IF, Lee PN, Brown CM: Randomised, controlled, parallel group clinical trials to evaluate the efficacy of isopropyl myristate/cyclomethicone solution against head lice. Pharm J 2008, 280: 371.Google Scholar
- Carpinella MC, Miranda M, Almiron WR, Ferrayoli CG, Almeida FL, Palacios SM: In vitro pediculicidal and ovicidal activity of an extract and oil from fruits of Melia azedarach L. J Am Acad Dermatol 2007,56(2):250–256. 10.1016/j.jaad.2006.10.027View ArticlePubMedGoogle Scholar
- Jadhav V, Kore A, Kadam VJ: In-vitro pediculicidal activity of Hedychium spicatum essential oil. Fitoterapia 2007,78(7–8):470–473. 10.1016/j.fitote.2007.02.016View ArticlePubMedGoogle Scholar
- Burgess IF, Brunton ER, Burgess NA: Clinical trial showing superiority of a coconut and anise spray over permethrin 0.43% lotion for head louse infestation, ISRCTN96469780. Eur J Pediatr 2009,169(1):55–62. 10.1007/s00431-009-0978-0View ArticlePubMedGoogle Scholar
- Connolly M, Stafford KA, Coles GC, Kennedy CT, Downs AM: Control of head lice with a coconut-derived emulsion shampoo. J Eur Acad Dermatol Venereol 2009,23(1):67–69. 10.1111/j.1468-3083.2008.02829.xView ArticlePubMedGoogle Scholar
- Strycharz JP, Yoon KS, Clark JM: A new ivermectin formulation topically kills permethrin-resistant human head lice (Anoplura: Pediculidae). J Med Entomol 2008,45(1):75–81. 10.1603/0022-2585(2008)45[75:ANIFTK]2.0.CO;2View ArticlePubMedGoogle Scholar
- Burgess IF: Current treatments for pediculosis capitis. Curr Opin Infect Dis 2009,22(2):131–136. 10.1097/QCO.0b013e328322a019View ArticlePubMedGoogle Scholar
- Burgess IF: The mode of action of dimeticone 4% lotion against head lice, Pediculus capitis . BMC Pharmacol 2009, 9: 3. 10.1186/1471-2210-9-3View ArticlePubMedPubMed CentralGoogle Scholar
- Richling I, Böckeler W: Lethal Effects of Treatment with a Special Dimeticone Formula on Head Lice and House Crickets (Orthoptera, Ensifera: Acheta domestica and Anoplura, Phthiraptera: Pediculus humanus ). Arzneimittelforschung 2008,58(5):248–254.PubMedGoogle Scholar
- Heukelbach J, Winter B, Wilcke T, Muehlen M, Albrecht S, Oliveira FA, Kerr-Pontes LR, Liesenfeld O, Feldmeier H: Selective mass treatment with ivermectin to control intestinal helminthiases and parasitic skin diseases in a severely affected population. Bull World Health Organ 2004,82(8):563–571.PubMedPubMed CentralGoogle Scholar
- Burgess IF, Brown CM, Lee PN: Treatment of head louse infestation with 4% dimeticone lotion: randomised controlled equivalence trial. BMJ 2005,330(7505):1423. 10.1136/bmj.38497.506481.8FView ArticlePubMedPubMed CentralGoogle Scholar
- Kaul N, Palma KG, Silagy SS, Goodman JJ, Toole J: North American efficacy and safety of a novel pediculicide rinse, isopropyl myristate 50% (Resultz). J Cutan Med Surg 2007,11(5):161–167.View ArticlePubMedGoogle Scholar
- Sonnberg S, Oliveira FA, de Melo IL, de Melo Soares MM, Becher H, Heukelbach J: Ovicidal efficacy of over-the-counter head lice products (German). In 104. Jahrestagung der Deutschen Gesellschaft für Kinder- und Jugendmedizin. Poster presentation. Munich (Germany); 2008.Google Scholar
- Asenov A, Oliveira FA, Speare R, Liesenfeld O, Hengge UR, Heukelbach J: Efficacy of chemical and botanical over-the-counter pediculicides available in Brazil, and off-label treatments, against head lice ex vivo . Int J Dermatol 2009, in press.Google Scholar
- Nuttall GHF: The biology of Pediculus humanus . Parsitology 1917, 10: 80–184. 10.1017/S0031182000003747View ArticleGoogle Scholar
- Canyon D, Speare R: Do head lice spread in swimming pools? Int J Dermatol 2007,46(11):1211–1213. 10.1111/j.1365-4632.2007.03011.xView ArticlePubMedGoogle Scholar
- Meinking TL, Taplin D, Kalter DC, Eberle MW: Comparative efficacy of treatments for pediculosis capitis infestations. Arch Dermatol 1986,122(3):267–271. 10.1001/archderm.122.3.267View ArticlePubMedGoogle Scholar
- Coleman CI, Gillespie EL, White CM: Probable topical permethrin-induced neck dystonia. Pharmacotherapy 2005,25(3):448–450. 10.1592/phco.25.3.448.61596View ArticlePubMedGoogle Scholar
- Menegaux F, Baruchel A, Bertrand Y, Lescoeur B, Leverger G, Nelken B, Sommelet D, Hemon D, Clavel J: Household exposure to pesticides and risk of childhood acute leukaemia. Occup Environ Med 2006,63(2):131–134. 10.1136/oem.2005.023036View ArticlePubMedPubMed CentralGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-5945/9/12/prepub
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