Research Signpost

37/661 (2), Fort P.O., Trivandrum-695 023, Kerala, India

Chemistry of Natural Products : Recent Trends & Developments, 2006:

ISBN: 81-308-0140-X Editor: Goutam Brahmachari

Natural products and their

7 application to the control of

head lice: An evidence-based
review
Jörg Heukelbach1,2, Richard Speare2 and Deon Canyon2
1
Department of Community Health, School of Medicine, Federal University of
Ceará, Brazil; 2School of Public Health, Tropical Medicine and Rehabilitation
Sciences, James Cook University, Townsville, Australia

Abstract
Head lice are insects that have been parasitizing
human beings for thousands of years. Chemical
pediculicides have been used extensively for the
treatment of infestations since the early 20th century.
Resistance to these pediculicides, such as permethrin,
is constantly increasing and there is a need for the
development of new effective compounds killing adult
lice and eggs. Natural products have been used in
traditional medicine since long and have been more
Correspondence/Reprint request: Dr. Jörg Heukelbach, Department of Community Health, School of Medicine
Federal University of Ceará, Brazil
2 Jörg Heukelbach et al.

and more the issue of interest, since the costs are usually lower and they are in
general considered less toxic. However, toxicology information on natural
products is poor. Here we present an evidence-based review on plant
compounds for the treatment of head lice infestations. An overview is given on
published evidence on the use of pediculicides and ovicides in in vitro studies
and clinical trials to cure pediculosis. Additionally, the available data on
deterrent compounds are reviewed. We conclude that large numbers of plant
products, such as neem and tea tree oils, offer promise for new compounds to
treat head lice infestation. The number of clinical studies is very limited, and
there is an urgent need to increase research assessing the effectiveness and
safety of promising compounds. Over the counter natural products should be
supported by in vitro data and adequately designed controlled trials that
evaluate cure rates and safety. Providing that a new family of synthetic
insecticides is not discovered, it is possible that plant products will replace
chemical insecticides on the market in future.

Introduction
Head lice, Pediculus humanus var capitis, are wingless insects that have
been obligate parasites of humans for thousands of years. Since the oldest
archaeological record is 8,000 years BC, some authors have proposed that lice
were associated with pre-hominoid ancestors and were dispersed globally
when humans migrated [1]. Prior to modern existence, humans have removed
head lice using physical techniques or attempted to kill them using various
substances applied to the hair. Mutual grooming with capture of lice by hand is
a common practice still today in many countries. Archaeological discoveries of
lice in coprolites indicates that captured lice were often eaten. Combs with
narrow teeth containing entrapped head lice have been found commonly in the
archaeological record [2,3].
Topical treatments applied to the hair using plant parts and plant
derivatives, also known as ‘natural products’, would have been used in
these times, but the archaeological record is inadequate. It is likely that
these botanicals contained insecticidal phytochemicals, predominantly
secondary compounds, produced by plants as anti herbivory agents.
However, there is little other than anecdotal, traditional or cultural
evidence on this topic [4,5].
Having head lice is called pediculosis and this is subdivided into active
pediculosis and inactive pediculosis. People with active pediculosis have live
lice motile in the hair of the head or live embryos in viable eggs attached to
hair shafts. People with inactive pediculosis have no live lice even in eggs, but
hatched or dead eggs are present on hair shafts. Inactive pediculosis is
historical evidence of past infection and although it is not an infection risk, it
often is a cosmetic, social, mental and economic problem. Distinguishing
Natural products against head lice 3

between these two states is unfortunately not often undertaken, but is critical
since a person with active pediculosis is an infection risk, in contrast to a
person with inactive pediculosis.
The child who has black hair and inactive pediculosis with prominent pale
hatched eggs visible on the hair shaft is more likely to be sent home from
school than the child with blond hair and active pediculosis whose eggs and
lice are more difficult to see. The former is not an infection risk while the latter
is. For active pediculosis lice and viable eggs need to be killed or removed. For
inactive pediculosis cosmetic measures only are needed and removal of eggs
becomes the major goal.

History of pediculicides and current pediculicide

situation
In the twentieth century treatments based on chemical insecticides began
to be used in developed countries. Dozens of natural and synthetic compounds
were used, and hundreds were tested by the military during World War I & II
in a search for an effective treatment for body lice [6], before DDT was
discovered in 1939 and used towards the end of World War II to control lice
[7].
Then in the late 1940’s, lindane, an organochlorine, was found to be a
more effective pediculicide than DDT [8] and gradually replaced it in many
countries [6]. Lindane is still used today in some countries but there remain
concerns about its safety. As resistance to DDT emerged a decade later in
Israel [9] and in the United Kingdom [10], organophosphates such as
malathion were investigated as alternatives. Other chemicals in this group and
carbamates were found to be highly effective against lice, but malathion’s
safety record and lack of significant resistance until recently, have rendered it a
permanent fixture in pharmacies even today. Carbaryl, a carbamate, was
initially sold over the counter in the United Kingdom, but was subsequently
restricted to doctor’s prescription in an attempt to limit resistance [11].
However, resistance to carbaryl is now developing in some centres in the
United Kingdom [12].
In some countries carbaryl, lindane and benzyl benzoate are still available
over the counter to treat pediculosis. Repeated or prolonged application of
lindane shampoo is known to have caused seizures and deaths, but also in rare
cases following a single application [13].
Casida (1980) [14] and Taplin and Meinking (1987) [15] wrote excellent
reviews on pyrethrins and pyrethroids and their use as ectoparasite
insecticides. It is certain that extracts from chrysanthemum flowers,
Chrysanthemum cinerariaefolium in particular, have been used as insecticides
for centuries since industry records date back to 1886. It was only around 1940
4 Jörg Heukelbach et al.

when pyrethrin, the active compound, was identified, and currently six natural
pyrethrins are known. Pyrethrin is still popular today, despite numerous
synthetic analogues on the market. Some assume that this is due to the
public’s desire for natural pesticides, but the fact is that they still work in
many situations. Natural pyrethrins have a number of advantages over
other insecticides. They are very active, have very low mammalian
toxicity, are biodegradable and have an important property, fast
knockdown: the ability to rapidly disable an insect. After almost 30 years
of research into synthetic analogues a suitable product, bioresmethrin, was
discovered in 1967 by Michael Elliott at Rothamsted. Today, a large
number of synthetic pyrethrins have been developed and they have largely
replaced natural pyrethrin because, in general, they are over 1,000 times
more active than natural pyrethrum I, and have extremely low mammalian
toxicities (average LD50 = 8,000 mg/kg). The mode of action of pyrethrins
is similar to that of organochlorines in that they interfere with the
permeability of sodium ion channels across nerve membranes. It could be
argued that the high cost of producing these complex structures is offset by
the very low application rates required. However, emerging resistance
coupled with rather toxic effects on bees and aquatic life means that it has
become imperative for new classes of insecticides to be discovered or
created.
Currently in many countries, the mainstay of head lice treatments are
topical chemical insecticides, such as permethrin, allethrin, deltamethrin,
lindane or benzyl benzoate [16]. However, in vitro and clinical resistance to
pediculicides containing insecticides, particularly to permethrin, has been
increasing [12,17-25]. Permethrin resistance is particularly frequent in
countries where head lice are common and where chemical insecticides are
intensively used, mainly developed countries such as the United States, United
Kingdom, France, Israel and Australia, but also in less developed countries,
such as Argentina.
There is thus an urgent need for the development of new effective
pediculicidal products on the market. One reason that natural products are
being increasingly looked at is that there is a general perception that they kill
lice using alternative mechanisms to manufactured chemicals. However, the
evidence for this belief is very limited, owing to lack of research on the way
natural products kill head lice. Most known insecticides target neurotransmitter
receptors, ion channels and membrane transport processes [22], and natural
product modes of action are not expected to be different. For instance, the
synergist, pipronyl butoxide, which slows the biotransformation of pyrethrum
in insects, works in the same way with natural products like neem [26]. This
suggests that the identification of alternative pathways may be more difficult
than first thought.
Natural products against head lice 5

Additional reasons that are prompting researchers to investigate natural

products more thoroughly are prohibitive costs of synthetic pyrethrins and
pyrethroids, environmental and food safety, unacceptable toxicity of many
organophosphates and organochlorines, besides the worldwide decreasing
susceptibility [27].

Life cycle and attributes of the ideal pediculicide

Understanding how the ideal pediculicide would work requires an
evidence-based approach and thorough knowledge of the head lice life cycle
(Figure 1). Points of the life cycle relevant to treatment strategies are that eggs
take about seven days to hatch and that lice become mature at about day 10
after hatching. Hence, if a treatment protocol does not kill embryos in eggs, it
needs to be repeated after lice have hatched (i.e. seven or more days), but
before the earliest hatched lice (i.e. those that hatched on day 1 after treatment)
have become mature, mated and started to produce a new crop of eggs (i.e. at
least 10 days). There is a narrow window of treatment opportunity (day 7 to
10) to cure an infection, assuming no reinfection. Most manufacturers,
therefore, recommend retreatment at day 7, as a week makes biological sense
and consumers find it easier to remember. It may, however, mean lice in eggs
that were 1 or 2 days old when the first treatment was given and were slower to
hatch, actually emerge after the second treatment.

Figure 1. Life cycle of the head louse (courtesy of Nitpickers, http://www.nitpickers.com.au).

6 Jörg Heukelbach et al.

The ideal topical head lice product has the following attributes:

• 100% kill of lice

• 100% kill of embryos
• removes all eggs from hair shafts (solving the cosmetic problem)
• repels lice (solving the reinfection problem)

This ideal product has not yet been developed! Research on topical
treatments for head lice has focused on achieving 100% insecticidal and
ovicidal effect. The former has been achieved with many chemicals and natural
products, but the latter has not. Research has been scanty on repellents, and
little research has been done on compounds to remove eggs from the hair
shafts.

Natural products
Increasing demand for natural products
In 2006, the Organic Trade Association [28] reported that organic foods
have a market share of 2.5% and have experienced annual growth rates of 15%
to 21% since 1997. In addition, sales of organic personal care products was
USD 282 million, an annual rise of 28% in 2005 alone. In contrast, Pamela G.
Marrone, chairman and founder of AgraQuest, a biotechnology company
specializing in the development of safe and environmentally friendly pest
management products, estimated that 26 billion dollars are spent on synthetic
pesticides worldwide per year, while only 300 million is spent on biological
pesticides [29], indicating a market share of only 0.1%. So, we can expect
significant growth in public demand for organic or natural products in all areas
including insect control. Possibly consumer demand for organic pediculicides
is leading this growth.

Are natural products a safer alternative?

If one of the main reasons for increased interest in ‘natural’ insecticides is
the concern about safety, and there is a paucity of toxicology information on
the topic, then one should look laterally for guidance. Food production requires
that insecticides are to be applied to products that are eventually ingested. This
is similar to pediculicides that are applied to the scalp except that the route of
exposure is different.
Interestingly, the ‘natural’ tag does not really mean that much in reality.
For instance, organic foods can be produced using approved synthetic
pesticides and ‘natural’ biopesticides, and the United States Department of
Agriculture (USDA) makes no claims that organically produced food is safer
or more nutritious than conventionally produced food [30]. Some
Natural products against head lice 7

biopesticides, such as the fungicide sulphur, are even more toxic than many
synthetic alternatives [29].
Natural biopesticides are derived from materials from animals, plants,
bacteria and minerals and can be classed as follows:

• Microbial pesticides: A pesticide consisting of a living bacterium, a

virus or a fungus as the active agent. Instead of poisoning the target, a
microbial pesticide infects a pest and then kills or inhibits it.
Pesticidal chemicals extracted from microorganisms are called
antibiotic pesticides. There are no microbial pesticides approved for
use in or on humans.
• Plant-Incorporated-Protectants (PIP): Modified plants that have
been enhanced by the addition of genetic material known as PIPs are
able to produce pesticide substances internally.
• Biochemical pesticides: These are naturally occurring substances,
such as pheromones, that can be used to manipulate or control pests
by non-toxic action.
• Natural pesticides: Pesticides or growth modifiers consisting of a
non-synthetic biochemical active ingredient or some other naturally
occurring substance.
• Organic pesticides: From a natural products perspective, this is a
misnomer. Organic chemicals consist mainly of a carbon skeleton
plus other elements such as hydrogen, oxygen, nitrogen, sulphur,
phosphorus or chlorine, so most pesticides are organic and not
natural.

Natural products are usually considered less toxic than synthetic insecticidal
compounds and culturally more acceptable. This mistaken perception is
perpetuated in part by the fact that natural products are not required to undergo the
rigorous toxicological testing required for standard pharmaceuticals.
In most countries natural products are listed, and are not required to be
registered by national drug licensing authorities [30,31]. Listing is a lower
category and usually can be achieved without demonstration of efficacy in
clinical trials. Registered products have to demonstrate efficacy and safety in
clinical trials. In Ellis et al (2004) [32], the United States Food and Drug
Administration was reputed to have said that holistic products are not regulated
as closely as pharmaceutical products, so false advertising and unfounded
claims are common. Ignorance also plays a role, since it is not widely known
that pyrethrin products are contraindicated for patients with contact allergy to
ragweed or turpentine [33].
Although this is economically beneficial to companies marketing these
products, it is unfortunate for safety since few, if any, scientists will deny that
8 Jörg Heukelbach et al.

many natural products (organic secondary compounds) have striking adverse

affects on mammals and are more toxic than some synthetic insecticides [34-
36].
Although decreased susceptibility to natural products has not been
reported in any significant way, this is no reason to believe that resistance is
less likely to develop if usage increases to the levels experienced by synthetic
compounds.
Many products consist of a mixture of different plant products, but
synergistic and even additive effects are not a standard expectation and
antagonistic effects are possible. Synergistic mixtures would act to reduce the
risk of possible resistance development in the future.

Natural product insecticides

Plant-based compounds or phytochemicals have been used in traditional
medicine throughout the world to treat a variety of conditions and diseases,
including ectoparasitic infestations, such as scabies and pediculosis. There
have been extensive laboratory and applied investigations into the insecticidal
activity of many phytochemicals against a wide variety of pathogens and
arthropods [37-39]. As early as 1947, Roark listed over 1200 plant species
from previous studies known to have insecticidal qualities. Biochemical
insecticides are not simple compounds and often contain a wide spectrum of
bioactive fungicides, nematicides, acaricides, insecticides and carcinogenic
inhibitors.
Nash (2003) [40] stated incorrectly that “Herbal treatments (including tea
tree oil) and aromatherapy are sometimes used to treat head lice. No studies
have evaluated their efficacy or possible toxicity.” Many natural products have
been evaluated in vitro against body lice and head lice and some in clinical
trials against pediculosis (Table 1). Many of the products available
commercially use combinations derived from several natural sources. In some
instances this is to achieve synergy. However, in such combinations the active
ingredient is difficult to identify unless the components are evaluated
individually. One reason manufacturers adopt the approach of combining
several source plants or products is that many of the combinations are not
patented and could be copied by competitors. However, by using combinations
the active ingredient can be disguised to some extent.
In this review we have included data from published in vitro or clinical
trials only and have omitted records of natural product pediculicides based on
historical or anthropological reports.

In vitro efficacy
The in vitro assessment of insecticidal activity is typically done prior to
clinical use. Head lice (P. humanus var capitis) or captive bred body lice (P.
Natural products against head lice 9

humanus var corporis) are used for in vitro studies, the latter much more
frequently than the former. The reason for this is that captive bred body lice
show no insecticide resistance and can be provided at uniform life stages in
suitable numbers when desired. Head lice are usually collected off heads prior
to use (posing a logistical problem in certainty of numbers available), are
always of different sex, stages and ages, and may be insecticide resistant. Head
lice have been raised in captivity, but not as a continuous captive strain unlike
body lice [41].
It is assumed that the killing effect on body lice is the same for head lice
although this has not been demonstrated comprehensively across a range of
products. Interestingly, a study using wild-caught head and body lice showed
significant differences in responses to a range of insecticides [42]. In vitro testing
techniques for assessment of the killing effect of chemicals and products on head
lice are not standardized, making comparison across techniques difficult [43-45].
The criteria for mortality used in laboratory-based studies differ from study to
study and are difficult to compare; in many cases, the definition of ‘mortality’ is
not sufficiently strict. For example, head lice may resurrect after being depressed
for some hours and thereafter show normal activity again [22,43-45]. As a
consequence, several compounds such as mayonnaise, petroleum jelly and olive
oil have been described to kill head lice, but in reality caused a transient knock-
down period; after some hours the head lice show normal activity [22,45,46]. In
vitro tests need to be done with negative and positive control groups using
standardised criteria for mortality and the lice have to be observed for a
prolonged period. We have not attempted here to differentiate between published
results based on the techniques used.
The most comprehensive in vitro study of natural products comprised 54
essential oils against adult female head lice collected from children in South
Korea and compared mortality against pyrethrum and δ-phenothrin [47].
Sixteen of the 54 essential oils had efficacy equal to or greater than pyrethrum
and a further six were slightly less active. Yang et al (2004) [47] also noted
differences in activity within plant genus indicating that finding an active
essential oil derived from one species does not imply other species in the same
genus are also active. These authors noted that the most active essential oils
had a fumigant activity due to volatile compounds as well as a contact activity
on head lice, whereas pyrethrum and δ-phenothrin had contact activity only.

Pyrethrins
The in vitro activity of pyrethrins is well known [15] and pyrethrum has
been used as a standard to screen other natural products for activity against
head lice [47-49]. Resistance of head lice to pyrethrins has also been shown
using in vitro tests [20,50], the prevalence of resistance varying from site to
site in both studies.
10 Jörg Heukelbach et al.

Tea tree oil

Tea tree oil is distilled by steam from the leaves of the tea tree, Melaleuca
alternifolia and is a complex mixture of over 100 hydrocarbons and terpenes
[51]. Veal (1996) [52] obtained 94% mortality against body lice with 1%
emulsion of tea tree oil in water, although efficacy varied between replicates.
In another study, tea tree oil killed head lice but less effectively than δ-
phenothrin and pyrethrum [47]. An in vitro study against head lice showed that
1% tea tree oil caused no mortality after 2 hours while 10% resulted in 86%
mortality [51]. We have shown a 97% mortality of head lice after four hours
with an emulsion of 5% tea tree oil in 20% ethanol, but <50% mortality with
concentrations of 1% and 2% tea tree oil (J. Heukelbach, personal
observation). However, since some extracts of tea tree oil are ineffective in
killing head lice in vitro (R. Speare, personal observation), careful
characterization of the extract is indicated.
Four compounds from tea tree oil showed markedly different efficacies
against head lice in vitro [51] although all failed to produce significant
mortality at 1%. The most active compounds were terpinen-4-ol, terralin and
α-terpeninol that were each 100% effective at 10% concentration. Walton et al
(2004) [53] showed that although tea tree oil was effective at killing the
scabies mite Sarcoptes scabiei in vitro, the killing efficacy of components of
tea tree oil varied markedly. Some of the compounds in tea tree oil, 1,8-cineole
and terpinen-4-ol, have an inhibitory effect on acetylcholinesterase [54], an
enzyme targeted by the organophosphate insecticides, and this action may play
a role in killing head lice.
A mixture of tea tree oil (Melaleuca alternifolia) and cinnamon leaf oil
(Cinnamonum zeylanicum) (1:1) at 1% with 40% ethanol had a 100% efficacy
against adult body lice after a 17 hr exposure to the oil mixture [52]. Exposure
to a 0.1% oil-vinegar emulsion resulted in only a 2% mortality.

Neem
Neem (Azadirachta indica) extract killed head lice slowly in vitro in a
filter paper test and was less effective than malathion, permethrin and benzyl
benzoate [55]. However, the units of concentration of active ingredient
reported in the paper are confusing. In the same study lemon (Citrus medica)
extract had less effect on head lice than neem extract, and Aloe vera extract
had no killing effect after 3 hours. A neem based shampoo was highly active in
vitro against head lice that were partly resistant to a 1% permethrin product
[44]. The neem extract in this shampoo is evidently derived from the residue
after extraction of the oil.
About 150 compounds have been isolated from neem tree products, for
example isoprenoids and its derivatives (such as nimbin, salanin and
azadirachtin), sulphur compounds, flavonoids and polyphenolics [56]. Some
Natural products against head lice 11

active compounds have been shown to be insecticidal and to have insect

repellent activity, such as 22,23-dihydronimocinol extracted from leaves and
azadirachtin, extracted from seeds [56].

Other plant products

Of the several plant essential oils identified as highly potent by Yang et al
(2004) [47,48], the most active was Eucalyptus globulus oil, followed by
pennyroyal (Mentha pulegium), marjoram and rosemary oil that were more
active than δ-phenothrin. Other essential oils, such as cade, cardamone ceylon,
clove bud and leaf, coriander, cypress, Eucalyptus citriodora, myrtle,
peppermint, spearmint, rosewood, basil and sage oil were comparable to δ-
phenothrin [47]. A previous study had demonstrated essential oils of clove bud
and leaf had in vitro activity against head lice comparable to δ-phenothrin and
pyrethrum and that this was probably due to the ingredients eugenol and
methyl salicylate [49]. These latter compounds also had fumigant activity
against head lice while δ-phenothrin and pyrethrum did not.
Red thyme (Thymus vulgaris), oregano and aniseed oils at 1% for 17
hrs followed by a 0.1% rinse each resulted in 100% mortality against adult
body lice [52]. Cinnamon oil tested in a similar technique had 86%
mortality [52] and was also shown to be effective against head lice in
another study [57]. Mixtures of oils of 1. red thyme and rosemary
(Rosmarinus officinalis) and 2. peppermint (Mentha piperita) and nutmeg
(Myristica fragrans) at 1% concentration for 17 hr resulted in 87% and
100% mortality in body lice [52].
Essential oil from the African tea bush, Lippia multiflora, killed head lice
in vitro but was less effective than kerosene and more effective than benzyl
benzoate [42]. Activity against wild-caught body lice was comparable. The
composition of the essential oil of Lippia multiflora varies with location
highlighting the potential problem of variability in composition of essential
oils with source [58].
Four combinations of paw paw (Asiminia triloba), thymol (Thymus
vulgaris), and tea tree oil (Melaleuca alternifolia) in a shampoo base were
trialled in vitro against head lice to select the most effective combination [59].
The most effective combination was then used in an open clinical trial (Table
1). The authors proposed that the product worked by depleting ATP levels in
lice, but provided no evidence to support this statement.
Priestley et al (2006) [60] in a very comprehensive in vitro study using
body lice examined 28 compounds found in essential oils. The compounds fell
into high and low efficacy groups, with mono-oxygenated compounds being
most active against body lice. Substances with flat compact molecules also
showed most activity. The top seven most active compounds had a methyl
group [60].
 12

Table 1. In vivo clinical studies on the efficacy/effectiveness of plant products against head lice (studies testing pyrethrins have not
been included).
Jörg Heukelbach et al.
Natural products against head lice 13

Custard apple (Annona squamosa) has been highly efficacious in killing

head lice in several studies (cited in [61]). An extract of custard apple seeds in
coconut oil killed 98% of head lice within two hours, and a petroleum ether
extract of 20% A. squamosa seeds achieved a mortality of 93% (cited in [61]).
In these studies, the seed extracts showed higher killing rates than leaf extracts.

Natural products from micro-organisms

Recently an insecticidal compound, spinosad, produced by the bacterium
Saccaropolyspora spinosa, has been shown to kill permethrin resistant head
lice in vitro [62]. Spinosad has a low mammalian toxicity (3783-5000 mg/kg in
the rat and may be suitable as a topical treatment for head lice [63].

Clinical trials
Pyrethrins
Several clinical trials, including blinded randomized comparative and
controlled trials have been conducted on head lice products based on
pyrethrins [14,15,64,65]. Resistance to pyrethrins is more common in the USA
than in Panama, a developing country [66].

Neem
A shampoo based on a neem tree seed extract (Azadirachta indica) was
effective in an open clinical trial [67]. Interestingly, this shampoo (Wash Away
Louse™), which is commercialized in Germany, is made from the fibrous
residue remaining after the oil is extracted, material which is usually regarded
as waste and thus cheap to obtain.
Formulations based on neem have been extensively used for more than a
thousand years in traditional Indian medicine due to its insecticidal, repellent
and pesticidal properties [56]. Neem-based products used in agriculture are
biodegradable, and the mammalian toxicity is considered low [56]. However, it
is toxic to fish and aquatic invertebrates which limits its agricultural use close
to aquatic environments [56].
There are many publications on the acute, subacute and chronic toxicity of
A. indica, indicating that the therapeutic topical use of neem products on
humans can be considered as safe [56,68]. An open trial with a topical
compound based on neem and turmeric achieved a 97% cure rate in scabies
[69]. However, there are single cases of intoxication in children after oral
ingestion of Margosa oil, which contains neem [68]. In fact, the crude oil can
induce toxic effects similar to the symptoms observed in the children having
ingested Margosa oil, when administered orally to animals [68,70,71].

Tea tree
Tea tree oil is occasionally used alone in natural products for pediculosis, but
typically it is used in combination with other essential oils and is arguably one of
14 Jörg Heukelbach et al.

the most common ingredients in natural products. However, adequately designed

clinical studies are similarly overdue as for most other plant-based products. A
clinical trial which evaluated a shampoo containing paw paw, thymol and tea tree
oil was an open study and evaluation criteria were poorly described [59].
The topical use of tea tree oil can be considered as safe. However, allergic
contact dermatitis has been observed after the use, and in higher doses it can
cause skin irritation [72-79]. Toxic effects occurred in children after accidental
oral ingestion of small amounts of the oil [80-82].

Other natural products

A preparation containing 20% custard apple (Annona squamosa) seed extract
was shown to be highly effective against head lice infestations in a small controlled
trial [61]. More than 90% of lice were dead three hours after application of the
product to infested school children, as compared to 60% dead lice in the control
group, treated with 25% benzyl benzoate emulsion. Custard apple has been used in
traditional Thai medicine against pediculosis since long [61].
A product containing coconut oil, anise and ylang ylang applied every five
days was highly effective (92% cure rate) in an unblinded comparative
therapeutic trial with clearly defined assessments [83]. Interestingly, in an in
vitro study, ylang ylang did not show any significant effect on the survival of
head lice [47], consistent with our studies in Australia that showed no killing
effect against head lice in vitro (R. Speare, personal observation).
A tincture prepared from Jamaica quassia (Picrasma excelsa) used to wash
the hair and then air-dried in an open study had a 98% cure rate a week after a
single treatment [84].

Natural product ovicides

Topical treatments are used to kill lice and if effective, will kill 100% of
the motile lice, but typically kill less than 50% of the embryos in eggs. One
reason for this is that most effective insecticides are neurotoxins and for young
embryos (two days and less), the nervous system is too immature to be
affected. Another reason is that penetration of products into the egg is
apparently inadequate, and killing doses are not attained.
Products are usually evaluated for their insecticidal effect (ability to kill
lice) and their ovicidal effect (ability to kill embryos). Since most products do
not claim a 100% ovicidal action, typically manufacturers recommend a
second application seven days after the first to kill lice which have hatched
over the intervening days.

In vitro efficacy
One of the earliest reports of ovicidal efficacy was published by King
(1954) [85], who demonstrated some ovicidal efficacy when using dodecyl
Natural products against head lice 15

alcohol, a component of coconut oil. Until the 1990s, studies on pediculicides

that have included an investigation into ovicidal properties have been lacking.
In an interesting study by Veal (1996) [52] on three blended oils (1: red
thyme & rosemary, 2: peppermint & nutmeg, 3: tea tree & cinnamon) with and
without an oil-vinegar-water rinse the procedure was as follows: eggs were
exposed to the oil in solvent, returned to the incubator overnight, washed in
shampoo, rinsed with the oil/vinegar/water mixture, and returned to the
incubator for about a week. After all the lice from the control gauzes had
emerged and died, the numbers of hatched, half-hatched, dead, and
undeveloped eggs were noted for each of the replicates. Ovicidal efficacy,
expressed as percentage mortality, without the rinse stage was not impressive
(Blend 1: 3.7%, 2: 12.6%, 3: 6%), however the rinse was surprisingly effective
(Blend 1: 39.4%, 2: 82.4%, 3: 96.2%) and did not work without prior exposure
of eggs to the oils. When seven essential oils (rosemary, pine, tea tree,
oregano, cinnamon, aniseed, red thyme) were tested independently with an
ethanol rinse, mortalities ranged from 83% to 100%.
The only other significant work has been conducted by Yang’s team in
Seoul National University, Korea. In 2003, they investigated Eugenia
caryophyllata bud and leaf oil-derived compounds against louse eggs [49].
Methyl salicylate and eugenol were found to be highly effective at 0.25 and 1.0
mg/cm2, respectively, whereas little or no activity at 5 mg/cm2 was observed
with the other test compounds as well as with δ-phenothrin and pyrethrum. In
2004, Yang et al. [48] investigated the toxic effects of Eucalyptus globulus leaf
oil-derived monoterpenoids (1,8-cineole, l-phellandrene, (-)-α-pinene, 2-β-
pinene, trans-pinocarveol, γ-terpinene, and 1-α-terpineol) and the known
Eucalyptus leaf oil terpenoids (β-eudesmol and geranyl acetate) on eggs and
females of the human head louse. At 1.0 mg/cm2, (-)-α-pinene, 2-β-pinene, and
γ-terpinene exhibited moderate ovicidal activity, whereas little or no ovicidal
activity was observed with the other terpenoids and with δ-phenothrin and
pyrethrum. In these studies, ovicidal activity was noted to be compound- and
dose-dependent, but the exact adulticidal and ovicidal mode of action of 1,8-
cineole, (E)-pinocarveol, and 1-α-terpineol remains unknown.
Finally, in 2005, Yang et al. [57] conducted a study on essential oils
from cinnamon bark and found that they could be useful as insect control
fumigants or ovicides for lice. Ovicidal effects from a direct contact bioassay
were measured by reduced hatching and were compared with those of δ-
phenothrin and pyrethrum. After 24 h of exposure, cinnamon reduced
hatching to 3% at 0.25 mg/cm2, to 27% at 0.125 mg/cm2 and to 55% at 0.063
mg/cm2. Component analysis showed no hatching with 0.063 mg/cm2
salicylaldehyde, 0.125 mg/cm2 benzaldehyde, 1.0 mg/cm2 cinnamaldehyde
and 1.0 mg/cm2 benzyl cinnamate. Salicylaldehyde and benzaldehyde gave
13% and 17% hatching at 0.031 and 0.063 mg/cm2, respectively.
16 Jörg Heukelbach et al.

Cinnamaldehyde and benzyl cinnamate caused 7 and 18% hatching at 0.5

mg/cm2, respectively. Little or no ovicidal activity at 1.0 mg/cm2 was
observed with benzyl alcohol, cinnamyl acetate, δ-phenothrin and pyrethrum
compared with the acetone control.
Priestley et al (2006) [60] evaluated in vitro ovicidal activity against eggs
of body lice for 19 compounds found in essential oils. Mono-oxygenated
monocyclic terpenoids had high ovicidal activity. Citronellic acid and nerolidol
were highly ovicidal, but had no activity against adult lice.

Clinical trials
Abramowicz (1995) [86] stated that pyrethrins must be applied twice,
separated by a week because clinical observations have shown them to be not
ovicidal. To enhance activity, most pyrethrins are now formulated with a
synergist, commonly piperonyl butoxide [6], but these still lack ovicidal
potency. Cordero and Zaias (1987) [87] conducted a clinical evaluation on 40
children into the ovicidal efficacy of two pyrethrin-piperonyl-butoxide
formulations. They found reasonable efficacy with the shampoo formulation
being significantly better than a lotion. Following this, Burgess (1994) [88]
published laboratory findings and a clinical trial involving a quick-break foam
mousse that appeared to overcome egg surface tension problems encountered
by other insecticides. Although it was claimed that only a single application
was required to kill all louse eggs, it must be noted that the eggs were removed
from the head after treatment to assess ovicidal activity which may have
skewed results.

Natural lice deterrents

Thinking that there are merely insecticides and repellents is a
misconception. Dethier’s (1947) [89]definition of a repellent, which states that
a repellent must cause ‘oriented movements away from its source’, does not
come close to describing the plethora of possibilities open to deterring lice.
Deterrents function by the following mechanisms:

• Mechanical – a product can deter transmission by rendering hair

slippery or clothing and hairstyle can constitute significant physical
barriers.
• Odorant – a product can contain chemicals that bind to odor receptors
to create a behavioral response.
• Irritant – a product that contains chemicals that repel insects by
produce an excito-repellent effect.
• Toxic – a product containing toxic compounds that are detectable or
whose effects are undesirable which leads to aversion of a treated
area.
Natural products against head lice 17

Canyon and Speare (2006) [31] stated that the following outcomes of
deterrents are important to consider:

• Tropotaxis (avoidance) - refusal of lice to walk onto repellent-treated

hair.
• Tropotaxis (hesitation) – lice do not avoid repellent-treated hair, but
do so with some hesitation and/or reversing and leaving the treated
area.
• Orthokinesis – the speed of progress of lice is negatively affected
while walking on the treated portion.
• Klinokinesis (confusion) – lice experience disorientation while on the
treated hair.
• Antifeedance – lice move onto treated areas, but are disinclined to
blood feed.

In vitro efficacy
Although Burgess (1993, 2004) [43,90] cited the first documented research
into lice repellents as being the evaluation of lavender for use against clothing
lice in World War II [91], several observations preceded this work. Twenty
eight years earlier, three notable researchers first made mention of the
detrimental effects of various oils used as hair dressing on head lice [92-94].
They made it fairly clear that some of the oils used as dressing for the hair
acted as deterrents to head lice transmission.
Twenty years later, Buxton (1938) [95] noted that hair samples originating
from Ceylon often contained very large numbers of first stage head lice
nymphs that were dead when the collections were made. He hypothesized that
the use of coconut oil on the hair had coated the eggs and rendered them so
sticky that the first stage larva failed to emerge from the egg. Subsequent trials
using dodecyl alcohol on body lice demonstrated complete knock-down within
24 hours and all exposed body lice were killed [85]. In 1969, Pence and Viray
[96] reported that dodecyl alcohol, a component of coconut oil, caused atrophy
and developmental abnormality in several species of insects.
Piperonal has an interesting history as a deterrent, but its story starts when
researchers evaluated its usefulness in controlling human lice in North
America [97] and in Australia [98]. Its repellent qualities remained unreported
until Peock and Maunder (1993) [99] tested a 2% piperonal spray in the lab
and found it to exhibit consistent high repellency after 30 minutes, dropping
slightly over 24 hours. This spray was found to be twice as effective as N,N-
diethyl-3-methylbenzamide (DEET). In what appears to be a rehash of this
research, Burgess (1993) [90] repeated the results and avidly supported
piperonal. This research, however, was vigorously refuted by Ibarra and
18 Jörg Heukelbach et al.

Williams (1994) [100] who had valid safety concerns and believed that it was
ineffective. In their dialogue, Ibarra and Williams went on to state that anyone
who used DEET, formerly known as N,N-diethyl-m-toluamide, betrayed a
misunderstanding of its mode of action. Despite this, it has been used in a
comparative way in several studies to evaluate the efficacy of various natural
product deterrents. In truth it is not a very useful control since it failed to
significantly outperform various essential oils and terpenoids applied to hair
substrates in vitro and skin [31,101]. The insecticidal qualities of terpenoid
compounds that are commonly found in essential oils, are well known [102].
Oladimeji et al (2000) [42] evaluated the pediculicidal efficacy of Lippia
multiflora Moldenke, synonym Lippia adoensis Hochst (Verbenaceae), a shrub
found growing in West Africa Savannah that contains terpenoid chemicals.
The major constituents were linalool (26.7%), geraniol (20.4%) and limonene
(15.4%). Minor constituents terpineol (2.9%), a-pinene (1%) and b-pinene
have known insecticidal properties and have been shown to kill body lice
[102,103].
Canyon and Speare (2006) [31] tested tea tree (Melaleuca alternifolia,
lavender, peppermint, coconut oil, a rosemary-bay-cedarwood-patchouli-ylang
ylang-jojoba-apricot mixture (Mix 1), a coconut-neem-citronella mixture (Mix
2), a tea tree-lavender-rosemary-citronella-neem mixture (Mix 3) and a neem-
citronella mixture (Mix 4) (Figure 2). This study found that all substances
tested were non-efficacious as head lice repellents with only a marginal level
of activity demonstrated. Tea tree was shown to be the superior repellent and
an antifeedant. Over half of the head lice transferring to a tea tree-treated head
would thus be expected to transfer out as soon as possible and failing that
would be less inclined to survive since blood meals would be inhibited.
Although all oils reduced transmission to a treated hair by 33%-65%, most of
this effect was due to the slippery nature of treated hair as demonstrated by the
response to KY-Jelly, which was used as a 'slip' and irritant control. This was
thought to partly explain why head lice are more prevalent in clean hair heads
than in greasy hair heads.
The value of the irritant response was questionable since most lice
progressed forward despite showing some tropotaxis except with coconut.
Neem and citronella were not significant irritants and reduced the irritancy of
coconut when combined.
Lavender, a common ingredient in head lice preventative preparations, is
only useful in limiting blood feeding, but may help to tone down the strong
smells of the other substances.
Any application of a repellent or other preventative in infested individuals
may act to increase the dispersal of head lice to other contacts in social groups
or family. Head lice are thought to view people's heads as 'rooms' in their
'home' rather than viewing a head as a permanent abode (D. Canyon, personal
Natural products against head lice 19

6 Tea tree

Response (0 = control)
5 Peppermint
4 Coconut
3 Lavender
2 Mix 1
1 Mix 2
0
Mix 3
-1 Prevent Irritant Repellent Antifeedant
Mix 4
transmission

Figure 2. Comparative summary of overall test substance efficacy against head lice in
various experimental conditions involving transmission, irritancy, repellence and
antifeedance.

observation). Core social groups in classrooms probably facilitate this

behaviour. Increased dispersal within the core group would thus cause a more
rapid change of rooms with greater potential to infest subsidiary contact
groups. So, application of preventatives to all subsidiary groups and family
would be beneficial if combined with identification and thorough treatment of
all core group members.
These results supported those obtained earlier by Mumcuoglu et al (1996)
[101]. In a study on several essential oils, such as lavender, rosemary,
piperonal, eucalyptus, D-limonen and citronella, they found that apart from
citronella oil and its active component citronella, all elicited less than 50%
repellency. Repellency was greatly affected by volatility resulting in limited
efficacy after a few hours.

Clinical trials
Following their promising in vitro results, Mumcuoglu et al (2004) [104]
went on to conduct a randomized, double-blind, placebo-controlled clinical
trial to evaluate the efficacy of a citronella formulation as a louse repellent.
The study was conducted over four months in four elementary schools in
which 103 children were treated with the test formulation and 95 received a
placebo. Evaluations every two months resulted in a significant difference
between treated children (15.4% infested) and controls (55.1% infested).
In what may be an end to the piperonal saga, CM Brown and IF Burgess
(unpublished in Burgess 2004 [43]) evaluated piperonal in a six month long,
double-blind, cross-over, clinical field trial, involving forty families. Although
this study is yet to be published, the author stated that piperonal failed to
demonstrate clear effectiveness.
Despite a distinct lack of impressive results in in vitro studies and little in
the way of clinical evidence of efficacy, home remedy deterrents are gaining
20 Jörg Heukelbach et al.

favour as a way of addressing resistance issues, mistreatment, and reinfection.

In action on the part of the scientific community in identifying an effective
compound may be changing due to the increasing global prevalence of
pediculosis and accompanying increased awareness, which has resulted in a
dramatic increase in the number of over the counter head lice repellents and
preventatives that are not accompanied by quality assurance or regulation.

Natural products able to remove head lice eggs

There are two reasons for needing to remove head lice eggs. The first was
discussed in the above ovicide section which described how few pediculicides
are effective as ovicides leading to the necessity to retreat after eggs have
hatched following initial treatment. The second is that empty or dead eggs can
lead to people being falsely accused of harbouring an infestation.
Louse eggs are laid at the base of hairs close to the scalp and are attached
firmly by means of a quick-hardening secretion from the ovipositing female.
Eclosure occurs from 6 to 10 days later. Empty eggshells (nits) and dead eggs
usually remain attached to the hair for as long as 6 months and sometimes over
a year. Since human hair grows at a rate of about 1 cm per month, nits slowly
become more visible as the hair they are on grows away from the scalp. The
presence of nits commonly results in misdiagnosis and they can cause social
and mental disturbance.
Mechanical removal of lice and lice eggs is common in many developing
countries and while it is often used to enhance social bonding, it is a time
consuming method. Since many eggs are often nonviable, their removal is
often impractical and unjustified [105,106]. Removal using fine toothed nit
combs is common and can be facilitated by wetting the hair or applying a
slicking agent.
Although the ultimate egg removal product would aim to dissolve the
secretion that binds the egg to the hair shaft, this has not been achieved yet and
most chemical and natural products assist in the removal of eggs by making
the hair more slippery. Several have been tried such as the use of 8% formic
acid [107], acid shampoos (pH 4.5–5.5), 5% acetic acid, vinegar (diluted 1:1
with water), conditioners and vegetable oils which are claimed to be effective
in detaching eggs and nits from the hair [105].
There are no chemical or natural remedies for nit removal on the market
that have been clinically evaluated.

Conclusions
Large numbers of plant products offer promise for new compounds to treat
head lice both as essential oils and as individual compounds identified as
active ingredients in the effective essential oils. A major challenge for
manufacturers of natural products will be maintaining a commercial product of
Natural products against head lice 21

consistent composition owing to the potential variation in composition of

essential oils with location, cultivar, season and over time.
The number of new commercially available natural products for head lice
has expanded over the last decade to a much greater extent than products
containing defined chemical insecticides. However, the evidence on the
efficacy of these new products based on published results of in vitro and
clinical trials is markedly deficient. Evidence on safety is also deficient. All
over the counter natural products should be supported by in vitro data and well
designed comparative therapeutic trials using head lice derived from the
populations for whom the product is intended.
Since the prevalence and degree of insecticide resistance of head lice to
pyrethrin, permethrin and malathion is expected to increase, alternative topical
therapies for pediculosis are needed. It is possible that, on the long run, plant
extracts, or their constituent compounds, will replace chemical insecticides on
the market.

References
1. Araujo, A., Ferreira, L.F., Guidon, N., Maues Da Serra, F.N., Reinhard, K.J., and
Dittmar, K. 2000, Ten thousand years of head lice infection, Parasitol. Today, 16, 269.
2. Mumcuoglu, Y.K., and Zias, J. 1988, Head lice, Pediculus humanus capitis
(Anoplura: Pediculidae) from hair combs excavated in Israel and dated from the
first century B.C. to the eighth century A.D., J. Med. Entomol., 25, 545.
3. Reinhard, K.J., and Buikstra, J. 2003, Louse infestation of the Chiribaya culture,
southern Peru: variation in prevalence by age and sex, Mem. Inst. Oswaldo Cruz,
98 Suppl 1, 173.
4. Grodner, M.L. 2003, Pesticide regulation and pesticide education. Report to
AAPCO. http://aapse.ext.vt.edu/archives/97AAPCO_report.html .
5. Casida, J.E., and Quistad, G.B. 1998, Golden age of insecticide research: past,
present, or future?, Annu. Rev. Entomol., 43, 1.
6. Burgess, I.F. 1995, Human lice and their management, Adv. Parasitol., 36, 271.
7. Buxton, P.A. 1945, The use of new insecticide DDT in relation to the problems of
tropical medicine, Trans. R. Soc. Trop. Med. Hyg., 38, 367.
8. Busvine, J.R. 1948, The head and body races of Pediculus humanus L.,
Parasitology, 39, 1.
9. Lidror, R., and Lifshitz, Y. 1965, A new method for louse control in Israel, Public
Health (Israel), 8, 1.
10. Maunder, J.W. 1971, Resistance to organochlorine insecticides in head lice, and
trials using alternative compounds, Medical Officer, 125, 27.
11. Scowen, P. 1995, Government restricts the use of carbaryl for head lice, Prof. Care
Mother. Child, 5, 163, 165.
12. Downs, A.M., Stafford, K.A., Hunt, L.P., Ravenscroft, J.C., and Coles, G.C. 2002,
Widespread insecticide resistance in head lice to the over-the-counter
pediculocides in England, and the emergence of carbaryl resistance, Br. J.
Dermatol, 146, 88.
22 Jörg Heukelbach et al.

13. United States Federal Drug Administration 2003, Lindane Shampoo, USP, 1%.
http://www.fda.gov/cder/foi/label/2003/006309shampoolbl.pdf .
14. Casida, J.E. 1980, Pyrethrum flowers and pyrethroid insecticides, Environ. Health
Perspect., 34, 189.
15. Taplin, D., and Meinking, T.L. 1987, Pyrethrins and pyrethroids for the treatment
of scabies and pediculosis, Semin. Dermatol., 6, 125.
16. Heukelbach, J., and Feldmeier, H. 2004, Ectoparasites--the underestimated realm,
Lancet, 363, 889.
17. Burkhart, C.G., Burkhart, C.N., and Burkhart, K.M. 1998, An assessment of
topical and oral prescription and over-the-counter treatments for head lice, J. Am.
Acad. Dermatol, 38, 979.
18. Elston, D.M. 2003, Drug-resistant lice, Arch. Dermatol., 139, 1061.
19. Picollo, M.I., Vassena, C.V., Mougabure Cueto, G.A., Vernetti, M., and Zerba,
E.N. 2000, Resistance to insecticides and effect of synergists on permethrin
toxicity in Pediculus capitis (Anoplura: Pediculidae) from Buenos Aires, J. Med.
Entomol., 37, 721.
20. Hunter, J.A., and Barker, S.C. 2003, Susceptibility of head lice (Pediculus
humanus capitis) to pediculicides in Australia, Parasitol. Res., 90, 476.
21. Mumcuoglu, K.Y., Hemingway, J., Miller, J. et al 1995, Permethrin resistance in
the head louse Pediculus capitis from Israel, Med. Vet. Entomol., 9, 427, 447.
22. Burkhart, C.G., and Burkhart, C.N. 2006, Safety and efficacy of pediculicides for
head lice, Expert Opin. Drug Saf., 5, 169.
23. Yoon, K.S., Gao, J.R., Lee, S.H., Clark, J.M., Brown, L., and Taplin, D. 2003,
Permethrin-resistant human head lice, Pediculus capitis, and their treatment, Arch.
Dermatol., 139, 994.
24. Kristensen, M., Knorr, M., Rasmussen, A.M., and Jespersen, J.B. 2006, Survey of
permethrin and malathion resistance in human head lice populations from
Denmark, J. Med. Entomol., 43, 533.
25. Burkhart, C.G. 2004, Relationship of treatment-resistant head lice to the safety and
efficacy of pediculicides, Mayo Clin. Proc., 79, 661.
26. Lange, W. 1984, Piperonyl butoxide: synergistic effects on different neem seed
extracts and influence on degradation of an enriched extract by ultra-violet light.
Rauischholzhausen, Germany. Natural Pesticides from the Neem Tree
(Azadirachta indica A. Juss) and Other Tropical Plants. Abstracts of the Second
International Neem Conference, 16.
27. Shaalan, E.A., Canyon, D., Younes, M.W., bdel-Wahab, H., and Mansour, A.H.
2005, A review of botanical phytochemicals with mosquitocidal potential, Environ.
Int., 31, 1149.
28. Organic Trade Association 2006, OTA's 2006 Manufacturer Survey.
http:www.ota.com/pics/documents/short%20overview%20MMS.pdf .
29. Muhawi, D. 2004, Safe pesticides? Natural vs. synthetic pesticides.
http:www.ecoworld.com/Home/Articles2.cfm?TID=351 .
30. United States Department of Agriculture 2002, Organic production and handling
standards. http://www.ams.usda.gov/nop/FactSheets/ProdHandE.html .
31. Canyon, D., and Speare, R. 2006, A comparison of botanical and synthetic
substances used to prevent head lice, Int. J. Dermatol., in press.
Natural products against head lice 23

32. Ellis, E.F., Frankowski, B.L., Schoessler, S.Z., West, D.P., Hansen, R.C., and
Meinking, T.L. 2004, Faculty discussion: definitive management of head lice in the
era of pediculicide resistance, Am. J. Manag. Care, 10, S283-S286.
33. Elston, D.M. 2005, Lice. http://www.emedicine.com/derm/topic229.htm .
34. Ciccia, G., Coussio, J., and Mongelli, E. 2000, Insecticidal activity against Aedes
aegypti larvae of some medicinal South American plants, J. Ethnopharmacol., 72,
185.
35. Kimball, J.W. 2006, Kimball's Biology Pages.
http://users.rcn.com/jkimball.ma.ultranet/BiologyPages/ .
36. Yang, Y.C., Lee, S.G., Lee, H.K., Kim, M.K., Lee, S.H., and Lee, H.S. 2002, A
piperidine amide extracted from Piper longum L. fruit shows activity against
Aedes aegypti mosquito larvae, J. Agric. Food Chem., 50, 3765.
37. Perrucci, S., Cioni, P.L., Cascella, A., and Macchioni, F. 1997, Therapeutic
efficacy of linalool for the topical treatment of parasitic otitis caused by Psoroptes
cuniculi in the rabbit and in the goat, Med. Vet. Entomol., 11, 300.
38. Momin, R.A., and Nair, M.G. 2002, Pest-managing efficacy of trans-asarone
isolated from Daucus carota L. seeds, J. Agric. Food Chem., 50, 4475.
39. Roth, G.N., Chandra, A., and Nair, M.G. 1998, Novel bioactivities of Curcuma
longa constituents, J. Nat. Prod., 61, 542.
40. Nash, B. 2003, Treating head lice, Br. Med. J., 326, 1256.
41. Takano-Lee, M., Yoon, K.S., Edman, J.D., Mullens, B.A., and Clark, J.M. 2003, In
vivo and in vitro rearing of Pediculus humanus capitis (Anoplura: Pediculidae), J.
Med. Entomol., 40, 628.
42. Oladimeji, F.A., Orafidiya, O.O., Ogunniyi, T.A., and Adewunmi, T.A. 2000,
Pediculocidal and scabicidal properties of Lippia multiflora essential oil, J.
Ethnopharmacol., 72, 305.
43. Burgess, I.F. 2004, Human lice and their control, Annu. Rev. Entomol., 49, 457.
44. Heukelbach, J., Oliveira, F.A., and Speare, R. 2006, A new shampoo based on neem
(Azadirachta indica) is highly effective against head lice in vitro, Parasitol. Res..
45. Burkhart, C.N., and Burkhart, C.G. 2001, Recommendation to standardize
pediculicidal and ovicidal testing for head lice (Anoplura: Pediculidae), J. Med.
Entomol., 38, 127.
46. Burkhart, C.N., and Burkhart, C.G. 2004, Head lice revisited: in vitro standardized
tests and differences in malathion formulations, Arch. Dermatol., 140, 488.
47. Yang, Y.C., Lee, H.S., Clark, J.M., and Ahn, Y.J. 2004, Insecticidal activity of
plant essential oils against Pediculus humanus capitis (Anoplura: Pediculidae), J.
Med. Entomol., 41, 699.
48. Yang, Y.C., Choi, H.Y., Choi, W.S., Clark, J.M., and Ahn, Y.J. 2004, Ovicidal and
adulticidal activity of Eucalyptus globulus leaf oil terpenoids against Pediculus
humanus capitis (Anoplura: Pediculidae), J. Agric. Food Chem., 52, 2507.
49. Yang, Y.C., Lee, S.H., Lee, W.J., Choi, D.H., and Ahn, Y.J. 2003, Ovicidal and
adulticidal effects of Eugenia caryophyllata bud and leaf oil compounds on
Pediculus capitis, J. Agric. Food Chem., 51, 4884.
50. Meinking, T.L. 2004, Clinical update on resistance and treatment of Pediculosis
capitis, Am. J Manag. Care, 10, S264.
51. Downs, A.M., Stafford, K.A., and Coles, G.C. 2000, Monoterpenoids and tetralin
as pediculocides, Acta Derm. Venereol., 80, 69.
24 Jörg Heukelbach et al.

52. Veal, L. 1996, The potential effectiveness of essential oils as a treatment for
headlice, Pediculus humanus capitis, Complement Ther. Nurs. Midwifery, 2, 97.
53. Walton, S.F., McKinnon, M., Pizzutto, S., Dougall, A., Williams, E., and Currie,
B.J. 2004, Acaricidal activity of Melaleuca alternifolia (tea tree) oil: in vitro
sensitivity of sarcoptes scabiei var hominis to terpinen-4-ol, Arch. Dermatol., 140,
563.
54. Mills, C., Cleary, B.J., Gilmer, J.F., and Walsh, J.J. 2004, Inhibition of
acetylcholinesterase by Tea Tree oil, J. Pharm. Pharmacol., 56, 375.
55. Morsy, T.A., el Ela, R.G., Nasser, M.M., Khalaf, S.A., and Mazyad, S.A. 2000,
Evaluation of the in-vitro pediculicidal action of four known insecticides and three
medicinal plant extracts, J. Egypt. Soc. Parasitol, 30, 699.
56. Brahmachari, G. 2004, Neem--an omnipotent plant: a retrospection,
ChemBiochem., 5, 408.
57. Yang, Y.C., Lee, H.S., Lee, S.H., Clark, J.M., and Ahn, Y.J. 2005, Ovicidal and
adulticidal activities of Cinnamomum zeylanicum bark essential oil compounds and
related compounds against Pediculus humanus capitis (Anoplura: Pediculicidae),
Int. J. Parasitol., 35, 1595.
58. Avlessi, A., Alitonou, G., Sohounhloue, D.K., Menut, C., and Bessiere, J.M. 2005,
Aromatic Plants of Tropical West Africa, Part XIV. Chemical and Biological
Investigation of Lippia multiflora Mold. Essential Oil from Benin.
http:www.findarticles.com/p/articles/mi_qa4091/is_200507/ai_n14901737.
59. McCage, C.M., Ward, S.M., Paling, C.A., Fisher, D.A., Flynn, P.J., and
McLaughlin, J.L. 2002, Development of a paw paw herbal shampoo for the
removal of head lice, Phytomedicine, 9, 743.
60. Priestley, C.M., Burgess, I.F., and Williamson, E.M. 2006, Lethality of essential
oil constituents towards the human louse, Pediculus humanus, and its eggs,
Fitoterapia, 77, 303.
61. Tiangda, C.H., Gritsanapan, W., Sookvanichsilp, N., and Limchalearn, A. 2000,
Anti-headlice activity of a preparation of Annona squamosa seed extract, Southeast
Asian J. Trop. Med. Public Health, 31 Suppl 1, 174.
62. Mougabure, C.G., Zerba, E.N., and Picollo, M.I. 2006, Permethrin-resistant head
lice (Anoplura: Pediculidae) in Argentina are susceptible to spinosad, J. Med.
Entomol., 43, 634.
63. Sparks, T.C., Crouse, G.D., and Durst, G. 2001, Natural products as insecticides:
the biology, biochemistry and quantitative structure-activity relationships of
spinosyns and spinosoids, Pest. Manag. Sci., 57, 896.
64. van der Stichele, R.H., Dezeure, E.M., and Bogaert, M.G. 1995, Systematic review
of clinical efficacy of topical treatments for head lice, Br. Med. J., 311, 604.
65. Dodd, C. 2001, Treatment of head lice, Br. Med. J., 323, 1084.
66. Meinking, T.L., Serrano, L., Hard, B. et al 2002, Comparative in vitro
pediculicidal efficacy of treatments in a resistant head lice population in the United
States, Arch. Dermatol., 138, 220.
67. Ghaffar, F.A., and Semmler, M. 2006, Efficacy of neem-seed extract shampoo on
head lice of naturally infected humans in Egypt, Parasitol. Res., in press.
68. Niemann, L., Stinchcombe, S., and Hilbig, V., 2002, The Neem Tree - Sources of
unique products for integrated pest management, medicine, industry and other
purposes, H. Schmutterer (Ed.), Neem Foundation, Mumbai, 607.
Natural products against head lice 25

69. Charles, V., and Charles, S.X. 1992, The use and efficacy of Azadirachta indica
ADR ('Neem') and Curcuma longa ('Turmeric') in scabies. A pilot study, Trop
Geogr. Med, 44, 178.
70. Gandhi, M., Lal, R., Sankaranarayanan, A., Banerjee, C.K., and Sharma, P.L.
1988, Acute toxicity study of the oil from Azadirachta indica seed (neem oil), J.
Ethnopharmacol., 23, 39.
71. Sinniah, D., Schwartz, P.H., Mitchell, R.A., and Arcinue, E.L. 1985, Investigation
of an animal model of a Reye-like syndrome caused by Margosa oil, Pediatr. Res.,
19, 1346.
72. Hartford, O., and Zug, K.A. 2005, Tea tree oil, Cutis, 76, 178.
73. Hammer, K.A., Carson, C.F., Riley, T.V., and Nielsen, J.B. 2006, A review of the
toxicity of Melaleuca alternifolia (tea tree) oil, Food Chem. Toxicol., 44, 616.
74. Willcox, M. 2005, An evaluation of tea tree oil as an alternative microbicide, Nurs.
Times, 101, 32.
75. Crawford, G.H., Sciacca, J.R., and James, W.D. 2004, Tea tree oil: cutaneous
effects of the extracted oil of Melaleuca alternifolia, Dermatitis, 15, 59.
76. Khanna, M., Qasem, K., and Sasseville, D. 2000, Allergic contact dermatitis to tea
tree oil with erythema multiforme-like id reaction, Am. J. Contact Dermat., 11,
238.
77. Bruynzeel, D.P. 1999, Contact dermatitis due to tea tree oil, Trop. Med. Int.
Health, 4, 630.
78. Rubel, D.M., Freeman, S., and Southwell, I.A. 1998, Tea tree oil allergy: what is
the offending agent? Report of three cases of tea tree oil allergy and review of the
literature, Australas. J. Dermatol., 39, 244.
79. Apted, J.H. 1991, Contact dermatitis associated with the use of tea-tree oil,
Australas. J. Dermatol., 32, 177.
80. Morris, M.C., Donoghue, A., Markowitz, J.A., and Osterhoudt, K.C. 2003,
Ingestion of tea tree oil (Melaleuca oil) by a 4-year-old boy, Pediatr. Emerg. Care,
19, 169.
81. Del Beccaro, M.A. 1995, Melaleuca oil poisoning in a 17-month-old, Vet. Hum.
Toxicol., 37, 557.
82. Jacobs, M.R., and Hornfeldt, C.S. 1994, Melaleuca oil poisoning, J. Toxicol. Clin.
Toxicol., 32, 461.
83. Mumcuoglu, K.Y., Miller, J., Zamir, C., Zentner, G., Helbin, V., and Ingber, A.
2002, The in vivo pediculicidal efficacy of a natural remedy, Isr. Med. Assoc. J., 4,
790.
84. Jensen, O., Nielsen, A.O., and Bjerregaard, P. 1978, Pediculosis capitis treated
with quassia tincture, Acta Derm. Venereol., 58, 557.
85. King, W.V. 1954, Chemicals evaluated as insecticides and repellents at Orlando,
Fla. United States Department of Agriculture - Agric.Res.
86. Abramowicz, M. 1995, Drugs for parasitic infections, Med. Lett. Drugs Ther., 37,
99.
87. Cordero, C., and Zaias, N. 1987, Clinical evaluation of pediculicidal and ovicidal
efficacy of two pyrethrin-piperonyl-butoxide formulations, Clin. Ther., 9, 461.
88. Burgess, I.F., Brown, C.M., and Burgess, N.A. 1994, Synergized pyrethrin mousse,
a new approach to head lice eradication: efficacy in field and laboratory studies,
Clin. Ther., 16, 57.
26 Jörg Heukelbach et al.

89. Dethier, V.G. 1947, Chemical insect attractants and repellents, HK Lewis and Co.
Ltd., London.
90. Burgess, I. 1993, New head louse repellent, Br. J Dermatol, 128, 357.
91. Spencer, G. 1941, The control of human lice under war conditions, Canadian
Entomologist, 73, 20.
92. Sobel, J. 1913, Pediculosis among school children, New York Medical Journal, 98,
656.
93. Lloyd, L. 1919, Lice and their menace to man, Oxford University Press, London.
94. Nuttall, G.H.F. 1918, Combating lousiness among soldiers and civilians,
Parasitology, 10, 411.
95. Buxton, P.A. 1938, Studies on populations of head lice (Pediculus humanus
capitis, Anoplura), Parasitology, 30, 85.
96. Pence, R.J., and Viray, M.S. 1969, Atrophy and developmental abnormality in
insects exposed to dodecyl alchohol, J. Econ. Entomol., 62, 622.
97. Moore, W. 1918, Methods of control of the clothes louse [Pediculus humanus
(vestimenti)], J. Lab. Clin. Med., 3, 1.
98. Corlette, C.E. 1925, Heliotropine: the best pediculicide, Med J Aust, 1, 185.
99. Peock, S., and Maunder, J.W. 1993, Arena tests with piperonal, a new louse
repellent, J. R. Soc. Health, 113, 292.
100. Ibarra, J., and Williams, B. 1994, Head louse repellents, J. R. Soc. Health, 114,
108.
101. Mumcuoglu, K.Y., Galun, R., Bach, U., Miller, J., and Magdassi, S. 1996,
Repellency of essential oils and their components to the human body louse,
Entomol. Exp. Appl., 78, 309.
102. Weston, S.E., Burgess, I., and Williamson, E.M. 1997, Oils against head lice in
'development in pharmacognosy', The Pharmaceutical Journal, 259, 482.
103. Windholz, M. 1983, The Merck Index, Merck, Rahway, USA.
104. Mumcuoglu, K.Y., Magdassi, S., Miller, J. et al 2004, Repellency of citronella for
head lice: double-blind randomized trial of efficacy and safety, Isr. Med. Assoc. J.,
6, 756.
105. Mumcuoglu, K.Y., and Gilead, L.T. 2006, Recommendations for the treatment of
scabies infestations in Israel, Isr. Med. Assoc. J., 8, 196.
106. Mumcuoglu, K.Y. 2006, International guidelines for effective control of head louse
infestations. http://www.phtiraptera.org/Guidelines/index_gl.html .
107. DeFelice, J., Rumsfield, J., Bernstein, J.E., and Roshal, J.Y. 1989, Clinical
evaluation of an after-pediculicide nit removal system, Int. J. Dermatol., 28, 468.