Head lice: Scientific assessment of the nit sheath with clinical ramifications and therapeutic options

Pediculosis capitis risk factors in schoolchildren: hair thickness and hair length

The human head lice is a cosmopolitan ectoparasite that causes pediculosis. The main way of spreading lice is through direct head-to-head contact. It is popular knowledge that some individuals are more susceptible to contracting head lice than others. Reports of individuals who have never been affected by the disease are common, even living in the same environment and under the same conditions as people who regularly have lice infestations. Previous research has been carried out on the risk of this infection associated with different human factors like gender or age. However, studies on the influence of the individual hair characteristics are scarce. The objective of the study was to analyze the pediculosis risk using geographical location, gender, age and individual hair characteristics as variables. Pediculosis was diagnosed through the detection of living lice in the hair. This cross-sectional school-based epidemiological study was conducted in 310 schoolchildren aged 1 to 13 years of schools in 4 municipalities situated in the State of Paraná, Brazil. The prevalence of head louse infection in primary school students was 49.35 %. The Odds Ratio of presence of pediculosis (OR) was estimated using multivariate logistic regression analysis. The results obtained indicate that hair length and thickness increase the risk of infection. Furthermore, the inclusion of hair color, hair shape, kind of hair-scale as covariates increases the risk of pediculosis, indicating that these variables partly explain this susceptibility and that pediculosis is independent of gender. A smaller hair diameter may favor insect fixation to the hair in the nymphal phases. These results may explain why girls are a greater risk as they let their hair grow for cultural reasons, i.e., being of female gender is an agglutinating variable. The conclusions drawn may explain the discrepancies obtained in previous analyses.

Embryonic Development of Pediculus humanus capitis: Morphological Update and Proposal of New External Markers for the Differentiation Between Early, Medium, and Late Eggs

BACKGROUND AND OBJECTIVES

The head louse Pediculus humanus capitis is a cosmopolitan ectoparasite that causes pediculosis. In the study of human lice, little research focuses on embryonic development. Currently, external markers of embryonic development represent a new approach in the evaluation of ovicidal drugs. The objective of this work was to update the morphology of embryonic development and propose novel external markers to differentiate between early, medium, or late P. h. capitis eggs.

METHODS

Using stereoscopic light microscopy, we describe the morphological characteristics of P. h. capitis eggs with a special focus on embryonic development.

RESULTS

The morphological analysis of the eggs revealed the presence of an operculum with ten aeropyles, although no micropyles were observed. For the first time, the presence of defective eggs that were non-viable due to the apparent absence of yolk granules was documented. The early eggs presented yolk granules and developing germ bands, while the medium eggs presented an embryonic rudiment and the outlines of the eyes and limbs. In late eggs, the head with eyes and antennae, the thorax with three pairs of legs, and the abdomen with six pairs of spiracles were observed as formed structures. At the end of this stage, the embryos acquired the morphology of the nymph I stage.

CONCLUSION

We propose novel biomarkers (e.g., the presence of spiracles and antennae, the proportion of the egg occupied by the embryo) to facilitate the differentiation between the developmental stages. The updated morphological characteristics of P. h. capitis eggs facilitate the standardization of toxicological tests in the quest for ovicidal drugs.

Ancient human genomes and environmental DNA from the cement attaching 2,000 year-old head lice nits

Over the past few decades, there has been a growing demand for genome analysis of ancient human remains. Destructive sampling is increasingly difficult to obtain for ethical reasons, and standard methods of breaking the skull to access the petrous bone or sampling remaining teeth are often forbidden for curatorial reasons. However, most ancient humans carried head lice and their eggs abound in historical hair specimens. Here we show that host DNA is protected by the cement that glues head lice nits to the hair of ancient Argentinian mummies, 1,500–2,000 years old. The genetic affinities deciphered from genome-wide analyses of this DNA inform that this population migrated from north-west Amazonia to the Andes of central-west Argentina; a result confirmed using the mitochondria of the host lice. The cement preserves ancient environmental DNA of the skin, including the earliest recorded case of Merkel cell polyomavirus. We found that the percentage of human DNA obtained from nit cement equals human DNA obtained from the tooth, yield 2-fold compared with a petrous bone, and 4-fold to a bloodmeal of adult lice a millennium younger. In metric studies of sheaths, the length of the cement negatively correlates with the age of the specimens, whereas hair linear distance between nit and scalp informs about the environmental conditions at the time before death. Ectoparasitic lice sheaths can offer an alternative, nondestructive source of high-quality ancient DNA from a variety of host taxa where bones and teeth are not available and reveal complementary details of their history.

Children’s Perception Scale of Head Lice Infestation (CPS-HLI): Design and Psychometrics

Background: Pediculosis is a common ectoparasitic infestation that involves especially the skin of children worldwide. Studying the children’s perception of the disease’s risk factors, the effectiveness of personal preventive measures, and its implications for their health could be a major leap forward in health promotion activities. Objectives: This study aimed to develop and evaluate the psychometric properties of the Children’s Perception Scale of Head Lice Infestation (CPS-HLI) and its initial feasibility assessment for use on Iranian and possibly other elementary school children. Methods: The scale’s items were retained based on an extensive literature search and classified into the underlying constructs of the extended health belief model (EHBM). An expert panel endorsed the qualitative content and face validity of the preliminary draft, and 47 items remained for quantitative validity testing on a sample of 362 elementary school students in the city of Paveh, West of Iran. Explanatory and confirmatory factor analyses (EFA and CFA) were employed to test the content and structural validity of the constructed instrument. Cronbach's alpha and intra-class correlation coefficients were calculated to assess the internal consistency and reliability of the scale. Results: The values of Lawshe's content validity index (0.90) and content validity ratio (0.77), the subscales’ Cronbach's alpha (0.59), and intra-class correlation (0.72) coefficients confirmed plausible internal consistency of the scale. The values of root mean square error of approximation (RMSEA) (< 0.08 with χ2 < 0.05), Tucker-Lewis index (TLI), and comparative fit index (CFI) > 0.9 approved the applied statistical model’s goodness of fit. The ranges of Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy for the underlying subscales (0.49 - 0.74) and the statistically significant result of Bartlett’s test of sphericity (P < 0.001) confirmed the patterned relationship among the constructed scale’s items. The principal component analysis that was performed using STATA favored the 11-factor solution. Conclusions: The study findings support the construct validity of CPS-HLI for use in studies on children’s perception of head lice infestation risk factors, the effectiveness of personal preventive measures, and the disease implications for their health and well-being. Further cross-cultural and cross-national validation studies are recommended for using the instrument in a wider range of populations and settings.

Who Bites Me? A Tentative Discriminative Key to Diagnose Hematophagous Ectoparasites Biting Using Clinical Manifestations

Arthropod blood feeders are vectors of several human pathogenic agents, including viruses (e.g., yellow fever, chikungunya, dengue fever), parasites (e.g., malaria, leishmaniasis, lymphatic filariasis), or bacteria (e.g., plague). Besides their role as a vector of pathogens, their biting activities cause a nuisance to humans. Herein, we document clinical symptoms associated with the biting of ten clusters of hematophagous arthropods, including mosquitoes, biting midges and sandflies, lice, ticks, tsetse flies, blackflies, horse flies, fleas, triatomine and bed bugs. Within the framework of clinical history and entomo-epidemiological information, we propose a tentative discriminative key that can be helpful for practicing physicians in identifying hematophagous arthropods biting humans and delivering treatment for the associated clinical disorders.

Head louse egg and nit remover-a modern "Quest for the Holy Grail"

Background

The eggs of head lice are fixed to the hair of their hosts by means of a persistent glue-like fixative that is not chemically bound to the substrate. Eggshells stuck to hairs after successfully treating the infestation are a cosmetic issue and a source of misunderstanding about whether the infestation is eliminated. Hitherto, no effective treatment to loosen louse eggs and nits has been found.

Methods

An extensive screening of surface active compounds, oils, esters, and other cosmetic lubricants used a slip-peel device to measure the forces required to release the grip of the fixative. Promisingly effective compounds were formulated into suitable carriers for further testing. The most effective combination formulation was tested, as a commercial product (Hedrin Stubborn Egg Loosening Lotion), in a usage study of 15 children with nits, in which one half of the head was combed only on damp hair and the other half combed after a 10 min treatment using the product.

Results

Laboratory tests of the forces required to remove nits found that pelagonic acid derivatives, particularly isononyl isononanoate, in the presence of a polymeric gelling agent and water, were most effective to reduce the initial grip of the fixative as well as reducing friction as the eggshell is drawn along the hair shaft and that the final product was significantly (p < 0.05) more effective than several other marketed materials. In the usage study significantly (p = 0.01046) more louse eggs and nits were removed after treatment with the gel.

Discussion

The product developed through this study is the first with a demonstrable efficacy for loosening the grip of the louse egg fixative from hair. Consequently, until now, and despite the availability of effective pediculicidal treatments, dealing with the eggshells persisting after an infestation has been an onerous task for most households. This type of product can enable families to deal more easily with persistent eggshells and improve self-esteem in affected children.

Effect of a New Head Lice Treatment, Abametapir Lotion, 0.74%, on Louse Eggs: A Randomized, Double-Blind Study

Few head lice treatments have demonstrated effectiveness against louse eggs. Abametapir, a metalloproteinase inhibitor, is able to target metalloproteinases critical to egg hatching and louse development. In this double-blind, phase 2 study, 50 subjects aged ≥3 years with active head lice infestation were randomized to receive a single treatment of abametapir lotion, 0.74%, or vehicle (control), applied to scalp and hair for 10 minutes. Ovicidal efficacy was measured by recording the hatch rate of eggs collected from each subject’s hair before and after treatment and incubated for 14 days. With abametapir, 100% of treated eggs remained unhatched compared with 64.0% for vehicle. Accounting for pretreatment hatch rates, the absolute reduction in egg hatching was 92.9% for abametapir versus 42.3% for vehicle (P < .0001). The most frequently reported adverse event was rash (16%). Abametapir lotion, 0.74%, demonstrated significant ovicidal activity against head lice eggs with a single application.

Characterization of the human head louse nit sheath reveals proteins with adhesive property that show no resemblance to known proteins

Human head and body lice attach their eggs respectively to human hair or clothing by female lice secreted glue that hardens into a nit sheath that protects the egg. In this study, a series of experiments were conducted to characterize the glue-like material of the nit sheath. Fourier transform infrared spectroscopy on embryo-cleared nit showed proteinaceous amide I bands. With this result, we determined the amino acid composition of the nit sheath proteins and performed similarity search against the protein products of the body louse genome to identify the candidate nit sheath proteins. The identified two homologous proteins newly named as louse nit sheath protein (LNSP) 1 and LNSP2 are composed of three domains of characteristic repeating sequences. The N-terminal and middle domains consist of tandem two-residue repeats of Gln-Ala and Gly-Ala, respectively, which are expected to fold into β-strands and may further stack into β-sheets, whereas the C-terminal domain contains multiple consecutive Gln residues. Temporal and spatial transcription profiling demonstrated that both LNSP1 and LNSP2 are most predominantly expressed in the accessory gland of females of egg-laying stage, supporting that they indeed encode the nit sheath proteins. Further adhesive property of recombinant partial LNSP1 suggests that both LNSP1 and LNSP2 may act as glues.

Head lice

Head lice infestation is associated with limited morbidity but causes a high level of anxiety among parents of school-aged children. Since the 2010 clinical report on head lice was published by the American Academy of Pediatrics, newer medications have been approved for the treatment of head lice. This revised clinical report clarifies current diagnosis and treatment protocols and provides guidance for the management of children with head lice in the school setting.

Influence of the formulations in removing eggs of Pediculus humanus capitis (Phthiraptera: Pediculidae)

Head lice lay eggs in human head hairs in order to reproduce. There is a difficulty associated to the process of detaching these eggs: they are tightly gripped to the hair by a secretion produced by female head lice. The physical removal of eggs has become an important part of treatment of louse infestations. The finding of new products to loosen the eggs is necessary to avoid mistaken diagnosis or reinfestations. This work aimed to compare different kinds of pediculicide formulations in order to find if their presentations represented differences in the egg remover effect. We also wanted to present a new device to test the efficacy of the egg remover formulations. Products with creamy presentations (Bio infant lice and egg remover and hair conditioner) and one containing dimethicone (Nyda) showed the lower mean forces compared with the control (lower mean forces represented best removal activity). Whereas, the Biferdil egg remover (gel) and Nopucid Tribit (hydroalcoholic lotion) had no egg removal effect, presenting the highest mean forces (177.82 and 189.99 mN, respectively) compared with the control. Additionally, we proposed a removal index (RI) to compare the efficacy of different products on the egg removal activity (RI > 0, good performance). The higher index values were for Bio infant lice and egg remover (0.72) and Biferdil hair conditioner (0.58). The lowest index values were for Biferdil egg remover (-0.26) and Nopucid Tribit (-0.35).The formulation of over the counter pediculicides in the egg remover effect was discussed.

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.

Severe head lice infestation in an Andean mummy of Arica, Chile

Pediculus humanus capitis is an ancient human parasite, probably inherited from pre-hominid times. Infestation appears as a recurrent health problem throughout history, including in pre-Columbian populations. Here, we describe and discuss the occurrence of pre-Columbian pediculosis in the Andean region of the Atacama Desert. Using a light microscope and scanning electron microscopy, we studied a highly infested Maitas Chiribaya mummy from Arica in northern Chile dating to 670-990 calibrated years A.D. The scalp and hair of the mummy were almost completely covered by nits and adult head lice. Low- and high-vacuum scanning electron microscopy revealed a well-preserved morphology of the eggs. In addition, the excellent preservation of the nearly 1,000-yr-old adult head lice allowed us to observe and characterize the head, antennae, thorax, abdomen, and legs. Leg segmentation, abdominal spiracles, and sexual dimorphism also were clearly observed. The preservation of the ectoparasites allowed us to examine the micromorphology using scanning electron microscopy; the opercula, aeropyles, and spiracles were clearly visible. This case study provides strong evidence that head lice were a common nuisance for Andean farmers and herders. Head lice are transmitted by direct head-to-head contact; thus, this ancient farmer and herder was potentially infesting other people. The present study contributes to the body of research focusing on lice in ancient populations.

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.

Head lice

Head lice infestation is associated with limited morbidity but causes a high level of anxiety among parents of school-aged children. Since the 2002 clinical report on head lice was published by the American Academy of Pediatrics, patterns of resistance to products available over-the-counter and by prescription have changed, and additional mechanical means of removing head lice have been explored. This revised clinical report clarifies current diagnosis and treatment protocols and provides guidance for the management of children with head lice in the school setting.

Do nit removal formulations and other treatments loosen head louse eggs and nits from hair?

Eggs of the head louse, Pediculus capitis De Geer (Phthiraptera: Pediculidae), are difficult to remove because the female louse fixes them to hairs using a proteinaceous secretion that hardens within seconds. The persistent eggshells are harmless but unsightly and are often mistaken for an active infestation. Combing with a fine comb (nit comb) does not readily remove the eggs or empty eggshells because of the resilience of the fixative and both folk remedies and medical products have claimed to facilitate their removal. Measurement of the force required to initiate sliding of the egg fixative using a slip-peel tester was unable to detect evidence that any of three products which claimed to have egg-loosening properties (Step 2 Nit Removal System, Clear Lice Egg Remover, RID Lice Egg Loosener Gel) had any activity or exerted any effect on the egg fixative beyond the lubricating effects conveyed by water or conventional hair conditioner.

Fomite transmission in head lice

Control of various infestations requires an accurate understanding of transmission. After thousands of years of lice infestation, scientific documentation of indirect contact transmission has been substantiated. Lice can be transferred in the egg, instar, and adult stages. Lice have now been shown in the laboratory to be readily dislodged by air movements such as blow-drying one's hair, combing, and toweling. Moreover, passive transfer to adjoining fabric is also frequently observed. Louse transmission by fomites occurs more frequently than has been commonly believed. Close proximity suffices to increase the likeliness of a new infestation. Thus louse control measures should take account of fomite transmission and include screening of all individuals within an infested person's immediate circle of contact, laundering of everything within the infested individuals' bed or quarantining of such material for 10 days, thorough vacuuming of floors, carpets, upholstery, with a standard vacuum cleaner.

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.

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.