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