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204346
REVIEW
Medicinal properties of jojoba (Simmondsia chinensis)
Zipora Tietela, Shirin Kahremanyb, Guy Cohenb,c and Navit Ogen-Shternb,c
aDepartment of Food Science, Gilat Research Center, Agricultural Research Organization, MP Negev 8531100, Israel; bThe Skin Re-
search Institute, The Dead-Sea and Arava Science Center, Masada, 86910, Israel; cBen Gurion University of the Negev, Eilat Campus,
Eilat 8855630, Israel
ABSTRACT
Jojoba,Simmondsia chinensis (Link) C.K. Schneider is an evergreen shrub widely grown in Israel,
the Middle East, South America, Africa, India and Australia used as an agricultural crop for com-
mercial purposes and as a source of its non-edible natural wax. It is widely used in pharmaceutics
and cosmetic formulation due to its unique structural characteristics and benecial health eects.
In addition, extensive work has been published on the plant’s health-promoting activities, ranging
from antioxidant activities to the treatment of cancer. Being a rich source of natural liquid wax, the
majority of research regarding jojoba focuses on its applications, as well as on the ability to exploit
the residual plant materials obtained in its production. To date, several potent phytochemicals
have been attributed to its medicinal properties, e.g. simmondsin and phenolic compounds. The
current review emphasizes the evidence-based medicinal qualities of the wax and plant extracts
and highlights the gaps of knowledge in these research areas and the importance of acquiring
additional understanding of jojoba distinctive traits.
Introduction – Jojoba, the desert gold
Jojoba,Simmondsia chinensis (Link) C.K. Schneider (Fig.
1), is an ever-green dioecious shrub growing in arid and
semi-arid areas. This desert shrub can be grown in harsh,
low irrigation and high-temperature environment (Ash
et al. 2005), and it is tolerant to various environmental
conditions (Kumar et al. 2012; Arya & Khan 2016). Taxo-
nomically, it is the single member of the Simmondsia-
ceae family (Chase et al. 2016). The plant is native to Baja
California and the Sonoran Desert in north-central Mex-
ico and the southwestern United States. It was rst men-
tioned in the literature by the Mexican historian Clavi-
jero (1789) as a plant used by native-Americans in Baja
California for its medicinal properties and as currency for
the exchange of goods. A number of botanists, the rst
of whom was Link, presented initial descriptions of the
plant and granted it its scientic name and taxonomic
classication (Daugherty et al. 1958). Since the 1930s,
jojoba has been scientically studied. Research intensi-
ed during the 1950s, when jojoba wax was suggested
as a substitute for banned whale sperm oil, and com-
mercial interest in jojoba as a new agricultural industry
emerged (Benzioni 2010). Due to its similarity to whale
sperm oil, it was originally used mainly as a renewable
non-animal substitute for industrial needs (Gisser et al.
1975). First successes in domesticating jojoba occurred
in California and Arizona in the late 1960s and shortly
after also in Israel (Benzioni 2010).
KEYWORDS
Jojoba; medicinal properties;
antioxidant; dermatology;
bioactive molecules;
Simmondsia chinensis;
simmondsin
ARTICLE HISTORY
Received August
Accepted December
© Tietel et al., 2021
CONTACT Guy Cohen Guy@adssc.org
This is an open access article distributed under the terms of the CC BY-NC 4.0 license.
http://dx.doi.org/./-bja
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Genetics and diversity
Being a dioecious plant, the genetic variability of jo-
joba is translated into hundreds of cultivated clones,
which hardens obtaining homogenous desired fea-
tures such as the quantity of seeds, and the quality
and yield of the liquid wax. Hence, the majority of cul-
tivation is performed using vegetative propagation of
mother plants, which reduces genetic variability but
paradoxically leads to genetic vulnerability (Al-Obaidi
et al. 2017). In light of this, it is especially important to
understand the genotypes responsible for the quality
of jojoba propagation and the content of jojoba seeds,
as well as additional compounds. Several studies were
published in this regard. Of these, few demonstrated
variability in the content and quality of jojoba oil, and
additional compounds, such as simmondsin (will be
later elaborated) content among dierent jojoba gen-
otypes (Benzioni et al. 2005; Al-Soqeer et al. 2012). In
parallel, several methods for detecting genetic poly-
morphism and providing genotypes with molecular
ngerprinting have been published and described in
more detail in (Al-Obaidi et al. 2017). Clearly, it is still
worthwhile to place great emphasis on understanding
the genetics of jojoba. In addition, the impact of cul-
tivation seems to play a key role in its variable yields
(Atteya et al. 2018; Khattab et al. 2019).
Market and usages
The uniqueness of the jojoba plant stems from the
unusual presence, amount, and chemical structure of
liquid wax in its seeds, which consists of approximate-
ly 50% of the seed weight (Al-Widyan & Al-Muhtaseb
2010). Jojoba wax, also termed jojoba oil, is com-
prised of long-chain esters. These can be exploited
in several industrial applications, most prominent are
pharmaceutics and cosmetics, due to the structural
resemblance with human skin sebum and structural
properties. Additional industrial uses that previously
utilized whale sperm oil take advantage of jojoba oil in
the production of plastics, detergents, renewable en-
ergy, and lubricants (Al-Widyan & Al-Muhtaseb 2010;
Sandouqa & Al-Hamamre 2019; Vaillant et al. 2019). As
a high yielding non-edible oil, its use as a raw mate-
rial for the creation of biodiesel has been considered
(Sandouqa & Al-Hamamre 2019). Of note, jojoba oil
global production is growing rapidly, and has already
exceeded 15,000 tons (2018) and is expected to reach
22,000 tons by 2022 (Worldwide analysis on the jojoba
oil market; Bilin et al. 2018). This tremendous growth
may be due to market demands, or alternatively, sug-
gests an uncontrolled increase that will result in conse-
quent over-supply, emphasizing the need to develop
novel jojoba-based products and usages.
Aside from the oil, other parts of the jojoba plant
possess properties that may become valuable (Wis-
niak 1994), e.g. jojoba meal and leaves were found to
have various other potential uses. The meal is rich in
proteins and bers, and as such, has the potential to
be used as food or staple feed. However, it contains an-
ti-nutritional factors, a problem that still has to be in-
dustrially overcome (Reddy & Chikara 2010). The meal
was also suggested as an anti-rodent agent (Al-Obaidi
et al. 2017). In addition, leaves were found to possess
potential medicinal properties, as further described in
detail below. From an ecological perspective, the plant
can also contribute to combat desertication due to
its ability to grow in arid areas (Al-Obaidi et al. 2017).
Like its usages, jojoba-based analyses can be roughly
divided into two main sections: evaluation of its liquid
Figure 1. Jojoba, grown in kibbutz Hatzerim, Israel. Pictures by Yair Arazi.
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wax and identication of phytochemicals in other
plant parts, including the jojoba meal obtained follow-
ing the extraction process.
Oil extraction methods and concomitant
composition
As mentioned earlier, jojoba wax is comprised of ap-
proximately 50% seed weight. However, to obtain pure
oil, several steps are required. After the initial harvest,
jojoba seeds are rst cleaned to remove rough de-
bris, such as dust and leaves, and are then typically
left to dry and dehull (Arya & Khan 2016). To obtain a
high yield, a combination of mechanical pressure and
chemical extraction using hexane (or other organic
solvents) is necessary (Wisniak 1994). The downside of
this process is the environmental impact and econom-
ic price of the organic solvent. Usage of other solvents,
such as chloroform and isopropanol has been tested
and found to be less ecient and occasionally with
leftover traces in the oil (Wisniak 1994; Abu-Arabi et al.
2000). Supercritical CO2, which is a solvent-free meth-
od, showed similar or higher oil yield, however, typi-
cally its initial establishment price is high. In addition
to its pre-mentioned disadvantages, solvent extrac-
tion also results in lower quality wax. Thus, jojoba oil is
currently mechanically extracted by cold-press meth-
od, at low heat, to conserve its quality characteristics,
e.g. tocopherol contents (El-Mallah & El-Shami 2009).
Naturally, the oil yield of this method is relatively low,
as some oil is retained in the meal (Kibbutz Hazerim,
personal communication), but the resulting wax is of
high quality.
Jojoba oil is a mixture of long-chain (C36-C46) es-
ters of fatty acid and fatty alcohol, distinguishing it
from other vegetable oils, which are triglyceride-based
(Figure 2) (Mokhtari et al. 2019). This gold-yellow odor-
less oxidation-resistant wax is liquid at room tempera-
ture, which is another unique characteristic dierenti-
ating it from other natural waxes used in cosmetics (Le
Dréau et al. 2009; Zięba et al. 2015).
Meticulous analysis demonstrated that the main
fatty chains composing the wax are C20:1 and C22:1
of both acids and alcohols, with changes of the ex-
act percentage linked to both genetic and environ-
mental factors (Busson-Breysse et al. 1994; Agarwal
et al. 2018). Trace elements have also been reported
in the wax (Agarwal et al. 2018). Free fatty acids, also
present in the wax, are negatively correlated with
wax quality (El-Mallah & El-Shami 2009). Tocopherols
and phytosterols, two other groups of bioactive me-
dicinal molecules, have also been observed in jojoba
oil. Tocopherols are common in oil crops, serving as
lipophilic antioxidants and oil stabilizers that also
possess health-promoting properties. In jojoba oil,
they were reported at relatively high concentrations
of 417 ppm, with gamma-tocopherol as the main
form (79.2%), and alpha, beta and delta-tocopherol
at lower concentrations (El-Mallah & El-Shami 2009).
Phytosterols are another group of characteristic com-
pounds of oil, with structural resemblance to choles-
terol. Thus, their consumption is recommended as
cholesterol-lowering treatment. In jojoba, various
types were recorded, including sitosterol, campes-
terol and stigmasterol (Busson-Breysse et al. 1994;
Ogbe et al. 2015)
Chemical parameters for wax quality analysis have
not been established yet, although such parameters
are very common in other oil crops, e.g. olive oil. Qual-
ity grading might allow growers to receive better com-
pensations for their high-quality wax.
Jojoba meal and other plant part
The remaining cake after oil extraction process (jo-
joba meal) is rich in dietary bers and proteins.
Figure 2. Jojoba oil (wax) structure.
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However, the presence of simmondsin, a unique jo-
joba secondary metabolite and a principal bioactive
component of jojoba, and its derivatives, prevents its
use as food or animal feed purposes. Simmondsin,
2-(cyanomethylene)-3-hydroxy-4,5- dimethoxycyclo-
hexyl-beta-D-glucoside (Figure 3) is present in seeds,
hulls, leaves, twigs and roots of jojoba. Approximately
5% of jojoba meal is simmondsin with additional 0.5–
1% of derivatives, of which the 2’-ferulate is the main
one. Isolated and characterized by Elliger et al. almost
thirty years ago, this unique molecule is toxic at high
concentrations and has an anorexic action at lower
levels (Elliger et al. 1973). Due to its cyano group, it is
listed as an antinutritional compound and thorough
removal of its content is required prior to usage as
animal feed. Thus, several methodologies have been
investigated for the neutralization/removal of this
agent prior to usage as feed supplements, including
chemical and enzymatic approaches (Verbiscar et al.
1981; Bouali et al. 2008; Elsanhoty et al. 2017). How-
ever, usage of simmondsin at low and at non-toxic
range may be harnessed as a health-promoting agent
as specied below. Unlike its well-characterized oil,
other parts of jojoba plant are yet to be fully explored
for their phytochemical composition. So far, research
was mainly performed on simmondsin and deriva-
tives, and on selected bioactive polyphenolic com-
pounds (described below). To date, comprehensive
in-depth metabolomic evaluation of the leaf, roots,
twigs and meal is still lacking and therefore other
unique compounds may be discovered in the near
future.
Medicinal properties
Antioxidant capacity
When evaluating the medicinal properties of a plant,
one of the most basic and simple characterizations re-
lies on the evaluation of its antioxidant capacity and
total phenolic content. Indeed, several studies have
evaluated jojoba antioxidant activity with various
methods and extraction methodologies.
Kara has evaluated the scavenging capacity of
methanolic and ethanolic extract of both the seed and
leaf of jojoba by the 2,2′-Diphenyl-1-picrylhydrazyl
(DPPH) method (Kara 2017). This colorimetric method
uses a stable free radical, which becomes discolored
in the presence of an anti-oxidant, either transferring
an electron or donating hydrogen (Brand-Williams et
al. 1995).In this system, all jojoba extracts were found
to possess similar scavenging ecacy (approximately
40% at 500 µg/ml). However, when determined by lin-
oleic acid bleaching assay, the antioxidant activity of
the methanolic and ethanolic leaf extracts was twice
as much as those measured for the seeds (45 nmol/g).
These conicting results may be due to the inherent dif-
ference between the methods and the favor of lipophilic
moieties in the second system. An interesting study by
Wagdy et al. investigated the possible usage of the seed
hull extract and found a considerable scavenging eect
in similar methodologies described above (Wagdy &
Taha 2012). This approach is of high interest, as typically
the hulls are a waste product of jojoba wax production,
while these authors showed that the hulls may provide
additional value in the industry. The impact of cultiva-
Figure 3. Simmondsin and derivatives.
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tion conditions on the antioxidant properties has also
been investigated, and it was reported that jojoba anti-
oxidant activity of the methanolic leaf extract could be
increased by 50% in enriched cultivation conditions (ad-
dition of putrescine and Moringa extract) in comparison
to control conditions (Taha et al. 2015).
Abdel-Wahhab at al. investigated the hepatopro-
tective impact of jojoba ethanolic seed extract in vivo.
Both low and high dosage (0.5 and 1 mg/kg, respec-
tively) attenuated liver oxidative stress in mycotoxin-
induced damage model. Malondialdehyde (mda ) levels,
an important r os-derived lipid peroxidation product of
polyunsaturated fatty acids, was doubled in the myco-
toxin group but dropped upon jojoba treatment. Con-
comitantly, the liver levels of the anti-oxidant enzyme
superoxide dismutase (sod) were raised to those of the
control group (Abdel-Wahhab et al. 2015). However,
these impressive results may not be exclusively attrib-
uted to direct jojoba antioxidant capacity, and can re-
sult from secondary action of jojoba extract, as it also
reduced inammation and hepatocellular necrosis in
that model (Abdel-Wahhab et al. 2015).
The majority of studies regarding jojoba do not
pinpoint the active compound assigned for the anti-
oxidant capacity of the above-mentioned extracts. In-
depth chemical analysis is still required in order to gain
insight into the active molecule or molecules. A com-
prehensive work was performed by Abdel-Mageed et
al, identifying avonoid aglycones from the ethanolic
leaf extract of jojoba (Abdel-Mageed et al. 2014). Quer-
cetin 3-methyl ether (isorhamnetin), quercetin 3,3-di-
methylether, and quercetin showed strong antioxidant
activity and lipoxygenase inhibition (Fig. 4). In a recent
study conducted in hyperglycemia-induced oxidative
stress model, it was found that simmondsin, one of the
principal bioactive components in jojoba mentioned
above, is sucient to reduce pancreatic beta-cell dam-
age, which may explain the protective antioxidant
properties of jojoba extract. The contribution of to-
copherol on the antioxidant capacity of the oil should
also be evaluated. The collective results demonstrate
that mainly leaf and hull extracts of jojoba, may pos-
sess strong antioxidant properties that can be used
as a remedy for oxidative stress-related pathologies.
However, it should be noted that the safety of such
extracts should be clinically validated for both their
safety and ecacy prior to usage as food supplements
or other health-promoting products.
Anti-fungal and anti-microbial properties
New antimicrobial agents are of constant need due to
the rise in antibiotic-resistant germs. The hypothesis
that jojoba may present such properties has been in-
vestigated by several research groups. Jojoba extracts
derived from hulls (extracted in 80% methanol, ethanol,
Figure 4. Bioactive flavonoids isolated from jojoba leaf (adapted from Abdel-Mageed et al. ).
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acetone, isopropanol and ethyl acetate) showed sig-
nicant anti-bacterial properties (Wagdy & Taha 2012);
Escherichia coli, Staphylococcus aureus, Bacillus cereus,
Listeria monocytogenes and Salmonella typhimurium
growth was inhibited in various degrees of ecacy.
The authors suggested that this phenomenon is in cor-
relation with ethnobotanical knowledge. However, the
active molecule(s) or mechanism of action (moa) were
not elucidated in this preliminary evaluation. Abu-
Salem and Ibrahim have also shown high ecacy on
both bacteria and fungi of root extract and latex of the
plant (Abu-Salem & Ibrahim 2014). In separate works,
antibacterial and antifungal activities were also found
for jojoba oil (Pooja Umaiyal et al. 2016; Al-Ghamdi et
al. 2019). Thus, it seems that the active agent(s) are not
restricted to a specic part of the plant. However, it is
important to mention that several other reports evalu-
ating similar extracts found no noticeable antimicrobial
activity. This discrepancy may be due to the bacterial
strains used, as well as the cultivating and genetic dif-
ferences between the plants (Elnimiri & Nimir 2011; Al-
Qizwini et al. 2014). In addition, although all researchers
used routine evaluation systems (agar diusion assay,
disc diusion assay and minimal inhibitory concentra-
tion (mic)), these models may be dierent between lab-
oratories and any modication may aect the obtained
results signicantly (Balouiri et al. 2016).
In a very interesting examination, the two gluco-
sides, simmondsin and simmondsin 2-ferulate have
been isolated form jojoba, and tested for their bioac-
tivity (Abbassy et al. 2007). In that study, both agents
showed high ecacy with moderated potency (Half
maximal eective concentration (EC50) of approxi-
mately 150 mg/l) against plant pathogenic fungi. Simi-
lar studies are required in order to attribute the antimi-
crobial properties to simmondsin, its derivatives, and
other compounds.
Dermatology and skin care
The skin is a vital homeostatic organ that acts as a
physical, chemical, and biological barrier (Gvirtz et al.
2020; Kahremany et al. 2020). As chronically exposed
to deleterious actions of the environment, its appear-
ance may be aected and extrinsic aging of the skin
may become visible (Choi 2019; Ogen-Shtern et al.
2020). Jojoba oil has long been used in dermo-cos-
metic products. Amongst its main functions, jojoba is
a key component of the oil phase in numerous topical
formulations (Di Berardino et al. 2006). In addition to
its structural importance to the formulation stability,
jojoba oil also serves as a carrier and enhancer of the
active compounds (Nasr et al. 2016). In addition, the an-
tioxidant and tocopherol content of jojoba mentioned
above may be used to reduce skin-related oxidative
stress (Kahremany et al. 2019). However, it should be
noted that jojoba can also exert contact dermatitis
(Wantke et al. 1996; Di Berardino et al. 2006) and may
be absorbed systemically if high topical amounts are
applied (Yaron et al. 1980; Matsumoto et al. 2019).
Numerous dermo-cosmetic products use jojoba as
part of their formulation and to date, almost 200 In-
ternational Nomenclature of Cosmetic Ingredients
(INCI) entries are listed with jojoba and derivatives.
However, its benecial potential as an active agent
in skin care has not been thoroughly investigated, in-
cluding the lack of large control trial supporting its ef-
fectiveness while used in massage, a key end-usage in
the current jojoba oil market.
Several clinical cosmetic trials have investigated the
properties of jojoba dermal applications. For instance,
it was reported that the addition of jojoba hydrolyzed
ester to lotions can enhance skin hydration by reduction
of trans-epidermal water loss (TEWL) (Meyer et al. 2008).
In a separate study, increasing concentrations of jojoba
oil in cream formulations enhanced their moisturizing
properties (Zięba et al. 2015). Nevertheless, it is exceed-
ingly dicult to elucidate the impact of jojoba in this
setup, separating its impact from the rest of the formula.
Thus, to evaluate whether this liquid wax has direct ac-
tion on epidermal and dermal layers, a more direct ap-
proach is of need. To address this, Ranzato et al. have
used the scratch assay, in which a wound is inicted by a
tip on dermal keratinocytes and broblast cell monolay-
ers (Ranzato et al. 2011). Their data demonstrated that
jojoba wax is safe at a wide range of concentrations and
may enhance wound closure in both keratinocytes and
broblasts cultures. They also have shown that jojoba
treatment triggers collagen synthesis in broblasts. Ca+
dependent mechanism that requires the involvement
of the PI3K–Akt–mTOR pathway and of the p38 and
ERK1/2 was suggested by the authors.
Interestingly, the benecial impact of jojoba oil on
psoriasis has also been suggested (Pazyar & Yaghoobi
2016). This chronic inammatory skin disease is typi-
cally displayed as plaques, covered with thick, silvery,
shiny scales that hampers the quality of life of the pa-
tients (Rendon & Schäkel 2019). El Mogy suggested
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that jojoba oil without or with 2% salicylic acid can
improve psoriatic skin (El Mogy 2005). In two clini-
cal trials, jojoba oil-based microemulsion was used
as a platform for enhancing the action of commercial
drugs (Nasr et al. 2016; Ramez et al. 2018). Further in vi-
tro and clinical studies are required to understand the
potential use of jojoba in psoriasis.
Acne-prone, lesioned skin is the result of combined
excessive sebum production, bacterial settlement, and
inammation. Results of a study by Meier et al. show that
treatment with jojoba oil clay facial masks can reduce
pustules, papules, cysts and comedones (Meier et al.
2012). Importantly, the study demonstrated the impact
of dermatological conditions on quality of life at a cost-
eective treatment regime. Other animal-studies experi-
ments, demonstrating anti-inammatory action of jojoba
oil (see below) may also be relevant to the eect on acne.
Metabolic syndrome and metabolism
The metabolic syndrome is a set of metabolic abnormal-
ities such as insulin resistance, nonalcoholic fatty liver
disease, glucose intolerance, obesity and type 2 diabe-
tes. A recent study by Belhadj et al. demonstrated that
incorporation of jojoba seed in the diet of rats might
reduce the deleterious eects of a high-fat diet and
high fructose diet (Belhadj et al. 2020). In their study, a
marked reduction was observed in insulin resistance, fat
mass and renal complications in the treatment group.
These ndings were accompanied by reduction in the
rat body mass, and thus the author concluded that this
anorexic impact is the main cause of the jojoba regi-
men. Their results are also in line with previous studies
demonstrating that jojoba leaf extract may reduce body
weight in rats (Makpoul et al. 2017). Interestingly, sim-
mondsin, present in both jojoba oil and leaf extracts,
has already been shown to reduce food intake in rats,
suggesting that the impact of jojoba on appetite is me-
diated by this unique molecule (Cokelaere et al. 1995).
In addition, a direct eect of simmondsin was observed
in pancreatic beta-cells, suggesting a multi-site action
of the molecule (Belhadj et al. 2018).
Additional medicinal values and the future of
jojoba research
Other scattered reports have shown additional health
benecial impacts of jojoba oil and extracts. For
instance, jojoba has been reported to possess anti-
inammatory properties, both in vitro and in vivo (Ha-
bashy et al. 2005). This may be linked to the ability of
the plant extract and simmondsinto inhibit with high
potency both lipoxygenase (LOX) and cyclooxygenase
(COX), key enzymes in the inammation cascade. LOX
and COX are responsible mainly for the metabolism of
arachidonic acid, generating its downstream signaling
and inammatory mediators, such as prostaglandins,
leukotrienes and lipid peroxidation by products (Co-
hen et al. 2013; Abdel-Mageed et al. 2014, 2016). Fur-
thermore, jojoba leaf extracts at as low as EC50 2 µg/ml
have been reported to present an anti-viral eect on
herpes simplex viruses type 1 and 2 (HSV-1, HSV-2) and
varicella-zoster virus (Yarmolinsky et al. 2010). Anti-
cancer cytotoxicity was also demonstrated in human
melanoma (MV 3), breast (MCF 7), and colorectal (HCT
116) tumor cell lines as well as inhibition of angiogen-
esis, required for tumor growth (D’oosterlynck & Raes
2008; Al-Qizwini et al. 2014; Al-Obaidi 2019).
Generally, jojoba usage may be separated roughly
into two branches: the use of its unique oil, and the
use of extracts obtained from other parts of the plant.
Currently, the jojoba liquid wax is mainly used as a
substrate for the formulation or as an ingredient with
an active role. However, as it was demonstrated, the
whole plant, including leaves, roots and hulls can be
used as a source of bioactive molecules and this direc-
tion should also be developed. A thorough investiga-
tion using metabolomic tools may reveal more unique
active compounds. Another diculty in jojoba re-
search is the current scarcity of commercially available
simmondsin and derivatives, thus more sources are of
need in order to understand the entire pharmaceutical
potential.
Acknowledgments
This study was supported by “Nitzan” industrial col-
laboration grant from the ministry of Agriculture and
Rural Development (Israel, grant no 20-06-0072) and
Jojoba Desert (kibbutz Hazerim). G.C, N.O.S. (Regional
R&D Center, 580458776) and SK (Scholarship number
3-16752) are partially supported by the Israeli ministry
of science and technology. The authors would like to
thank Dr. Sarit Melamed and Dr. Arnon Dag for their
vital perspective intertwined in this review.
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