Management of acute skin toxicity with Hypericum perforatum and neem oil during platinum-based concurrent chemo-radiation in head and neck cancer patients

Evolution of radiation-induced dermatitis treatment

Radiation-induced skin damage (RID) is the most prevalent, significant side effect of radiotherapy (RT). Nearly 95% of patients experience moderate to severe skin reactions after receiving radiation therapy. However, criteria for acute radiation dermatitis (ARD) treatment remain unavailable. Topical agents with anti-inflammatory properties may protect the skin and facilitate tissue regeneration in patients with RID. Many of these topical agents function through nuclear factor kappa B pathway regulation. They either reduce the levels of inflammatory factors or elicit anti-inflammatory properties of their own, thus preventing oxidative stress and inflammatory responses and thus enabling RID prevention and management. Herein, we explore the 25 topical agents investigated for RID prevention and management thus far and evaluate their mechanisms of action. These agents include 11 natural agents, 3 miscellaneous agents, 9 topical nonsteroidal agents, and 2 topical corticosteroids.

Limonoids from neem (Azadirachta indica A. Juss.) are potential anticancer drug candidates

Neem (Azadirachta indica A. Juss.), a versatile evergreen tree recognized for its ethnopharmacological value, is a rich source of limonoids of the triterpenoid class, endowed with potent medicinal properties. Extracts of neem have been documented to display anticancer effects in diverse malignant cell lines as well as in preclinical animal models that has largely been attributed to the constituent limonoids. Of late, neem limonoids have become the cynosure of research attention as potential candidate agents for cancer prevention and therapy. Among the various limonoids found in neem, azadirachtin, epoxyazadiradione, gedunin, and nimbolide, have been extensively investigated for anticancer activity. Azadirachtin, a potent biodegradable pesticide, exhibits profound antiproliferative effects by preventing mitotic spindle formation and cell division. The antiproliferative activity of gedunin has been demonstrated to be mediated primarily via inhibition of heat shock protein90 and its client proteins. Epoxyazadiradione inhibits pro-inflammatory and kinase-driven signaling pathways to block tumorigenesis. Nimbolide, the most potent cytotoxic neem limonoid, inhibits the growth of cancer cells by regulating the phosphorylation of keystone kinases that drive oncogenic signaling besides modulating the epigenome. There is overwhelming evidence to indicate that neem limonoids exert anticancer effects by preventing the acquisition of hallmark traits of cancer, such as cell proliferation, apoptosis evasion, inflammation, invasion, angiogenesis, and drug resistance. Neem limonoids are value additions to the armamentarium of natural compounds that target aberrant oncogenic signaling to inhibit cancer development and progression.

MASCC clinical practice guidelines for the prevention and management of acute radiation dermatitis: part 1) systematic review

Acute radiation dermatitis (ARD) commonly develops in cancer patients undergoing radiotherapy and is often characterized by erythema, desquamation, and pain. A systematic review was conducted to summarize the current evidence on interventions for the prevention and management of ARD. Databases were searched from 1946 to September 2020 to identify all original studies that evaluated an intervention for the prevention or management of ARD, with an updated search conducted in January 2023. A total of 235 original studies were included in this review, including 149 randomized controlled trials (RCTs). Most interventions could not be recommended due to a low quality of evidence, lack of supporting evidence, or conflicting findings across multiple trials. Photobiomodulation therapy, Mepitel® film, mometasone furoate, betamethasone, olive oil, and oral enzyme mixtures showed promising results across multiple RCTs. Recommendations could not be made solely based on the published evidence due to limited high-quality evidence. As such, Delphi consensus recommendations will be reported in a separate publication.

Therapeutic benefits of natural oils along with permeation enhancing activity

The skin is the largest organ of the integumentary system with a multifunctional purpose to protect the body from heat and microbes, regulate body temperature, and act as a sensory organ. A topical dosage form applied on the skin will have to cross the stratum corneum, which would then allow the dosage form to traverse the subsequent layers of the skin. The drug with poor solubility and short half-life would serve as an ideal candidate for its delivery via the transdermal route. This review reports the role of natural oils in enhancing the permeation of drugs through skin as they possess different features like natural origin, favorable penetration enhancement, and partitioning action in the skin. Chemical penetration enhancers have been used widely but are associated with toxicities. Thus, more research should be channelized in the area of extraction of oils from natural sources, along with their active constituents, which can serve as therapeutic alternatives to various disorders and diseases. Natural oils are obtained from leaves, fruits, flowers, seeds, bark, and roots, which have a therapeutic potential as well as penetration enhancing activity. The demerits of oral drug delivery include degradation of drugs in the gastrointestinal tract, addition of taste masking, and coating of tablets, which can be overcome by delivering the drug via the transdermal route. Natural oil contains lipids, flavonoids, and terpenes, which play a significant role in anti-inflammatory and penetration enhancing activity.

Traditionally Used Natural Products in Preventing Ionizing Radiation-Induced Dermatitis: First Review on the Clinical Studies

In the treatment of cancer, the use of ionizing radiation is an important modality. However, on the downside, radiation, when used for curative purposes, causes acute dermatitis or radiodermatitis at the site of radiation in most individuals. From a clinical viewpoint, severe dermatitis causes a burning and itching sensation is very painful, and severely affects the quality of life of the individual undergoing treatment. In worse situations, acute radiation dermatitis can cause gaps or breaks in the planned treatment and this can adversely affect the treatment objective and outcome.

BACKGROUND

In various traditional and folk systems of medicine, plants and plant products have been used since time immemorial for treating various skin ailments. Further, many cosmeceutical creams formulated based on knowledge from ethnomedicinal use are marketed and used to treat various ailments. In the current review, an attempt is made at summarizing the beneficial effects of some plants and plant products in mitigating acute radiation dermatitis in humans undergoing curative radiotherapy. Additionally, the emphasis is also placed on the mechanism/s responsible for the beneficial effects.

OBJECTIVE

The objective of this review is to summarize the clinical observations on the prevention of radiodermatitis by plant products. In this review, the protective effects of Adlay (Coix lachryma-jobi L.) bran extract, Aloe vera, Calendula officinalis, Cucumis sativus, green tea constituent the epigallocatechin-3-gallate, honey, Achillea millefolium, Matricaria chamomilla, olive oil and some polyherbal creams are addressed by also addressing on the mechanism of action for the beneficial effects.

METHODS

Two authors' data mined for information in Google Scholar, PubMed, Embase and the Cochrane Library for publications in the field from 1901 up to July 2020. The focus was on acute radiation dermatitis, ionizing radiation, curative radiotherapy, human cancer. The articles were collected and analyzed.

RESULTS

For the first time, this review addresses the usefulness of natural products like adlay bran, Aloe vera, Calendula officinalis, Cucumis sativus, green tea constituent the epigallocatechin-3-gallate, honey, Achillea millefolium, Matricaria chamomilla, olive oil and some experimentally constituted and commercially available polyherbal creams as skincare agents against the deleterious effects of ionizing radiation on the skin. The protective effects are possibly due to the free radical scavenging, antioxidant, anti-inflammatory, wound healing and skin protective effects.

CONCLUSION

The authors suggest that these plants have been used since antiquity as medicinal agents and require in-depth investigation with both clinical and preclinical validated models of study. The results of these studies will be extremely useful to cancer patients requiring curative radiotherapy, the dermatology fraternity, agro-based and pharmaceutical sectors at large.

Prophylaxis of Radiation-Induced Dermatitis in Patients With Breast Cancer Using Herbal Creams: A Prospective Randomized Controlled Trial

Radiation-induced toxicity is a major limiting factor for prescribing radiation dose in cancer radiotherapy. Skin reaction to radiation is one of the primary concerns, which could affect quality of life of the patients both physically and mentally. Reviews of the literature show limited number of effective reagents for its prophylaxis. In this study, we attempted to determine whether prophylactic treatment of the 3 different herbal creams containing Centella asiatica, Cucumis sativus, and Thunbergia laurifolia extracts as well as a commercial moisturizing cream could reduce acute skin reaction in breast cancer patients undergoing radiotherapy. A total of 153 breast cancer patients undergoing radiotherapy were randomly assigned into 5 different groups with one group receiving no treatment. The patients were instructed to apply their designated creams once daily from their first radiotherapy session until 1-month post-irradiation. Their skins were graded by a radiation oncologist on a weekly basis until 1-month post-irradiation to identify any skin reactions. The results showed that the administration of the herbal creams or the moisturizing cream could neither reduce the severity nor delay the onset of dermatitis compared with the no treatment group. However, despite the limited benefits from the prophylaxis, the Cucumis sativus cream was shown to help with the skin recovery post-irradiation. These results suggested that breast cancer patients undergoing radiotherapy should be advised to apply moisturizing cream to the area of irradiated skin.