Iontophoretic delivery of methotrexate in the treatment of palmar psoriasis: A randomised controlled study

Comparison of the clinical efficacy of topical tretinoin 0.05% cream and tacrolimus 0.1% ointment plus iontophoresis in the management of palmoplantar psoriasis

BACKGROUND

Palmoplantar psoriasis (PPP) is a localized variant of psoriasis that may be resistant to topical therapy, owing to the poor penetrability of topical agents at this anatomical site. Modalities that enhance localized cutaneous delivery of drugs could help to solve this problem. Iontophoresis is one such procedure that augments transdermal drug delivery, thus enabling better and expeditious therapeutic outcomes.

OBJECTIVE

To compare the therapeutic efficacy and safety of iontophoresis with tretinoin 0.05% cream and tacrolimus 0.1% ointment in treating patients with PPP.

METHODS

Sixty patients with PPP (28 males and 32 females, age range 8-76 years) were enrolled and randomly assigned to one of two groups comprising 30 patients each. One group (12 males and 18 females) received iontophoresis with tretinoin 0.05% cream; the other (16 males and 14 females) received iontophoresis treatment with tacrolimus 0.1% ointment. Both groups received treatment weekly from baseline until 4 weeks and then fortnightly at weeks 6 and 8. Clinical images were taken at each visit and improvement of psoriasis was evaluated using the erythema, scaling, induration and fissuring (ESIF) score. The percentage reduction in ESIF score was also assessed on completion of treatment and the grade of improvement noted for each patient.

RESULTS

Twenty-seven patients in the iontophoresis with tretinoin 0.05% cream group and 29 in the iontophoresis treatment with tacrolimus 0.1% ointment group completed the study. The mean (SD) ESIF score in the former decreased significantly from 8.7 (2) at baseline to 3.2 (1.7) at the study endpoint (P < 0.001). Similarly, in the latter group, there was a substantial reduction in mean (SD) ESIF score from 8.2 (1.9) at baseline to 3.3 (1.1) at the study end (P < 0.001). No significant adverse effects were encountered in either treatment arm.

CONCLUSIONS

Iontophoresis using tretinoin and tacrolimus was found to be effective and safe for the treatment of PPP. Although iontophoresis with tretinoin showed slightly better results than with tacrolimus, these were not statistically significant.

Intradermal Delivery of Naked mRNA Vaccines via Iontophoresis

Messenger RNA (mRNA) vaccines against infectious diseases and for anticancer immunotherapy have garnered considerable attention. Currently, mRNA vaccines encapsulated in lipid nanoparticles are administrated via intramuscular injection using a needle. However, such administration is associated with pain, needle phobia, and lack of patient compliance. Furthermore, side effects such as fever and anaphylaxis associated with the lipid nanoparticle components are also serious problems. Therefore, noninvasive, painless administration of mRNA vaccines that do not contain other problematic components is highly desirable. Antigen-presenting cells reside in the epidermis and dermis, making the skin an attractive vaccination site. Iontophoresis (ItP) uses weak electric current applied to the skin surface and offers a noninvasive permeation technology that enables intradermal delivery of hydrophilic and ionic substances. ItP-mediated intradermal delivery of biological macromolecules has also been studied. Herein, we review the literature on the use of ItP technology for intradermal delivery of naked mRNA vaccines which is expected to overcome the challenges associated with mRNA vaccination. In addition to the physical mechanism, we discuss novel biological mechanisms of iontophoresis, particularly ItP-mediated opening of the skin barriers and the intracellular uptake pathway, and how the combined mechanisms can allow for effective intradermal delivery of mRNA vaccines.

Validation and usability of modified palmoplantar psoriasis area and severity index in patients with palmoplantar psoriasis: A prospective longitudinal cohort study

Background Palmoplantar psoriasis (PPP), a troublesome variant, does not have any validated scoring system to assess disease severity. Objective To validate modified Palmoplantar Psoriasis Area and Severity Index (m-PPPASI) in patients affected with PPP and to categorise it based on Dermatology Life Quality Index (DLQI). Methods In this prospective study, patients with PPP aged > 18 years visiting the psoriasis clinic at a tertiary care centre were included and requested to complete DLQI during each visit at baseline, 2nd week, 6th and 12th week. m-PPPASI was used by the raters to determine the disease severity. Results Overall, 73 patients were included. m-PPPASI demonstrated high internal consistency (α = 0.99), test-retest reliability of all three raters, that is, Adithya Nagendran (AN) (r = 0.99, p < 0.0001), Tarun Narang (TN) (r = 1.0, p < 0.0001) and Sunil Dogra (SD) (r = 1.0, p < 0.0001) and inter-rater agreement (intra-class correlation coefficient = 0.83). Face and content validity index for items I-CVI = 0.845 were robust, and the instrument was uniformly rated as easy to use (Likert scale 2) by all three raters. It was found to be responsive to change (r = 0.92, p < 0.0001). Minimal clinically important differences (MCID)-1 and MCID-2 calculated by receiver operating characteristic curve using DLQI as anchor were 2 and 35%, respectively. DLQI equivalent cutoff points for m-PPPASI were 0-5 for mild, 6-9 for moderate, 10-19 for severe, and 20-72 for very severe disease. Limitation Small sample size and single-center validation were the major limitations. m-PPPASI doesn't objectively measure all characteristics of PPP such as "fissuring" and "scaling" which could also be taken into consideration. Conclusion m-PPPASI is validated in PPP and can be readily utilized by physicians. However, further large-scale studies are needed.

An update on therapeutic options for palmoplantar pustulosis: a narrative review and expert recommendations

INTRODUCTION

Palmoplantar pustulosis (PPP) is a chronic inflammatory skin disease belonging to the localized form of pustular psoriasis. It is characterized by sterile pustule formation in palms and soles and a recurrent disease course. Although we have many treatments for PPP, there is no authoritative guidance.

AREAS COVERED

A thorough search of PubMed was conducted to identify studies in PPP from 1973 onwards, with additional references to specific articles. Any treatment methods were outcomes of interest, including topical treatment, systemic treatment, biologics, other targeted treatments, phototherapy, and tonsillectomy.

EXPERT OPINION

Topical corticosteroids are suggested as first-line therapy. Oral acitretin has become the most applied systemic retinoid recommended in PPP without joint involvement. For patients with arthritis, immunosuppressants like cyclosporin A and methotrexate are more recommended. UVA1, NB-UVB, and 308-nm excimer laser are effective phototherapy options. The combinations of topical or systemic agents and phototherapy may enhance the efficacy, particularly in recalcitrant cases. Secukinumab, ustekinumab, and apremilast are the most investigated targeted therapies. However, heterogeneous reported outcomes in clinical trials provided low-to-moderate quality evidence of their efficacy. Future studies are required to address these evidence gaps. We suggest managing PPP based on the acute phase, maintenance phase, and comorbidities.

The Anti-Psoriatic Efficacy and Safety Profile of Topical and Intralesional Methotrexate: A Literature Review

Methotrexate (MTX) has long been considered the first-line oral systemic pharmacotherapy for psoriasis. The drug has several well-known systemic side effects, such as bone marrow suppression and hepatotoxicity. To avoid them, the use of topical or intralesional administrations of MTX has become an interesting option. With the advent of novel drug delivery systems, especially nanocarriers, the usage of a high-efficacy and safe topical MTX for psoriasis has nearly been attained. This review examined the development, anti-psoriatic efficacy and adverse effects of topical forms of MTX (plain MTX; MTX with chemical enhancer; MTX using nanotechnology; MTX with protein transduction domains; MTX with liquid crystalline systems; and MTX with physical enhancer/laser) and intralesional MTX in psoriasis patients and psoriasis-induced animals. The efficacy of topical MTX varied with the drug delivery technology employed. Nevertheless, the overall safety profile of the topical forms was favourable. A 25 mg/mL MTX solution injected intralesionally at the nail matrix worked well for nail psoriasis recalcitrant to topical treatment. To improve the standard of care for patients with psoriasis, randomized controlled trials that establish the most effective MTX-delivery system are needed.

Influences of methotrexate iontophoresis on functional lifestyle disabilities, functional capacity, and pain in patients with plantar psoriasis

Objectives

This study was aimed to evaluating the influences of methotrexate iontophoresis on functional lifestyle disabilities, functional capacity, and pain after a 6-min walking distance (6MWD) test in patients with plantar psoriasis (PP).

Patients and methods

Forty‑five patients (29 females, 16 males; mean age 33.9±6.6 years; range, 20 to 45 years) with hyperkeratotic PP were enrolled in the randomized, placebo-controlled, parallel-groups, double-blinded study. They were assigned randomly into the active methotrexate iontophoresis (MI) group (n=23) and the placebo iontophoresis group (n=22). The patients in both groups were assessed before starting the treatment intervention and after completing eight sessions of the treatment intervention through functional lifestyle disabilities measured on the Arabic version of psoriasis disability index, functional capacity using the 6MWD test, and pain after the 6MWD test.

Results

The pre-treatment measurements of the three variables among the two groups did not reveal statistically significant differences (p>0.05). However, there were statistically significant differences in the post-treatment results between the two groups (p<0.05). Additionally, the pre-and post-treatment values of the three outcome measures revealed statistically significant differences within the MI group (p<0.05). In contrast, there were no significant differences within the placebo group (p>0.05).

Conclusion

Methotrexate iontophoresis is effective in improving functional lifestyle disabilities, enhancing functional capacity, and decreasing pain in patients with PP.

Iontophoresis of Biological Macromolecular Drugs

Over the last few decades, biological macromolecular drugs (e.g., peptides, proteins, and nucleic acids) have become a significant therapeutic modality for the treatment of various diseases. These drugs are considered superior to small-molecule drugs because of their high specificity and favorable safety profiles. However, such drugs are limited by their low oral bioavailability and short half-lives. Biological macromolecular drugs are typically administrated via invasive methods, e.g., intravenous or subcutaneous injections, which can be painful and induce needle phobia. Noninvasive transdermal delivery is an alternative administration route for the local and systemic delivery of biological macromolecular drugs. However, a challenge with the noninvasive transdermal delivery of biological macromolecular drugs is the outermost layer of the skin, known as the stratum corneum, which is a physical barrier that restricts the entry of extraneous macromolecules. Iontophoresis (IP) relies on the application of a low level of electricity for transdermal drug delivery, in order to facilitate the skin permeation of hydrophilic and charged molecules. The IP of several biological macromolecular drugs has recently been investigated. Herein, we review the IP-mediated noninvasive transdermal delivery of biological macromolecular drugs, their routes of skin permeation, their underlying mechanisms, and their advance applications.

Transdermal Delivery of Therapeutic Compounds With Nanotechnological Approaches in Psoriasis

Psoriasis is a chronic, immune-mediated skin disorder involving hyperproliferation of the keratinocytes in the epidermis. As complex as its pathophysiology, the optimal treatment for psoriasis remains unsatisfactorily addressed. Though systemic administration of biological agents has made an impressive stride in moderate-to-severe psoriasis, a considerable portion of psoriatic conditions were left unresolved, mainly due to adverse effects from systemic drug administration or insufficient drug delivery across a highly packed stratum corneum via topical therapies. Along with the advances in nanotechnologies, the incorporation of nanomaterials as topical drug carriers opens an obvious prospect for the development of antipsoriatic topicals. Hence, this review aims to distinguish the benefits and weaknesses of individual nanostructures when applied as topical antipsoriatics in preclinical psoriatic models. In view of specific features of each nanostructure, we propose that a proper combination of distinctive nanomaterials according to the physicochemical properties of loaded drugs and clinical features of psoriatic patients is becoming a promising option that potentially drives the translation of nanomaterials from bench to bedside with improved transdermal drug delivery and consequently therapeutic effects.

Influencing factors and drug application of iontophoresis in transdermal drug delivery: an overview of recent progress

Transdermal drug delivery is limited by the stratum corneum of skin, which blocks most molecules, and thus, only few molecules with specific physicochemical properties (molecular weight < 500 Da, adequate lipophilicity, and low melting point) are able to penetrate the skin. Recently, various technologies have been developed to overcome the strong barrier properties of stratum corneum. Iontophoresis technology, which uses a small current to improve drug permeation through skin, is one of the effective ways to circumvent the stratum corneum. This approach not only provides a more efficient, noninvasive, and patient-friendly method of drug delivery but also widens the scope of drugs for transdermal delivery. In this review, the mechanisms underlying iontophoresis and affecting factors are outlined. The focus will be on the latest advancements in iontophoretic transdermal drug delivery and application of iontophoresis with other enhancing technologies. The challenges of this technology for drug administration have also been highlighted, and some iontophoretic systems approved for clinical use are described.

Smartphone-powered iontophoresis-microneedle array patch for controlled transdermal delivery

The incidence rate of diabetes has been increasing every year in nearly all nations and regions. The traditional control of diabetes using transdermal insulin delivery by metal needles is generally associated with pain and potential infections. While microneedle arrays (MAs) have emerged as painless delivery techniques, the integration of MA systems with electronic devices to precisely control drug delivery has rarely been realized. In this study, we developed an iontophoresis-microneedle array patch (IMAP) powered by a portable smartphone for the active and controllable transdermal delivery of insulin. The IMAP in situ integrates iontophoresis and charged nanovesicles into one patch, achieving a one-step drug administration strategy of "penetration, diffusion and iontophoresis". The MA of the IMAP is first pressed on the skin to create microholes and then is retracted, followed by the iontophoresis delivery of insulin-loaded nanovesicles through these microholes in an electrically controlled manner. This method has synergistically and remarkably enhanced controlled insulin delivery. The amount of insulin can be effectively regulated by the IMAP by applying different current intensities. This in vivo study has demonstrated that the IMAP effectively delivers insulin and produces robust hypoglycemic effects in a type-1 diabetic rat model, with more advanced controllability and efficiency than delivery by a pristine microneedle or iontophoresis. The IMAP system shows high potential for diabetes therapy and the capacity to provide active as well as long-term glycemic regulation without medical staff care.