Salicylate Poisoning Potential of Topical Pain Relief Agents: From Age Old Remedies to Engineered Smart Patches

Short-term cutaneous vasodilatory and thermosensory effects of topical methyl salicylate

Introduction

Methyl salicylate, the main compound of wintergreen oil, is widely used in topical applications. However, its vascular and thermosensory effects are not fully understood. The primary aim was to investigate the effects of topical methyl salicylate on skin temperature (Tskin), skin microcirculation (MCskin) and muscle oxygen saturation (SmO2) compared to a placebo gel. The secondary aim was to assess thermosensory responses (thermal sensation, thermal comfort) and to explore to which extent these sensations correspond to the physiological responses over time.

Methods

21 healthy women (22.2 ± 2.9 years) participated in this single-blind, randomized controlled trial. Custom-made natural wintergreen oil (12.9%), containing methyl salicylate (>99%) and a placebo gel, 1 g each, were applied simultaneously to two paravertebral skin areas (5 cm × 10 cm, Th4-Th7). Tskin (infrared thermal imaging), MCskin (laser speckle contrast imaging) and SmO2 (deep tissue oxygenation monitoring) and thermosensation (Likert scales) were assessed at baseline (BL) and at 5-min intervals during a 45 min post-application period (T0-T45).

Results

Both gels caused an initial decrease in Tskin, with Tskin(min) at T5 for both methyl salicylate (BL-T5: Δ-3.36°C) and placebo (BL-T5: Δ-3.90°C), followed by a gradual increase (p < .001). Methyl salicylate gel resulted in significantly higher Tskin than placebo between T5 and T40 (p < .05). For methyl salicylate, MCskin increased, with MCskin(max) at T5 (BL-T5: Δ88.7%). For placebo, MCskin decreased (BL-T5: Δ-17.5%), with significantly lower values compared to methyl salicylate between T0 and T45 (p < .05). Both gels had minimal effects on SmO2, with no significant differences between methyl salicylate and placebo (p > .05). Thermal sensation responses to topical methyl salicylate ranged from "cool" to "hot", with more intense sensations reported at T5.

Discussion

The findings indicate that topical methyl salicylate induces short-term cutaneous vasodilation, but it may not enhance skeletal muscle blood flow. This study highlights the complex sensory responses to its application, which may be based on the short-term modulation of thermosensitive transient receptor potential channels.

Prediction rule of supratherapeutic peak serum salicylate level in poisoning patients attending emergency departments

Background:

Analgesic poisoning is common in Hong Kong. Analgesics containing salicylate are easily available. Salicylate poisoning may be encountered in the daily practice of the accident and emergency department. The issue of routine salicylate screening was discussed in a number of articles, and the viewpoints of most authors were that routine salicylate screening was unnecessary.

Objectives:

The primary outcome is to explore the predictive factors of supratherapeutic peak serum salicylate level (>2.17 mmol/L) and delineate the role of routine screening serum salicylate level in poisoned patients attending the accident and emergency department.

Methods:

This is a retrospective cohort study. Poisoning cases presented to Hong Kong Poison Information Centre between 1 July 2008 and 31 October 2020 with serum salicylate level checked were included. The demographics, laboratory parameters and clinical outcomes were reviewed.

Results:

There were 8673 cases included with serum salicylate level checked, accounting for 17% of all poisoning cases. Sixty-six (0.76%) cases had supratherapeutic peak serum salicylate level and 11 (0.13%) of them were undeclared salicylate ingestion. Worse clinical outcomes were observed in cases with supratherapeutic peak serum salicylate level. Univariate analysis showed that tinnitus, hyperthermia, alkalaemia, metabolic acidosis, respiratory alkalosis and therapeutic use of aspirin were significantly associated with supratherapeutic peak serum salicylate level. Variables with p < 0.3 were entered into the backward stepwise logistic regression by likelihood ratio. A clinical prediction rule with three attributes (tinnitus, therapeutic use of aspirin and partial pressure of CO2 <5 kPa) was derived. It showed 100% sensitivity in internal validation.

Conclusion:

Serum salicylate level should be checked in poisoned patients with (1) tinnitus, (2) the therapeutic use of aspirin or (3) partial pressure of CO2 <5 kPa in arterial or venous blood gas. Routine salicylate screening remained a tool for clinicians not experienced in toxicology.

The Volatile Phytochemistry of Seven Native American Aromatic Medicinal Plants

As part of our evaluation of essential oils derived from Native American medicinal plants, we have obtained the essential oils of Agastache foeniculum (Pursch) Kuntze (Lamiaceae), Gaultheria procumbens L. (Ericaceae), Heliopsis helianthoides (L.) Sweet (Asteraceae), Liatris spicata (L.) Willd. (Asteraceae), Pycnanthemum incanum (L.) Michx. (Lamiaceae), Smallanthus uvedalia (L.) Mack. ex Mack. (Asteraceae), and Verbena hastata L. (Verbenaceae) by hydrodistillation. The essential oils were analyzed by gas chromatographic techniques. The essential oil of A. foeniculum was dominated by estragole (88–93%), while methyl salicylate (91%) dominated the G. procumbens essential oil. Germacrene D was the major component in H. helianthoides (42%) and L. spicata (24%). 1,8-Cineole (31%) and α-terpineol (17%) were the main compounds in P. incanum essential oil. The essential oil of S. uvedalia showed α-pinene (24%), perillene (15%), and β-caryophyllene (17%) as major components. Verbena hastata essential oil was rich in 1-octen-3-ol (up to 29%) and palmitic acid (up to 22%). Four of these essential oils, H. helianthoides, L. spicata, P. incanum, and V. hastata, are reported for the first time. Additionally, the enantiomeric distributions of several terpenoid components have been determined.

Topical delivery of salicylates

Salicylates have a long history of use for pain relief. Salicylic acid and methyl salicylate are among the widely used topical salicylates namely for keratolytic and anti-inflammatory actions, respectively. The current review summarises both passive and active strategies, including emerging technologies employed to enhance skin permeation of these two salicylate compounds. The formulation design of topical salicylic acid targets the drug retention in and on the skin based on the different indications including keratolytic, antibacterial and photoprotective actions, while the investigations of topical delivery strategies for methyl salicylate are limited. The pharmacokinetics and metabolisms of both salicylate compounds are discussed. The current overview and future perspectives of the topical delivery strategies are also highlighted for translational considerations of formulation designs.

Salicylate toxicity from chronic bismuth subsalicylate use

A 79-year-old man presented to the emergency department with a 1-week history of worsening confusion, falls and hearing impairment. An initial workup for infectious, metabolic and structural causes was unrevealing. However, further history discovered that he had been ingesting one to two bottles of Pepto-Bismol (bismuth subsalicylate) daily for gastro-oesophageal reflux symptoms. On his second day of admission, the plasma salicylate concentration was 2.08 mmol/L (reference range 1.10-2.20 mmol/L), despite no sources of salicylate in hospital. He was diagnosed with chronic salicylate toxicity and Pepto-Bismol use was discontinued. The patient was treated supportively with isotonic intravenous fluids only and plasma salicylate concentration fell to less than 0.36 mmol/L. Concurrently, all his symptoms resolved. This case highlights the potential adverse effects of over-the-counter medications. The diagnosis of chronic salicylate toxicity is challenging, specifically in the elderly and in undifferentiated presentations, as it can be missed if not suspected.

Identification and analysis of key genes involved in methyl salicylate biosynthesis in different birch species

Species of the perennial woody plant genus Betula dominate subalpine forests and play a significant role in preserving biological diversity. In addition to their conventional benefits, birches synthesize a wide range of secondary metabolites having pharmacological significance. Methyl salicylate (MeSA) is one of these naturally occurring compounds constitutively produced by different birch species. MeSA is therapeutically important in human medicine for muscle injuries and joint pain. However, MeSA is now mainly produced synthetically due to a lack of information relating to MeSA biosynthesis and regulation. In this study, we performed a comprehensive bioinformatics analysis of two candidate genes mediating MeSA biosynthesis, SALICYLIC ACID METHYLTRANSFERASE (SAMT) and SALICYLIC ACID-BINDING PROTEIN 2 (SABP2), of high (B. lenta, B. alleghaniensis, B. medwediewii, and B. grossa) and low (B. pendula, B. utilis, B. alnoides, and B. nana) MeSA-producing birch species. Phylogenetic analyses of SAMT and SABP2 genes and homologous genes from other plant species confirmed their evolutionary relationships. Multiple sequence alignments of the amino acid revealed the occurrence of important residues for substrate specificity in SAMT and SABP2. The analysis of cis elements in different birches indicated a functional multiplicity of SAMT and SABP2 and provided insights into the regulation of both genes. We successfully developed six prominent single nucleotide substitution markers that were validated with 38 additional birch individuals to differentiate high and low MeSA-producing birch species. Relative tissue-specific expression analysis of SAMT in leaf and bark tissue of two high and two low MeSA-synthesizing birches revealed a high expression in the bark of both high MeSA-synthesizing birches. In contrast, SABP2 expression in tissues revealed indifferent levels of expression between species belonging to the two groups. The comparative expression and bioinformatics analyses provided vital information that could be used to apply plant genetic engineering technology in the mass production of organic MeSA.

Critical illness and multi-organ failure following topical application of skin-lightening preparation

Topical application of skin-lightening cream is increasingly undertaken in many non-Caucasian populations for cultural and social reasons. It is a rare cause of poisoning that has potential to lead to significant harm due to skin damage and systemic absorption of cream following application over prolonged periods of time. This case report describes for the development of multi-organ failure in an adult due to salicylate toxicity after whole-body application of a skin-lightening cream for 24 h. It highlights the need for vigilance and awareness of the toxic potential of topical salicylates.