Atypical Fibroxanthoma Treated with a Topical Combination of Imiquimod, Tazarotene, and 5-Fluorouracil

This case report describes an 80-year-old man who presented with a growing erythematous nodule with erosion, measuring 0.6 cm × 0.6 cm, on his right temple. This lesion was later diagnosed as atypical fibroxanthoma (AFX). Instead of undergoing Mohs surgery, the gold standard treatment, the patient opted to pursue a topical treatment regimen because of financial costs associated with surgical removal and repair. This topical regimen consisted of tazarotene cream, imiquimod cream, and 5-fluorouracil solution, applied for 30 days. The patient was directed to use this combination 5 days per week for 6 weeks. The specified dosage for each medication was a fifth of a packet of imiquimod 5% cream, an equivalent amount of tazarotene 0.1% cream, and a single drop of 5-fluorouracil 2% solution. These were combined on a bandage and placed on the lesion overnight. Following the treatment, a 3-week post-application examination revealed an erosion, 1.0 cm × 0.9 cm, amidst erythema. A subsequent incisional biopsy with histopathology and stains for CD10 and CD99, 3 weeks after treatment, and three punch biopsies with histopathology and stains for CD10 and CD99, 1-year post-treatment, confirmed the absence of AFX. AFX is a superficial variant of pleomorphic dermal sarcoma (PDS), which shares histologic similarities, yet the exact relationship between AFX/PDS and undifferentiated pleomorphic sarcoma is still not well understood. Previous studies have indicated a genomic similarity between AFX/PDS and cutaneous squamous cell carcinoma (cSCC), which suggests the potential efficacy of cSCC-targeted treatments for AFX/PDS. This case marks the first recorded instance of successful topical medical treatment of AFX, offering an alternative for patients who may opt out of surgical intervention. Continued research to assess the broader efficacy of this approach is encouraged.

Rapid Improvements in Itch with Tapinarof Cream 1% Once Daily in Two Phase 3 Trials in Adults with Mild to Severe Plaque Psoriasis

INTRODUCTION

Patients with psoriasis report pruritus as their most bothersome symptom. Tapinarof cream 1% once daily demonstrated significant efficacy versus vehicle and was well tolerated in adults with mild to severe plaque psoriasis in two 12-week trials: PSOARING 1 (NCT03956355) and PSOARING 2 (NCT03983980). Here, we present patient-reported pruritus outcomes from these trials.

METHODS

Outcomes included a Peak Pruritus Numerical Rating Scale (PP-NRS) score of 0 or 1 (itch-free state); Dermatology Life Quality Index (DLQI) itch item scores; and Psoriasis Symptom Diary (PSD) itch item scores.

RESULTS

Analyses included 683 tapinarof- and 342 vehicle-treated patients. At baseline, mean pruritus scores were similar across trials with only 7-11% of patients reporting an itch-free state. At week 12, the proportion of tapinarof-treated patients achieving an itch-free state was 50% in both trials compared with 32% (P = 0.0007) and 27% (P < 0.0001) in the vehicle groups. Improvements were apparent at the earliest assessments with continued improvement over the course of the trials. There were rapid and statistically significant improvements in the proportion of patients with a ≥ 4-point improvement in PP-NRS for tapinarof-treated patients versus vehicle from week 2 with 68% vs 46% (P = 0.0004) and 60% vs 31% (P = 0.0001) at week 12 achieving a response in each trial. Significantly greater reductions in itch with tapinarof versus vehicle were also demonstrated at week 12 for DLQI itch item 1 (P = 0.0026 and P < 0.0001), PSD item 1 (both P < 0.0001), and PSD item 2 (both P < 0.0001).

CONCLUSION

Tapinarof was highly efficacious in reducing pruritus across multiple patient-reported outcome measures, with rapid, statistically significant, and clinically meaningful improvements. The high proportion of patients achieving the treatment target of an itch-free state at week 12 (50%) is a noteworthy clinical outcome for a non-steroidal topical cream in the treatment of mild to severe plaque psoriasis.

TRIAL REGISTRATION

Clinical trial registration information: NCT03956355, NCT03983980.

Resorcinol 10% as a Promising Therapeutic Option for Mild Hidradenitis Suppurativa: A Prospective, Randomized, Open Study

Introduction

Treatment of hidradenitis suppurativa (HS) is challenging, and in Hurley stage I, it is based on topical measures. Our aim was to compare the efficacy and safety of topical resorcinol 10% with topical clindamycin 1% and no therapy, in Hurley stage I HS.

Methods

In this open, prospective, randomized trial, we studied 60 Hurley stage I patients with IHS4 ≤10. Group A was treated with topical resorcinol 10%; group B with clindamycin lotion 1%; and group C received no treatment. Patients were evaluated by total lesion count, the International Hidradenitis Suppurativa Severity Score System (IHS4) and the Dermatology Life Quality Index (DLQI) at baseline, 12 and 24 weeks. Self-reported number of flares and adverse events (AEs) were recorded.

Results

A significant reduction in the mean total lesion count and DLQI scores were observed in group A, compared to group B at week 12 (p = 0.036, p < 0.001, respectively), and in the mean total lesion count, IHS4, and DLQI scores at week 24 (p = 0.034, p = 0.017, p < 0.001, respectively). Resorcinol 10% was well-tolerated with only mild AEs.

Conclusion

Resorcinol 10% may represent a useful alternative for the long-term treatment of mild HS, which is superior to topical clindamycin and has a favorable safety profile.

Tapinarof Cream 1% Once Daily for the Treatment of Plaque Psoriasis: Case Photography of Clinical Outcomes from Three Phase 3 Trials

Tapinarof cream 1% (VTAMA®; Dermavant Sciences, Inc.) is a non-steroidal, topical, aryl hydrocarbon receptor agonist approved by the US Food and Drug Administration (FDA) to treat plaque psoriasis in adults and under investigation for the treatment of psoriasis in children down to 2 years of age, and for atopic dermatitis in adults and children down to 2 years of age. The PSOARING phase 3 clinical trial program evaluated tapinarof cream 1% once daily (QD) in adults with mild to severe plaque psoriasis for up to 52 weeks (NCT03956355, NCT03983980, NCT04053387). Here we present case photography documenting outcomes in the PSOARING trials. Cases illustrate various outcomes across different body areas, including responses meeting the formal FDA-mandated regulatory endpoint of a Physician Global Assessment (PGA) score of 0 (clear) or 1 (almost clear) and a decrease of at least 2 points from baseline at week 12, meaningful clinical improvement not meeting this formal endpoint, patient-reported outcomes, and pre-specified adverse events of special interest (AESIs). Tapinarof cream 1% QD demonstrated rapid and highly statistically significant efficacy, with improvements in disease activity and quality of life. In addition, a high rate (40.9%; n = 312/763) of complete disease clearance (PGA = 0) was achieved, and improvements exceeding National Psoriasis Foundation treatment goals were demonstrated. After first achieving complete disease clearance (PGA = 0), patients treated with tapinarof experienced an approximately 4-month remittive effect off therapy. Incidence and severity of folliculitis and contact dermatitis AESIs were generally mild or moderate, localized to the site of application, and associated with low discontinuation rates. Medical images are of importance in trials of dermatologic therapies to inform clinical decision-making and enhance patient assessment. Tapinarof cream 1% QD is efficacious and well tolerated in patients with mild to severe plaque psoriasis, with clinically relevant improvements seen early in the course of treatment.Clinicaltrials.gov numbers: NCT03956355, NCT03983980, NCT04053387.

European consensus-based interdisciplinary guideline for diagnosis and treatment of basal cell carcinoma-update 2023

Basal cell carcinoma (BCC) is the most common malignant tumour in white populations. Multidisciplinary experts from European Association of Dermato-Oncology (EADO), European Dermatology Forum, European Society for Radiotherapy and Oncology (ESTRO), Union Européenne des Médecins Spécialistes, and the European Academy of Dermatology and Venereology developed updated recommendations on diagnosis and treatment of BCC. BCCs were categorised into 'easy-to-treat' (common) and 'difficult-to-treat' according to the new EADO clinical classification. Diagnosis is based on clinico-dermatoscopic features, although histopathological confirmation is mandatory in equivocal lesions. The first-line treatment of BCC is complete surgery. Micrographically controlled surgery shall be offered in high-risk and recurrent BCC, and BCC located on critical anatomical sites. Topical therapies and destructive approaches can be considered in patients with low-risk superficial BCC. Photodynamic therapy is an effective treatment for superficial and low-risk nodular BCCs. Management of 'difficult-to-treat' BCCs should be discussed by a multidisciplinary tumour board. Hedgehog inhibitors (HHIs), vismodegib or sonidegib, should be offered to patients with locally advanced and metastatic BCC. Immunotherapy with anti-PD1 antibodies (cemiplimab) is a second-line treatment in patients with a progression of disease, contraindication, or intolerance to HHI therapy. Radiotherapy represents a valid alternative in patients who are not candidates for or decline surgery, especially elderly patients. Electrochemotherapy may be offered when surgery or radiotherapy is contraindicated. In Gorlin patients, regular skin examinations are required to diagnose and treat BCCs at an early stage. Long-term follow-up is recommended in patients with high-risk BCC, multiple BCCs, and Gorlin syndrome.

[Treatment of actinic keratoses in older adults]

Actinic keratoses (AKs) are common precancerous skin lesions that primarily affect older adults due to cumulative sun exposure. Given the increased vulnerability of older adults to developing AKs, appropriate therapeutic strategies are crucial to prevent their progression to invasive squamous cell carcinoma. This comprehensive review aims to explore the various treatment modalities available for AKs in the elderly population, focusing on their efficacy, safety, and suitability for this specific age group. The article discusses topical treatments, cryotherapy, photodynamic therapy, chemical peels, and surgical interventions, providing a detailed analysis of their mechanisms of action, benefits, limitations, and considerations in geriatric patients. Furthermore, the importance of individualized treatment plans, considering factors such as comorbidities, medication interactions, and patient preferences, are highlighted.

Assessment of anti-psoriatic activity of bakuchiol-loaded solid lipid nanoparticles-based gel: design, characterization, and mechanistic insight via NF-kB signaling pathway

The aim of the current study is to evaluate the anti-psoriatic potential of bakuchiol (Bak) loaded solid lipid nanoparticles (SLNs) via modulating inflammatory and oxidative pathways. Bak-loaded SLNs were prepared using hot homogenization method and characterized by various spectroscopic techniques. Bak-SLNs suspension was formulated into gel using Carbopol. Different in vivo assays were executed to explore the role of inflammatory markers and oxidative enzymes in psoriasis. DLS (dynamic light scattering) analysis showed suitable particle size, zeta potential, and polydispersity index (PDI) of developed formulation. TEM (transmission electron microscopy) reveal the spherical shape of Bak-SLNs particles. The release studies confirmed the sustained release of Bak-SLNs-based gel. UV-B-induced psoriatic Wistar rat model showed significant anti-psoriatic effect of Bak via regulating inflammatory markers (NF-kB, IL-6, IL-4, and IL-10) and levels of anti-oxidant enzymes, superoxide dismutase (SOD), catalase (CAT), glutathione (GSH), and glutathione-S-transferase (GST). Furthermore, RT-qPCR analysis confirms that Bak downregulates the expression of inflammatory markers, while histology and immunohistology results also confirm the anti-psoriatic effect of Bak. The study indicates that Bak-loaded SLNs-based gel significantly downregulates the level of cytokines and interleukins involve in NF-kB signaling cascade; hence, it can prove to be a novel therapeutic approach to cure psoriasis.

Long term study of topical interferon α-2b eye drops as primary treatment of ocular surface squamous neoplasia

PURPOSE

To assess the efficacy of topical interferon α-2β(IFN) eye drops as a primary treatment for ocular surface squamous neoplasia(OSSN) and evaluate factors that impact response to treatment and recurrence of OSSN.

METHOD

A retrospective study of 143 OSSN patients treated with topical IFN(1MIU/ml) from January 1998 to June 2021. The diagnosis was based on clinical examination and anterior segment optical coherence tomography, with histologic confirmation was present in 46.2% of patients. Data on demographic, tumor characteristics, treatment outcome, and side effects were collected. The primary outcomes were tumor resolution frequency and recurrence rate. Secondary outcomes were predictive factors for resolution and recurrence and side effects of treatment.

RESULT

Participants were mostly older (mean age, 69 years, SD 12.9, range 29-97), white(89%) males (74%). Complete tumor resolution was achieved in 80.4% of individuals with a mean time to resolution of 4.2 months (SD 2, range 0.5-12.3 months). On multivariable analysis, history of skin cancer (HR: 0.66, p = 0.05, 95%CI: 0.44-0.99) and immune system abnormalities (HR: 0.37, p = 0.009, 95%CI: 0.18-0.79) reduced the risk of tumor resolution, while a prior history of OSSN (HR: 3.49, p < 0.001, 95%CI: 1.76-6.93) increased the risk of resolution. With a mean follow-up time of 44.3 months (SD 50.9, 0-290 months), the recurrence rate was 0%, 2.3% and 3.1% at 1, 2, and 5 years respectively. Mild hyperemia(18.9%) and pain(10.6%) were the two most common side effects.

CONCLUSION

Topical IFN eye drops are a safe and effective primary treatment modality for OSSN with a reasonable side effect profile.

The importance of topical metronidazole in the treatment of acute anal fissure: a double-blind study controlled for prospective randomization

Purpose

Acute anal fissure, a disease characterized by severe pain in the anorectal area, reduces quality of life and becomes chronic absent appropriate treatment. More recently, anaerobic infections have been noted as contributive to etiopathogenesis. This study investigates topical metronidazole's effect in the treatment of acute anal fissure.

Methods

Our prospective randomized controlled double-blind study included 2 groups of 100 patients older than 18 years from our General Surgery Clinic with anal fissure complaints for less than 8 weeks. Topical diltiazem treatment was started in group 1, and topical diltiazem and metronidazole treatment in group 2. Pain levels were evaluated by the visual analogue scale (VAS) score, and recovery status was evaluated by physical examination findings ab initio and at the 1st, 4th, and 6th weeks. VAS score levels, demographic, clinical, and recovery status were then compared.

Results

There was no difference between the groups as to age, sex, pain on defecation, bleeding, constipation, and duration of pain, bleeding and constipation (P>0.05). From week 1, fissure epithelialization and healing rates were higher in group 2 (P<0.001); group 2 VAS score levels were lower than in group 1 (P<0.001) and achieved by group 1 only in week 4 (P=0.073).

Conclusion

Adding topical metronidazole to treatment reduces the duration and severity of pain, shortens healing time, and increases the healing rate.

Nanomedicines for the topical treatment of vulvovaginal infections: Addressing the challenges of antimicrobial resistance

Recent years have, surprisingly, witnessed an increase in incidence of sexually transmitted infections (STIs). At the same time, antimicrobial therapy came under the threat of ever rising antimicrobial resistance (AMR), resulting in STIs with extremely limited therapy options. In this review, we addressed the challenges of treating vaginal infections in an era of AMR. We focused on published work regarding nanomedicine destined for localized treatment of vaginal infections. Localized therapy offers numerous advantages such as assuring high drug concentration at the infection site, limiting systemic drug exposure that can lead to faster development of AMR reduction in the systemic side effects and potentially safe therapy in pregnancy. We provided a state-of-the-art overview of nanoformulations proposed to topically treat STIs, emphasizing the challenges and advantages of each type of nanocarriers, as well as issues of potential toxicity.

Successful Treatment of Recurrent Dermatitis after Physalia physalis (Portuguese Man O' War) Envenomation with Extracorporeal Shock Wave Therapy

For more than 3 decades, extracorporeal shock wave therapy (ESWT) has been clinically implemented in urologic and orthopaedic indications. Here, we present the case of a patient with envenomation from a highly toxic jellyfish-like siphonophore (Physalia physalis) with a toxic contact dermatitis resulting in chronic eruptive skin lesions. The skin lesions on the dorsal right hand lasted more than 16 weeks and were refractive to local cortisone treatment. They finally healed after 8 applications of low-energy planar/defocused ESWT over 4 weeks. In detail, the clinical course, ESWT specifications and the possible mechanisms of ESWT in the light of the current literature are discussed. Our case indicates that ESWT is an underestimated, promising non-invasive, non-immunosuppressive treatment for chronic eruptive skin lesions after jellyfish or related toxin envenomations.

A Randomized Placebo-Controlled Trial of Efficacy and Safety: Drug-Free Gel Containing Ultra-Deformable Phospholipid Vesicles (TDT 064) in Osteoarthritic Knees

Background:

There are a number of topical agents that are used for treatment of knee osteoarthritis. Drug-free gels, containing ultra-deformable phospholipid vesicles (TDT 064) are one such topical therapy, which have been stated to act as a bio lubricant. However, the evidence of TDT 064 in treatment of knee osteoarthritis is limited. Hence, the aim of this study was to evaluate the efficacy of pain control as a primary outcome and safety of TDT 064 compared with a topical placebo.

Methods:

Sixty-four patients with primary osteoarthritis, with radiographic showing Kellgren and Lawrence classification grade II to III, were randomized into 2 groups. In the first group of 32 patients TDT 064 was used as topical agent, whilst in the second group of 32 patients a placebo identical in appearance was used instead. The verbal numerical rating scale (VNRS) was used for recording pain levels, Self-reported Knee Injury and Osteoarthritis Outcome Scores (KOOS) as well as amounts of rescue medication were also recorded. The data were recorded at the start of the study, and then at follow-up appointments of 14 days, 6 weeks, and 3 months.

Results:

The mean VNRS for pain in both groups were significantly improved, when compared to the start of treatment (P < .0001); however, there were no differences between groups at any follow up visit. KOOS in all subscales were not significantly different between both groups at baseline and at the end of treatment. However, the average amount of NSAIDs in the TDT 064 group was 26.39 ± 22.11 tabs, which was significantly lower than the control group; which used an average 37.03 ± 19.22 tabs in 3 months (P = .047).

Conclusions:

There were no differences in the VNRS for pain and KOOS scores between the active and placebo groups. Although, TDT 064 could decrease usage of rescue medication the difference with use of a placebo was minimal. Further, larger trials would also be beneficial to demonstrate any differences between TDT 064 and a placebo.

Trial Registration:

TCTR, TCTR 20190302001. Registered 1 March, 2019: http://www.clinicaltrials.in.th

Inadequate Disease Control, Treatment Dissatisfaction, and Quality-of-Life Impairments Among US Patients Receiving Topical Therapy for Atopic Dermatitis

Introduction

Patients with atopic dermatitis (AD) experience burdensome symptoms and impaired quality of life (QoL). The objective of this study was to investigate the effects of topical AD therapies on disease control, physician and patient treatment satisfaction, and QoL in a real-world setting.

Methods

This was a retrospective, point-in-time study of physician-completed medical records and patient surveys drawn from two Adelphi AD Disease Specific Programmes™ (1. adults ≥ 18 years old; 2. pediatrics ≤ 17 years old) in the USA. Eligible physicians completed patient record forms and provided disease control assessments. Physicians and matched patients were surveyed regarding their satisfaction with current treatment. Patient-reported outcomes included the Dermatology Life Quality Index (DLQI), Children’s DLQI (CDLQI), Patient-Oriented Eczema Measure (POEM), and the Work Productivity and Activity Impairment (WPAI) questionnaire.

Results

A total of 394 adult (topicals only, n = 284; topical plus systemic, n = 110) and 144 adolescent (aged 12–17 years; topicals only, n = 114; topical plus systemic, n = 30) patients who had received their current treatment for at least 1 month were included. Overall, 24.5% of patients had physician-reported uncontrolled disease (adults, 22.8%; adolescents, 29.2%). Rates of physician- and patient-reported dissatisfaction with current treatment were 32.0% (adults, 28.2%; adolescents, 42.4%) and 24.8% (adults, 24.0%; adolescents, 26.8%), respectively, and were higher for patients with uncontrolled versus controlled disease. Poorer disease control and higher rates of treatment dissatisfaction were generally reported among patients receiving topical plus systemic therapy versus topicals alone. Patients with uncontrolled versus controlled disease reported more impairment in the DLQI, CDLQI, POEM, and WPAI (P < 0.05 for all), with generally greater impairments observed among patients on topical plus systemic therapy versus topicals alone.

Conclusion

Patients receiving topical AD therapies experienced uncontrolled disease and reported decreased overall functioning and lower QoL. An unmet need for topical AD treatments that improve disease control and patient outcomes exists.

Atopic dermatitis (or eczema) is a common skin condition that causes dry, cracked, and itchy skin. Patients are frequently prescribed topical therapy, such as ointments and creams, to apply directly to the affected skin. Additionally, patients may be prescribed systemic therapies, which are oral or injectable medications that work throughout the entire body. This study included 394 adults and 144 adolescents (aged 12–17 years) with atopic dermatitis. All patients in the study were receiving topical therapy, and some received both topical and systemic therapy. The goal of the study was to evaluate how satisfied patients and their doctors were with current treatment and to learn how patients in the study felt about their quality of life. Patients and their doctors completed surveys that asked about feelings, symptoms, and whether their condition affects their work. The study results showed that patients had high levels of dissatisfaction with their treatment. Doctors reported that between one-fifth and one-quarter of adult patients and up to one-half of adolescent patients had uncontrolled disease (defined as changeable or worsening). Patients with uncontrolled disease reported higher dissatisfaction with their therapy and a negative outlook on their quality of life versus those with controlled disease (defined as stable or improving by their doctors). In summary, doctors and their patients currently using topical medications to treat atopic dermatitis reported that treatments were not working well enough and that uncontrolled disease was negatively affecting patients’ quality of life and work, indicating that additional treatment options are needed.

Real-World Experience Using Topical Therapy-Calcipotriol and Betamethasone Dipropionate Foam in Adults with Beyond-Mild Psoriasis

Introduction

Determining optimal treatment for moderate plaque psoriasis can be challenging. Recent studies have demonstrated the effectiveness of calcipotriol and betamethasone dipropionate (Cal/BD) foam in patients with moderate-to-severe plaque psoriasis.

Methods

This research explored the use of Cal/BD foam in patients with beyond-mild psoriasis (defined as patients eligible for topical treatment, systemic treatment, or combined topical/systemic treatments) using an online questionnaire, retrospective medical-record review, and by capturing the attitudes and treatment approaches of dermatology specialists.

Results

Data from 409 patients with beyond-mild psoriasis treated with Cal/BD foam were provided by 120 dermatology specialists from Germany, Spain, and the UK. Cal/BD foam was prescribed as monotherapy for most (58%) patients and was considered to be effective. Cal/BD foam was infrequently used in combination with biologics (7%) in this segment; 26% of patients received Cal/BD foam in combination with a non-biologic systemic treatment. Cal/BD foam prescribers generally use topical agents to bridge the waiting time to non-biologic/biologic systemic treatment, and as an add-on to systemic treatment for residual lesions.

Conclusions

In patients with beyond-mild psoriasis, the most commonly prescribed topical medication was Cal/BD foam, which was regarded as an effective treatment. Further research is needed to determine optimal use of Cal/BD foam in these patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13555-021-00501-3.

Treating Melanoma in Situ During a Pandemic with Telemedicine and a Combination of Imiquimod, 5-Fluorouracil, and Tretinoin

The recent coronavirus disease 2019 (COVID-19) pandemic has created a quandary for the physician in terms of evaluating and treating cutaneous skin cancers, particularly melanomas. At the onset of the pandemic, many planned medical and surgical visits for skin cancers were postponed. Physicians and patients have had to balance the risk of exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) with that of worsening morbidity and mortality due to delays in skin cancer treatments. We present a male patient who had two melanoma-in-situs (MISs) that were treated during the COVID-19 pandemic with a combination of topical imiquimod 5% cream, 5-fluorouracil 2% solution, and tretinoin 0.1% cream. The successful treatments occurred without in-person visits and with the aid of telemedicine. Although surgery is the standard for the treatment of melanoma in situ, this case demonstrates an effective viable treatment modality for MIS during a pandemic situation.

Evaluation of the antiseptic and wound healing potential of polyhexamethylene guanidine hydrochloride as well as its toxic effects

The synthetic polyhexamethylene guanidine hydrochloride (PHMGH) polymer presents antifungal and antimicrobial activities in vitro. However, in vivo reports regarding its antiseptic and healing activity are scarce in the scientific literature. Thus, the present study aimed to evaluate the antimicrobial and healing effects, as well as toxicological parameters, of a topical solution containing 0.5% PHMGH (Akwaton®) in the treatment of superficial skin wounds experimentally induced on the dorsum of rodents. In addition, non-clinical safety studies were also conducted for use in human health, such as acute oral toxicity and genotoxicity tests. Animals did clinically not present dermatitis. After two days of topical treatment, PHMGH showed a significant antiseptic effect compared to the untreated group, reducing the number of colony-forming units by 72%, reaching 100% on the fourth day of treatment. The animals treated with PHMGH showed a significant area reduction of the skin lesions in relation to the untreated group, indicating a healing effect of the polymer. Moreover, PHMGH treatment led to a significant increase in fibroblasts when compared to the untreated group, revealing its healing action. No significant differences were observed between the biochemical indicators of hepatoxicity and nephrotoxicity, nor genotoxicity between the PHMGH-treated and the negative control groups. The results of acute oral toxicity showed that PHMGH at 5% presents a lethal dose 50% greater than the 2000 mg/kg. At a concentration of 5%, PHMGH did not show genotoxicity nor cytotoxicity at doses up to 1500 mg/kg through the micronucleus assay in mice. Therefore, 0.5% PHMGH showed an antimicrobial and healing effect, with no toxicity, and could be a promising adjunct in the microbial control of healing wounds.

Treatment of Mild-to-Moderate Plaque Psoriasis with a New 650-Microsecond 1064-nm Nd:YAG Laser: Clinical and Dermoscopic Assessment

INTRODUCTION

About 70-80% of patients with psoriasis suffer from mild disease, and new modalities of topical treatment are urgently needed. This study aims to evaluate the effectiveness of 650-microsecond 1064-nm Nd:YAG laser in the therapy of psoriatic plaques and assess the utility of dermoscopy in predicting treatment response.

METHODS

Ten patients (mean age 37.4 ± 16.2 years) with stable plaque-type psoriasis were enrolled. The microsecond Nd:YAG laser treatment was applied to representative plaques on day 0, 7, 14, and 21. Clinical and dermoscopic photographs were performed at each session and follow-up visit (day 28). The disease severity was assessed using modified Psoriasis Area and Severity Index (mPASI) and Investigator Global Assessment (IGA). Patients were asked to rate the intensity of subjective symptoms, tolerability, and final outcome of the treatment.

RESULTS

Significant improvement of all mPASI components was observed, although the maximal mean reduction of total mPASI was only 30.3%. At baseline, three patients were assessed as "moderate" and seven as "mild" according to IGA, while on day 28, eight patients were scored as "mild" and two as "almost clear." Complete resolution of itching was achieved in all patients. Local adverse reactions were also observed, which resulted in moderate tolerance of treatment in four patients. Three participants reported marked improvement on day 28, although 30% of patients observed no benefit. All subjects with dotted vessels, linear vessels, or hemorrhagic spots under dermoscopy at baseline reported some improvement after laser therapy. Three out of six patients with globular vessels were unresponsive to Nd:YAG laser.

CONCLUSIONS

Microsecond Nd:YAG laser treatment may provide some improvement of psoriatic plaques, but its routine applicability seems to be limited due to ambiguous efficacy and local adverse reactions. Dermoscopy may be useful in identifying patients who will benefit from the procedure.

Importance of microRNAs in Skin Oncogenesis and Their Suitability as Agents and Targets for Topical Therapy

Skin cancer is the most common cancer worldwide, with rapidly increasing incidence and consistent mortality. Skin cancer encompasses melanoma and non-melanoma skin cancer, which in turn is mainly divided into cutaneous squamous cell carcinoma and basal cell carcinoma. Small noncoding micro-RNAs (miRNAs) regulate protein expression after transcription and play a role in the development and progression of skin cancer. Deregulated expression of miRNAs in skin cancer is associated with cell proliferation, angiogenesis, metastasis, apoptosis, immune response, and drug resistance. Specific patterns of miRNAs in specific skin cancer types can be used as diagnostic markers. For therapeutic purposes, both miRNA and chemically modified variants thereof as well as miRNA antagonists (antagomiRs) or RNA inhibitors may be applied topically. Due to their specific physicochemical properties, physical or chemical diffusion promoters are used with varying degrees of success. There is no question by now that such preparations have a high potential for the treatment of epithelial skin tumors in particular.

Adjunctive Use of Calcipotriene/Betamethasone Dipropionate Foam in a Real-World Setting Curtails the Cost of Biologics Without Reducing Efficacy in Psoriasis

Introduction

Although the efficacy of monotherapy with biologics for psoriasis is well established, many patients fail to achieve complete plaque clearance from their initial biologic treatment alone. Adjunctive treatment with topical calcipotriene plus betamethasone dipropionate (Cal/BD) foam may offer substantial clinical benefit and potential cost savings.

Methods

We conducted a 16-week, open-label, single-arm study of adjunctive therapy with Cal/BD foam in subjects who had been treated with etanercept or adalimumab for ≥ 24 weeks but had not obtained a satisfactory treatment response. Assessments included affected body surface area (BSA), Physician’s Global Assessment (PGA) of disease severity, BSA × PGA, National Psoriasis Foundation (NPF) Treat to Target status, and likelihood of the physician to switch biologics. In parallel, a cost analysis was performed to compare the cost of switching to a different biologic versus adding Cal/BD foam to the original biologic.

Results

Four weeks of daily adjunctive treatment with Cal/BD foam led to notable reductions in BSA, PGA, and BSA × PGA relative to baseline. Additionally, by week 4, > 75% of subjects achieved NPF Treat to Target status, and the likelihood of the investigator to switch biologics decreased from 90.0% at baseline to 7.1%. The improved efficacy was maintained throughout the additional 12 weeks of maintenance Cal/BD foam application. The pharmacoeconomic evaluation demonstrated that adjuvant use of Cal/BD foam led to cost savings compared with switching biologic treatments.

Limitations

Due to the nature of the open-label study lacking a vehicle-treated control, no statistical comparison can be made.

Conclusions

The results of this study demonstrate that the addition of Cal/BD foam to plaque psoriasis patients who still have significant disease activity despite being on stable biologic therapy improves treatment outcomes to the point where switching to a more expensive biologic therapy is a less suitable treatment option.

Therapeutic challenges in managing pediatric psoriasis

Background

Each year, 20,000 patients aged <10 years are diagnosed with psoriasis. Pediatric-onset psoriasis has many similarities to adult-onset disease, and previous studies suggest that the incidence might be increasing in both populations.

Objective

The challenges that arise when treating patients with psoriasis, especially those age <12 years, are summarized, as well as the limited available treatment options for treating pediatric patients with psoriasis and the evidence supporting each of them.

Methods

Recently published guidelines by the American Academy of Dermatology and the National Psoriasis Foundations, as well as guidelines published by the German Society of Dermatology, provide considerable insight in managing patients who have this condition. The latest studies on pediatric psoriasis treatment were reviewed, including recent and current clinical trials with U.S. Food and Drug Administration approved and nonapproved medications, case reports, case series, and reviews. The authors also reviewed American and European guidelines, as well as recommendations from expert panels.

Results

Currently, only six medications are approved by the U.S. Food and Drug Administration for the treatment of pediatric psoriasis: three biologics and three topical. Many off-label topical treatments have been used in pediatric psoriasis, with variable effectiveness and safety profiles. Data from adult clinical trials, as well as case reports and series from pediatric patients, suggest that other biologic medications are effective for pediatric psoriasis.

Conclusion

Many questions remain unanswered, leaving clinicians facing multiple challenges when encountering pediatric patients with psoriasis. This summation will help provide an overview of current on- and off-label medications for pediatric psoriasis. Pediatric clinical trials should be implemented to obtain data that can result in expanding the therapeutic spectrum for this population, parallel to their adult counterparts.

Novel treatment of upper tract urothelial carcinoma in situ with docetaxel in BCG refractory patients

INTRODUCTION

Patients with upper-tract carcinoma in situ (UT-CIS) that have failed treatment with BCG are recommended for radical nephroureterectomy (RNU). We describe a cohort of patients with BCG-refractory UT-CIS that were treated with docetaxel, a novel agent in the approach to topical therapy.

METHODS

Patients with pathologically proven UT-CIS from 2012 to 2020 with an imperative indication for organ preservation and history of BCG-refractory disease were included. Each patient underwent ureteroscopy with biopsy and selective cytology pre- and postinduction, and after each maintenance course. Complete response (CR) was defined as the absence of visualized lesions on ureteroscopy, negative selective cytology, and absence of clinical progression. No response (NR) was defined as persistence of lesions after induction or absence of visualized lesions with persistently positive cytology.

RESULTS

Seven patients and 10 renal units were treated. Six of the 10 renal units had initial CR (60%). Three patients with NR went on to have RNU, one of which subsequently died due to cancer-specific mortality. One patient with bilateral disease had NR in 10 renal unit and cure in the other. This patient subsequently developed recurrence in his remaining renal unit. A second patient had CR in both kidneys for 6 years, but 1 year after finishing maintenance regimen developed HG disease in 1 ureter. Average follow-up was 33 months.

CONCLUSION

This study demonstrates efficacy of docetaxel as a treatment option for patients with UT-CIS with a contraindication to RNU after failing BCG. Response rates of 60% appear to be similar to those of BCG-refractory bladder CIS.

Topical therapies for the treatment of cervical intraepithelial neoplasia (CIN) 2-3: A narrative review

•

CIN management is currently surveillance or surgical therapy. This review describes current research on medical therapies.

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Imiquimod is the most studied with evidence of safety and efficacy.

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5-Fluorouracil has also shown promise with two clinical trials showing efficacy as adjuvant and primary treatment.

•

Antivirals therapies have produced mixed results with cidofovir showing the most potential.

•

The data remains weak regarding hormonal, herbal and alternative therapies rending it difficult to draw conclusions.

Current management of Cervical Intraepithelial Neoplasia (CIN), caused by high-risk human papillomavirus (hr-HPV), is based on surveillance and surgical therapy. Procedures carry potential risks such as preterm birth, and access remains limited throughout the world. However, there are no medical therapies recommended to promote the clearance of hr-HPV infection or CIN. Ultimately, even if less efficacious than excision procedures, medical therapies have the potential to decrease cervical cancer by eliminating barriers to treatment, such as access to treatment, or serving as an adjunct to surgical treatment in both high- and low-resource settings.

This review describes current research on topical therapies with the potential for self-application for the treatment of HPV or CIN. Therapies included are immune-modulators, anti-proliferative medications, antivirals, hormones, and herbal/alternative therapies. Randomized trials of immune-modulating (imiquimod), anti-proliferative (5-fluorouracil), and anti-viral (cidofovir) therapies have had the most promising results. However, no option has sufficient clinical trial evidence to be recommended as treatment for CIN 2–3 and surgery remains the standard of care.

The research described in this review serves as a guide for the development of future trials in the burgeoning arena of topical therapies for CIN 2–3.

Topical corticosteroids for pediatric atopic dermatitis: Thoughtful tips for practice

Atopic dermatitis (AD) is one of the most common chronic inflammatory skin disease, affecting up to 25% of children. Topical corticosteroids (TCS) are currently used as first-line antiinflammatory treatment for AD, due to their overall therapeutic efficacy, and the availability of different potency classes and a wide array of formulations. Therapeutic efficacy of TCS depends upon selecting the appropriate vehicle and potency, and the frequency of application, also taking into account the duration of treatment and patient preferences. This article focuses on TCS benefits and potential risks and it provides practical tips to properly use these drugs in clinical practice, to make a patient-tailored treatment approach.

Topical treatments for skin cancer

Skin cancer is a broad term used to describe a number of different malignant indications of the skin. Skin cancers mostly comprise of the keratinocyte cancers [Basal Cell Carcinoma (BCC) and cutaneous Squamous Cell Carcinoma (SCC)], and melanoma. Surgical excision of these malignancies has been the preferred treatment of patients for decades. However, the decision to perform surgery can be affected by various considerations, including co-morbidities of the patient, the anatomical site of the lesion and potential intolerance for repeated excisions. Topical treatment of skin cancer may therefore be more appropriate in certain instances. Topical treatment potentially allows for higher drug levels at the tumor site, and may result in less overall toxicity than systemic agents. This review will specifically address the current agents used in topical treatment of skin cancers, and introduce emerging treatments from the natural product field that may also find utility in these indications.

An Open Study to Evaluate Effectiveness and Tolerability of a Nail Oil Composed of Vitamin E and Essential Oils in Mild to Moderate Distal Subungual Onychomycosis

BACKGROUND

Onychomycosis is the most common nail disease and can affect both fingernails and toenails. When possible, topical treatment is generally preferred both by patients and physicians because it is associated with lower risk of systemic side effects and drug interactions than oral antifungals, avoiding laboratory monitoring.

OBJECTIVE

The aim of our study was to evaluate the efficacy, tolerability, and patient's compliance of a new topical antifungal containing vitamin E and essential oils of lime, oregano, and tea tree.

PATIENTS AND METHODS

We enrolled 20 patients with mild-moderate distal subungual onychomycosis due to dermatophytes or non-dermatophyte molds. The product was applied once daily on the periungual tissues and on the nail plate for 6 months. Follow-up without therapy continued for another 6 months in order to evaluate the product's effect maintenance. Periodic evaluation of treatment efficacy was performed by standardized photography and mycological examination (KOH + culture) of the target nail at baseline (T0), after 3 months (T1) and 6 months (T2) of therapy, and after 6 months of follow-up (T3).

RESULTS

At the end of the 12-month study, the majority of patients achieved a complete cure of onychomycosis (78.5%). All patients were very satisfied by the treatment. No side effects were recorded.

CONCLUSIONS

The results of our study indicate that this new topical antifungal containing vitamin E and essential oils of lime, oregano, and tea tree is an effective and safe option for topical therapy of onychomycosis. This topical antifungal nail oil restructures the nail appearance, improving patient's adherence to therapy and reducing the risk of relapses, maintaining results over time.

Potential factors contributing to the poor antimicrobial efficacy of SAAP-148 in a rat wound infection model

BACKGROUND

We investigated the efficacy of a synthetic antimicrobial peptide SAAP-148, which was shown to be effective against Methicillin-resistant Staphylococcus aureus (MRSA) on tape-stripped mice skin. Unexpectedly, SAAP-148 was not effective against MRSA in our pilot study using rats with excision wounds. Therefore, we investigated factors that might have contributed to the poor efficacy of SAAP-148. Subsequently, we optimised the protocol and assessed the efficacy of SAAP-148 in an adapted rat study.

METHODS

We incubated 100 µL of SAAP-148 with 1 cm2 of a wound dressing for 1 h and determined the unabsorbed volume of peptide solution. Furthermore, 105 colony forming units (CFU)/mL MRSA were exposed to increasing dosages of SAAP-148 in 50% (v/v) human plasma, eschar- or skin extract or PBS. After 30 min incubation, the number of viable bacteria was determined. Next, ex vivo skin models were inoculated with MRSA for 1 h and exposed to SAAP-148. Finally, excision wounds on the back of rats were inoculated with 107 CFU MRSA overnight and treated with SAAP-148 for 4 h or 24 h. Subsequently, the number of viable bacteria was determined.

RESULTS

Contrary to Cuticell, Parafilm and Tegaderm film, < 20% of peptide solution was recovered after incubation with gauze, Mepilex border and Opsite Post-op. Furthermore, in plasma, eschar- or skin extract > 20-fold higher dosages of SAAP-148 were required to achieve a 2-log reduction (LR) of MRSA versus SAAP-148 in PBS. Exposure of ex vivo models to SAAP-148 for 24 h resulted in a 4-fold lower LR than a 1 h or 4 h exposure period. Additionally, SAAP-148 caused a 1.3-fold lower mean LR at a load of 107 CFU compared to 105 CFU MRSA. Moreover, exposure of ex vivo excision wound models to SAAP-148 resulted in a 1.5-fold lower LR than for tape-stripped skin. Finally, SAAP-148 failed to reduce the bacterial counts in an adapted rat study.

CONCLUSIONS

Several factors, such as absorption of SAAP-148 by wound dressings, components within wound exudates, re-colonisation during the exposure of SAAP-148, and a high bacterial load may contribute to the poor antimicrobial effect of SAAP-148 against MRSA in the rat model.

Real-World Data on Topical Therapies and Annual Health Resource Utilization in Hospitalized Swiss Patients with Ulcerative Colitis

Objectives

Topical treatment with aminosalicylates and/or budesonide was shown to be highly effective in patients with ulcerative colitis (UC), while reducing the likelihood of systemic adverse effects. However, previous research has shown that topical treatment is clearly underused. We aimed to evaluate the use of topical therapy in the real-world setting.

Methods

This is an observational study based on claims data of 201 Swiss adult patients who were hospitalized for UC between 2012 and 2014 and who were then followed for 1 year. A variety of factors presumably associated with topical treatment were examined. Annual health care utilization (UC-related medications, diagnostic procedures, consultations, and rehospitalizations) of patients with versus without topical therapy was compared.

Results

Of the 201 hospitalized UC patients, 82 (40.8%) were treated with topical 5-acetylsalicylic acid (ASA) and/or topical rectal steroids. The main factors significantly and positively associated with receiving topical treatment were the use of topical treatment in the year prior to the hospitalization, receiving oral 5-ASA, and living in an urban area. The mode of administration was further related to the language area. Patients with topical therapy significantly more often received other UC-related medications, such as combinations with systemic steroids. They significantly more often underwent colonoscopies and calprotectin measurements, and more often consulted a gastroenterologist in the follow-up, while there was no significant difference regarding rehospitalizations.

Conclusions

Topical treatment is underused in patients with UC, which stands in contrast to the current European Crohn's and Colitis Organization guidelines. Patients' preferences and considerations need to be taken into account when prescribing medical therapy.

Dressings, Topical Therapy, and Negative Pressure Wound Therapy

The current epidemic of diabetes has created a high demand for skilled wound-care professionals. Wound-care treatment begins with an appreciation of the cause of the ulceration and an adherence to the fundamental pillars of wound care. Also critical in the wound management paradigm is the optimization of the wound environment to facilitate the progression through the stages of healing. This can be accomplished through the use of different topical therapies and wound dressings to generate a favorable condition conducive to healing. This article summarizes the updated literature and best practices related to this topic.

Efficacy of commercially available biological agents for the topical treatment of cervical intraepithelial neoplasia: a systematic review

BACKGROUND

Cervical cancer is a major public health issue in the world, especially in developing countries. It can be prevented through vaccination against HPV (primary prevention) and through screening and treatment of cervical intraepithelial neoplasia (CIN) (secondary prevention). Surgical methods for treatment of CIN are linked to complications such as bleeding and adverse pregnancy outcomes. Furthermore, these methods are not generally available in resource-poor settings. Therefore, topical agents for local application on the cervix have been used since decades to overpass complications and limitations of the surgical methods.

AIMS

Review of the literature on the efficacy of commercially available biological agents used for topical treatment of cervical intraepithelial neoplasia (CIN).

METHODS

A systematic search through PubMed and the Cochrane database was performed up to December 2017, using the medical subheadings (MesH) for topical agent, treatment, and cervical intraepithelial neoplasia. Appropriate inclusion/exclusion criteria have been used for the selection of eligible clinical studies. Clinical studies containing a minimum of 20 women, aged 18-50 with a diagnosis of CIN 1-3, and at least a 4 weeks follow-up after the end of the topical treatment were included.

RESULTS

The initial electronic database search resulted in a total of 849 articles. After screening titles and abstracts, 62 articles were selected as potential studies. Of these, six articles were included in the review after reading the full text: two were on 5-FluoroUracil, two on trans retinoic acid, one on Imiquimod, and one on Cidofovir. The reported regression/remission rates for CIN differed among studies. In CIN2 patients, the overall remission rate ranged between 43 and 93% for the active agents.

CONCLUSION

Among the topical agents studied, 5-FluoroUracil showed good remission rates above 80%. Varying results seen in this review is due to the differences in quality of the design between studies. Large-scale and less biaised studies are needed to elucidate the true efficacy and safety of topical agents in the treatment of CIN.

Optimization of hydrogel containing toluidine blue O for photodynamic therapy in treating acne

Antibiotics and photodynamic therapy (PDT) are widely employed in curing acne. However, antibiotics as an effective treatment would lead to bacterial resistance and severe side effects. In this study, we aimed to develop a novel TBO hydrogel, which could prolong the retention time of photosensitizer (TBO) at the lesion site and improve therapeutic effect. In vitro antibacterial experiments (against Staphylococcus aureus and Escherichia coli), the response surface methodology was used to optimize the formulation of TBO hydrogel. The results indicated that the optimal formulation was 0.5% (v/v) carbomer, 0.01 mg/mL TBO, 0.5% (v/v) ethanol concentration, 0.5% (v/v) Tween 80, the mass ratio of NaOH to carbomer of 0.4 (w/w). The TBO hydrogel formulation showed the strong antibacterial activity for Propionibacterium acnes. The stability, pH, and antibacterial activity of TBO hydrogel did not significantly change under 4 °C, 25 °C, and 40 °C during 6-week storage. Furthermore, TBO combined with carbomer hydrogel showed the 51.28% (4 h) and 69.80% (24 h) release. In summary, the hydrogel TBO might be a vital therapeutic strategy to promote the PDT applied in the topical therapy of acne. Graphical abstract A TBO hydrogel for photodynamic therapy in the treatment of acne.

Tolerability of Topical Treatments for Atopic Dermatitis

Atopic dermatitis (AD) is a common inflammatory skin disease that is accompanied by increased sensitivity to itch-provoking and pain-provoking stimuli. Patients with AD experience skin pain before initiation of therapy and have also reported painful application site reactions in clinical trials of emollients and prescription topical therapies, including topical corticosteroids (TCSs), topical calcineurin inhibitors (TCIs), and a topical phosphodiesterase 4 (PDE4) inhibitor. To compare the sensory tolerability of prescription topical therapies for AD, a comprehensive literature search and analysis of published clinical trials was conducted. Sensory tolerability issues such as application site pain, burning, stinging, and pruritus were often among the most common adverse events or treatment-related adverse events in clinical trials for prescription topical therapies. Tolerability issues occurred at highest rates in trials of TCIs, followed by trials of the PDE4 inhibitor crisaborole and TCSs, although direct comparisons are not possible because of differences in study design. Tolerability issues in these clinical trials were generally mild to moderate and transient. This article also reviews published strategies for managing sensory tolerability issues in AD patients during treatment with topical therapies.

Funding: Pfizer Inc., New York, NY.

Critically appraised topic for the most effective and safe treatment for canine generalised demodicosis

BACKGROUND

Canine generalised demodicosis is an inflammatory parasitic skin disease caused by an excessive proliferation of Demodex spp. Generalized demodicosis is a severe skin disease, that can be life threatening if not treated properly. Many of the current treatment options are not licensed for the treatment of generalised demodicosis, it have a low safety margin and may be poorly efficacious and time-consuming for the owner; there is a need for a safe, efficacious treatment for canine demodicosis. Our objective was to systematically review the literature to determine the most effective and safe topical or systemic therapy for canine generalised demodicosis. Single case reports and case series with fewer than five patients were not reviewed as they were considered to be poor quality evidence. A detailed literature search identified 21 relevant clinical trials and these were critically assessed.

RESULTS

The analysis of the best available evidence on March 5, 2018, suggests that six are the most effective and safe treatments for generalised canine demodicosis including (in alphabetical order): doramectin (oral or parenteral); fluralaner (oral); imidacloprid/moxidectin (topical); ivermectin (oral, not as first choice treatment); milbemycin oxime (oral); and sarolaner (oral). There was insufficient evidence to allow comment on the appropriateness of other treatment protocols for canine generalised demodicosis in this CAT.

CONCLUSIONS

In our critical appraisal of the best scientific literature, there is evidence for recommending the use of 6 therapeutic options against demodectic mange. Further, in vivo, controlled, randomized and blinded clinical trials are required, to evaluate new therapies.

Optimized Management of Ulcerative Proctitis: When and How to Use Mesalazine Suppository

BACKGROUND

Ulcerative proctitis, one of the disease types of ulcerative colitis, is considered one of the initial manifestations of ulcerative colitis. Prevention of aggravation of ulcerative proctitis is important for improving the prognosis of ulcerative colitis. Here we reviewed the epidemiology, diagnosis, and management of ulcerative proctitis.

SUMMARY

The number of patients with ulcerative proctitis is increasing. Disease extension occurs in many patients with ulcerative proctitis. Differential diagnosis from other chronic proctitis is important and should be performed based on the clinical history and endoscopical and histological features. Mesalazine suppository has been the first-line therapy for patients with ulcerative proctitis because of its high effectiveness and safety. Topical treatment of ulcerative proctitis, particularly using mesalazine suppository has been underused in clinical practice. Key Messages: Mesalazine suppositories are more effective than dose intensification of oral mesalazine for relapsed patients with maintenance dose of oral mesalazine. However, low adherence to rectal mesalazine has hindered remission in patients with ulcerative proctitis.

Combination of paromomycin plus human anti-TNF-α antibodies to control the local inflammatory response in BALB/ mice with cutaneous leishmaniasis lesions

BACKGROUND

Cutaneous leishmaniasis (CL) skin lesions are the result of a deregulated immune response, which is unable to eliminate Leishmania parasites. The control of both, parasites and host immune response, is critical to prevent tissue destruction. The skin ulceration has been correlated with high TNF-α level.

OBJECTIVE

Because human anti-TNF-α antibodies (Ab) have been successfully assayed in several mice inflammatory diseases, we hypothesized that their anti-inflammatory effect could optimize the healing of CL lesions achieved after topical application of paromomycin (PM), the current chemotherapy against CL.

METHODS AND RESULTS

We first compared the in vitro efficacy of PM and Ab alone and the drug given in combination with Ab to assess if the Ab could interfere with PM leishmanicidal activity in L. major-infected bone marrow-derived macrophages. The combination therapy had similar antileishmanial activity to the drug alone and showed no influence on NO production, which allows macrophage-mediated parasite killing. Next, we demonstrated in an in vivo model of Imiquimod®-induced inflammation that topical Ab and PM inhibit the infiltration of inflammatory cells in the skin. In the efficacy studies in L. major-infected BALB/c mice, PM combined with Ab led to a sharp infection reduction and showed a stronger anti-inflammatory activity than PM alone. This was confirmed by the down-regulation of TNF-α, IL-1β, iNOS, IL-17, and CCL3 as well as by a decrease of the neutrophilic infiltrate during infection upon treatment with the Ab.

CONCLUSIONS

In terms of parasite elimination and inflammation reduction, topical application of Ab in combination with PM was more effective than the drug alone.

Salvage topical therapy for upper tract urothelial carcinoma

PURPOSE

Topical therapy (TT) for upper tract urothelial carcinoma (UTUC) has been explored as a kidney sparing approach to treat carcinoma in situ (CIS) and as adjuvant for endoscopically treated Ta/T1 tumors. In bladder cancer, data support use of salvage TT for repeat induction. We investigate the outcomes of salvage TT for UTUC in patients ineligible for or refusing nephroureterectomy.

METHODS

A single-center retrospective review on patients receiving salvage TT via percutaneous nephrostomy tube or cystoscopically placed ureteral catheters was performed. Primary outcome was response to therapy based on International Bladder Cancer Group criteria.

RESULTS

51 patients with 58 renal units (RUs) received TT. Of these, 17 patients with 18 RUs received the second-line TT, with a median follow-up of 36.5 months (IQR 24.5-67 months). 44% (8/18) received salvage TT for refractory disease and 56% (10/18) as reinduction. 5 RUs with CIS were unresponsive to initial TT and went on to receive salvage TT, of which 20% (1/5) responded. 13 RUs recurred or relapsed following initial TT and received salvage TT for papillary tumors, with 62% (8/13) responding.

CONCLUSION

Our data provide preliminary clinical rationale for the second-line TT for refractory and recurrent, endoscopically managed papillary UTUC in patients ineligible for or refusing nephroureterectomy. However, refractory upper tract CIS appears to have poor response to salvage TT.

Topical therapy for refractory rhinosinusitis caused by methicillin-resistant Staphylococcus aureus: First report in a prospective series

OBJECTIVE

The incidence of refractory chronic rhinosinusitis (CRS) associated with methicillin-resistant Staphylococcus aureus (MRSA) is rising and remains a therapeutic challenge. The goal of this study is to demonstrate the efficacy of a non-invasive topical therapy against MRSA in these patients.

METHODS

Seventeen patients with refractory CRS caused by MRSA were treated with a topical therapy protocol. Treatment consisted of weekly endoscopic sinus debridement followed by intra-sinus installation of a hydroxyl-ethylcellulose gel that releases mometasone and a culture-directed antibiotic for a period of 6 weeks, along with daily nasal nebulization of mometasone with the same antibiotic and saline rinses. Clinical outcome was assessed using the Lund-Kennedy (LK) symptom and endoscopic appearance scores. Sinus mucosal tissue was homogenized and cultured, and microbial biofilm burden was assessed based on colony forming units (CFUs) counts.

RESULTS

Rhinotopic therapy resulted in clearance of MRSA in 13 of 16 patients (81.2%). Treated patients also demonstrated significant improvement clinically as measured by the LK scores. In addition, a significant decrease in mucosal CFUs was observed post-therapy.

CONCLUSION

Our findings demonstrate that topical therapy is an effective method for treating MRSA-associated refractory CRS.

HIV-Associated Psoriasis

Human immunodeficiency virus (HIV) prevalence is increasing worldwide as people on antiretroviral therapy are living longer. These patients are often susceptible to debilitating inflammatory disorders that are frequently refractory to standard treatment. Psoriasis is a systemic inflammatory disorder, associated with both physical and psychological burden, and can be the presenting feature of HIV infection. In this population, psoriasis tends to be more severe, to have atypical presentations and higher failure rates with the usual prescribed treatments. Management of moderate and severe HIV-associated psoriasis is challenging. Systemic conventional and biologic agents may be considered, but patients should be carefully followed up for potential adverse events, like opportunist infections, and regular monitoring of CD4 counts and HIV viral loads.

Topical application of Cassia fistula L. fruit gel in management of cutaneous lesions of pemphigus vulgaris: A double-blind, placebo-controlled clinical trial

OBJECTIVE

Cassia fistula L. fruit extract has been traditionally used in the treatment of pemphigus vulgaris (PV) lesions in Iran. The aim of this study was to determine the efficacy of C. fistula fruit gel on healing time of PV lesions in a clinical setting.

MATERIALS AND METHODS

This was a randomized, double-blind placebo-controlled clinical trial that was performed in dermatology ward at Saadi hospital, affiliated to Shiraz University of Medical Sciences, Shiraz, Iran. Right- or left- sided lesions of PV patients on standard systemic treatment were randomized for treatment with either C. fistula fruit gel or placebo prescribed twice daily. The largest diameter of each lesion was measured at the baseline (day 0) and on days 10 and 20. Epithelialization Index (EI), as outcome measure was calculated and compared between the two groups.

RESULTS

The present study comprised 20 patients, with overall 82 cutaneous lesions including 41 lesions in the C. fistula fruit gel group and 41 lesions in the placebo group. The EI in the C. fistula fruit gel group was significantly higher than that of the placebo group both on day 10 (65±28vs 30±34; p=0.001) and at the end of the study (91±22 vs 69±49; p=0.003).

CONCLUSION

Topical application of C. fistula fruit gel can be considered as an effective adjuvant therapy in treatment of PV.

Opportunities for topical antimicrobial therapy: permeation of canine skin by fusidic acid

BACKGROUND

Staphylococcal infection of the canine epidermis and hair follicle is amongst the commonest reasons for antimicrobial prescribing in small animal veterinary practice. Topical therapy with fusidic acid (FA) is an attractive alternative to systemic therapy based on low minimum inhibitory concentrations (MICs, commonly <0.03 mg/l) documented in canine pathogenic staphylococci, including strains of MRSA and MRSP (methicillin-resistant Staphylococcus aureus and S. pseudintermedius). However, permeation of canine skin by FA has not been evaluated in detail. This study aimed to define the degree and extent of FA permeation in canine skin in vitro from two sites with different hair follicle density following application of a licensed ophthalmic formulation that shares the same vehicle as an FA-betamethasone combination product approved for dermal application in dogs. Topical FA application was modelled using skin held in Franz-type diffusion cells. Concentrations of FA in surface swabs, receptor fluid, and transverse skin sections of defined anatomical depth were determined using high-performance liquid chromatography and ultraviolet (HPLC-UV) analysis.

RESULTS

The majority of FA was recovered by surface swabs after 24 h, as expected (mean ± SEM: 76.0 ± 17.0%). FA was detected within 424/470 (90%) groups of serial sections of transversely cryotomed skin containing follicular infundibula, but never in 48/48 (100%) groups of sections containing only deeper follicular structures, nor in receptor fluid, suggesting that FA does not permeate beyond the infundibulum. The FA concentration (mean ± SEM) in the most superficial 240 μm of skin was 2000 ± 815 μg/g.

CONCLUSIONS

Topically applied FA can greatly exceed MICs for canine pathogenic staphylococci at the most common sites of infection. Topical FA therapy should now be evaluated using available formulations in vivo as an alternative to systemic therapy for canine superficial bacterial folliculitis.

A Retrospective Study Comparing K101 Nail Solution as a Monotherapy and in Combination with Oral Terbinafine or Itraconazole for the Treatment of Toenail Onychomycosis

Background

Onychomycosis is a difficult-to-treat fungal infection of the nails. The efficacy of monotherapy is not ideal, and combination therapies provide an alternative that may increase treatment efficacy.

Method

A retrospective analysis of data from 91 patients was undertaken. Treatment for toenail onychomycosis occurred between 2014 and 2016 and consisted of combination therapy with oral terbinafine (250 mg/day for 12 weeks) or itraconazole (3 pulses, 400 mg/day for 7 days) + K101 nail solution daily, or K101 nail solution monotherapy. Efficacy outcomes at 12 and 15 months were analyzed.

Results

At 12 months, the clinical cure rate for combination of terbinafine + K101 solution was significantly higher than that for K101 monotherapy (p = 0.008). Patients receiving this combination also showed significant improvement in percent of affected nail at 3 months (p = 0.029), while patients receiving itraconazole + K101 solution demonstrated improvement in percent of affected nail at 6 months (p = 0.037). At 15 months, there was no significant difference between treatments for complete, clinical, and mycological cure.

Conclusion

Combination therapy with oral terbinafine or itraconazole and K101 nail solution results in clearance of infected nail earlier than that with topical K101 alone. These combinations may encourage compliance and be effective for patients with moderate onychomycosis.

Topical alprostadil (Vitaros©) in the treatment of erectile dysfunction after non-nerve-sparing robot-assisted radical prostatectomy

OBJECTIVE

The aim of the study is the evaluation of the efficacy and safety of the treatment with topical alprostadil (Vitaros^©) in post-robot assisted radical prostatectomy (RARP) rehabilitation therapy of patients with erectile dysfunction (ED).

METHODS

Seventy-four patients were enrolled and underwent non-nerve-sparing RARP.

INCLUSION CRITERIA

age <75, preoperatively International Index of Erectile Function (IIEF-5) >16, erection hardness score (EHS) ⩾2, weekly sexual intercourse ⩾1, affirmative answers to Sexual Encounter Profile Question (SEP-Q) 2 and SEP-Q3, Charlson Comorbidity Index (CCI) ⩽5, Eastern Cooperative Oncology Group (ECOG) performance status ⩽1, no moderate/severe cardiovascular disease.

RESULTS

Vitaros was administered ⩾2 twice a week. At month 6, the IIEF-5 decreased from 20.5 preoperative to 18.1 post-treatment. EHS score decreased from a mean of 3.3 to a mean of 3.0. The quality of life score decreased from an average of 5.1 to 2.3. Weekly sexual intercourse decreased from an average of 2.1 to 1.7. Six patients dropped out; 89.7% patients showed a positive SEP-Q2 and 77.8% a positive SEP-Q3. All patients responded positively to Global Assessment Questions (GAQ)-1 and 97% to GAQ-2. Of all 68 analyzed patients, 13 (17.6%) switched to intracavernous injection therapy.

CONCLUSIONS

In conclusion, Vitaros may become a viable alternative to common injective therapies in well-selected patients after RARP.

Topical delivery of anthramycin I. Influence of neat solvents

Anthramycin (ANT) was the first pyrrolobenzodiazepine (PBD) molecule to be isolated, and is a potent cytotoxic agent. Although the PBD family has been investigated for use in systemic chemotherapy, their application in the management of actinic keratoses (AK) or skin cancer has not been investigated to date. In the present work, anthramycin (ANT) was selected as a model PBD compound, and the skin penetration of the molecule was investigated using conventional Franz diffusion cells. Finite dose permeation studies of ANT were performed using propylene glycol (PG), 1,3-butanediol (BD), dipropylene glycol (DiPG), Transcutol P® (TC), propylene glycol monocaprylate (PGMC), propylene glycol monolaurate (PGML) and isopropyl myristate (IPM). The skin penetration of BD, DiPG, PG and TC was also measured. Penetration of ANT through human skin was evident for TC, PG and PGML with the active appearing to "track" the permeation of the vehicle in the case of TC and PG. Deposition of ANT in skin could be correlated with skin retention of the vehicle in the case of IPM, PGMC and PGML. These preliminary findings confirm the ability of ANT to penetrate human skin and, given the potency of the molecule, suggest that further investigation is justified. Additionally, the findings emphasise the critical importance of understanding the fate of the excipient for the rational design of topical formulations.

Topical Therapies for Refractory Chronic Rhinosinusitis

Topical therapy has become an important tool in the otolaryngologist's armamentarium for refractory chronic rhinosinusitis (CRS). Daily high-volume sinonasal saline irrigation and standard metered-dose topical nasal steroid therapy are supported by the most evidence. Nonstandard topical sinonasal steroid therapies are a potential option for refractory CRS. Current evidence recommends against the use of topical antifungal therapy and topical antibiotic therapy delivered using spray and nebulized techniques in routine cases of CRS. Stents are a new modality with preliminary data showing they are an option when traditional treatment has failed. Further research with long-term effects and outcomes studies for refractory CRS are needed.

Topical ambroxol for the treatment of neuropathic pain. An initial clinical observation

BACKGROUND

Neuropathic pain is difficult to treat, and the available options are often inadequate. The expectorant ambroxol also acts as a strong local anaesthetic and blocks sodium channels about 40 times more potently than lidocaine. It preferentially inhibits the channel subtype Nav 1.8, which is expressed especially in nociceptive C-fibres. In view of the low toxicity of ambroxol, it seemed reasonable to try using it for the treatment of neuropathic pain that failed to respond to other standard options.

MATERIAL AND METHODS

The medical records of seven patients with severe neuropathic pain and pain reduction following topical ambroxol treatment are reported retrospectively. As standard therapies had not proved sufficient, a topical ambroxol 20% cream was repeatedly applied by the patients in the area of neuropathic pain.

RESULTS

The reasons for neuropathic pain were postherpetic neuralgia (2 ×), mononeuropathy multiplex, phantom pain, deafferentation pain, postoperative neuralgia and foot neuropathy of unknown origin. The individual mean pain intensity reported was between 4 and 6/10 (NRS), maximum pain at 6-10/10 (NRS). The pain reduction achieved individually following ambroxol cream was 2-8 points (NRS) within 5-30 min and lasted for 3-8 h. Pain attacks were reduced in all five patients presenting with this problem. Four patients with no improvement after lidocaine 5% and one patient with no response to capsaicin 8% nevertheless experienced a pain reduction with topical ambroxol. No patient reported any side effects or skin changes during a treatment that has since been continued for up to 4 years.

CONCLUSION

Ambroxol acts as a strong local anaesthetic and preferentially inhibits the nociceptively relevant sodium channel subtype Nav 1.8. For the first time, we report below on a relevant pain relief following topical ambroxol 20% cream in patients with neuropathic pain. In view of the positive side effect profile, the clinical benefit in patients with pain should be investigated further.

Under-Treatment of Patients with Moderate to Severe Psoriasis in the United States: Analysis of Medication Usage with Health Plan Data

Introduction

Psoriasis is a chronic inflammatory disorder with significant morbidity and mortality, but a persistent gap appears to exist for the adequate treatment of patients with moderate to severe disease. As the extent of under-treatment is unknown, we attempted to determine overall treatment patterns and estimate under-treatment using a large database.

Methods

Data from the US National Health and Wellness Survey was used to estimate the proportion of patients with mild, moderate or severe psoriasis. The proportion with moderate to severe disease was estimated by excluding those with mild disease, and projecting this to the total insured US population, weighted by age and gender. Using US health plan claims data, patient totals by treatment type were determined between October 1, 2007 and September 30, 2012. Patients had to be continuously enrolled in a health plan and be ≥18 years at the end of the analysis window. Psoriasis was confirmed if patients had at least one claim of any type of psoriasis except psoriatic arthropathy (ICD-9 code 696.1). A monthly treatment history, classified by biologic, traditional oral systemic, phototherapy and topical therapy, was recorded for each patient.

Results

There were an estimated 1.7 million insured US patients with moderate to severe psoriasis. Of these, 1 million (59%) were not treated for their condition in the preceding year. Among 695,488 patients who were treated for psoriasis in the preceding year, 346,201 were currently receiving treatment and 349,287 had lapsed treatment. Of the patients lapsed and currently treated in this period, the numbers who received each treatment type were 156,409 (biologic), 222,657 (traditional oral systemic), 22,911 (phototherapy), and 293,511 (topical). A limitation of the study was that only insurance claims were analyzed.

Conclusion

Moderate to severe psoriasis remains persistently untreated or under-treated. We suggest that potential barriers preventing access to care be explored.

Funding

This study was sponsored by Pfizer Inc.

Effect of topical lidocaine in the oral and facial regions on tactile sensory and pain thresholds

OBJECTIVE

The aim of the present study was to examine the effect of lidocaine application to the face, tongue and hand on sensory and pain thresholds of symptom-free subjects.

DESIGN

Eighteen females (mean age 25.7 years, range 22-38) participated. Using Semmes-Weinstein monofilaments, the tactile detection threshold (TDT) and the filament-prick pain detection threshold (FPT) were measured on the cheek skin (CS), tongue tip (TT) and palm side of the thenar skin (TS). Subjects were tested in 2 sessions at a 1week interval in randomised order. Lidocaine (session A) or placebo gel (session B) was applied for 5min. The TDT and FPT were measured before and after application.

RESULTS

The TDT at all sites in session A significantly increased after 5min, but a significant session effect on the TDT was only found at the TT (P<0.01). On the other hand, there were significant session effects on the FPT at all sites (P<0.01).

CONCLUSION

These results indicate that the pain threshold (FPT) is more susceptible to local anesthetics than the sensory threshold (TDT), but further study is needed to use topical lidocaine for the control of oral and facial pain in the clinic.

Topical Products for Human Hair Regeneration: A Comparative Study on an Animal Model

Background

Hair loss and hair growth is the subject of tremendous amount of research.

Objective

This study investigated the efficacy of three chemical treatments used in humans for hair loss, using a rat model of hair regrowth. The products tested were 2% minoxidil, Hairgrow (Dar-Al-Dawa Pharma), Aminexil, Dercos (Vichy Laboratoires), and Kerium, Anti-chute (La Roche-Posay).

Methods

Thirty-two adult female Wistar-Bratislava rats were assigned to 4 groups. Two rectangular areas (2×4 cm) were shaved on either sides of the mid dorsal line (left side - control; right side - test area). Group I was treated topically with 2% minoxidil, group II with Aminexil, and group III with Kerium. Each rat received 0.3 ml of substance applied topically to the shaved dorsal skin every day for 28 days. Rats in group IV served as sham controls receiving no treatment. Hair regrowth was evaluated by trichoscopy (with a dermatoscope), grown hair weight (from a surface area of 1 cm²), and histopathological examination for skin thickness, follicle count, and percentage of anagen induction (morphometric assessment).

Results

Treatment with 2% minoxidil significantly induced hair regrowth as assessed by trichoscopy, hair weight examination, and morphometric evaluation. Hair weight examination and morphometric assessment demonstrated the lowest hair growth effect with Aminexil among the tested products. Treatment with Kerium was found to significantly induce hair regrowth (p<0.05 as compared to the control group).

Conclusion

Our study demonstrates that hair regrowth efficacy of products recommended for human use is not similar when tested on an animal model.

Engineered honey: In vitro antimicrobial activity of a novel topical wound care treatment

Surgihoney is a novel engineered organic honey product for wound care. Its antimicrobial activity can be controlled and adjusted by the engineering process, allowing preparation of three different potencies, labelled Surgihoney 1-3. Susceptibility testing of a range of wound and ulcer bacterial isolates to Surgihoney by the disc diffusion method, minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) determination, and time-kill measurements by time suspension tests were performed. Surgihoney demonstrated highly potent inhibitory and cidal activity against a wide range of Gram-positive and Gram-negative bacteria and fungi. MICs/MBCs were significantly lower than concentrations likely to be achieved in topical clinical use. The topical concentration of Surgihoney in wounds was estimated at ca. 500g/L. MICs/MBCs for Staphylococcus aureus were 32/125g/L for Surgihoney 1 and 0.12/0.25g/L for Surgihoney 3. Cidal speed depended on potency, being 48h for Surgihoney 1 and 30min for Surgihoney 3. Maintenance of the Surgihoney inoculum preparation for up to a week demonstrated complete cidal activity and no bacterial persistence. Surgihoney has wide potential as a highly active topical treatment combining the effects of the healing properties of honey with the potent antimicrobial activity of the engineered product for skin lesions, wounds, ulcers and cavities. It is highly active against multidrug-resistant bacteria. It is more active than other honeys tested and is comparable with chemical antiseptics in antimicrobial activity.

Recurrent aphthous stomatitis

Recurrent aphthous stomatitis (RAS) is the most common ulcerative disease affecting the oral mucosa. RAS occurs mostly in healthy individuals and has an atypical clinical presentation in immunocompromised individuals. The etiology of RAS is still unknown, but several local, systemic, immunologic, genetic, allergic, nutritional, and microbial factors, as well as immunosuppressive drugs, have been proposed as causative agents. Clinical management of RAS using topical and systemic therapies is based on severity of symptoms and the frequency, size, and number of lesions. The goals of therapy are to decrease pain and ulcer size, promote healing, and decrease the frequency of recurrence.