A review of combined treatments for melasma involving energy-based devices and proposed pathogenesis-oriented combinations.

BACKGROUND: Melasma is an acquired disorder of hyperpigmentation, affecting a million individuals worldwide. Energy-based devices (EBDs) employed to treat melasma include various types of lasers, intense pulsed light (IPL), and radiofrequency (RF). Recent studies have attempted to address recalcitrant and recurring melasma by combining energy-based devices with topical or oral medications. OBJECTIVE: This article reviews EBDs-based augmented treatment for melasma and suggests practical pathogenesis-oriented treatment regimens. Treatment algorithms are proposed to address various components of melasma. METHODS: A systematic PubMed search was conducted acquiring information from various studies on combination treatments of melasma involving EBDs. RESULTS: The 286 retrieved articles were filtered by title to contain at least one type of energy-based modality such as laser, IPL, or RF along with at least one other treatment method. Based on their subject matter, combinations were further categorized into the subheadings: laser plus medication, laser plus laser, and IPL- and RF-containing treatment methods. CONCLUSION: There are many energy-based combination treatments that have been explored for mitigation of melasma including laser therapy with medication, multi-laser therapies, IPL, RF, and microneedling devices. Melasma is an exceedingly difficult condition to treat, however, choosing the appropriate tailor-made treatment combination can improve the final outcome.

Enhanced Percutaneous Delivery of Beta-Blockers Using Thermal Resurfacing Drug Delivery System for Topical Treatment of Infantile Hemangiomas.

BACKGROUND: Infantile hemangiomas (IHs) are the most common vascular tumors in children. In the past few years, topical beta-blockers (bBs) have been reported to be an effective treatment of superficial IHs. OBJECTIVE: We sought to evaluate the clinical effectiveness and safety profile of enhanced percutaneous delivery of bBs for the treatment of IH. METHODS: A retrospective study of all cases of IHs treated with enhanced percutaneous delivery of bBs between 2018 and 2019 was performed. Epidemiologic, clinical, and treatment data, including effectiveness score and safety, were reviewed. RESULTS: The study included 11 patients with a total of 11 IHs. Of the total number of IHs, 7 (63.7%) showed a good response to treatment and 4 (36.3%) had a partial response; thus all patients (100%) had good or partial response to treatment. No systemic or local adverse effects were reported. LIMITATIONS: This is an uncontrolled retrospective study. CONCLUSION: Enhanced percutaneous delivery of bBs is a safe and efficient topical therapy for IH.

Thermomechanical Ablation-Assisted Photodynamic Therapy for the Treatment of Acne Vulgaris. A Retrospective Chart Review of 30 Patients.

BACKGROUND AND OBJECTIVES: Acne vulgaris, a chronic inflammatory disease, affects more than 90% of teenagers. The first-line treatments for acne vulgaris are topical and oral medications, mainly antibiotics and retinoids. However, antibiotic resistance of Propionibacterium acnes, contraindications, partial response, significant adverse effects, or recurrence creates demand for novel treatment options in acne. Aminolevulinic acid (ALA) photodynamic therapy (PDT) is a well-established modality in the treatment of acne. Nevertheless, PDT has limitations: it may not be effective for every patient; several treatments are usually required to achieve sufficient outcome; incubation time is 1-3 hours; treatment pain and post-treatment downtime may be difficult for some patients to endure; and adverse effects may occur. This retrospective chart review was conducted to evaluate the efficacy and safety of PDT, assisted by a thermomechanical ablation (TMA) fractional injury device in the treatment of patients with moderate to severe acne. STUDY DESIGN/MATERIALS AND METHODS: We conducted a retrospective chart review of 30 acne patients treated with TMA immediately before 5% ALA application with an incubation time of 1 hour and exposure to 60 J/cm2 red light (630 nm). Patients received up to three monthly treatments and were followed for 16 weeks. Two independent investigators evaluated the subject outcomes according to high definition photographs taken at baseline, before each treatment and at follow-up visits. Three acne grading methods were used: Acne Grading Scoring System (AGSS), the Leeds revised acne grading system, and the general response to the treatment score. Patients also provided self-assessments of improvement using the patient global impression of change (PGIC). RESULTS: Compared with baseline, the AGSS has showed a statistically significant reduction of 26.7% and 23.7%, respectively, at weeks 8 and 16 after final treatment. The Leeds score showed 65.2% and 60.6% improvement at the respective visits. The overall response rate was graded 3.3 ± 0.5 out of 4. PGIC score given by the patients was 5.5 out of 7, reflecting high satisfaction. CONCLUSION: TMA used immediately prior to ALA application may enhance the effectiveness of PDT in the treatment of acne with minimal side effects, reduced downtime, and fewer sessions. The exact mechanism of TMA-assisted PDT is still to be understood. Lasers Surg. Med. © 2020 Wiley Periodicals, Inc.

Low-dose Pilocarpine Spray to Treat Xerostomia.

Although pilocarpine hydrochloride tablets are currently indicated for the treatment of xerostomia, their adverse effects are frequently reported. The development of a new, low-dose pilocarpine solution for topical oral-cavity use is needed. This article discusses a few clinical trials to formulate a topical low-dose solution of pilocarpine hydrochloride for the treatment of xerostomia and presents two low dose, stable formulations of pilocarpine topical spray that can improve the patient's quality of life with minimal adverse effects.

Systematic review of natural and miscellaneous agents, for the management of oral mucositis in cancer patients and clinical practice guidelines - part 2: honey, herbal compounds, saliva stimulants, probiotics, and miscellaneous agents.

OBJECTIVE: To update the clinical practice guidelines for the management of oral mucositis (OM) that were developed by the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO). This part focuses on honey, herbal compounds, saliva stimulants, probiotics, and miscellaneous agents. METHODS: A systematic review was conducted by the Mucositis Study Group of MASCC/ISOO. The body of evidence for each intervention, in each clinical setting, was assigned an evidence level. The findings were added to the database used to develop the 2014 MASCC/ISOO clinical practice guidelines. Based on the evidence level, one of the following guidelines were determined: Recommendation, Suggestion, No Guideline Possible. RESULTS: A total of 78 papers were identified within the scope of this section, of which 49 were included in this review and merged with nine publications that were reported in the previous guidelines update. A new Suggestion was made for honey (combined topical and systemic delivery) for the prevention of OM in head and neck cancer patients receiving radiotherapy with or without chemotherapy. A new Suggestion clarified that chewing gum is not effective for the prevention of OM in pediatric patients with hematological or solid cancer treated with chemotherapy. No guideline was possible for other interventions. CONCLUSIONS: Numerous natural products and herbal remedies were studied for the management of OM. Of the agents reviewed in this systematic review, a guideline in favor was made for honey (combined topical and systemic), while a guideline against was made for chewing gum. Additional research is warranted to clarify the potential of other interventions.

Oral Viscous Sucralfate Gel for Post-procedural Treatment of Barrett's Esophagus.

Barrett's esophagus refers to an abnormal change in the cells of the lower portion of the esophagus. It is characterized by the replacement of the normal stratified squamous epithelium lining of the esophagus by columnar epithelium cells which are usually found lower in the gastrointestinal tract. The medical significance of this pathology is approximately 0.5% risk to develop esophageal adenocarcinoma (per patient diagnosed with Barrett's esophagus per year). Diagnosis requires endoscopy and biopsy. In general, high-grade dysplasia and early stages of adenocarcinoma can be treated by endoscopic resection and/or endoscopic ablative therapy, whereas advanced stages (submucosal) are generally advised to undergo surgical treatment. Patients who undergo endoscopic resection and/or endoscopic ablative therapy might suffer from retrosternal discomfort and transient dysphagia, adverse effects that sometimes accompanies these procedures. One of the common post-procedural treatments is sucralfate 1 g 3 to 4 times daily for two weeks after the procedure. The rational for this treatment is to enhance the wound-healing process in the esophagus tissues and to coat the wounded tissues with a cytoprotective agent. As no clinical trials have been performed in order to prove the efficacy of sucralfate in the postprocedural treatment of Barrett's esophagus, this article summarizes the clinical experience accumulated from the treatment with sucralfate as a wound-healing enhancer. In addition, the article deals with the hypothesized mechanism of action of sucralfate and gives one option for compounding sucralfate oral viscous gel.

Systematic review of natural and miscellaneous agents for the management of oral mucositis in cancer patients and clinical practice guidelines-part 1: vitamins, minerals, and nutritional supplements.

PURPOSE: To update the clinical practice guidelines for the use of natural and miscellaneous agents for the prevention and/or treatment of oral mucositis (OM). METHODS: A systematic review was conducted by the Mucositis Study Group of the Multinational Association of Supportive Care in Cancer / International Society of Oral Oncology (MASCC/ISOO). The body of evidence for each intervention, in each cancer treatment setting, was assigned an evidence level. The findings were added to the database used to develop the 2014 MASCC/ISOO clinical practice guidelines. Based on the evidence level, the following guidelines were determined: Recommendation, Suggestion, and No Guideline Possible. RESULTS: A total of 78 papers were identified within the scope of this section, out of which 29 were included in this part, and were analyzed with 27 previously reviewed studies. A new Suggestion was made for oral glutamine for the prevention of OM in head and neck (H&N) cancer patients receiving radiotherapy with concomitant chemotherapy. The previous Recommendation against the use of parenteral glutamine for the prevention of OM in hematopoietic stem cell transplantation (HSCT) patients was re-established. A previous Suggestion for zinc to prevent OM in H&N cancer patients treated with radiotherapy or chemo-radiotherapy was reversed to No Guideline Possible. No guideline was possible for other interventions. CONCLUSIONS: Of the vitamins, minerals, and nutritional supplements studied for the management of OM, the evidence supports a Recommendation against parenteral glutamine in HSCT patients and a Suggestion in favor of oral glutamine in H&N cancer patients for the management of OM.

Topical Treatment of Primary Focal Hyperhidrosis, Part 1.

Primary focal hyperhidrosis is idiopathic, localized, uncontrollable, excessive, and unpredictable sweating beyond what is necessary to regulate body temperature. Primary hyperhidrosis is thought to affect approximately 2% to 3% of the population, and its effect on a patient's quality of life is very significant. Primary focal hyperhidrosis can be managed using various therapeutic options, including drugs (topical and systemic), nonsurgical interventions (e.g., iontophoresis, botulinum toxin injections), and surgery. This article, which is presented in 2 parts, is a comprehensive review of the topical, evidence-based treatments of primary focal hyperhidrosis, and it covers the following active pharmaceutical ingredients: aluminum salts, methenamine, glycopyrronium salts, oxybutynin chloride; the latter 2 ingredients will be discussed in part 2 of this article. This article discusses the evidence-based data that exists from clinical trials that support the use of topical medications to treat the pathology from efficacy and from a safety point of view. This review also discusses compounding considerations for professionally and safely compounding various topical preparations. In addition, a range of relevant formulas are attached to the article and can be used by compounding pharmacists.

Treatment of Dermatologic Adverse Events Induced by Oncological Treatments Using Compounded Medications.

Radiotherapy and epidermal growth factor receptor inhibitors, as important representatives of current chemotherapy, are crucial and irreplaceable treatments of modern oncology. These two types of treatments frequently cause severe dose-dependent dermatologic adverse events that can negatively affect a patient's quality of life and compliance and cause inappropriate dose reductions and even treatment brakes. This article aims to emphasize new scientific data, published in peer reviews, regarding new possibilities to manage these debilitating dermatological adverse events. Since part of the scientific findings is new, the responsibility to enable pharmacologic treatment is in the compounding pharmacist domain. The article also suggests new formulations to the new pharmacologic treatment.

Topical propranolol improves epistaxis in patients with hereditary hemorrhagic telangiectasia - a preliminary report.

BACKGROUND: Severe epistaxis is often difficult to control in patients with hereditary hemorrhagic telangiectasia (HHT). Propranolol has been shown to have antiangiogenic properties in vitro and in vivo and is commonly used to treat hemangiomas. We present our experience with topical nasal propranolol for the treatment of moderate to severe epistaxis in patients with HHT. METHODS: Retrospective case series. Six patients with HHT were treated with 0.5 cm3 of 1.5% propranolol gel, applied to each nostril twice daily for at least 12 weeks. Outcome measures were epistaxis severity score (ESS), hemoglobin level, and number of blood transfusions prior to and while on treatment. Local and systemic side effects were recorded. RESULTS: The mean duration of treatment was 30 ± 5.6 weeks. A significant improvement in the ESS was found in all patients, with a mean decrease from 6.4 ± 2.1 at treatment onset to 3.5 ± 1.7 at 12 weeks (p = 0.028). Hemoglobin level increased significantly from 8.4 ± 3.1 to 11.0 ± 1.8 g/dL at 12 weeks (p = 0.043). The mean number of blood transfusions decreased from 4.5 ± 4.9 before treatment to 2.5 ± 2.9 at 12 weeks and 0.3 ± 0.8 at 24 weeks, but the difference did not reach statistical significance (p = 0.109 for both). No significant side effects of treatment were recorded. CONCLUSIONS: These preliminary results suggest that topical propranolol may be effective for the treatment of epistaxis in patients with HHT. A prospective controlled trial is required to confirm our findings.

The Effect of Tranilast 8% Liposomal Gel Versus Placebo on Post-Cesarean Surgical Scars: A Prospective Double-Blind Split-Scar Study.

BACKGROUND: Tranilast (N-[3, 4-dimethoxycinnamoyl] anthranilic acid), an antiallergic drug, has been shown to attenuate scar formation possibly through inhibition of transforming growth factor beta 1 activity and consequent suppression of collagen synthesis in fibroblasts. OBJECTIVE: The authors aimed at evaluating the efficacy and safety of tranilast 8% gel in improving the appearance and symptoms of new post-cesarean section surgical wounds. METHODS: In this prospective double-blind split-scar study, the authors treated each half scar of 26 women with either tranilast 8% liposomal gel or tranilast-free liposomal gel (placebo). Treatment was applied twice daily for 3 months. Twenty women completed the trial. Scar halves were evaluated by 2 investigators and by the patients 9 months after the last application using the Patient and Observer Scar Assessment Scale (POSAS). The participants also rated overall satisfaction and recorded side effects of the treatment. RESULTS: The mean POSAS scores at 9 months post-treatment were significantly lower for tranilast-treated half scars compared with placebo-treated half scars (p < .001). The women were significantly more satisfied with the tranilast-treated half-scar appearance (p = .002). Three participants reported itching and erythema on the tranilast-treated side. CONCLUSION: Topical tranilast 8% gel provided significantly better postcaesarian section scar cosmesis and user satisfaction compared with placebo.

Oral mucositis: etiology, and clinical and pharmaceutical management.

Oral mucosal damage is one of the common and worst side effects of radiotherapy and chemotherapy treatment for cancer. With prevalence between 10% and 100%, depending on the cytotoxic and/or radiotherapy regimen and patient-associated variables, this morbid condition represents a significant problem in oncology. This article addresses oral mucositis and discusses its prevalence, risk factors, clinical and economical impacts, etiology, and clinical management in view of the most recent evidence. Despite clear progress and the development of clinical guidelines on this topic, what we currently have to offer to patients to manage mucositis and oropharyngeal pain is still inadequate. This article offers two compounded preparations supported by evidence-based data to treat oral mucositis. Expansion of the knowledge of the pathogenesis of mucositis as well as a better insight into individual risk factors will provide opportunities to improve management strategies.

Gastrointestinal mucositis: focus on the treatment of the effects of chemotherapy and radiotherapy on the rectum.

In an article published in the January/February 2012 issue of the International Journal of Pharmaceutical Compounding, damage to the oral mucosa, commonly referred to as oral mucositis, as a result of chemotherapy, radiotherapy, or a combination of both therapies was discussed. his article continues that discussion but in respect to the injury that these rapies cause to the gastrointestinal tract. Like oral mucositis, gastrointestinal mucositis is a significant problem in oncology, as it causes very serious pathologies along the alimentary tract, damaging the quality of life of the oncologic patient, and sometimes the damages are life-threatening. The most vulnerable organs of the gastrointestinal tract to radiation and chemotherapy toxicities are the small intestine, colon, and rectum. This article concentrates on the chronic rectum and anus toxicities of radiotherapy and escribes two compounding preparations to treat chronic radiation induced proctitis with rectal bleeding. As in oral mucositis, although substantial scientific progress has been made in learning more about this pathology, current treatments to manage gastrointestinal mucositis is inadequate.

Eosinophilic esophagitis: treatment with oral viscous budesonide.

Eosinophilic esophagitis is a clinicopathologic disease isolated to the esophagus. It is caused by immunologic reactions to ingested and inhaled allergans. Symptoms include regurgitation, vomiting, pain, anorexia, and dysphagia. Endoscopy with biopsy is currently the only reliable diagnostic test for eosinophilic esophagitis. The disease should remit with treatments of dietary exclusion, topical corticosteroids, or both. Oral viscous budesonide is one of the promising options of topical corticosteroid to treat eosinophilic esophagitis. Since there are no commercial medicines of oral viscous budesonide, it is solely a compounded medication. This article briefly discusses the properties of the disease and covers a few compounding possibilities to oral viscous budesonide.

Elegant compounded solutions for the treatment of thrombosed external hemorrhoids.

A thrombosed external hemorrhoid is a complication of external hemorrhoids. Usually, this disease is accompanied by severe pain that lasts for several days. The common conservative treatment is a slow, ineffective pain reliever. Surgery produces a lot of discomfort and inconvenience, affects the patient's quality of life, and presents some risks of post-operative complications. The purpose of this article is to propose an elegant compounded preparation to quickly treat the pain associated with thrombosed external hemorrhoids with a minimum of side effects and complications.