Phase 3 Trial of Epicutaneous Immunotherapy in Toddlers with Peanut Allergy.

BACKGROUND: No approved treatment for peanut allergy exists for children younger than 4 years of age, and the efficacy and safety of epicutaneous immunotherapy with a peanut patch in toddlers with peanut allergy are unknown. METHODS: We conducted this phase 3, multicenter, double-blind, randomized, placebo-controlled trial involving children 1 to 3 years of age with peanut allergy confirmed by a double-blind, placebo-controlled food challenge. Patients who had an eliciting dose (the dose necessary to elicit an allergic reaction) of 300 mg or less of peanut protein were assigned in a 2:1 ratio to receive epicutaneous immunotherapy delivered by means of a peanut patch (intervention group) or to receive placebo administered daily for 12 months. The primary end point was a treatment response as measured by the eliciting dose of peanut protein at 12 months. Safety was assessed according to the occurrence of adverse events during the use of the peanut patch or placebo. RESULTS: Of the 362 patients who underwent randomization, 84.8% completed the trial. The primary efficacy end point result was observed in 67.0% of children in the intervention group as compared with 33.5% of those in the placebo group (risk difference, 33.4 percentage points; 95% confidence interval, 22.4 to 44.5; P<0.001). Adverse events that occurred during the use of the intervention or placebo, irrespective of relatedness, were observed in 100% of the patients in the intervention group and 99.2% in the placebo group. Serious adverse events occurred in 8.6% of the patients in the intervention group and 2.5% of those in the placebo group; anaphylaxis occurred in 7.8% and 3.4%, respectively. Serious treatment-related adverse events occurred in 0.4% of patients in the intervention group and none in the placebo group. Treatment-related anaphylaxis occurred in 1.6% in the intervention group and none in the placebo group. CONCLUSIONS: In this trial involving children 1 to 3 years of age with peanut allergy, epicutaneous immunotherapy for 12 months was superior to placebo in desensitizing children to peanuts and increasing the peanut dose that triggered allergic symptoms. (Funded by DBV Technologies; EPITOPE ClinicalTrials.gov number, NCT03211247.).

Annular Lichenoid Dermatitis of Youth: Its Pathogenesis, Diagnosis, and Management.

Annular lichenoid dermatitis of youth (ALDY) is a newly described controversial benign lichenoid inflammatory cutaneous disorder often characterized by annular patches with hypopigmented center and surrounding erythematous border. Primarily, it affects the trunk and groin of young patients. Since its first description in 2003, additional patients have been reported, leading to better characterization of the entity; nevertheless, the pathogenesis is still unclear, and several hypotheses have been provided about possible triggering or causative factors. It tends to follow a chronic course, with some lesions spontaneously remitting, while others may be persistent or recur post-treatment. No standard validated treatment has been indicated so far for this disorder. Commonly prescribed topical treatment includes corticosteroids and calcineurin inhibitors with variable response.

Design and Development of Functionalized Single-walled Carbon Nanotube-ethosomes for Transdermal Delivery of Ketoprofen.

The purpose of this study was to combine carbon nanotube with ethosomes in order to obtain hybrid nanocarriers for transdermal delivery of ketoprofen (KP). KP-loaded functionalized single-walled carbon nanotube (f-SWCNTs) composite ethosomes (f-SWCNTs-KP-ES) were designed and were verified by a series of characterizations. The particle size of the preparation is less than 400 nm. DSC and XRD experiments showed that KP existed in an amorphous state after it was adsorbed and loaded on f-SWCNTs. TEM experiments showed that the structure of SWCNTs remained intact after oxidation and modification by PEI. FTIR results showed that PEI were successfully modified on the surface of SWCNT-COOH, and KP was successfully loaded on f-SWCNTs. In vitro release characteristics showed that the preparation had sustained release behavior and conformed to the first-order kinetic equation model. In addition, f-SWCNTs-KP-ES gel were prepared and in vitro skin permeation and in vivo pharmacokinetics were studied. The results showed that f-SWCNTs-KP-ES gel could enhance the skin permeation rate of KP and increase the drug retention of drugs in the skin. The characterization results consistently showed f-SWCNTs is a promising drug carrier. The hybrid nanocarrier prepared by the combination of f-SWCNTs and ethosomes can enhance the transdermal absorption of drugs and improve the bioavailability of drugs, which has a certain significance for the development of advanced hybrid nano-preparations.

Lipid-based nanoformulation optimization for achieving cutaneous targeting: Niosomes as the potential candidates to fulfill this aim.

The present study screened the utility of topically-applied nanoformulations to target the drugs/actives into the skin reservoir with the reduction of possible systemic absorption. The lipid-based nanoformulations selected in this study included solid lipid nanoparticles (SLNs), nanostructured lipid carriers (NLCs), nanoemulsions (NEs), liposomes, and niosomes. We loaded flavanone and retinoic acid (RA) as the penetrants. The prepared nanoformulations were assessed for their average diameter, polydispersity index (PDI), and zeta potential. An in vitro permeation test (IVPT) was utilized to determine the skin delivery into/across pig skin, atopic dermatitis (AD)-like mouse skin, and photoaged mouse skin. We found an increased skin absorption of lipid nanoparticles following the increase of solid lipid percentage in the formulations (SLNs > NLCs > NEs). The use of liposomes even reduced the dermal/transdermal selectivity (S value) to lessen the cutaneous targeting. The niosomes resulted in significantly greater RA deposition and reduced permeation in the Franz cell receptor compared to the other nanoformulations. The S value of the RA delivery via stripped skin was increased by 26-fold in the niosomes compared to the free RA. The dye-labeled niosomes displayed a strong fluorescence in the epidermis and upper dermis through the visualization of fluorescence and confocal microscopies. The cyanoacrylate skin biopsy manifested greater hair follicle uptake of the niosomes compared to the free penetrants by 1.5 to three-fold. The 2,2'-azino-bis(3-ethylbenzothiazoline-6-sulfonic acid) (ABTS) assay indicated an increase in antioxidant ability from 55% to 75% after flavanone entrapment in the niosomes. In the activated keratinocytes, the niosomal flavanone could suppress the overexpressed CCL5 to the baseline control because of the facile cell internalization. After the formulation optimization, the niosomes with higher phospholipid amount had a superior effect in delivering penetrants into the skin reservoir, with limited permeation to the receptors.

Engineering of clarithromycin loaded stimulus responsive dissolving microneedle patches for the treatment of biofilms.

This study aimed to fabricate clarithromycin laden Eudragit S-100-based microfibers (MF), microfibers coated film (MB), clarithromycin loaded polyvinyl pyrollidone, hyaluronic acid and sorbitol-based dissolving microneedle patches (CP) and microfibers coated microneedle patches (MP). Morphological and phase analysis of formulations were carried out by scanning electron microscopy and differential scanning calorimetry, X-ray diffraction, respectively. Substrate liquefaction test, in vitro drug release, antimicrobial assay and in vivo antibiofilm studies were performed. MF exhibited a uniform surface and interconnected network. Morphological analysis of CP revealed sharp-tipped and uniform-surfaced microstructures. Clarithromycin was incorporated within MF and CP as amorphous solid. Liquefaction test indicated hyaluronate lyase enzyme responsiveness of hyaluronic acid. Fibers-based formulations (MF, MB and MP) provided an alkaline pH (7.4) responsive drug release; ∼79 %, ∼78 % and ∼81 %, respectively within 2 h. CP showed a drug release of ∼82 % within 2 h. MP showed ∼13 % larger inhibitory zone against Staphylococcus aureus (S. aureus) as compared to MB and CP. A relatively rapid eradication of S. aureus in infected wounds and subsequent skin regeneration was observed following MP application as compared to MB and CP indicating its usefulness for the management of microbial biofilms.

Brij® integrated bilosomes for improving the transdermal delivery of niflumic acid for effective treatment of osteoarthritis: In vitro characterization, ex vivo permeability assessment, and in vivo study.

Bilosomes are innovative vesicular carriers containing bile salt with a non-ionic surfactant. Being highly flexible, bilosomes can squeeze themselves through the skin carrying the drug to the action site and improving its skin penetration. The objective of this research was to encapsulate niflumic acid (NA), a non-steroidal anti-inflammatory drug into Brij® integrated bilosomes (BIBs) for effective treatment of osteoarthritis through transdermal delivery. BIBs were formulated using 100 mg of Span 20 with different amounts of sodium cholate (NaC), sodium taurocholate (NaTC), or sodium glycocholate (NaGC) as bile salt, with the addition of 5 mg of Brij-93 or Brij-35. BIBs were prepared utilizing ethanol injection method with the application of (31 × 22) complete factorial design using Design-Expert® software. The optimal BIBs formulation determined was (B5) which contains 5 mg of NaTC used as bile salt and 5 mg of Brij-93. B5 exhibited entrapment efficiency% = 95.21 ± 0.00%, particle size = 373.05 ± 0.07 nm, polydispersity index = 0.27 ± 0.01, and zeta potential = -32.00 ± 0.00 mV. It also had a high elasticity with a spherical shape. B5 gel displayed a sustained release profile with a significantly 2.3 folds' higher drug permeation percent across rat skin than that permeated from NA gel. Moreover, in vivo anti-osteoarthritic and histopathological studies assured the efficacy and safety of B5 gel and its superiority over NA gel. Generally, the outcomes confirmed the great efficacy of NA loaded BIBs for the topical treatment of osteoarthritis.

Acacetin-loaded microemulsion for transdermal delivery: preparation, optimization and evaluation.

CONTEXT: Acacetin is reported as a potential drug candidate for the treatment of atrial fibrillation. However, clinical applications are limited by poor water solubility, limited ethanol solubility, and extremely low oral bioavailability. OBJECTIVE: The present study prepared and evaluated acacetin-loaded microemulsion (ME) to achieve efficient pharmacokinetics together with no or minimal invasiveness for transdermal delivery. MATERIALS AND METHODS: The formulation of ME was determined by the water titration method based on solubility results. The optimized formulation was achieved by the simplex lattice experiment design. The optimized ME formulations FA, FB and FC (FA with 10% and 50% DMSO as enhancers, respectively) were evaluated by ex vivo permeation with Franz diffusion cell and excised mice skin. In vivo pharmacokinetic studies were also performed at 8 mg/kg in rats within 6 h by transdermal administration. RESULTS: The optimal ME (FA) was comprised of 12.2% caprylic acid decanoate monoditriglyceride (MCF-NF), 39.8% Smix (RH40: Trans = 2:1 w/w) and 48% water, respectively. Acacetin-loaded FA with particle size 36.0 ± 3.6 nm and drug solubility 803.7 ± 32.1 mg/g was prepared. FB had significantly higher cumulative amounts and higher AUC0-∞ (196.6 ± 11.0 min × µg/mL, p < 0.05) than that FA alone (121.4 ± 33.1 min × µg/mL). DISCUSSION AND CONCLUSIONS: The formulation of ME combined with the penetration enhancer can effectively improve the solubility and percutaneous absorption efficiency of acacetin, providing a new option for the non-invasive delivery of acacetin.

The Effect of Biological Treatment on Stress Parameters Determined in Saliva in Patients with Severe Psoriasis.

Background and objectives: In psoriatic patients, stress is the most common aggravating factor. Despite the use of quality-of-life assessment questionnaires, diagnosing stress in psoriatic patients is not a flawless procedure. This study aimed to assess the usefulness of potential stress biomarkers in saliva for monitoring the treatment of psoriasis. Materials and methods: A total of 104 adult patients with severe psoriasis were included and randomly treated via biological treatment or symptomatic therapy: 84 received biological treatment, with 20 formed a control group receiving symptomatic therapy. The administered biological treatment was adalimumab, whilst in controls calcipotriol/betamethasone dipropionate topical gel and emollients were used. Patients were monitored monthly with a dermatological examination and the dispensing of a biological drug. During each of the four visits, the severity of the disease was assessed (PASI, BSA, and DLQI), and a sample of the patient's saliva was taken. In all the participants, the saliva concentrations of immunoglobulin A (sIgA), α-amylase (sAA), and chromogranin A (CgA) were measured. Results: The majority of patients in both the study and control groups achieved clinical improvement, though favoring the group receiving biological treatment. The concentration of sIgA in the saliva was constantly increasing in the study group during subsequent visits (Fr = 27.26; p < 0.001). Meanwhile, there were no statistically significant changes in the control group during the same follow-up period (Fr = 6.66; p = 0.084). Levels of sAA underwent statistically significant changes in both groups (Fr = 58.02; p < 0.001-study group and Fr = 13.74; p = 0.003-control group). In the study group, a steady, statistically significant increase in sAA was observed from the first to the third visit. In the study group, a downward trend in CgA concentration was observed. In the control group, no significant differences in the level of CgA were obtained. Conclusions: sIgA, sAA, and CgA are potential markers of the severity of psoriasis and the associated stress reaction. Based on the presented observations, only sIgA and CgA seem to be valuable biomarkers for monitoring the effectiveness of the systemic treatment of psoriasis.

Recent Advancement of Medical Patch for Transdermal Drug Delivery.

Transdermal patches are a non-invasive method of drug administration. It is an adhesive patch designed to deliver a specific dose of medication through the skin and into the bloodstream throughout the body. Transdermal drug delivery has several advantages over other routes of administration, for instance, it is less invasive, patient-friendly, and has the ability to bypass first-pass metabolism and the destructive acidic environment of the stomach that occurs upon the oral ingestion of drugs. For decades, transdermal patches have attracted attention and were used to deliver drugs such as nicotine, fentanyl, nitroglycerin, and clonidine to treat various diseases or conditions. Recently, this method is also being explored as a means of delivering biologics in various applications. Here, we review the existing literatures on the design and usage of medical patches in transdermal drug delivery, with a focus on the recent advances in innovation and technology that led to the emergence of smart, dissolvable/biodegradable, and high-loading/release, as well as 3D-printed patches.

Advances in dermatological application of GelMA hydrogel microneedles.

BACKGROUND: Compared with systemic administration methods like injection and oral administration, traditional transdermal drug delivery has the advantages of rapid onset of activity and low side effects. However, hydrophilic drugs and bioactive substances are often unsuitable for traditional transdermal drug delivery. METHODS: The application of microneedles made from gelatin methylacryloyl (GelMA) has greatly expanded thepossibilities for skin transdermal drug delivery. We have reviewed the latest literatures about the dermatological application of GelMA hydrogel microneedles in recent years using Google Scholar, PubMed and Springer. RESULTS: GelMA hydrogel microneedles exhibit huge potency in the diagnosis and treatment of skin diseases, and this technology also brings broad application prospects for subcutaneous micro-invasive transdermal targeted drug delivery, which mainly used in skin tissue fluid collection, local substance delivery and wound healing. CONCLUSION: With in-depth research on GelMA hydrogel, this technology will bring more breakthroughs and developments in the clinical diagnosis and treatment of skin diseases.

Non-invasive transcutaneous influenza immunization using vaccine-loaded vaterite particles.

Transcutaneous immunization receives much attention due to the recognition of a complex network of immunoregulatory cells in various layers of the skin. The elaboration of non-invasive needle-free approaches towards antigen delivery holds especially great potential here while searching for a hygienically optimal vaccination strategy. Here, we report on a novel protocol for transfollicular immunization aiming at delivery of an inactivated influenza vaccine to perifollicular antigen presenting cells without disrupting the stratum corneum integrity. Porous calcium carbonate (vaterite) submicron carriers and sonophoresis were utilized for this purpose. Transportation of the vaccine-loaded particles into hair follicles of mice was assessed in vivo via optical coherence tomography monitoring. The effectiveness of the designed immunization protocol was further demonstrated in an animal model by means of micro-neutralization and enzyme-linked immunosorbent assays. The titers of secreted virus-specific IgGs were compared to those obtained in response to intramuscular immunization using conventional influenza vaccine formulation demonstrating no statistically significant differences in antibody levels between the groups. The findings of our pilot study render the intra-follicular delivery of the inactivated influenza vaccine by means of vaterite carriers a promising alternative to invasive immunization.

Le syndrome de compression du nerf cutané antérieur chez l'enfant.

QUESTION: À ma clinique de médecine familiale, je vois souvent des adolescents souffrant de douleur abdominale récurrente. Le diagnostic est fréquemment un problème bénin comme la constipation, mais j'ai récemment entendu dire qu'un adolescent, après 2 ans de douleur récurrente, avait reçu un diagnostic de syndrome de compression du nerf cutané antérieur (ACNES). Comment ce problème est-il diagnostiqué, et quel est le traitement recommandé? RÉPONSE: Le syndrome de compression du nerf cutané antérieur, décrit initialement il y a près de 100 ans, est causé par la compression de la branche antérieure du nerf cutané abdominal qui empiète sur le fascia du muscle grand droit antérieur de l'abdomen. La connaissance limitée de ce problème en Amérique du Nord entraîne des diagnostics erronés et un retard dans le diagnostic réel. Le signe de Carnett, selon lequel la douleur s'aggrave lors de la palpation de la paroi abdominale intentionnellement tendue avec un doigt « en forme de crochet ¼, aide à confirmer si la douleur provient des viscères abdominaux ou de la paroi abdominale. L'acétaminophène et les anti-inflammatoires non stéroïdiens ne se sont pas révélés efficaces, mais des injections locales d'anesthésiques guidées par échographie semblent un traitement sûr et efficace pour l'ACNES, et elles entraînent un soulagement de la douleur chez la plupart des adolescents. Pour ceux dont l'ACNES et les douleurs persistent, il y a lieu d'envisager une neurectomie cutanée par un chirurgien pédiatrique.

Treatment satisfaction of patients with psoriasis with topical therapy in a real-world setting: unmet need for higher effectiveness.

BACKGROUND: Topical medication is the mainstay for treatment of mild psoriasis. However, dissatisfaction with topicals is common and rates of non-adherence are high. Assessing patients' perspectives can help to identify unmet needs. OBJECTIVE: Our aim was to investigate satisfaction of patients with psoriasis with topical therapy and to determine influencing factors. METHODS: Patients were recruited from the Department of Dermatology, University Medical Center Mannheim, Germany. Satisfaction was assessed using the Treatment Satisfaction Questionnaire for Medication version 1.4 with the domains effectiveness, side effects, convenience, and global satisfaction (scale 0-100 each). The impact of sociodemographic and disease characteristics was determined by multivariate regression. RESULTS: Averaged across the cohort (n = 122, mean age 52.5 years, 58.2% male), the side effects domain had the highest mean satisfaction score (89.7), followed by convenience (72.5), global satisfaction (60.8), and effectiveness (55.0). Comparing specific medications, combinations of corticosteroids and vitamin D analogues were rated best in effectiveness. Treatment satisfaction was influenced by age, partnership, ability to apply topicals independently, disease-related quality-of-life impairment, sole or adjunctive use of topicals and pruritus. CONCLUSIONS: Participants were particularly satisfied with safety but rather dissatisfied with effectiveness of topicals. Topical therapy should be adapted to individual needs with special attention to effectiveness.

Skin penetration of caffeine from commercial eye creams and eye creams designed and optimized based on Hansen solubility parameters.

Computer-aided formulation design can streamline and speed up product development. In this study, ingredient screening and optimizing software, Formulating for Efficacy® (FFE), was used to design and optimize creams for the topical delivery of caffeine. FFE was set up to optimize lipophilic active ingredients, therefore, this study challenged the program's capabilities. The effect of two chemical penetration enhancers, including dimethyl isosorbide (DMI) and ethoxydiglycol (EDG), were studied based on their favorable Hansen Solubility Parameter physicochemical input parameters for the skin delivery of caffeine in the FFE® software application. Four oil-in-water emulsions containing 2% caffeine were formulated, one without a chemical penetration enhancer, one with five percent of DMI, one with five percent of EDG, and one with 2.5% of DMI and EDG each (DMI + EDG). Additionally, three commercial products were used as reference products. The cumulative amount of caffeine released and permeated, and the flux across Strat-M® membranes were determined using Franz diffusion cells. The eye creams had skin-compatible pH, excellent spreadability for the application area, were opaque emulsions with 14-17 µm droplet size, and were stable at 25 °C for 6 months. All four eye creams formulated released over 85% of caffeine in 24 h, outperforming the commercial products. DMI + EDG cream provided the highest permeation in vitro in 24 h, which was significantly higher than the commercial products (p < 0.05). FFE proved to be a valuable and quick tool to aid in the topical delivery of caffeine.

Elastic cationic liposomes for vitamin C delivery: Development, characterization and skin absorption study.

The influence of hydrophilic surfactants acting on the membrane elasticity of liposomes on the skin absorption of vitamin C is investigated. The purpose of encapsulation inside cationic liposomes is to improve the skin delivery of vitamin C. The properties of elastic liposomes (ELs) are compared to that of conventional liposomes (CLs). ELs are formed by the addition of the "edge activator" Polysorbate 80 to the CLs composed of soybean lecithin, cationic lipid DOTAP (1,2-dioleoyl-3-trimethylammoniopropane chloride), and cholesterol. The liposomes are characterized by dynamic light scattering and electron microscopy. No toxicity is detected in human keratinocyte cells. Evidences of Polysorbate 80 incorporation into liposome bilayers and of the higher flexibility of ELs are given by isothermal titration calorimetry and pore edge tension measurements in giant unilamellar vesicles. The presence of a positive charge in the liposomal membrane increases the encapsulation efficacy by approximately 30% for both CLs and ELs. Skin absorption of vitamin C from CLs, ELs and a control aqueous solution measured in Franz cells shows a high delivery of vitamin C into each skin layer and the acceptor fluid from both liposome types. These results suggest that another mechanism drives skin diffusion, involving interactions between cationic lipids and vitamin C depending on the skin pH.

Quantification methods comparing in vitro and in vivo percutaneous permeation by microneedles and passive diffusion.

Microneedles (MNs) are needles with a tip diameter ranging from 10 to 100 um and a length ranging up to 1 mm. The first patent for drug delivery device for percutaneous administration filed by Alza corporation dates back to 1976 (Gerstel and Place, 1976), and in between 1989 and 2021 the filed patents for MNs are >4500 [1]. These devices can potential overcome some drawbacks of traditional needles, such as the pain generated during insertion, requirement for trained personnel to manipulate syringes, and difficulty of performing injections in elderly and obese patients. MNs and MN arrays are emerging as a convenient method to deliver compounds and extract blood without causing any pain. A promising application is the use of MNs as alternative solution to topical creams (TC) and transdermal patches (TP) for transdermal drug delivery. The external layer of human skin, the epidermis, offers a major barrier to transdermal drug delivery, thanks to the stratum corneum (SC). Exposed to the external environment, SC ultimately protects the human body from UV light radiation, heat, water loss, bacteria, fungi and viruses, and it is the barrier that controls diffusion rate for almost all compounds. TC and TP applications are limited by the skin permeability to lipophilic compounds and small molecules, and by the slow delivery rate of some compounds. MNs have been around for >35 year now, and it is a general opinion that MNs increase delivery compared to passive diffusion, thanks to the feature of penetrating the SC and reaching the dermis. This review recollects the existing studies that compare MN delivery of drugs with passive diffusion of the same drugs in alive organisms, giving an overview of what are the type of MNs, the chemical delivered and the methods employed to quantify drug delivery into skin and/or in the bloodstream. The final aim is to quantify the enhancement factor of MNs with respect to passive diffusion, and establish a possible standard on how tests can be performed in order to compare different data.