Itraconazole in the Treatment of Nonfungal Cutaneous Diseases: A Review.Dermatol Ther (Heidelb). 2019;9:271-280. [PMID: 31041664 DOI: 10.1007/s13555-019-0299-9]

Possible Clinical Effects of Ketoconazole on Sorafenib-induced Hand-Foot Skin Reaction and Cytoprotection Mechanisms of Antifungal Agents against Multikinase Inhibitor-induced Keratinocyte Toxicity

In recent years, molecular target drugs have become integral in treating malignant tumours. Multikinase inhibitors (MKIs) have been associated with serious skin disorders, including hand-foot skin reaction (HFSR), which impair patient quality of life, often disrupting activities of daily living necessitating dose reduction or discontinuation. As the pathogenic mechanisms of these skin disorders are unknown, no effective treatments have been established. Previously, by drug repurposing using an in vitro culture system, certain azole antifungal drugs (AFDs) were identified that prevented sorafenib-induced cell death of normal human epidermal keratinocytes. In this study, topical ketoconazole demonstrated clinical improvement in hyperkeratosis and pain associated with sorafenib-induced HFSR. Investigation of the mechanism using the in vitro culture system revealed sorafenib to be particularly cytotoxic among MKIs. Annexin V and TUNEL staining revealed apoptosis was mainly involved in this cytotoxicity. Antibody arrays and western blot showed increased levels of secretion of interleukin-1 receptor antagonist and macrophage migration inhibitory factor in culture supernatants. AFDs suppressed the secretion of these cytokines and reduced apoptosis in keratinocytes. This study reveals one aspect of the pathogenesis of sorafenib-induced HFSR and demonstrates that AFDs may be an effective treatment.

Identification of Keratinocyte Cytoprotectants against Toxicity by the Multikinase Inhibitor Sorafenib Using Drug Repositioning

Hand-foot skin reaction is the most common adverse event of multikinase inhibitors, such as sorafenib. Although hand-foot skin reaction is not life threatening, severe cases impair quality of life because of pain and reduced activities of daily living. However, the pathological mechanisms of hand-foot skin reaction have not yet been elucidated in detail, and there is currently no effective treatment. We aimed to identify keratinocyte cytoprotectants against sorafenib toxicity. The screening of cytoprotectants against sorafenib toxicity was performed using cultured normal human epidermal keratinocytes or a reconstructed human epidermis model and off-patent approved drugs in the Prestwick Chemical library. Among 1273 drugs in the chemical library, 8 dose-dependently increased cell viability by >200% in the presence of sorafenib. In the presence of sorafenib, the number of proliferating cell nuclear antigen-positive cells was significantly higher in clofazimine-, cyclosporin A-, and itraconazole-treated reconstructed human epidermis models than in sorafenib-treated models, and candidate drugs suppressed sorafenib-induced apoptosis in normal human epidermal keratinocytes. In addition, clofazimine, itraconazole, and pyrvinium pamoate significantly recovered the phosphorylation of extracellular signal-regulated kinase 1/2 in the presence of sorafenib. Collectively, hit drugs promoted cell viability and normalized keratinocyte proliferation in the presence of sorafenib. These candidate drugs have potential as treatments for multikinase inhibitor-induced hand-foot skin reaction.

Repositioning itraconazole for amelioration of bleomycin-induced pulmonary fibrosis: Targeting HMGB1/TLR4 Axis, NLRP3 inflammasome/NF-κB signaling, and autophagy

BACKGROUND AND AIMS

Bleomycin (BLM) is one of the antitumor medications that had proven efficacy in the treatment of a wide range of malignant conditions. Pulmonary fibrosis which is frequently encountered during the course of bleomycin therapy may significantly reduce the potential efficacy of bleomycin in cancer therapy. This study tested the hypothesis that itraconazole may have mitigating effects on BLM-induced pulmonary fibrosis and tried to delineate the potential mechanisms of these effects.

MATERIALS AND METHODS

In a rat model of pulmonary fibrosis elicited by BLM, the effect of different doses of itraconazole was explored at the biochemical, histopathological, and electron microscopic levels.

KEY FINDINGS

Itraconazole, in a dose-dependent manner, exhibited significant effects on the pro-oxidant/antioxidant balance, the inflammatory consequences, high-mobility group box 1/toll-like receptor-4 Axis, autophagy and nuclear factor kappa B/Nod-like receptor protein 3 inflammasome signaling and alleviated the histopathological, immunohistochemical, and electron microscopic perturbations induced by BLM in the pulmonary tissues.

SIGNIFICANCE

In view of the afore-mentioned data, itraconazole may be a promising drug that efficiently mitigates the deleterious effects of BLM on the pulmonary tissues.

Repurposed itraconazole for use in the treatment of malignancies as a promising therapeutic strategy

Understanding cancer biology and the development of novel agents for cancer treatment has always been the goal of cancer researchers. However, the research and development of new drugs is hindered by its long development time, exorbitant cost, high regulatory hurdles, and staggering failure rates. Given the challenges involved drug development for cancer therapies, alternative strategies, in particular the repurposing of 'old' drugs that have been approved for other indications, are attractive. Itraconazole is an FDA-approved anti-fungal drug of the triazole class, and has been used clinically for more than 30 years. Recent drug repurposing screens revealed itraconazole exerts anti-cancer activity via inhibiting angiogenesis and multiple oncogenic signaling pathways. To explore the potential utilization of itraconazole in different types of malignancies, we retrieved the published literature relating to itraconazole in cancer and reviewed the mechanisms of itraconazole in preclinical and clinical cancer studies. Current research predicts the hedgehog signaling pathway as the main target by which itraconazole inhibits a variety of solid and hematological cancers. As clinical trial results become available, itraconazole could emerge as a new antitumor drug that can be used in combination with first-line antitumor drugs.

Efficacy of Antimicrobial Treatment in Dogs with Atopic Dermatitis: An Observational Study

There is a shortage of studies reporting the efficacy of antimicrobial treatment of dogs with atopic dermatitis (AD) and skin infections (SIs). The aim of this study was to evaluate the change in the severity of skin lesions and pruritus, and the overall efficacy of antimicrobial treatment, in dogs with AD and bacterial overgrowth/infection and/or Malassezia dermatitis. A total of 20 dogs with AD and SIs were prospectively enrolled (group A) and they were examined before and after the administration of systemic antimicrobials that resulted in the resolution of SIs. In addition, 19 dogs fulfilling the same inclusion criteria and treated with systemic, with or without topical antimicrobials, were included retrospectively (group B). Since there were no major differences between the groups, their results were combined. The severity of skin lesions decreased significantly, by 30% based on Canine Atopic Dermatitis Extent and Severity Index-4 (CADESI-4), by 28.1% based on the erythema domain of CADESI-4 and based on owner’s global assessment of the severity of skin lesions. Pruritus decreased significantly, by 34.7% based on the Pruritus Visual Analogue Scale (PVAS). The efficacy of antimicrobial treatment was assessed as good to excellent by the investigator and the owner in 55% and 60% of the dogs, respectively. Despite the significant improvement, there was high variability in the response to treatment among dogs. Further studies are needed to find factors that determine the response to antimicrobial treatment in dogs with AD and SIs.

Itraconazole therapy for infant hemangioma: Two case reports

BACKGROUND

Infantile hemangiomas (IHs) are the most common childhood benign tumors, showing distinctive progression characteristics and outcomes. Due to the high demand for aesthetics among parents of IH babies, early intervention is critical in some cases. β-Adrenergic blockers and corticosteroids are first-line medications for IHs, while itraconazole, an antifungal medicine, has shown positive results in recent years.

CASE SUMMARY

In the present study, itraconazole was applied to treat two IH cases. The therapeutic course lasted 80-90 d, during which the visible lesion faded by more than 90%. Moreover, no obvious side effects were reported, and the compliance of the baby and parents was desirable.

CONCLUSION

Although these outcomes further support itraconazole as an effective therapeutic choice for IHs, large-scale clinical and basic studies are still warranted to improve further treatment.

Successful treatment of acquired reactive perforating collagenosis with itraconazole

Background

Acquired reactive perforating collagenosis (ARPC) is a rare form of transepithelial elimination in which altered collagen is extruded through the epidermis.

Case presentation

A 23-year-old male presented with cup-like ulcerated lesions on his limbs since 3 months. A series of serological and immunological tests showed no abnormalities. A diagnosis of ARPC was based on skin biopsy findings. The patient was cured using treatment with itraconazole for 8 weeks, in the absence of a fungal infection.

Conclusions

The anti-inflammatory and anti-angiogenic effects of itraconazole can have good therapeutic benefits for ARPC.

Drug Repurposing of Itraconazole and Estradiol Benzoate against COVID-19 by Blocking SARS-CoV-2 Spike Protein-Mediated Membrane Fusion

SARS-CoV-2 caused the emerging epidemic of coronavirus disease in 2019 (COVID-19). To date, there are more than 82.9 million confirmed cases worldwide, there is no clinically effective drug against SARS-CoV-2 infection. The conserved properties of the membrane fusion domain of the spike (S) protein across SARS-CoV-2 make it a promising target to develop pan-CoV therapeutics. Herein, two clinically approved drugs, Itraconazole (ITZ) and Estradiol benzoate (EB), are found to inhibit viral entry by targeting the six-helix (6-HB) fusion core of SARS-CoV-2 S protein. Further studies shed light on the mechanism that ITZ and EB can interact with the heptad repeat 1 (HR1) region of the spike protein, to present anti-SARS-CoV-2 infections in vitro, indicating they are novel potential therapeutic remedies for COVID-19 treatment. Furthermore, ITZ shows broad-spectrum activity targeting 6-HB in the S2 subunit of SARS-CoV and MERS-CoV S protein, inspiring that ITZ have the potential for development as a pan-coronavirus fusion inhibitor.

Feline sporotrichosis in Asia

Sporothrix schenckii sensu lato is currently recognized as a species complex with only Sporothrix brasiliensis, Sporothrix schenckii sensu stricto, Sporothrix globosa and Sporothrix pallida identified to cause disease in the cat. Feline sporotrichosis in Asia is mainly reported from Malaysia where a single clonal strain of clinical clade D, Sporothrix schenckii sensu stricto manifesting low susceptibility to major antifungal classes, has been identified as the agent of the disease. Sporothrix globosa has been identified to cause disease from a single cat in Japan while the specific species of agent has not been identified yet for the disease in Thailand. Despite efforts to elucidate and describe the pathogenicity of the agent and the disease it causes, the paucity of data highlights the need for further molecular epidemiological studies to characterize this fungus and the disease it causes in Asia. Its prognosis remains guarded to poor due to issues pertaining to cost, protracted treatment course, zoonotic potential and low susceptibility of some strains to antifungals.

Case Report: Sweet Syndrome in Patients with Sporotrichosis: A 10-Case Series

Human sporotrichosis is an emerging disease caused by fungi of the genus Sporothrix, distributed worldwide, but mostly in tropical and subtropical regions. This disease is caused by traumatic inoculation of contaminated material (either animal or vegetal in origin) into the skin. Sporotrichosis cases caused by zoonotic transmission through felines have significantly increased over the last 20 years in Brazil. There is a spectrum of clinical outcomes, from classical lymphocutaneous and fixed forms to disseminated manifestations and extracutaneous lesions; however, hypersensitivity reactions related to sporotrichosis, including Sweet syndrome (acute febrile neutrophilic dermatoses), are uncommon. In Brazil, Sporothrix brasiliensis is repeatedly associated with feline infection and has consistently shown higher virulence, tendency to escalate to outbreaks or epidemics, and development of atypical forms. Therefore, the objective of the present study was to report the cases of 10 patients with sporotrichosis infected by S. brasiliensis species who developed Sweet syndrome to alert this association, especially in endemic areas.

Turning liabilities into opportunities: Off-target based drug repurposing in cancer

Targeted drugs and precision medicine have transformed the landscape of cancer therapy and significantly improved patient outcomes in many cases. However, as therapies are becoming more and more tailored to smaller patient populations and acquired resistance is limiting the duration of clinical responses, there is an ever increasing demand for new drugs, which is not easily met considering steadily rising drug attrition rates and development costs. Considering these challenges drug repurposing is an attractive complementary approach to traditional drug discovery that can satisfy some of these needs. This is facilitated by the fact that most targeted drugs, despite their implicit connotation, are not singularly specific, but rather display a wide spectrum of target selectivity. Importantly, some of the unintended drug "off-targets" are known anticancer targets in their own right. Others are becoming recognized as such in the process of elucidating off-target mechanisms that in fact are responsible for a drug's anticancer activity, thereby revealing potentially new cancer vulnerabilities. Harnessing such beneficial off-target effects can therefore lead to novel and promising precision medicine approaches. Here, we will discuss experimental and computational methods that are employed to specifically develop single target and network-based off-target repurposing strategies, for instance with drug combinations or polypharmacology drugs. By illustrating concrete examples that have led to clinical translation we will furthermore examine the various scientific and non-scientific factors that cumulatively determine the success of these efforts and thus can inform the future development of new and potentially lifesaving off-target based drug repurposing strategies for cancers that constitute important unmet medical needs.