Local vancomycin administration in Orthopaedic Surgery - A systematic review of comparative studies

Background

There is still controversy surrounding the routine use of vancomycin locally in primary orthopaedic surgery procedures. Therefore, the aim of this review is to assess how local vancomycin impacts the rates and microbiology of surgical site infections.

Methods

A systematic electronic search of MEDLINE, EMBASE, and Web of Science was carried out for all comparative studies comparing locally applied vancomycin to control for primary orthopaedic surgery procedures published before August 14, 2022.

Results

A total of 61 studies with 65,671 patients were included for analysis. Forty-six studies used vancomycin powder, 12 studies with grafts soaked in vancomycin, two studies used vancomycin irrigation, and one study administered vancomycin interosseously. There were 15 studies (of 26) in spine surgery, five (of 14) in arthroplasty, ten (of 11) in sports medicine, and two (of five) in trauma surgery that found statistically significant decreases in overall infection rates when applying local vancomycin. Only one study (in spine surgery) found significant increases in infection rates with local vancomycin application. For spine surgery, local vancomycin application had the greatest proportion of gram-negative bacteria (40.7%) isolated compared to S. aureus (42.4%) in controls. In arthroplasty and trauma surgery, there were increases in the proportions of gram-negative bacteria when vancomycin was added. There were no reported systemic adverse reactions associated with local vancomycin use in any of the studies.

Conclusion

Applying local vancomycin during primary orthopaedic surgery procedures may reduce the rates of infections in multiple different orthopaedic specialties, particularly in spine surgery and sports medicine. However, careful consideration should be applied when administering local vancomycin during specific orthopaedic procedures given the heterogeneity of included studies and breadth of surgeries included in this review.

Level of evidence

Level III. A systematic review of level I - III studies.

Topical pickering emulsion versus classical excipients: A study of the residual film on the human skin

The interest in Pickering emulsions is based on the possibility of replacing classical emulsifiers with solid particles. These emulsions are very attractive in the pharmaceutical field for their stability virtues and as a vehicle to deliver active ingredients. The study aimed to analyze the properties of the residual film of the Pickering emulsions on the human skin compared to conventional systems. For this project, three types of solid particles were used: titanium dioxide, zinc oxide and silicon dioxide. All of them are capable of stabilizing the oil/water interface and thus forming totally emulsified systems. To create an emulsion of reference, a classical surfactant was used as an excipient. Complementary systems containing both particles and the emulsifier were also analyzed. Then, a combined approach between physicochemical and biometrological in vivo analysis was employed. The study proved that Pickering emulsions stabilized by the metal oxides were distinct from the reference emulsion in terms of droplet sizes and organization, rheological and textural responses. Consequently, it impacted the properties of the residual film once the product was applied to the skin. The particle-stabilized emulsions formed a hydrophobic film counter to conventional excipients. Also, the Friction parameter (or the roughness of the film) was directly linked to the quantity of the particles used in the formulation and their perception on the skin surface. The use of the particles blurs the glossy effect of the oil phase. Finally, it was observed that the appearance of the residual film was impacted by the type of the particle, namely TiO2 and ZnO particles.

Novel Topical Treatments for Itch

The experience of itch often poses a burden on patient quality of life and has the capacity to inflict significant suffering. Topical therapies are a mainstay of treatment for many cutaneous and systemic diseases and afford patients the opportunity to manage their conditions without many of the systemic side effects of non-topical therapies. We review a multitude of new topical medications targeting the skin, immune system, and neural receptors. The list includes Janus kinase inhibitors, tyrosine kinase inhibitors, phosphodiesterase inhibitors, transient receptor vanilloid inhibitors, topical cannabinoids, and topical acetaminophen. Many of the topical therapies reviewed show promising data in phase 2-3 clinical trials, but further research is needed to compare therapies head-to-head and test their efficacy on a broader range of conditions.

Combination of self-assembling system and N,O-carboxymethyl chitosan improves ocular residence of anti-glaucoma drug

Glaucoma is known to be one of the principal causes of vision loss due to elevated intraocular pressure. Currently, latanoprost eye drops is used as first-line treatment for glaucoma; however, it possesses low bioavailability due to rapid precorneal clearance. A novel delivery system with a mucoadhesive property could overcome this problem. Therefore, we attempt to develop a combination of self-assembling latanoprost nanomicelles (Latcel) and a mucoadhesive polymer (N,O-carboxymethyl chitosan: N,O-CMC) to improve the corneal residence time. Latcel was developed using Poloxamer-407 by thin film hydration method, followed by the addition of N,O-CMC using simple solvation to obtain Latcel-CMC and characterized using various physicochemical characterization techniques. The particle size of Latcel-CMC was 94.07 ± 2.48 nm and a zeta potential of -16.03 ± 0.66 mV, with a sustained release for 24h whereas marketed latanoprost drops released 90 % of the drug within 1h. In vitro cytotoxicity studies, HET-CAM, and in vivo Draize test showed the biocompatibility of Latcel-CMC. Cellular uptake studies performed using fluorescein isothiocyanate (FITC) loaded nanomicelles in human corneal epithelial cells indicates the increased cellular uptake as compare to plain FITC solution. In vivo ocular residence time was evaluated in Wistar rats using Indocyanine green (ICG) loaded nanomicelles by an in vivo imaging system (IVIS), indicating Latcel-CMC (8h) has better residence time than plain ICG solution (2h). The Latcel-CMC showed improved corneal residence time and sustained release of latanoprost due to increased mucoadhesion. Thus, the developed N,O-Carboxymethyl chitosan based nanomicelles eye drop could be a better strategy than conventional eye drops for topical delivery of latanoprost to treat glaucoma.

A Four-Arm Randomized Clinical Trial of Topical Pain Control for Sentinel Node Radiotracer Injections in Patients with Breast Cancer

BACKGROUND

Radioactive tracer injections for breast cancer sentinel lymph node mapping can be painful. In this randomized trial, we compared four approaches to topical pain control for radiotracer injections.

METHODS

Breast cancer patients were randomized (9 April 2021-8 May 2022) to receive the institutional standard of ice prior to injection (n = 44), or one of three treatments: ice plus a vibrating distraction device (Buzzy®; n = 39), 4% lidocaine patch (n = 44), or 4% lidocaine patch plus ice plus Buzzy® (n = 40). Patients completed the Wong-Baker FACES® pain score (primary outcome) and a satisfaction with pain control received scale (secondary). Nuclear medicine technologists (n = 8) rated perceived pain control and ease of administration for each patient. At study conclusion, technologists rank-ordered treatments. Data were analyzed as intention-to-treat. Wilcoxon rank-sum tests were used to compare pain scores of control versus pooled treatment arms (primary) and then control to each treatment arm individually (secondary).

RESULTS

There were no differences in pain scores between the control and treatment groups, both pooled and individually. Eighty-five percent of patients were 'satisfied/very satisfied' with treatment received, with no differences between groups. No differences in providers' perceptions of pain were observed, although providers perceived treatments involving Buzzy© more difficult to administer (p < 0.001). Providers rated lidocaine patch as the easiest, with ice being second.

CONCLUSION

In this randomized trial, no differences in patient-reported pain or satisfaction with treatment was observed between ice and other topical treatments. Providers found treatments using Buzzy® more difficult to administer. Given patient satisfaction and ease of administration, ice is a reasonable standard.

Topical and Intralesional Therapies for Hidradenitis Suppurativa: A Systematic Literature Review

BACKGROUND AND OBJECTIVE

Topical and intralesional (IL) treatments may be considered the first-line therapy in patients with hidradenitis suppurativa (HS); however, the evidence supporting their use is limited. The aim of our review is to evaluate the efficacy and safety profile of topical and IL treatments in patients with HS.

MATERIALS AND METHODS

We designed a systematic review of the current medical literature available following the PICO(T) method. And including all types of studies (Study type [T]) of individuals with HS of any sex, age, and ethnicity (Population [P]) who received any topical or IL treatment for HS (Intervention [I]) compared to placebo, other treatments, or no treatment at all (Comparator [C]), and reported efficacy and/or safety outcomes (Outcomes [O]). Two outcomes were defined: quality of life and the no. of patients with, at least, one adverse event. The search was conducted in the Cochrane Library, MEDLINE, and Embase databases; study selection was performed based on pre-defined criteria. The risk of bias was determined in each study.

RESULTS

We obtained a total of 11,363 references, 31 of which met the inclusion criteria. These studies included 1143 patients with HS, 62% of whom were women. A total of 10, 8, 6, 2, and 5 studies, respectively, evaluated the use of photodynamic therapy (PDT), glucocorticoids, resorcinol, topical antibiotics, and other interventions. Most articles were case series (n=25), with only five randomized clinical trials (RCTs) and one cohort study. RCTs showed improvement in disease activity with topical clindamycin and botulinum toxin (BTX) vs placebo, and PDT with methylene blue (MB) niosomal vs free MB; however, intralesional triamcinolone acetonide was not superior to placebo. The risk of bias was low in three RCTs and high in two RCTs.

CONCLUSION

The quality of evidence supporting the use of topical, or IL treatments is low. However, it supports the use of topical clindamycin, PDT, and BTX. Well-designed RCTs with standardized outcomes and homogeneous populations of patients and lesions are needed to support decision-making in the routine clinical practice.

Topical Tacrolimus and Mycophenolic Acid Therapy Synergizes with Low Dose Systemic Immunosuppression to Sustain Vascularized Composite Allograft Survival

AIM

The goal of this study was to evaluate whether topical administration of tacrolimus (TAC) and mycophenolic acid (MPA) at the transplant site enables vascularized composite allograft (VCA) survival with significant minimization of the dose and adverse effects of systemic TAC (STAC) immunosuppression.

MATERIALS AND METHODS

Lewis (Lew) rats received orthotopic hind limb allotransplants from fully mismatched Brown Norway (BN) donors. Group 1 (Controls) received no treatment. Other groups were treated with STAC at a dose of 1 mg/kg/day for 7 days. On post-operative day (POD) 8, the STAC dose was dropped to 0.1 mg/kg/day for Group 2 and maintained at 1 mg/kg for Group 3. Group 4 received topical application of TAC and MPA on the transplanted (Tx) limb starting POD 8 without STAC. Group 5 received topical TAC and MPA on the contralateral non-Tx limb and Group 6 received topical TAC and MPA on the Tx limb starting POD 8 along with low dose STAC (0.1 mg/kg/day). Treatment was continued until the study end point was reached, defined as either grade 3 rejection or allograft survival exceeding 100 days. .We conducted sequential LC-MS/MS measurements to assess TAC and MPA concentrations in both blood/plasma and allograft tissues. Additionally, we evaluated markers indicative of organ toxicity associated with STAC immunosuppression.

RESULTS

Compared to controls, topical therapy with TAC+MPA significantly prolonged allograft survival beyond 100 daysat very low dose STAC (0.1 mg/kg/day) (Group 6). The histopathological assessment of the grafts was consistent with the clinical outcomes. .Drug levels in blood/plasma remained low or undetectable, while allograft tissues showed higher drug concentrations compared to contralateral limb tissues (P<0.05). . Urinary creatinine clearance remained within the normal range at 2.5 mL/min.

CONCLUSION

Combination therapy with topical TAC and MPA synergizes with a very low dose, corticosteroid- free-STAC regimen and facilitates rejection-free, prolonged VCA survival without morbidity.

Effect of Receptor Solution in Studies of In Vitro Permeation Test (IVPT)

In Vitro Permeation Test (IVPT) is commonly used to evaluate skin penetration of chemicals and performance of dermatological products. For a permeant with low aqueous solubility, an additive that is expected not to alter the skin barrier can be used in the receptor solution to improve permeant solubility. The objective of this study was to (a) evaluate the effects of these additives in IVPT receptor solution on skin permeability of model permeants and skin electrical resistance and (b) determine the solubility of the permeants in these receptor solutions. Bovine serum albumin (BSA), 2-hydroxypropyl-beta-cyclodextrin (HPCD), ethanol, nonionic surfactant Brij-98, and propylene glycol were the additives, and phosphate buffered saline (PBS) was the control. Steady-state skin permeability coefficients and resistances were determined. The receptor solutions examined in this study did not cause a significant increase in skin permeability or decrease in resistance (less than 40 % changes) except 25 % ethanol. The receptor solution containing 25 % ethanol induced an approximately twofold average increase in skin permeability and reduced skin electrical resistance by approximately threefold. The receptor solution of 2.5 % HPCD provided the highest levels of solubility for the model lipophilic permeants, while 0.2 % Brij-98 and 5 % ethanol showed the lowest solubility enhancement from those in PBS.

Real-World Adverse Events Associated with Encapsulated Benzoyl Peroxide/Tretinoin, 3%/0.1%, and Encapsulated Benzoyl Peroxide, 5

Encapsulated benzoyl peroxide, 5%, for rosacea and a combined formulation of encapsulated benzoyl peroxide/tretinoin, 3%/0.1%, for acne vulgaris, utilize microencapsulation, a process by which active pharmaceutical agents are enclosed in inert, permeable silica shells that provide a buffer between the drug and the skin. The silica shells allow a gradual release of the drug while also allowing combinations of active ingredients that would not otherwise be possible. This technology allows benzoyl peroxide and tretinoin to be combined in the same vehicle without risking the benzoyl peroxide-mediated oxidative destruction of tretinoin. In the current study, we queried the Galderma pharmacovigilance database to quantify and categorize adverse events associated with using these products in the USA during a 12-month period from May 2022 through April 2023. The adverse events were generally mild and restricted to local irritation, pruritus, burning sensation, and erythema. The real-world incidence and type of adverse events reported by the community for encapsulated benzoyl peroxide/tretinoin, 3%/0.1%, and benzoyl peroxide, 5%, were consistent with the safety and tolerability findings from the phase III clinical studies of these treatments.

The physicochemical properties and molecular docking study of plasticized amphotericin B loaded sodium alginate, carboxymethyl cellulose, and gelatin-based films

Plasticizers are employed to stabilize films by safeguarding their physical stability and avoiding the degradation of the loaded therapeutic drug during processing and storage. In the present study, the plasticizer effect (glycerol) was studied on bioadhesive films based on sodium alginate (SA), carboxymethyl cellulose (CMC) and gelatin (GE) polymers loaded with amphotericin B (AmB). The main objective of the current study was to assess the morphological, mechanical, thermal, optical, and barrier properties of the films as a function of glycerol (Gly) concentration (0.5-1.5 %) using different techniques such as Scanning Electron Microscope (SEM), Texture analyzer (TA), Differential Scanning Calorimeter (DSC), X-Ray Diffraction (XRD), and Fourier Transforms Infrared Spectroscopy (FTIR). The concentration increase of glycerol resulted in an increase in Water Vapor Permeability (WVP) (0.187-0.334), elongation at break (EAB) (0.88-35.48 %), thickness (0.032-0.065 mm) and moisture level (17.5-41.76 %) whereas opacity, tensile strength (TS) (16.81-0.86 MPa), and young's modulus (YM) (0.194-0.002 MPa) values decreased. Glycerol incorporation in the film-Forming solution decreased the brittleness and fragility of the films. Fourier Transform Infrared (FTIR) spectra showed that intermolecular hydrogen bonding occurred between glycerol and polymers in plasticized films compared to control films. Furthermore, molecular docking was applied to predict the binding interactions betweem AmB, CMC, gelatin, SA and glycerol, which further endorsed the stabilizing effects of glycerol in the complex formation between AmB, CMC, SA, and gelatin. The Findings of the current study demonstrated that this polymeric blend could be used to successfully prepare bioadhesive films with glycerol as a plasticizer.

Topical tranexamic acid (TXA) is non-inferior to intravenous TXA in adult spine surgery: a meta-analysis

Tranexamic acid (TXA) has long been utilized in spine surgery and can be administered through intravenous (IV) and topical routes. Although, topical and IV administration of TXA are both effective in decreasing blood loss during spine surgery, complications like deep vein thrombosis (DVT) and pulmonary embolism have been reported with the use of intravenous TXA (ivTXA). These potential complications may be mitigated through the use of topical TXA (tTXA). To assess optimal dosing protocols and efficacy of topical TXA in spine surgery, Embase, Ovid-MEDLINE, Scopus, Cochrane, and clinicaltrials.gov were queried for original research on the use of tTXA in adult patients undergoing spine surgery. Data parameters analyzed included blood loss, transfusion rate, thromboembolic, and other complications. Data was synthesized and confidence evaluated according to the Grades of Recommendation, Assessment, Development, and Evaluation approach. Nineteen studies were included in the final analysis with 2197 patients. Of the 18 published studies, 9 (50%) displayed high levels of evidence. Topical TXA showed a trend towards a lower risk of transfusion and complications. Protocols that used 1g tTXA showed a significantly reduced risk for transfusion when compared to controls (risk ratio -1.05, 95% CI (-1.62, -0.48); P = 0.94, I2 = 0%). Complications associated with tTXA included DVTs and wound infections. Topical TXA was non-inferior to intravenous TXA with similar efficacy and complication profiles for bleeding control in spine surgery; however, more studies are needed to discern benefits and risks.

Vesicular Nanocarriers: A Potential Platform for Topical/Transdermal Delivery of Antibiotics

BACKGROUND

Bacterial infections are becoming difficult to treat nowadays due to the development of resistance towards conventional treatments. Conventional topical formulations loaded with antibiotics display various disadvantages, like high dosing frequency, high toxicity, and poor patient compliance. The former limitations may sometimes lead to severe complications and hospitalization of patients. However, these can be overcome by employing vesicular nanocarriers for the delivery of antibiotics following the topical/transdermal route.

OBJECTIVE

The objective of this review paper was to summarize the role of vesicular nanocarriers, like liposomes, elastic liposomes, niosomes, ethosomes, solid lipid nanoparticles, nanostructured lipid carriers, and nanoemulsions for topical/transdermal delivery of antibiotics, and patents associated with them.

METHODS

Literature for the present review was collected using various search engines, like PubMed, Google Scholar, and Google Patents.

RESULTS

Various literature investigations have revealed the in vitro and preclinical efficacy of vesicular nanocarrier systems in the delivery of antibiotics following the topical/transdermal route.

CONCLUSION

Vesicular nanocarrier systems, via targeted delivery, may subside various side effects of antibiotics associated with conventional delivery, like high dosing frequency and poor patient compliance. However, their existence in the pharmaceutical market will be governed by effective clinical assessment and scale-up methodologies.

Selection, activity, and nuclease stabilization of cross-neutralizing DNA aptamers targeting HSV-1 and HSV-2

Cross-neutralizing aptamers targeting both HSV-1 and HSV-2 were developed by selecting against the ectodomains of glycoprotein D (gD) from both viruses in parallel as well as sequentially using the SELEX method. Since gD facilitates viral invasion, sterically blocking the host-receptor interaction prevents infection. Candidate aptamers were screened, and lead aptamers were identified that exhibited exceptional neutralizing activity against both viruses in vitro. The specificity of the aptamers was confirmed by comparing their activity to scrambled versions of themselves. Modifications of the lead compounds were tested to define critical motifs to guide development. Stability of the aptamers was increased using phosphorothioate backbone linkages, and 2' methoxy substitutions of terminal and key internal bases. Aptamers were applied in a guinea pig vaginal HSV-2 infection model and found to reduce both the viral load of infected animals and the severity of the resulting disease. These results suggest that cross-neutralizing aptamers can be developed into on-demand antiviral interventions effective against both HSV-1 and HSV-2.

Topical and Intralesional Therapies for Hidradenitis Suppurativa: A Systematic Literature Review

BACKGROUND AND OBJECTIVE

Topical and intralesional (IL) treatments may be considered the first-line therapy in patients with hidradenitis suppurativa (HS); however, the evidence supporting their use is limited. The aim of our review is to evaluate the efficacy and safety profile of topical and IL treatments in patients with HS.

MATERIALS AND METHODS

We designed a systematic review of the current medical literature available following the PICO(T) method. And including all types of studies (Study type [T]) of individuals with HS of any sex, age, and ethnicity (Population [P]) who received any topical or IL treatment for HS (Intervention [I]) compared to placebo, other treatments, or no treatment at all (Comparator [C]), and reported efficacy and/or safety outcomes (Outcomes [O]). Two outcomes were defined: quality of life and the no. of patients with, at least, one adverse event. The search was conducted in the Cochrane Library, MEDLINE, and EMBASE databases; study selection was performed based on pre-defined criteria. The risk of bias was determined in each study.

RESULTS

We obtained a total of 11,363 references, 31 of which met the inclusion criteria. These studies included 1143 patients with HS, 62% of whom were women. A total of 10, 8, 6, 2, and 5 studies, respectively, evaluated the use of photodynamic therapy (PDT), glucocorticoids, resorcinol, topical antibiotics, and other interventions. Most articles were case series (n=25), with only five randomized clinical trials (RCTs) and one cohort study. RCTs showed improvement in disease activity with topical clindamycin and botulinum toxin (BTX) vs placebo, and PDT with methylene blue (MB) niosomal vs free MB; however, intralesional triamcinolone acetonide was not superior to placebo. The risk of bias was low in three RCTs and high in two RCTs.

CONCLUSION

The quality of evidence supporting the use of topical, or IL treatments is low. However, it supports the use of topical clindamycin, PDT, and BTX. Well-designed RCTs with standardized outcomes and homogeneous populations of patients and lesions are needed to support decision-making in the routine clinical practice.

Topical Chinese herbal medicine in treating atopic dermatitis (eczema): A systematic review and meta-analysis with core herbs exploration

ETHNOPHARMACOLOGICAL RELEVANCE

Topical Chinese herbal medicine (CHM) is commonly used to relieve atopic dermatitis (AD); however, the up-to-date evidence concerning the effectiveness of topical CHM on treating AD is lacking. Moreover, the CHM prescriptions are often too complicated to realize the overall mechanisms of CHM, especially when compared to western medicines (WM).

AIM OF THE STUDY

To evaluate the effectiveness of topical CHM for treating AD by conducting a meta-analysis on randomized clinical trials (RCTs).

METHODS

Twenty RCTs comparing topical CHM to active control/placebo were included in the final analysis. The primary outcome was the symptom scores changed from baseline and the effectiveness rate was the secondary outcome. Subgroup analysis on different initial symptom severity and the different interventions in control groups was performed. System pharmacology analysis was performed to explore core CHM and possible pharmacological mechanisms of CHM for AD.

RESULTS

Compared with active/blank placebo, topical CHM seemed more effective (SMD: -0.35, 95 %CI: -0.59 to -0.10, p-value = 0.005, I2 = 60%). The effectiveness rate was higher (RR: 1.29, 95 %CI 1.15-1.44, p-value <0.00001, I2 = 71%). In subgroup analysis, mild and moderate AD patients with topical CHM were more effective than placebo (SMD: -0.28, 95 %CI -0.56 to -0.01, p-value = 0.04, I2 = 5%; -0.34, 95%CI -0.64 to -0.03, p-value = 0.03, I2 = 0%, separately). Topical CHM has 1.25 times more effective than the topical glucocorticoid (95 %CI 1.09-1.43, p-value = 0.001, I2 = 64%). Core CHMs, such as Phellodendron chinense C.K. Schneid., Sophora flavescens Ait., Cnidium monnieri (L.) Cusson, and Dictamnus dasycarpus Turcz., had effects on the pathways on immune and metabolism systems different from WM.

CONCLUSION

Our results exploit the potential role of CHM on treating AD, especially for mild and moderate AD.

Topical Tranexamic Acid: Risks, Benefits and Novel Complications in Aesthetic Plastic Surgery

Antifibrinolytics, particularly tranexamic acid (TXA), are agents used to reduce bleeding. TXA is a synthetic reversible competitive inhibitor to the lysine receptor found on plasminogen. By reversibly binding to this site, it leads to plasminogen being unable to bind to fibrin and so prevents fibrinolysis, this stabilizes the clot and thus prevents hemorrhage. (Pekrul in Der Anaesth 70:515-521, 2021) It can be used either intravenously or topically but has never entered mainstream use in plastic surgery. (Pekrul in Der Anaesth 70:515-521, 2021) This is most likely due to understandable fears of thromboembolic events. On the other hand, the tempting benefits are reduced bleeding (perioperatively) decreased bruising and swelling, and thus increased aesthetic, important for obvious reasons. A review of the literature was done to go deeper on this issue, examining topical use in aesthetic surgery. Clear benefit was shown in the literature, it could be postulated that it would not be unwise to consider more research on topical use of TXA in certain cases, the benefits could greatly outweigh the risks. Old fears and conceptions, unsupported by the literature at the time of writing, should not hold back further research, and the benefits shown could even potentially justify the topical use of these agents in the near future. Further studies evaluating the utility of TXA in Panniculectomy and Abdominoplasty surgery should be performed especially, since only one was found which reported no significant benefit. Minor complications were present, such as minor delayed post-auricular skin healing, temporary unilateral marginal mandibular neuropraxia and increased cumulative seroma volume. These were novel findings and could warrant further investigation as well. After performing a review of the literature, it was seen that topical TXA generally adds benefit in aesthetic plastic surgery, with no particularly significant complications. We would like to bring more attention to the issue and support more studies on TXA use. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors   www.springer.com/00266 .

Risk and management of osteoporosis due to inhaled, epidural, intra-articular or topical glucocorticoids

Glucocorticoids (GCs) are widely used by several specialties for the treatment of a variety of diseases and conditions. The unfavorable effect of oral GCs on bone health is well-documented. The ensuing from their use glucocorticoid-induced osteoporosis (GIOP) is the most common cause of medication-induced osteoporosis and fractures. It is uncertain, however, if, and in what extent, GCs administered by other routes affect the skeleton. In the present review, we quote current evidence on the effect of inhaled GCs, epidural and intra-articular steroid injections, and topical GCs on bone outcomes. Although evidence is limited and weak, it seems that a small proportion of the administered GCs may be absorbed, enter the systemic circulation, and adversely affect the skeleton. Potent GCs, higher doses, and longer treatment duration seem to infer the greater risk for bone loss and fractures. There are scarce data, and only for inhaled GCs, regarding the efficacy of antiosteoporotic medications in patients receiving GCs through routes other than oral. Further studies are needed to clarify the relationship between GC administration through these routes and bone outcomes and to help establishing guidelines for the optimal management of such patients.

Long-term effects of intraoperative topical bevacizumab in sutureless scleral tunnel trabeculectomy: a prospective clinical trial

PURPOSE

To investigate the long-term efficacy and safety of the novel method sutureless trabeculectomy with topical administration of bevacizumab.

MATERIALS/METHODS

Primary open-angle glaucoma patients with intraocular pressure (IOP) > 21 mmHg despite maximum tolerated medication were included in a single-blind prospective interventional clinical trial. Group 1 underwent sutureless scleral tunnel trabeculectomy with intraoperative topical administration of bevacizumab (1.25 mg) applied on the scleral incision for 1 min. Group 2 underwent sutureless trabeculectomy alone and group 3 (control group) underwent conventional trabeculectomy with mitomycin C (MMC). Outcome measures were surgical success, IOP, number of needed anti-glaucoma medications, and complications. Patients were followed for two years.

RESULTS

Finally, 50 eyes from group 1, 46 from group 2, and 47 from group 3 were analyzed. At the end of 24 months, 52% (n = 26) of group 1, 34.8% (n = 16) of group 2, and 57.4% (n = 27) of group 3 had complete success (IOP < 18 mmHg without medication). The difference was only significant between groups 2 and 3 (p = 0.003). 94% (n = 47) of group 1, 89.1% (n = 41) of group 2, and 91.5% (n = 43) of group 3 had qualified success (IOP < 18 mmHg with ≤ 2 anti-glaucoma medications) (p = 0.69). There was a significant difference in the overall IOP mean between the three groups (p < 0.0001). There was no significant difference between the three groups in complication rates and the number of needed anti-glaucoma medications for IOP control.

CONCLUSION

Sutureless trabeculectomy with topical application of bevacizumab showed comparable surgical success rates with conventional trabeculectomy and MMC in long-term follow-up. Additionally, adjuvant use of topical bevacizumab had a significant positive impact on long-term IOP control.

New Insights into Pharmaceutical Nanocrystals for the Improved Topical Delivery of Therapeutics in Various Skin Disorders

Nanotechnology has provided nanostructure-based delivery of drugs, among which nanocrystals have been investigated and explored for feasible topical drug delivery. Nanocrystals are nano-sized colloidal carriers, considered pure solid particles with a maximum drug load and a very small amount of stabilizer. The size or mean diameter of the nanocrystals is less than 1 μm and has a crystalline character. Prominent synthesis methods include the utilization of microfluidic- driven platforms as well as the milling approach, which is both adaptable and adjustable. Nanocrystals have shown a high capacity for loading drugs, utilization of negligible amounts of excipients, greater chemical stability, lower toxic effects, and ease of scale-up, as well as manufacturing. They have gained interest as drug delivery platforms, and the significantly large surface area of the skin makes it a potential approach for topical therapeutic formulations for different skin disorders including fungal and bacterial infections, psoriasis, wound healing, and skin cancers, etc. This article explores the preparation techniques, applications, and recent patents of nanocrystals for treating various skin conditions.

[In total knee arthroplasty surgeries, what is the effective dose of intra-articular tranexamic acid?]

Objective

The aim of our study was to evaluate the effect of different doses of intra-articular (IA) tranexamic acid (TXA) on blood loss in total knee arthroplasty surgeries and compare it to the control group.

Materials and Methods

A total of 160 patients who underwent unilateral total knee arthroplasty surgery at Edirne State Hospital between 2016 and 2020 were divided into four groups. The estimated blood loss and amount of blood loss from drainage, as well as transfusion rates, were compared between the groups based on surgical pre- and post-operative blood parameters to evaluate the dose effectiveness.

Results

In our study, all TXA groups significantly reduced the estimated blood loss and amount of blood loss from drainage compared to the control group. No statistically significant difference was found between the control group and the group receiving 1 g of TXA in terms of transfusion rates (p = 0.062), and no statistically significant difference was found between the groups receiving 2 g and 3 g of TXA.

Conclusion

The use of 2 g of IA TXA is an effective dose for controlling blood loss in total knee arthroplasty surgeries. Lower doses do not have a significant effect on transfusion rates, whereas higher doses do not significantly increase effectiveness.

Chromatographic method for dacarbazine quantification in skin permeation experiments

Dacarbazine (DTIC) is a chemotherapeutic drug currently used for the systemic treatment of melanomas. Considering the easy access to these tumors, a topical route of drug administration could provide a more comfortable and less toxic treatment. However, DTIC quantification aiming at the design of topical formulations is challenging, pondering all the interferents present in the drug samples recovered from the skin. Hence, this work intended to validate a selective chromatographic method for DTIC determination in skin permeation studies. A reversed-phase C18 column was used as a stationary phase, and gradient elution of a mobile phase consisting of methanol and pH 6.5 sodium phosphate monohydrate buffer (0.01 mol/L) at a flow rate of 1.0 mL/min was implemented. DTIC was detected at 364 nm. The method was selective against skin interferents, linear (r = 0.9995) in a concentration range of 1.0-15.0 μg/mL, precise with an overall variation coefficient lower than 3.8%, accurate achieving recovery from the skin layers within 91-112%, and sensitive for the proposed application (detection limit = 0.10 μg/ mL, quantification limit = 0.30 μg/mL). Furthermore, the analytical method was successfully tested in in vitro skin permeation studies. In conclusion, the developed method is appropriate for DTIC analysis from the skin sample matrix.

Calcipotriene and Betamethasone Dipropionate PAD-Cream Demonstrates Greater Treatment Efficacy in Patients with Moderate-to-Severe Psoriasis Compared to Topical Suspension/Gel: A Subgroup Analysis of Two Phase 3 Studies

INTRODUCTION

Psoriasis ranges from mild to severe with the majority of patients having mild disease. Mild to moderate disease is often treated with topical therapies while photo-, oral, and biologic therapies are generally reserved for moderate-to-severe disease. There is a strong scientific rationale for the combination of calcipotriene (CAL) and betamethasone dipropionate (BDP) with respect to mode of action, efficacy, and safety and CAL/BDP has shown an inhibitory effect on key pathogenic cytokines in psoriasis including tumor necrosis factor-α, interleukin (IL)-17, and IL-23.

METHODS

The objective of this pooled post hoc analysis is to investigate the efficacy of CAL/BDP polyaphron dispersion (PAD)-cream in subgroups of patients with moderate-to-severe psoriasis from two completed phase 3 studies conducted in the USA and Europe.

RESULTS

The proportion of patients achieving Physician Global Assessment (PGA) treatment success as well as a modified Psoriasis Area and Severity Index (mPASI)75 response was higher in the subgroup with a body surface area > 10% and mPASI > 10 and Dermatology Life Quality Index > 10 at baseline compared to the overall patient population. Furthermore, the numerical difference in treatment efficacy between CAL/BDP PAD-cream and CAL/BDP topical suspension/gel increased in patient subgroups with higher baseline severity. Similar patterns were shown for the patient-reported outcomes.

CONCLUSION

In this subgroup analysis, patients who had higher disease severity at baseline achieved greater efficacy than the total patient population when treated with 8 weeks of CAL/BDP PAD-cream as compared to a currently marketed active comparator. Additionally, as indicated by this analysis, CAL/BDP PAD-cream treatment may also be more convenient and less greasy, which may reduce the burden of daily treatment and improve adherence to therapy.

TRIAL REGISTRATION

NCT03308799 and NCT03802344.

Lipid-based amphotericin B gel treatment eradicates vulvovaginal candidiasis in patients who failed to azole therapy

Vaginal yeast infection is one of the most common diseases caused by vulvovaginal candidiasis (VVC). Effective therapy for VVC is needed. A lipid-based amphotericin B gel 0.1% (LAB) was developed and evaluated for the treatment of VVC patients and those who failed to azole therapy. LAB was applied topically twice daily for 7 days to 64 moderate patients and 14 days to 55 severely infected VVC patients. Additionally, 66 patients who failed to azole therapy were treated twice daily with LAB for 14 days. A 91.5% clinical response and 93.16% mycological response was observed in VVC patients. The patients treated with LAB who failed to azole therapy showed a 75% clinical, 95.3% mycological response and 83% remission was observed.Overall, the LAB was found to be efficacious and safe for the treatment of VVC patients. Clinical Trial Registration All the trials were registered at Clinical Trial Registry of India (CTRI/2013/02/003378, CTRI/2014/02/004409).

Advances of liposomal mediated nanocarriers for the treatment of dermatophyte infections

Due to the adverse effects associated with long-term administration of antifungal drugs used for treating dermatophytic lesions like tinea unguium, there is a critical need for novel antifungal therapies that exhibit improved absorption and minimal adverse effects. Nanoformulations offer a promising solution in this regard. Topical formulations may penetrate the upper layers of the skin, such as the stratum corneum, and release an appropriate amount of drugs in therapeutic quantities. Liposomes, particularly nanosized ones, used as topical medication delivery systems for the skin, may have various roles depending on their size, lipid and cholesterol content, ingredient percentage, lamellarity, and surface charge. Liposomes can enhance permeability through the stratum corneum, minimize systemic effects due to their localizing properties, and overcome various challenges in cutaneous drug delivery. Antifungal medications encapsulated in liposomes, including fluconazole, ketoconazole, croconazole, econazole, terbinafine hydrochloride, tolnaftate, and miconazole, have demonstrated improved skin penetration and localization. This review discusses the traditional treatment of dermatophytes and liposomal formulations. Additionally, promising liposomal formulations that may soon be available in the market are introduced. The objective of this review is to provide a comprehensive understanding of dermatophyte infections and the role of liposomes in enhancing treatment.

Emerging Treatments and the Clinical Trial Landscape for Hidradenitis Suppurativa Part I: Topical and Systemic Medical Therapies

Hidradenitis suppurativa (HS) is an oftentimes debilitating condition that presents with painful nodules, abscesses, and sinus tracts. This condition is challenging to treat, in part because the pathogenesis of the condition is incompletely understood but also because there are limited therapeutic options. HS research is undergoing explosive growth with multiple new molecular pathways under study, which will hopefully lead to improved disease control for patients. Part I of this review will provide an overview of the emerging topical and systemic therapies under investigation for HS.

Topical use of tranexamic acid can reduce opioid consumption compared with intravenous use for patients undergoing primary total hip arthroplasty: a prospective randomized controlled trial

BACKGROUND

The problem of opioid addiction after total hip arthroplasty (THA) has been widely concerned. Tranexamic acid (TXA) has been shown to be effective in reducing blood loss for patients undergoing THA, but few studies focus on its alleviation of postoperative local pain symptoms. The purpose of this study was to investigate whether topical TXA could reduce early postoperative hip pain for primary THA patients, thereby reducing the use of opioids, and whether local pain is related to inflammatory response.

METHODS

In this prospective randomized controlled study, we randomly divided 161 patients into a topical group (n = 79) and an intravenous group (n = 82). Hip pain was assessed using the visual analogue scale (VAS) score within three days after surgery and tramadol was used for pain relief when necessary. Inflammatory markers such as high-sensitivity C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), interleukin-6 (IL-6), total blood loss and hemoglobin drop were assessed by hematologic tests. The primary outcomes included the VAS score and dose of tramadol from the first to the third day after surgery. The secondary outcomes included the inflammatory markers level, total blood loss and complications.

RESULTS

The pain score and inflammation markers level on the first day in the topical TXA group were significantly lower than those in the intravenous TXA group (P < 0.05). The correlation analysis showed that the VAS score on the first day after surgery was positively correlated with the inflammation markers level (P < 0.05). The tramadol dose for topical group was lower than intravenous group on the first and second day after surgery. There were no differences in total blood loss between the two groups (640.60 ± 188.12 ml vs. 634.20 ± 187.85 ml, P = 0.06). There was no difference in the incidence of complications.

CONCLUSION

Topical use of TXA could relieve the local pain symptoms and reduce opioid consumption compared with intravenous use for patients undergoing primary THA by reduce the early postoperative inflammatory response.

TRIAL REGISTRATION

The trial was registered at the China Clinical Trial Registry (ChiCTR2100052396) on 10/24/2021.

Recent advancements in novel formulations of anti-psoriatic agents for effective delivery: clinical importance and patent survey

Objectives An autoimmune-mediated dermatological ailment featuring recurrent episodes is acknowledged as psoriasis. Around the world, 2-3% of people suffer from this autoimmune skin condition. The primary goal of the current review is to analyse and determine the effectiveness of conventional and emerging nano technological strategies to alleviate psoriasis and discuss future perspectives. Evidence acquisition A thorough search of numerous electronic databases, including Science Direct, Scopus, Google Scholar, Clinical Trials, Google Patents, Research Gate, and PubMed, yielded all the data used in this review paper about the management of psoriasis via various anti-psoriatic agent and nanotechnology approaches. Keywords such as topical, liposomes, niosomes, micro needles, clinical trials, patents, pathogenesis, biosimilars, cytokines, and other pertinent words were investigated. Results Nano technological approaches are gaining prominence since they enable targeted delivery, rapid onset of action with limited systemic exposure. Researchers have investigated innovative, alternative therapeutic approaches that are both secure and efficient for treating psoriatic conditions. Further, the potential role of numerous psoriatic conventional therapies has been explored. The patents granted or in process to address psoriasis via topical route have been well explored. Modern nanotechnology has made it possible for pharmaceuticals to be delivered with improved physical, chemical, pharmacokinetic, and pharmacodynamic qualities. Despite extensive research complete cure for psoriasis is hampered. Conclusion Relying on the extensive literature review, it can be inferred that nanoparticles based novel delivery strategies have the possibility of enhancing the pharmacological activity and eliminating or resolving problems associated with this ailment. The different drug delivery systems available for the treatment of psoriasis along with the clinical trials in different stages, patents in process and granted, the commercialized status of therapeutic molecules, and the future of research in this area have been thoroughly reviewed.

Guidelines for the Management of Patients with Alopecia Areata in Korea: Part I Topical and Device-based Treatment

BACKGROUND

Alopecia areata (AA) is a chronic disease with an unpredictable disease course and severe psychological impact.

OBJECTIVE

To provide evidence- and consensus-based insights regarding the treatment of patients with AA in Korea.

METHODS

We searched for relevant studies on the topical and device-based treatment of AA in the literature from inception until May 2021. Evidence-based recommendations were also prepared. The evidence for each statement was graded and classified according to the strength of the recommendations. Hair experts from the Korean Hair Research Society (KHRS) voted on the statements, and an agreement of 75% or greater was considered as consensus.

RESULTS

Currently, there remains a scarcity of topical treatments, which is supported by robust evidence from a number of high-quality randomized controlled trials. Current evidence supports the efficacy of topical corticosteroids, corticosteroid intralesional injection, and contact immunotherapy in AA patients. Topical corticosteroids and contact immunotherapy are recommended for pediatric AA. A consensus was achieved in 6 out of 14 (42.8%), and 1 out of 5 (20.0%) statements pertaining to topical and device-based treatments in AA, respectively. The expert consensus was from a single country, and the study may not cover all the treatments used.

CONCLUSION

The present study provides up-to-date, evidence-based treatment guidelines for AA based on the consensus reached among experts after considering regional healthcare circumstances, adding diversity to the previous guidelines.

Topical Diclofenac-Induced Hepatotoxicity

The hepatotoxic potential of diclofenac, a commonly used non-steroidal anti-inflammatory agent, is well established in literature. However, cases of diclofenac-induced liver disease have occurred almost exclusively with the oral formulation of this medication. We report the case of an elderly man with Paget's disease and osteoarthritis who developed acute hepatotoxicity, as evidenced by laboratory diagnostics, four months after use of topical diclofenac 1% gel. Once diclofenac gel was discontinued, repeat blood work three weeks after discharge demonstrated return of liver function tests to baseline. Given the temporal relationship between the initiation and escalation of topical diclofenac and the changes in liver function tests, the likelihood of diclofenac-induced liver injury was deemed possible using a well-recognized causality assessment tool. Further research on topically administered non-steroidal anti-inflammatory agents is needed to identify monitoring intervals for early detection and avoidance of adverse effects in patients using topical diclofenac.

Topical tranexamic acid reduces postoperative hematomas in reduction mammaplasties

BACKGROUND

Postoperative bleeding requiring reoperation is an untoward event in breast surgery. Topical tranexamic acid (TXA) has been routinely used to reduce the risk of postoperative bleeding in some surgical fields. In breast surgery, it is not routinely used owing to scarce information. We investigated whether the intraoperatively applied topical TXA reduces the incidence of postoperative hematoma in reduction mammaplasty surgeries.

METHODS

This retrospective, single-center cohort study comprises of 415 consecutive patients who underwent reduction mammaplasty between 2019 and 2021. The prophylactic use of topically applied TXA (20 mg/ml) was implemented as a part of the hospital protocol in November 2020. The patients who were rinsed with TXA before the wound closure were compared with those who were not rinsed. The results were analyzed using statistical tests, two-sided Pearson's Chi-Square and Fisher's exact tests.

RESULTS

Topical TXA significantly reduced the number of postoperative hematomas requiring evacuation (p = 0.008). In the non-TXA control group, 12 (5.8%) hematomas were observed out of 208 patients. In the topical TXA group, only one (0.6%) hematoma occurred among the 168 patients. A tendency towards fewer wound infections, seromas, and other minor wound-healing problems can also be seen in the topical TXA group (ns). No adverse events of topical TXA were detected.

CONCLUSIONS

The incidence of postoperative hematomas decreased to a tenth after the introduction of topical TXA in reduction mammaplasty surgeries. This simple procedure may save patients from reoperations owing to bleeding. Randomized controlled trials are warranted.

Topical cannabidiol is well tolerated in individuals with a history of elite physical performance and chronic lower extremity pain

INTRODUCTION

Cannabidiol (CBD) is a potential therapeutic for pain management. Yet, there exists a dearth of studies of its tolerability and efficacy, especially in special populations. Former elite athletes are a special population both susceptible to chronic pain and also highly trained and attuned to assess medication tolerability concerns. The purpose of the present open-label pilot study was to assess the tolerability of CBD in this population.

MATERIALS AND METHODS

Retrospective analysis was conducted in deidentified data from 20 individuals who were all previously professional athletes in US/American football, track and field, or basketball, with careers ranging from 4 to 10 years. Participants received topical CBD (10 mg twice daily by controlled dispenser) for chronic pain resulting from acute lower extremity injuries. Assessments of tolerability and secondary analyses of pain, pain-related disability, and activities of daily living were collected by self-report over the 6-week study period. Data were analyzed by descriptive statistics, pairwise t-test, and linear regression.

RESULTS

Seventy percent of participants completed the study. Of the individuals who completed the study, 50% reported minor adverse effects, none of which required medical attention, and 50% did not report any adverse effects. The mostly commonly reported effects were skin dryness (43% of study completers) and skin rash (21% of study completers), which rapidly resolved. There was a significant improvement in self-reported pain levels (intake mean 3.5 ± 0.29; exit mean 1.7 ± 0.23; P < 0.001) and pain-related disability, including family and home responsibilities, life support activities, occupational activities, recreational activities, self-care, sexual function, and social activities (all P < 0.001).

DISCUSSION

To the best of our knowledge, this is the first study to assess CBD treatment in elite athletes, who are disproportionally susceptible to disabling injuries. Topical administration of CBD was tolerated well by this population and resulted in only minor adverse effects. As elite athletes are trained and attuned to assess their own bodies due to their professional lives, this population is likely to detect tolerability concerns. However, this study was limited to a convenience sample and self-reported data. These pilot findings warrant further study of topical CBD in randomized and controlled studies of elite athletes.

Unconventional and conventional Pickering emulsions: Perspectives and challenges in skin applications

Pickering emulsions are free from molecular and classical surfactants and are stabilized by solid particles, creating long-term stability against emulsion coalescence. Additionally, these emulsions are both environmentally and skin-friendly, creating new and unexplored sensorial perceptions. Although the literature mostly describes conventional emulsions (oil-in-water), there are unconventional emulsions (multiple, oil-in-oil and water-in-water) with excellent prospects and challenges in skin application as oil-free systems, permeation enhancers and topical drug delivery agents, with various possibilities in pharmaceutical and cosmetic products. However, up to now, these conventional and unconventional Pickering emulsions are not yet available as commercial products. This review brings to the discussion some important aspects such as the use of phases, particles, rheological and sensorial perception, as well as current trends in the development of these emulsions.

Exploring potential of diacerin nanogel for topical application in arthritis: Formulation development, QbD based optimization and pre-clinical evaluation

Diacerein (DCN) is a chondroprotective agent which shows inadequate oral bioavailability along with gastrointestinal side effects. This study is intended to develop a topical novel DCN delivery system. DCN nanogel was prepared by emulsion solvent diffusion technique. The formulation was optimized by response surface methodology by taking two independent variables, concentration of carbopol 940 and eudragit RSPO and three dependent variables, particle size, % entrapment efficiency (EE) and % drug release at 24 h. The optimized formulation had adequat% EE, % drug release at 24 h and particle size. The particle size for optimized nanogel was 190.3 nm with % EE of 83.51% whereas % drug release at 24 h was found 90.13%. The optimized DCN nanogel was analyzed by differential scanning calorimetry (DSC), X-ray diffraction (XRD), Fourier-transform infrared spectroscopy (DTIR) and transmission electron microscopy (TEM) studies. The drug release kinetic study has shown that the gel followed Higuchi's model and the diffusion was anomalous in nature. The nanogel was characterized for physical examination, viscosity, homogeneity and stability parameters and the results obtained were found upto the mark. The ex-vivo permeation study data was in correlation with results of in-vitro study. In-vivo anti-arthritic study proved the efficacy of developed formulation for arthritis in Freund's Adjuvant Arthritic model. This research work has proved the significant potential of innovated product for arthritis by topical route, as it overcomes the drawbacks of oral route, highly efficient, sustained and targeted the release of drug without any accumulation and toxicity.

A Systematic Review and Meta-Analysis of the Effects of Topical Tranexamic Acid versus Topical Vasoconstrictors in the Management of Epistaxis

OBJECTIVE

We aimed to evaluate the effectiveness of topical tranexamic acid (TXA) versus topical vasoconstrictors in the management of epistaxis via a systematic review and meta-analysis.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards were followed for the meta-analysis. We systematically searched Embase, Web of Science, Cochrane Library, CNKI, and PubMed for randomized controlled trials (from inception to August 2022; no language restrictions), comparing the effect of topical TXA and topical vasoconstrictors on the treatment of epistaxis. The Q test was used to evaluate heterogeneity, and funnel plots were utilized to identify bias. For the meta-analysis, the fixed-effects model was employed, and the t-test was utilized to determine significance.

RESULTS

Of 1012 identified studies, 5 were found to be eligible for our analysis. In total, 598 patients were included; 297 of them received TXA and 301 received vasoconstrictors. Hemostasis was more likely to be achieved at the first re-assessment in patients treated with TXA. Subgroup analysis indicated patients treated with TXA to have less likelihood of bleeding recurrence, compared to patients treated with vasoconstrictors. The detected time interval of rebleeding was 10 min, between 24h to 72h, and after 7 days, respectively, and the differences were significant between the two groups of patients treated with TXA and vasoconstrictors.

CONCLUSION

Topical TXA was associated with better post-treatment hemorrhagic arrest rates compared to topical vasoconstrictors in the management of epistaxis.

Encapsulation of Ginger Extract in Nanoemulsions: Preparation, Characterization and in vivo Evaluation in Rheumatoid Arthritis

Ginger is an anti-inflammatory and antioxidant natural substance, however, its effectiveness is limited primarily due to insufficient solubility and low oral bioavailability. This study aimed to formulate ginger extract into nanoemulsion (NE) to enhance therapeutic benefits against rheumatoid arthritis (RA). Hence, ginger extract-loaded NEs were prepared by the spontaneous emulsification method. The NE that passed the thermodynamic stability analyses showed no phase changes or appearance of turbidity. They had an average droplet diameter of 76 ± 45 nm with a zeta potential of - 35 ± 12 mV. Besides, the high antioxidant activities (IC50 = 53.89 µg/mL), about ten times increment of the skin permeability, and no sign of skin irritancy were observed from the ginger-loaded NE. The anti-arthritic evaluations of RA-induced rats treated with ginger-loaded NE showed a significant decline in arthritic symptoms and the highest rate of paw edema inhibition (27.7 %). In addition, the level of involved inflammatory cytokines in the serum of rats was significantly reduced (p < 0.05) compared to the negative control, so that histopathological manifestations also approved the reduction of inflammation indications. Thus, the topical delivery of ginger-loaded NE can be an efficient approach for reducing inflammation and inhibit of RA symptoms.

Microneedles as a momentous platform for psoriasis therapy and diagnosis: A state-of-the-art review

Psoriasis is a chronic, autoimmune, and non-communicable skin disease with a worldwide prevalence rate of 2-3%, creating an economic burden on global health. Some significant risk factors associated with psoriasis include genetic predisposition, pathogens, stress, medications, etc. In addition, most patients with psoriasis should also deal with comorbidities such as psoriatic arthritis, inflammatory bowel diseases, cardiovascular diseases, and psychological conditions, including suicidal thoughts. Based on its severity, the treatment approach for psoriasis is categorised into three types, i.e., topical therapy, systemic therapy, and phototherapy. Topical therapy for mild-to-moderate psoriasis faces several issues, such as poor skin permeability, low skin retention of drug formulation, greasy texture of topical vehicle, lack of controlled release, and so on. On the other arrow, systemic therapy via an oral or parenteral route of drug administration involves numerous drawbacks, including first-pass hepatic metabolism, hepatotoxicity, gastrointestinal disturbances, needle pain and phobia, and requirement of healthcare professional to administer the drug. To overcome these limitations, researchers devised a microneedle-based drug delivery system for treating mild-to-moderate and moderate-to-severe psoriasis. A single microneedle system can deliver the anti-psoriatic drugs either locally (topical) or systemically (transdermal) by adjusting the needle height without involving any pain. In this contemplate, the current review provides concise information on the pathophysiology, risk factors, and comorbidities of psoriasis, followed by their current treatment approaches and limitations. Further, it meticulously discusses the potential of microneedles in psoriasis therapy and diagnosis, along with descriptions of their patents and clinical trials.

Laser microporation facilitates topical drug delivery: a comprehensive review about preclinical development and clinical application

INTRODUCTION

Topical drug delivery is highly attractive and yet faces tissue barrier challenges. Different physical and chemical methods have been explored to facilitate topical drug delivery.

AREAS COVERED

Ablative fractional laser (AFL) has been widely explored by the scientific community and dermatologists to facilitate topical drug delivery since its advent less than two decades ago. This review introduces the major efforts in exploration of AFL to facilitate transdermal, transungual, and transocular drug delivery in preclinical and clinical settings.

EXPERT OPINION

Most of the preclinical and clinical studies find AFL to be safe and highly effective to facilitate topical drug delivery with little restriction on physicochemical properties of drugs. Clinical studies support AFL to enhance drug efficacy, shorten treatment time, reduce pain, improve cosmetic outcomes, reduce systemic drug exposure, and improve safety. Considering most of the clinical trials so far involved a small sample size and were in early phase, future trials will benefit from enrolling a large group of patients for thorough evaluation of the safety and efficacy of AFL-assisted topical drug delivery. The manufacturing of small and less costly AFL devices will also facilitate the translation of AFL-assisted topical drug delivery.

Examining the Systemic Bioavailability of Cannabidiol and Tetrahydrocannabinol from a Novel Transdermal Delivery System in Healthy Adults: A Single-Arm, Open-Label, Exploratory Study

INTRODUCTION

Transdermal cannabinoids may provide better safety and bioavailability profiles compared with other routes of administration. This single-arm, open-label study investigated a novel topical transdermal delivery system on the pharmacokinetics of cannabidiol (CBD) and tetrahydrocannabinol (THC).

METHODS

Participants were 39.5 ± 7.37 years old and healthy, based on a review by the Medical Director. Blood was collected pre-dose and 10, 20, 30, and 45 min, and 1, 1.5, 2, 2.5, 3, 4, 5, 6, 8, and 12 h after topical application of 100 mg CBD:100 mg THC. Psychoactive effects were assessed prior to each timepoint. Area-under-the-curve (AUC_0-12 h), maximum concentration (C_max), time to maximum concentration (T_max), area-under-the-curve to infinity (AUC_I), terminal elimination rate constant (λ), terminal half-life (t½), and absorption rate constant (k_a) were measured individually for CBD and THC. Safety was assessed by clinical chemistry, hematology, and adverse events.

RESULTS

AUC_0-12 h for CBD and THC was 3329.8 ± 3252.1 and 2093.4 ± 2090.6 pg/mL/h, with C_max of 576.52 ± 1016.18 and 346.57 ± 776.85 pg/mL, respectively. T_max for CBD and THC was 8 h, ranging from 2.5 h to 12 h and 10 min to 12 h, respectively. AUC_I for CBD and THC was 6609.2 ± 7056.4 and 3721.0 ± 3251.7 pg/mL/h, with t_1/2 of 5.68 ± 1.5 and 5.38 ± 1.25 h, respectively. CBD was absorbed at a faster rate compared with THC (123.36 ± 530.97 versus 71.5 ± 1142.19 h^-1) but with similar λ (0.12 ± 0.029 versus 0.13 ± 0.03 h^-1). No psychoactive effects were reported. Transdermal cannabinoid delivery was safe and well tolerated in the population studied.

CONCLUSION

To our knowledge, this is the first pharmacokinetic study in humans that demonstrated CBD and THC entering systemic circulation via transdermal administration . This study represents an important contribution to understanding the pharmacokinetics of transdermal cannabinoids.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov Identifier-NCT05121506 (November 16, 2021).

Effectiveness of Silver Diamine Fluoride and Sodium Fluoride Varnish in Preventing New Carious Lesion in Preschoolers: A Randomized Clinical Trial

Introduction

Dental caries is a site-specific, multifactorial chronic disease affected globally. The prevalence of dental caries is strongly associated with social and economic disadvantage, and also the susceptibility of children to dental caries. Dental caries prevention can be achieved with topical fluoride agents. Topical fluoride promotes the remineralization of early carious lesions and reduces the demineralization of healthy enamel.

Aim

The aim of this randomized clinical trial was to compare the effectiveness of silver diamine fluoride (SDF) and sodium fluoride varnish (FV) in preventing new carious lesions in preschoolers.

Materials and methods

This randomized clinical trial was conducted on 285 children aged 3-6 years. Children were randomly allocated into three groups namely, group I-deionized distilled water (DIW), group II-sodium FV, and group III-SDF. The biannual application was performed at an interval of 6 months. New carious lesions were recorded using defs and International Caries Detection and Assessment System (ICDAS II) under LED magnifying loupes. Descriptive and inferential statistics were applied and tabulated using Statistical Package for the Social Sciences (SPSS) 23.0 software.

Result

There was a significant difference seen in the mean values of group III (SDF) when compared with group II (FV) and also between group III (SDF) and group I (DIW) when defs index was used. The mean score of ICDAS II after 12 months in group I (DIW) was -1.171, group II (FV) was -0.690, and group III (SDF) was -0.374.

Conclusion

silver diamine fluoride (SDF) was found to be most effective in preventing dental caries and also it appears to be the most cost-saving fluoride therapy.

How to cite this article

Jain A, Deshpande AN, Shah YS, et al. Effectiveness of Silver Diamine Fluoride and Sodium Fluoride Varnish in Preventing New Carious Lesion in Preschoolers: A Randomized Clinical Trial. Int J Clin Pediatr Dent 2023;16(1):1-8.

The Effect of Topical Tranexamic Acid on Intraoperative Blood Loss in Patients Undergoing Posterior Lumbar Laminectomy and Discectomy: A Randomized, Double-Blind, Controlled Trial Study

STUDY DESIGN

Randomized, double-blind, controlled trial study.

PURPOSE

This study aimed to evaluate the safety and efficacy of topical tranexamic acid (TXA) on intraoperative blood loss (IBL) in patients that have degenerative lumbar canal stenosis and undergo posterior lumbar laminectomy and discectomy.

OVERVIEW OF LITERATURE

The volume of IBL is directly proportional to potential surgical complications. Recent reports have shown that the topical use of antifibrinolytic drugs, such as TXA, during surgery might decrease IBL and improve patient outcomes.

METHODS

A total of 104 patients with lumbar canal stenosis were enrolled in this randomized, double blinded clinical trial. Participants were randomized and divided into two groups: TXA (54 cases) and control (50 cases). In the TXA group, a TXA solution was used for washing and soaking, whereas, in the control group, irrigation of wound was with normal saline. IBL, pre- and postoperative coagulative studies, operation time, conventional hemostatic agent usage, systemic complications, and length of hospitalization were consecutively recorded. All participants were followed for an additional two months to gather data on their recovery status and time to return to work (RTW).

RESULTS

At baseline, there was no difference in clinical or lab findings, between the groups. IBL and use of hemostatic agents were significantly decreased in TXA group, as compared to the control group (p=0.001 and p=0.011, respectively). Systemic complications, length of hospitalization, and RTW were not significantly different between groups (p=0.47, p=0.38, and p=0.08, respectively).

CONCLUSIONS

This study showed that topical use of TXA during surgery may decrease IBL and minimize the use of hemostatic materials during posterior midline-approach laminectomy and discectomy, without increasing the potential for complications seen with intravenous TXA usage.

Topical and Oral Oestrogen for Recurrent Urinary Tract Infection-Evidence-based Review of Literature, Treatment Recommendations, and Correlation with the European Association of Urology Guidelines on Urological Infections

CONTEXT

Urinary tract infection (UTI) represents a significant disease for women, with 20-40% suffering from recurrent UTIs (rUTIs) across their lifetime.

OBJECTIVE

This review aims to provide evidence for current European Association of Urology (EAU) guidance that topical, but not oral, oestrogen is a worthwhile preventative therapy for rUTIs in postmenopausal women. We also aim to establish whether a relationship exists between oestrogen dosage and treatment efficacy.

EVIDENCE ACQUISITION

A literature search was performed across databases for this review. All studies that included oral or topical oestrogen in females with urinary tract infections were selected. Studies were inspected to establish treatment and follow-up duration, average weekly oestrogen dosage, efficacy of treatment, and reasons for dropout.

EVIDENCE SYNTHESIS

Clinical resolution and reduction of UTIs were evaluated. Six studies (seven treatment groups) using topical oestrogen as a treatment arm (258 patients total) and four studies using oral oestrogen as the treatment arm were included (1376 patients total). Topical oestrogen was administered as creams, pessaries, or per-vaginal tablets with follow-up spanning 2-12 mo. Of the patients, 51-100% remained UTI free throughout the duration of follow-up with minimal dropouts. Patients enrolled and treated with oral oestrogen were generally given higher weekly doses and had follow-up between 3 mo and 4.1 yr. All included studies agreed that topical oestrogen is an effective prophylaxis for rUTIs in women, with higher efficacy associated with weekly doses of ≥850 µg. Conversely, only one study arrived at the same conclusion for oral oestrogen.

CONCLUSIONS

Our review concurs with current EAU guidance that topical but not oral oestrogen therapy can be a valid treatment for women suffering from rUTIs. Administration weekly topical doses of ≥850 µg is associated with the best outcomes.

PATIENT SUMMARY

In this study, we look at the role of oral and topical oestrogens for the treatment of urinary tract infections and their adherence to European Association of Urology guidelines. We found that administration of weekly topical doses of ≥850 µg is associated with the best outcomes.

Enriched enrollment randomized double-blind placebo-controlled cross-over trial with phenytoin cream in painful chronic idiopathic axonal polyneuropathy (EPHENE): a study protocol

Background

Patients with chronic idiopathic axonal polyneuropathy (CIAP) can have neuropathic pain that significantly impacts quality of life. Oral neuropathic pain medication often has insufficient pain relief and side effects. Topical phenytoin cream could circumvent these limitations.

The primary objectives of this trial are to evaluate (1) efficacy in pain reduction and (2) safety of phenytoin cream in patients with painful CIAP. The main secondary objective is to explore the usefulness of a double-blind placebo-controlled response test (DOBRET) to identify responders to sustained pain relief with phenytoin cream.

Methods

This 6-week, enriched enrollment randomized double-blind, placebo-controlled triple cross-over trial compares phenytoin 20%, 10% and placebo cream in 48 participants with painful CIAP. Enriched enrollment is based on a positive DOBRET in 48 participants who experience within 30 minutes ≥2 points pain reduction on the 11-point numerical rating scale (NRS) in the phenytoin 10% cream applied area and ≥1 point difference in pain reduction on the NRS between phenytoin 10% and placebo cream applied area, in favour of the former. To explore whether DOBRET has predictive value for sustained pain relief, 24 DOBRET-negative participants will be included.

An open-label extension phase is offered with phenytoin 20% cream for up to one year, to study long-term safety.

The main inclusion criteria are a diagnosis of CIAP and symmetrical neuropathic pain with a mean weekly pain score of ≥4 and <10 on the NRS.

The primary outcome is the mean difference between phenytoin 20% versus placebo cream in 7-day average pain intensity, as measured by the NRS, over week 2 in DOBRET positive participants.

Key secondary outcomes include the mean difference in pain intensity between phenytoin 10% and phenytoin 20% cream, and between phenytoin 10% and placebo cream. Furthermore, differences between the 3 interventions will be evaluated on the Neuropathic Pain Symptom Inventory, EuroQol EQ5-5D-5L, and evaluation of adverse events.

Discussion

This study will provide evidence on the efficacy and safety of phenytoin cream in patients with painful CIAP and will give insight into the usefulness of DOBRET as a way of personalized medicine to identify responders to sustained pain relief with phenytoin cream.

Trial registration

ClinicalTrials.gov NCT04647877. Registered on 1 December 2020.

Rheological analysis of a novel phenylboronic acid-closomer gel

This study aims to characterize the rheological behavior of a novel phenylboronic acid (PBA)-based closomer nanoconjugate (Closogel) with potential application in pharmaceutical formulation. PBA was used as a cross-linking agent and model (antiviral) drug. The PBA loaded Closogel chemical structure was analyzed by boron (¹¹B) NMR and Fourier transform infrared (FTIR) spectroscopy. The Closogel and control hydroxyethyl cellulose (HEC) gel were analyzed under oscillatory and continuous shear rheometry followed by mathematical modeling to characterize the gel flow behavior. The chemical analysis confirmed the existence of characteristic borate esters peaks and Boron chemical shifts within Closogel spectra. Due to its more flexible molecular structure, undiluted Closogel exhibited lower, yield stress, viscosity and relaxation time (30 Pa &163 Pa.s & 0.21 s vs 45 Pa &301 Pa.s & 0.39 s for HEC). Both Closogel and HEC gels exhibited a thixotropic behavior. The plastic undiluted and pseudoplastic 2.5 % w/v aqueous Closogels were more viscous than elastic (tan (δ) > 1) in the linear viscoelastic range. The Herschel-Bulkley model showed a significant fitting to all experimental data (R² > 0.95). The 0.25 % w/v aqueous Closogel nearly exhibited a Newtonian behavior with a flow index of 0.93. These data suggest that PBA loaded Closomer-based gels have similar rheological behavior, with lower complex modulus than that of HEC gels, and they can be a promising platform used for delivery of topical antiviral or other bioactive agents.

Adverse-Event Reports in Over-the-Counter Topical Acne Drug Products Containing Benzoyl Peroxide from a Specific Pharmaceutical Company in the USA

Benzoyl peroxide (BPO) has been used extensively in dermatology, often for the treatment of acne vulgaris. In a 20-year period, dermatologists in the United States used over-the-counter BPO more than 13 million times. However, skin irritation and other adverse events (AEs) are associated with the use of BPO. AEs associated with BPO were identified using the Galderma pharmacovigilance system, which collects AE reports from multiple sources. Over approximately 20 years, 558 AE reports were collected from the database, ranging from application site reactions to systemic hypersensitivity reactions, resulting in a reporting rate of under 1%. These data show that the risk of OTC topical acne drug products containing BPO is low.

Pentoxifylline/Valsartan co-delivery in liposomal gel alters the inflammatory HMGB-1/ TLR pathway and promotes faster healing in burn wounds: A promising repurposed approach

Burn wounds are one of the most severe complex forms of trauma. Hence, new treatment strategies that facilitate the healing process; reduce the severity and the healing time is the main concern of the health care systems. In this work, pentoxifylline-valsartan, (PTX- VAL), loaded liposomes integrated into gel were designed for the first time as a novel co-delivery carrier for the treatment of burn wounds. The objective of this work was to investigate the ability of the nano-based liposomal system to co-entrap two repurposed drugs; hydrophilic pentoxifylline and lipophilic valsartan for topical treatment of burn wounds. The impact of increasing the phospholipid amount to enhance the co-entrapment of PTX and VAL was investigated and in-vitro evaluation of the prepared formulations was conducted to choose the optimum composition with the highest entrapment of both drugs adopting a simple, reliable derivative spectrophotometric method. Structure elucidation was also performed using a transmission electron microscope. In addition, A simple selected derivative spectrophotometric method was developed for the assay of PTX-VAL novel combination. The proven selectivity, precision and accuracy assured the reliability of this analytical method. Being economic and fast makes routine application of the developed analytical method is recommended in pharmaceutical industry. The selected liposomal formulation integrated into gel matrix (PTX-VAL-LG) showed; nanometric size, acceptable entrapment efficiency of both PTX and VAL as well as sustained release profiles and thus, enhanced action.

What Do International Guidelines Recommend? A Systematic Review

Background

Choosing adequate topical antimicrobial agents in burn patients still represents a challenge. Therefore, this systematic review was conducted to compile and evaluate current recommendations in international clinical practice guidelines (CPGs) to develop more consistent clinical guidance.

Methods

A systematic search for CPGs was conducted independently by two reviewers using PubMed, EMBASE, Google Scholar, and external citations. The quality of the selected CPGs was evaluated separately using the AGREE II instrument, and intraclass correlation coefficients were calculated. Statistical analysis was performed using R V 1.4.1 statistical software.

Results

Eleven CPGs were included in the study. Most guidelines tend to recommend silver-containing dressings over antiseptics or antibiotics, regardless of the depth of the burn. Silver sulfadiazine is the most recommended topical antimicrobial in low-resource settings. An overall mean appraisal AGREE II score of 68.2% was obtained. The global intraclass correlation coefficient was 0.62 (95% confidence intervals 0.54-0.69), which corresponds to a substantial global concordance between both appraisers.

Conclusions

Great heterogeneity was found between recommendations and CPGs. The three determining factors considered to issue a recommendation were the clinical scenario, burn-wound depth, and burn severity. There is consensus among the guidelines to use topical antimicrobials as a tool to prevent infection, and most of these recommend the use of silver-containing dressings for most scenarios. However, there is currently no ideal topical antimicrobial agent that can be recommended for all clinical scenarios. The development of more consistent recommendations is warranted to standardize clinical practice.

Activation of peripheral TRPM8 mitigates ischemic stroke by topically applied menthol

Background

No reports exist as to neuroprotective effects associated with topical activation of transient receptor potential melastatin 8 (TRPM8), a noted cold receptor. In the present study, we identified whether activating peripheral TRPM8 can be an adjuvant therapy for ischemic stroke.

Methods

Menthol, an agonist of TRPM8, was applied orally or topically to all paws or back of the mouse after middle cerebral artery occlusion (MCAO). We used Trpm8 gene knockout (Trpm8^−/−) mice or TRPM8 antagonist and lidocaine to validate the roles of TRPM8 and peripheral nerve conduction in menthol against ischemic stroke.

Results

Application of menthol 16% to paw derma attenuated infarct volumes and ameliorated sensorimotor deficits in stroke mice induced by MCAO. The benefits of topically applied menthol were associated with reductions in oxidative stress, neuroinflammation and infiltration of monocytes and macrophages in ischemic brains. Antagonizing TRPM8 or Trpm8 knockout dulls the neuroprotective effects of topically application of menthol against MCAO. Immunohistochemistry analyses revealed significantly higher TRPM8 expression in skin tissue samples obtained from the paws compared with skin from the backs, which was reflected by significantly smaller infarct lesion volumes and better sensorimotor function in mice treated with menthol on the paws compared with the back. Blocking conduction of peripheral nerve in the four paws reversed the neuroprotective effects of topical menthol administrated to paws. On the other hand, oral menthol dosing did not assist with recovery from MCAO in our study.

Conclusion

Our results suggested that activation of peripheral TRPM8 expressed in the derma tissue of limbs with sufficient concentration of menthol is beneficial to stroke recovery. Topical application of menthol on hands and feet could be a novel and simple-to-use therapeutic strategy for stroke patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12974-022-02553-4.

Efficacy and tolerability of three topical acne treatments by body mass index: post hoc analysis including overweight and obese patients

BACKGROUND

Acne prevalence may be higher in overweight/obese individuals, potentially due to hormonal, inflammatory, and/or dietary factors. However, the effects of body mass index (BMI) on topical acne treatments are largely unknown.

METHODS

Post hoc analyses of changes in inflammatory/noninflammatory lesions and treatment success were conducted using phase 3 data: clindamycin phosphate/benzoyl peroxide (CP/BPO) 1.2%/3.75% gel (NCT01701024); tretinoin 0.05% lotion (NCT02965456 and NCT02932306; pooled); and tazarotene 0.045% lotion (NCT03168321 and NCT03168334; pooled). Data were analyzed by BMI subgroups: <25kg/m² (underweight-to-normal), 25-<30kg/m² (overweight), and ≥30kg/m² (obese).

RESULTS

Among participants analyzed (CP/BPO = 495; tretinoin = 1,636; tazarotene = 1,612), ∼20-25% were overweight and 15-20% were obese. At week 12, mean percent changes from baseline in inflammatory lesions were: CP/BPO (overweight: -63.2%, obese: -56.0%); tretinoin (-57.6%, -53.1%); tazarotene (-59.9%, -56.8%). Mean changes in noninflammatory lesions were: CP/BPO (-54.2%, -50.8%); tretinoin (-51.6%, -44.9%); tazarotene (-56.7%, -54.6%). Treatment success rates with active treatment ranged from 16.2% to 33.5% across BMI groups.

CONCLUSIONS

CP/BPO 1.2%/3.75% gel, tretinoin 0.05% lotion, and tazarotene 0.045% lotion were all effective in reducing acne lesions by ≥45% in overweight/obese patients with moderate-to-severe acne, comparable to the underweight-to-normal group. Efficacy of these topical acne treatments is not greatly impacted by BMI and may be affected more by the formulation.

Comparative study between topical methotrexate 1% gel and minoxidil 5% gel in the treatment of localized alopecia areata

Alopecia areata (AA) is an autoimmune disease that results in non-scarring hair loss. Topical minoxidil 5% gel and methotrexate 1% gel are important modalities used in the treatment of many dermatological diseases. We aimed to evaluate the efficacy of methotrexate 1% gel versus topical minoxidil 5% gel in the treatment of localised AA both clinically and dermoscopically. Fifty patients were randomly divided into two groups of 25 each; the first was treated with topical minoxidil 5% gel, and the second was with methotrexate 1% gel. Dermoscopic and photographic pictures were used to follow up at baseline, 3, 6, and 12 weeks. By comparing the two therapies, we noticed that minoxidil has a statistically significant higher frequency of broken hair and black dots after 6 weeks than methotrexate. After 12 weeks, dermoscopy revealed that the minoxidil group had a lower frequency of vellus hair than the methotrexate group. Clinically after 6 weeks, minoxidil showed significantly more excellent improvement than methotrexate (16% versus 0%), and after 12 weeks, minoxidil and methotrexate showed excellent improvement (52% and 36%), respectively. There was no significant difference in side effects (erythema and itching) between the methotrexate and minoxidil groups. Both topical methotrexate 1% gel and topical minoxidil 5% gel had high efficacy in treating localised alopecia areata, with no significant differences between them as evaluated by clinical and dermoscopic examination. This article is protected by copyright. All rights reserved.

Cutaneous Pharmacokinetic Approaches to Compare Bioavailability and/or Bioequivalence for Topical Drug Products

The evaluation of bioequivalence (BE) involves comparing the test product to its reference product in a study whose fundamental scientific principles allow inferring of the clinical performance of the products. Several test methods have been discussed and developed to evaluate topical bioavailability (BA) and BE. Pharmacokinetics-based approaches characterize the rate and extent to which an active ingredient becomes available at or near its site of action in the skin. Such methodologies are considered to be among the most accurate, sensitive, and reproducible approaches for determining the BA or BE of a product.