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Trends in Clinical and Experimental Dermatology<br />
Editor: J. Wohlrab<br />
VOLUME 1<br />
<strong>TRENDS</strong> <strong>IN</strong> <strong>DERMATOPHARMACY</strong><br />
- UPDATE 2002 -<br />
Volume Editors<br />
J. Wohlrab<br />
R.R.H. Neubert<br />
W.Ch. Marsch<br />
Shaker Verlag<br />
Aachen
Trends in Clinical and Experimental Dermatology<br />
Editor: J. Wohlrab<br />
Volume 1<br />
_______________________________________________________<br />
<strong>TRENDS</strong> <strong>IN</strong> <strong>DERMATOPHARMACY</strong><br />
- UPDATE 2002 -<br />
Volume Editors:<br />
Johannes Wohlrab<br />
Reinhard R.H. Neubert<br />
Wolfgang Ch. Marsch<br />
Shaker Verlag<br />
Aachen 2002
Dedicated to<br />
Prof.Dr.rer.nat.W.A.Wohlrab<br />
in honor of his 65 th birthday
Contents<br />
Cutaneous NO-Metabolism and its therapeutic Influence................. 1<br />
J.Wohlrab<br />
The value of high-frequency sonography in objectifying drug<br />
effects...................................................................................................... 25<br />
A.Unholzer, H.C.Korting<br />
Bioengineering of the skin: non-invasive methods for the<br />
evaluation of efficacy............................................................................. 32<br />
T.Gambichler, F.G.Bechara. M.Stücker, K.Hoffmann, P.Altmeyer<br />
The Repetitive Washing Test as a Mo<strong>de</strong>l for the Evaluation of<br />
Barrier Creams...................................................................................... 47<br />
W.Gehring<br />
Impact of Topical Skin Care and Maintenance Products on<br />
Stratum corneum Barrier..................................................................... 52<br />
M.Gloor<br />
The Tan<strong>de</strong>m Repeated Irritation Test (TRIT) – A New Method for<br />
the Evaluation of Barrier Creams........................................................ 58<br />
J.Spoo, W.Wigger-Alberti, S.Schliemann-Willers, A.Klotz, P.Elsner<br />
Atomic absorption spectrometry for the <strong>de</strong>termination of physical<br />
sunscreen filters..................................................................................... 70<br />
G.Gottbrath, J.Grünefeld, C.C.Müller-Goymann<br />
Determination of Clobetasol Propionate in Extracts by Means of<br />
HPLC and LC-MS................................................................................. 80<br />
T.Hagemeister, M.Lienscheid, H.-J.Weigmann, J.La<strong>de</strong>mann, R.v.Pelchrzim,<br />
W.Sterry<br />
Analytical methods fort he <strong>de</strong>termination of <strong>de</strong>rmatopharmacoki<strong>net</strong>ics...................................................................................<br />
90<br />
J.La<strong>de</strong>mann<br />
HPTLC and LC/MS in cerami<strong>de</strong> analysis........................................... 106<br />
K.Raith, H.Farwanah, R.Neubert<br />
HPLC-analysis for permeation studies of 5-aminolevulinic acid<br />
and its <strong>de</strong>rivatives.................................................................................. 118<br />
A.Winkler, C.C.Müller-Goymann
Photoinduced Lesions in DNA – Detection using Micro-HPLC and<br />
Ion Trap MS........................................................................................... 129<br />
G.Zhang, M.Linscheid<br />
The Topical Application of Vitamin D3-Analogues in Psoriasis<br />
vulgaris................................................................................................... 137<br />
M.Fischer<br />
Trends of topical immunmodulatory Therapy................................... 145<br />
K.Jahn, R.H.H.Neubert, J.Wohlrab<br />
Trends of Treatment with Topical Glucocorticoids........................... 153<br />
R.Niedner<br />
The Topical Treatment of Atopic Dermatitis and Psoriasis with<br />
Vitamin B12........................................................................................... 158<br />
C.Stoerb, P.Altmeyer, R.Niedner, J.Hartung, M.Stücker<br />
Mo<strong>de</strong>rn Vehicle Systems....................................................................... 167<br />
C.Huschka, J.Wohlrab<br />
Microemulsions as drug vehicles for <strong>de</strong>rmal application.................. 181<br />
K.Jahn, R.H.H.Neubert, J.Wohlrab<br />
Transfersomes ® and their Application in Dermatopharmacy........... 186<br />
J.Lehmann, M.Rother<br />
Trends in the systemic antibiotic therapy of <strong>de</strong>rmatological<br />
infectious diseases.................................................................................. 195<br />
N.H.Brockmeyer, A.Kreuter<br />
Systemic therapy with immunomodulatory drugs in <strong>de</strong>rmatology.. 198<br />
M.Sticherling<br />
Systemic Therapy with Recombinant Antibodies in Dermatology... 209<br />
M.Lüftl<br />
Current state and perspectives of immunomodulation of the<br />
allergic contact <strong>de</strong>rmatitis..................................................................... 220<br />
H.-D. Göring<br />
Therapy of Immediate Type Reactions................................................ 228<br />
W.Ch.Marsch<br />
In vitro Mo<strong>de</strong>ls for the <strong>de</strong>tection of immunomodulating properties<br />
of pharmaceuticals................................................................................. 236<br />
G.Wichmann, I.Lehmann
Editors Preface<br />
Dermatopharmacy and –pharmacology have <strong>de</strong>veloped enormously over<br />
the past years, especially thanks to the rapid technical <strong>de</strong>velopment of<br />
analytical, synthesis and diagnostic procedures. In addition, ge<strong>net</strong>echnical<br />
and molecular-biological methods have brought innovation not<br />
only in systemic, but especially also in topical applications of medicinal<br />
and active substances. Mo<strong>de</strong>rn vehicle systems have initiated a new age<br />
in galenics and make it possible to apply even high-molecular or hard-todissolve<br />
substances in therapeutic doses.<br />
With <strong>de</strong>tailed knowledge of the structure and function of the skin, as<br />
well as the regulation of metabolic processes, there is an increasing<br />
merging of biological processes with pharmacological-therapeutic<br />
manipulations.<br />
Despite these positive <strong>de</strong>velopments, <strong>de</strong>rmatopharmacy needs<br />
enthusiastic, engaged persons with a broad range of i<strong>de</strong>as, who will work<br />
out the basic scientific foundation, <strong>de</strong>sign the practical relationships and<br />
lead in the conception of an effective, marketable product.<br />
In this sense, I wish to thank all the authors of this book for their<br />
collaboration and innovative contributions.<br />
Johannes Wohlrab, MD<br />
Editor
Address of Volume Editors:<br />
Johannes Wohlrab, MD<br />
Department of Dermatology<br />
Martin-Luther-University Halle-Wittenberg<br />
Ernst-Kromayer-Str. 5-6<br />
D-06097 Halle (Saale)<br />
Germany<br />
Reinhardt Neubert, PhD<br />
Institut of Pharmaceutic Technology and Biopharmacy<br />
Martin-Luther-University Halle-Wittenberg<br />
Wolfgang-Langenbeck-Str. 4<br />
D-06120 Halle (Saale)<br />
Germany<br />
Wolfgang Ch. Marsch, MD<br />
Department of Dermatology<br />
Martin-Luther-University Halle-Wittenberg<br />
Ernst-Kromayer-Str. 5-6<br />
D-06097 Halle (Saale)<br />
Germany
Volume Editors Preface<br />
In March 2002, in honor of the 65 th birthday of our esteemed teacher,<br />
colleague and friend, Professor Wolfgang A. Wohlrab, we held the<br />
Congress “Trends in Dermatopharmacy” in Halle an <strong>de</strong>r Saale<br />
(Germany). It was our particular intention to honor his many-si<strong>de</strong>d<br />
aca<strong>de</strong>mic life’s work. In nearly 3 <strong>de</strong>ca<strong>de</strong>s of <strong>de</strong>dicated and responsible<br />
work in the areas of experimental <strong>de</strong>rmatology and <strong>de</strong>rmatopharmacy,<br />
Prof. Wohlrab has created an exceptional life’s work and stood firm<br />
against the sharp headwinds of social-political circumstances. The<br />
numerous publications and patents, the hor<strong>de</strong>s of his stu<strong>de</strong>nts and an<br />
outstanding institution document both his performance and the quality of<br />
his work.<br />
We thank Wolfgang Wohlrab for his engagement, his friendship and his<br />
loyalty, which is characterized by profound aca<strong>de</strong>mic and Christian<br />
principles. We wish him health and continued vitality for the coming<br />
years, without the pressures of daily, always enthusiastically-performed<br />
duties.<br />
We hope that this book will contribute with its number of excellent<br />
articles to the mo<strong>de</strong>rn un<strong>de</strong>rstanding of <strong>de</strong>rmatopharmacy, as the<br />
Honoree would wish!<br />
J. Wohlrab, MD R.R.H. Neubert, PhD W.Ch. Marsch, MD
Cutaneous NO-Metabolism and its therapeutic Influence 1<br />
Cutaneous NO-Metabolism and its therapeutic<br />
Influence<br />
J. Wohlrab<br />
Universitätsklinik und Poliklinik für Dermatologie und Venerologie<br />
Martin-Luther-Universität Halle-Wittenberg<br />
Ernst-Kromayer-Str. 5-6<br />
D-06097 Halle (Saale)<br />
Germany<br />
Arginine .......................................................................... 5<br />
• Chemistry of Arginine....................................................5<br />
• Arginine and its biochemical-metabolic importance......5<br />
• Place of Arginine in NO-metabolism............................7<br />
Transmembranous Transport of L-Arginine................. 14<br />
Therapeutic Influence of L-Arginine Metabolism ....... 15<br />
References..................................................................... 18<br />
In 1980, Robert Furchgott discovered rather by acci<strong>de</strong>nt the<br />
endothelium-<strong>de</strong>rived relaxing factor (EDRF) which has been<br />
recognized as a central messenger substance in the regulation of<br />
hemovascular perfusion. Furchgott was able to show that EDRF is<br />
produced by endothelial cells, has a potent vasodilatative effect and<br />
a very short half-life. Despite intensive efforts to chemically<br />
i<strong>de</strong>ntify EDRF, it was not until 1986 that Salvador Moncada and<br />
Louis Ignarro in<strong>de</strong>pen<strong>de</strong>ntly i<strong>de</strong>ntified EDRF as the gas nitric<br />
oxi<strong>de</strong>. (NO). At least since the Nobel Prize for Physiology and<br />
Medicine was awar<strong>de</strong>d to the American scientists Robert Furchgott<br />
(State University of New York), Louis Ignarro (University of<br />
California, Los Angeles) and Ferid Murad (University of Texas<br />
Medical School, Houston) in 1998, the biochemical importance of<br />
nitric oxi<strong>de</strong>. (NO) in the regulation of hemo- and lymphovascular<br />
perfusion and in the initiation and maintenance of immunoprocesses<br />
has become wi<strong>de</strong>ly known and the subject of intensive basic<br />
scientific research. The central position of NO in the pathogenesis<br />
of various <strong>de</strong>rmatoses has been increasingly examined only in<br />
recent years. Knowledge of the pathoge<strong>net</strong>ic relationships,<br />
especially in inflammatory skin conditions, has revealed new<br />
------------------------------------------------------------------------------------<br />
Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
2 Cutaneous NO-Metabolism and its therapeutic Influence<br />
aspects and also opened new therapeutic options in the treatment of<br />
these and other diseases.<br />
The amino acid arginine is a very promising active substance with<br />
respect to topical and possibly also systemic application thanks to<br />
its central metabolic involvement in cell metabolism. Arginine is<br />
the substrate for enzymatic synthesis of NO. Moreover, arginine has<br />
other important functions as a regulating starting material in the<br />
urea cycle, protein biosynthesis and creatin metabolism.<br />
Little information is available at present about the<br />
<strong>de</strong>rmatopharmaceutical use of arginin. The activity of arginase,<br />
which is expressed especially strongly in the basal epi<strong>de</strong>rmal layers,<br />
is increased by L-arginin substitution and manganese ions acting as<br />
a cofactor. The result of this influence is increased urea synthesis in<br />
the keratinocytes. In healthy subjects, there is a reduction in<br />
transepi<strong>de</strong>rmal water loss and an increased in hydratation of the<br />
horny layer following topical application of preparations containing<br />
L-arginin. Application of an amphiphilic standard vehicle system<br />
containing L-arginin to patients with atopic <strong>de</strong>rmatitis showed<br />
clinical effects comparable to equivalent systems containing urea,<br />
but without the irritative effect. The therapeutic efficacy of Larginin<br />
in subepi<strong>de</strong>rmal skin layers has not yet been examined. For<br />
this reason, clarification of interactions with relevant cutaneous cell<br />
systems (such as cutaneous microvascular endothelial cells),<br />
objectification of the pe<strong>net</strong>ration dynamics and ki<strong>net</strong>ics from<br />
various vehicle systems, examination of the influence on vital<br />
perfusion mo<strong>de</strong>ls and examination of the effects in healthy subjects<br />
are prerequisite to therapeutic application to patients.<br />
The fundament of regulation of the cutaneous microcirculation is<br />
the basic tone of the small arteries, arterioles and venoles. This is<br />
mediated essentially by a basic innervation, realized by the<br />
vegetative nervous system. There is no direct nervous innervation in<br />
the capillary end pathways. No<strong>net</strong>heless an adrenergic effect due to<br />
diffusion of neurotransmitters or intercellular signal transduction in<br />
the sense of a stimulation system must be assumed. Moreover,<br />
numerous vasoconstricting transmitter substances are known. Un<strong>de</strong>r<br />
physiological conditions Endothelin-I is very important. NO acts as<br />
a vasodilatative competitor. The basic production of NO is probably<br />
realized by iNOS, that is by the inducible NOS-isoform. The<br />
purpose of these antagonistically-directed systems is to make<br />
------------------------------------------------------------------------------------<br />
Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
Cutaneous NO-Metabolism and its therapeutic Influence 3<br />
possible the need-oriented distribution of blood for nutrition of the<br />
tissues and for thermoregulation, to maintain a laminar blood flow<br />
and prevent sludge phenomena of erythrocytes and thrombocytes.<br />
Moreover, NO binds very rapidly to iron-containing hemoglobin in<br />
the cutaneous microcirculation because of the narrow spatial<br />
relationship between the endothelial cells (vascular wall) and<br />
erythrocytes (flow medium) compared to the macrocirculation, and<br />
is almost completely inactivated to nitrates. Nitrite and Snitrosothiol,<br />
which are formed in plasma, are largely absent here.<br />
However, pe<strong>net</strong>ration of NO into the cell <strong>de</strong>pends on the diffusion<br />
rate with respect to NO/NO 2- , the oxidative saturation of Hb and on<br />
the redox potential.<br />
The process of inactivation of NO is specific to the endothelial cells<br />
and proportional to the expressed NO-concentration. It can thus be<br />
used as a comparison measure for NO-production. In human blood<br />
plasma in equilibrium there are about 3nM NO. With respect to the<br />
temporal dimension of synthesis, NO-production is estimated at<br />
about 4 pmol/min per mg protein or 0.8 pmol/min pro mg<br />
endothelial cells. Given a total weight of endothelial cells of 1.5 kg<br />
per person, about 1728 µmol NO/day, are produced by eNOS.<br />
In addition to the basic production of NO by iNOS, a rapid reaction<br />
capacity is important in or<strong>de</strong>r to adapt to the rapidly changing<br />
functional states. This is realized via the non-inducible, though<br />
activatable NOS forms (eNOS, nNOS). A mid-term or even longer<br />
period of elevated NO requirement can only be increased to adjust<br />
the basic equilibrium by synthesis of the protein. In addition to<br />
eNOS there is also an iNOS in microvascular endothelial cells,<br />
which causes increase in NO-concentration in mid- or long-term<br />
in<strong>de</strong>pen<strong>de</strong>nt of the intracellular calcium content.<br />
Interesting in this connection is also the NO-production by<br />
granulocytes in the flowing medium blood and tissue-immigrating<br />
populations. It is known that NO also increases the expression of<br />
adhesion molecules (e.g. VCAM-1). This prepares a recruiting of<br />
blood cells, which is centrally important, especially in inflammation<br />
processes. The initial phase of this recruiting process is<br />
characterized by the rolling phenomon, in which the flow velocity<br />
of mononuclear cells slows until they adherent on the vascular wall.<br />
The NO-production of such activated granulocytes may also be<br />
------------------------------------------------------------------------------------<br />
Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
4 Cutaneous NO-Metabolism and its therapeutic Influence<br />
important for the regulation of the contraction state of regional<br />
vascular segments, un<strong>de</strong>r physiological conditions as well.<br />
The quantity consumed by guanylate-cyclase and thus for cGMPproduction<br />
represents only a small portion of the expressed NO. Of<br />
interest are especially the peroxynitrites, which form during<br />
reaction with superoxi<strong>de</strong>s. These enter directly and indirectly via<br />
NO2, NO2+, �OH in interaction with the tissue (tissue damage) and<br />
lead to endoluminal platelet adhesion and to increased vascular<br />
permeability. After induction of iNOS, high NO concentrations<br />
result. NO interacts thereby with thiol groups or so-called<br />
transition-metal-containing protein (TMCP). This interaction leads<br />
to functional influence of certain regulatory proteins or to induction<br />
of gene expression of cell-protective or apoptosis-inducing<br />
substances. The reaction patterns of various types of cell differ very<br />
markedly. In mesenchymal cells, apoptosis is elicited. In<br />
macrophages or endothelial cells, as well as lymphocytes,<br />
eosinophilic granulocytes or hepatocytes, antiapoptotic processes<br />
are observed. The knowledge that there is no uniform function<br />
pattern of NO-induced regulation processes, which <strong>de</strong>pend<br />
<strong>de</strong>cisively on the pathoge<strong>net</strong>ic influence factors of a pathological<br />
functional state, is of great importance for the conception of<br />
therapeutic strategies.<br />
The NO-mediated effects on human skin are particularly<br />
proinflammatory and cytotoxic in nature. Ormerod et al.<br />
<strong>de</strong>monstrated that NO leads to increased expression of CD3, CD4,<br />
CD8, CD68, neutrophile elastase, ICAM-1, VCAM-1,<br />
nitrosotyrosin and p53 on relevant cells. Moreover, there is<br />
increased induction of apoptosis and reduction in the proportion of<br />
CD1a-positive Langerhans cells in the epi<strong>de</strong>rmis. The <strong>de</strong>scribed<br />
effects <strong>de</strong>pend on the NO-concentration and the application time.<br />
Thus, the cytotoxic effect is caused essentially by accumulation of<br />
p53 and subsequent apoptosis. High doses of NO lead paradoxically<br />
to a smaller increase in the number of macrophages and T-cells and<br />
give rise to the assumption of an immunosuppressive effect of<br />
higher NO-concentrations.<br />
------------------------------------------------------------------------------------<br />
Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
Arginine<br />
• Chemistry of Arginine<br />
Cutaneous NO-Metabolism and its therapeutic Influence 5<br />
The basic structure of arginine (2-Amino-5-guanidovalerianic acid)<br />
consists, like that of all amino acids, of an amino group (NH2), a<br />
carboxyl group (COOH) and a hydrogen atom bound to the 2 nd<br />
carbon atom. Arginine is a diaminomonocarbonic acid and, like<br />
lysine and histidine, carries an additional basic group in the si<strong>de</strong><br />
chain. It is easily soluble in water and a white crystalline pow<strong>de</strong>r at<br />
room temperature. The melting point is 238°C and the specific<br />
rotation at 20°C in sodium light is 27.4°. Of the more than 300<br />
known amino acids, 20 have been i<strong>de</strong>ntified in animal proteins. All<br />
of them, except glycine, are found in the optical L-configuration.<br />
Arginine is a glucoplastic, non-essential amino acid and can be<br />
synthesized by human cells.<br />
H2N<br />
NH<br />
NH<br />
NH 2<br />
Fig. 1: Arginine (C6H15N4O2; Molweight 174.20 g/mol)<br />
However, functional conditions are known (e.g. shock, sepsis,<br />
growth), in which there may be a <strong>de</strong>ficiency in endogenous<br />
synthesis or impaired distribution. For this reason, arginine is also<br />
referred to as a “conditionally essential” amino acid.<br />
• Arginine and its biochemical-metabolic importance<br />
In 1866, Schulze and Steiger first isolated arginine in crystalline<br />
form. 10 years later, its presence in animal tissues was proven for<br />
the first time. It was recognized that arginine has essential<br />
importance in connection with growth processes and in the<br />
regulation of nitrogen balance.<br />
O<br />
OH<br />
------------------------------------------------------------------------------------<br />
Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
6 Cutaneous NO-Metabolism and its therapeutic Influence<br />
L-arginine is synthesized intracellular by proteolyse and in the urea<br />
cycle from arginine succinate in the arginine succinase-reaction, or<br />
it is transported from extracellular to intracellular by a specific<br />
transport system. In addition to protein synthesis in human <strong>de</strong>rmal<br />
microvascular endothelial cells (HDMEC) L-arginine is available as<br />
a substrate for two very important enzymatic reactions.<br />
A Nitric oxi<strong>de</strong> (NO)-Synthase-Reaction<br />
In this reaction, NO and L-citrullin are formed from Larginine,<br />
catalytically controlled by NO-synthase. L-citrullin<br />
functions as a substrate for the citrate and urea cycle.<br />
B Arginase-Reaction<br />
The enzyme arginase converts L-arginine to urea and Lornithin.<br />
L-ornithin, in turn, may also be metabolized by<br />
ornithintranscarbomylase in the urea cycle to L-citrullin, or is<br />
available for polyamine synthesis.<br />
L-arginine is thus very important in the biochemistry of the organ<br />
skin. In forming NO, it contributes essentially to the regulation of<br />
hemo- and lymphovascular perfusion and thus makes a needappropriate<br />
distribution and recycling of nutrients and fluids<br />
possible. Moreover, it indirectly regulates the temperature balance.<br />
For the epi<strong>de</strong>rmis, L-arginine serves as a source of urea and thus<br />
largely <strong>de</strong>termines the water-binding capacity of the Stratum<br />
corneum. The intracellular urea synthesized by arginase thus is of<br />
essential importance in the formation and maintenance of the<br />
epi<strong>de</strong>rmal barrier function.<br />
------------------------------------------------------------------------------------<br />
Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
UREA<br />
+ ORNITH<strong>IN</strong>E<br />
Arginase<br />
NO-<br />
Synthase<br />
Cutaneous NO-Metabolism and its therapeutic Influence 7<br />
PROTE<strong>IN</strong><br />
METABOLISM<br />
ARG<strong>IN</strong><strong>IN</strong>E<br />
CITRULL<strong>IN</strong>E<br />
+<br />
NITRIC OXIDE<br />
Fig. 2: Schema of Arginine Metabolism in the Skin<br />
• Place of Arginine in NO-metabolism<br />
CREAT<strong>IN</strong><br />
METABOLISM<br />
Fumarat Malat<br />
ARG<strong>IN</strong><strong>IN</strong> -<br />
SUCC<strong>IN</strong>AT<br />
Aspartat<br />
Oxal<br />
- azetat<br />
One of the most important regulation factors in the cardiovascular<br />
system is the gas nitric oxi<strong>de</strong>. NO is formed along with L-citrullin<br />
by the enzyme NO-synthase (NOS) from L-arginine and rapidly<br />
metabolized after oxygenation to nitrates and nitrites and thus<br />
inactivated. There are three known isoforms of NOS. In addition to<br />
two membrane-bound, calcium and calmodulin-<strong>de</strong>pen<strong>de</strong>nt forms<br />
(cNOS or niNOS), there is a cytosolic, calcium-in<strong>de</strong>pen<strong>de</strong>nt form<br />
induced by endotoxins or inflammatory cytokines such as IL-1β or<br />
TNF-α (iNOS). The non-inducible isoforms can be found in<br />
neuronal (nNOS – in the brain also bNOS) and endothelial cells<br />
(eNOS) and the inducible form (iNOS) e.g. in macrophages. The<br />
intracellular calcium content is <strong>de</strong>cisive for the regulation of the<br />
enzyme activity of cNOS. The iNOS, by contrast, contain the<br />
------------------------------------------------------------------------------------<br />
Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
8 Cutaneous NO-Metabolism and its therapeutic Influence<br />
calcium-binding protein calmodulin, but their control is not<br />
calcium-<strong>de</strong>pen<strong>de</strong>nt. Increased activity is only possible by means of<br />
protein synthesis. All NOS-isoforms are specific for the L-isomer of<br />
arginine. They all occur in particulate (membrane-bound) and<br />
soluble (cytosolic) form.<br />
Fig. 3: Schema of Arginase Molecule<br />
By contrast, little is known about the regulation of the gene<br />
expression of NOS. A key function is ascribed to NO itself. It is<br />
assumed that NO contributes to the expression of redox-controlled<br />
transcription factors by changing the intracellular oxidationreduction<br />
(Redox) balance. To date, this regulation route could be<br />
<strong>de</strong>monstrated for the transcription factors NF-κB and activator<br />
protein 1 (AP-1). The potential of NO to <strong>de</strong>velop both anti- and<br />
pro-oxidative effects explains the different reaction patterns in<br />
different cell types.<br />
The catalysed reaction by NOS of L-arginine to L-citrullin and NO<br />
proceeds in two steps. Both partial reactions are NADPH-, calcium-<br />
or. calmodulin- (except iNOS) and tetrahydrobiopterin (BH4)<strong>de</strong>pen<strong>de</strong>nt.<br />
In an intermediate step, N-hydroxy-L-arginine is formed<br />
from L-arginine with formation of water and NADP+ (Fig. 4). The<br />
product stochiometry of L-citrullin and NO is 1:1.<br />
NADPH, O2, Tetrahydrobiopterin (BH4) and frequently also<br />
flavina<strong>de</strong>nosindinukleotid (FAD) and flavinmononukleotid (FMN)<br />
act as cofactors for all isoforms. The NADPH- and flavin-binding<br />
domain of cNOS is i<strong>de</strong>ntical with the cytochrome P450-reductase.<br />
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Cutaneous NO-Metabolism and its therapeutic Influence 9<br />
The molecular weight of the monomers of the isoforms differs and<br />
is cited for iNOS at ca. 130kDa and for cNOS at 155kDa.<br />
Moreover, differences can be <strong>de</strong>monstrated between the soluble and<br />
particulate type. All NOS-isoforms have a binding site for Larginine,<br />
Hem, FAD, FMN, NADPH and calmodulin. The bNOS<br />
also has a PDZ binding domain and the eNOS a myristoylation<br />
(M)- and a caveolin (C)-binding domain. By comparison, a<br />
transmembranous binding site TMD) could be <strong>de</strong>monstrated for<br />
cytochrome P 450 reductase.<br />
L-arginine<br />
Ca 2 + / C a M / B H 4<br />
O 2<br />
H 2 O<br />
N AD P H N A DP +<br />
N-hydroxy-L-arginine<br />
F A D - F MN o x . F A D -FMN r e d .<br />
F e - H e m r e d . F e - Hem ox.<br />
Ca 2 + /CaM/BH4<br />
O2<br />
H2 O<br />
NADPH NADP +<br />
L-citrulline + NO<br />
Fig. 4: Metabolic steps of NO-Reaction<br />
The molecular-biological characterization of NOS shows largely<br />
homology between individual species with respect to the amino<br />
acid sequence (human eNOS and bovine eNOS; homology = 94%).<br />
In 1991, Bredt et al. cloned NOS for the first time. By means of<br />
gene mapping, the sequence was localized on the human<br />
chromosome 12q12-q24 and gene 12q24.3 i<strong>de</strong>ntified by<br />
fluorescence-in-situ-hybridization (FISH). Later the eNOSsequence<br />
on 7q35-q36 and the iNOS-sequence on 17q11.2 were<br />
found. Moncada et al. found multiple copies of the gene-specific<br />
sequences in human genomes for iNOS, unlike bNOS and eNOS,<br />
which show monochromosomal localization. For this reason, 3<br />
subtypes (A-C) of iNOS are differentiated, of which the biological<br />
function is not yet completely un<strong>de</strong>rstood.<br />
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In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
10 Cutaneous NO-Metabolism and its therapeutic Influence<br />
bNOS<br />
eNOS<br />
iNOS (murin)<br />
iNOS (human)<br />
Cytochrome P450<br />
reductase<br />
PDZ Arg Hem CAL FAM FAD NADPH<br />
M C 500 1000<br />
TMD<br />
Fig. 5: Sequence homologies of the molecular isoforms of NOS<br />
compared to Cytochrome P450 Reductase.<br />
The varying physiological importance of NOS-isoforms was tested<br />
in knock-out mice. eNOS knock-out mice <strong>de</strong>veloped arterial<br />
hypertension due to elevation of peripheral resistance. iNOS-Gene<br />
knock-out mice, by contrast, showed an elevated susceptibility to<br />
viral, bacterial and parasitic infections and <strong>de</strong>veloped a higher<br />
number of malignant tumors. Moreover, a high-polymorph<br />
microsatellite marker has been i<strong>de</strong>ntified in the human iNOSpromotor<br />
region, for which a strong positive allele association to<br />
the fetal form of cerebral malaria has been found. This observation<br />
un<strong>de</strong>rlines the assumption that the iNOS have an essential function<br />
in signal transduction within immunological regulatory processes.<br />
The distribution of the NOS-isoforms in human microvascular<br />
endothelial cells (HDMEC) is of <strong>de</strong>cisive importance for the<br />
regulation of perfusion in the end-flow pathways. Especially with<br />
respect to complex biological functional processes, in which a<br />
different reactions of the macro- and microvascular system or<br />
individual function areas of the macro- and/or microvascularization<br />
appear meaningful or necessary (such as thermoregulation, shock,<br />
etc), different regulation mechanisms must be assumed.<br />
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In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
Name Isotype Regulation<br />
bNOS Constitutive<br />
eNOS Constitutive<br />
iNOS-A Inducible<br />
Cutaneous NO-Metabolism and its therapeutic Influence 11<br />
Ca 2+ /Calmodulin,<br />
Stress<br />
Ca 2+ /Calmodulin,<br />
Stress, UV,<br />
HSP90<br />
Endotoxins,<br />
cytokines<br />
neuropepti<strong>de</strong>s<br />
Predominant<br />
occurrence<br />
Brain, neuronal<br />
structures<br />
chromosomal<br />
ascription<br />
12q24.1–<br />
12q24.31<br />
Endothelial cells 7q35-7q36<br />
Macrophages<br />
neutrophils<br />
mesenchymal<br />
cells<br />
iNOS-B Unknown unknown<br />
iNOS-C Unknown unknown<br />
17q11.2<br />
17p11.2-<br />
17q11.2<br />
17p11.2-<br />
17q11.2<br />
Tab. 1: Chromosomal localization of gene sequences of the NOSisotypes<br />
in different regions of human chromosomes<br />
The question thus arises, whether this is primarily a calcium<strong>de</strong>pen<strong>de</strong>nt<br />
process (eNOS), as in the case of macrohemovascular<br />
endothelial cells (e.g. HUVEC) or a calcium-in<strong>de</strong>pen<strong>de</strong>nt process<br />
via increased concentrations of enzyme inductors (e.g. L-arginine),<br />
which causes an increase in the NOS activity via gene activation<br />
and increased expression of the protein (iNOS). Pathoge<strong>net</strong>ic<br />
involvement of such regulation patterns must be discussed<br />
especially in chronic-inflammatory skin diseases. Moreover, it is<br />
known that about a 1000x higher (in the nmol/L range) NO<br />
expression prolonged up to several days compared to the output of<br />
constitutive NOS-isotypes (in the pmol/L range) can be expected<br />
due to induction of iNOS (for example by TNF-α, IFN-γ, IL-8, IL-<br />
1β) with a latency time of 6-8 hours. Our team examined the gene<br />
expression of eNOC and iNOS on HDMEC un<strong>de</strong>r the influence of<br />
L-arginine and the cofactors calcium and tetrahydrobiopterin. We<br />
could <strong>de</strong>monstrate a concentration-<strong>de</strong>pen<strong>de</strong>nt increase in iNOSmRNA<br />
expression by L-arginine. The eNOS-mRNA expression<br />
was not influenced by L-arginine.<br />
Weitzberg et al. discovered a non-enzymatic synthesis route of NO<br />
in 1998. In this, NO is formed un<strong>de</strong>r particular conditions via<br />
reduction of anorganic nitrites. This non-enzymatic generation of<br />
NO occurs on the skin surface and is thought to be important for<br />
primitive biological processes, such as <strong>de</strong>fence against bacteria and<br />
viruses.<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
12 Cutaneous NO-Metabolism and its therapeutic Influence<br />
Chemically, nitric oxi<strong>de</strong> is a very simple molecule. It consists of a<br />
simple oxygen atom bound to a nitrogen atom. This trivial structure<br />
has ma<strong>de</strong> very extensive and <strong>de</strong>tailed chemical characterization<br />
possible in the past few years. Three biochemical reactions of<br />
dissolved NO have been found to be basic to physiological<br />
regulatory processes. The first and probably most important<br />
reaction for in-vivo NO consumption is the irreversible and rapid<br />
formation of nitrate by binding to oxyhemoglobin (Hb) or<br />
oxymyoglobin.<br />
Hb-Fe 2+ -O2 + �NO → Hb-Fe 2+ OONO → Hb-Fe 2+ -<br />
+ NO3<br />
(Reaction 1)<br />
The second reaction is the binding of NO to iron-containing Hem of<br />
guanylate-cyclase or other proteins This is important for the<br />
activation of signal transduction pathways.<br />
Hem - Fe 2+ + �NO → Häm-Fe 2+ - NO (Reaction 2)<br />
The third reaction is the formation of peroxynitrite anions<br />
(ONOO - ). In this, superoxi<strong>de</strong>s (O2� - ) react irreversibly with NO.<br />
�NO + �O-O: - → ONOO - (Reaction 3)<br />
All of the reactions cited contribute together to the short half-life of<br />
NO in the hemovascular system. This remarkable variety of<br />
reactions is based on an unpaired electron in the so-called “highest<br />
occupied molecular orbital (HOMO)“, that is, on the outermost<br />
electron shell.<br />
.. ..<br />
.<br />
:O=N-N=O: 2 :N O: :N O:<br />
Dinitrogendioxi<strong>de</strong> Nitric oxi<strong>de</strong> Nitrosonium ion<br />
+<br />
-1 e- Fig. 6: Chemical Reactivity of NO<br />
Nitric oxi<strong>de</strong> is known as a toxic gas. It thus appears very surprising<br />
that NO controls important cellular processes. But the same<br />
chemical properties which are responsible for the toxicity of NO are<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
Cutaneous NO-Metabolism and its therapeutic Influence 13<br />
also responsible for the rapid and locally-limited effect of NO as a<br />
messenger substance. As a small-molecular hydrophobic gas, NO<br />
pe<strong>net</strong>rates cell membranes more easily than molecular oxygen or<br />
carbon dioxi<strong>de</strong>, and needs no receptor or transmembranous<br />
transport mechanism. NO distributes isotropically in the tissue. The<br />
diffusion coefficient (at 37°C) of NO in water is greater than that of<br />
O2, CO2 or CO. Due to the high reactivity and the resultant<br />
extremely short half-life, the biological effect of NO is locally<br />
limited. The concentration and the biological effect of NO<br />
<strong>de</strong>creases radially around the formation site by reaction with<br />
oxygen. Due to the unpaired electron, as <strong>de</strong>scribed above, NO binds<br />
with high affinity to metallic cofactors of enzymes. Activation of<br />
the guanylate-cyclase has special importance for the vasoactive<br />
effect and leads to an increase in the intracellular messenger cGMP.<br />
This produces inactivation of the contractile elements in smooth<br />
muscle cells of the vascular walls and thus leads to vasodilatation.<br />
Moreover, nitrinergic neurotransmission in peripheral smooth<br />
muscle cells, inhibition of blood coagulation (thrombocyte<br />
aggregation and adhesion) and modulation of synaptic plasticity are<br />
mediated.<br />
Intracellular cGMP is catalyzed by the soluble isoform of guanylatcyclase<br />
(sGC) and has effects on transcription, mRNA translation<br />
and interacts directly with DNA. A posttranslational modification<br />
of proteins and inhibition of Fe-<strong>de</strong>pen<strong>de</strong>nt enzymes are of central<br />
importance especially with respect to NO-metabolism. GTP is<br />
transformed by the key enzyme GTP-cyclohydrolase I to<br />
tetrahydrobiopterin (BH4), which is an essential cofactor for all<br />
NOS isoforms.<br />
Important facts are already known about the importance of NO for<br />
the microcirculation in the skin. However, it is still unclear whether<br />
the extensive knowledge gained on macrovascular NO-metabolism<br />
in recent years can be transposed to the cutaneous microcirculation.<br />
Some functional and morphological <strong>de</strong>tails make it appear that this<br />
is not entirely possible or permissible.<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
14 Cutaneous NO-Metabolism and its therapeutic Influence<br />
Transmembranous Transport of L-Arginine<br />
The transmembranous transport of the cationic amino acid Larginine<br />
occurs with L-ornithin and L-lysin in animal cells largely<br />
selectively via the stereospecific and sodium, calcium and pHin<strong>de</strong>pen<strong>de</strong>nt<br />
Y + -System. The activity of the Y + -system is controlled,<br />
tension-<strong>de</strong>pen<strong>de</strong>nt, via hyperpolarization of the cell membrane and<br />
is very low un<strong>de</strong>r normal conditions. The opening of calcium<strong>de</strong>pen<strong>de</strong>nt<br />
potassium channels thus leads to increased influx of Larginine.<br />
Moreover, the activity of the Y + -system is increased by<br />
elevated glucose, insulin or PGI2 concentrations as well as by<br />
Interleukin-1 (IL-1)- and tumor necrosis factor α (TNFα)-mediated<br />
release of endotoxin, and reduced by lysophosphatidylcholin (14),<br />
cationic proteins (15) or hypoxia (16). L-arginine transport is<br />
effectively inhibited by an excess of cationic arginine-analogues<br />
and by the eNOS-blockers L-N G -monomethyl-L-arginine (L-<br />
NMMA) and L-N G -(1-Iminoethyl)-L-ornithin-dihydrochlori<strong>de</strong> (L-<br />
NIO). It remains unclear, however, whether the Y + -System is<br />
involved in the regulation of the activity of the NOS-isoforms<br />
and/or the arginase and the extent to which the extracellular<br />
arginine concentration influences the expression and activity of the<br />
Y + -System. Moreover, it is known from in-vitro studies on rat<br />
hepatocytes (FTO2B) and human vascular smooth muscle cells<br />
(VSMC) and in vivo- studies on rats that the genes CAT1 and<br />
CAT2, of which the expression is regulated in various ways<br />
transcriptional and post-transcriptional, are particularly important.<br />
Stimulation by lipopolysacchari<strong>de</strong>s (LPS) causes expression of<br />
CAT1 mRNA and CAT2B mRNA in lung, heart and kidney cells of<br />
rats. CAT2A mRNA is expressed LPS-in<strong>de</strong>pen<strong>de</strong>ntly in the liver.<br />
Un<strong>de</strong>r physiological conditions, the CAT1 mRNA expression in<br />
liver cells is largely stable. By contrast, stimulation of cell growth,<br />
elevated insulin levels or application of glucocorticoids leads to<br />
induction of mRNA expression of CAT1. The molecular<br />
mechanisms of CAT-expression regulation are, however, totally<br />
unknown.<br />
Our team was recently able to prove hCAT1, hCAT2A and B as<br />
well as hCAT4 in human <strong>de</strong>rmal microvascular endothelial cells<br />
(HDMEC) and in human native keratinocytes (NHEK) by RT-PCR<br />
using a gene-specific primer. The expression of the gene was<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
Cutaneous NO-Metabolism and its therapeutic Influence 15<br />
quantified cell-specifically by <strong>de</strong>nsitometric assessment. A high<br />
expression of hCAT1 and low expression of hCAT2 was found in<br />
both types of cells examined. By contrast, expression of hCTA4 of<br />
keratinocytes was consi<strong>de</strong>rably higher than in human <strong>de</strong>rmal<br />
microvascular endothelial cells. Whether one may conclu<strong>de</strong> an<br />
elevated functional transport capacity for cationic amino acids can<br />
only be speculated at the moment. Recently, it was <strong>de</strong>monstrated<br />
that the CAT3-gene, which had been assumed only in rats and mice,<br />
is also expressed in humans. In addition to this specific transport<br />
system, unspecific amino acid transporters are known which<br />
probably have no relevance for cationic amino acids un<strong>de</strong>r<br />
physiological conditions. Noteworthy in this connection are the A-<br />
(neutral amino acid transporter), ASC- and B 0+ -systems, which<br />
require an Na 2+ -gradient on the plasma membrane and the Lsystem,<br />
which is Na 2+ -in<strong>de</strong>pen<strong>de</strong>nt. Unlike the Y + -system, they<br />
accept a broa<strong>de</strong>r range of substrates, like cationic and neutral amino<br />
acids.<br />
extrazellulär<br />
intrazellulär<br />
Y + -System<br />
L-Arginin<br />
L-Ornithin<br />
L-Lysin<br />
L-NMMA<br />
L-NIO<br />
Fig. 7: Schema of Y + -System<br />
+<br />
Em<br />
L-Arginin<br />
Therapeutic Influence of L-Arginine Metabolism<br />
Directed influence of pathobiochemical processes requires precise<br />
knowledge of the physiological regulation mechanisms and<br />
functional processes. With respect to cutaneous NO-metabolism,<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
16 Cutaneous NO-Metabolism and its therapeutic Influence<br />
important changes of general pathological importance and also<br />
disease-specific regulatory <strong>de</strong>ficits can be differentiated. The latter<br />
are not only <strong>de</strong>pen<strong>de</strong>nt on the etiology and pathogenesis of the<br />
disease itself, but also involve individual pathological and phaseassociated<br />
differences.<br />
Intensive research into NO-metabolism has disclosed the following<br />
relationships as being of particular importance:<br />
1. cell type-specific expression and activity of the NOSisoforms<br />
2. cell type-specific expression and activity of the Y+-system<br />
3. cell type-specific expression and activity of other arginineconsuming<br />
enzymatic reactions<br />
4. concentration-time profile of L-arginine and NOS-cofactors<br />
5. concentration time profile of NOS-inhibiting metabolites<br />
From a <strong>de</strong>rmatopharmaceutical point of view, two basic principles<br />
of action arise from the metabolic relationships: NO-induction and<br />
NO-repression. There are a number of possible indications for both<br />
action principles. However, special attention should be paid to the<br />
concentration-<strong>de</strong>pen<strong>de</strong>nt effect of NO mentioned earlier.<br />
For the Induction of NO in the skin, two different procedures are<br />
possible. In addition to induction of the enzymatic synthesis of NO<br />
by NOS, NO can also be substituted non-enzymatically. Table 2<br />
shows practical, relevant examples of these types of reactions.<br />
Increase in NOS-Expression<br />
- L-Arginin<br />
- Tetrahydrobiopterin<br />
- Calcium<br />
- Nisoldipin (Dihydropyridin)<br />
- Oxygen <strong>de</strong>ficiency<br />
- Carbon dioxi<strong>de</strong> excess<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1<br />
Non-enzymatic NO-Induction<br />
- Nitro compounds<br />
- Sodium nitrite<br />
- Isosorbitdinitrate<br />
- Na-nitroprussi<strong>de</strong><br />
- direct NO application<br />
Tab. 2: Examples of substances for therapeutic induction of NO
Cutaneous NO-Metabolism and its therapeutic Influence 17<br />
In practical applications, the following prescriptions have proven<br />
beneficial (Tab. 3). However, no studies validated according to<br />
GCP Gui<strong>de</strong>lines are available.<br />
Prescriptions Indication(s)<br />
Sodium nitrite<br />
Ascorbic acid<br />
(alternative salicylic acid<br />
Basis Creme DAC<br />
Isosorbitdinitrate (ISDN)<br />
Basis Creme DAC<br />
Sodium nitroprussi<strong>de</strong><br />
Basis Creme DAC<br />
L-arginine-HCl<br />
Basis Creme DAC<br />
0.1-0.5<br />
0.1-0.5<br />
(0.5)<br />
ad 10.0<br />
0.1<br />
ad 10.0<br />
0.1<br />
ad 10.0<br />
1.0<br />
ad 10.0<br />
Application:<br />
- 1-2x daily un<strong>de</strong>r occlusion where<br />
appropriate<br />
- separate application of the substances<br />
is possible<br />
Indication:<br />
- Mollusca contagiosa<br />
- kutane Leishmaniose<br />
- Tinea pedis<br />
Application:<br />
- 2x daily<br />
Indication:<br />
- Anal rhaga<strong>de</strong>s, fissures<br />
- Verrucae vulgares<br />
- Impaired wound healing<br />
Application:<br />
- 2x daily<br />
Indication:<br />
- Verrucae vulgares<br />
- Impaired wound healing<br />
Application:<br />
- 2-3x daily<br />
Indication:<br />
- Mollusca contagiosa<br />
- erectile dysfunction; aphrodisiac<br />
Tab 3: Examples for Prescriptions with practical Relevance<br />
The Blocka<strong>de</strong> of NO in the skin can be realized both by inhibition<br />
of NO-synthesis and indirectly by inhibition of the substrate<br />
transport. It must be remembered that a number of already-known<br />
antiinflammatory drugs very sufficiently inhibit the expression or<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
18 Cutaneous NO-Metabolism and its therapeutic Influence<br />
activity of the NOS-isoforms directly or indirectly. Such<br />
mechanisms of action have been <strong>de</strong>scribed particularly for<br />
ciclosporin and glucocorticoids. There is also evi<strong>de</strong>nce that the heat<br />
shock protein 90 (HSP90)-blocker geldanamycin leads to a<br />
therapeutically utile reduction of NO. Moreover, a number of socalled<br />
specific NOS-blockers have been <strong>de</strong>scribed in the literature<br />
which have only rarely been clinically applied. The exceptions are<br />
some arginine-analogues like N-methyl-L-arginine acetate (NMA,<br />
L-NMA, L-NMMA) and N-nitro-L-arginine methylester (L-<br />
NAME). An antipsoriatic or antiinflammatory effect has been<br />
<strong>de</strong>scribed for these substances after topical application. Blocka<strong>de</strong> of<br />
NO-synthesis can also be realized by NADPH- and flavin- or<br />
tetrahydrobiopterin-antagonists, since the compounds are essential<br />
cofactors of NOS. Finally, Hem-binding nitro-compounds like<br />
azoles (antimycotic efficacy) should be cited, which inhibit NOsynthesis<br />
at least in vitro.<br />
Finally, it remains to be said that there are numerous situations for<br />
therapeutic application of substances which directly or indirectly<br />
influence NO-metabolism. Only future, GCP-validated therapeutic<br />
studies will show whether and in which diseases such experimental<br />
forms of therapy are effective and what place they will occupy in<br />
practical <strong>de</strong>rmatopharmaceuticals.<br />
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In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
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In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
The value of high-frequency sonography in objectifying drug effects 25<br />
The value of high-frequency sonography in<br />
objectifying drug effects<br />
A. Unholzer, H.C. Korting<br />
Ludwig-Maximilians-Universität München<br />
Klinik und Poliklinik für Dermatologie und Allergologie<br />
Frauenlobstr. 9-11<br />
D-80337 München<br />
Germany<br />
The <strong>de</strong>velopment of high-frequency ultrasound........... 25<br />
The value of 20 MHz sonography in objectifying<br />
unwanted drug effects................................................... 26<br />
The value of 20 MHz sonography in objectifying<br />
wanted drug effects....................................................... 28<br />
The value of 50 MHz and 100 MHz sonography in<br />
objectifying drug effects ............................................... 28<br />
References..................................................................... 29<br />
The <strong>de</strong>velopment of high-frequency ultrasound<br />
In the 1970s, ultrasound was introduced into medicine. Frequencies<br />
around 3,5 MHz are used for sonographic imaging of the organs of<br />
the abdomen. In <strong>de</strong>rmatology, high-frequency ultrasound, with<br />
frequencies of 15 MHz and above, is employed [1].<br />
The first ultrasound <strong>de</strong>vices used in <strong>de</strong>rmatology were 15 MHz Amo<strong>de</strong><br />
<strong>de</strong>vices. A-(amplitu<strong>de</strong>-)mo<strong>de</strong> systems handle the amplitu<strong>de</strong>s<br />
of the echoes received in a one-dimensional way [2]. B-(brightness-<br />
)mo<strong>de</strong> <strong>de</strong>vices visualize the intensity of ultrasound echoes using a<br />
scale of grey-sha<strong>de</strong>s respectively so-called false colours and<br />
compute a sectional image of the skin [2]. The first 20 MHz B-scan<br />
systems – DUB 20 by Taberna pro medicum (Lüneburg, Germany)<br />
and Dermascan C by Cortex Technology (Hadsund, Denmark) –<br />
were introduced in 1987 [1].<br />
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In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
26 The value of high-frequency sonography in objectifying drug effects<br />
The value of 20 MHz sonography in objectifying<br />
unwanted drug effects<br />
High-frequency ultrasound, in particular 20 MHz B-mo<strong>de</strong><br />
ultrasound, has proved to be a precise method for objectifying and<br />
quantifying both unwanted and wanted pharmacological effects on<br />
the skin [1]. Skin atrophy following long-term application of topical<br />
glucocorticoids is one of the most important unwanted drug effects<br />
in <strong>de</strong>rmatology. Usually, it is prece<strong>de</strong>d by a reversible reduction of<br />
total skin thickness, so-called preatrophy [3]. 20 MHz B-scan<br />
sonography enabled us and other working groups to <strong>de</strong>monstrate<br />
that nonhalogenated glucocorticoid C-17,21 double esters such as<br />
prednicarbate or hydrocortisone aceponate reduce total skin<br />
thickness less than conventional, halogenated glucocorticoids such<br />
as betamethasone 17-valerate or clobetasol 17-propionate [4-7]. The<br />
nonhalogenated glucocorticoid C-17,21 double esters exert an antiinflammatory<br />
activity comparable to that of betamethasone 17valerate<br />
[8]. Thus, the nonhalogenated glucocorticoid C-17,21<br />
double esters are topical glucocorticoids with an improved<br />
benefit/risk ratio [3, 9].<br />
In several randomized, double-blind clinical trials, the skin thinning<br />
effect of prednicarbate 0.25 % cream, hydrocortisone 1 % cream<br />
and the medium-potent halogenated glucocorticoid mometasone<br />
furoate 0.1 % cream did not differ clearly from that of the base<br />
preparation, but was less than that with betamethasone 17-valerate<br />
0.1 % or clobetasol 17-propionate 0.05 % cream [4-6]. Similarly,<br />
prednicarbate 0.25 % ointment and hydrocortisone aceponate 0.1 %<br />
ointment reduced skin thickness not more than vehicle, whereas<br />
betamethasone 17-valerate ointment proved to be more<br />
atrophogenic [5].<br />
These studies were performed with an explorative approach. In an<br />
explorative study, data are analyzed after the conduct of the clinical<br />
trial. In a confirmatory study, a null hypothesis is formulated before<br />
the clinical trial is performed. Recently, we compared the skinthinning<br />
effect of prednicarbate 0.25 %, betamethasone17-valerate<br />
0.1 % and mometasone furoate 0.1 % ointments to that of a the<br />
vehicle corresponding to the prednicarbate 0.25 % ointment in a<br />
double-blind, placebo-controlled randomized trial with a<br />
confirmatory approach [10]. Over a six week period, 24 healthy<br />
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In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
The value of high-frequency sonography in objectifying drug effects 27<br />
volunteers non-occlusively applied 100 mg of each ointment twice<br />
daily to the volar aspects of their forearms. Total skin thickness was<br />
measured weekly using a 20 MHz B-scan ultrasound <strong>de</strong>vice.<br />
Change in total skin thickness relative<br />
to baseline<br />
0%<br />
-5%<br />
-10%<br />
-15%<br />
-20%<br />
-25%<br />
day 1 day 8 day 15 day 22 day 29 day 36 day 43<br />
Vehicle<br />
Prednicarbate 0.25 %<br />
Mometasone furoate 0.1 %<br />
Betamethasone 17-valerate 0.1 %<br />
Time<br />
Fig. 1: Time course of total skin thickness reduction, relative to<br />
baseline in percent, during treatment with three different topical<br />
glucocorticoid ointment preparations and a vehicle preparation. On<br />
day 36, total skin thickness was reduced by a mean of 1 % in test<br />
fields treated with vehicle; for prednicarbate, mometasone furoate<br />
and betamethasone 17-valerate, the relative <strong>de</strong>creases amounted to<br />
13 %, 17 % and 24 %, respectively. From [10], with permission.<br />
The percental <strong>de</strong>crease of total skin thickness in relation to baseline<br />
was calculated for each test area and for each time of measurement.<br />
The differences to baseline were compared intraindividually, and<br />
the null hypothesis H0: „Reduction of total skin thickness in the test<br />
areas treated with prednicarbate, mometasone furoate,<br />
betamethasone 17-valerate and the ointment vehicle is the same (µ1<br />
= µ2=µ3=µ4)“ was tested. Application of betamethasone 17valerate<br />
and mometasone furoate led to a <strong>de</strong>crease of total skin<br />
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In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
28 The value of high-frequency sonography in objectifying drug effects<br />
thickness by 24 % and 17 %, respectively, on day 36 (figure 1). The<br />
skin thinning effects of betamethasone 17-valerate and mometasone<br />
furoate were clearly more marked than that of prednicarbate, the<br />
differences being statistically highly significant with p < 0.0001 and<br />
p = 0.0061, respectively. Prednicarbate ointment still reduced total<br />
skin thickness to a higher extent than its vehicle (13 % versus 1 %<br />
on day 36; p < 0.0001; figure 1).<br />
The value of 20 MHz sonography in objectifying wanted<br />
drug effects<br />
20 MHz B-mo<strong>de</strong> ultrasound is appropriate not only for objectifying<br />
and quantifying unwanted drug effects, but also for objectifying<br />
certain wanted pharmacological effects on the skin. For example,<br />
the clinical improvement of atopic eczema during therapy can be<br />
confirmed sonographically: In this disease, total skin thickness is<br />
usually increased, and the upper part of the <strong>de</strong>rmis appears echopoor,<br />
due to oe<strong>de</strong>ma and inflammatory infiltrate [11]. Topical<br />
application of a glucocorticoid, i. e. of mometasone furoate, for 14<br />
days leads to normalization of both total skin thickness and<br />
echo<strong>de</strong>nsity of the <strong>de</strong>rmis [11].<br />
In cutaneous radiation fibrosis, total skin thickness and the<br />
echo<strong>de</strong>nsity of the <strong>de</strong>rmis are increased, and the extension of the<br />
subcutaneous fatty tissue is reduced [11]. In a patient suffering from<br />
cutaneous radiation fibrosis as a complication of radiation therapy<br />
on account of a mammary carcinoma, oral treatment with<br />
pentoxifyllin (3 x 400 mg per day) and vitamin E (1 x 400 mg per<br />
day) induced a reduction of fibrosis and a continuous <strong>de</strong>crease in<br />
total skin thickness from the sixth month onward, amounting to 25<br />
% of the previous skin thickness after six months and 40 % after<br />
eight months [12].<br />
The value of 50 MHz and 100 MHz sonography in<br />
objectifying drug effects<br />
Total skin thickness, i. e. the thickness of <strong>de</strong>rmis plus epi<strong>de</strong>rmis,<br />
can be <strong>de</strong>termined precisely and reproducibly by means of 20 MHz<br />
B-mo<strong>de</strong> ultrasound. However, the resolution of 20 MHz<br />
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In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
The value of high-frequency sonography in objectifying drug effects 29<br />
sonography (200 µm to the si<strong>de</strong> and 75-80 µm to the <strong>de</strong>pth [2, 11])<br />
is not high enough for imaging the comparatively thin epi<strong>de</strong>rmis<br />
[1]. This problem might be solved by the introduction of systems<br />
with higher frequency and thus higher resolution. In 1989, the<br />
working group around Hoffmann <strong>de</strong>veloped a 50 MHz B-scan<br />
ultrasound <strong>de</strong>vice with an axial and lateral resolution of 37.5 µm<br />
and 120 µm, respectively [13]. Their 100 MHz system, introduced<br />
in 1993, offers a resolution of 11 µm to the <strong>de</strong>pth and 30 µm to the<br />
si<strong>de</strong> [14]. These <strong>de</strong>vices make sonographic imaging of the<br />
epi<strong>de</strong>rmis possible. Evi<strong>de</strong>nce from first applications in monitoring<br />
the course of psoriasis vulgaris during therapy suggests that both 50<br />
MHz and 100 MHz ultrasound are appropriate for the evaluation of<br />
drug effects on the skin [13-15]. 100 MHz sonography even allows<br />
quantification of changes in the stratum corneum after occlusive<br />
application of different topical preparations (e. g. petrolatum, waterin-oil<br />
emulsion, oil-in-water emulsion and water) to the<br />
<strong>de</strong>rmatoglyphic-bearing skin of the fingertip [16]. It could be<br />
<strong>de</strong>monstrated that a higher water content leads to faster and more<br />
marked swelling of the stratum corneum [16].<br />
In conclusion, 20 MHz B-scan sonography is a proven method for<br />
objectifying and quantifying drug effects in <strong>de</strong>rmatology. 50 MHz<br />
and 100 MHz B-mo<strong>de</strong> ultrasound are very promising new<br />
technologies. It remains to be seen whether they will prove to be<br />
superior to 20 MHz B-scan sonography in the evaluation of drug<br />
effects on the skin.<br />
References<br />
1 Unholzer A, Korting HC (2002) High-frequency ultrasound in<br />
the evaluation of pharmacological effects on the skin. Skin<br />
Pharmacol Appl Skin Physiol 15:71-84<br />
2 Hoffmann K, El Gammal S, Altmeyer P (1990) B-scan-<br />
Sonographie in <strong>de</strong>r Dermatologie. Hautarzt 41:W7-W16<br />
3 Schäfer-Korting M, Korting HC, Kerscher MJ, Lenhard S<br />
(1993) Prednicarbate activity and benefit/risk ratio in relation to<br />
other topical glucocorticoids. Clin Pharmacol Ther 54:448-456<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
30 The value of high-frequency sonography in objectifying drug effects<br />
4 Korting HC, Vieluf D, Kerscher M (1992) 0.25% prednicarbate<br />
cream and the corresponding vehicle induce less skin atrophy<br />
than 0.1% betamethasone-17-valerate cream and 0.05%<br />
clobetasol-17-propionate cream. Eur J Clin Pharmacol 42:159-<br />
161<br />
5 Kerscher MJ, Korting HC (1992) Topical glucocorticoids of the<br />
non-fluorinated double-ester type. Lack of atrophogenicity in<br />
normal skin as assessed by high-frequency ultrasound. Acta<br />
Derm Venereol 72:214-216<br />
6 Kerscher MJ, Hart H, Korting HC, Stalleicken D (1995) In vivo<br />
assessment of the atrophogenic potency of mometasone furoate,<br />
a newly <strong>de</strong>veloped chlorinated potent topical glucocorticoid as<br />
compared to other topical glucocorticoids old and new. Int J Clin<br />
Pharmacol Ther 33:187-189<br />
7 Lévy J, Gassmüller J, Schrö<strong>de</strong>r G, Audring H, Sönnichsen N<br />
(1994) Comparison of the effects of calcipotriol, prednicarbate<br />
and clobetasol 17-propionate on normal skin assessed by<br />
ultrasound measurement of skin thickness. Skin Pharmacol<br />
7:231-236<br />
8 Schackert C, Korting HC, Schäfer-Korting M (2000) Qualitative<br />
and quantitative assessment of the benefit-risk ratio of medium<br />
potency topical corticosteroids in vitro and in vivo.<br />
Characterisation of drugs with an increased benefit-risk ratio.<br />
Biodrugs 13:267-277<br />
9 Schäfer-Korting M, Schmid M-H, Korting HC (1996) Topical<br />
glucocorticoids with improved risk-benefit ratio. Rationale of a<br />
new concept. Drug Safety 14:375-385<br />
10 Korting HC, Unholzer A, Schäfer-Korting M, Tausch I,<br />
Gassmueller J, Nietsch K-H (2002) Different skin thinning<br />
potential of equipotent medium-strength glucocorticoids. Skin<br />
Pharmacol Appl Skin Physiol 15:85-91<br />
11 Korting HC, Gottlöber P, Schmid-Wendtner M-H, Peter RU<br />
(1996) Ultraschall in <strong>de</strong>r Dermatologie. Ein Atlas. Blackwell,<br />
Berlin<br />
12 Gottlöber P, Krähn G, Korting HC, Stock W, Peter RU (1996)<br />
Behandlung <strong>de</strong>r kutanen Strahlenfibrose mit Pentoxifyllin und<br />
Vitamin E – Ein Erfahrungsbericht. Strahlenther Onkol 172:34-<br />
38<br />
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In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
The value of high-frequency sonography in objectifying drug effects 31<br />
13 El Gammal S, Auer T, Popp C, Hoffmann K, Altmeyer P,<br />
Passmann C, Ermert H (1994) Psoriasis<br />
14 vulgaris in 50 MHz B-scan ultrasound – Characteristic features<br />
of stratum corneum, epi<strong>de</strong>rmis and <strong>de</strong>rmis. Acta Derm Venereol<br />
Suppl 186:173-176<br />
15 El Gammal S, El Gammal C, Kaspar K, Pieck C, Altmeyer P,<br />
Vogt M, Ermert H (1999) Sonography of the skin at 100 MHz<br />
enables in vivo visualization of stratum corneum and viable<br />
epi<strong>de</strong>rmis in palmar skin and psoriatic plaques. J Invest<br />
Dermatol 113:821-829<br />
16 Vaillant L, Berson M, Machet L, Callens A, Pourcelot L, Lorette<br />
G (1994) Ultrasound imaging of psoriatic skin: A noninvasive<br />
technique to evaluate treatment of psoriasis. Int J Dermatol<br />
33:786-790<br />
17 Kaspar K, Vogt M, Ermert H, Altmeyer P, El Gammal S (1999)<br />
100-MHz-Sonographie zur Darstellung <strong>de</strong>s Stratum corneum an<br />
<strong>de</strong>r Palmarhaut nach Anwendung verschie<strong>de</strong>ner Externa.<br />
Ultraschall in Med 20:110-114<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
32 Bioengineering of the skin: non-invasive methods for the evaluation of efficacy<br />
Bioengineering of the skin: non-invasive methods<br />
for the evaluation of efficacy<br />
T. Gambichler, F.G. Bechara, M. Stücker, K. Hoffmann, P. Altmeyer<br />
Department of Dermatology<br />
Ruhr-University Bochum<br />
Gudrunstr. 56<br />
D-44791 Bochum<br />
Germany<br />
Introduction................................................................... 32<br />
Bioengineering of different skin functions ................... 33<br />
• Skin hydration.............................................................. 33<br />
• Transepi<strong>de</strong>rmal water loss (TWL)............................... 34<br />
• Skin-pH........................................................................ 34<br />
• Skin surface lipids........................................................ 34<br />
• Skin color..................................................................... 35<br />
• Skin elasticity............................................................... 35<br />
• Transcutaneous pO2 and pCO2 and microcirculation .. 36<br />
Imaging methods in the investigation of the skin......... 36<br />
• Capillary microscopy and thermography..................... 36<br />
• Laser Doppler fluxmetry/scanning .............................. 37<br />
• Profilometry................................................................. 37<br />
• High-frequency sonography ........................................ 38<br />
• Optical coherence tomography (OCT) ........................ 38<br />
• Confocal laser scanning microscopy (CLSM)............. 40<br />
Conclusions................................................................... 41<br />
References..................................................................... 42<br />
Introduction<br />
Classic <strong>de</strong>rmatology is based on the observation of characteristics<br />
that can be appreciated by sensory perception. Dermatologists learn<br />
to recognize and classify lesions to i<strong>de</strong>ntify stereotypes that permit<br />
diagnosis. That is why many <strong>de</strong>rmatologists have not previously<br />
seen the necessity to <strong>de</strong>velop instruments to <strong>de</strong>tect skin changes.<br />
Their particular methodology has led some <strong>de</strong>rmatologists to the<br />
conviction that their perception is superior to that of any apparatus.<br />
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Bioengineering of the skin: non-invasive methods for the evaluation of efficacy 33<br />
Nowadays <strong>de</strong>rmatologists have started to make use of methods and<br />
research tools to aid diagnosis. Increasingly sophisticated<br />
techniques in skin exploration in a non-invasive way supply<br />
biophysical parameters of skin characteristics <strong>de</strong>tected by analog<br />
methods. In particular in the field of <strong>de</strong>rmatopharmacological<br />
research functional and morphological changes of the skin have to<br />
be recor<strong>de</strong>d accurately in or<strong>de</strong>r to study the effect of therapeutic<br />
agents on the skin [1-3]. In the following a brief overview of<br />
selected bioengineering methods used in <strong>de</strong>rmatopharmacology is<br />
provi<strong>de</strong>d.<br />
Bioengineering of different skin functions<br />
• Skin hydration<br />
The measurement of skin hydration is based on the electrical<br />
impedance of the horny layer (corneometry). The impedance of the<br />
horny layer measured by two high-gra<strong>de</strong> steel electro<strong>de</strong>s is<br />
reciprocally proportional to the water content of the horny layer<br />
[4,5]. The measured conductibility is directly converted into<br />
numeric values corresponding to the relative moisture of the horny<br />
layer. Skin hydration can also be assessed by high-frequency<br />
currents, infrared spectroscopy, and nuclear mag<strong>net</strong>ic resonance.<br />
These procedures are however less common and much more<br />
expensive than simple corneometry. The methods mentioned above<br />
can be employed in the evaluation of hydrating and/or <strong>de</strong>hydrating<br />
effects of topical formulations as applied in <strong>de</strong>rmatology and<br />
cosmetology. Corneometry is frequently used in the assessment of<br />
effectiveness and tolerability of various therapeutics and care<br />
products with regard to inflammatory diseases such as atopic<br />
eczema and psoriasis. Corneometry finds also broad application in<br />
cosmetology recording the effects of skin cleaning products and<br />
moisturizers.<br />
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34 Bioengineering of the skin: non-invasive methods for the evaluation of efficacy<br />
• Transepi<strong>de</strong>rmal water loss (TWL)<br />
The evaporimetric measurement of TWL is based on the law of<br />
water diffusion. The probe measures the temperature and relative<br />
humidity. By that, the partial steam pressure in the air is <strong>de</strong>termined<br />
in two different levels. The inference onto the water vaporization<br />
and/or the TWL occurs about the gradient of the partial pressure<br />
that is directly proportional to the <strong>de</strong>gree of vaporization (6). The<br />
TWL reflects the function of the skin barrier. Analogous to<br />
corneometry, evaporimetry is a basic method for monitoring<br />
eczematous skin diseases (1,2). Both, the efficacy of skin protection<br />
products and irritative potential of creams and effects of skin<br />
cleaning products, can accurately be examined by evaporimetry.<br />
• Skin-pH<br />
Since the skin surface with its secretion and high water content<br />
corresponds to the qualities of a diluted solution, it is well suitable<br />
for direct skin pH measurements. The potentiometric assessment is<br />
based on electrochemical processes on the skin surface. The pH<br />
value is expressed as the logarithmically reciprocal value of the<br />
concentration of free hydrogen ions (1). Skin pH measurement is<br />
elementary in the evaluation of cosmetic products (e.g., soaps,<br />
shampoos, <strong>de</strong>odorants).<br />
• Skin surface lipids<br />
The quantitative <strong>de</strong>termination of the skin surface lipids (sebum) is<br />
usually carried out via the spectrophotometric method. An opaque<br />
plastic film is pressed onto the skin and coated with sebum. The<br />
resulting increased transmission of the film is measured<br />
spectrophotometrically [1]. With a precision balance, measuring the<br />
absorbent fat content of a paper strip, being pressed on the skin<br />
before, the sebum content can also be <strong>de</strong>termined (gravimetry). The<br />
assessment of the sebum content of the skin surface is<br />
predominantly used in cosmetology for skin type <strong>de</strong>termination.<br />
The method is also employed in the evaluation of cosmetic products<br />
that have a potentially altering influence on the formation of skin<br />
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Bioengineering of the skin: non-invasive methods for the evaluation of efficacy 35<br />
surface lipids. In the same way the effect of topical or systemic<br />
retinoids can be investigated (e.g., monitoring of acne vulgaris) [2].<br />
• Skin color<br />
The colorimetry is based on the tristimulus analysis of light that is<br />
reflected from the skin. The colors are expressed in a threedimensional<br />
coordinate system with black-white axis (L*), greenred<br />
axis (a*), and yellow-blue axis (b*). Another method frequently<br />
used is based on spectrophotometric measurements of the relevant<br />
chromophores (melanin, hemoglobin). The dio<strong>de</strong>s employed emit<br />
light at 568 nm and 655 nm onto the skin. The reflected light<br />
encounters the photo<strong>de</strong>tector and the calculation of the melanin and<br />
erythema in<strong>de</strong>x is provi<strong>de</strong>d, respectively [7]. The measurement of<br />
color, in particular the erythema in<strong>de</strong>x, is often used during therapy<br />
to quantify the cutaneous findings of inflammatory diseases (e.g.,<br />
atopic eczema, psoriasis). Correspondingly, adverse effects of<br />
topical and systemic therapeutics can be quantified [8,9].<br />
• Skin elasticity<br />
The mechanical properties of the skin are influenced by maturation,<br />
aging, and various cutaneous disor<strong>de</strong>rs. A couple of methods for<br />
measurement of biomechanical qualities of the skin have been<br />
proposed [10]. Current <strong>de</strong>vices induce measurable <strong>de</strong>formation of<br />
the skin by torsion, pressure, or suction. A common technique for<br />
the quantification of skin elasticity is based on the use of a vacuum<br />
pump that is put vertically on the skin surface. The <strong>de</strong>formation of<br />
the skin within a test area of three mm² is measured. The resultant<br />
<strong>de</strong>formation curve is characterized by an elastic, a visco-elastic and<br />
a viscous part. This method is particularly suitable for the<br />
monitoring of diseases that cause skin induration (e.g.,<br />
<strong>de</strong>rmatosclerosis) or hyperelasticity of the skin (e.g., Ehlers-Danlos-<br />
Syndrom). In addition, the efficacy of anti-aging products can be<br />
examined [11-13].<br />
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In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
36 Bioengineering of the skin: non-invasive methods for the evaluation of efficacy<br />
• Transcutaneous pO2 and pCO2 and microcirculation<br />
In the quantification of the cutaneous pO2 and pCO2, both the<br />
systemic blood gases and the function of the nutritive vasculature of<br />
the skin is objectively assessed. The measurement of the pO2 is<br />
performed un<strong>de</strong>r constant temperature by means of a thermoelectro<strong>de</strong><br />
with integrated catho<strong>de</strong> and ano<strong>de</strong>. The aperture of the<br />
electro<strong>de</strong> is covered with a membran pervious to oxygen. Combined<br />
probes enable simultaneous measurement of the pO2 and the<br />
transcutaneous pCO2. Laser-doppler <strong>de</strong>vices with an integrated<br />
vi<strong>de</strong>o microscopic function are also employed. In addition, the O2reflection<br />
spectroscopy is used in the quantification of the<br />
cutaneous oxygen content per tissue unit. Therefore, a spectrum<br />
analysis of reflected light is used in examining the oxygenation of<br />
the hemoglobin. These methods are applied in<br />
<strong>de</strong>rmatopharmacology, particularly in monitoring of arterial and<br />
venous circulation malfunctions [14].<br />
Imaging methods in the investigation of the skin<br />
• Capillary microscopy and thermography<br />
The capillary microscopy is a direct technique in qualitative and<br />
quantitative investigation of the capillaries in the papillary <strong>de</strong>rmis.<br />
An optical microscope (magnification: 50-200) equipped with<br />
specific spectral filters and a cold light source is used. Changes of<br />
microcirculation can also be measured indirectly by means of<br />
thermographical methods. The infrared thermography is employed<br />
in the measurement of the skin surface and enables selective<br />
<strong>de</strong>termination of absolute temperature levels, averaged temperature<br />
over a whole skin site, and the distribution of temperature. Capillary<br />
microscopy and thermography are frequently used for the<br />
investigation of disor<strong>de</strong>rs of microcirculation as observed in<br />
collagenoses (e.g., sclero<strong>de</strong>rma). Effects of vasoconstrictive<br />
substances (e.g., nicotine acid) can be well established with<br />
thermography [14].<br />
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Bioengineering of the skin: non-invasive methods for the evaluation of efficacy 37<br />
• Laser Doppler fluxmetry/scanning<br />
Laser Doppler flow analysis is one of the most commonly used<br />
method in the evaluation process of cutaneous microcirculation.<br />
The method is based on measuring the velocity of blood flow in the<br />
capillaries by Doppler effect. A laser beam (e.g., helium, neon)<br />
gui<strong>de</strong>d by an optical fiber interacts with skin structures. The<br />
stationary tissue components reflect the light at the same<br />
wavelength, whereas those in movement (e.g., erythrocytes) reflect<br />
it at a different wavelength. Measuring with unidimensional laser<br />
Doppler fluxmetry the blood flow is selectively assessed by means<br />
of a single probe, whereas laser Doppler scanning enables<br />
systematic measurement of a larger skin site. Thereby, a twodimensional<br />
perfusion pattern is given [14,15]. In<br />
<strong>de</strong>rmatopharmacology laser Doppler techniques are frequently used<br />
in appraising the efficacy of topical and systemic therapeutics.<br />
Analogous to the classic circulation malfunctions (e.g.,<br />
atherosclerosis, chronic venous insufficiency) disor<strong>de</strong>rs of<br />
microcirculation (e.g., Raynaud’s syndrome, <strong>de</strong>rmatosclerosis,<br />
<strong>de</strong>rmatomyositis) can be evaluated with these techniques out of<br />
diagnostic reasons and in monitoring therapy. In addition<br />
experimentally caused erythema can be quantified. In numerous<br />
studies on patients with chronic inflammatory skin diseases laser<br />
Doppler methods were employed in the assessment of therapeutic<br />
and pharmacological effects [16-20].<br />
• Profilometry<br />
The surface of the skin is frequently <strong>de</strong>scribed with the term<br />
"roughness". Apart from direct mechanical-electronical scanners,<br />
indirect optical procedures are used for the <strong>de</strong>termination of skin<br />
roughness. Besi<strong>de</strong>s interferometry, transmission profilometry,<br />
holography, and laser profilometry are frequently employed today.<br />
By means of these methods the effectiveness of anti-aging<br />
substances (e.g., topical retinoids) can be quantified. Changes of<br />
skin roughness caused by cosmetic products, hormone-containing<br />
emollients, alpha-hydroxy acids, and peeling substances are<br />
investigated via profilometric methods. Furthermore laser<br />
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38 Bioengineering of the skin: non-invasive methods for the evaluation of efficacy<br />
profilometry is performed in measuring the therapeutic outcome in<br />
inflammatory skin diseases such as psoriasis [21,22].<br />
• High-frequency sonography<br />
The high-frequency sonography provi<strong>de</strong>s information concerning<br />
the spatial (axial and lateral) spreading of tumerous and<br />
inflammatory processes of the skin. Today, the 20 MHz<br />
sonographie is well established in <strong>de</strong>rmatological clinics and skin<br />
research centers. The most important physical characteristics of 20<br />
MHz sonography inclu<strong>de</strong> the skin <strong>de</strong>pth of eight mm, the axial<br />
solution of 80 µm, and the lateral solution of 200 µm. Ultrasound<br />
transducers with higher medium frequencies (e.g., 50 MHz, 100<br />
MHz) offer on the one hand increasing resolution, on the other hand<br />
<strong>de</strong>creased <strong>de</strong>pth. Thus, in particular morphology of the epi<strong>de</strong>rmis<br />
can be investigated with 50 MHz and 100 MHz scanners. However,<br />
only a small number of specialised centers are equipped with these<br />
instruments. High-frequency sonography of inflammatory diseases<br />
such as psoriasis vulgaris, lichen ruber planus, and diverse forms of<br />
eczema showes characteristic echo-poor areas in the <strong>de</strong>rmis. It<br />
represents, both the acanthosis of the epi<strong>de</strong>rmis and the <strong>de</strong>rmal<br />
infiltration[19,23,24]. Thus a distinction between acanthotic<br />
epithelium and subepithelial infiltration cannot be ma<strong>de</strong>. Evaluation<br />
of micromorphological structures and their differentiation does not<br />
succeed in 20 MHz sonography. Nevertheless this method helps to<br />
objectify therapeutic effects, being observed during the treatment of<br />
<strong>de</strong>rmatosclerosis-like skin modifications. Changes of skin thickness<br />
and <strong>de</strong>rmal echogenicity are of special interest in therapy<br />
monitoring [25-27]. Pharmacological effects of anti-aging<br />
substances can also be examined with the high-frequency<br />
sonography [23].<br />
• Optical coherence tomography (OCT)<br />
OCT is a relatively new non-invasive imaging tool in the<br />
investigation of epi<strong>de</strong>rmal morphology. The procedure is based on<br />
the principle of interference of coherent light waves in a scattering<br />
medium (Michelson interferometry). Infrared light (830 and/or<br />
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Bioengineering of the skin: non-invasive methods for the evaluation of efficacy 39<br />
1300 nm) of a short coherence length (≅ 15 mm) is divi<strong>de</strong>d into<br />
both a reference beam and a test beam. The reflected reference light<br />
is compared with the reflected light of the skin tissue. The skin<br />
<strong>de</strong>pth is about one mm. Structures smaller than ten mm can be<br />
established with OCT. Instruments with a lateral resolution of four<br />
mm and an axial resolution of seven mm have already been used in<br />
<strong>de</strong>rmatopharmacological studies [28,29]. Because of the high<br />
resolution of OCT, structures in the horny layer and the vital<br />
epi<strong>de</strong>rmis up to the papillary <strong>de</strong>rmis can be studied precisely.<br />
Fig. 1: Optical coherence tomography (OCT) of a pigmented nevus<br />
on the forearm. Clear <strong>de</strong>marcation of the <strong>de</strong>rmal papillae and rete<br />
ridges.<br />
Experimental investigations on dimethyl-sulfate-oxi<strong>de</strong> (DMSO)<br />
revealed, that in spite of clinically hardly perceptible wheals, the<br />
OCT showed clearly hyporeflective areas in the epi<strong>de</strong>rmis. These<br />
areas most probably correspon<strong>de</strong>d to a spongiosis. Accordingly, it<br />
has previously been <strong>de</strong>monstrated that this method is suitable to<br />
establish spongiotic and vesicular epi<strong>de</strong>rmal changes in patients<br />
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40 Bioengineering of the skin: non-invasive methods for the evaluation of efficacy<br />
with clinically inapparent dishydrotic eczema. Furthermore typical<br />
histological changes of psoriasis such as thickening of the horny<br />
layer and acanthosis can be <strong>de</strong>monstrated and quantified by means<br />
of OCT. These observations have been confirmed by experimental<br />
studies on contact <strong>de</strong>rmatitis. Furthermore, keratolytic effects on<br />
palmoplantar skin can also be evaluated accurately. Moisturising<br />
preparations (e.g., urea-containing emollients) enhance the waterbinding<br />
capacity of the horny layer, whose thickening can be shown<br />
by means of OCT. Atrophogenic effects can easily be quantified<br />
through this method [28,29].<br />
• Confocal laser scanning microscopy (CLSM)<br />
CLSM represents a new non-invasive bioengineering tool, which is<br />
used in the investigation of both functional and morphological<br />
changes of the skin. It allows skin imaging of a virtual section on<br />
the basis of living tissue. The Vivascope 1000 (Lucid Inc., USA) is<br />
frequently employed for this purpose. The system uses a laser<br />
source with wavelength of 830 nm, an illumination power up to 20<br />
mW on the object, a water immersion objective and an imaging rate<br />
of 20 per second. The field of view shows 128µm × 260µm. Its<br />
lateral resolution is 0.4µm, the vertical resolution is roughly 1.9µm.<br />
The microscope allows imaging of the epi<strong>de</strong>rmis and papillary<br />
<strong>de</strong>rmis on a cellular level (a maximum of 250 µm skin <strong>de</strong>pth).<br />
Unlike the high-frequency sonography and OCT, the CLSM<br />
produces horizontal image sections. Due to the high resolution<br />
single cells and cell structures can be <strong>de</strong>monstrated (for example<br />
cell nuclei, pigmented granula, capillaries, blood flow, membraneprotein-complexes).<br />
This method was already validated in the<br />
course of comparative studies on histological section series.<br />
Epi<strong>de</strong>rmal thickness and thydration of all epi<strong>de</strong>rmal cell<br />
populations can be quantified with the CLSM. Additionally<br />
different cell types can be distinguished from each other and the<br />
evalutation of differentiation disor<strong>de</strong>rs of cells is possible. Both<br />
inflammatory and sclero<strong>de</strong>rma-like skin changes can be<br />
<strong>de</strong>monstrated and quantified by means of CLSM (30-33). Apart<br />
from the great advances of CLSM in non-invasive skin tumor<br />
diagnostics this technique has an extremly high potential in the field<br />
of <strong>de</strong>rmatopharmacological and cosmetic research.<br />
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Bioengineering of the skin: non-invasive methods for the evaluation of efficacy 41<br />
Fig. 2: Dermal papilla with dilated capillaries and erythrocytes in<br />
psoriatic skin investigated by confocal laser scanning microscopy in<br />
vivo (CLSM) [K. Sauermann, Hamburg, Germany].<br />
Conclusions<br />
This brief overview of selected bioengineering methods has<br />
provi<strong>de</strong>d an insight into possibilities and the broad spectrum of noninvasive<br />
methods in the skin investigation. The use of<br />
bioengineering is of great advantage in mo<strong>de</strong>rn medicine, as the<br />
parameters investigated can accurately be quantified with noninvasive<br />
objective procedures and can be subsequently evaluated<br />
and stored electronically. In addition, morphological and functional<br />
skin parameters can be investigated which are inaccessible to<br />
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42 Bioengineering of the skin: non-invasive methods for the evaluation of efficacy<br />
simple clinical investigation. In <strong>de</strong>rmatopharmacology as well as<br />
cosmetology, bioengineering is therefore indispensable in<br />
objectifying the efficacy and si<strong>de</strong> effects of topical and systemic<br />
agents. The techniques vary from relatively simple methods to<br />
sophisticated and cost-intensive methods. Today, in<br />
<strong>de</strong>rmatopharmacology as well as cosmetology bioengineering<br />
represent established components in evaluation pharmacological<br />
effects on the skin. Some selected methods are suitable in the<br />
investigation of specific functional parameters of the skin (e.g.,<br />
sebum, pH, moisture) as relevant in testing cosmetic products.<br />
Other methods provi<strong>de</strong> objective data on morphological structures<br />
of the skin. Especially the currently established skin imaging tools<br />
enable a differentiated insight into structural and<br />
micromorphological skin changes. Prior to starting<br />
<strong>de</strong>rmatopharmacological investigations the foreknowledge on<br />
possible effects as well as adverse effects of pharmacological<br />
substances used is essential for the correct choice of a research tool.<br />
The characteristically functional and/or morphological alterations of<br />
different skin diseases can precisely be examined with a<strong>de</strong>quate<br />
methods un<strong>de</strong>r standardized conditions. Special attention needs to<br />
be turned to the experimental protocol, study sample, and test<br />
conditions [34]. Further improvement and progress in<br />
bioengineering, in particular skin imaging, is ongoing. The fusion<br />
of different techniques - for example - the implementation of laser<br />
Doppler techniques into high-frequency sonography systems, or a<br />
combination of OCT with high-frequency sonography – is in<br />
<strong>de</strong>velopment. However, all recent <strong>de</strong>velopments and sophisticated<br />
methods cannot replace the <strong>de</strong>rmatological expertise and<br />
physician’s intuition.<br />
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In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
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Bioengineering of the skin: Methods and Instrumentation, CRC<br />
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Dermatopharmazie: Vehikel – Wirkstoffe – Pharmakologie,<br />
Wiss. Verl.-Ges., Stuttgart<br />
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Bestimmung <strong>de</strong>s relativen Wassergehaltes <strong>de</strong>s Stratum corneum<br />
<strong>de</strong>r menschlichen Haut. Arch Dermatol Res 270:67-75<br />
5 Tagami H (1994) Quantitative measurements of water<br />
concentration of the stratum corneum in vivo by high-frequency<br />
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6 Pinnagoda JTupker RA, Agner T, Serup J (1990) Gui<strong>de</strong>lines for<br />
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22:164-178<br />
7 Fullerton A, Fischer T, Lathi A, Wilhelm KP, Taikiwaki H,<br />
Serup J (1996) Gui<strong>de</strong>lines for measurement of skin colour and<br />
erythema. A report from the standardization group of the<br />
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8 Hoffmann K, Jansen T, Sauermann K, Rotterdam S, Altmeyer P,<br />
Gambichler T (2001) Hautreinigungswirkung textiler<br />
Mikrofasern. Kosmetische Medizin 3:138-142<br />
9 Hoffmann K, Auer T, Stücker M, Dirschka T, el Gammal S,<br />
Altmeyer P (1994) Evaluation of the efficacy of H1 blockers by<br />
noninvasive measurement techniques. Dermatology 189:146-<br />
151<br />
10 Vogel HG (1994) Mechanical measurements of skin. Acta Derm<br />
Venereol 185(Suppl.):39-43.<br />
11 Bere<strong>de</strong>sca E, Farinelli N, Rabbiosi G, Maibach HI (1991). Skin<br />
bioengineering in noninvasive assessment of cutaneous aging.<br />
Dermatologica 182:1-6.<br />
12 Oikarinen A (1992) Dermal connective tissue modulated by<br />
pharmalogic agents. In J Dermatol 31:149156<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
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13 Marks R, Edwards C (1992) The measurement of photodamage.<br />
Br J Dermatol 127(Suppl. 41):7-13<br />
14 Altmeyer P, Hoffmann K, Stücker M (1997) Kutane<br />
Mikrozirkulation, Springer-Verlag, Berlin Hei<strong>de</strong>lberg<br />
15 el Gammal S, Hoffmann K, Stücker M, Altmeyer P (1997)<br />
Bildgeben<strong>de</strong> Verfahren in <strong>de</strong>r Dermatologie. Hautarzt 48:432-<br />
450<br />
16 Allard P, Stücker M, von Kobyletzki G, el Gammal S, Altmeyer<br />
P (1999) Zyklische intravenöse Antibiose als effizientes<br />
Therapiekonzept <strong>de</strong>s chronisch-rezidivieren<strong>de</strong>n Erysipels.<br />
Hautarzt 50:34-38<br />
17 San<strong>de</strong>r P, Happe M, Stücker M, Hermes N, Hoffmann K,<br />
Altmeyer P (1999) Tazaroten verstärkt <strong>de</strong>n antipsoriatischen<br />
Effekt von Dithranol bei <strong>de</strong>r chronisch stationären Psoriasis<br />
(CSP). Hautarzt 50:723-727.<br />
18 Auer T, Bararach-Buhles M, el Gammal S, Stücker M, Panz B,<br />
Popp C, et al. (1994) The hyperperfusion of the psoriatric plaque<br />
correlates histologically with dilatation of vessels. Acta Derm<br />
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19 Hoffmann K, Auer T, Stücker M, Hoffmann A, Altmeyer P<br />
(1998) Comparison of skin atrophy and vasoconstriction due to<br />
mometasone furoate, methylprednisolone and hydrocortisone. J<br />
Eur Acad Dermatol Venereol 10:137-142<br />
20 Stücker M, Happe M, Hoffmann K, Altmeyer P (2001)<br />
Evaluation <strong>de</strong>r okklusiven Effekte von Hydrokolloidfolien bei<br />
chronischer stationärer Psoriasis. Akt Dermatol 27:351-356<br />
21 Wolff HH, Kreusch JF, Wilhelm KP, Klaus S (1993) The<br />
psoriasis plaque test and topical corticosteroids: evaluation by<br />
computerized laser profilometry. Curr Probl Dermatol 21:107-<br />
113<br />
22 Fluhr JW, Gehring W, Bettinger J, Gloor M (1997) Skin<br />
Visiometer SV 400 zur Hautrauhigkeitsmessung: EDV-gestützte<br />
Transmissions-Profilometrie. Grundlagen und erste<br />
Untersuchungen. Kosmetische Medizin;18:42:47<br />
23 Altmeyer P, el Gammal S, Hoffmann K (1992) Ultrasound in<br />
<strong>de</strong>rmatology, Springer-Verlag, Berlin New York<br />
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In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
Bioengineering of the skin: non-invasive methods for the evaluation of efficacy 45<br />
24 Stücker M, Memmel U, Hoffmann M, Hartung J, Altmeyer P<br />
(2001) Vitamin B(12) cream containing avocado oil in the<br />
therapy of plaque psoriasis. Dermatology 203:141-147<br />
25 Kreuter JA, Gambichler T, Jansen T, Avermaete A, Happe M,<br />
Bacharach-Buhles M, Hoffmann K, Altmeyer P, von Kobyletzki<br />
G (2002) Low-dose UVA1 phototherapy in extragenital lichen<br />
sclerosus. J Am Acad Dermatol 46:251-255<br />
26 Kreuter A, Gambichler T, Avermaete A, Jansen T, Hoffmann M,<br />
Hoffmann K, Altmeyer P, von Kobyletzki G, Bacharach-Buhles<br />
M (2001) Combined treatment with calcipotriol ointment and<br />
low-dose ultraviolet A1 phototherapy in childhood morphea.<br />
Pediatr Dermatol 18:241-245<br />
27 Kaspar K, Vogt M, Ermert H, Altmeyer P, el Gammal S (1999)<br />
100 MHz sonography in the visualization of the palmar stratum<br />
corneum after application of various creams and ointments.<br />
Ultraschall Med 20:110-114<br />
28 Pagnoni A, Knuettel A, Welker P, Rist M, Stou<strong>de</strong>mayer T,<br />
Kolbe L, et al. (1999) Optical coherence tomography in<br />
<strong>de</strong>rmatology. Skin Res Technol 5:83-87<br />
29 Welzel J (2001) Optical coherence tomography in <strong>de</strong>rmatology:<br />
a review. Skin Res Technol 7:1-9<br />
30 Sauermann K, Clemann S, Jaspers S, Gambichler T, Altmeyer P,<br />
Hoffmann K, Ennen J (2002) Age related changes of human skin<br />
investigated with histometric measurements by confocal laser<br />
scanning microscopy in vivo. Skin Res Technol 8:52-56<br />
31 Sauermann K, Gambichler T, Jaspers S, Ra<strong>de</strong>nhausen M, Rapp<br />
S, Reich S, Altmeyer P, Teichmann S, Ennen J, Hoffmann K.<br />
Histometric data obtained by in vivo confocal laser scanning<br />
microscopy in patients with systemic sclerosis. BMC Dermatol<br />
(in press)<br />
32 Gonzales S, Gonzales E, White WM, Rajadhyaksha M,<br />
An<strong>de</strong>rson R (1999) Allergic contact <strong>de</strong>rmatitis: correlation of in<br />
vivo confocal imaging to routine histology. J Am Acad<br />
Dermatol 40:708-713<br />
33 Rajadhyaksha M, Gonzalez S, Zavislan JM, An<strong>de</strong>rson RR,<br />
Webb RH (1999) In vivo confocal scanning laser microscopy of<br />
human skin II: advances in instrumentation and comparison with<br />
histology. J Invest Dermatol 113:293-303<br />
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In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
46 Bioengineering of the skin: non-invasive methods for the evaluation of efficacy<br />
34 Serup J (1995) Bioengineering and the skin: standardization.<br />
Clin Dermatol 13:293-297<br />
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In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
The Repetitive Washing Test as a Mo<strong>de</strong>l for the Evaluation of Barrier Creams 47<br />
The Repetitive Washing Test as a Mo<strong>de</strong>l for the<br />
Evaluation of Barrier Creams<br />
W. Gehring<br />
Hautklinik am Klinikum <strong>de</strong>r Stadt Karlsruhe gGmbH<br />
Moltkestr, 120<br />
D-76133 Karlsruhe<br />
Germany<br />
Introduction................................................................... 47<br />
Principle of the repetitive washing test......................... 48<br />
Method .......................................................................... 48<br />
Emulsions as barrier creams ......................................... 49<br />
Modulation of an o/w-emulsion as a barrier cream by<br />
addition of glycerol and urea ........................................ 49<br />
Skin protection by Ectoin ............................................. 50<br />
Hydrating effect of Dexpanthenol ................................ 50<br />
Summary....................................................................... 50<br />
References..................................................................... 50<br />
Introduction<br />
The repetitive washing test shall be presented as a new method to<br />
evaluate barrier creams and to <strong>de</strong>monstrate the efficacy of<br />
moisturisers (1, 2). The method is based on the following<br />
procedure: Any washing procedure may lead to a disturbance of the<br />
barrier function, because tensi<strong>de</strong>s are able to emulgate barrier lipids<br />
and to disturb the bilamellary structure of the barrier lipids, which is<br />
important for the water binding capacity of the stratum corneum.<br />
This disturbance of the barrier lipids can be documented as an<br />
increase in transepi<strong>de</strong>rmal water loss and as a reduction in horny<br />
layer moisture.<br />
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In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
48 The Repetitive Washing Test as a Mo<strong>de</strong>l for the Evaluation of Barrier Creams<br />
Principle of the repetitive washing test<br />
The principle of the repetitive washing test is the standardisation<br />
and maximisation of toxic irritant influences of a washing<br />
procedure. Thus comparative studies can be performed in a state<br />
that is similar to the situation encountered un<strong>de</strong>r frequent exposure<br />
of the skin to cleansing agents. This test method is specially suited<br />
for the evaluation of barrier creams used to protect the skin from<br />
hydrophilic irritants.<br />
Method<br />
The repetitive washing test can be performed on one single day or<br />
on several consecutive days. The repeated washing procedures<br />
represent a maximisation process simulating a situation usually<br />
encountered in occupational <strong>de</strong>rmatology when the skin is exposed<br />
intensively to cleansing agents. The test is performed on the volar<br />
si<strong>de</strong> of both forearms using 0.01 n SLS (Fig 1). For the<br />
standardisation of the washing process the test persons use a foam<br />
rubber roll with a diameter of 3.5 cm and a length of 5 cm to which<br />
a handle is fixed. A piece of lead is fixed within the hollow handle<br />
to achieve a weight of the roll of 200 g. For the washing procedure<br />
the roll is soaked with the cleansing solution. Subsequently it is<br />
moved 50 times back and forth over the test area with the pressure<br />
of its own weight. Afterwards the forearms are rinsed shortly with<br />
lukewarm water to remove the residues of the tensi<strong>de</strong>s from the<br />
skin surface. Finally the forearms are carefully dried with a paper<br />
towel.<br />
To evaluate the effect of barrier creams the test preparations are<br />
applied directly before the washing procedure. A prevention or<br />
reduction of the increase in TEWL produced by the washing<br />
procedure documents the efficacy of a barrier cream. Often the<br />
<strong>de</strong>crease in TEWL is accompanied by an improvement of the<br />
Stratum corneum hydration.<br />
The efficacy of moisturisers is expressed as an increase in Stratum<br />
corneum hydration which can be <strong>de</strong>monstrated best if the test<br />
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The Repetitive Washing Test as a Mo<strong>de</strong>l for the Evaluation of Barrier Creams 49<br />
preparations are applied after the washing procedure which causes a<br />
<strong>de</strong>ficiency in the moisture content of the skin.<br />
Emulsions as barrier creams<br />
The application of emulsions alone produces an increase in skin<br />
hydration (Fig. 2). For this effect it is of minor importance which<br />
emulsion system is used. The water content <strong>de</strong>termines the <strong>de</strong>gree<br />
of moisturising. It makes no difference for the increase in Stratum<br />
corneum hydration whether the same amount of water is applied in<br />
a w/o or an o/w emulsion (3). For the effect as barrier cream, the<br />
situation is different. In a repetitive washing test with SLS it could<br />
be shown that only a w/o emulsion can form an efficient protective<br />
barrier (Fig. 3). There is no protective effect of an o/w emulsion<br />
against the washing procedure (Fig. 4). This is the reason for the<br />
basic <strong>de</strong>mand for w/o systems as skin protection of sensitive skin<br />
against hydrophilic irritants.<br />
Modulation of an o/w-emulsion as a barrier cream by<br />
addition of glycerol and urea<br />
The addition of glycerol and urea to an o/w-emulsion doesn't<br />
improve only the hydration of the Stratum corneum (Fig. 5) but also<br />
the protective effect against cleansing agents (3). Thus, an excellent<br />
cosmetic acceptance can be combined with the formation of an<br />
efficient protective barrier equalling that produced by a w/o<br />
emulsion (Fig. 6 and 7). A combination of 5% urea and 5% glycerol<br />
also is of advantage concerning the protective effect. The practical<br />
importance of this observation for care and protection in sensitive<br />
skin has been confirmed by a study of Grunewald et. al. where the<br />
situation encountered in occupations where the skin is exposed to<br />
prolonged or repeated water contact was mimicked. In an in-use test<br />
with five daily washing procedures on eight consecutive days with<br />
intermitting application of an o/w emulsion containing 5% urea and<br />
5% glycerol an almost complete prevention of irritation as<br />
compared with unprotected skin could be <strong>de</strong>monstrated (4).<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
50 The Repetitive Washing Test as a Mo<strong>de</strong>l for the Evaluation of Barrier Creams<br />
Skin protection by Ectoin<br />
For the substance ectoin a stabilising effect on membranes is<br />
expected. In a study which is not yet published we could<br />
<strong>de</strong>monstrate that pre-treatment with a micro-emulsion containing<br />
ectoin had a stabilising effect on the epi<strong>de</strong>rmal barrier function<br />
shown by a <strong>de</strong>crease of TEWL in a repetitive washing test. This<br />
observation justifies the use of ectoin for sensitive skin (Fig. 8).<br />
Hydrating effect of Dexpanthenol<br />
After the experimental <strong>de</strong>struction of the epi<strong>de</strong>rmal barrier function<br />
which was accompanied by a loss of Stratum corneum hydration in<br />
a repetitive washing test over 5 days, Dexpanthenol increased the<br />
skin's moisture content (5). In spite of the repetitive washing<br />
procedures the Stratum corneum hydration increased on the third<br />
day. This effect could clearly attributed to Dexpanthenol. On the<br />
fifth day of the repetitive washings the loss of hydration of the<br />
Stratum corneum was markedly reduced (Fig. 9).<br />
Summary<br />
Among various test methods, the repetitive washing test has shown<br />
its usefulness for the evaluation of the efficacy of barrier creams<br />
and their modulation. Furthermore the test can be applied to<br />
investigate the hydrating effects of certain substances.<br />
References<br />
1 Gehring W., Gloor M., Kleesz P.: Predictive Washing Test for<br />
Evaluation the Individual Eczema Risk. Contact Dermatitis 39,<br />
8-13, 1998<br />
2 Gehring W., Gloor M.: Der repetitive Waschtest als Mo<strong>de</strong>ll zur<br />
Beurteilung von Hautschutzpräparaten am Beispiel einer<br />
<strong>de</strong>xpanthenolhaltigen Formulierung. Akt. Dermatogie, 27, 279-<br />
284, 2001<br />
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In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
The Repetitive Washing Test as a Mo<strong>de</strong>l for the Evaluation of Barrier Creams 51<br />
3 Bettinger J., Gloor M., Gehring W.: Influence of a pretreatment<br />
with emulsions on the <strong>de</strong>hydration of the skin by surfactants. Int.<br />
J. Cosm. Sci. 16, 53-60, 1994<br />
4 Grunewald A.M., Gloor M., Bettinger J., Gehring W., Kleesz P.:<br />
Barrier creams: Commercially available barrier creams versus<br />
urea- and glycerol- containing oil in water emulsions.<br />
Dermatosen 43, 69-74, 1995<br />
5 Gehring W., Gloor M., Der Effekt von Dexpanthenol bei<br />
experimentell geschädigter Haut. Z Hautkr. 76,1-7, 2001<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
52 Impact of Topical Skin Care and Maintenance Products on Stratum Corneum Barrier<br />
Impact of Topical Skin Care and Maintenance<br />
Products on Stratum Corneum Barrier<br />
M. Gloor<br />
Hautklinik am Klinikum <strong>de</strong>r Stadt Karlsruhe gGmbH<br />
Moltkestr, 120<br />
D-76133 Karlsruhe<br />
Germany<br />
Preventive Skin Protection............................................ 53<br />
Regenerative Skin Protection........................................ 53<br />
A Case Apart: Aluminum Chlori<strong>de</strong> .............................. 55<br />
References..................................................................... 55<br />
The structure of the human stratum corneum resembles a brick wall,<br />
with the offset between corneocyte layers conferring greater<br />
mechanical stability than the columnar structure of the horny layer<br />
found in some animal species. This brick wall structure causes<br />
substantial lengthening of the intercellular permeation pathway<br />
used by both outbound diffusion of water (transepi<strong>de</strong>rmal water<br />
loss) and inbound pe<strong>net</strong>ration of most topical drugs and harmful<br />
substances in crossing the stratum corneum barrier. The barrier<br />
function of the stratum corneum results from the lamellar structure<br />
of the stratum corneum intercellular lipids. These polar lipids are<br />
aligned so that the lipophilic ends and the hydrophilic ends are next<br />
to each other, resulting in multilamellar layers in which a lipophilic<br />
layer alternates with a hydrophilic layer. The hydrophilic layers are<br />
characterized by their water-holding capacity. The lipophilic layers<br />
can switch between a solid crystalline state, a gel crystalline state,<br />
and a liquid crystalline state. When in the solid crystalline state,<br />
skin lipids can prevent drug pe<strong>net</strong>ration. Some ingredients of<br />
topical skin products, glycerol in particular, can modify the stratum<br />
corneum lipid crystallization state, which, however, <strong>de</strong>pends also<br />
on numerous other factors including temperature [1,2].<br />
Atopic <strong>de</strong>rmatitis is characterized by a change in barrier lipids.<br />
There is a relative lack of cerami<strong>de</strong>s, above all of cerami<strong>de</strong> 1,<br />
thought to have a key role in maintaining stratum corneum barrier<br />
function. Reduced barrier regeneration after stratum corneum<br />
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Impact of Topical Skin Care and Maintenance Products on Stratum Corneum Barrier 53<br />
compromise appears to be a major un<strong>de</strong>rlying problem in atopic<br />
<strong>de</strong>rmatitis sufferers. The physiological correlate of those<br />
biochemical changes is the known reduction in stratum corneum<br />
moisture content and the known increase in transepi<strong>de</strong>rmal water<br />
loss in atopic <strong>de</strong>rmatitis patients [3]. Atopic <strong>de</strong>rmatitis sufferers<br />
therefore feel a particular need for the use of skin care creams. The<br />
skin of ol<strong>de</strong>r people poses different problems. While transepi<strong>de</strong>rmal<br />
water loss seems to be <strong>de</strong>creased with age, barrier regeneration after<br />
injury appears to be impaired in the skin of el<strong>de</strong>rly people. The<br />
moisture content of the stratum corneum appears to be essentially<br />
unchanged with age [4]. Atopic <strong>de</strong>rmatitis sufferers and, to a lesser<br />
extent, ol<strong>de</strong>r people therefore require skin protection creams. A<br />
basic distinction is to be ma<strong>de</strong> between preventive and regenerative<br />
skin protection.<br />
Preventive Skin Protection<br />
Preventive skin protection has long been known. In fact, over three<br />
<strong>de</strong>ca<strong>de</strong>s ago, lipophilic topical skin products had already been<br />
recognized to confer preventive skin protection against hydrophilic<br />
harmful substances, and, conversely, hydrophilic products had been<br />
consi<strong>de</strong>red to protect the skin against lipophilic harmful compounds.<br />
Recent research by the author has shown that preventive<br />
skin protection remains substantial over a treatment period of<br />
3 weeks. After longer treatment periods, however, there was a<br />
ten<strong>de</strong>ncy for reduced preventive skin protection [5]. Also, W/O<br />
emulsions are known to be capable of preventing skin <strong>de</strong>hydration<br />
produced by washing [6].<br />
Regenerative Skin Protection<br />
Regenerative skin protection has been known for a comparatively<br />
short period of time. Most studies along these lines have used<br />
glycerol, some urea, and one polyethylene glycol.<br />
Bettinger et al. [6] found that O/W emulsions containing glycerol or<br />
urea prevented skin <strong>de</strong>hydration caused by a single washing<br />
procedure although the same O/W emulsion without these active<br />
constituents was completely ineffective. In a study by Grunewald<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
54 Impact of Topical Skin Care and Maintenance Products on Stratum Corneum Barrier<br />
et al. [7], healthy volunteers un<strong>de</strong>rwent standardized washings three<br />
times daily for one week. This treatment produced a substantial<br />
increase in transepi<strong>de</strong>rmal water loss (TEWL) as evi<strong>de</strong>nce of<br />
barrier compromise, a marked increase in laser Doppler readings as<br />
evi<strong>de</strong>nce of irritative hyperemia, and pronounced <strong>de</strong>hydration of the<br />
stratum corneum. Application of a 10% glycerol or 10% urea O/W<br />
emulsion after each washing prevented the <strong>de</strong>crease in corneometry<br />
readings and impressively reduced the TEWL and laser Doppler<br />
increases. In another study, Bettinger et al. [8] further investigated<br />
the mechanism of this effect on the example of glycerol. After<br />
producing stratum corneum damage either by exposure to sodium<br />
lauryl sulfate (SLS) or by tape stripping, these authors treated the<br />
test areas either with glycerol or with water un<strong>de</strong>r occlusive<br />
conditions. Treatment was followed by barrier function tests. Both<br />
the alkali resistance test and the SLS irritation test showed that<br />
glycerol treatment improved stratum corneum barrier function, as<br />
compared with water treatment. In a similar study along these<br />
lines, Fluhr et al. [9] produced barrier compromise by 3 days' treatment<br />
with SLS. This was followed by 4 days' treatment with<br />
glycerol products. TEWL was <strong>de</strong>termined after one week with no<br />
treatment at all. Active-treated test areas were compared with<br />
untreated and vehicle-treated sites. Glycerol produced significant<br />
reductions in TEWL versus both vehicle and untreated. An<br />
intriguing finding of this study was that the effect of glycerol<br />
persisted for a full week beyond treatment. Taken together, the<br />
results of the studies presented above go to show that glycerol<br />
modulates barrier regeneration.<br />
Animal studies by Proksch et al. [10] suggest that barrier<br />
regeneration is controlled by TEWL. An increase in TEWL,<br />
associated with a flux of electrolytes, results in improved barrier<br />
regeneration. Proksch et al. observed this effect also in humans,<br />
while two other study groups failed to confirm this [11,12,13]. It<br />
has thus not been <strong>de</strong>termined <strong>de</strong>finitively whether the hygroscopic<br />
effect of glycerol is in<strong>de</strong>ed the mechanism of action un<strong>de</strong>rlying its<br />
ability to improve barrier regeneration. Supportive evi<strong>de</strong>nce comes<br />
from studies with other hygroscopic substances (including urea and<br />
polyethylene glycol) which have also <strong>de</strong>monstrated barrierrestoring<br />
effects [14,15,16,17].<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
Impact of Topical Skin Care and Maintenance Products on Stratum Corneum Barrier 55<br />
Until recently, there was <strong>de</strong>bate whether regenerative skin<br />
protection persists for prolonged treatment periods. Lodén et al.<br />
found that regenerative skin protection was no longer <strong>de</strong>monstrable<br />
after prolonged treatment with urea. In later studies, however, the<br />
same authors observed persistence of skin protection when using a<br />
cream containing urea, but they could not rule out that that effect<br />
might have been due to the vehicle [15,16]. Long-term glycerol<br />
treatment studies by the author <strong>de</strong>monstrated persistence of skin<br />
protection for a period of 6 weeks [5].<br />
A Case Apart: Aluminum Chlori<strong>de</strong><br />
Five percent aluminum chlori<strong>de</strong> solution occlusive film dressings<br />
reduce TEWL and hydrocortisone blanching but show no effect<br />
whatsoever in the SLS irritation test. These conflicting findings<br />
suggest an intriguing interpretation: While reducing TEWL and<br />
drug pe<strong>net</strong>ration from a topical skin product into the skin,<br />
aluminum chlori<strong>de</strong> showed no protective effect in a standard skin<br />
irritation mo<strong>de</strong>l, suggesting that aluminum chlori<strong>de</strong> and/or any<br />
compounds it may form with cutaneous proteins are immediately<br />
<strong>de</strong>stroyed by the surfactant SLS. This constellation shows a striking<br />
similarity to the situation in the skin of ol<strong>de</strong>r people where TEWL<br />
and drug pe<strong>net</strong>ration are also reduced, while barrier compromise<br />
tests appear to produce greater irritation than in younger individuals<br />
[4].<br />
References<br />
1 Forslind B (1996) New barrier mo<strong>de</strong>ls critically compared. Turk<br />
J Dermatopathol 5:35-43<br />
2 Melnik BC (1991) Disturbances of epi<strong>de</strong>rmal lipid metabolism<br />
and barrier function in atopic eczema. In: Ruzicka T, Ring J,<br />
Przybilla B (eds): Handbook of atopic <strong>de</strong>rmatitis. Springer<br />
Verlag, Berlin, Hei<strong>de</strong>lberg, New York, pp 296-305<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
56 Impact of Topical Skin Care and Maintenance Products on Stratum Corneum Barrier<br />
3 Gloor M (2000) Externagrundlagen bei speziellen Indikationen.<br />
In: Gloor M, Thoma K, Fluhr J (eds) Dermatologische<br />
Externatherapie unter beson<strong>de</strong>rer Berücksichtigung <strong>de</strong>r<br />
Magistralrezeptur. Springer Verlag, Berlin, Hei<strong>de</strong>lberg, New<br />
York, pp 133-151<br />
4 Gloor M (2001) Anfor<strong>de</strong>rungen an Kosmetika bei <strong>de</strong>r<br />
Altershaut. SÖFW J 127:60-68<br />
5 Gloor M, Gehring W (2001) Increase in hydratation and<br />
protective function of horny layer by glycerol and a w/o<br />
emulsion: are these effects maintained during long-term use?<br />
Contact Dermatitis 44:123-125<br />
6 Bettinger J, Gloor M, Gehring W (1994) Influence of a<br />
pretreatment with emulsions on the <strong>de</strong>hydration of the skin by<br />
surfactants. Int J Cosm Sci 16:53-60<br />
7 Grunewald AM, Gloor M, Gehring W, Kleesz P (1995) Barrier<br />
creams-commercially available barrier creams versus urea- and<br />
glycerol containing oil-in water emulsions. Dermatosen 43:69-<br />
74<br />
8 Bettinger J, Gloor M, Peter C, Kleesz P, Fluhr J, Gehring W<br />
(1998) Opposing effects of glycerol on the protective function of<br />
the horny layer against irritants and on the pe<strong>net</strong>ration of hexyl<br />
nicotinate. Dermatology 197:18-24<br />
9 Fluhr JW, Gloor M, Lehmann L, Lazzerini S, Distante P,<br />
Berar<strong>de</strong>sca E (1999) Glycerol accelerates recovery of barrier<br />
function in vivo. Acta Derm Venereol (Stockh) 79: 418-421<br />
10 Proksch E, Feingold KR, Mao Quiang M, Elias PM (1991)<br />
Barrier function regulates epi<strong>de</strong>rmal DNA synthesis. J Clin<br />
Invest 87:1668-1673<br />
11 Proksch E, Brasch J, Sterry W (1996) Integrity of the<br />
permeability barrier regulates epi<strong>de</strong>rmal Langerhans cell<br />
<strong>de</strong>nsity. Br J Dermatol 134:630-638<br />
12 Kerkhof PCM van <strong>de</strong>, Mare S <strong>de</strong>, Arnold WP, Erp PEJ (1995)<br />
Epi<strong>de</strong>rmal regeneration and occlusion. Acta Derm Venereol<br />
(Stockh) 75:6-8<br />
13 Welzel J, Wilhelm KP, Wolff HH (1996) Skin permeability<br />
barrier and occlusion: No <strong>de</strong>lay of repair in irritated human skin.<br />
Contact Dermatitis 35:163-169<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
Impact of Topical Skin Care and Maintenance Products on Stratum Corneum Barrier 57<br />
14 Gloor M, Wolnicki D (2001) Do polyethylene glycol gels have a<br />
protective effect on the skin. Contact Dermatitis 44:316-317<br />
15 Lodén M (1996): Urea containing moisturizers influence barrier<br />
properties of normal skin. Arch Dermatol Res; 288:103-107<br />
16 Lodén M, An<strong>de</strong>rsson AC, Lindberg M (1999) Improvement of<br />
skin barrier function in patients with atopic <strong>de</strong>rmatitis after<br />
treatment with a moisturizing cream (Cano<strong>de</strong>rm®). Br J<br />
Dermatol 140:264-267<br />
17 Serup J (1992) A double blind comparison of two creams<br />
containing urea as the active ingredient. Acta Derm Venereol<br />
(Stockh) Suppl 177: 34-37<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
58 The Tan<strong>de</strong>m Repeated Irritation Test (TRIT)<br />
The Tan<strong>de</strong>m Repeated Irritation Test (TRIT)<br />
A New Method for the Evaluation of Barrier Creams<br />
J. Spoo 1 , W. Wigger-Alberti 1 , S. Schliemann-Willers 1 , A. Klotz 2 , P. Elsner 1<br />
1<br />
Department of Dermatology, Friedrich-Schiller-University<br />
2<br />
Stockhausen GmbH & Co. KG, Krefeld<br />
Erfurter Str. 35<br />
D-07740 Jena<br />
Germany<br />
Introduction................................................................... 58<br />
Patients and Methods .................................................... 60<br />
• Subjects........................................................................ 60<br />
• Protective cream (STOKODERM ®, Stockhausen,<br />
Krefeld, Germany)....................................................... 60<br />
• Procedure ..................................................................... 60<br />
• Evaluation methods ..................................................... 61<br />
• Statistics....................................................................... 62<br />
Results........................................................................... 62<br />
Discussion ..................................................................... 65<br />
References..................................................................... 66<br />
Introduction<br />
Much effort has been un<strong>de</strong>rtaken to <strong>de</strong>velop valid methods for<br />
evaluation of the benefit of protective creams to prevent irritant<br />
contact <strong>de</strong>rmatitis (ICD) which remains the most common<br />
professional skin disease. Since Suskind introduced the 'sli<strong>de</strong> test' to<br />
evaluate protective creams in the 1950s [1] various in vitro and in<br />
vivo studies have been performed to investigate both the effects of<br />
irritants on skin barrier function and the benefit of protective<br />
creams un<strong>de</strong>r experimental conditions [1-8] All of these studies,<br />
however, are consi<strong>de</strong>red not to be close enough to real work place<br />
situations.<br />
In 1994, Frosch & Kurte introduced the repetitive irritation test<br />
(RIT) with cumulative irritation over a two-week period by<br />
standard irritants such as sodium lauryl sulfate (SLS), sodium<br />
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In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
The Tan<strong>de</strong>m Repeated Irritation Test (TRIT) 59<br />
hydroxi<strong>de</strong>, lactic acid and toluene [9]. This mo<strong>de</strong>l has been<br />
modified and used in many laboratories as a routine procedure as it<br />
was consi<strong>de</strong>red to be suitable for comparing protective creams<br />
simultaneously to non-pretreated control sites on the backs of<br />
volunteers [10]. Since short duration and easy application given in a<br />
one-week test using the forearm of healthy volunteers was<br />
consi<strong>de</strong>red highly <strong>de</strong>sirable, a test mo<strong>de</strong>l based on the RIT was<br />
<strong>de</strong>veloped for opitimizing the concentrations of irritants against<br />
which protective creams are tested, and for evaluating the necessary<br />
cumulative application time [11, 12]. A one-week period proved<br />
sufficient for evaluating the efficacy of protective creams against<br />
most irritants even if lower concentrations of irritants were used.<br />
A multicentre study subsequently was <strong>de</strong>signed to standardize a test<br />
procedure for the evaluation of skin protective products. In this<br />
irritation study, a repeated short-time occlusive irritation test<br />
(ROIT) was evaluated [13]. Using 2 irritants (SLS and toluene, each<br />
applied twice daily for 30 min) the evaluation showed that<br />
significant results could be achieved with the 5-day protocol.<br />
It may be criticized that in all mo<strong>de</strong>ls presented the investigation of<br />
protective cream efficacy has been limited to the exposure of a<br />
single irritant only. The anionic surfactant SLS and the organic<br />
solvent toluene have mainly been used although repetitive contact<br />
to both hydrophilic and hydrophobic substances together or, more<br />
commonly, one after the other, is frequent in the workplace setting.<br />
We recently investigated concurrent application of SLS and toluene<br />
showing that a mixed application of these irritants induced<br />
significantly stronger reactions than those caused by twice daily<br />
application of each irritant on its own [14]. It is obvious that the<br />
additive effect is important for the use of protective creams in<br />
practice and the way they should be tested.<br />
Therefore, the sequential application of two irritants in the so-called<br />
tan<strong>de</strong>m repeated irritation test (TRIT) was investigated in the<br />
present study to evaluate the benefit of a commercially available<br />
protective cream compared to non-pretreated control sites.<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
60 The Tan<strong>de</strong>m Repeated Irritation Test (TRIT)<br />
Patients and Methods<br />
• Subjects<br />
Twenty healthy non-preselected Caucasian volunteers (17 women<br />
and 3 men; aged 18 - 49 years, median 29 years,) without any skin<br />
diseases were inclu<strong>de</strong>d. Informed consent was obtained from all<br />
participants, and the study was approved by the local ethical<br />
committee. Subjects were allowed to bathe as usual, but were<br />
instructed to avoid direct application of <strong>de</strong>tergents, moisturizers or<br />
emollients on their forearms during the 5 days of investigation.<br />
• Protective cream (STOKODERM ® )<br />
Composition according to <strong>IN</strong>CI <strong>de</strong>claration: aqua, octyl stearate,<br />
glyceryl stearate SE, glycerin, cetearyl alcohol, sodium<br />
bischlorophenyl sulfamine, isopropyl palmitate, glycol distearate,<br />
xanthan gum, ceteareth-6, phenoxyethanol, methylparaben,<br />
ethylparaben, propylparaben, butylparaben, ceteareth-25, fragrance.<br />
• Procedure<br />
The application area was the clinically normal skin of the medial<br />
volar forearms. The placement of test fields and arms (6 chambers<br />
on the right and left forearms) was randomized. Three test fields<br />
were treated with 0.05 ml of protective cream rubbed onto a skin<br />
area 2 cm in diameter with a gloved finger. The other test fields<br />
served as untreated controls. After 10 min pretreatment, the irritants<br />
were applied on all 6 premarked test sites on the forearms for 30<br />
min un<strong>de</strong>r occlusion (Finn Chambers, 12mm diameter, filling<br />
volume 0.05 ml; Epitest Ltd., Hyrlä, Finland). The volunteers were<br />
tested with 0.5% aqueous SLS (Sigma, St. Louis, MO) or undiluted<br />
toluene (E. Merck, Darmstadt, Germany). After removal of the<br />
patches the skin was cleaned with a dry paper tissue. A second<br />
exposure with 0.5% aqueous SLS or undiluted toluene was<br />
performed the same day after 3 h. Thus, 3 treatment combinations<br />
were investigated, resulting in a repeated irritation due to SLS/SLS;<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
The Tan<strong>de</strong>m Repeated Irritation Test (TRIT) 61<br />
toluene/toluene; and SLS/toluene and the pre-irritation application<br />
of Stoko<strong>de</strong>rm on the respective test areas. Since in a previous study<br />
the exact chronological or<strong>de</strong>r of the irritants was shown not to have<br />
any effect on the <strong>de</strong>gree of irritation [14] the combination<br />
toluene/SLS was not inclu<strong>de</strong>d in the present study. Using this<br />
scheme of application the volunteers were treated from day 1 to day<br />
4 (in each case at the same time of day).<br />
• Evaluation methods<br />
The study was carried out from October to November 2000. All<br />
visual scorings and bioengineering measurements to compare the<br />
intensity of reactions were performed daily before starting<br />
treatments (day 1-4) and on day 5 by the same observer un<strong>de</strong>r<br />
controlled environmental conditions. All measurements were<br />
carried out in an air-conditioned room (room temperature 20-22°C,<br />
relative humidity between 34% and 46%) after 30 min for<br />
equilibration.<br />
Clinical score gra<strong>de</strong>d for erythema, scaling and fissuring was<br />
recor<strong>de</strong>d according to Frosch & Kligman [15].<br />
Transepi<strong>de</strong>rmal water loss (TEWL) (expressed in g/m 2 h) was<br />
measured using an evaporation meter (Tewameter TM 210,<br />
Courage & Khazaka, Cologne, Germany). Measurements were<br />
taken according to the Gui<strong>de</strong>lines of the Standardization Group of<br />
the European Society of Contact Dermatitis [16].<br />
Instrumental colour measurements were taken with a Minolta<br />
Chromameter (CR-200, Minolta, Osaka, Japan) according to<br />
published recommendations [17]. The colour coordinates were<br />
expressed in the L*a*b* 3-dimensial colourimetric system. The a*<br />
value is the component of separation between red (positive value)<br />
and green (negative value) as a sensitive measure for quantifying<br />
erythema.<br />
Electrical capacitance, indicating the hydration level of the skin,<br />
was measured by a Corneometer CM 825 (Courage & Khazaka,<br />
Cologne, Germany) [18].<br />
If the clinical score progressed to a severe <strong>de</strong>gree (>5), exposure<br />
was discontinued. For these test areas, the maximal scores and the<br />
measured values for TEWL, chromametry, and capacitance<br />
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In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
62 The Tan<strong>de</strong>m Repeated Irritation Test (TRIT)<br />
obtained on the day of discontinuance were used for the final<br />
calculation.<br />
• Statistics<br />
Statistical analysis was conducted with SPSS/PC+ (Version 10.0,<br />
SPSS, Chicago, ILL, USA). Data of visual scoring are presented as<br />
means ± SEM. TEWL, skin colour a*, and skin hydration<br />
(differences between baseline values and after irritation) were<br />
<strong>de</strong>termined. As the data were not normally distributed the<br />
differences between means were checked for significance using the<br />
Wilcoxon test for paired data for the erythema score, the<br />
comparison of TEWL, skin capacitance, and skin colour. The<br />
chosen level of significance was p
The Tan<strong>de</strong>m Repeated Irritation Test (TRIT) 63<br />
SLS/SLS d5 Visual Score TEWL Chromametry Capacitance<br />
Control mean 1.95 20.92 3.14 -9.07<br />
SEM 0.25 3.34 0.75 2.15<br />
Stoko<strong>de</strong>rm mean 0.95 12.15 1.12 -8.21<br />
SEM 0.18 1.74 0.41 2.07<br />
TOL/TOL d5 Visual Score TEWL Chromametry Capacitance<br />
Control mean 1.55 3.57 1.78 -14.33<br />
SEM 0.32 0.82 0.69 2.74<br />
Stoko<strong>de</strong>rm mean 1.80 2.38 1.62 -11.43<br />
SEM 0.22 0.33 0.53 2.97<br />
SLS/TOL d5 Visual Score TEWL Chromametry Capacitance<br />
Control mean 3.75 32.65 5.76 -14.27<br />
SEM 0.27 5.92 0.79 3.50<br />
Stoko<strong>de</strong>rm mean 2.65 14.54 4.60 -13.97<br />
SEM 0.34 2.44 0.84 2.10<br />
Table 1: Mean-values and standard errors of the mean (SEM) at<br />
day 5 for visual scoring (VS), transepi<strong>de</strong>rmal water loss (TEWL,<br />
g/m 2 h), skin redness (chromametry, a*) and skin hydration<br />
measured by capacitance (arbitrary units). Data are given for twice<br />
daily application of SLS, toluene and tan<strong>de</strong>m irritation.<br />
∆ TEWL [g/m²h]<br />
30<br />
25<br />
20<br />
15<br />
10<br />
5<br />
0<br />
SLS/SLS<br />
Stoko<strong>de</strong>rm/SLS/SLS<br />
*<br />
d2 d3 d4 d5<br />
Fig. 1: TEWL (mean ± SEM, n=20) after sequential application of<br />
SLS/SLS. On day 3, 4 and 5 the protective effect of Stoko<strong>de</strong>rm on<br />
the irritation was statistically significant (*p
64 The Tan<strong>de</strong>m Repeated Irritation Test (TRIT)<br />
period that was slightly suppressed by Stoko<strong>de</strong>rm (Fig. 2). A<br />
mo<strong>de</strong>rate benefit of the test product against toluene was also<br />
confirmed by the measurement of skin capacitance and<br />
chromametry while the visual score showed contrary results.<br />
∆ TEWL [g/m²h]<br />
5<br />
4,5<br />
4<br />
3,5<br />
3<br />
2,5<br />
2<br />
1,5<br />
1<br />
0,5<br />
0<br />
TOL/TOL<br />
Stoko<strong>de</strong>rm/TOL/TOL<br />
d2 d3 d4 d5<br />
Fig. 2: TEWL (mean ± SEM, n=20) after sequential application of<br />
TOL/TOL. The protective effect of Stoko<strong>de</strong>rm on the irritation was<br />
not statistically significant.<br />
Monitoring of the instrumental measurements and the visual score<br />
following sequential application of SLS/toluene showed that the<br />
induced reactions were significantly stronger than those caused by<br />
twice daily application of the single irritants SLS or toluene.<br />
Additionally, pretreatment with Stoko<strong>de</strong>rm suppressed the irritant<br />
reaction presented by all measurements. The TEWL and the visual<br />
scoring indicated a significant benefit of the product tested (Fig. 3).<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
∆ TEWL [g/m²h]<br />
45<br />
40<br />
35<br />
30<br />
25<br />
20<br />
15<br />
10<br />
5<br />
0<br />
SLS/TOL<br />
Stoko<strong>de</strong>rm/SLS/TOL<br />
d2 d3 d4 d5<br />
The Tan<strong>de</strong>m Repeated Irritation Test (TRIT) 65<br />
Fig. 3: TEWL (mean ± SEM, n=20) after sequential application of<br />
SLS/TOL. On day 4 and 5 the protective effect of Stoko<strong>de</strong>rm on the<br />
irritation was statistically significant (* p
66 The Tan<strong>de</strong>m Repeated Irritation Test (TRIT)<br />
instance, are repetitively exposed to water-based metal working<br />
fluids, neat oils, <strong>de</strong>tergents and organic solvents. This emphasizes<br />
the significant practical consequences of an interaction between<br />
irritant chemicals.<br />
Stoko<strong>de</strong>rm® has previously been shown to significantly suppress<br />
the irritation due to SLS and toluene as single irritants in an animal<br />
mo<strong>de</strong>l. The irritants were applied daily for 2 weeks to shaved back<br />
skin of young guinea pigs and the cream was applied 2 h prior to<br />
and immediately after exposure to the irritants. Control animals<br />
were treated with the irritants only [26]. It is satisfying that our<br />
results confirm the protective effect of Stoko<strong>de</strong>rm against the single<br />
irritants though the benefit against toluene was not significant in our<br />
test, which confirms the results for other creams. The animal study<br />
did, however, not assess combined irritation in a tan<strong>de</strong>m mo<strong>de</strong>l.<br />
To establish a new method to evaluate the benefit of protective<br />
creams we performed the study with SLS and toluene which have<br />
been used as standard irritants in various types of patch tests [2, 3,<br />
9-14, 20, 23, 26]. Our results show that the TRIT seems to have<br />
great potential in differentiating the efficacy of protective creams in<br />
a relevant experimental setting that is quite close to a workplace<br />
situation where <strong>de</strong>tergents and organic solvents are the major<br />
irritants used not exclusively, but concurrently. Nevertheless, this<br />
mo<strong>de</strong>l must be validated by field studies un<strong>de</strong>r actual usage<br />
conditions. Interactive profiles of further relevant irritants should be<br />
investigated with attention to professions where a multitu<strong>de</strong> of<br />
hazardous substances may cause ICD. We hope that this mo<strong>de</strong>l also<br />
proves useful in other hands to investigate both the effect of<br />
combinations of irritants to the skin and the way skin care products<br />
may prevent contact <strong>de</strong>rmatitis.<br />
References<br />
1 Suskind RR (1955) The present status of silicone protective<br />
creams. Indust Med Surg 24:413-416<br />
2 Boman A, Wahlberg JE, Johansson G (1982) A method for the<br />
study of the effect of barrier creams and protective gloves on the<br />
percutaneous absorption of solvents. Dermatologica 164:157-<br />
160<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
The Tan<strong>de</strong>m Repeated Irritation Test (TRIT) 67<br />
3 Mahmoud G, Lachapelle JM, Van Neste D (1984) Histological<br />
assessment of skin damage by irritants: its possible use in the<br />
evaluation of a 'barrier cream'. Contact Dermatitis 11:179-185<br />
4 Lodén M (1986) The effect of 4 barrier creams on the absorption<br />
of water, benzene, and formal<strong>de</strong>hy<strong>de</strong> into excised human skin.<br />
Contact Dermatitis 14:292-296<br />
5 Treffel P, Gabard B, Juch R (1994) Evaluation of barrier creams:<br />
an in vitro technique on human skin. Acta Derm Venereol 74:7-<br />
11<br />
6 Grunewald A, Gloor M, Gehring W, Kleesz P (1995) Efficacy of<br />
skin barrier creams. In: Elsner P. Maibach HI. (Eds.) Irritant<br />
Dermatitis: New clinical and experimental aspects. Karger,<br />
Basel, p 187-197<br />
7 Fine Olivarius F, Hansen A B, Karlsmark T, Wulf H C (1996)<br />
Water protective effect of barrier creams and moisturizing<br />
creams: a new in vivo test method. Contact Dermatitis 35:219-<br />
225<br />
8 Zhai H, Willard P, Maibach HI (1998) Evaluating skinprotective<br />
materials against contact irritants and allergens.<br />
Contact Dermatitis 38:155-158<br />
9 Frosch P J, Kurte A (1994) Efficacy of skin barrier creams (IV).<br />
The repetitive irritation test (RIT) with a set of 4 standard<br />
irritants. Contact Dermatitis 31:161-168<br />
10 Schlüter-Wigger W, Elsner P (1996) Efficacy of 4 commercially<br />
available protective creams in the repetitive irritation test (RIT).<br />
Contact Dermatitis 34:278-283<br />
11 Wigger-Alberti W, Rougier A, Richard A, Elsner P (1998)<br />
Efficacy of protective creams in a modified repeated irritation<br />
test (RIT): methodological aspects. Acta Derm Venereol 78:270-<br />
273<br />
12 Wigger-Alberti W, Caduff L, Burg G, Elsner P (1999)<br />
Experimentally-induced chronic irritant contact <strong>de</strong>rmatitis to<br />
evaluate the efficacy of protective creams in vivo. J Am Acad<br />
Dermatol 40:590-596<br />
13 Sch<strong>net</strong>z E, Diepgen TL, Elsner P, Frosch PJ, Klotz AJ, Kresken<br />
J et al. (2000) Multicentre study for the <strong>de</strong>velopment of an in<br />
vivo mo<strong>de</strong>l to evaluate the influence of topical formulations on<br />
irritation. Contact Dermatitis 42: 336-343<br />
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14 Wigger-Alberti W, Krebs A, Elsner P (2000) Experimental<br />
irritant contact <strong>de</strong>rmatitis due to cumulative epicutaneous<br />
exposure to sodium lauryl sulphate and toluene: single and<br />
concurrent application. Br J Dermatol 143:551-556<br />
15 Frosch PJ, Kligman AM (1979) The soap chamber test. A new<br />
method for assessing the irritancy of soaps. J Am Acad<br />
Dermatol 1:35-41<br />
16 Pinnagoda J, Tupker R A, Agner T, Serup J (1990) Gui<strong>de</strong>lines<br />
for transepi<strong>de</strong>rmal water loss (TEWL) measurement. A report<br />
from the Standardization Group of the European Society of<br />
Contact Dermatitis. Contact Dermatitis 22:164-178<br />
17 Fullerton A, Fischer T, Lahti A, Wilhelm KP, Takiwaki H,<br />
Serup J (1996) Gui<strong>de</strong>lines for measurement of skin colour and<br />
erythema. A report from the Standardization Group of the<br />
European Society of Contact Dermatitis. Contact Dermatitis<br />
35:1-10<br />
18 Courage W (1994) Hardware and Measuring Principle:<br />
Corneometer. In: Elsner P, Bera<strong>de</strong>sca E, Maibach HI (Eds.)<br />
Bioengineering of the Skin: Water and the Stratum Corneum.<br />
CRC Press, Boca Raton p 171-175<br />
19 Hogan DJ, Dannaker CJ, Lal S, Maibach HI (1990) An<br />
international survey on the prognosis of occupational contact<br />
<strong>de</strong>rmatitis of the hands. Derm Beruf Umwelt 38:143-147<br />
20 Lachapelle JM (1996) Efficacy of protective creams and/or gels.<br />
In: Elsner P, Lachapelle JM, Wahlberg JE, Maibach HI (Eds.)<br />
Prevention of Contact Dermatitis. Karger, Basel p. 182-192<br />
21 Wigger-Alberti W, Elsner P (1998) Do barrier creams and<br />
gloves prevent or provoke contact <strong>de</strong>rmatitis? Am J Contact<br />
Dermatitis 9:100-106<br />
22 Wigger-Alberti W, Elsner P (2000) Barrier Creams and<br />
Emollients. In: Kanerva L, Elsner P, Wahlberg JE, Maibach HI<br />
(Eds.) Handbook of Occupational Dermatology. Springer, Berlin<br />
Hei<strong>de</strong>lberg New York p. 490-496<br />
23 Frosch P, Schulze-Dirks A, Hoffmann M, Axthelm I (1993).<br />
Efficacy of skin barrier creams (II). Ineffectiveness of a popular<br />
"skin protector" against various irritants in the repetitive<br />
irritation test in the guinea pig. Contact Dermatitis 29:74-77<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
The Tan<strong>de</strong>m Repeated Irritation Test (TRIT) 69<br />
24 Wigger-Alberti W, Maraffio B, Wernli M, Elsner P (1997) Selfapplication<br />
of a protective cream: pitfalls of occupational skin<br />
protection. Arch Dermatol 133:861-864.<br />
25 Diepgen TL, Coenraads PJ (2000) The epi<strong>de</strong>miology of<br />
occupational contact <strong>de</strong>rmatitis. In: Kanerva L, Elsner P,<br />
Wahlberg JE, Maibach HI (Eds.) Handbook of Occupational<br />
Dermatology. Springer, Berlin Hei<strong>de</strong>lberg New York p 4-16<br />
26 Frosch P, Schulze D, Hoffmann M, Axthelm I, Kurte A (1993)<br />
Efficacy of skin barrier creams (I). The repetitive irritation test<br />
(RIT) in the guinea pig. Contact Dermatitis 28:94-100.<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
70 Atomic absorption spectrometry for the <strong>de</strong>termination of physical sunscreen filters<br />
Atomic absorption spectrometry for the<br />
<strong>de</strong>termination of physical sunscreen filters<br />
S. Gottbrath, J. Grünefeld*, C.C. Müller-Goymann<br />
Technische Universität Carolo-Wilhelmina<br />
Institut für Pharmazeutische Technologie,<br />
* Institut für Pharmazeutische Chemie<br />
Men<strong>de</strong>lssohnstraße 1<br />
D-38106 Braunschweig<br />
Germany<br />
Introduction................................................................... 70<br />
Materials and Methods.................................................. 71<br />
• Ingredients of the formulation ..................................... 71<br />
• Tape stripping .............................................................. 71<br />
• Atomic absorption spectrometry (AAS)...................... 71<br />
• Sun protection factor measurement (SPF)................... 74<br />
• Preparation of formulation........................................... 74<br />
• Area analysis................................................................ 75<br />
• Transmission electron microscopy (TEM) .................. 76<br />
Results........................................................................... 76<br />
Discussion ..................................................................... 78<br />
References..................................................................... 79<br />
Introduction<br />
Microfine titanium dioxi<strong>de</strong> is well established as an effective UVfilter.<br />
Besi<strong>de</strong>s sun protection potential the evaluation of titanium<br />
dioxi<strong>de</strong> formulations has to inclu<strong>de</strong> stability aspects of the<br />
formulations as well as pe<strong>net</strong>ration potential of the physical<br />
sunscreen filter into <strong>de</strong>eper layers of the stratum corneum. Tape<br />
stripping can be used to remove corneocytes layer by layer with an<br />
adhesive film and to <strong>de</strong>termine the amount of titanium dioxi<strong>de</strong> in<br />
these layers. The present contribution presents atomic absorption<br />
spectrometry for the <strong>de</strong>termination of titanium dioxi<strong>de</strong> particles<br />
removed with an adhesive film from the skin of the proband.<br />
Atomic absorption spectrometry is often used for trace<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
Atomic absorption spectrometry for the <strong>de</strong>termination of physical sunscreen filters 71<br />
<strong>de</strong>termination because of its high specificity, selectivity, and<br />
sensitivity. [1, 2, 3]<br />
Materials and Methods<br />
• Ingredients of the formulation<br />
Titanium dioxi<strong>de</strong> predispersion Tioveil AQ N (Tioxi<strong>de</strong> Specialties,<br />
Billingham, Great Britain), Synperonic PE/F 68 (Uniqema,<br />
Everberg, Belgium), Cetiol HE (Henkel, Düsseldorf, Germany),<br />
lecithin Phospholipon ® G 90 (Nattermann Phospholipid GmbH,<br />
Düsseldorf, Germany), propylene glycol (BASF, Ludwigshafen,<br />
Germany), ammonium sulfate (Caelo, Hil<strong>de</strong>n, Germany), sulfuric<br />
acid (Merck, Darmstadt, Germany). Water was used in bistilled<br />
quality.<br />
• Tape stripping<br />
The formulation either with or without titanium dioxi<strong>de</strong> was applied<br />
on the ventral si<strong>de</strong> of the forearm, according to COLIPA standard in<br />
a concentration of 2 mg/cm 2 . After 45 minutes of equilibration the<br />
formulation was removed from the skin with a dry tissue. 10 strips<br />
were taken from the pretreated area and analysed by atomic<br />
absorption spectrometry in the case of titanium dioxi<strong>de</strong> formulation.<br />
The strips taken from the placebo treated area were viewed with an<br />
inverted microscope to obtain the amount of corneocyte aggregates<br />
(see <strong>de</strong>tails in chapter: area analysis).<br />
• Atomic absorption spectrometry (AAS)<br />
Sample preparation<br />
The amount of titanium dioxi<strong>de</strong> on the removed strips was<br />
<strong>de</strong>termined by atomic absorption spectrometry. Each single strip<br />
was dissolved in concentrated sulfuric acid combined with<br />
ammonium sulfate at boiling temperature. Ammonium sulfate is<br />
responsible for the formation of titanium sulfato complexes. The<br />
complexation of titanium reduces the amount of titanium adsorbed<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
72 Atomic absorption spectrometry for the <strong>de</strong>termination of physical sunscreen filters<br />
to the inner surface of the sample vials. After dilution and filtration<br />
with a cellulose acetate filter of a pore size of 0.2 µm (Sartorius<br />
AG, Göttingen, Germany) samples were analysed by atomic<br />
absorption spectrometry.<br />
Instrumentation<br />
Atomic absorption spectrometry uses the absorption of light to<br />
measure the concentration of gas phase atoms. The main<br />
components of an atomic absorption spectrometer are a radiation<br />
source, an atomisation cell and a <strong>de</strong>vice for wavelength selection<br />
and <strong>de</strong>tection.<br />
The most common radiation source is the hollow catho<strong>de</strong> lamp<br />
(HCL). The HCL is a line source that emits radiation characteristic<br />
of a particular element.<br />
A Perkin Elmer 2380 (Perkin Elmer, Überlingen, Germany) atomic<br />
absorption spectrometer was used, equipped with an AS-40<br />
autosampler, a HGA-500 graphite furnace for vaporization of the<br />
titanium ions or atoms from the sample and a titanium hollow<br />
catho<strong>de</strong> lamp (L.O.T.-Oriel, Darmstadt, Germany).<br />
Using a graphite furnace in contrast to flame atom absorption<br />
spectrometry avoids interferences of the matrices. Furthermore very<br />
small sample quantities can be analysed. Samples are placed<br />
directly into the graphite furnace by the sampling capillary (sample<br />
amount 5-100 µl). The maximum temperature is 2700° C by<br />
electrical heating with 10 V. An optical temperature measuring unit<br />
is installed to control the temperature of the external wall of the<br />
graphite tube. Argon as protective gas is used to avoid burning of<br />
the graphite tube. The protective gas flows around the graphite tube<br />
externally and protects from unwanted oxidation. The internal gas<br />
flow is divi<strong>de</strong>d into two corresponding gas flows. They flow from<br />
the two endings to the center of the graphite tube and leave the<br />
graphite tube through the sample opening. The external gas flow is<br />
limited to a value of 900 ml/min. The internal gas flow is variable<br />
in the range from 0 to 300 ml/min. The transport of volatile<br />
compounds out of the graphite tube is executed by the internal gas<br />
flow. The inner surface of the graphite tube is grooved to avoid that<br />
the liquid sample runs out of the tube. The instrumental parameters<br />
are listed in Tab. 1.<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
Atomic absorption spectrometry for the <strong>de</strong>termination of physical sunscreen filters 73<br />
Wavelength 364.3 nm<br />
Lamp current 21 mA<br />
Slit 0.2 nm<br />
Mo<strong>de</strong> Peak height<br />
Sample volume 25 µl<br />
Tab. 1: Instrumental parameters<br />
Another important fact for the successful <strong>de</strong>termination of titanium<br />
is the heating rate and heating time of the graphite furnace. The<br />
heating program should avoid splattering or boiling of the sample<br />
which may cause sample loss. The program was <strong>de</strong>veloped by<br />
Skipor et al. and was slightly modified. The heating program<br />
sequence is listed in Tab. 2.<br />
Temperature [°C] Ramp [sec] Hold [sec] Read<br />
130 30 30<br />
500 40 20<br />
1400 15 20<br />
2600 0 5 x<br />
2700 1 5<br />
20 1 45<br />
Tab. 2: Heating program sequence<br />
The first step of the heating program is responsible for drying the<br />
sample and to vaporize low boiling liquids from the sample. The<br />
chosen temperature <strong>de</strong>pends on the boiling point of the solvent. For<br />
diluted aqueous samples a drying temperature in the range from<br />
100° C to 130° C is necessary.<br />
The Second step is responsible for the thermic pretreatment of the<br />
sample and to remove components of the matrix. The removal of<br />
components of the matrix that are more volatile than compounds of<br />
the interesting element avoids unspecific absorptions. To assure that<br />
all disturbing components leave the sample during the thermic<br />
pretreatment phase, the temperature and its duration have to be<br />
sufficient although an increased temperature for a longer period of<br />
time may lead to a loss of the interesting element. In this case the<br />
high temperature of 1400° C for thermic pretreatment was selected<br />
to remove all matrix compounds and for an undisturbed<br />
<strong>de</strong>termination of titanium.<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
74 Atomic absorption spectrometry for the <strong>de</strong>termination of physical sunscreen filters<br />
Third step is the phase of atomization of the sample. For titanium a<br />
minimum temperature of 2600° C is necessary. An increased<br />
temperature leads to higher sensitivity but causes a reduced lifetime<br />
of the graphite tube. The temperature of 2600° C is held for 5<br />
seconds. During atomization the internal gas flow is stopped to<br />
extend the duration of stay of the titanium atoms in the graphite<br />
tube.<br />
Fourth step is to anneal the graphite tube to eliminate the<br />
components of the sample remaining in the graphite tube. At the<br />
end of the heating program sequence the graphite tube is cooled<br />
down to a temperature of 20° C.<br />
Carbi<strong>de</strong> generating elements like titanium provoke chemical<br />
interferences with components of the graphite tube which cause<br />
tailed signals and memory effects. To avoid formation of carbi<strong>de</strong><br />
compounds pyrocarbon coated graphite tubes were used. An<br />
instrumental background compensation was not necessary, because<br />
a blank sample showed no absorption. The blank sample was taken<br />
from a placebo treated area and processed following the same way<br />
as TiO2 containing strips.<br />
Limit of <strong>de</strong>tection of this method was 5.8 ppb. [4, 5, 6]<br />
• Sun protection factor measurement (SPF)<br />
The sun protection factor of the titanium dioxi<strong>de</strong> formulations was<br />
<strong>de</strong>termined by a SPF-290 Analyzer (Optometrics, Leeds, Great<br />
Britain). For the in vitro measurement the formulations were<br />
applied on a Transpore ® tape (3M, Neuss, Germany) with a<br />
concentration of 2 mg/cm 2 . The attenuation of the radiation by the<br />
formulation on the Transpore ® tape was measured in the range of<br />
290-400 nm.<br />
• Preparation of formulation<br />
Tab. 3 shows the percentage composition (w/w) of the standard<br />
formulation.<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
Atomic absorption spectrometry for the <strong>de</strong>termination of physical sunscreen filters 75<br />
Tioveil AQ N 12.5%<br />
Synperonic PE/F68 10.0%<br />
Cetiol HE 20.0%<br />
propylene glycol 8.0%<br />
water 49.5%<br />
Tab. 3: Composition of the standard formulation (micellar solution<br />
with dispersed titanium dioxi<strong>de</strong> particles)<br />
The lipophilic and hydrophilic ingredients were heated to 60°C<br />
separately and homogenized with an ultra turrax (IKA-Werk,<br />
Staufen, Germany). Tioveil AQ N was stirred with an ultra turrax<br />
prior to use.<br />
Tab. 4 shows the percentage composition (w/w) of the liposomal<br />
formulation<br />
Phospholipon G 90 20.0%<br />
Tioveil AQ N 12.5%<br />
water 67.5%<br />
Tab. 4: Composition of the liposomal formulation. All components<br />
were heated to 60°C while being stirred on a mag<strong>net</strong>ic stirrer.<br />
• Area analysis<br />
For <strong>de</strong>termination of the amount of corneocytes removed with<br />
every single strip, the strips were viewed using an inverted<br />
microscope (Olympus IX50, Hamburg, Germany).<br />
The digital pictures taken from the strips were analysed using<br />
analySIS ® software (Soft Imaging System GmbH, Münster,<br />
Germany). The software allows the quantification of the strips in<br />
terms of the area covered with corneocytes. The knowledge of the<br />
amount of corneocytes removed with every strip is necessary for a<br />
more precise location of the titanium dioxi<strong>de</strong> microparticles in the<br />
stratum corneum.<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
76 Atomic absorption spectrometry for the <strong>de</strong>termination of physical sunscreen filters<br />
• Transmission electron microscopy (TEM)<br />
TEM was used for the visualization of titanium dioxi<strong>de</strong><br />
microparticle distribution. The sample was frozen at a temperature<br />
of –210° C and fractured (Balzers GmbH BAF 400, Wiesba<strong>de</strong>n,<br />
Germany) at a temperature of –100° C and 5x10 -6 bar. The fractured<br />
surface was shadowed with platinum/carbon of 2 nm thickness and<br />
with pure carbon for mechanical stabilization of the replica.<br />
Sulfuric acid was used for cleaning the replica. The replica on<br />
uncoated grids were viewed using a transmission electron<br />
microscope (Philips EM-300, Kassel, Germany).<br />
Results<br />
Two different formulations were compared in terms of sun<br />
protection factor and pe<strong>net</strong>ration into the stratum corneum. The first<br />
formulation was a micellar solution with a sun protection factor of<br />
7.6 (s.d.= 1.2) (n=3).<br />
The second formulation was a liposomal formulation with a sun<br />
protection factor of 3.1 (s.d.= 0.6) (n=3). Figure 1 shows the<br />
distribution of the titanium dioxi<strong>de</strong> particles and the liposomes<br />
within the formulation.<br />
Fig. 1: TEM micrograph of the liposomal formulation (bar = 1 µm)<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
Atomic absorption spectrometry for the <strong>de</strong>termination of physical sunscreen filters 77<br />
The picture shows multilamellar liposomes of sizes between 320<br />
and 1 µm and needle-shaped titanium dioxi<strong>de</strong> microparticles with a<br />
length of 20 – 30 nm.<br />
titanium concentration [µg/cm2]<br />
14<br />
12<br />
10<br />
8<br />
6<br />
4<br />
2<br />
standard formulation 1. <strong>de</strong>termination<br />
standard formulation 2. <strong>de</strong>termination<br />
liposomal formulation 1. <strong>de</strong>termination<br />
liposomal formulation 2. <strong>de</strong>termination<br />
0<br />
0 1 2 3 4 5 6 7 8 9 10 11<br />
number of strip<br />
Fig. 2: Pe<strong>net</strong>ration from standard formulation and liposomal<br />
formulation<br />
Both the standard formulation and the liposomal formulation, with a<br />
concentration of 5% titanium dioxi<strong>de</strong> each, were applied on the<br />
ventral si<strong>de</strong> of the forearm of a male test person (30 years old). Fig.<br />
2 represents the AAS results from tape stripping.<br />
Plotting AAS results versus the number of strips shows an<br />
exponential <strong>de</strong>cline. At strip 6 the titanium concentration<br />
approaches a value of 1.0 µg/cm 2 . After application of the standard<br />
formulation higher amounts of titanium dioxi<strong>de</strong> can be removed<br />
with the first strips in comparison with the liposomal formulation.<br />
This result has to be consi<strong>de</strong>red together with the results from the<br />
area analysis of the placebo strips. The removed amount of<br />
corneocyte aggregates after treatment with the standard formulation<br />
was much higher compared to the liposomal formulation due to the<br />
adhesive power of the standard formulation. Fig. 3 assigns the<br />
amount of corneocyte aggregates to the titanium concentration of<br />
every strip.<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
78 Atomic absorption spectrometry for the <strong>de</strong>termination of physical sunscreen filters<br />
number of strips<br />
1<br />
2<br />
3<br />
4<br />
5<br />
6<br />
7<br />
8<br />
9<br />
10<br />
percental amount of removed corneocytes aggregates [%/10] or titanium concentration [µg/cm2]<br />
0 1 2 3 4 5 6 7 8 9 10<br />
standard formulation, AAS<br />
------------------------------------------------------------------------------------<br />
Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1<br />
standard formulation, area analysis<br />
liposomal formulation, AAS<br />
liposomal formulation, area analysis<br />
Fig. 3: Titanium concentration respectively corneocyte aggregates<br />
vs. number of strips<br />
Discussion<br />
To <strong>de</strong>tect small amounts of titanium dioxi<strong>de</strong> within <strong>de</strong>eper layers of<br />
the stratum corneum tape stripping in combination with AAS is a<br />
suitable analytical method. The proposed heating program causes<br />
no splattering or boiling of the analysed sample which may lead to a<br />
loss of the sample. For the evaluation of titanium dioxi<strong>de</strong> pe<strong>net</strong>rated<br />
into stratum corneum from different formulations the amount of the<br />
removed corneocyte aggregates has to be consi<strong>de</strong>red, too. This<br />
leads to a more precise localization of the titanium dioxi<strong>de</strong><br />
microparticles in the stratum corneum. Results reveal a higher<br />
amount of titanium dioxi<strong>de</strong> in <strong>de</strong>eper layers of the stratum corneum<br />
after treatment with the standard formulation compared to the<br />
liposomal formulation. Hence, the effect of different formulations<br />
on the pe<strong>net</strong>ration potential of titanium dioxi<strong>de</strong> microparticles is<br />
obvious.
References<br />
Atomic absorption spectrometry for the <strong>de</strong>termination of physical sunscreen filters 79<br />
1 La<strong>de</strong>mann J, Weigmann HJ, Rickmeyer C, Barthelmes H,<br />
Schaefer H, Mueller G, Sterry W (1999) Pe<strong>net</strong>ration of titanium<br />
dioxi<strong>de</strong> particles in a sunscreen formulation into the horny layer<br />
and the follicular orifice, Skin Pharmacol Appl Skin Physiol<br />
12:247-256<br />
2 Weigmann HJ, La<strong>de</strong>mann J, Meffert H, Schaefer H, Sterry W<br />
(1999) Determination of the horny layer profile by tape stripping<br />
in combination with optical spectroscopy in the visible range as<br />
a prerequisite to quantify percutaneous absorption, Skin<br />
Pharmacol Appl Skin Physiol 12:34-45<br />
3 Müller-Goymann CC, Bennat C, Grünefeld J (1998) Pe<strong>net</strong>ration<br />
von partikulären UV-Filtern in die Haut, Parfümerie und<br />
Kosmetik 5:24-26<br />
4 Skipor AK, Jacobs JJ, Schavocky J, Black J, Galante JO (1994)<br />
Determination of titanium in human serum by zeeman<br />
electrothermal atomic absorption spectroscopy, Atomic<br />
Spectroscopy 5/6:131-134<br />
5 Welz B, Sperling M (1997) Atomabsorptionsspektroskopie.<br />
Wiley-VCH, Weinheim<br />
6 Mason JT (1980) Quantitative <strong>de</strong>termination of titanium in a<br />
commercial sunscreen formulation by atomic absorption<br />
spectrometry, Journal of Pharmaceutical Sciences 1:101-102<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
80 Determination of Clobetasol Propionate in SC Extraxts by Means of HPLC and LC-MS<br />
Determination of Clobetasol Propionate in SC<br />
Extraxts by Means of HPLC and LC-MS<br />
T. Hagemeister, M. Linscheid, *H.-J. Weigmann, *J. La<strong>de</strong>mann,<br />
*R. v. Pelchrzim, *W. Sterry<br />
Institut für Chemie, *Charité, Klinik für Dermatologie, Venerologie und<br />
Allergologie mit Asthmapoliklinik <strong>de</strong>r Humboldt-Universität zu Berlin<br />
D-10098 Berlin<br />
Germany<br />
Abstract ......................................................................... 80<br />
Introduction................................................................... 81<br />
Materials and Methods.................................................. 82<br />
• The tape stripping protocol.......................................... 82<br />
• The extraction protocol................................................ 82<br />
• UV/VIS-Spectroscopic Measurements........................ 83<br />
• The HPLC method....................................................... 84<br />
• Mass Spectrometry ...................................................... 85<br />
Conclusion .................................................................... 88<br />
References..................................................................... 88<br />
Abstract<br />
The introduced LC/ESI-MS investigations were based on an<br />
isocratic HPLC method for the <strong>de</strong>termination of Clobetasol<br />
propionate (<strong>de</strong>tection limit of 0,15 mg/l [1]). The HPLC eluate was<br />
led directly to an ESI-Single Quad Mass Spectrometer. The<br />
characteristic protonated molecular ions [M+H] + of Clobetasol<br />
Propionate and the internal standard Betametasone-17-valerate were<br />
generated and the quantification was carried out in the (single ion<br />
mo<strong>de</strong> SIM) and the multiple ion mo<strong>de</strong> (MIM) respectively. The<br />
chromatographic separation by HPLC and the selective mass<br />
spectrometric <strong>de</strong>tection of the target compounds allowed a reliable<br />
i<strong>de</strong>ntification with a remarkable improvement of sensitivity<br />
(<strong>de</strong>tection limit: 2.15 µg/l).<br />
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In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
Determination of Clobetasol Propionate in SC Extraxts by Means of HPLC and LC-MS 81<br />
Introduction<br />
The synthetic corticosteroid Clobetasol propionate (CB), an analog<br />
of prednisolone, is the active component in some commercial<br />
creams for topical <strong>de</strong>rmatologic use (Figure 1). The <strong>de</strong>termination<br />
of the pe<strong>net</strong>ration behavior of the substrate in <strong>de</strong>pen<strong>de</strong>nce of<br />
different creme formulations is of special pharmacological interest.<br />
Therefore the stratum corneum was sampled by tape stripping. Prior<br />
to extraction the number of corneocytes attached to the tape strip<br />
were measured by a UV/VIS-procedure [2]. Subsequently the<br />
quantitative measurement of Clobetasol propionate with HPLC-<br />
MS-SIM of an extract of the particular single tape was performed.<br />
For quantification the internal standard method was utilized. The<br />
possible correlation of the number of corneocytes with the amount<br />
of Clobetasol extracted from a single tapestrip admits the<br />
establishment of high resolution horny layer profiles. These are a<br />
reliable basis for the interpretation and comprehension of the<br />
bioavailability of <strong>de</strong>rmatologic relevant substances. The tape strip<br />
investigations are closely related to the proposals outlined in [3],<br />
and given in the Draft Guidance for Industry (FDA) [4]. For<br />
additional and <strong>de</strong>tailed information on these topics refer to<br />
reference [1].<br />
O<br />
HO<br />
CH3<br />
F<br />
CH 3<br />
CH 2Cl<br />
C=O<br />
OCOCH 2CH 3<br />
CH 3<br />
O<br />
HO<br />
CH3<br />
F<br />
CH 3<br />
CH 2OH<br />
C=O<br />
OCO(CH 2) 3CH 3<br />
Fig.1: Clobetasol propionate (M=466g/mol) and the internal<br />
standard Betametason-17-valerate (M=476g/mol)<br />
CH 3<br />
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In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
82 Determination of Clobetasol Propionate in SC Extraxts by Means of HPLC and LC-MS<br />
Materials and Methods<br />
• The tape stripping protocol<br />
Three cremes were examined, namely Clobetasol Propionate<br />
Cream, Temovate Crème and Temovate Emollient. The stratum<br />
corneum removal from the drug treated skin site was performed by<br />
tape stripping with TESA tape (TESA film No. 5529, Beiersdorf,<br />
Hamburg, Germany) for which it was ascertained that during the<br />
HPLC measurements matrix peaks did not disturb the Clobetasol<br />
propionate (CB; MW: 466 g/mol) peak. Tape stripping was done at<br />
0.5, 2.0 and 6.0 hours after application. In brief, the treated skin site<br />
was tape stripped 21 times. The first tape strip was discar<strong>de</strong>d due to<br />
potential residual drug contamination, and the tape strips 2-21 were<br />
submitted for successive chemical extraction and analysis by<br />
HPLC-MS.<br />
• The extraction protocol<br />
The tapes 2-21 (1.9 x 2 cm in size) corresponding to the application<br />
areas were solely placed in a test tube respectively. The adhesive<br />
layer was directed towards the insi<strong>de</strong> of the test tube. 1500 µl of<br />
solvent (acetonitrile : water = 55 : 45) were pipetted in two steps<br />
into the tube, using a volume adjustable digital pipette (Eppendorf,<br />
500 - 1000 µL). 40 µl of the internal standard solution, containing<br />
6.68 mg/l Betamethasone-17-valerate (BM; MW: 476 g/mol), were<br />
ad<strong>de</strong>d with a volume adjustable digital pipette (Eppendorf, 10 -<br />
100 µL). The test tube, 160 mm long, 16 mm in diameter, was<br />
closed with a ground glass stopper. A PTFE, disposal sleeve for<br />
ground joints, was used in combination with Parafilm "M"<br />
(Laboratory Film; American National Can) to prevent leaking. The<br />
tube was fixed on a shaker in the horizontal position and shaken for<br />
20 minutes. During this time the tube was turned twice to make sure<br />
that all parts of the tapes would be in contact with the solution. The<br />
solution was drawn from the test tube with a syringe and filtered<br />
through a nylon syringe filter (ISO - DISC N - 34; 3 mm Diameter<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
Determination of Clobetasol Propionate in SC Extraxts by Means of HPLC and LC-MS 83<br />
Nylon Membrane; 0.45 µm Pore Size; Supelco). An aliquot of the<br />
solution was analyzed by HPLC-MS.<br />
• UV/VIS-Spectroscopic Measurements<br />
The amount of the corneocyte aggregates removed with a single<br />
tape and the thickness of the horny layer vary consi<strong>de</strong>rably for<br />
different individuals [2]. Therefore a method is required that allows<br />
the correlation of the amount of the active substance (CB) on<br />
individual adhesive film strips to the <strong>de</strong>pth profile of the horny<br />
layer. For the <strong>de</strong>termination of that <strong>de</strong>pth profile, a correct<br />
measurement of the amount of the corneocyte aggregates is<br />
mandatory. Optical spectroscopy in the visible spectral range fulfils<br />
the prerequisites. The particulate corneocyte aggregates reflect and<br />
scatter the light nearly wavelength in<strong>de</strong>pen<strong>de</strong>ntly. All other<br />
components on the tape strips act as absorbers with absorption<br />
bands in the UV range (Figure 2).<br />
absorbance (au)<br />
1,2<br />
1,1<br />
1,0<br />
0,9<br />
0,8<br />
0,7<br />
0,6<br />
0,5<br />
0,4<br />
0,3<br />
0,2<br />
0,1<br />
0,0<br />
1,23<br />
Clobetasol propionate<br />
Clobetasol Propionate Cream<br />
Temovate Cream<br />
Temovate Emollient<br />
200 220 240 260 280 300 320 340 360 380 400 420 440 460 480 500<br />
wavelength (nm)<br />
Fig. 2: UV/VIS-spectra of Clobetasol Propionate and the analysed<br />
cremes containing the substrate<br />
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In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
84 Determination of Clobetasol Propionate in SC Extraxts by Means of HPLC and LC-MS<br />
The UV/VIS spectroscopic measurements were ma<strong>de</strong> with a<br />
spectrophotometer (Lambda 20, Perkin Elmer), modified to obtain a<br />
rectangular beam diameter of 10x10 mm 2 . The spectra from 240-<br />
500 nm were recor<strong>de</strong>d. The transmission was corrected with a blank<br />
tape in the reference beam. The absorbance at 430 nm was taken as<br />
the measure for the number of the corneocyte aggregates on the<br />
tape to obtain tape strip resolved <strong>de</strong>pth profiles correlated with the<br />
quantitative data of Clobetasol propionate.<br />
• The HPLC method<br />
Clobetasol propionate was <strong>de</strong>termined using an HPLC method (for<br />
<strong>de</strong>tails of the extraction procedure refer to reference [4]). The<br />
HPLC system comprised a binary pump (HP 1100 ChemStation), a<br />
reversed phase column system (main column: 2 × 100 mm with a<br />
precolumn: 2 × 5 mm; Hypersil ODS 5 µm; Knauer Berlin;<br />
Germany) and a UV dio<strong>de</strong> array <strong>de</strong>tector (HP 1100 ChemStation).<br />
The solvent was acetonitrile / 1 mmol/l NH4CH3COO buffer (55 :<br />
45) with a flow of 0.2 ml/min. 20 µl of each sample was injected.<br />
The retention time of the drug was 5.07 + 0.04 min and for the<br />
standard BM was 3.83 + 0.02 min. It was ascertained that the peaks<br />
of interest were seperated from peaks of interfering substances like<br />
matrix of cream, tape and skin (figure 3). The <strong>de</strong>tection wavelengh<br />
(240 nm) allowed the i<strong>de</strong>ntification of Clobetasol propionate (CB)<br />
and of the internal standard Betametasone-17-valerate (BM)<br />
(<strong>de</strong>tection limit of a HPLC based UV-<strong>de</strong>tection: 0.16mg/l [4]).<br />
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In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
Determination of Clobetasol Propionate in SC Extraxts by Means of HPLC and LC-MS 85<br />
Fig. 3: UV-Chromatogramm: Absorbance at 240nm wavelength.<br />
• Mass Spectrometry<br />
For the analysis a HPLC/single quad mass spectrometer equipped<br />
with an electrospray ion source (LC/MSD Hewlett Packard ® ) was<br />
used. The ion source parameters were optimized to maximum<br />
intensity of the selected molecular ions and minimal fragmentation.<br />
Therefore a drying gas flow of 10 l/min with a temperature of 310<br />
°C (N2; Purity ≥ 98 %) was established.<br />
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In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
86 Determination of Clobetasol Propionate in SC Extraxts by Means of HPLC and LC-MS<br />
100<br />
80<br />
60<br />
40<br />
20<br />
0<br />
rel.<br />
Int.<br />
O<br />
HO<br />
CH3<br />
CH2Cl<br />
C=O<br />
CH3<br />
200 300 400 500<br />
Fig. 4: Mass spectrum of CB in positive ionisation mo<strong>de</strong>. Inset<br />
structure corresponds to loss of ketene from sodiated molecular ion<br />
(m/z 447).<br />
Especially thermally induced fragmentations could be avoi<strong>de</strong>d by a<br />
<strong>de</strong>crease of the drying gas temperature. The [M+H] + of CB at m/z<br />
467 and BM at m/z 477 were chosen for quantification (Figure 4).<br />
Single ion monitoring was performed with low resolution and a<br />
dwell time of 109 msec. Besi<strong>de</strong> the protonated molecular ions<br />
[M+H] + the sodium adducts [M+Na] + appear at m/z 489 for CB and<br />
at m/z 499 for BM. One single fragment of consi<strong>de</strong>rable intensity<br />
can be seen at m/z 447 (CB) and at m/z 457 (BM), respectively.<br />
That fragment is obviously generated by a fragmentation of the<br />
sodium adducts [M+Na] + . The ring A of the steroid structure is a<br />
candidate for the loss of ketene CH2=C=O (42 u).<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1<br />
F<br />
OCOCH2CH3<br />
CH3<br />
[M+Na] + -CH2CO<br />
447<br />
467<br />
[M+H] +<br />
[M+Na] +<br />
489<br />
505<br />
[M+K] +<br />
m/z
Norm.<br />
Determination of Clobetasol Propionate in SC Extraxts by Means of HPLC and LC-MS 87<br />
Int.<br />
2 4 6 8 10 12 14 16 18 min<br />
Fig. 5a: Single ion monitoring mass chromatograms of tapestrip<br />
extracts. 3 rd tapestrip (0,114mg/l),<br />
Rel. Int.<br />
2 4 6 8 10 12 14 16 18 min<br />
Fig. 5b: Single ion monitoring mass chromatograms of tapestrip<br />
extracts. 17 th tape strip (0,00695mg/l). Dotted line: SIM of internal<br />
standard BM (m/z 477), solid line: SIM of analyte CB (m/z 467).<br />
Signals in chromatogramm B are normalised.<br />
The LC/MS SIM <strong>de</strong>tection strategy overcomes problems with<br />
chromatographic interference of background substances and with<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1<br />
A<br />
B
88 Determination of Clobetasol Propionate in SC Extraxts by Means of HPLC and LC-MS<br />
the mo<strong>de</strong>rate UV absorption of the target compounds (Figure 5).<br />
Consequently an enormous increase in sensitivity of the introduced<br />
LC-ESI-MS procedure was achieved: calibration function:<br />
y=0.488x-0.00486; fit: 0.998; <strong>de</strong>tection limit: 2.15 µg/l.<br />
Conclusion<br />
The HPLC/ESI-MS method for the <strong>de</strong>tection and quantification of<br />
steroids <strong>de</strong>monstrates the analytical power of the applied technique.<br />
The mass spectrometrical <strong>de</strong>tection of the substrates of interest<br />
allows new comprehension of the complex behavior of<br />
<strong>de</strong>rmatologic active substances because of the possibility to<br />
<strong>de</strong>termine horny layer profiles of high resolution. This example<br />
un<strong>de</strong>rlines the success of the interdiciplinary collaboration of<br />
different techniques for the solution of analytical problems.<br />
References<br />
1 Weigmann H.-J, La<strong>de</strong>mann J, Pelchrzim R v, Sterry W,<br />
Hagemeister T, Molzahn R, Schäfer M,<br />
Linscheid M, Schaefer H, Shah V P (1999) Bioavailability of<br />
Clobetasol Propionate – Quantification of Drug Concentrations<br />
in the Stratum Corneum by Dermatoki<strong>net</strong>ics using Tape<br />
Stripping. Skin Pharmacol Appl Skin Physiol (Switzerland)<br />
12:46-53<br />
2 Weigmann H-J, La<strong>de</strong>mann J, Meffert H, Sterry W (1999)<br />
Determination of the Horny Layer Profile by Tape Stripping in<br />
Combination with Optical Spectroscopy in the Visible Range as<br />
a Prerequisite to Quantify Percutaneous Absorption. Skin<br />
Pharmacol Appl Skin Physiol (Switzerland) 12:34-45<br />
3 Weigmann H-J, La<strong>de</strong>mann J, Meffert H, Sterry W (1997)<br />
Influence of sunscreen on the spectral energy distribution of<br />
ultraviolet radiation in human skin. In: Altmeyer P, Hoffmann<br />
K, Stuecker M (ed) Skin Cancer and UV Radiation. Springer-<br />
Verlag, Berlin Hei<strong>de</strong>lberg New York, S 357-362.<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
Determination of Clobetasol Propionate in SC Extraxts by Means of HPLC and LC-MS 89<br />
4 Guidance for Industry, Topical Dermatological Drug Product<br />
NDAs and ANDAs - In Vivo Bioavailability, Bioequivalence, In<br />
Vitro Release, and Associated, U. S. Department of Health and<br />
Human Services, Food and Drug Administration, Center for<br />
Drug Evaluation and Research (CDER), June 1998.<br />
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In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
90 Analytical methods for the <strong>de</strong>termination of <strong>de</strong>rmatopharmacoki<strong>net</strong>ics<br />
Analytical methods for the <strong>de</strong>termination of<br />
<strong>de</strong>rmatopharmacoki<strong>net</strong>ics<br />
J. La<strong>de</strong>mann<br />
Center of Experimental and Applied Cutaneous Physiology (CCP)<br />
at the Charité, Department of Dermatology, Humboldt-Universität<br />
D-10098 Berlin<br />
Germany<br />
Introduction................................................................... 90<br />
Pe<strong>net</strong>ration measurements by tape stripping in<br />
combination with spectroscopic measurements............ 92<br />
Dermatopharmacoki<strong>net</strong>ics of sunscreen components... 96<br />
Dermatopharmacoki<strong>net</strong>ics of topically applied drugs .. 98<br />
Perspectives in <strong>de</strong>rmatopharmacoki<strong>net</strong>ics.................... 99<br />
Summary ..................................................................... 102<br />
References................................................................... 102<br />
Introduction<br />
The pe<strong>net</strong>ration ki<strong>net</strong>ics of cosmetic products and drugs in or<br />
through the skin, the so-called <strong>de</strong>rmatopharmacoki<strong>net</strong>ics, has a<br />
significant influence on the action and protection properties of<br />
topically applied substances.<br />
The <strong>de</strong>termination of the pe<strong>net</strong>ration ki<strong>net</strong>ics and the pe<strong>net</strong>ration<br />
pathways of chemical compounds is still an object of intensive<br />
investigations. Different analytical in vitro and in vivo methods<br />
were used for this purpose (Figure 1). The investigations were<br />
carried out on human and animal skin.<br />
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in vitro<br />
• Franz Cell experiments [1,2]<br />
• Biopsy [3,4]<br />
• Tape stripping [5,6]<br />
Analytical methods for the <strong>de</strong>termination of <strong>de</strong>rmatopharmacoki<strong>net</strong>ics 91<br />
Animal mo<strong>de</strong>l<br />
Human tissue<br />
in vivo<br />
• Rad ioactive labeling [7,8 ]<br />
• Biopsy [9,10]<br />
• Tape stripping [11,12]<br />
• Surface recovery [13]<br />
• Biological/pharmacological response [14]<br />
• A utoradiography [15]<br />
• Fluorescence measurements [16]<br />
Fig. 1: Method for the investigation of <strong>de</strong>rmatopharmacoki<strong>net</strong>ics<br />
On the one hand, the in-vitro measurements have the advantage that<br />
both allergens and toxic substances can be investigated. On the<br />
other hand, it is sometimes difficult to correlate the in-vitro to the<br />
in-vivo measurements.<br />
In the present paper, the state of the art and the perspectives of invivo<br />
measuring methods used in <strong>de</strong>rmatopharmacoki<strong>net</strong>ics will be<br />
discussed. Some of the in-vivo methods frequently used for<br />
measuring the cutaneous absorption of substances are presented in<br />
the right column of Figure 1.<br />
Only the first three methods allow both a qualitative and<br />
quantitative analysis of the pe<strong>net</strong>ration of topically applied<br />
substances into the skin. The time factor must be taken into<br />
consi<strong>de</strong>ration for the <strong>de</strong>termination of the pe<strong>net</strong>ration ki<strong>net</strong>ics. This<br />
means, that the process must be analyzed either by on-line<br />
measurements or by taking samples from the same volunteer at<br />
different times.<br />
Although well-suited to pe<strong>net</strong>ration measurements, the method of<br />
applying radioactive labeled substances is unacceptable from an<br />
ethical point of view. This applies also to skin biopsies.<br />
Tape stripping is a non-invasive method only suited to analyze the<br />
stratum corneum. Regardless of this limitation, this method can be<br />
used for the investigation of <strong>de</strong>rmatopharmacoki<strong>net</strong>ics of cosmetic<br />
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In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
92 Analytical methods for the <strong>de</strong>termination of <strong>de</strong>rmatopharmacoki<strong>net</strong>ics<br />
products and topically applied drugs, because the horny layer<br />
mainly <strong>de</strong>termines the barrier and reservoir function of the skin.<br />
The only disadvantage of this method is the insufficient<br />
reproducibility, as the pe<strong>net</strong>ration curves are related to the number<br />
of tape strips and not to the actual horny layer profile. The amount<br />
of corneocytes on the removed tapes <strong>de</strong>pends on different factors,<br />
e.g. skin type of the volunteers, pretreatment of the skin, and the<br />
formulation of the substances applied.<br />
A new analytical method for pe<strong>net</strong>ration measurements was<br />
<strong>de</strong>veloped at the Center of Experimental and Applied Cutaneous<br />
Physiology (CCP). The method is based on the well-known tape<br />
stripping technique in combination with spectroscopic<br />
measurements that allow the <strong>de</strong>termination of the amount of<br />
corneocytes on each tape strip removed [17].<br />
Pe<strong>net</strong>ration measurements by tape stripping in<br />
combination with spectroscopic measurements<br />
During the tape stripping procedure, a transparent, adhesive film is<br />
pressed onto a <strong>de</strong>fined surface area of the skin after application and<br />
pe<strong>net</strong>ration of topically applied substances. The next film is pressed<br />
onto the same area after having removed the tape from the skin.<br />
Using this procedure, the stratum corneum is removed in thin<br />
layers. The removed tape strips contain specific amounts of<br />
corneocytes and substances applied topically.<br />
The distribution of the corneocyte aggregates on different tape<br />
strips of the same series is presented in Figure 2. It is obvious that<br />
the corneocyte <strong>de</strong>nsity is reduced with increasing numbers of tapes.<br />
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In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
Analytical methods for the <strong>de</strong>termination of <strong>de</strong>rmatopharmacoki<strong>net</strong>ics 93<br />
1. strip 12. strip 30. strip<br />
Fig. 2: Distribution of the corneocyte aggregates of different tape<br />
strips from the same series<br />
The spectra of the first tapes, removed from sunscreen treated and<br />
untreated skin surfaces, are compared in Figure 3. The absorption<br />
bands of the applied UVA and UVB filter substance removed with<br />
the corneocyte aggregates can be clearly recognized. The<br />
absorbance at wavelengths higher than 400 nm, which is only<br />
caused by the scattering properties of the corneocytes, is i<strong>de</strong>ntical<br />
for both tapes. The value of the absorbance at 430 nm was used in<br />
the following for the characterization of the amount of corneocytes<br />
on the removed tapes. Because of the inhomogeneous distribution<br />
of the corneocytes on the removed tape strips, PERK<strong>IN</strong> ELMER<br />
<strong>de</strong>veloped a special spectrometer with a measuring spot of 1 cm 2<br />
for integral measurements.<br />
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In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
94 Analytical methods for the <strong>de</strong>termination of <strong>de</strong>rmatopharmacoki<strong>net</strong>ics<br />
ABSORBANCE<br />
1,4<br />
1,2<br />
1<br />
0,8<br />
0,6<br />
0,4<br />
0,2<br />
1. Strip<br />
sunscreen<br />
applied<br />
0<br />
230 248 270 295 326 364 412 474<br />
WAVELENGTH [nm]<br />
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UVB f ilter<br />
absorption<br />
UVA f ilter<br />
absorption<br />
1. strip<br />
untreated skin Inf luence of<br />
corneocyte<br />
aggregates<br />
Fig. 3: Spectra of the first tapes removed from a sunscreen treated<br />
and untreated skin surface<br />
The principle of the combined method is summarized schematically<br />
in Figure 4. Using the additional information concerning the<br />
amount of corneocytes on the removed tape strips, it became<br />
possible to relate the amount of substance <strong>de</strong>tected on the single<br />
tapes to the actual horny layer profile.<br />
This standardized method allows reproducible measurements of the<br />
pe<strong>net</strong>ration ki<strong>net</strong>ics of topically applied substances into the stratum<br />
corneum.<br />
Amount of corneocytes<br />
• Light scattering measurements<br />
• Staining techniques<br />
• Determination of the corneocyte<br />
<strong>de</strong>nsity on the tape strips<br />
Amount of topically applied<br />
substances<br />
• HPLC<br />
• GC/MS<br />
• AAS<br />
• Spectrometry<br />
• Spectroscopy<br />
Tab. 1: Analytical methods frequently used for the <strong>de</strong>termination of<br />
the amount of corneocytes and the concentration of the topically<br />
applied Substances on the removed tape strips
Analytical methods for the <strong>de</strong>termination of <strong>de</strong>rmatopharmacoki<strong>net</strong>ics 95<br />
The influence of different factors, such as the applied formulation<br />
and the skin type of the volunteers can be investigated qualitatively<br />
and quantitatively [18]. The analytical methods frequently used for<br />
the <strong>de</strong>termination of the amount of corneocytes and the<br />
concentration of the substances on the removed tape strips are<br />
summarized in Table 1.<br />
Amount of corneocytes<br />
0,2<br />
0,15<br />
0,1<br />
0,05<br />
0<br />
Exten<strong>de</strong>d method<br />
UV/VIS spectroscopy<br />
Horny layer profile<br />
1 2 3 4 5 6 7 8 9 10<br />
Tape number<br />
Amount of corneocytes [%]<br />
0<br />
100<br />
0<br />
Series of tapes<br />
Amount of active agent<br />
3,5<br />
Amount of active agent [%]<br />
3<br />
2,5<br />
2<br />
1,5<br />
1<br />
0,5<br />
0<br />
Traditional method<br />
UV/VIS spectroscopy,<br />
XRF, AAS, HPLC, GC/MS<br />
Concentration on<br />
the single tapes<br />
1 2 3 4 5 6 7 8 9<br />
Tape number<br />
1<br />
5<br />
10<br />
30<br />
40<br />
70<br />
100<br />
Fig. 4: Principle of the tape stripping method in combination<br />
with spectroscopic measurements<br />
Tape number<br />
------------------------------------------------------------------------------------<br />
Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
96 Analytical methods for the <strong>de</strong>termination of <strong>de</strong>rmatopharmacoki<strong>net</strong>ics<br />
Dermatopharmacoki<strong>net</strong>ics of sunscreen components<br />
The pe<strong>net</strong>ration profiles of two different filter substances<br />
EUSOLEX 6300 and PARSOL 1789 of the same sunscreen sample<br />
after a pe<strong>net</strong>ration time of one hour are presented in Figure 5. It is<br />
obvious that the filter substances pe<strong>net</strong>rated i<strong>de</strong>ntically and were<br />
located in the upper part of the stratum corneum [17]. The<br />
pe<strong>net</strong>ration ki<strong>net</strong>ics can be <strong>de</strong>termined by analyzing the pe<strong>net</strong>ration<br />
profiles of a topically applied substance at different times after<br />
application. In the following example, this is <strong>de</strong>monstrated for<br />
coated titanium dioxi<strong>de</strong> microparticles used in sunscreens. The<br />
amount of corneocytes on the removed tapes was <strong>de</strong>termined by<br />
spectroscopic measurements at 430 nm.<br />
The amount of TiO2 on the tapes was measured by x-ray<br />
fluorescence analysis. The TiO2 concentration was not analyzed on<br />
every tape, because of the expensive x-ray fluorescence<br />
measurements. The pe<strong>net</strong>ration profiles obtained 1 hour and 24<br />
hours after sunscreen application are shown in Figure 6. The filter<br />
substances are mainly located in the upper layers of the stratum<br />
corneum.<br />
After 24 hours the amount of TiO2 was reduced significantly, on<br />
account of the fact that the skin was covered with textiles during the<br />
night. Small amounts of titanium dioxi<strong>de</strong> were <strong>de</strong>tected in the lower<br />
part of the stratum corneum. These TiO2 microparticles were<br />
located in the follicle orifices [19].<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
Horny layer thickness [%]<br />
100<br />
90<br />
80<br />
70<br />
60<br />
50<br />
40<br />
30<br />
20<br />
10<br />
Analytical methods for the <strong>de</strong>termination of <strong>de</strong>rmatopharmacoki<strong>net</strong>ics 97<br />
44 ,3<br />
6,2<br />
0<br />
0 5 10 15 20 25 30 35 40 45 50<br />
UVB filter concentration [µg/cm 2 77<br />
]<br />
0,5<br />
1, 5<br />
1,0<br />
1<br />
5<br />
10<br />
20<br />
50<br />
Strip number<br />
Horny layer thickness [%]<br />
100<br />
90<br />
80<br />
70<br />
60<br />
50<br />
40<br />
30<br />
20<br />
10<br />
0<br />
0 5 1 0 15 20 2 5 30 35 40 45 50<br />
UVA filter conc en tratio n [µg/ cm 2 ]<br />
EUSOLEX 6300 PARSOL 1789<br />
Fig. 5: Pe<strong>net</strong>ration profiles of the VU filter substances EUSOLEX<br />
6300 and PARSOL of a sunscreen sample after a pe<strong>net</strong>ration time<br />
of one hour<br />
0<br />
RELATIVE<br />
HORNY<br />
LAYER<br />
THICKNESS<br />
[%]<br />
100<br />
0,04<br />
0,15<br />
2,8<br />
1,5<br />
0,26<br />
TITANIUM CONCENTRATION [µg/square centimeter tape]<br />
1<br />
5<br />
10<br />
15<br />
NUMBER RELATIVE<br />
OF HORNY<br />
TAPE LAYER<br />
STRIPP<strong>IN</strong>G THICKNESS<br />
[%]<br />
30<br />
40<br />
83<br />
0<br />
100<br />
18,6<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1<br />
0,5<br />
0,2<br />
2,7<br />
0, 7<br />
1<br />
5<br />
10<br />
20<br />
50<br />
77<br />
Strip number<br />
TITANIUM CONCENTRATION [µg/square centimeter tape]<br />
1 hour 24 hour<br />
Fig. 6: Pe<strong>net</strong>ration profiles of coated titanium dioxi<strong>de</strong> obtained<br />
1 hour and 24 hours after sunscreen application<br />
0,04<br />
0,15<br />
2,8<br />
1,5<br />
0,26<br />
1<br />
5<br />
10<br />
15<br />
NUMBER<br />
OF<br />
TAPE<br />
STRIPP<strong>IN</strong>G<br />
30<br />
40<br />
83
98 Analytical methods for the <strong>de</strong>termination of <strong>de</strong>rmatopharmacoki<strong>net</strong>ics<br />
Dermatopharmacoki<strong>net</strong>ics of topically applied drugs<br />
Although the combined method of tape stripping and spectroscopic<br />
measurements is only applicable to the analysis of the pe<strong>net</strong>ration<br />
ki<strong>net</strong>ics insi<strong>de</strong> the stratum corneum, this method can be used for the<br />
investigation of the <strong>de</strong>rmatopharmacoki<strong>net</strong>ics of topically applied<br />
drugs passing through the skin. The differences in the pe<strong>net</strong>ration<br />
profiles of the steroid compound, clobetasol, applied at the same<br />
concentration in different formulations on the skin, are shown in<br />
Figure 7 [20]. The influence of the formulation on the amount of<br />
corneocytes removed with the single tapes is obvious in this case.<br />
These significant differences could not be ma<strong>de</strong> visible by the<br />
conventional tape stripping methods, which relate the <strong>de</strong>termined<br />
concentration of the substances on the removed tape strips to the<br />
strip number instead of to the horny layer profile.<br />
The pe<strong>net</strong>ration profiles in Figure 7 clearly <strong>de</strong>monstrate the<br />
reservoir function of the stratum corneum. Clobetasol has different<br />
pe<strong>net</strong>ration ki<strong>net</strong>ics <strong>de</strong>pending on the type of formulation [21].<br />
The blanching effect is the biological response of living tissue on<br />
the interaction with clobetasol. This effect, caused by the<br />
constriction of the blood vessels, correlates to the <strong>de</strong>tected<br />
pe<strong>net</strong>ration ki<strong>net</strong>ics.<br />
Rel horny layer thickness [%]<br />
0<br />
-20<br />
-40<br />
-60<br />
-80<br />
-100<br />
0 Concentration 1 2of clobetasolpropionate 3 [µg/cm 4 5<br />
2 40<br />
-80<br />
40<br />
50<br />
50<br />
60<br />
60<br />
0 ],<br />
85<br />
5<br />
-100<br />
0 Concentration<br />
1<br />
of<br />
2<br />
clobetasolpropionate<br />
3<br />
[µg/cm<br />
4<br />
79<br />
5<br />
correlated to the absorbance 430 nm<br />
2 ],<br />
correlated to the absorbance at 430 nm<br />
------------------------------------------------------------------------------------<br />
Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1<br />
1<br />
5<br />
10<br />
20<br />
30<br />
Tape number<br />
Fig. 7: Pe<strong>net</strong>ration profiles of clobetasol in different<br />
formulations 6 hours after application [21]<br />
Rel. horny layer thickness [%]<br />
0<br />
-20<br />
-40<br />
-60<br />
1<br />
5<br />
10<br />
20<br />
30<br />
Tape number
Analytical methods for the <strong>de</strong>termination of <strong>de</strong>rmatopharmacoki<strong>net</strong>ics 99<br />
Perspectives in <strong>de</strong>rmatopharmacoki<strong>net</strong>ics<br />
The perspectives in <strong>de</strong>rmatopharmacoki<strong>net</strong>ics are directed to the<br />
<strong>de</strong>velopment and application of online methods for pe<strong>net</strong>ration<br />
measurements. These methods are based on optical and<br />
spectroscopic measurements, which utilize the absorption or<br />
scattering properties of the topically applied substances. In the case<br />
of laser Doppler blood flow measurements, the influence of a<br />
topically applied substance on the blood flow is investigated<br />
<strong>de</strong>pen<strong>de</strong>nt on pe<strong>net</strong>ration time.<br />
The most promising online methods are the attenuated totalreflection<br />
spectroscopy (ATR) [22], opto-acoustic spectroscopy,<br />
optical coherent tomography (OCT) [23, 24], and the laser scanning<br />
microscopy (LSM) [25, 26]. These methods are presented<br />
schematically in Figure 8.<br />
However all these methods still have limitations, especially<br />
concerning the insufficient <strong>de</strong>pth resolution of the measurements<br />
insi<strong>de</strong> the stratum corneum or on account of the non-quantitative<br />
character of the measurements. In several cases, the substances<br />
un<strong>de</strong>r investigation should be dye or isotope labeled [25, 22]. In<br />
other cases, the direct contact of the sensor head to the skin surface<br />
leads to occlusion effects [22,23].<br />
The rapid technical progress, especially in the field of laser<br />
techniques and spectroscopic methods, will overcome these<br />
limitations in the near future. One example for this is the<br />
<strong>de</strong>velopment and application of a <strong>de</strong>rmatological laser scanning<br />
microscope [27], which permits the <strong>de</strong>tection of substances in<br />
different <strong>de</strong>pths of the stratum corneum and in different layers<br />
(Figure 9) of the living human skin, by fluorescent measurements.<br />
------------------------------------------------------------------------------------<br />
Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
100 Analytical methods for the <strong>de</strong>termination of <strong>de</strong>rmatopharmacoki<strong>net</strong>ics<br />
ATR<br />
LSM<br />
Opto<br />
acoustics<br />
------------------------------------------------------------------------------------<br />
Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1<br />
OCT<br />
Laser Doppler<br />
measurements<br />
Fig. 8: Promising online methods for the <strong>de</strong>termination of<br />
<strong>de</strong>rmatopharmacoki<strong>net</strong>ics<br />
Using the principle of two-phonon excitation, laser radiation in the<br />
red or near infrared spectral region will be applied in the future to<br />
LSM systems. In this way, it will also be possible, to investigate<br />
<strong>de</strong>eper skin layers with a high space resolution.<br />
As mentioned before, the <strong>de</strong>rmatopharmacoki<strong>net</strong>ics of topically<br />
applied substances can be analyzed by <strong>de</strong>tection of the biological<br />
response. In the case of skin treatment with clobetasol, the observed<br />
blanching effect is caused by changes in the blood flow. By<br />
applying the method of optical coherent tomography (OCT), series<br />
of images obtained (Figure 10) can be used for the <strong>de</strong>termination of<br />
the blood flow in different <strong>de</strong>pths of the skin [28]. These results are<br />
in correlation with the pe<strong>net</strong>ration ki<strong>net</strong>ics of steroids into the living<br />
skin.
Analytical methods for the <strong>de</strong>termination of <strong>de</strong>rmatopharmacoki<strong>net</strong>ics 101<br />
Stratum corneum<br />
Stratum Basale<br />
Stratum Granulosum<br />
Papillary Dermis<br />
Fig. 9: Detection of substances in different layers of the living<br />
human skin by laser scanning microscopy measurements [27]<br />
Fig. 10: The blood flow in different <strong>de</strong>pths of the skin can be<br />
<strong>de</strong>termined by optical coherent tomography (OCT image, forearm)<br />
------------------------------------------------------------------------------------<br />
Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
102 Analytical methods for the <strong>de</strong>termination of <strong>de</strong>rmatopharmacoki<strong>net</strong>ics<br />
Summary<br />
In summary, it can be established that tape stripping, in<br />
combination with the <strong>de</strong>termination of the horny layer profile, is a<br />
suitable qualitative and quantitative in vivo method for the analysis<br />
of <strong>de</strong>rmatopharmacoki<strong>net</strong>ics of topically applied substances. The<br />
<strong>de</strong>velopment of non-invasive online methods based on optical and<br />
spectroscopic measurements will expand and improve the<br />
<strong>de</strong>termination of the pe<strong>net</strong>ration processes, thus permitting a new<br />
insight into pe<strong>net</strong>ration pathways.<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
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------------------------------------------------------------------------------------<br />
Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
106 HPTLC and LC/MS in cerami<strong>de</strong> analysis<br />
HPTLC and LC/MS in cerami<strong>de</strong> analysis<br />
K. Raith, H. Farwanah, R. Neubert<br />
Martin Luther University Halle-Wittenberg<br />
Institute of Pharmaceutics and Biopharmaceutics<br />
W.-Langenbeck-Str. 4<br />
D-06120 Halle (S.)<br />
Germany<br />
Abstract ....................................................................... 106<br />
Introduction................................................................. 107<br />
Materials and Methods................................................ 108<br />
• Extraction................................................................... 108<br />
• Thin-layer Chromatography ...................................... 108<br />
• Mass Spectrometry .................................................... 109<br />
Results and Discussion ............................................... 110<br />
• Thin-layer Chromatography ...................................... 111<br />
• LC/MS ....................................................................... 112<br />
• Tan<strong>de</strong>m MS ............................................................... 113<br />
Conclusion .................................................................. 115<br />
Acknowledgement ...................................................... 116<br />
References................................................................... 116<br />
Abstract<br />
The investigation of the role of cerami<strong>de</strong>s in maintaining the barrier<br />
function of stratum corneum has brought about the need of specific<br />
analytical methods. The article <strong>de</strong>scribes a combination of highperformance<br />
thin-layer chromatography using automated multiple<br />
<strong>de</strong>velopment, with subsequent liquid chromatography-electrospraymass<br />
spectrometry for the profiling of cerami<strong>de</strong>s. The fractionation<br />
of complex lipid extracts with the help of thin-layer<br />
chromatography facilitates a specific, sensitive and reliable<br />
analysis. Characteristic patterns of the molecular mass distribution<br />
in different cerami<strong>de</strong> fractions are easily obtainable. Additional<br />
electrospray tan<strong>de</strong>m mass spectrometry using an ion trap mass<br />
spectrometer provi<strong>de</strong>s fragment ions which indicate the sphingoid<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
HPTLC and LC/MS in cerami<strong>de</strong> analysis 107<br />
base as well as the fatty acid moiety and therefore enables the exact<br />
assignment of cerami<strong>de</strong> structures.<br />
Introduction<br />
The stratum corneum lipids are known to play a <strong>de</strong>cisive role in<br />
maintaining the barrier function of the skin against transepi<strong>de</strong>rmal<br />
water loss and pe<strong>net</strong>ration of substances from the environment [1].<br />
It has been shown that a number of skin disor<strong>de</strong>rs, such as psoriasis,<br />
atopic <strong>de</strong>rmatitis, ichthyosis or xerosis, entail changes in lipid<br />
composition [2-6]. Therefore, the analysis of the major stratum<br />
corneum lipid classes, particularly of the cerami<strong>de</strong>s, is a<br />
prerequisite to a better un<strong>de</strong>rstanding of these disor<strong>de</strong>rs and to their<br />
specific treatment.<br />
For the separation of the major stratum corneum lipid classes, i.e.<br />
cerami<strong>de</strong>s, fatty acids, cholesterol and its esters, thin-layer<br />
chromatography (TLC) is the method of choice. Normal phase<br />
HPLC as a possible alternative [7] is less robust to matrix<br />
components from biological lipid extracts. Furthermore, <strong>de</strong>tection<br />
problems result from lacking UV absorbance of the lipids and<br />
incompatibility of the used mobile phase to electrospray mass<br />
spectrometry, respectively. Reversed phase LC implies a different<br />
selectivity due to its susceptibility to chain length influences,<br />
therefore not allowing cerami<strong>de</strong> class separation according to<br />
number and position of the hydroxy functions.<br />
The automated multiple <strong>de</strong>velopment high performance thin-layer<br />
chromatography (AMD-HPTLC) uses automated procedures for<br />
eluent mixing, chamber conditioning, <strong>de</strong>velopment and drying<br />
steps. Furthermore, it is less time and solvent consuming and avoids<br />
band broa<strong>de</strong>ning due to the reconcentration effect [8].<br />
The cerami<strong>de</strong>s can be separated in at least seven previously<br />
<strong>de</strong>scribed subclasses [9], which are known to consist of a certain<br />
type of sphingoid base (sphingosine or phytosphingosine) and a<br />
certain type of fatty acid (normal or α-hydroxy fatty acids),<br />
respectively. Each of these subclasses consists of a variety of<br />
species differing with respect to chain length.<br />
A further analysis of the composition of each cerami<strong>de</strong> subclass can<br />
be performed using mass spectrometry. For this purpose, the<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
108 HPTLC and LC/MS in cerami<strong>de</strong> analysis<br />
separated bands can be recovered and submitted to mass<br />
spectrometry. Due to the nature of cerami<strong>de</strong>s as polar lipids,<br />
electrospray ionization is the method of choice. In negative<br />
ionization mo<strong>de</strong> the best sensitivity can be achieved. To handle<br />
small amounts of sample and to prevent ion suppression effects, a<br />
preceding liquid chromatography on reversed phase columns is<br />
advisable.<br />
The i<strong>de</strong>ntification of the different cerami<strong>de</strong> species is possible using<br />
tan<strong>de</strong>m mass spectrometry (MS/MS). This requires an ion trap,<br />
triple quadrupole or any other type of mass analyzer capable of<br />
performing MS/MS experiments.<br />
Materials and Methods<br />
• Extraction<br />
For surface extraction purposes a cylindric glass beaker with 4 cm<br />
ID (contact area 12.56 cm 2 ) was filled with 8 ml n-hexane/ethanol<br />
2:1 (V/V). The open si<strong>de</strong> was pressed tightly to a skin area at the<br />
inner forearm to prevent lateral leakage. The extraction time was 5<br />
min throughout. The extraction mixture was thereafter evaporated<br />
at 50 °C and the residue dried un<strong>de</strong>r a stream of argon. The dried<br />
lipids were then dissolved in 500 µl chloroform/methanol 1:1.<br />
• Thin-layer Chromatography<br />
The HPTLC plates were washed three times with<br />
chloroform/methanol 65:35 (V/V) before use. Sample application<br />
has been carried out automatically using an Automatic TLC<br />
Sampler 4 (Camag, Muttenz, Switzerland) at a dosage speed of 100<br />
µl/s. 15 samples were applied on each plate at a start line 8 mm<br />
from the bottom, including 6 lanes for skin lipid samples (each 6 µl)<br />
and 9 lanes for reference lipids ranging from 200 ng to 4 µg for<br />
each standard lipid. The band width was 8 mm with 4 mm distance<br />
to the neighbouring lane.<br />
The <strong>de</strong>velopment of the plates has been carried out automatically<br />
using an AMD-2 apparatus (Camag, Muttenz, Switzerland). The<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
HPTLC and LC/MS in cerami<strong>de</strong> analysis 109<br />
used AMD procedure inclu<strong>de</strong>d a 17 step gradient of <strong>de</strong>creasing<br />
polarity using ethanol, acetone, chloroform, ethylacetate and nhexane.<br />
After drying, the plates were dipped into an aqueous solution of<br />
10% CuSO4, 8% H3PO4 (V/V), and 5% methanol for 20 s.<br />
Afterwards, the plates were charred in a drying oven at 150°C for<br />
20 min.<br />
The <strong>de</strong>veloped and visualised plates were scanned from 7 cm to<br />
front using a TLC Scanner 3 (Camag, Muttenz, Switzerland). The<br />
measurement was performed in reflectance mo<strong>de</strong> at a wavelength of<br />
546 nm. The slit dimensions were 4 x 0.2 mm at a scan speed of 20<br />
C hole sterolester<br />
Cho lest erol<br />
Cerami<strong>de</strong> 1 [EOS]<br />
Cerami <strong>de</strong> 2 [NS]<br />
C erami<strong>de</strong> 3 [NP]<br />
Cerami<strong>de</strong> 4<br />
Cerami <strong>de</strong> 5 [AS]<br />
C erami<strong>de</strong> 6 [AP]<br />
Cerami<strong>de</strong> 7<br />
Fa ty Acids<br />
Fig. 1: The AMD-2 apparatus Fig. 2: Stratum corneum lipid<br />
(Camag, Muttenz, Schweiz) lipid separation using AMD-<br />
HPTLC<br />
mm/s and a data resolution of 25 µm per step. Integration and<br />
quantification based on peak areas were performed using CATS<br />
software (Camag, Muttenz, Switzerland). To avoid experimental<br />
errors, individual curves were set up for each HPTLC plate.<br />
Quantitative results for all cerami<strong>de</strong>s were related to Cerami<strong>de</strong> NP.<br />
• Mass Spectrometry<br />
Provi<strong>de</strong>d that a non-<strong>de</strong>structive <strong>de</strong>tection is used or <strong>de</strong>tection is<br />
limited to the margin zones of the plate [10], the bands<br />
corresponding to the cerami<strong>de</strong> subclasses can be recovered from the<br />
plate and submitted to mass spectrometry. Herefore, the loa<strong>de</strong>d<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
110 HPTLC and LC/MS in cerami<strong>de</strong> analysis<br />
silica fractions can be reextracted for 10 min with<br />
chloroform/methanol 1:1 assisted by ultrasound. After<br />
centrifugation the supernatant can be analysed directly by LC/MS.<br />
These analyses were performed using a Spectra System P 4000 LC<br />
pump equipped with an autosampler AS 3000, a membrane<br />
<strong>de</strong>gasser SCM 1000 and a controller SN 4000 (ThermoFinnigan,<br />
San Jose, CA, USA). In cerami<strong>de</strong> analysis a reversed phase column<br />
Nucleosil ® 120 3C18 (125x2mm ID) (Macherey-Nagel, Düren,<br />
Germany) and a mobile phase consisting of<br />
methanol/tetrahydrofurane 97:3 was used.<br />
An ion trap mass spectrometer Finnigan LCQ (ThermoFinnigan,<br />
San Jose, CA, USA) equipped with an electrospray interface was<br />
used throughout. More <strong>de</strong>tails about the LC/MS method are given<br />
in literature [11]. Electrospray ionization was performed preferably<br />
in the negative ion full scan mo<strong>de</strong>. Tan<strong>de</strong>m mass spectra are<br />
obtained by collision-induced dissociation in the ion trap. A relative<br />
collision energy of 28 % was applied, which resulted in a <strong>de</strong>crease<br />
of the precursor ion to approx. 10 % relative intensity.<br />
Fig. 3. The LC/MS system <strong>de</strong>scribed<br />
un<strong>de</strong>r Materials and Methods<br />
(ThermoFinnigan, San Jose, CA, USA).<br />
Results and Discussion<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1<br />
Fig. 4: The ion trap<br />
mass analyzer of the<br />
LCQ (cross-section).<br />
To obtain the results <strong>de</strong>scribed below, using the methods of AMD-<br />
HPTLC and LC/MS, two strategies turned out to be practicable:<br />
firstly, lipid extraction of stratum corneum samples obtained by<br />
means of a Bligh-Dyer extraction. This approach requires a<br />
sufficient amount of stratum corneum (> 60 mg) and is therefore
HPTLC and LC/MS in cerami<strong>de</strong> analysis 111<br />
limited to body areas were such an amount can be obtained, namely<br />
the plantar sole skin. The second approach is the in-vivo-surface<br />
extraction of stratum corneum lipids. The general advantage of<br />
surface extraction is that it is noninvasive and can be performed<br />
easily in vivo. However, one has to bear in mind that sebum lipids<br />
consisting mainly of triacylglycerol and wax esters and are<br />
coextracted with the stratum corneum lipids. Several solvent<br />
mixtures have been tested. In contrast to some literature reports<br />
[12], mixtures containing diethylether turned out to be<br />
impracticable, because the high steam-pressure caused solvent<br />
losses. Furthermore, many solvents including chloroform or acetone<br />
should not be used, for they are inducing pain and lasting skin<br />
damages. The chosen hexane/ethanol 2:1 mixture was a<br />
compromise between extraction efficiency and ethical aspects.<br />
If the analysis is exclusively aimed at the cerami<strong>de</strong>s, a preceding<br />
solid phase extraction is advisable to separate the cerami<strong>de</strong>s from<br />
other lipids [13].<br />
• Thin-layer Chromatography<br />
An improved procedure for the separation of major stratum<br />
corneum lipids by means of AMD-HPTLC has recently been<br />
<strong>de</strong>veloped [14]. The first 11 steps were performed using mixtures of<br />
chloroform, ethanol and aceton. Thereafter followed 3 isocratic<br />
steps with chloroform. These steps allowed the separation of<br />
cholesterol sulfate, the various cerami<strong>de</strong> classes and cholesterol.<br />
For the separation of cholesterol, fatty acids, triacylglycerol,<br />
cholesterol esters, and squalene, 2 additional steps were required<br />
with a mixture containing n-hexane and ethylacetate followed by an<br />
isocratic hexane step. Before each step the plates were conditioned<br />
with a stream of 4 N acetic acid in or<strong>de</strong>r to focus the fatty acid<br />
bands and to achieve a better resolution in the cerami<strong>de</strong> fractions.<br />
This gradient enables base line separation of the lipid standards<br />
cholesterol sulfate, cerami<strong>de</strong> AP, cerami<strong>de</strong> AS, cerami<strong>de</strong> NP,<br />
cerami<strong>de</strong> NS, cholesterol, palmitic acid, triacylglycerol, cholesterol<br />
oleate, and squalene. Since the used cerami<strong>de</strong> AP is a semisynthetic<br />
substance containing a racemic 2-hydroxy fatty acid moiety, the<br />
corresponding spot is separated into 2 bands.<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
112 HPTLC and LC/MS in cerami<strong>de</strong> analysis<br />
The <strong>de</strong>veloped AMD-HPTLC method has been applied to surface<br />
lipid extracts of human skin. The skin lipids were extracted in vivo<br />
as <strong>de</strong>scribed un<strong>de</strong>r Materials and Methods.<br />
Lipid bands could be unequivocally i<strong>de</strong>ntified by relating the Rf<br />
values to those of the standard lipids as well as profiles from<br />
previous studies [12,15,16]. In some cases, the Rf of the skin lipids<br />
was slightly larger. This results because the fatty acid as well as<br />
sphingoid base moieties in stratum corneum cerami<strong>de</strong>s have longer<br />
chain lengths compared to the standards. In addition, the broad<br />
spectrum of chain lengths implies a more complex <strong>de</strong>nsitometric<br />
profile, although the resolution obtainable using AMD is still much<br />
better than with conventional manual procedures. The present<br />
protocol enables a good separation of all major stratum corneum<br />
and sebum lipids in 150 min with less solvent consumption<br />
(ethanol: 8 ml, acetone and ethylacetate: 6 ml each, n-hexane: 19<br />
ml, and chloroform: 81 ml). It can be emphasised, that particularly<br />
the separation of cerami<strong>de</strong>s could be improved in comparison to<br />
previously reported AMD protocols [17]. Hence, the present<br />
procedure is suitable to be used for diagnostic purposes as well as<br />
for high-throughput analysis of the major stratum corneum lipids.<br />
The calibration curves for <strong>de</strong>nsitometric quantification are usually<br />
not linear and were fitted using a saturation function such as the<br />
Michaelis-Menten equation as <strong>de</strong>scribed before [18].<br />
Detailed comments on the results obtainable by AMD-HPTLC<br />
quantification are given in [14].<br />
• LC/MS<br />
LC/MS enables a rapid and sensitive cerami<strong>de</strong> quantification,<br />
which is completed by structural information obtainable by tan<strong>de</strong>m<br />
mass spectrometry. Unfortunately, the disturbing effects of the<br />
extremely complex matrix do not allow the direct quantitation of<br />
single cerami<strong>de</strong> species in the lipid extract. For this reason, stratum<br />
corneum cerami<strong>de</strong> profiling by ESI-MS and MS/MS without<br />
chromatographic separation was not successful (in contrast to the<br />
less complex intracellular cerami<strong>de</strong>s), especially in view of the fact<br />
that suitable internal standards (<strong>de</strong>uterated cerami<strong>de</strong>s) are not<br />
available. Therefore, we combined AMD-HPTLC and LC/MS.<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
HPTLC and LC/MS in cerami<strong>de</strong> analysis 113<br />
The fractions containing Cer [NS], [NP], [AS] and [AP] were<br />
localized by comparison with the Rf values of the <strong>de</strong>tected standard<br />
lipids at the edge of the plate, scraped from the plate, reextracted<br />
and analyzed using LC/MS. All measurements were acquired in full<br />
scan mo<strong>de</strong>. Therefore, it has been possible to extract every mass-tocharge<br />
ratio from the total ion current, if evi<strong>de</strong>nce has been found<br />
for in average mass spectra. As a reference, “expected” molecular<br />
weights were calculated from the percentages of inci<strong>de</strong>nce, that<br />
Wertz et al. have presented for fatty acids and long chain bases in<br />
each of the cerami<strong>de</strong> classes [6]. Details are given in [10]. In<br />
accordance to the predicted data, the largest peaks have been<br />
<strong>de</strong>tected at m/z= 706 and m/z= 678. Additional tan<strong>de</strong>m mass<br />
spectrometry revealed that these peaks are caused mostly by<br />
cerami<strong>de</strong>s formed by the combination of C-20-sphinganine with<br />
lignoceric and hexacosanoic acid, respectively. In the cerami<strong>de</strong><br />
fractions [NP], [AS] and [AP] also a good correlation of the<br />
predicted and observed molecular weight distribution was found.<br />
In the <strong>de</strong>scribed LC/MS approach, the calculation of the relative<br />
abundance of the most important cerami<strong>de</strong>s in each fraction was<br />
performed in two ways. First, the peak areas of all distinguished<br />
peaks were calculated and related to the largest one. Second, the<br />
calculation refered to the relative abundance in a mass spectrum,<br />
which has been summed over a time range from 1 to 8 min<br />
retention time in LC. The first approach is more specific but less<br />
sensitive. In the case of several coeluting substances the peak<br />
integration becomes difficult. The second approach provi<strong>de</strong>s better<br />
sensitivity and reproducibility (3% RSD versus 5-10%) but sums<br />
the homologs with i<strong>de</strong>ntical m/z. The molecular mass distribution<br />
of cerami<strong>de</strong>s in the cerami<strong>de</strong>-2-fraction is obviously not a simple<br />
Gaussian distribution.<br />
• Tan<strong>de</strong>m MS<br />
For a real species specific quantitation LC/MS/MS is nee<strong>de</strong>d.<br />
Whereas in positive mo<strong>de</strong> in many cases only multiple stage MS<br />
(MS n ) enables an unequivocal i<strong>de</strong>ntification, in negative mo<strong>de</strong> this<br />
goal can be achieved yet in MS/MS. The parameters for cerami<strong>de</strong><br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
114 HPTLC and LC/MS in cerami<strong>de</strong> analysis<br />
fragmentation have been reported in [19]. Figure 5 shows a<br />
negative ESI-Tan<strong>de</strong>m mass spectrum of N-Stearoylsphinganine, a<br />
Cer[NS] species. Figure 6 illustrates the corresponding fragment<br />
structures. As can be seen, both the sphingoid base as well as the<br />
fatty acid moiety are directly accessible. By means of LC/MS/MS<br />
even homologs within a fraction with i<strong>de</strong>ntical molecular mass and<br />
retention behaviour may be separately profiled. Electrospray<br />
tan<strong>de</strong>m mass spectra of cerami<strong>de</strong>s and the proposed structures of<br />
the fragment ions have been discussed in <strong>de</strong>tail in [10] and [19],<br />
respectively. The exhaustive LC/MS/MS investigation of all<br />
possible cerami<strong>de</strong>s (probably by far more than 1000) is a largescale<br />
task. It seems to be more useful to screen cerami<strong>de</strong> samples<br />
from different origins by LC/MS and use MS/MS as an additional<br />
tool, if significant differences in the molecular mass distribution are<br />
observed.<br />
It is also possible to perform equal MS/MS studies using a triple<br />
quadrupole mass spectrometer. Thereby the obtainable sensitivity is<br />
slightly better in Selected Ion Monitoring, but not so good in Full<br />
Scan, which may be disadvantageous in the analysis of complex<br />
samples including unknown substances.<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
Relative Abundance<br />
100<br />
90<br />
80<br />
70<br />
60<br />
50<br />
40<br />
30<br />
20<br />
10<br />
Conclusion<br />
0<br />
26 5.4<br />
23 9.4<br />
300.3<br />
283.5<br />
30 8.4<br />
324.3<br />
HPTLC and LC/MS in cerami<strong>de</strong> analysis 115<br />
200 250 300 350 400 450 500 550 600<br />
m/z<br />
Fig. 5: Negative ESI-Tan<strong>de</strong>m mass spectrum of N-<br />
Stearoylsphinganine.<br />
Stearic acid<br />
m/z=283<br />
R O<br />
m/z=239<br />
R<br />
-<br />
Cerami<strong>de</strong> II [M-H]<br />
N-Stearoylsphinganine<br />
m/z=567<br />
m/z=265<br />
O<br />
R<br />
N<br />
H 2<br />
O<br />
m/z=300<br />
N<br />
OH<br />
O<br />
R<br />
OH<br />
OH<br />
N<br />
-H 2 O<br />
O<br />
m/z=308<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1<br />
518.6<br />
-CH 2 OH,-2H<br />
R<br />
53 4.5<br />
m/z=548<br />
R<br />
548.4<br />
m/z=518<br />
N<br />
H<br />
O<br />
567.5<br />
N<br />
O<br />
R<br />
m/z=324<br />
m/z=534<br />
Fig. 6: Fragment structure corresponding to Fig. 5.<br />
The <strong>de</strong>scribed combined approach provi<strong>de</strong>s <strong>de</strong>tailed information<br />
about stratum corneum lipid composition, particularly with respect<br />
to cerami<strong>de</strong> structures. However, the evaluation of all the<br />
obtainable data is not yet completed. These methods are capable of<br />
solving numerous analytical problems raising from <strong>de</strong>rmatological<br />
studies. From the analytical point of view, the further <strong>de</strong>velopment<br />
should be aimed to online coupling and automation. In future<br />
assays, TLC could be replaced by normal phase LC, e.g. with<br />
evaporative light scattering <strong>de</strong>tection. After fraction collection the<br />
samples could be submitted to reversed phase LC/MS/MS.<br />
Thereafter, an online LC/LC/MS/MS approach could be <strong>de</strong>veloped.<br />
O
116 HPTLC and LC/MS in cerami<strong>de</strong> analysis<br />
Acknowledgement<br />
We wish to thank Manuela Woigk for excellent technical<br />
assistance.<br />
References<br />
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and E.E. Tuinenburg, Arch. Dermatol. Res., 1994, 286, 495.<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
HPTLC and LC/MS in cerami<strong>de</strong> analysis 117<br />
16 S.A. Long, P.W. Wertz, J.S. Strauss and D.T. Downing , Arch.<br />
Dermatol. Res., 1985, 277, 284.<br />
17 S. Motta, M. Monti, S. Sesana, R. Caputo, S. Carelli and R.<br />
Ghidoni, Biochim. Biophys. Acta, 1993, 1182, 147.<br />
18 S. Zellmer, J. Lasch, J. Chromatogr. B, 1997, 691, 321.<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
118 HPLC-analysis for permeation studies of 5-aminolevulinic acid and its <strong>de</strong>rivatives<br />
HPLC-analysis for permeation studies of 5aminolevulinic<br />
acid and its <strong>de</strong>rivatives<br />
A. Winkler C.C. Müller-Goymann<br />
Technische Universität Carolo-Wilhelmina<br />
Institut für Pharmazeutische Technologie,<br />
Men<strong>de</strong>lssohnstraße 1<br />
D-38106 Braunschweig<br />
Germany<br />
Introduction................................................................. 118<br />
Experimental methods................................................. 120<br />
• Materials .................................................................... 120<br />
• HPLC conditions ....................................................... 120<br />
• Derivatisation of ALA and ABE ............................... 121<br />
• In vitro permeation studies ........................................ 122<br />
• Stability of ALA and ABE during in vitro<br />
permeation ................................................................. 122<br />
Results and Discussion ............................................... 123<br />
Conclusion .................................................................. 126<br />
Acknowledgements..................................................... 126<br />
References................................................................... 126<br />
Introduction<br />
5-Aminolevulinic acid (ALA) is a precursor in the biosynthetic<br />
pathway of porphyrins, especially protoporphyrin IX (Pp IX), and<br />
heme [1]. Photodynamic therapy (PDT) uses ALA induced<br />
accumulation of Pp IX in abnormal cells to treat skin diseases or<br />
cancer of the blad<strong>de</strong>r, oesophagus, and lung after topical or<br />
systemic application of exogenous ALA. The subsequent activation<br />
by light of an appropriate wavelength causes photodamage of the<br />
tumour by photochemical reaction [2, 3].<br />
A major drawback of ALA is its high hydrophilicity as a<br />
hydrochlori<strong>de</strong> which results in a low intercellular bioavailability. In<br />
or<strong>de</strong>r to increase lipophilicity and to improve the diffusion<br />
properties of ALA several <strong>de</strong>rivatives of ALA were synthesized by<br />
Kloek et al. [4], one of which is 5-aminolevulinic acid-n-butyl ester<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
HPLC-analysis for permeation studies of 5-aminolevulinic acid and its <strong>de</strong>rivatives 119<br />
(ABE). ABE induced higher Pp IX concentration in cultivated cells<br />
than ALA did.<br />
In or<strong>de</strong>r to investigate and compare the diffusion properties of ALA<br />
and ABE into human skin an in vitro mo<strong>de</strong>l was <strong>de</strong>veloped using<br />
modified Franz cells. The separating membrane between donor and<br />
receiver was excised human stratum corneum which is the main<br />
barrier of human skin especially for hydrophilic substances.<br />
Furthermore artificial skin constructs (ASC) were used, being an<br />
alternative to excised human skin. ASC can be produced by<br />
standardised cultivation in highly reproducible quality [5, 6].<br />
Quantification of the permeated amounts of either drug requires a<br />
sufficiently sensitive method. ALA and ABE concentrations which<br />
are likely to be sampled during in vitro permeation studies cannot<br />
be <strong>de</strong>termined by UV <strong>de</strong>tection with sufficient sensitivity, as has<br />
been <strong>de</strong>monstrated by [7]. The UV <strong>de</strong>tection limit for a reversed<br />
phase ion pair chromatography on octa<strong>de</strong>cyl silica with a mobile<br />
phase of methanol water containing 1-heptanesulphonic acid was 50<br />
µg/ml [7]. A colorimetrical <strong>de</strong>termination of ALA based on the<br />
colour reaction of ALA-pyrrole with Ehrlich´s reagent also shows a<br />
low sensitivity [8, 9]. Sensitive methods using fluorescence<br />
<strong>de</strong>tection after <strong>de</strong>rivatisation of ALA with acetylacetone and<br />
formal<strong>de</strong>hy<strong>de</strong> [10] or o-phthaldial<strong>de</strong>hy<strong>de</strong> (OPA) [11] have been<br />
reported in combination with high performance liquid<br />
chromatography. OPA <strong>de</strong>rivatisation was <strong>de</strong>veloped by Roth<br />
originally for amino acid analysis [12]. Primary amines react with<br />
OPA in the presence of thiol forming an instable fluorescent<br />
product [13]. Advantages of this method are a short reaction time of<br />
2 minutes and an a<strong>de</strong>quate reactivity of the used reagents at ambient<br />
temperature opposite to the <strong>de</strong>rivatisation with acetylacetone and<br />
formal<strong>de</strong>hy<strong>de</strong> which needs heating of the mixture for 10 min at<br />
100°C [10]. However amino acids released from stratum corneum<br />
and ASC during in vitro permeation studies react the same way.<br />
Hence, these substances have to be separated from ALA and ABE.<br />
Due to frequent sampling during permeation studies, HPLC<br />
separation of ALA and ABE from other amino acids should occur<br />
within time intervals as short as possible.<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
120 HPLC-analysis for permeation studies of 5-aminolevulinic acid and its <strong>de</strong>rivatives<br />
This report provi<strong>de</strong>s in vitro permeation studies, including an HPLC<br />
method for the quantification of ALA and ABE, respectively. ALA<br />
quantification has been adopted from Ho et al. [11] whereas ABE<br />
quantification combines both [11] and an amino acid quantification<br />
according to Graser et al. [14]. The methods from the literature are<br />
slightly modified to <strong>de</strong>termine ALA or ABE and amino acids from<br />
stratum corneum or ASC simultaneously.<br />
Experimental methods<br />
• Materials<br />
ALA was provi<strong>de</strong>d by Medac GmbH, We<strong>de</strong>l, Germany. ABE was<br />
synthesized according to Kloek et al. [4]. n-butanol and thionyl<br />
chlori<strong>de</strong> were used to esterify ALA. n-butanol was purchased from<br />
Heraeus GmbH, Karlsruhe, Germany, thionylchlori<strong>de</strong> from Merck<br />
KGaA, Darmstadt, Germany. ABE was purified by recrystallisation<br />
in diethylether purchased from Fluka, Neu-Ulm, Germany (all<br />
chemicals were reagent gra<strong>de</strong>).<br />
Acetonitrile, methanol and acetic acid (all chemicals were HPLC<br />
gra<strong>de</strong>) were purchased from J.T. Baker, VA Deventer, The<br />
Netherlands. OPA (HPLC quality) was purchased from Fluka, Neu-<br />
Ulm, Germany, mercaptoethanol (pro analysi) and all buffer<br />
substances (pro analysi) from Merck KGaA, Darmstadt, Germany.<br />
Boric acid (HPLC quality) was purchased from Carl Roth GmbH,<br />
Karlsruhe, Germany, absolute ethanol (HPLC quality) by Rie<strong>de</strong>l <strong>de</strong><br />
Haën, Seelze, Germany. Water was used in bidistilled quality.<br />
• HPLC conditions<br />
The HPLC system consisted of a fluorescence HPLC monitor RF-<br />
353 (Shimadzu, Kyoto, Japan) and a Spectroflow 400 solvent<br />
<strong>de</strong>livery system (Kratos Analytical, New Jersey, USA) equipped<br />
with a Rheodyne 7125 syringe loading sample injector (Rheodyne,<br />
Cotati, USA). The injector was fitted with a 20 µl loop. The<br />
analytical column (250 mm x 4.6 mm) was connected in line with a<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
HPLC-analysis for permeation studies of 5-aminolevulinic acid and its <strong>de</strong>rivatives 121<br />
guard column (10 mm x 4.6 mm). Both columns were packed with<br />
Hypersil ODS (particle size 5 µm) (Grom, Herrenberg, Germany).<br />
Eluation of ALA and ABE was performed with different mobile<br />
phases <strong>de</strong>pending on different physicochemical properties of both<br />
drugs. ALA was eluted according to [9] with a mixture of an<br />
aqueous acetate buffer (22 mM) and methanol in the ratio of 7.5:5.<br />
The flow rate was 1.3 ml/min at ambient temperature. The mobile<br />
phase for ABE elution was prepared according to Graser et al. [14]<br />
who used this method for the <strong>de</strong>termination of amino acids. An<br />
aqueous monobasic potassium phosphate buffer (12.5 mM, pH 7.2)<br />
was mixed with acetonitrile in the ratio of 5.5 to 5.0. ABE was<br />
isolated by isocratic elution at a flow rate of 1.5 ml/min at ambient<br />
temperature.<br />
• Derivatisation of ALA and ABE<br />
The <strong>de</strong>rivatisation reagent was prepared according to Ho et al. [11].<br />
27 mg OPA were dissolved in 500 µl ethanol. Subsequently 4.5 ml<br />
of a sodium borate buffer (0.4 M, adjusted to pH 9.5 with a 20 %<br />
sodium hydroxi<strong>de</strong> solution) were ad<strong>de</strong>d to this solution. At least 25<br />
µl mercaptoethanol were ad<strong>de</strong>d. Prior to use the mixture was stored<br />
over night at room temperature.<br />
The <strong>de</strong>rivatisation was performed according to Ho et al. [11], too.<br />
One hundred microliters of the <strong>de</strong>rivatisation reagent were mixed<br />
with 100 µl of the sample. Aliquots from the receiver enriched with<br />
ABE after the permeation studies with ASC were diluted by ratio<br />
1:10 with phosphate buffer of pH 5.0 (Ph. Helv. 8) because of the<br />
high concentration of ABE. After a reaction time of exactly 2<br />
minutes 100 µl monobasic potassium phosphate buffer (0.1 M, pH<br />
4.0) were ad<strong>de</strong>d to the mixture. Immediately afterwards 20 µl of<br />
this solution were injected onto the <strong>de</strong>scribed column to avoid<br />
fading of fluorescence. Fluorescence was monitored with an<br />
excitation wavelength of 330 nm and an emission wavelength of<br />
418 nm.<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
122 HPLC-analysis for permeation studies of 5-aminolevulinic acid and its <strong>de</strong>rivatives<br />
• In vitro permeation studies<br />
In vitro permeation studies were performed with a modified Franz<br />
cell [15]. Excipial ® Fettcreme enriched with either 10 % (w/w)<br />
ALA or 10 % (w/w) ABE prior to the permeation studies served as<br />
donor. The donor was freshly prepared while mixing the drug with<br />
Excipial ® Fettcreme for 2.5 minutes using an Unguator ® (GAKO<br />
Konietzko GmbH, Bamberg, Germany).<br />
The receiver contained 4.5-6.0 ml of phosphate buffer of pH 5.0<br />
(Ph. Helv. 8) to guarantee for stability of ALA and ABE. At a pH<br />
above 5.2 an instability of ALA is recognized by an increasingly<br />
yellow colour and a <strong>de</strong>crease in pH of the solution due to formation<br />
of pyrazin <strong>de</strong>rivatives [16-18]. The temperature of the receiver was<br />
maintained at 37 °C by a waterbath.<br />
Donor and receiver were separated by stratum corneum or ASC,<br />
respectively. Stratum corneum which was separated from human<br />
skin samples by trypsination was placed on a polycarbonate filter<br />
(Isopore ® membrane filters, type TMTP, 5.0 µm, Millipore, Ireland)<br />
for higher mechanical stability. ASC cultivated un<strong>de</strong>r standard<br />
conditions [5, 6] was used together with the polycarbonate<br />
membrane of the Transwell ® insert.<br />
• Stability of ALA and ABE during in vitro permeation<br />
For each substance stability was checked un<strong>de</strong>r the conditions of<br />
the in vitro permeation studies. While being stirred aqueous<br />
phosphate buffer solutions of pH 5.0 (Ph. Helv. 8) with ALA or<br />
ABE (40 µg/ml) were incubated at 37°C together with pieces of<br />
stratum corneum for 28 h or with pieces of ASC for 10 h,<br />
respectively (total diameter of stratum corneum and ASC was about<br />
1.5 cm each). Same solutions without stratum corneum or ASC<br />
were treated the same way as standards. Samples were taken as<br />
shown in figure 4. The concentration of each substance was<br />
analysed by HPLC as <strong>de</strong>scribed.<br />
------------------------------------------------------------------------------------<br />
Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
HPLC-analysis for permeation studies of 5-aminolevulinic acid and its <strong>de</strong>rivatives 123<br />
Results and Discussion<br />
The mobile phases of the HPLC methods from the literature [11,<br />
14] were optimised in or<strong>de</strong>r to improve separation of ABE or ALA<br />
from other amino acids. In the case of ABE a mobile phase of<br />
acetonitrile/ phosphate buffer in a ratio of 5.0:5.5 resulted in a<br />
retention time of about 11 minutes and sufficiently high sensitivity.<br />
With solvent systems of acetonitrile/ phosphate buffer in ratios of<br />
5.0:5.0 or 5.5:5.0 retention time <strong>de</strong>creased but the ABE peak<br />
interfered sometimes with other peaks. For quantification of ALA, a<br />
mobile phase of aqueous acetate buffer (22 mM) and methanol in<br />
the ratio of 7.5:5 yiel<strong>de</strong>d a separation superior to that with the<br />
mobile phase <strong>de</strong>scribed by Ho et al. [11].<br />
Representative HPLC chromatograms for ABE and ALA <strong>de</strong>rived<br />
from permeation studies with stratum corneum are shown in figure<br />
1. Several peaks besi<strong>de</strong> ABE are caused by amino acids and the<br />
<strong>de</strong>rivatisation reagent, but no interference occurs between the drug<br />
and the other peaks. The reaction time for <strong>de</strong>rivatisation of ALA<br />
and ABE and the running time of a single analysis are short enough<br />
for routine analysis of a large number of samples. About 5 runs<br />
could be performed per hour.<br />
The <strong>de</strong>tection limit for both HPLC-methods is 0.100 µg/ml. The<br />
correlation coefficient for calibration in the range of 0.100 to 5.000<br />
µg/ml for ALA and 0.100 to 20.000 µg/ml for ABE was higher than<br />
0.999. This sensitive analysis of either drug is required for<br />
permeation studies with stratum corneum. The permeation profiles<br />
of ALA and ABE from Excipial ® Fettcreme across stratum<br />
corneum are shown in figure 3 (left). ALA or ABE could be proven<br />
in the receiver after 6 to 10 hours. The highest analysed ALA and<br />
ABE concentrations in the receiver were about 0.5 µg/ml and 4<br />
µg/ml, respectively, at the end of the permeation study.<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
124 HPLC-analysis for permeation studies of 5-aminolevulinic acid and its <strong>de</strong>rivatives<br />
Fluorecsence<br />
0,0010<br />
0,0005<br />
0,0000<br />
-0,0005<br />
Fluorescence<br />
ABE (11.03)<br />
0 2 4 6 8 10 12<br />
Time [min]<br />
Fluorescence<br />
0,0015<br />
0,0010<br />
0,0005<br />
0,0000<br />
-0,0005<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1<br />
ALA (8.3)<br />
-0,0010<br />
0 2 4 6 8 10<br />
Time [min]<br />
Fig. 1: HPLC chromatogram for ABE (left) and ALA (right)<br />
<strong>de</strong>rived from permeation studies with stratum corneum;<br />
concentration of ABE: 0.42 µg/ml and ALA: 0.51 µg/ml<br />
0,020<br />
0,015<br />
0,010<br />
0,005<br />
0,000<br />
ABE (11.02)<br />
0 2 4 6 8 10 12<br />
Time [min]<br />
Fluorescence<br />
0,025<br />
0,020<br />
0,015<br />
0,010<br />
0,005<br />
0,000<br />
ALA (8.8)<br />
-0,005<br />
0 2 4 6 8 10<br />
Time [min]<br />
Fig. 2: HPLC chromatogram for ABE (left) and ALA (right)<br />
<strong>de</strong>rived from permeation studies with ASC; concentration of ABE:<br />
30.57 µg/ml and ALA: 37.08 µg/ml<br />
Permeated amounts [µg/cm²]<br />
45<br />
40<br />
35<br />
30<br />
25<br />
20<br />
15<br />
10<br />
5<br />
0<br />
0 500 1000 1500 2000<br />
Time [min]<br />
Permeated amounts [µg/cm²]<br />
7000<br />
6000<br />
5000<br />
4000<br />
3000<br />
2000<br />
1000<br />
0<br />
0 100 200 300 400 500 600 700<br />
Time [min]<br />
Fig. 3: Permeation of ALA (▲) and ABE (■) from Excipial ®<br />
Fettcreme enriched with ALA (10 % (w/w)) and ABE (10 % (w/w))<br />
across stratum corneum (left) and ASC (right); ABE, n=6 for<br />
stratum corneum and 7 for ASC; ALA, n=9 for stratum corneum<br />
and 8 for ASC; graphs represent mean values and standard<br />
<strong>de</strong>viation [19]
HPLC-analysis for permeation studies of 5-aminolevulinic acid and its <strong>de</strong>rivatives 125<br />
The permeation profiles of ALA and ABE through ASC are shown<br />
in figure 3 (right). Permeability of ASC for both substances were<br />
much higher than for stratum corneum. Within the first 3 hours of<br />
the permeation studies permeated amounts of ALA and ABE<br />
increased rapidly. After 2 and 4-5 hours the ascent of the curve<br />
became linear, respectively. This rapid increase in permeated<br />
amounts agrees with the results of permeation studies with<br />
ibuprofen acid through ASC from literature [5]. Hence, each<br />
substance may be <strong>de</strong>tected from the beginning of the permeation<br />
studies. Representative HPLC chromatograms for ABE and ALA<br />
<strong>de</strong>rived from permeation studies with ASC are shown in figure 2.<br />
Resolution between ALA or ABE and other substances, which were<br />
released from ASC, were well <strong>de</strong>fined. Higher amounts of either<br />
drug could be separated as well as small amounts as <strong>de</strong>scribed<br />
above. Correlation coefficients for ALA and ABE calibrations in<br />
the range of 1-200 µg/ml were higher than 0.999.<br />
Concentration<br />
of ALA [µg/ml]<br />
Concentration<br />
of ABE [µg/ml]<br />
42<br />
40<br />
38<br />
0 400 800 1200 1600<br />
Time [min]<br />
44<br />
42<br />
40<br />
38<br />
0 400 800 1200 1600<br />
Time [min]<br />
Concentration<br />
of ALA [µg/ml]<br />
Concentration<br />
of ABE [µg/ml]<br />
42<br />
40<br />
38<br />
42<br />
40<br />
38<br />
0 100 200 300 400 500 600<br />
Time [min]<br />
0 100 200 300 400 500 600<br />
Time [min]<br />
Fig. 4: Stability studies for ALA and ABE (40 µg/ml) in phosphate<br />
buffer of pH 5.0 (Ph. Helv. 8) at 37°C; ALA (□, n=4) or ABE (○,<br />
n=4) was stirred in the presence of stratum corneum (left) or ASC<br />
(right); ▲: ALA or ABE was stirred without stratum corneum or<br />
ASC (n=2); graphs represent mean values and standard <strong>de</strong>viation<br />
Stability of ALA and ABE is guaranteed at the <strong>de</strong>scribed conditions<br />
as shown in figure 4. Sample concentration of ALA or ABE did not<br />
<strong>de</strong>crease with time either in the presence of stratum corneum and<br />
ASC or in absence of stratum corneum and ASC. Therefore<br />
<strong>de</strong>termination of either drug was not affected by substances which<br />
were released from stratum corneum or ASC.<br />
------------------------------------------------------------------------------------<br />
Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
126 HPLC-analysis for permeation studies of 5-aminolevulinic acid and its <strong>de</strong>rivatives<br />
Conclusion<br />
HPLC with precolumn OPA <strong>de</strong>rivatisation is an important method<br />
for quantification of ALA and its <strong>de</strong>rivatives besi<strong>de</strong>s other amino<br />
acids. ALA and ABE can be analysed with different mobile phases<br />
from 0.100 µg/ml upwards. Hence, sensitivity is sufficient for<br />
quantification of either drug from in vitro permeation studies with<br />
stratum corneum. Permeated amounts across ASC for both<br />
substances were higher than across stratum corneum. Stability<br />
studies for both substances show that sample concentration of ALA<br />
or ABE did not <strong>de</strong>crease at conditions of the permeation studies.<br />
Acknowledgements<br />
We would like to thank Medac GmbH, We<strong>de</strong>l, Germany for the<br />
generous donation of ALA and Hans Karrer GmbH for the donation<br />
of Excipial ® Fettcreme. Dr. Flory (Hollwe<strong>de</strong> Hospital, D-<br />
Braunschweig) is thanked for the donation of skin samples. The<br />
study was supported in part by Fonds <strong>de</strong>r Chemischen Industrie.<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
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15 Franz TJ (1975) Percutaneous absorption. On the relevance of in<br />
vitro data. J Invest Dermatol 64: 190-195<br />
16 Novo M, Hüttmann G, Did<strong>de</strong>ns H (1996) Chemical instability of<br />
5-aminolevulinic acid used in the fluorescence diagnosis of<br />
blad<strong>de</strong>r tumours. J Photochem Photobiol B 34: 143-148<br />
17 Franck B, Stratmann H (1981) Con<strong>de</strong>nsation products of the<br />
porphyrin precursor 5-aminolevulinic acid. Heterocycles 15:<br />
919-923<br />
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In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
128 HPLC-analysis for permeation studies of 5-aminolevulinic acid and its <strong>de</strong>rivatives<br />
18 Butler AR, George S (1992) The nonenzymatic cyclic<br />
dimerisation of 5-aminolevulinic acid. Tetrahedron 48: 7879-<br />
7886<br />
19 Winkler A, Müller-Goymann CC Comparative permeation<br />
studies for δ-aminolevulinic acid and its n-butyl ester through<br />
stratum corneum and artificial skin constructs. Eur J Pharm<br />
Biopharm in press (2002)<br />
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In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
Photoinduced Lesions in DNA - Detection using Micro-HPLC and Ion Trap MS 129<br />
Photoinduced Lesions in DNA - Detection using<br />
Micro-HPLC and Ion Trap MS<br />
G. Zhang and M. Linscheid<br />
Humboldt University<br />
Department of Chemistry<br />
Brook-Taylor-Str.2<br />
D-12489 Berlin<br />
Germany<br />
Introduction................................................................. 129<br />
Experimental............................................................... 130<br />
Results and Discussion ............................................... 130<br />
• Detection of UV-dimers .............................................130<br />
• Detection of 8-Oxo-<strong>de</strong>oxyguanosine..........................134<br />
Conclusions................................................................. 135<br />
References................................................................... 135<br />
Introduction<br />
Exposure to sunlight can cause lesions in skin DNA. The failure of<br />
the reparation of these UV-induced DNA damages is associated<br />
with mutagenesis and skin cancer[1][2]. Several of these lesions<br />
have been <strong>de</strong>scribed already[3]. The UV portions of the sun light<br />
can induce different types of lesions <strong>de</strong>pending on the energy and<br />
wavelength. UVB and UVC can directly excite DNA and cause<br />
pyrimidine nucleobases to form Cyclobutane dimers or (6-4)<br />
photoproducts. The longer wavelength radiation (UVA) can lead to<br />
oxidative DNA modifications, most importantly 8-oxo-dGuo, as the<br />
result of oxidative stress including hydroxyl radicals and singlet<br />
oxygen.<br />
To un<strong>de</strong>rstand the biological consequences of both types, it is<br />
mandatory to command highly sensitive analytical methods. In the<br />
light of the extending ozone holes in both hemispheres, the risks<br />
associated with sun light exposure are increasing and skin cancer<br />
became one of the major causes for early <strong>de</strong>aths.<br />
In the last half century, many analytical methods have been<br />
<strong>de</strong>veloped for the <strong>de</strong>tection of DNA photoaducts[3][4]. Recently,<br />
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130 Photoinduced Lesions in DNA - Detection using Micro-HPLC and Ion Trap MS<br />
HPLC-tan<strong>de</strong>m mass spectrometry has been used to analyze both the<br />
photodimers and oxidative photoproducts of DNA[5][6]. We<br />
introduce here the use of micro-HPLC coupled with ion trap mass<br />
spectrometer to <strong>de</strong>tect and characterize these photoproducts of<br />
DNA. Micro-HPLC-MS/MS can reduce the sample consumption<br />
and increase the sensitivity.<br />
Experimental<br />
Sample preparation: 0,5 mg/ml mo<strong>de</strong>l compound TpT was<br />
irradiated with UVC (254nm). One 1mg/ml DNA sample was<br />
irradiated with UVC (254nm) and the other 1mg/ml DNA sample<br />
was irradiated with UVA (366nm). Then each of these two samples<br />
was enzymatically digested by Nuclease P1 and Phosphatase.<br />
HPLC condition: Column: 15 cm, 300 µm I.D., C18 RP, Flow rate:<br />
4 µl/min Eluent A: 0.01M ammonium acetate (pH 5), Eluent B:<br />
50% Methanol + 50% Eluent A Gradient: 100 %A to 95 %A for the<br />
first 15 minutes, 95 %A to 0 %A from 15 to 55 min. and isocratic<br />
100 %B from 55 to 60 min. Ion trap mass spectrometer:<br />
F<strong>IN</strong>NIGAN Ion-trap LCQ Deca<br />
Results and Discussion<br />
• Detection of UV-dimers<br />
Figure 1 shows the molecular structure of TpT, which is the most<br />
important source of UV-induced dimer in DNA. The main<br />
photoproducts of UVB and UVC are cis-syn TpT, trans-syn TpT<br />
and 6-4 TpT. 6-4 TpT is converted partly to its Dewar valence<br />
isomer upon exposure to UVA and UVB light (Figure 2).<br />
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Photoinduced Lesions in DNA - Detection using Micro-HPLC and Ion Trap MS 131<br />
Fig. 1: Thymidylyl- 3´-5´-Thymidylic acid (TpT) as the most<br />
important source for pyrimidine dimmer<br />
HO<br />
HO<br />
O<br />
O<br />
O<br />
O<br />
P O<br />
OH<br />
Cis-syn TpT OHTrans-syn<br />
TpT<br />
O<br />
O<br />
HN<br />
HN<br />
O<br />
O<br />
P<br />
OH<br />
O<br />
O<br />
N<br />
O<br />
N<br />
CH 3<br />
H<br />
CH 3<br />
H<br />
OH<br />
OH<br />
OH<br />
CH 3<br />
H<br />
O<br />
O<br />
N<br />
O<br />
N<br />
N<br />
NH<br />
O<br />
O<br />
6-4 TpT Dewar TpT<br />
HO<br />
HO<br />
O<br />
O<br />
O<br />
O<br />
P O<br />
O<br />
HN<br />
O<br />
O<br />
O P<br />
OH<br />
O<br />
O<br />
HN<br />
CH<br />
3<br />
OH<br />
Fig. 2: Structure of a few UV-induced TpT photoproducts<br />
OH<br />
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N<br />
O<br />
CH 3<br />
N<br />
H<br />
OH<br />
H<br />
CH 3<br />
H<br />
O<br />
O<br />
O<br />
N<br />
N<br />
NH<br />
N<br />
O<br />
O
132 Photoinduced Lesions in DNA - Detection using Micro-HPLC and Ion Trap MS<br />
Relative Abundance<br />
100<br />
90<br />
80<br />
70<br />
60<br />
50<br />
40<br />
30<br />
20<br />
10<br />
0<br />
Unknown<br />
Cis-syn TpT<br />
m/z 545� m/z 447<br />
Dewar TpT<br />
m/z 545�<br />
m/z 432<br />
Unknown<br />
6-4 TpT<br />
m/z 545 � m/z 432<br />
Trans-syn TpT<br />
m/z 545� m/z 447<br />
Unknown<br />
0 10 20 30 40 50<br />
Time (min)<br />
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TpT<br />
m/z 545� m/z 419<br />
Fig. 3 Extracted single ion mass chromatogram (mass 545) of UVC<br />
irradiated TpT<br />
As <strong>de</strong>scribed in the experimental part, our undamaged TpT sample<br />
was irradiated by 254 nm UVC light and the sample was then<br />
separated by micro-HPLC system and then analyzed by ion trap<br />
mass spectrometer. Ion-trap mass spectrometer was programmed to<br />
perform two scan events in the same run. One event was full scan<br />
from m/z 250-650, the other event was to monitor the fragment of<br />
m/z 545. Figure 3 is the extracted single ion mass chromatogram of<br />
mass 545 from the full scan mass chromatogram of UVC irradiated<br />
TpT. When we perform MS/MS experiment in negative mo<strong>de</strong> of<br />
ion trap mass spectrometer, TpT and its several photoproducts have<br />
relatively clean fragment pattern, that is one dominant daughter ion<br />
peak and low background. In the negative mo<strong>de</strong>, all TpT, Cis-syn<br />
TpT, Trans-syn TpT, 6-4 TpT and Dewar TpT have mass 545. Due<br />
to the loss of a thymine base, the major fragment peak of TpT is<br />
419. Cis-syn TpT and Trans-syn TpT have the same main daughter<br />
ion of m/z 447 after losing one 2-<strong>de</strong>oxyribose unit. 6-4 TpT and its<br />
Dewar valence isomer have also the same main daughter fragment<br />
peak at 432. This can be accounted for by the fragmentation of this<br />
saturated pyrimidine ring. The suspected losses of fragment from<br />
TpT and its 4 photodimers are circled in Figure 2. From Figure 3,<br />
we can see that those photodimers elute earlier than original
Photoinduced Lesions in DNA - Detection using Micro-HPLC and Ion Trap MS 133<br />
undamaged TpT. Cis-syn TpT and 6-4 TpT are two major<br />
photoproducts. Trans-syn TpT is produced in a smaller amount.<br />
Surprisingly, we found also trace Dewar TpT in the sample, this<br />
may be due to UVB impurity in UVC lamp. The structures of<br />
several minor substances remain uni<strong>de</strong>ntified.<br />
Figure 4 is the extracted single ion mass chromatogram of mass 545<br />
from the full scan chromatogram of enzymes digested UVC<br />
irradiated DNA sample. Undamaged TpT were completely digested<br />
to monomers and not <strong>de</strong>tectable any more. Cis-syn and 6-4 TpT<br />
were still the main photoproducts. Trace Dewar TpT was found<br />
again in this DNA sample. Trans-syn TpT was not <strong>de</strong>tected and it<br />
may be because the stereo restriction of thymine bases in DNA is<br />
less favor to the formation of trans-syn TpT.<br />
These results suggest that the substances of equal mass, but with<br />
slightly different structure can be separated by micro-HPLC.<br />
MS/MS data can provi<strong>de</strong> structural information necessary to<br />
i<strong>de</strong>ntify these substances.<br />
Relative Abundance<br />
100<br />
90<br />
80<br />
70<br />
60<br />
50<br />
40<br />
30<br />
20<br />
10<br />
0<br />
Cis-syn TpT<br />
m/z 545� m/z 7<br />
Dewar TpT<br />
m/z 545�<br />
m/z 432<br />
6-4TpT<br />
m/z 545� m/z 432<br />
0 10 20 30 40 50 60 70 80<br />
Time (min)<br />
Fig. 4: Extracted single ion mass chromatogram (mass 545) of<br />
enzymes digested UVC irradiated DNA<br />
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134 Photoinduced Lesions in DNA - Detection using Micro-HPLC and Ion Trap MS<br />
• Detection of 8-Oxo-<strong>de</strong>oxyguanosine<br />
UVA in solar radiation generates reactive oxygen species and OH·<br />
radicals in the living cells . Within DNA, guanine base is the major<br />
target of the oxidative modification by these free radicals. 8-oxodGuo<br />
is the main oxidative DNA damage and is regar<strong>de</strong>d as the<br />
biomarker of the oxidative stresses. Figure 4 is the single ion mass<br />
chromatogram (m/z 284) of enzymes digested UVA irradiated DNA<br />
sample in the positive electrospray mo<strong>de</strong>. We ran two scan events in<br />
the same measurement. The first scan event was the SIM of m/z<br />
284. This is the [M+H] + of 8-oxo-dGuo. The second scan event was<br />
the MS/MS experiment. By losing one protonated 2-<strong>de</strong>oxyribose,<br />
the characteristic fragment peak of 8-oxo-dGuo is 168 (shown in<br />
Fig. 6)<br />
Fig. 5: Single ion mass chromatogram (m/z 284) of enzymes<br />
digested UVA irradiated DNA sample in the positive electrospray<br />
mo<strong>de</strong><br />
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In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
Rel.<br />
abundant<br />
Photoinduced Lesions in DNA - Detection using Micro-HPLC and Ion Trap MS 135<br />
8-Oxo<strong>de</strong>oxyguanosine<br />
m/z 284<br />
Fig. 6: Positive electrospray ionization MS/MS spectrum of 8-Oxo<strong>de</strong>oxyguanosine<br />
(m/z 284)<br />
Conclusions<br />
Our results <strong>de</strong>monstrate that we can separate TT, cis-syn TT, transsyn<br />
TT and 6-4 TT, and to i<strong>de</strong>ntify them using micro-HPLC<br />
coupled to an ion-trap mass spectrometer. Furthermore, the most<br />
important oxidative DNA damage caused by UVA-exposure, i.e., 8oxo-<strong>de</strong>oxyguanosine<br />
can be <strong>de</strong>tected and structurally confirmed.<br />
References<br />
168,2<br />
H2N<br />
HO<br />
HN<br />
O<br />
N<br />
HO<br />
O<br />
N +<br />
H<br />
N<br />
OH<br />
m/z 168<br />
266,9<br />
185,7 194,0 203,8 224,0<br />
242,8<br />
153,2 181,3 221,4 235,6<br />
253,9 277,7 285,9 295,8<br />
1 Cleaver JE (1968) Deficiency in repair replication of DNA in<br />
xero<strong>de</strong>rma pigmentosum, Nature 218:652-656<br />
2 Cleaver JE (1970) DNA repair and radiation sensitivity in<br />
human (xero<strong>de</strong>rma pigmentosum) cells, Int. J. Radiat. Biol.<br />
18:557-565<br />
3 Ca<strong>de</strong>t J, Vigny P (1990) Photochemistry of nucleic acids. In:<br />
Bioorganic Photochemistry, Volumn 1, Wiley, New York, S1-<br />
272<br />
4 Ca<strong>de</strong>t J, Weinfeld M (1993) Detecting DNA damage, Anal.<br />
Chem. 65:675A-682A<br />
HO<br />
HO<br />
O +<br />
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In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1<br />
H2N<br />
HN<br />
O<br />
N<br />
+<br />
NH2 160 180 200 220 240 260 280 300<br />
NH<br />
O
136 Photoinduced Lesions in DNA - Detection using Micro-HPLC and Ion Trap MS<br />
5 Douki T, Court M, Sauvaigo S, Odin F, and Ca<strong>de</strong>t J, (2000)<br />
Formation of the main UV-induced Thymine dimeric lesions<br />
within isolated and cellular DNA as measured by high<br />
performance liquid chromatography-tan<strong>de</strong>m mass spectrometry,<br />
J. Biol. Chem. 275: 11678-11685<br />
6 Ravanat J, Duretz B, Guiller A, Douki T, and Ca<strong>de</strong>t J, (1998) J.<br />
Chromatogr. B 715:349-356<br />
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In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
The Topical Application of Vitamin D3-Analogues in Psoriasis vulgaris 137<br />
The Topical Application of Vitamin D3-Analogues<br />
in Psoriasis vulgaris<br />
M. Fischer<br />
Department of Dermatology and Venereology<br />
Martin-Luther-University Halle-Wittenberg<br />
Ernst-Kromayer-Strasse 5-6<br />
D-06097 Halle (Saale)<br />
Germany<br />
Introduction................................................................. 137<br />
Mo<strong>de</strong> of action............................................................ 137<br />
Use in Psoriasis vulgaris............................................. 138<br />
References................................................................... 141<br />
Introduction<br />
A positive effect of vitamin D3 on psoriasis was first <strong>de</strong>scribed in<br />
the 1930s, but this treatment concept was dropped because of<br />
unacceptable si<strong>de</strong> effects, especially elicitation of hypercalcemias<br />
[1]. 50 years later, vitamin D3 was rediscovered thanks to a chance<br />
clinical observation. Further research in the following years led to<br />
the <strong>de</strong>velopment of various locally-applicable vitamin D3analogues,<br />
of which calcipotriol and tacalcitol have become<br />
established in therapy. Moreover, the active form of vitamin D3<br />
(calcitriol = 1α,25-dihydroxycholecalciferol) is also available for<br />
the topical treatment of psoriasis.<br />
Mo<strong>de</strong> of action<br />
Vitamin D3 (cholecalciferol) is converted by double hydroxylation<br />
to its active form 1,25-dihydroxycholecalciferol [2]. This<br />
metabolization occurs primarily in the liver and kidneys. However,<br />
studies on porcine skin have shown that keratinocytes may also<br />
form 1,25-dihydroxy vitamin D3 in consi<strong>de</strong>rable quantities [3].<br />
1,25-dihydroxycholecalciferol and its analogues <strong>de</strong>velop their effect<br />
via genomic and non-genomic mechanisms. The genomic effect<br />
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138 The Topical Application of Vitamin D3-Analogues in Psoriasis vulgaris<br />
proceeds via binding to the vitamin-D receptor (VDR), a member of<br />
the steroid receptor family. Activation of transcription is supported<br />
by the closely-related retinoid-X-receptor (RXR), which is<br />
consi<strong>de</strong>red a cofactor, with which the VDR forms a heterodimer<br />
[2]. This leads via acetylation of histones to exposure of individual<br />
DNA-segments, which can then be transcribed. The downregulation<br />
of proinflammatoy cytokines, like Interleukin 2 (IL-2)<br />
and of adhesion molecules is ascribed to this roughly-outlined<br />
mechanism of the genomic effect [4].<br />
In addition to the genomic effect, an increase in intracellular<br />
calcium concentration induced by vitamin D3 analogues is seen as a<br />
non-genome-<strong>de</strong>pen<strong>de</strong>nt effect. There is consi<strong>de</strong>rable evi<strong>de</strong>nce that<br />
an elevated intracellular calcium level promotes keratinocytic<br />
differentiation [5]. However, the actual importance of this<br />
observation remains unclear.<br />
Use in Psoriasis vulgaris<br />
Psoriasis vulgaris is an inflammatory <strong>de</strong>rmatosis with a prevalence<br />
in western industrial countries of just un<strong>de</strong>r 3% [6]. It has been<br />
proven that the macro- and micromorphological changes observed<br />
during the course of the disease are mediated by T-lymphocytes [7].<br />
Based on their cytokine pattern, these T-lymphocytes, which are<br />
found in lesional psoriatic skin, are ascribed to the Th1subpopulation.<br />
A number of different proinflammatory cytokines,<br />
such as Interferon gamma (IFN-δ) [8], Interleukin 2 (IL-2) and<br />
Tumor-Necrosing Factor alpha (TNFα), play a special role during<br />
the inflammation reaction in psoriasis [7]. Also, elevated serum<br />
levels and an intralesional increase in Interleukin 8 (IL-8) has been<br />
<strong>de</strong>monstrated in patients with psoriasis [9, 10]. As a consequence of<br />
this inflammation process, the elucidation of which is still only<br />
rudimentary, the typical hyperproliferation becomes manifest, with<br />
altered differentation as expressed histologically in<br />
hyperparakeratosis.<br />
Recent knowledge concerning the immunological background of<br />
psoriasis has led to novel treatment approaches, like the use of<br />
monoclonal chimeric antibodies to the various cytokines and their<br />
receptors [11, 12]. At the same time, it helps to explain the long-<br />
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The Topical Application of Vitamin D3-Analogues in Psoriasis vulgaris 139<br />
known good efficacy of various therapeutics in psoriasis. Various<br />
possible sites of action become apparent for calcitriol and the<br />
vitamin D3 analogues.<br />
Alroy and colleagues [4] were able to <strong>de</strong>monstrate a downregulation<br />
of IL-2 by vitamin D3. Reduced transcription could be<br />
shown for δ-<strong>IN</strong>F in both naive and activated Th1-cells [13]. The<br />
reduction of IL-8 proven for both calcipotriol [14] and tacalcitol<br />
[15] is cited as another favorable influence on the psoriasis-relevant<br />
mediators. In the study by Kang et al. it was accompanied by an<br />
increase in the immunosuppressive IL-10. Moreover, Lee et al. [16]<br />
found that calcipotriol exerts proliferation-inhibiting properties via<br />
inhibition of the Epi<strong>de</strong>rmal Growth Factor (EGF) receptors. Thus,<br />
vitamin D3 and its analogues have the basic capacity to act<br />
favourably on cytokine-regulation in psoriasis. The high number of<br />
articles published on this topic show that the trend in the treatment<br />
of psoriasis with vitamin D3-analogues lies in the progressive<br />
discovery of proliferation and anti-inflammatory influences.<br />
Both calcitriol and its analogues calcipotriol and tacalcitol are<br />
approved for treatment of mild and mo<strong>de</strong>rate cases of Psoriasis<br />
vulgaris. The good efficacy of all such preparations has been<br />
repeatedly confirmed in clinical studies.<br />
Calcipotriol is available as a cream, ointment and solution. The<br />
application quantity should not exceed 100g (ointment/cream) or<br />
60mL (solution) per week. The recommendations for Tacalcitol<br />
Ointment are similar. These limitations are aimed at prevention of<br />
hypercalcemia, but it must be noted that in patients with limited<br />
kidney function, hypercalcemia may occur even at lower quantities<br />
of active substance [1]. An elevation of the serum calcium level<br />
must be expected more frequently in application of Calcitriol<br />
Ointment, but this was limited in the various studies to isolated<br />
cases and was asymptomatic [17]. Erythema and irritative contact<br />
<strong>de</strong>rmatitis occur as si<strong>de</strong> effects in 4-26% of cases, but this led in the<br />
various studies to withdrawal of therapy in only about 4% of cases<br />
[1].<br />
Although various studies could <strong>de</strong>monstrate better or comparable<br />
efficacy of calcipotriol vs. betamethason [18], dithranol [19] and tar<br />
[20, 21], the great potential of all vitamin D3-(analogues) lies in the<br />
excellent combination possibilities with various local and systemic<br />
antipsoriatica [22]. For example, Lebwohl et al. [23] could<br />
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140 The Topical Application of Vitamin D3-Analogues in Psoriasis vulgaris<br />
<strong>de</strong>monstrate increased efficacy of calcipotriol in combination with<br />
halobetasol over the monosubstances alone. In general, a corticoidsparing<br />
effect can be attributed to both calcitriol and the vitamin<br />
D3-analogues. At the same time, combination with a corticosteroid<br />
can suppress a potential irritative contact <strong>de</strong>rmatitis associated with<br />
the vitamin D3-analogues.<br />
A combination of calcipotriol with PUVA-therapy permitted<br />
reduction of the total UVA dose nee<strong>de</strong>d compared to PUVAtherapy<br />
alone [24]. Similar experience on synergistic effects is also<br />
available for UVB [25] and narrow-band UVB [26]. Although most<br />
studies on the combination of vitamin D3-analogues with UV-light<br />
were performed with calcipotriol, there is an increasing number of<br />
studies on calcitriol and tacalcitol which show similar results. Ring<br />
et al. [27] found a reduction of the UV dose by 34% for calcitriol, in<br />
addition to improved response to the combination therapy. This is<br />
very important, especially with respect to the possible induction of<br />
malignant tumors by UV therapy. In or<strong>de</strong>r to avoid inactivation of<br />
the vitamin D3-analogues by UV-radiation, the preparations should<br />
be applied after exposure or at least 2 hours prior to exposure [22].<br />
Recent studies also indicate that vitamin D3-analogues exert a<br />
supportive effect on systemic antipsoriatica. In a placebo-controlled<br />
study, Grossman et al. [28] found synergistic effects of calcipotriol<br />
with Cyclosporin A. The placebo-arm with an active-free vehicle in<br />
local therapy showed lower response rates of the psoriasis lesions<br />
and a higher Cyclosporin dose compared to the group treated with<br />
calcipotriol. Van <strong>de</strong> Kerkhof et al. could also show dose-sparing<br />
effects with improved efficacy by the combination of retinoids with<br />
locally-applied calcipotriol [29]. Similar results also seem to apply<br />
for methotrexate, but there are no controlled studies as yet [22].<br />
In monotherapy, vitamin D3-analogues have also been found<br />
beneficial when used in problem areas. Calcipotriol solution was<br />
<strong>de</strong>veloped for application to the hairy scalp. Exceptional efficacy on<br />
the scalp could be <strong>de</strong>monstrated in various prospective application<br />
observations on several hundred patients [30]. Moreover, there are<br />
also positive experience reports on the use of calcipotriol in the<br />
intertrigines [31]. Although the irritative potential of the vitamin<br />
D3-analogues is generally increased in skin folds, clinical<br />
experience has shown that the use can still be justified on the basis<br />
of good efficacy. Possible cutaneous irritations are of minor<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
The Topical Application of Vitamin D3-Analogues in Psoriasis vulgaris 141<br />
importance in our own experience. However, no controlled studies<br />
have yet been performed on the use of vitamin D3-analogues in<br />
intertriginous areas. Another very promising use of vitamin D3analogues<br />
is nail psoriasis, which affects about 50% of all psoriasis<br />
patients. In a double-blind, placebo-controlled study, calcipotriol<br />
was effective and comparable to betamethason plus salicylic acid<br />
[32].<br />
In addition to use in Psoriasis vulgaris, vitamin D3-analogues have<br />
also been successfully used in other skin diseases. There are<br />
positive reports for vitiligo, Pityriasis rubra pilaris, Acanthosis<br />
nigricans, various forms of Ichthyoses and Keratosis lichenoi<strong>de</strong>s<br />
chronica [33]. In contrast, no effect or even <strong>de</strong>terioration was<br />
observed after use in Morbus Darier and Acro<strong>de</strong>rmatitis continua<br />
suppurativa [33, 34]<br />
In summary, it can be said that calcitriol, calcipotriol and tacalcitol<br />
are effective, safe preparations which are also excellent in<br />
combinations for the treatment of Psoriasis vulgaris. The<br />
therapeutic effect also appears applicable to a number of other skin<br />
diseases.<br />
References<br />
1 Fuhrmeister K (2001) Vitamin-D3-Analoga. In Korting HC,<br />
Sterry W (Eds.) Therapeutische Verfahren in <strong>de</strong>r Dermatologie.<br />
Blackwell Wissenschafts-Verlag GmbH Berlin, S 139-146<br />
2 Jones G, Strugnell SA, DeLuca HF (1998) Current<br />
un<strong>de</strong>rstanding of the molecular actions of vitamin D. Physiol<br />
Rev 78:1193-1231<br />
3 Bikle DD, Halloran BP, Riviere JE (1994) Production of 1,25<br />
dihydroxyvitamin D3 by perfused pig skin. J Invest Dermatol<br />
102:796-798<br />
4 Alroy I, Towers TL, Freedman LP (1995) Transcriptional<br />
repression of the interleukin-2 gene by vitamin D3: direct<br />
inhibition of NFATp/AP-1 complex formation by a nuclear<br />
hormone receptor. Mol Cell Biol 15:5789-5799<br />
5 Bikle DD (1996) 1,25(OH)2D3-modulated calcium induced<br />
keratinocyte differentiation. J Investig Dermatol Symp Proc<br />
1:22-27<br />
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In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
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6 Koo JY (1999) Current consensus and update on psoriasis<br />
therapy: a perspective from the U.S. J Dermatol 26:723-733<br />
7 Krueger JG (2002) The immunologic basis for the treatment of<br />
psoriasis with new biologic agents. J Am Acad Dermatol 46:1-<br />
23<br />
8 Fierlbeck G, Rassner G, Muller C (1990) Psoriasis induced at<br />
the injection site of recombinant interferon gamma. Results of<br />
immunohistologic investigations. Arch Dermatol 126:351-355<br />
9 Jiang WY, Chatte<strong>de</strong>e AD, Raychaudhuri SP, Raychaudhuri SK,<br />
Farber EM (2001) Mast cell <strong>de</strong>nsity and IL-8 expression in<br />
nonlesional and lesional psoriatic skin. Int J Dermatol 40:699-<br />
703<br />
10 Zheng M, Sun G, Cai S, Mrowietz U (1998) T-lymphocyte<br />
chemotaxis to IL-8 in patients with psoriasis in vitro. Chin Med<br />
J (Engl) 111:166-168<br />
11 Ogilvie AL, Antoni C, Dechant C, Manger B, Kal<strong>de</strong>n JR,<br />
Schuler G, Luftl M (2001) Treatment of psoriatic arthritis with<br />
antitumour necrosis factor-alpha antibody clears skin lesions of<br />
psoriasis resistant to treatment with methotrexate. Br J Dermatol<br />
144:587-589<br />
12 Wohlrab J, Fischer M, Taube KM, Marsch WC (2001)<br />
Treatment of recalcitrant psoriasis with daclizumab. Br J<br />
Dermatol 144:209-210<br />
13 Staeva-Vieira TP, Freedman LP (2002) 1,25-dihydroxyvitamin<br />
D3 inhibits IFN-gamma and IL-4 levels during in vitro<br />
polarization of primary murine CD4+ T cells. J Immunol<br />
168:1181-1189<br />
14 Kang S, Yi S, Griffiths CE, Fancher L, Hamilton TA, Choi JH<br />
(1998) Calcipotriene-induced improvement in psoriasis is<br />
associated with reduced interleukin-8 and increased interleukin-<br />
10 levels within lesions. Br J Dermatol 138:77-83<br />
15 Fukuoka M, Ogino Y, Sato H, Ohta T, Komoriya K, Nishioka K,<br />
Katayama I (1998) RANTES expression in psoriatic skin, and<br />
regulation of RANTES and IL-8 production in cultured<br />
epi<strong>de</strong>rmal keratinocytes by active vitamin D3 (tacalcitol). Br J<br />
Dermatol 138:63-70<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
The Topical Application of Vitamin D3-Analogues in Psoriasis vulgaris 143<br />
16 Lee E, Jeon SH, Yi JY, Jin YJ, Son YS (2001) Calcipotriol<br />
inhibits autocrine phosphorylation of EGF receptor in a calcium<strong>de</strong>pen<strong>de</strong>nt<br />
manner, a possible mechanism for its inhibition of<br />
cell proliferation and stimulation of cell differentiation. Biochem<br />
Biophys Res Commun 284:419-425<br />
17 Kowalzick L (2001) Clinical experience with topical calcitriol<br />
(1,25-dihydroxyvitamin D3) in psoriasis. Br J Dermatol 144<br />
Suppl 58:21-25<br />
18 Kragballe K, Barnes L, Hamberg KJ, Hutchinson P, Murphy F,<br />
Moller S, Ruzicka T, Van De Kerkhof PC (1998) Calcipotriol<br />
cream with or without concurrent topical corticosteroid in<br />
psoriasis: tolerability and efficacy. Br J Dermatol 139:649-654<br />
19 Wall AR, Poyner TF, Menday AP (1998) A comparison of<br />
treatment with dithranol and calcipotriol on the clinical severity<br />
and quality of life in patients with psoriasis. Br J Dermatol<br />
139:1005-1011<br />
20 Kaur I, Saraswat A, Kumar B (2001) Comparison of calcipotriol<br />
and coal tar in conjunction with sun exposure in chronic plaque<br />
psoriasis: a pilot study. J Dermatol 28:448-450<br />
21 Tham SN, Lun KC, Cheong WK (1994) A comparative study of<br />
calcipotriol ointment and tar in chronic plaque psoriasis. Br J<br />
Dermatol 131:673-677<br />
22 Lamba S, Lebwohl M (2001) Combination therapy with vitamin<br />
D analogues. Br J Dermatol 144 Suppl 58:27-32<br />
23 Lebwohl M, Yoles A, Lombardi K, Lou W (1998) Calcipotriene<br />
ointment and halobetasol ointment in the long-term treatment of<br />
psoriasis: effects on the duration of improvement. J Am Acad<br />
Dermatol 39:447-450<br />
24 Kokelj F, Plozzer C, Torsello P (1997) Reduction of UV-A<br />
radiation induced by calcipotriol in the treatment of vulgar<br />
psoriasis with oral psoralen plus UV-A. Arch Dermatol 133:668-<br />
669<br />
25 Molin L (1999) Topical calcipotriol combined with<br />
phototherapy for psoriasis. The results of two randomized trials<br />
and a review of the literature. Calcipotriol-UVB Study Group.<br />
Dermatology 198:375-381<br />
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In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
144 The Topical Application of Vitamin D3-Analogues in Psoriasis vulgaris<br />
26 Ramsay CA, Schwartz BE, Lowson D, Papp K, Bolduc A,<br />
Gilbert M (2000) Calcipotriol cream combined with twice<br />
weekly broad-band UVB phototherapy: a safe, effective and<br />
UVB-sparing antipsoriatric combination treatment. The<br />
Canadian Calcipotriol and UVB Study Group. Dermatology<br />
200:17-24<br />
27 Ring J, Kowalzick L, Christophers E, Schill WB, Schopf E,<br />
Stan<strong>de</strong>r M, Wolff HH, Altmeyer P (2001) Calcitriol 3 microg g-<br />
1 ointment in combination with ultraviolet B phototherapy for<br />
the treatment of plaque psoriasis: results of a comparative study.<br />
Br J Dermatol 144:495-499<br />
28 Grossman RM, Thivolet J, Claudy A, Souteyrand P, Guilhou JJ,<br />
Thomas P, Amblard P, Belaich S, <strong>de</strong> Belilovsky C, <strong>de</strong> la<br />
Brassinne M, et al. (1994) A novel therapeutic approach to<br />
psoriasis with combination calcipotriol ointment and very lowdose<br />
cyclosporine: results of a multicenter placebo-controlled<br />
study. J Am Acad Dermatol 31:68-74<br />
29 van <strong>de</strong> Kerkhof PC, Cambazard F, Hutchinson PE, Haneke E,<br />
Wong E, Souteyrand P, Damstra RJ, Combemale P, Neumann<br />
MH, Chalmers RJ, Olsen L, Revuz J (1998) The effect of<br />
addition of calcipotriol ointment (50 micrograms/g) to acitretin<br />
therapy in psoriasis. Br J Dermatol 138:84-89<br />
30 Thaci D, Daiber W, Boehncke WH, Kaufmann R (2001)<br />
Calcipotriol solution for the treatment of scalp psoriasis:<br />
evaluation of efficacy, safety and acceptance in 3,396 patients.<br />
Dermatology 203:153-156<br />
31 Kienbaum S, Lehmann P, Ruzicka T (1996) Topical calcipotriol<br />
in the treatment of intertriginous psoriasis. Br J Dermatol<br />
135:647-650<br />
32 Tosti A, Piraccini BM, Cameli N, Kokely F, Plozzer C, Cannata<br />
GE, Benelli C (1998) Calcipotriol ointment in nail psoriasis: a<br />
controlled double-blind comparison with betamethasone<br />
dipropionate and salicylic acid. Br J Dermatol 139:655-659<br />
33 Sönnichsen N, Johannböcke R (2001) Calcipotriol: Neue<br />
Aspekte zu einer bewährten Substanz. Nichtpsoriatische<br />
Dermatosen. Der Deutsche Dermatologe 49:626-628<br />
34 Kokelj F, Plozzer C, Trevisan G (2001) Uselessness of topical<br />
calcipotriol as monotherapy for acro<strong>de</strong>rmatitis continua of<br />
Hallopeau. Acta Derm Venereol 81:153<br />
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In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
Trends of topical immunomodulatory Therapy 145<br />
Trends of topical immunomodulatory Therapy<br />
K. Jahn, R.H.H. Neubert, *J. Wohlrab<br />
Institut für Pharmazeutische Technologie,<br />
* Universitätsklinik und Poliklinik für Dermatologie und Venerologie<br />
Martin-Luther-Universität Halle-Wittenberg<br />
Wolfgang-Langenbeck-Straße 4<br />
D-06120 Halle (Saale)<br />
Germany<br />
Trends of topical immunmodulatory Therapy............ 145<br />
References................................................................... 150<br />
The topical application of drugs is generally associated with a lower<br />
risk of si<strong>de</strong> effects and a lower systemic exposure. The research and<br />
use of immunosuppressive drugs for topical application in chronic<br />
inflammatory skin diseases will be summarised in this paper.<br />
Ciclosporin A (CsA, Mr = 1202 g·mol -1 ) was the first T-cell active<br />
immunosuppressant approved for the systemic treatment of severe<br />
psoriasis and atopic <strong>de</strong>rmatitis. Its use is limited due to the<br />
potentially systemic adverse effects such as arterial hypertension<br />
and nephrotoxicity. In or<strong>de</strong>r to reduce si<strong>de</strong> effects after systemic<br />
application a topical formulation for skin disor<strong>de</strong>rs might be useful.<br />
In previous reports, conventional preparations (creams, ointments,<br />
solutions) containing different concentrations of CsA were<br />
examined for their topical use. Mostly, the ineffectiveness of the<br />
vehicles tested was explained with the drug’s inability to overcome<br />
the pe<strong>net</strong>ration barrier, stratum corneum [1].<br />
The aim of our studies was the <strong>de</strong>velopment of microemulsions for<br />
<strong>de</strong>rmal application of ciclosporin A and the investigation of the<br />
pe<strong>net</strong>ration behaviour into human skin ex vivo using FRANZ-type<br />
diffusion cells. Microemulsions (ME) are special vehicle systems<br />
with a favourable solubilization capacity and pe<strong>net</strong>ration enhancing<br />
properties and should be used as drug <strong>de</strong>livery systems for topical<br />
application of CsA.<br />
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In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
146 Trends of topical immunomodulatory Therapy<br />
concentration of CsA [mM]<br />
50<br />
40<br />
30<br />
20<br />
10<br />
concentration of CsA [µM]<br />
100<br />
80<br />
60<br />
40<br />
20<br />
0<br />
0<br />
Stratum corneum<br />
epi<strong>de</strong>rmis<br />
concentration of CsA [µM]<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1<br />
15<br />
10<br />
5<br />
0<br />
<strong>de</strong>rmis<br />
permeated amount in acceptor solution [µg/cm 2 ]<br />
4<br />
3<br />
2<br />
1<br />
0<br />
acceptor<br />
microemulsion<br />
hydrophilic cream (O/W)<br />
lipophilic cream (W/O)<br />
Fig. 1: Concentration of CsA in different skin layers as well as<br />
permeated amount of CsA in the acceptor solution after pe<strong>net</strong>ration<br />
into excised human skin using a microemulsion, a hydrophilic<br />
cream (O/W), and a lipophilic cream (W/O). all formulations: 2 %<br />
(w/w) CsA, [ξ ± SD; n=3]<br />
The results of the pe<strong>net</strong>ration study from a microemulsion, a<br />
hydrophilic (O/W) and a lipophilic cream (W/O) after 30 minutes<br />
into excised human skin are presented in Fig. 1. As shown in this<br />
figure, only microemulsions are able to transport CsA through the<br />
viable skin layers into the acceptor solution. After application of the<br />
microemulsion approximately 20 % of the applied dose could be<br />
<strong>de</strong>tected in the acceptor solution [2]. This fact is of special interest<br />
because the drug amount which permeated into the accector passed<br />
the viable skin layers.<br />
Furthermore, the clinical efficacy of the microemulsions containing<br />
CsA was evaluated in patients with chronic-plaque type psoriasis. A<br />
pilot study using the microplaque assay with a randomized, doubleblind<br />
and placebo-controlled <strong>de</strong>sign was performed. Erythema,<br />
infiltration and scaling were gra<strong>de</strong>d on a scale of 0-4 and laser-<br />
Doppler-flow and erythrometry were used to assess the efficacy of<br />
the formulations. After 14 days the antipsoriatic effect of one<br />
microemulsions was comparable to the positive controls calcipotriol<br />
and betamethasone-17-valerate cream. The results <strong>de</strong>monstrate that
Trends of topical immunomodulatory Therapy 147<br />
microemulsions enable the pe<strong>net</strong>ration of CsA into human skin<br />
after topical application and the clearing of psoriatic lesions using<br />
the microplaque assay.<br />
Mycophenolate mofetil (MMF, Mr = 433,5 g·mol -1 ) is an<br />
immunosuppressive agent registered in combination with<br />
ciclosporin A and corticosteroids for the prevention of organ<br />
rejections after allogenic heart and kidney transplantations. It is the<br />
morpholinoethylester prodrug of mycophenolic acid (MPA).<br />
Recently, reports have been published concerning the use of MMF<br />
for the treatment of several autoimmune and inflammatory skin<br />
disor<strong>de</strong>rs such as psoriasis [3,4]. The systemic administration in<br />
<strong>de</strong>rmal therapy is limited due to the si<strong>de</strong> effects nausea, leucopenia,<br />
sepsis, and diarrhoea. The purpose of our studies was the<br />
investigation of the pe<strong>net</strong>ration behaviour of MMF into human skin<br />
ex vivo using FRANZ-type diffusion cells. Therefore, the drug was<br />
incorporated in an amphiphilic cream (2 %).<br />
The pe<strong>net</strong>ration of MMF from this formulation into excised human<br />
skin is shown in Fig. 2A. An interesting fact of these examinations<br />
was the <strong>de</strong>tection of the active metabolite of MMF, MPA, in human<br />
skin, too. In vivo, MMF is rapidly converted to the active metabolite<br />
MPA by tissue and plasma esterases. The amounts of MPA arising<br />
from the metabolism of pe<strong>net</strong>rated MMF are presented in Fig. 2B.<br />
After 30 minutes MPA was found in none of the skin layers. The<br />
<strong>de</strong>tected amounts of MPA are very small because of limited enzyme<br />
capacity in excised human skin. Because of the limited enzyme<br />
capacity in excised human skin, a greater extent of metabolism will<br />
be expected in vivo. MPA was mainly <strong>de</strong>tected in the viable<br />
epi<strong>de</strong>rmis and the upper <strong>de</strong>rmis where the hydrolysing enzymes are<br />
located [5,6]. The clinical efficacy of this formulation after topical<br />
application in three patients with psoriasis could be <strong>de</strong>monstrated<br />
and was comparable to 0,1 % betamethasone-17-valerate cream [7].<br />
The new class of immunmodulatory macrolactames such as<br />
tacrolimus and pimecrolimus (Ascomycin) may provi<strong>de</strong> an<br />
alternative to glucocorticoids in topical treatment of psoriasis and<br />
atopic <strong>de</strong>rmatitis.<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
148 Trends of topical immunomodulatory Therapy<br />
% of applied dose<br />
8 A<br />
7<br />
6<br />
5<br />
4<br />
3<br />
2<br />
1<br />
0<br />
SC<br />
EP<br />
MMF<br />
DR<br />
4 B<br />
------------------------------------------------------------------------------------<br />
Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1<br />
3<br />
2<br />
1<br />
0<br />
30 min<br />
300 min<br />
1000 min<br />
SC EP<br />
MPA<br />
Fig. 2: Pe<strong>net</strong>ration of MMF from an amphiphilic cream into human<br />
skin ex vivo; (A) MMF expressed as % of applied dose, (B)<br />
metabolised amount of MPA, expressed as % of applied dose of<br />
MMF; SC = Stratum corneum, EP = epi<strong>de</strong>rmis, DR = <strong>de</strong>rmis,<br />
[ξ ± SD; n=3]<br />
Tacrolimus (FK 506, Mr = 822 g·mol -1 ) is a hydrophobic<br />
substance, insoluble in water (< 1mg/ml), but soluble in ethanol and<br />
was first isolated from Streptomyces-species in 1984 [8]. The log<br />
PC (partition coefficient) between octanol and water is 2,74 [9]. Its<br />
mo<strong>de</strong> of action is similar to ciclosporin A, but the drug exerts in<br />
vitro a 10 to 100 times higher immunosuppressive activity [10].<br />
Tacrolimus is used in combination with glucocorticoids to prevent<br />
organ rejections after heart and kidney transplantations. A<br />
randomized, double-blind, multicenter study <strong>de</strong>monstrated, that<br />
tacrolimus ointment is effective in the treatment of atopic <strong>de</strong>rmatitis<br />
[11]. In 2000, tacrolimus has been approved for the topical use in<br />
atopic <strong>de</strong>rmatitis in Japan and the USA (Protopic ® ). It is available<br />
as an ointment containing 0,3 and 0,1 % tacrolimus, respectively.<br />
DR
Trends of topical immunomodulatory Therapy 149<br />
The efficacy of tacrolimus after systemic administration in psoriasis<br />
patients has been proven in a multicenter study [12]. Contrary<br />
results have been published concerning the topical use of this drug<br />
in psoriasis. ZONNEFELD et al. performed a study with 70 patients.<br />
The tacrolimus ointment (0,3 %) was applied once daily un<strong>de</strong>r nonocclusive<br />
conditions. No statistically significant difference to<br />
placebo could be observed [13]. REMITZ et al. used the microplaque<br />
assay in or<strong>de</strong>r to evaluate topical tacrolimus formulations for<br />
treatment of chronic plaque-type psoriasis in 16 patients. In this<br />
study two tacrolimus ointments (0,3 %, with and without<br />
pe<strong>net</strong>ration enhancer), betamethasone and calcipotriol ointment<br />
were compared regarding their ability to clear psoriasis relative to<br />
the vehicle controls. As a result the tacrolimus ointment was<br />
effective un<strong>de</strong>r <strong>de</strong>scaling and occlusion. The authors conclu<strong>de</strong>d that<br />
the drug generally pe<strong>net</strong>rates into psoriatic skin. In future,<br />
formulations with pe<strong>net</strong>ration enhancing properties should be<br />
<strong>de</strong>veloped in or<strong>de</strong>r to use this substance for topical application in<br />
psoriasis [14].<br />
The finding that tacrolimus does not cause skin atrophy may be an<br />
advantage in the treatment in comparison to topical glucocorticoids<br />
[15].<br />
Pimecrolimus (syn. ascomycin, SDZ ASM 981,<br />
Mr = 810,5 g·mol -1 ) is a lipophilic substance, soluble in ethanol and<br />
dimethylsulfoxi<strong>de</strong>, but slightly soluble in water (< 1 mg/ml) [16].<br />
Different studies were performed in or<strong>de</strong>r to evaluate its efficacy<br />
after topical application in patients with atopic <strong>de</strong>rmatitis [17,18]. A<br />
cream containing 1 % pimecrolimus was significantly better than<br />
placebo, but not as effective as 0,1 % betamethasone-17-valerate<br />
cream [19]. Pimecrolimus was well tolerated, caused no serious<br />
si<strong>de</strong> effects except burning or feeling of warmth in the treated area<br />
and did not induce skin atrophy [20]. Therefore it can be regar<strong>de</strong>d<br />
as an alternative to topical glucocorticoids. The substance was<br />
licensed in December 2001 in the USA un<strong>de</strong>r the product name<br />
Eli<strong>de</strong>l ® as a cream and an ointment for treatment of patients with<br />
atopic <strong>de</strong>rmatitis. MROWIETZ et al. examined the topical efficacy of<br />
1 % ascomycin in psoriasis un<strong>de</strong>r occlusion using the microplaqueassay.<br />
According to the study 1 % ascomycin was comparable to<br />
0,5 % clobetasol-17-propionate cream [21].<br />
------------------------------------------------------------------------------------<br />
Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
150 Trends of topical immunomodulatory Therapy<br />
The future will show if the wi<strong>de</strong> use of the immunmodulatory<br />
macrolactames tacrolimus and pimecrolimus in atopic <strong>de</strong>rmatitis is<br />
without any risks as expected.<br />
References<br />
1 Mrowietz U (1992) The enigma of Cyclosporin A treatment for<br />
psoriasis: Systemic efficacy versus topical Non-responsiveness.<br />
Acta Derm Venereol 72:321-326<br />
2 Wohlrab J, Neubert R, Jahn, K (2002) Patent application:<br />
Arzneiformulierung, enthaltend Ciclosporin A und <strong>de</strong>ren<br />
Verwendung. PCT/EO 01/14749<br />
3 Haufs MG, Beissert S, Grabbe S, Schütte B, Luger TA (1998)<br />
Psoriasis vulgaris treated successfully with mycophenolate<br />
mofetil. Br J Dermatol 138:179-181<br />
4 Nousari HC, Sragovich A, Kimyai-Asadi A, Orlinsky D, Anhalt<br />
GJ (1999) Mycophenolate mofetil in autoimmune and<br />
inflammatory skin disor<strong>de</strong>rs. J Am Acad Dermatol 40:265-268<br />
5 Jahn K, Fischer A, Neubert RHH, Wohlrab J (2001)<br />
Investigation of the pe<strong>net</strong>ration behaviour of mycophenolate<br />
mofetil from a semisolid formulation into human skin ex vivo. J<br />
Pharm Pharmacol 53:1581-1587<br />
6 Plätzer M, Jahn K, Wohlrab J, Neubert RHH (2001)<br />
Quantification of mycophenolate mofetil in human skin extracts<br />
using high performance liquid chromatography-electrospray<br />
mass spectrometry. J Chrom B 755:355-359<br />
7 Wohlrab J, Jahn K, Plätzer M, Neubert R, Marsch W (2001)<br />
Topical application of mycophenolate mofetil in plaque-type<br />
psoriasis. Br J Dermatol 144:1263-1264<br />
8 Merck In<strong>de</strong>x – an encyclopaedia of chemicals, drugs and<br />
biologicals (1996) Merck & Co. Inc., Whitehouse Station 12.<br />
Aufl.<br />
9 Lauerma AI, Surber C, Maibach HI (1997) Absorption of topical<br />
tacrolimus (FK 506) in vitro through human skin: comparison<br />
with cyclosproin A. Skin Pharmacol 10:230-234<br />
10 Ruzicka T, Assmann T, Homey B (1999) Tacrolimus – the drug<br />
for the turn of the millennium? Arch Dermatol 135:574-580<br />
------------------------------------------------------------------------------------<br />
Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
Trends of topical immunomodulatory Therapy 151<br />
11 Ruzicka T, Bieber T, Schöpf E, Rubins A, Dobozy A, Bos JD,<br />
Jablonska S, Ahmed I, Thestrup-Pe<strong>de</strong>rsen K, Daniel F, Finzi A,<br />
Reitamo S (1997) A short-term trial of tacrolimus ointment for<br />
atopic <strong>de</strong>rmatitis. New Engl J Med 337:816-821<br />
12 The European FK 506 Multicentre Psoriasis study group (1996)<br />
Systemic tacrolimus (FK 506) is effective for the tretament of<br />
psoriasis in a double-blind, placebo-controlled study. Arch<br />
Dermatol 132: 419-423<br />
13 Zonnefeld IM, Rubins A, Jablonska S, Dobozy A, Ruzicka T,<br />
Kind P, Dubertret L, Bos JD (1998) Topical tacrolimus is not<br />
effective in chronic plaque psoriasis. Arch Dermatol 134:1101-<br />
1102<br />
14 Remitz A, Reitamo S, Erkko P, Granlund H, Lauerma AI (1999)<br />
Tacrolimus ointment improves psoriasis in a microplaque assay.<br />
Br J Dermatol 141:103-107<br />
15 Reitamo S, Rissanen J, Remitz A, Granlund H, Erkko P, Elg P,<br />
Autio P, Lauerma AI (1998) Tacrolimus ointment does not<br />
affect collagen synthesis: results of a single-center randomized<br />
trial. J Invest Dermatol 111:396-398<br />
16 Grassberger M, Baumruker T, Enz A, Hiestand P, Hultsch T,<br />
Kalthoff F, Schuler W, Schulz M, Werner F-J, Winiski A, Wolff<br />
B, Zenke G (1999) A novel anti-inflammatory drug, SDZ ASM<br />
981, for the treatment of skin diseases: in vitro pharmacology.<br />
Br J Dermatol 141:264-273<br />
17 Harper J, Green A, Scott G, Gruendl E, Dorobek B, Cardno M,<br />
Burtin P (2001) First experience of topical SDZ ASM 981 in<br />
children with atopic <strong>de</strong>rmatitis. Br J Dermatol 144:781-787<br />
18 Van Leent EJM, Gräber M, Thurston M, Wagenaar A, Spuls PI,<br />
Bos JD (1998) Effectiveness of the ascomycin macrolactam<br />
SDZ ASM 981 in the topical treatment of atopic <strong>de</strong>rmatitis.<br />
Arch Dermatol 134:805-809<br />
19 Luger T, Van Leent EJM, Graeber M, Hedgecock S, Thurston<br />
M, Kandra A, Berth-Jones J, Bjerke J, Christophers E, Knop J,<br />
Knulst AC, Morren M, Morris A, Reitamo S, Roed-Petersen J,<br />
Schoepf E, Thestrup-Pe<strong>de</strong>rsen K, Van <strong>de</strong>r Valk PGM, Bos JD<br />
(2001) SDZ ASM 981: an emerging safe and effective treatment<br />
for atopic <strong>de</strong>rmatitis. Br J Dermatol 144:788-794<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
152 Trends of topical immunomodulatory Therapy<br />
20 Queille-Roussel C, Paul C, Duteil L, Lefebvre M-C, Rapatz G,<br />
Zagula M, Ortonne J-P (2001) The new topical ascomycin<br />
<strong>de</strong>rivative SDZ ASM 981 does not induce skin atrophy when<br />
applied to normal skin for 4 weeks: a randomised, double-blind<br />
controlled study. Br J Dermatol 144: 507-513<br />
21 Mrowietz U, Graeber M, Bräutigam M, Thurston M, Wagenaar<br />
A, Weidinger G, Christophers E (1998) The novel ascomycin<br />
<strong>de</strong>rivative SDZ ASM 981 is effective for psoriasis when used<br />
topically un<strong>de</strong>r occlusion. Br J Dermatol 139:992-996<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
Trends of Treatment with Topical Glucocorticoids 153<br />
Trends of Treatment with Topical Glucocorticoids<br />
R. Niedner<br />
Klinik für Dermatologie<br />
Klinikum Ernst von Bergmann<br />
Charlottenstr. 72<br />
D-14467 Potsdam<br />
Germany<br />
Trends of Treatment with Topical Glucocorticoids ... 153<br />
References................................................................... 156<br />
Talking about trends we want to find out in which direction the<br />
theory and practice of glucocorticoids will go. Some things will be<br />
new, others are well known, but new <strong>de</strong>tails will lead the discussion<br />
in a new direction. Now, what is being discussed?<br />
Browsing through the Inter<strong>net</strong> by using the keyword “cortisone”, I<br />
found a lot of remarks about the “dangerous“ use of corticoids. It is<br />
my impression that corticophobia is still a problem even though we<br />
have already been using topical corticoids (TCCs) of the 4 th<br />
generation for more than a <strong>de</strong>ca<strong>de</strong>. These TCCs are free from si<strong>de</strong><br />
effects. Are they really?<br />
TCCs of the 4 th generation are double esters of hydrocortisone or<br />
prednisolone which will be split by esterases, first into the active<br />
drug, and then in a second step within the epi<strong>de</strong>rmis into<br />
unesterified <strong>de</strong>rivates. These <strong>de</strong>rivates are not effect-free fragments<br />
which do no harm, they are still working like classical<br />
corticosteroids of the 1 st generation, either hydrocortisone or<br />
prednisolone. As weak TCCs they do not cause any or only mild<br />
atrophia of the skin [1], but when treating the face you have to be<br />
aware of perioral rosacea-like <strong>de</strong>rmatitis.<br />
The pharmaceutical formulations of TCCs will influence their<br />
action. Transfersomes are special formulations which enable a<br />
better pe<strong>net</strong>ration of TCCs through the skin - they will be discussed<br />
in <strong>de</strong>tail during this congress. But what about the “old“<br />
formulations? TCCs are classified as weak or strong substances, but<br />
their corresponding formulation is not taken into account.<br />
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In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
154 Trends of Treatment with Topical Glucocorticoids<br />
Regardless of their pharmaceutical composition as cream, ointment,<br />
lotion, solution etc. they are classified as having the same power –<br />
but that is not correct. Even the same active substance sold as<br />
different brands of ointment show marked differences (a factor of<br />
four) in their activity [2]. Furthermore, it has to be expected that<br />
these differences are greater when different formulations are used.<br />
To my knowledge only one pharmaceutical manufacturer takes<br />
account of this: fluticasone cream needs a tenfold concentration<br />
(0,05 %) of the active substance to approximate the activity of the<br />
ointment (0,005 %) [3]). Many years ago Lubach [4] proved this<br />
fact with other TCCs by vasoconstriction assays, but nobody took<br />
this into consi<strong>de</strong>ration.<br />
Tachyphylaxis of TCCs is a phenomenon which is barely<br />
un<strong>de</strong>rstood but well-proven experimentally by vasoconstriction [5],<br />
DNA synthesis [6] and by histamine-induced wheal suppression<br />
[7]). Tachyphylaxis in general means a reduction or even cessation<br />
of the action of drugs, best known of indirect sympathomimetics<br />
which empty the reservoirs of noradrenalin. The corresponding<br />
action of the skin when treated with TCCs for some days is the<br />
reduction of blanching un<strong>de</strong>r experimental conditions. How often<br />
do we really observe tachyphylaxis of TCCs in practice, during<br />
therapy of atopic <strong>de</strong>rmatitis or psoriasis? Miller and coworkers [8]<br />
looked for the clinical effects of betamethasone on psoriatic<br />
plaques. They treated 27 patients over a period of twelve weeks and<br />
registered the elevation, erythema, and scaling of the psoriatic<br />
plaques. These symptoms did not change and Miller consistently<br />
conclu<strong>de</strong>d that he was not able to prove tachyphylaxis of<br />
betamethasone in psoriasis.<br />
Absorption of TCCs is well known and the more powerful the<br />
corticoid is the more one has to be aware of adrenal suppressive<br />
effects, but mo<strong>de</strong>rn topical corticoids are said not to have these<br />
effects. Visscher and coworkers [9] treated 12 healthy volunteers<br />
with hydrocortisone-17-butyrate (HCB) or mometasone furoate<br />
(MMF) un<strong>de</strong>r occlusion in a crossover study for 14 days. Both<br />
agents suppressed plasma cortisol concentrations, MMF more than<br />
HCB, but the ACTH test was normal in both, indicating that<br />
adrenocortical insufficiency had not <strong>de</strong>veloped. Comparable results<br />
were seen in treatment with methyprednisolone aceponate [1].<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
Trends of Treatment with Topical Glucocorticoids 155<br />
The skin of children is much thinner than the skin of adults and<br />
absorption of corticoids is much better, so it is not surprising that<br />
the blood level of hydrocortisone (HC), externally applied to young<br />
children suffering from atopic <strong>de</strong>rmatitis, was very high [10]. It is<br />
of great interest to know whether or not these findings correlate<br />
with a suppression of the endogenous hydrocortisone as a sign of<br />
disturbance of the hypothalamic-pituitary-adrenal (HPA) axis.<br />
Lucky and coworkers [11] treated children with 0.05 % <strong>de</strong>soni<strong>de</strong> or<br />
2.5 % HC for four weeks. Neither HC nor <strong>de</strong>soni<strong>de</strong> ointment<br />
compromised the HPA axis. Patel and coworkers [12] came to the<br />
same conclusion: when they checked children with atopic <strong>de</strong>rmatitis<br />
who were treated un<strong>de</strong>r open conditions with mild TCCs like HC,<br />
clobetasone butyrate 0.05 %, betamethasone valerate 0.025 % or<br />
fluocinolone acetoni<strong>de</strong> 0.00625 % for a long period of 6.5 years,<br />
neither the basal or peak, nor the increment and area-un<strong>de</strong>r-curve in<br />
plasma cortisol concentrations differed from controls, indicating<br />
normal adrenal sensitivity.<br />
Treatment with TCCs also means the application of corticosteroids<br />
to the nose or to the bowel – the latter will not be discussed here.<br />
Patients suffering from allergic rhinitis may need<br />
glucocorticosteroids because of severe symptoms. To avoid<br />
systemic effects topically (nasally) administered CCs are preferred.<br />
But is there really no CC absorption and regulation of the HPA<br />
axis? Wihl and coworkers [13] nasally applied two different TCCs<br />
(bu<strong>de</strong>sonid (BUD) and beclomethasone dipropionate (BDP)) with<br />
doses of 100, 200, 400, and 800 µg. None of the treatments<br />
influenced the plasma cortisol values, but cortisol in the urine was<br />
significantly lower after BUD 400 and 800 µg, but not after any<br />
dose of BDP. When TCC administration was repeated for four days,<br />
a dose-related <strong>de</strong>crease in urine-cortisol was observed in both<br />
drugs, BUD being twice as potent as BDP. These data <strong>de</strong>monstrate<br />
systemic effects from nasally administered TCCs.<br />
TCCs are applied by interval therapy in or<strong>de</strong>r to economize TCCs<br />
and in or<strong>de</strong>r to avoid si<strong>de</strong> effects like atrophy. Lubach and<br />
coworkers [14] pretreated the skin with clobetasol propionate (CP)<br />
twice daily for 16 days and measured the atrophy. Thereafter, CPtreatment<br />
was continued every 5, 7, 10, or 14 days. The skin<br />
thickness was approximately the same when CP was applied every<br />
5 or 7 days, and it reached normal levels when applied every 10<br />
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In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
156 Trends of Treatment with Topical Glucocorticoids<br />
days. The results <strong>de</strong>monstrate that atrophy must be expected from<br />
an intermittent maintenance therapy even when applied at rather<br />
long intervals.<br />
References<br />
1 Kecskés A, Heger-Mahn D, Kleine Kuhlmann R, Lange L<br />
(1993) Comparison of the local and systemic si<strong>de</strong> effects of<br />
methylprednisolone aceponate and mometasone furoate applied<br />
as ointment with equal antiinflammatory activity. J am Acad<br />
Dermatol 29:576-580<br />
2 Stoughton RB (1992) Copies of Innovator Formulations of<br />
Topical Clucocorticoids. In: Maibach HI, Surber C (eds.)<br />
Topical Corticosteroids. Karger, Basel, S 54-64<br />
3 Rote Liste 2001 (2001) Editio Cantor, Aulendorf<br />
4 Lubach D, Kietzmann M (1992) Dermatokortikoi<strong>de</strong> –<br />
Pharmakologie und Therapie. Kohlhammer, Stuttgart Berlin<br />
Köln, S 96<br />
5 duVivier A, Stoughton RB (1975) Tachyphylaxis to the action<br />
of topically applied corticosteroids. Arch Dermatol 111:581-583<br />
6 duVivier A (1976) Tachyphylaxis to topically applied steroids.<br />
Arch Dermatol 112:1245-1248<br />
7 Singh G, Singh PK (1986) Tachyphylaxis to topical steroid<br />
measured by histamine-induced wheal suppression. Int J<br />
Dermatol 25:324-326<br />
8 Miller JJ, Roling D, Margolis D, Guzzo C (1999) Failure to<br />
<strong>de</strong>monstrate therapeutic tachyphylaxis to topically applied<br />
steroids in patients with psoriasis. J Am Acad Dermatol 41:546-<br />
549<br />
9 Vissher HW, Ebels JT, Ro<strong>de</strong>rs GA, Jonkman JGH (1995)<br />
Randomised crossover comparison of adrenal suppressive<br />
effects of <strong>de</strong>rmal creams containing glucocorticosteroids. Europ<br />
J Clin Pharmacol 48:123-125<br />
10 Wester RC, Maibach HI (1992) Percutaneous absorption in<br />
diseased skin. In: Maibach HI, Surber C (eds.) Topical<br />
Corticosteroids. Karger, Basel, S 128-141<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
Trends of Treatment with Topical Glucocorticoids 157<br />
11 Luckey AW, Grote GD, Williams JL, Tuley MR, Czernielewski<br />
JM, Dolak TM, Herdorn JH, Baker MD (1997) Effect of<br />
Desoni<strong>de</strong> Ointment, 0.05 %, oh the Hypothalamic-Pituitary-<br />
Adrenal Axis of Children with Atopic Dermatitis. Cutis 59:151-<br />
153<br />
12 Patel L, Clayton PE, Addison GM, Price DA, David TJ (1995)<br />
Adrenal function following topical steroid treatment in children<br />
with atopic <strong>de</strong>rmatitis. Brit J Dermatol 132:950-955<br />
13 Wihl J-A, An<strong>de</strong>rsson K-E, Johansson S-A (1997) Systemic<br />
effects of two nasally administered glucocorticosteroids. Allergy<br />
52:620-626<br />
14 Lubach D, Rath J, Kietzmann M (1955) Skin Atrophy Induced<br />
by Initial Continuous Topical Applicaton of Clobetasol<br />
Followed by Intermittent Application. Dermatology 190:51-55<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
158 The Topical Treatment of Atopic Dermatitis and Psoriasis with Vitamin B12<br />
The Topical Treatment of Atopic Dermatitis and<br />
Psoriasis with Vitamin B12<br />
C. Stoerb, P. Altmeyer, *R. Niedner, **J. Hartung, M. Stücker<br />
Clinic for Dermatology and Allergology of the Ruhr University Bochum<br />
St. Josef Hospital<br />
*Clinic for Dermatology; Clinical Centre Ernst von Bergmann Potsdam<br />
** Institute for Statistics; Dortmund University<br />
Gudrunstr. 56<br />
D-44791 Bochum<br />
Germany<br />
Introduction................................................................. 158<br />
Trial Medication and Design ...................................... 159<br />
• Study Population and Investigational Plan................ 159<br />
• Modified PASI Score................................................. 160<br />
• Modified SASSAD Score.......................................... 160<br />
• 20 MHz Sonography.................................................. 161<br />
Results......................................................................... 161<br />
• Primary Efficacy Parameter: PASI Score.................. 161<br />
• Primary Efficacy Parameter: SASSAD Score ........... 161<br />
• Sonographic Efficacy Parameters.............................. 162<br />
• Tolerability ................................................................ 163<br />
Discussion ................................................................... 163<br />
• Mo<strong>de</strong> of Action of the External Vitamin B12<br />
Therapy...................................................................... 164<br />
References................................................................... 165<br />
Introduction<br />
In these two placebo-controlled and double-blind clinical trials, the<br />
efficacy of a vitamin B12 cream in atopic <strong>de</strong>rmatitis and psoriasis<br />
was assessed by means of an intra-individual left/right comparison.<br />
Vitamin B12 is a crystalline pow<strong>de</strong>r, dark red and odourless, used<br />
for therapeutic purposes in the form of cyanocobalamin and/or<br />
hydroxocobalamin acetate. These two forms represent pro-drugs,<br />
which are converted in the body into the active forms of methyl-<br />
and 5-a<strong>de</strong>nosylcobalamin. Vitamin B12 has a wi<strong>de</strong> therapeutic<br />
range, toxic effects or symptoms of overdosage as well as<br />
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The Topical Treatment of Atopic Dermatitis and Psoriasis with Vitamin B12 159<br />
indications of a teratogenic or mutagenic potential are not known.<br />
Adverse reactions reported in isolated cases with parenteral use<br />
consisted of eczematous or urticarial drug reactions [1,2].<br />
It was <strong>de</strong>monstrated already some time ago, that <strong>de</strong>spite the size of<br />
the molecule, the skin is permeable to vitamin B12 [3] and that skin<br />
cells express the transcobalamin II required for the intracellular<br />
transport of vitamin B12 [4].<br />
In view of the poor systemic bioavailability of vitamin B12 (rapid<br />
elimination of up to 90% of a single dose of 1 mg [2]), it is not<br />
surprising that systemic administration gave no evi<strong>de</strong>nce of a<br />
reliable therapeutic effect of systemic vitamin B12 in psoriasis<br />
[5,6,7].<br />
Trial Medication and Design<br />
The vitamin B12-containing investigational drug, with the<br />
concentration of the active ingredient Cyanocobalamin DAB being<br />
0.07%, contained the following excipients: avocado oil DAC, citric<br />
acid DAB, distilled water, methyl glucose sesquistearate <strong>IN</strong>CI and<br />
potassium sorbate DAB. As the investigational drug is of a light<br />
pink colour due to the vitamin B12, the placebo was ma<strong>de</strong><br />
indistinguishable by adding the colorant E122 azurubin.<br />
Determined by a randomisation list, the patients applied the vitamin<br />
B12-containing active preparation to the affected skin areas of one<br />
body half and the placebo preparation to the contralateral si<strong>de</strong> twice<br />
daily, the dosage <strong>de</strong>pending on the extent of the affected skin areas<br />
and the severity of the disease symptoms.<br />
• Study Population and Investigational Plan<br />
The studies were conducted as placebo-controlled, double-blind,<br />
prospective and randomised phase III clinical trials with intraindividual<br />
left/right-comparison to assess the efficacy and<br />
tolerability of vitamin B12 cream in atopic <strong>de</strong>rmatitis and psoriasis.<br />
Trial centres were the Clinic for Dermatology and Allergology of<br />
the Ruhr University Bochum at St. Josef Hospital in Bochum and<br />
the Clinic for Dermatology at Clinical Centre Ernst von Bergmann<br />
in Potsdam.<br />
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160 The Topical Treatment of Atopic Dermatitis and Psoriasis with Vitamin B12<br />
A total of 51 patients (21 female, 30 male, age 49.4 ± 10.7 years)<br />
were enrolled for psoriasis and 47 patients (28 female, 19 male, age<br />
33.6 ± 14.1 years) for atopic <strong>de</strong>rmatitis. The treatment duration was<br />
8 weeks in both trials. Apart from the baseline and final<br />
examination, each patient had interim examinations after 2, 4 and 6<br />
weeks.<br />
The primary efficacy parameters were a modified PASI (Psoriasis<br />
Area and Severity In<strong>de</strong>x) score [8] in psoriasis and a modified<br />
SASSAD (Six Area Six Sign Atopic Dermatitis) score [9] in atopic<br />
<strong>de</strong>rmatitis. The secondary efficacy parameters inclu<strong>de</strong>d an<br />
investigator's and patient's global assessment of efficacy and,<br />
additionally in psoriasis, the thickness and <strong>de</strong>nsity of the echolucent<br />
area of a reference plaque on each body half by 20 MHz<br />
sonography [10,11]. The efficacy parameters were <strong>de</strong>termined at all<br />
examination dates.<br />
Drug safety variables in both trials were the recor<strong>de</strong>d adverse<br />
events, investigator's and patient's global assessments of tolerability<br />
and a patient's assessment of the cream formulation with regard to<br />
feeling of the skin after application, odour, colour and effects on<br />
clothing. The safety parameters were <strong>de</strong>termined at all interim<br />
examinations and the final examination, the patient's assessment of<br />
the cream formulation was performed at the final examination only.<br />
• Modified PASI Score<br />
The modified PASI score used in this trial records the severity of<br />
the three psoriasis symptoms <strong>de</strong>squamation, erythema and<br />
infiltration as well as the size of the affected skin areas. The<br />
modification consists in halving the weighting of the test area sizes<br />
due to the left/right comparison and the exclusion of the head from<br />
the assessment.<br />
• Modified SASSAD Score<br />
The SASSAD score inclu<strong>de</strong>s the six atopic <strong>de</strong>rmatitis symptoms<br />
dryness/<strong>de</strong>squamation, itching, erosion, lichenification, erythema<br />
and infiltration, whose severity and extent on the affected skin areas<br />
are assessed on an ordinal scale analogous to the PASI score. The<br />
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The Topical Treatment of Atopic Dermatitis and Psoriasis with Vitamin B12 161<br />
modification of the original score consists in replacing the symptom<br />
"exudation" with the more typical "infiltration" [12].<br />
• 20 MHz Sonography<br />
High-frequency sonography is increasingly gaining importance in<br />
<strong>de</strong>rmatological diagnostics. For the 20 MHz technique, the<br />
thickness and <strong>de</strong>nsity of an epi<strong>de</strong>rmal echolucent aera, which is<br />
characteristic for psoriatic plaques, have been found to be the most<br />
sensitive parameters of the response profile during therapy [10].<br />
Sonographic examination during the healing process of the plaque<br />
reveals a <strong>de</strong>crease in thickness accompanied by an increase in<br />
<strong>de</strong>nsity.<br />
Results<br />
• Primary Efficacy Parameter: PASI Score<br />
The modified PASI score of the body halves treated with the<br />
investigational drug <strong>de</strong>creased with marked statistical significance<br />
compared to the body halves treated with placebo (p
162 The Topical Treatment of Atopic Dermatitis and Psoriasis with Vitamin B12<br />
period of 8 weeks would result in further alleviation of symptoms to<br />
the point of complete remission.<br />
Fig. 1: Treatment effect phase III trial psoriasis: Significantly more<br />
marked <strong>de</strong>crease of PASI un<strong>de</strong>r vitamin B12 cream compared to<br />
placebo.<br />
• Sonographic Efficacy Parameters<br />
With comparable baseline values, both forms of treatment revealed<br />
a continuously progressive reduction in the thickness of the<br />
echolucent areas throughout the entire treatment period. This effect<br />
was highly significantly more pronounced for the plaques treated<br />
with vitamin B12 cream than for the placebo-treated plaques<br />
(p
The Topical Treatment of Atopic Dermatitis and Psoriasis with Vitamin B12 163<br />
Fig. 2: Treatment effect phase III trial atopic <strong>de</strong>rmatitis:<br />
Significantly more marked <strong>de</strong>crease of SASSAD un<strong>de</strong>r vitamin B12<br />
cream compared to placebo.<br />
• Tolerability<br />
Compared to other antipsoriatic drugs like vitamin A <strong>de</strong>rivatives<br />
(tazaroten), vitamin D3 analogues (calcipotriol), tar preparations or<br />
anthralin, vitamin B12 cream caused no skin irritations at all. This<br />
good tolerability enhances the patients' compliance.<br />
Discussion<br />
Based on the hitherto available trials with vitamin B12 cream, the<br />
fields of application may be <strong>de</strong>fined as follows: The non-irritant<br />
vitamin B12 cream means a therapeutic progress for patients with<br />
easily irritable skin (skin types I und II according to Fitzpatrick<br />
[13]). Furthermore the preparation is probably very suitable for the<br />
use in children and problematic intertriginous skin areas like<br />
armpits, groins or the buttocks' cleft.<br />
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164 The Topical Treatment of Atopic Dermatitis and Psoriasis with Vitamin B12<br />
To increase the efficacy of vitamin B12 cream in psoriasis, a<br />
preliminary treatment with keratolytic agents like salicylic acid<br />
could be useful, as the keratolysis facilitates the pe<strong>net</strong>ration of the<br />
active principle into the skin. After the intensive therapy of an acute<br />
psoriatic or eczematous episo<strong>de</strong>, the after-treatment with vitamin<br />
B12 cream could maintain the therapeutic success and prolong the<br />
relapse-free interval. It would be possible as well to use vitamin B12<br />
cream in the combination resp. rotation therapy together with other<br />
external therapeutics for a higher efficiency of topical treatment.<br />
• Mo<strong>de</strong> of Action of the External Vitamin B12 Therapy<br />
Vitamin B12 is involved in numerous biochemical processes in the<br />
human body, as it affects nucleic acid synthesis, especially in<br />
haematopoiesis and other cell maturation processes. The established<br />
indications of vitamin B12 to date are exclusively the prevention and<br />
therapy of clinical vitamin B12 <strong>de</strong>ficiencies like hyperchromic<br />
macrocytic megaloblastic anaemia and funicular myelosis [1,2].<br />
Recent research gave indications for an immunological action of<br />
vitamin B12 in the cytokine <strong>net</strong>work of T-cell mediated<br />
inflammation. It was <strong>de</strong>monstrated that vitamin B12 is able to induce<br />
T-suppressor-cells [14] and to inhibit dose-<strong>de</strong>pen<strong>de</strong>ntly the<br />
production of interferon-gamma and interleukin-6 by Tlymphocytes<br />
[15] in vitro. Moreover, vitamin B12 is an effective<br />
scavenger of nitric oxi<strong>de</strong> (NO) [16,17]. NO, e.g. produced by the<br />
iNOS (inducible nitric oxi<strong>de</strong> synthase) in inflammatory <strong>de</strong>rmatoses,<br />
is a part of the vasodilatory component of inflammation and able to<br />
stimulate keratinocyte proliferation [18]. Both atopic <strong>de</strong>rmatitis and<br />
psoriasis are associated with an increase in cytokine formation and<br />
NO generation due to over-expression of iNOS [19,20], psoriasis<br />
additionally is characterised by an up to tenfold acceleration of<br />
epi<strong>de</strong>rmipoiesis. As NO-donor stimulated keratinocyte proliferation<br />
can be antagonised by vitamin B12 in vitro [18] and the topical<br />
application of a nitric oxi<strong>de</strong> synthase inhibitor led to marked<br />
improvement in atopic <strong>de</strong>rmatitis [21], the probable mo<strong>de</strong> of action<br />
of topical applied vitamin B12 is the inhibition of cytokine<br />
formation and the binding of NO (thus restraining its influence on<br />
keratinocyte proliferation) in inflammative skin diseases.<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
References<br />
The Topical Treatment of Atopic Dermatitis and Psoriasis with Vitamin B12 165<br />
1 Bun<strong>de</strong>sanzeiger vom 29.03.1989; Jg. 41, Nr. 59: 1614<br />
2 Europäisches Arzneibuch; Band II: 1366 (1975); Deutscher<br />
Apotheker-Verlag Stuttgart, Govi-Verlag GmbH Stuttgart<br />
3 Howe EE, Dooley CL,Geoffroy RF, Rosenblum C (1967):<br />
Percutaneous absorption of vitamin B12 in the rat and guinea pig,<br />
J Nutrition 92: 261-266<br />
4 Fràter-Schrö<strong>de</strong>r M, Porck HJ, Erten J, Müller MR, Steinmann B,<br />
Kierat L, Arwert (1985): Synthesis and secretion of the human<br />
vitamin B12-binding protein, transcobalamin II, by cultured skin<br />
fibroblasts and bone marrow cells Biochim Biophys Acta 845:<br />
421-427<br />
5 Baker H, Comaish JS (1962): Is vitamin B12 of value in<br />
psoriasis?, Br Medical J ii: 1729-1730<br />
6 Sneddon IB (1963): Vitamin B12 in psoriasis; Br Medical J; iii:<br />
328<br />
7 MacLennan A, Hellier FF (1961): The treatment time in<br />
psoriasis, Br J Dermatol 73: 439-444<br />
8 Fredriksson T, Pettersson U (1978): Severe psoriasis – oral<br />
therapy with a new retinoid; Dermatologica 157: 238-244<br />
9 Berth-Jones J (1996): Six area, six sign atopic <strong>de</strong>rmatitis<br />
(SASSAD) severity score: a simple system for monitoring<br />
disease activity in atopic <strong>de</strong>rmatitis; Br J Dermatol 135 (Suppl<br />
48): 25-30<br />
10 Hoffmann K, Dirschka T, Schwarze H, el-Gammal S, Matthes<br />
U, Hoffmann A, Altmeyer P(1995): 20 MHz sonography,<br />
colorimetry and image analysis in the evaluation of psoriasis<br />
vulgaris; J Dermatol Science 9: 103-110<br />
11 Bangha E, Elsner P (1996): Evaluation of topical antipsoriatic<br />
treatment by chromametry, visiometry and 20-MHz ultrasound<br />
in the psoriasis plaque test; Skin Pharmacology 9: 298-306<br />
12 Hanifin JM (1989): Standardized grading of subjects for clinical<br />
research studies in atopic <strong>de</strong>rmatitis: Workshop report; Acta<br />
Derm Venereol 144: 28-30<br />
13 Fitzpatrick TB (1988): The validity and practicality of sunreactive<br />
skin types I through VI; Arch Dermatol 124: 869-871<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
166 The Topical Treatment of Atopic Dermatitis and Psoriasis with Vitamin B12<br />
14 Sakane T, Takada S, Kotani H, Tsunematsu T (1982):<br />
Effects of methyl-B12 on the in vitro immune functions of human<br />
T lymphocytes; J Clin Immunol 2: 101-109<br />
15 Yamashiki M, Nishimura A, Kosaka Y (1992): Effects of<br />
methylcobalamin (vitamin B12) on in vitro cytokine production<br />
of peripheral blood mononuclear cells; J Clin Lab Immunol 37:<br />
173-182<br />
16 Greenberg SS, Xie J, Zatarain JM, Kapusta DR, Miller MJ<br />
(1995): Hydroxocobalamin (vitamin B12a) prevents and reverses<br />
endotoxin-induced hypotension and mortality in ro<strong>de</strong>nts: Role of<br />
nitric oxi<strong>de</strong>; J Pharmacol Exp Therap 273: 257-265<br />
17 Danishpajooh IO, Gudi T, Chen Y, Kharitonov VG, Sharna VS,<br />
Boss GR (2001): Nitric oxi<strong>de</strong> inhibits methionine synthase<br />
activity in vivo and disrupts carbon flow through the folate<br />
pathway; J Biol Chem 276: 27296-27303<br />
18 Clark JE, Green CJ, Motterlini R(1997): Involvement of the<br />
heme oxygenase-carbon monoxi<strong>de</strong> pathway in keratinocyte<br />
proliferation; Biochem Biophys Res Com 241: 215-220<br />
19 Rowe A, Farrell AM, Bunker CB (1997): Constitutive<br />
endothelial and inducible nitric oxi<strong>de</strong> synthase in inflammatory<br />
<strong>de</strong>rmatoses; Br J Dermatol 136: 18-23<br />
20 Ormerod AD, Weller R, Copeland P, Benjamin N, Ralston SH,<br />
Grabowski P, Herriot R (1998): Detection of nitric oxi<strong>de</strong> and<br />
nitric oxi<strong>de</strong> synthases in psoriasis; Arch Dermatol Res 290: 3-8<br />
21 Morita H, Semma M, Hori M, Kitano Y (1995): Clinical<br />
application of nitric oxi<strong>de</strong> synthase inhibitor for atopic<br />
<strong>de</strong>rmatitis; Int J Dermatol 34: 294-295<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
Mo<strong>de</strong>rn Vehicle Systems<br />
C. Huschka, J. Wohlrab<br />
Mo<strong>de</strong>rn Vehicle Systems 167<br />
Universitätsklinik und Poliklinik für Dermatologie und Venerologie <strong>de</strong>r<br />
Martin-Luther-Universität Halle-Wittenberg<br />
Ernst-Kromayer-Str. 5-6<br />
D-06097 Halle/S.<br />
Germany<br />
Mo<strong>de</strong>rn Vehicle Systems............................................ 167<br />
References................................................................... 178<br />
The application of common vehicles like ointments, creams, gels or<br />
emulsions is only possible to a limited <strong>de</strong>gree for several externallyapplied<br />
active substances, since the skin barrier cannot be crossed.<br />
In recent years, alternatives have been sought in intensive research.<br />
Thus, mo<strong>de</strong>rn, colloidal vehicle systems, like liposomes and their<br />
further <strong>de</strong>velopments such as the DMS ® System, nanoparticles<br />
(nanoemulsions), multiple emulsions or microemulsions are gaining<br />
importance. Among the so-called problem drugs in topical therapy<br />
are, for example, substances with low solubility in the vehicle, since<br />
uptake in the skin is only possible in the dissolved state. Likewise,<br />
drugs with pronounced hydrophilic properties need the support of<br />
galenic excipients, since their affinity to the lipophilic structures of<br />
the external skin layer is very low. The application of colloidal<br />
vehicle systems is can also be used for substances which tend to be<br />
unstable, for example in the form of hydrolysis, photosensitivity or<br />
oxidation.<br />
An overview of the activities of the last ten years in the area of<br />
research of colloidal vehicle systems for <strong>de</strong>rmal application is<br />
found in Fig. 1. This patent search discloses a marked trend in<br />
patent applications for liposomal formulations which peaked in<br />
2001 at more than 300 applications. By contrast, the number of<br />
patent applications for nanoparticles and microemulsions appears<br />
small. However, there is also an increasing ten<strong>de</strong>ncy here.<br />
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168 Mo<strong>de</strong>rn Vehicle Systems<br />
Individual colloidal vehicle systems are <strong>de</strong>scribed in some <strong>de</strong>tail<br />
and recent <strong>de</strong>velopments are discussed below. An overview of the<br />
basic structures of these vehicles is shown in Fig. 2. The liposomes<br />
are vesicles in the nanometer range, which are constructed of one or<br />
more double layers. Their structure is similar to that of a cell<br />
membrane. Lecithin from chicken egg yolk or soy is usually used as<br />
the basic building block for the liposomes. The use of non-ionic<br />
tensi<strong>de</strong>s is also common. Technological procedures like extrusion,<br />
mixing and also high-pressure homogenisation are used for<br />
manufacture [Lichtenberg and Barenholz 1988].<br />
Aqueous suspensions of nanoparticles or nanoemulsions can be<br />
produced using high-pressure homogenization. For this, carrier<br />
lipids, like triglyceri<strong>de</strong>s, are dispersed in the aqueous phase and<br />
stabilized by means of tensi<strong>de</strong>s, such as phospholipids. When the<br />
particle core produced is fluid, they are usually termed<br />
nanoemulsions, although they may be termed solid lipid<br />
nanoparticles (SLN ® , Lipopearls ® Nanopearls ® ) [Dingler and Gohla<br />
2002, <strong>de</strong> Vringer and <strong>de</strong> Ron<strong>de</strong> 1995]. If a polymer or polymerbuil<strong>de</strong>r<br />
is used instead of carrier lipids, nanoparticles with a shell or<br />
fixed matrix can be formed. For this, technologies of coacervation<br />
or solvent evaporation are used [Quintanar-Guerrero et al. 1998].<br />
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Mo<strong>de</strong>rn Vehicle Systems 169<br />
Fig. 1: Patient applications for colloidal vehicle systems for topical<br />
application<br />
Fig. 2: Basic structures of colloidal vehicle systems<br />
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170 Mo<strong>de</strong>rn Vehicle Systems<br />
The basic building blocks of microemulsions may be micelles of<br />
various types. Due to their properties, these systems appear clear to<br />
opalescent. Microemulsions are usually ma<strong>de</strong> of a mixture of<br />
tensi<strong>de</strong> and cotensi<strong>de</strong>, a lipophilic and hydrophilic component (Fig.<br />
3) These microemulsions form in a specific mixture without<br />
applying energy, such as shearing strength, which means they are<br />
simple to produce. Microemulsions have several advantages over<br />
the other vehicles. They possess an excellent dissolution capacity<br />
for poorly-soluble substances and have very good pe<strong>net</strong>ration<br />
properties. They are able to reversibly reduce the barrier function of<br />
the skin. It must also be emphasized that these systems are<br />
thermodynamically stable and have a good spreading capacity,<br />
which is attributable to the low-viscous properties [Osborne et al.<br />
1991, Tenjarla 1999]. From a <strong>de</strong>rmatological point of view, the<br />
frequently quite high tensi<strong>de</strong> content of microemulsions must be<br />
viewed as a disadvantage, since it is associated with the occurrence<br />
of skin irritations. For this reason, a possible minimization of the<br />
tensi<strong>de</strong> content and the selection of components well-tolerated by<br />
the skin should be given particular attention in the <strong>de</strong>velopment of<br />
new microemulsion systems for <strong>de</strong>rmal application. Thus far,<br />
application of microemulsions to the skin have been ma<strong>de</strong> mostly<br />
for the purpose of trans<strong>de</strong>rmal application of drugs [Alvarez-<br />
Figueroa and Blanco-Men<strong>de</strong>z 2001]. Experience over the past years<br />
has shown that these systems are also excellently suited for specific<br />
topical therapy [Schmalfuß 1997]. Depending on the composition<br />
of the ME, lipophilic or hydrophilic molecules can be enriched<br />
specially in the horny layer and the living layers of the skin. Thus<br />
effective concentration-time profiles can be achieved in the<br />
epi<strong>de</strong>rmis using these special formulations. Interesting<br />
<strong>de</strong>velopments for various indications are presented below from the<br />
numerous studies of microemulsions for topical application.<br />
The studies by Baroli et al. show that the use of microemulsions can<br />
improve the topical availability of 8-methoxypsoralen (8-MOP),<br />
the active substance for PUVA-therapy. In addition to<br />
isopropylmyristate and water as vehicles, several microemulsions of<br />
various compositions were tested. A selection of skin-tolerated<br />
tensi<strong>de</strong>s was ma<strong>de</strong> in producing the microemulsions. The active<br />
substance 8-MOP was applied in the saturated systems and the<br />
pe<strong>net</strong>ration and permeation of the active <strong>de</strong>termined 8 hours after<br />
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Mo<strong>de</strong>rn Vehicle Systems 171<br />
application. Compared to the references IPM and water, the<br />
microemulsions stand out in their potency to promote pe<strong>net</strong>ration<br />
and permeation. With a specific composition of the vehicle,<br />
particularly high concentrations of the active could be attained in<br />
the skin, thus minimizing systemic stress. As a resumé of the<br />
studies, application of 8-MOP in a microemulsion can be<br />
recommen<strong>de</strong>d for local treatment of psoriasis [Baroli et al. 2000].<br />
The use of non-steroidal antiphlogistics for external therapy of<br />
musculoskeletal or antirheumatic diseases is wi<strong>de</strong>spread, in or<strong>de</strong>r<br />
to avoid the typical si<strong>de</strong> effects of oral administration of nonsteroidal<br />
antiphlogistics. The vehicle system used is <strong>de</strong>cisive for the<br />
biological activity of the applied active substance. Usually, gel<br />
vehicles are selected for application, but they do not always<br />
guarantee optimal efficacy.<br />
Using piroxicam as an example, Dalmora et al. could <strong>de</strong>monstrate<br />
that improvement in the efficacy of piroxicam can be achieved<br />
when microemulsions are used as vehicle systems. In an<br />
inflammation mo<strong>de</strong>l in rats, granuloma was first induced by<br />
implanting cotton pellets. The rats’ <strong>de</strong>fence reaction was to be<br />
stopped by application of the antiphlogistic. The pe<strong>net</strong>rationpromoting<br />
effect of the microemulsion was particularly clear in<br />
these studies, since the externally-applied microemulsions could be<br />
shown to have the same efficacy (reduction of the granuloma mass)<br />
as the subcutaneously-applied microemulsions. Thus, efficient<br />
enriching of piroxicam in tissue could be guaranteed by the use of<br />
special microemulsions [Dalmora et al. 2001].<br />
Hydrophilic active substances are generally consi<strong>de</strong>red problem<br />
drugs for topical application. The topical availability of these<br />
actives can usually be increased with the help of colloidal vehicle<br />
systems. In the case of the hydrophilic active substance Biotin,<br />
microemulsions of various compositions were produced and the<br />
pe<strong>net</strong>ration of the active in human skin ex vivo <strong>de</strong>termined after a<br />
short (30 min) and prolonged (300 min) application time. An O/W<br />
emulsion (Hydrophilic Ointment containing water DAB) was used<br />
as the reference vehicle, since Biotin can pe<strong>net</strong>rate the skin better<br />
from this vehicle than when it is applied in water-in-oil type<br />
emulsion (such as lanolin-alcohol ointment containing water,<br />
DAB). While the microemulsion alone was only as effective as the<br />
standard in form of an O/W emulsion, double the quantity of Biotin<br />
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172 Mo<strong>de</strong>rn Vehicle Systems<br />
could be introduced after the addition of cholesterol. To our<br />
knowledge, this is due to the fact that cholesterol is capable of<br />
opening hydrophilic domains in the horny layer for the<br />
transportation especially of hydrophilic substances. The active<br />
substance quantity thus introduced in the horny layer of human skin<br />
could be diffused off from this <strong>de</strong>pot into the living skin layers<br />
[Huschka et al. 2001].<br />
Drawing conclusions from a number of studies on microemulsionsn<br />
and their topical applications, the following aspects can be rated as<br />
positive. The systems are simple to produce and show excellent<br />
stability. Microemulsions possess a high <strong>de</strong>gree of dissolution<br />
capacity, which supports the application of problem drug<br />
substances. They have low viscosity and low surface tension and<br />
thus can be easily spread on the skin. Dermal and trans<strong>de</strong>rmal<br />
applications can be recommen<strong>de</strong>d. The high tensi<strong>de</strong> content must be<br />
consi<strong>de</strong>red a disadvantage, since it is associated with the risk of<br />
intolerance<br />
Liposomes are another colloidal vehicle system for topical<br />
application. In the past twenty years, intensive work has been done<br />
to improve the topical availability of various active substances by<br />
using liposomes. Since then, especially the pe<strong>net</strong>ration-promoting<br />
effect of liposomes has been intensively studied for a range of<br />
vitamins, for steroidal and non-steroidal antiphlogistics,<br />
antimycotics and antibiotics and in addition to many other<br />
substances for macromolecules. Current examples of research in the<br />
area of topical application of liposomal formulations are discussed<br />
below.<br />
Improvement of the topical efficacy of the gyrase inhibitor<br />
enoxacin was the objective of studies by Fang et al. The<br />
accumulation of the active in the skin of hairless/nu<strong>de</strong>? mice was<br />
<strong>de</strong>termined after 48 hours. A pure enoxacin solution was used as the<br />
reference vehicle. As comparison, enoxacin was worked into<br />
various liposomal systems. The various vehicle systems produced<br />
different results with respect to the pe<strong>net</strong>rating quantity of active<br />
substance. While liposomes of dimyristoylphosphatidylcholine<br />
(DMPC) and the combination of DMPC and cholesterol led to a<br />
reduction of active pe<strong>net</strong>ration, increased quantities of enoxacin<br />
could be found in the skin when lecithin of chicken egg yolk and of<br />
soy was used. The use of pure niosomes harvested from the vesicle<br />
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Mo<strong>de</strong>rn Vehicle Systems 173<br />
former SPAN ® (Sorbitan fatty acid ester) produced the greatest<br />
pe<strong>net</strong>ration-promoting effect [Fang et al. 2001].<br />
An increasing number of articles is being published in the literature<br />
about a reduction of the damaging effects of UV-light. Among<br />
these are the articles by Yarosh [Yarosh 2001, Yarosh et al. 2001].<br />
They are all aimed at the repair of UV-induced damage to DNA by<br />
the effect of a bacterial endonuclease. An essential requisite for the<br />
efficacy of this enzyme is the transport in intact liposomes into the<br />
living epi<strong>de</strong>rmis. The positive accomplishment of this i<strong>de</strong>a could be<br />
confirmed by electronic microscopic images.<br />
Exposure to too much UV-light causes damage to the living<br />
epi<strong>de</strong>rmis, which is expressed by typical signs of inflammation.<br />
One signal for excessive light exposure can be found in the<br />
expression of IL-10. This interleukin could be<br />
immunohisotochemically proven in samples of damaged skin.<br />
There was no signal in skin treated with T4 endonuclease V<br />
(T4N5). A negative control, in which inactivated enzyme in<br />
liposomes was applied, disproved the efficacy of the vehicle alone<br />
[Wolf et al. 2000].<br />
Patients with the ge<strong>net</strong>ically-caused disease Xero<strong>de</strong>rma<br />
pigmentosum tend to <strong>de</strong>velop actinic keratoses or basal cell<br />
carcinoma after contact with UV-light. In or<strong>de</strong>r to prevent this,<br />
patients with this disease were treated for a year with T4N5liposomes.<br />
Compared to placebo, the sequelae could be greatly<br />
reduced. Thus, therapy or prophylaxis with enzyme-loa<strong>de</strong>d<br />
liposomes appears meaningful in cases of UV-induced damage<br />
[Yarosh et al. 2001].<br />
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174 Mo<strong>de</strong>rn Vehicle Systems<br />
Fig. 3: Properties and components of microemulsions<br />
Fig. 4: Nanoparticles with 5-ALA in the treatment of basal cell<br />
carcinomas<br />
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Mo<strong>de</strong>rn Vehicle Systems 175<br />
The following aspects can be summarized from the studies<br />
discussed: Liposomes are diverse in their structure and efficacy.<br />
Thanks to their specific structure, liposomes can enter into intensive<br />
interactions with the lipids in the horny layer. Thus, liposomal<br />
systems can provi<strong>de</strong> for pe<strong>net</strong>ration enhancement of a number of<br />
molecules. Even for active substances with low topical availability,<br />
liposomal systems offer a possibility of enabling trans<strong>de</strong>rmal<br />
effects. The proprio-effect of blank liposomes (only phospholipids<br />
without active substance load), expressed by increased hydratation<br />
of the epi<strong>de</strong>rmis, should not be ignored. Although the manufacture<br />
itself of the vehicle can be consi<strong>de</strong>red simple, there is a need to<br />
product liposomes with long-term stability. Simply-constructed<br />
liposomes (such as those from pure lecithin) tend to be unstable<br />
(release of the active due to structural loss, fusion of the vesicle).<br />
Nanoparticles are colloidal vehicle systems, with dimensions in the<br />
lower nanometer range. High-pressure homogenization has become<br />
established among the possibilities of producing the particles from<br />
stabilized triglyceri<strong>de</strong>s [Lippacher et al. 2001]. A review of the<br />
published activities shows an increasing frequency of reports on the<br />
use of solid lipid nanoparticles (SLN ® ) for skin-care therapy.<br />
Several vitamins and other skin-care substances propagated also for<br />
the treatment of damaged skin or skin requiring special care, are<br />
worked into these particles [Berna<strong>de</strong>sca et al. 2001, Jenning et al.<br />
2000]. The use of nanoparticles un<strong>de</strong>r the aspect of controlled<br />
release of the active should be mentioned. Such <strong>de</strong>velopments are<br />
among the goals in the application of glucocorticoids [Maia et al.<br />
2000].<br />
Improved pe<strong>net</strong>ration of the photosensitizer 5-Aminolaevulinic acid<br />
(5-ALA) was the object of the following study. Photodynamic<br />
therapy with nanoparticles containing 5-ALA was performed in<br />
patients with basal cell carcinoma, in or<strong>de</strong>r to better transport the<br />
active substance to the site of action. The active concentration in the<br />
particles was 10%. After single application for 6 hours with<br />
subsequent light exposure, efficacy of therapy could be<br />
<strong>de</strong>monstrated after 6 months in 15% of the patients (Fig. 4). Costs<br />
could be saved by reducing the quantity of active substance used (in<br />
cream vehicles, 20% is the usual concentration).<br />
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176 Mo<strong>de</strong>rn Vehicle Systems<br />
Fig. 5: Electronic-microscopic images of nanopartikels of starch<br />
acetate<br />
Fig. 6: Pe<strong>net</strong>ration of Biotin from starch acetate nanoparticles in<br />
human skin ex vivo That efficacy is attained is explained as an<br />
occlusive effect of uniform covering of the skin surface by the<br />
particles [Hürlimann et al. 1998].<br />
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Mo<strong>de</strong>rn Vehicle Systems 177<br />
Physical filters have been used for several years to reduce the effect<br />
of sunlight on human skin, also to replace chemical filter substances<br />
(absorber) to reduce si<strong>de</strong> effects. With the further <strong>de</strong>velopment of<br />
micronized particles down to real nanoparticles of titanium dioxi<strong>de</strong>,<br />
a new quality has been attained. The miniaturization of the particles<br />
lets the unattractive effect of whitening, such as happens after<br />
application of micronized partles, disappear. The smaller particles<br />
are invisible to the human eye and, thanks to their <strong>de</strong>nser packing<br />
on the skin surface, also provi<strong>de</strong> improved protection. The excellent<br />
spread of the particles on the surface means that even the smallest<br />
pores are reached, so that trouble spots are avoi<strong>de</strong>d and the effect<br />
optimized.<br />
In addition to the lipids, polymers can also be used in the<br />
production of solid particles. Using a lipophilic acetylated starch,<br />
nanoparticles with porous structure can be produced (solvent<br />
evaporation technique) and these loa<strong>de</strong>d with the active substance<br />
Biotin (Fig. 5). Then the pe<strong>net</strong>ration of Biotin in human skin was<br />
traced [Huschka et al. 2001]. Differences in the extent of<br />
pe<strong>net</strong>ration were observed <strong>de</strong>pending on the tensi<strong>de</strong> used. Lipid and<br />
polymer systems brought more Biotin into the horny layer than the<br />
standard (Water-containing Hydrophilic Ointment DAB) (Fig. 6).<br />
Observed in a short application time, the affinity of the positivecharged<br />
particles produced with the emulgator benzalconium<br />
chlori<strong>de</strong> was higher than the negative-charged particles (sodium<br />
do<strong>de</strong>cylsulfate). This may be attributed to the more intensive<br />
interactions with the negative-charged skin surface.<br />
The following aspects summarize again in brief the main points on<br />
nanoparticles. Nanoparticles can be easily produced in large scale<br />
from a technological point of view. Overall, most particulate<br />
systems are stable. With respect to <strong>de</strong>rmal application, lipid<br />
particles are particularly well tolerated. By contrast, attention must<br />
be paid to a residual content of toxic monomers in several polymer<br />
particles. Due to the minimal surface of the particles, they are able<br />
to completely cover the skin surface. Thus occlusion is attained and<br />
the hydratation of the horny layer is increased. These are, therefore,<br />
systems which can be recommen<strong>de</strong>d for dry or aged skin.<br />
Moreover, the use of pure particles as light protection is possible. In<br />
addition, nanoparticles can be easily worked into other bases. The<br />
uptake of active substances can be realized, <strong>de</strong>pends however on<br />
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178 Mo<strong>de</strong>rn Vehicle Systems<br />
the physicochemical properties of the particle. Nanoparticles can<br />
protect the active ingredient against external influence and thanks to<br />
their matrix are able to control the release of the incorporated<br />
substances [Wissing and Müller 2001].<br />
References<br />
1 Alvarez-Figueroa MJ, Blanco-Men<strong>de</strong>z J.: Trans<strong>de</strong>rmal <strong>de</strong>livery<br />
of methotrexate: iontophoretic <strong>de</strong>livery from hydrogels and<br />
passive <strong>de</strong>livery from microemulsions.<br />
Int J Pharm 2001; 215 (1-2): 57-65<br />
2 Baroli B, Lopez-Quintela MA, Delgado-Charro MB, Fadda AM,<br />
Blanco-Men<strong>de</strong>z J: Microemulsions for topical <strong>de</strong>livery of 8methoxsalen;<br />
J Control Release 2000; 69 (1): 209-218<br />
3 Berar<strong>de</strong>sca E, Barbareschi M, Veraldi S, Pimpinelli N.:<br />
Evaluation of efficacy of a skin lipid mixture in patients with<br />
irritant contact <strong>de</strong>rmatitis, allergic contact <strong>de</strong>rmatitis or atopic<br />
<strong>de</strong>rmatitis: a multicenter study; Contact Dermatitis 2001; 45 (5):<br />
280-285<br />
4 Dalmora ME, Dalmora SL, Oliveira AG: Inclusion complex of<br />
piroxicam with beta-cyclo<strong>de</strong>xtrin and incorporation in cationic<br />
microemulsion. In vitro drug release and in vivo topical antiinflammatory<br />
effect. Int. J Pharm 2001; 222 (1): 45-55<br />
5 Dingler A, Gohla S.: Production of solid lipid nanoparticles<br />
(SLN): scaling up feasibilities.; J Microencapsul 2002; 19 (1):<br />
11-16<br />
6 Hürlimann AF, Hänggi G, Panizzon RG.: Photodynamic therapy<br />
of superficial basal cell carcinomas using topical 5aminolevulinic<br />
acid in a nanocolloid lotion; Dermatology 1998;<br />
197 (3): 248-254.<br />
7 Huschka C, Wolf R, Raith K, Neubert R, Wohlrab W. Relevance<br />
of topical application of biotin containing formulations. In<br />
Bonnekoh B, Gollnick H. (eds.) Dermatological treatment: novel<br />
clinical and experimental approaches 2002 (in press)<br />
8 Jenning V, Gysler A, Schafer-Korting M, Gohla SH.: Vitamin A<br />
loa<strong>de</strong>d solid lipid nanoparticles for topical use: occlusive<br />
properties and drug targeting to the upper skin; Eur J Pharm<br />
Biopharm. 2000; 49 (3): 211-218.<br />
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In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
Mo<strong>de</strong>rn Vehicle Systems 179<br />
9 Lichtenberg D, Barenholz Y.: Liposomes: preparation,<br />
characterization, and preservation; Methods Biochem Anal<br />
1988; 33: 337-462<br />
10 Lippacher A, Muller RH, Ma<strong>de</strong>r K.: Preparation of semisolid<br />
drug carriers for topical application based on solid lipid<br />
nanoparticles; Int J Pharm 2001 Feb 19; 214 (1-2): 9-12.<br />
11 Fang JY, Hong CH, Chiu WT, Wang YY.: Effect of liposomes<br />
and niosomes on skin permeation of enoxacin; Int J Pharm 2001;<br />
219 (1-2): 61-72.<br />
12 Maia CS, Mehnert W, Schafer-Korting M. Related Articles:<br />
Solid lipid nanoparticles as drug carriers for topical<br />
glucocorticoids; Int J Pharm 2000; 196 (2):165-167<br />
13 Osborne DW, Ward AJ, O'Neill KJ.: Microemulsions as topical<br />
drug <strong>de</strong>livery vehicles: in-vitro trans<strong>de</strong>rmal studies of a mo<strong>de</strong>l<br />
hydrophilic drug; J Pharm Pharmacol 1991; 43 (6): 450-454<br />
14 Quintanar-Guerrero D, Allemann E, Fessi H, Doelker E.:<br />
Preparation techniques and mechanisms of formation of<br />
bio<strong>de</strong>gradable nanoparticles from preformed polymers; Drug<br />
Dev Ind Pharm 1998 (12): 1113-1128<br />
15 Schmalfuß, U: Untersuchungen zur Modulation <strong>de</strong>r Pe<strong>net</strong>ration<br />
eines hydrophilen Arzneistoffes aus Mikroemulsionssystemen in<br />
humane Haut unter ex vivo-Bedingungen; 1997; Dissertation,<br />
Math.-Nat.-Tech. Fak., Martin-Luther-Universität Halle-<br />
Wittenberg<br />
16 Tenjarla S.: Microemulsions: an overview and pharmaceutical<br />
applications; Crit Rev Ther Drug Carrier Syst 1999;16 (5): 461-<br />
521<br />
17 <strong>de</strong> Vringer T, <strong>de</strong> Ron<strong>de</strong> HA. : Preparation and structure of a<br />
water-in-oil cream containing lipid nanoparticles; J Pharm Sci<br />
1995; 84 (4): 466-472<br />
18 Wolf P, Maier H, Müllegger RR, Chadwick CA, Hofmann-<br />
Wellenhof R, Soyer HP, Hofer A, Smolle J, Horn M, Cerroni L,<br />
Yarosh D, Klein J, Bucana C, Dunner K, Potten CS,<br />
Hönigsmann H, Kerl H, Kripke ML.: Topical treatment with<br />
liposomes containing T4 endonuclease V protects human skin in<br />
vivo from ultraviolet-induced upregulation of interleukin-10 and<br />
tumor necrosis factor-alpha; J Invest Dermatol 2000; 114 (1):<br />
149-156<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
180 Mo<strong>de</strong>rn Vehicle Systems<br />
19 Yarosh DB: Liposomes in investigative <strong>de</strong>rmatology;<br />
Photo<strong>de</strong>rmatol Photoimmunol Photomed 2001; 17 (5): 203-212<br />
20 Yarosh D, Klein J, O'Connor A, Hawk J, Rafal E, Wolf P: Effect<br />
of topically applied T4 endonuclease V in liposomes on skin<br />
cancer in xero<strong>de</strong>rma pigmentosum: a randomised study.<br />
Xero<strong>de</strong>rma Pigmentosum Study Group; Lancet 2001; 357: 926-<br />
929<br />
21 Wissing SA, Muller RH.: Solid lipid nanoparticles (SLN)--a<br />
novel carrier for UV blockers; Pharmazie 2001; 56 (10): 783-<br />
786<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
Microemulsions as drug vehicles for <strong>de</strong>rmal application 181<br />
Microemulsions as drug vehicles for <strong>de</strong>rmal<br />
application<br />
K. Jahn, R.H.H. Neubert, *J. Wohlrab<br />
Institut für Pharmazeutische Technologie und Biopharmazie,<br />
* Universitätsklinik und Poliklinik für Dermatologie und Venerologie <strong>de</strong>r<br />
Martin-Luther-Universität Halle-Wittenberg<br />
Wolfgang-Langenbeck-Straße 4<br />
D-06120 Halle<br />
Germany<br />
Microemulsions for <strong>de</strong>rmal use .................................. 181<br />
Summary..................................................................... 183<br />
References................................................................... 184<br />
Microemulsions (ME’s) are isotropic, transparent or slightly<br />
opalescent, thermodynamically stable and low viscous systems.<br />
They are quaternary systems consisting usually of a hydrophilic and<br />
a lipophilic phase stabilized by a surfactant and a cosurfactant.<br />
ME’s can be manufactured easily, simply by stirring the<br />
components together. The spontaneous formation without energy<br />
input and the thermodynamic stability belong to their special<br />
features and are caused by the dramatic <strong>de</strong>crease of the interfacial<br />
tension between the hydrophilic and the lipophilic phase by mixing<br />
the components. Consequently, a characteristic microstructure of<br />
small droplets is formed. Alternating surfactant and cosurfactant<br />
molecules surround the internal phase. The main distinction<br />
between cru<strong>de</strong> emulsions and ME’s is their particle diameter in the<br />
range of 10 to 200 nm. This property is the reason for the long-term<br />
stability without phase separation. These systems show structural<br />
similarities to micelles and inverse micelles. They represent highly<br />
dynamic structures due to the fluctuating surfaces as a consequence<br />
of the forming and <strong>de</strong>forming processes. Just as cru<strong>de</strong> emulsions<br />
they can be divi<strong>de</strong>d into two types: w/o (water-in-oil) and o/w (oilin-water).<br />
The formation is <strong>de</strong>pen<strong>de</strong>nt on the oil-to-water ratio and<br />
the physicochemical characteristics of the surfactant and<br />
cosurfactant used. Bicontinuous structures are also possible [1,2,3].<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
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182 Microemulsions as drug vehicles for <strong>de</strong>rmal application<br />
Table 1 shows possible administration routes of microemulsions<br />
and some drug examples (literature data).<br />
administration<br />
route<br />
oral<br />
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drugs<br />
Ciclosporin A [4] (Sandimmun ® Optoral), hydrophilic pepti<strong>de</strong>s<br />
[5]<br />
Ophthalmic timolol [6], pilocarpine [7]<br />
parenteral flurbiprofen [8], diazepam [9]<br />
<strong>de</strong>rmal/trans<strong>de</strong>rmal azelaic acid [10], local anaesthetics [11], ß-blockers [12]<br />
Tab. 1: Possible administration routes of microemulsions<br />
Microemulsions for <strong>de</strong>rmal use<br />
In pharmacy, ME’s have been attracted great interest as <strong>de</strong>rmal<br />
drug <strong>de</strong>livery systems to improve percutaneous pe<strong>net</strong>ration of<br />
problematical drugs. The <strong>de</strong>rmal application of drugs can be<br />
advantageous in the treatment of several <strong>de</strong>rmatologic diseases, in<br />
or<strong>de</strong>r to minimize si<strong>de</strong> effects after systemic application as well as<br />
to avoid the hepatic first-pass metabolism or the <strong>de</strong>struction and<br />
inactivation of drugs following oral application.<br />
Numerous in-vitro release and pe<strong>net</strong>ration studies have been<br />
reported by several authors to assess the suitability of ME’s for<br />
<strong>de</strong>rmal and trans<strong>de</strong>rmal application. Currently, the therapeutic use<br />
of these systems for <strong>de</strong>rmal drug <strong>de</strong>livery is limited due to the high<br />
content of emulsifiers. In future, it is necessary to create vehicles<br />
containing surfactants with low irritative potential and good skin<br />
acceptability. It is possible to overcome this problem if non-ionic<br />
and polymeric surfactants will be preferred.<br />
Microemulsions of o/w-type are the more suitable vehicles for<br />
lipophilic drugs, whereas the w/o-type seems to be the better one<br />
for hydrophilic drugs.<br />
Generally, hydrophilic drugs have difficulties to pass lipophilic<br />
membranes. Therefore, the pe<strong>net</strong>ration-enhancing activities of w/o-<br />
ME’s can facilitate the drug diffusion into the skin. Lipophilic
Microemulsions as drug vehicles for <strong>de</strong>rmal application 183<br />
drugs are mostly problematical regarding their pe<strong>net</strong>ration rate. Due<br />
to the physicochemical properties they enter into the lipophilic<br />
stratum corneum forming a drug <strong>de</strong>pot, but they are not capable of<br />
diffusing in <strong>de</strong>eper skin layers. Incorporating such drugs into o/w-<br />
ME’s can lead to a greater pe<strong>net</strong>ration extent.<br />
An example for the <strong>de</strong>rmal use of microemulsions containing an<br />
extremely lipophilic compound, ciclosporin A, is shown in another<br />
contribution to this book („Trends of topical immunomodulatory<br />
therapy“).<br />
Advantages of microemulsions for <strong>de</strong>rmal use<br />
- favourable solubilization capacity for slightly soluble drugs<br />
- exert pe<strong>net</strong>ration enhancing properties due to their structure and<br />
composition<br />
- <strong>de</strong>rmal or trans<strong>de</strong>rmal effect of applied drugs<br />
- Transport of drugs, which are problematical regarding their<br />
pe<strong>net</strong>ration behaviour, into human skin<br />
- reversible modification of the main pe<strong>net</strong>ration barrier Stratum<br />
corneum<br />
Summary<br />
Microemulsions are due to their favourable solubilization capacity<br />
suitable vehicles for slightly soluble drugs. In contrast to<br />
conventional preparations (creams and ointments) the <strong>de</strong>rmal<br />
application of ME’s leads to a <strong>de</strong>eper and exten<strong>de</strong>d pe<strong>net</strong>ration of<br />
incorporated drugs into the skin. Further advantages of<br />
microemulsions are the thermodynamic stability, ease of<br />
manufacturing and spontaneous formation. In future, the interest<br />
has to be focused on the <strong>de</strong>velopment of microemulsions with<br />
pharmaceutically-acceptable compounds.<br />
For further information see several reviews and book chapters<br />
[1,2,3,13,14].<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
184 Microemulsions as drug vehicles for <strong>de</strong>rmal application<br />
References<br />
1 Attwood D (1994) Microemulsions. In: Kreuter, J. (ed.)<br />
Colloidal drug <strong>de</strong>livery systems. Marcel Dekker, New York p<br />
31-71<br />
2 Lawrence MJ (1996) Microemulsions as drug <strong>de</strong>livery vehicles.<br />
Curr Opin Colloid Interface Sci 1:464-471<br />
3 Tenjarla S (1999) Microemulsions: An overview and<br />
pharmaceutical applications. Crit Rev Ther Drug Carrier Syst<br />
16(5):461-521<br />
4 Kovarik JM, Mueller EA, van Bree JB, Tetzloff W, Kutz K<br />
(1994) Reduced inter- and intraindividual variability in<br />
cyclosporine pharmacoki<strong>net</strong>ics from a microemulsion<br />
formulation. J Pharm Sci 83:444-446<br />
5 Constantini<strong>de</strong>s PP, Lancester CM, Marcello J, Chiossone DC,<br />
Orner D, Hidalgo I, Smith PL, Sarkahian AB, Yiv SH, Owen AJ<br />
(1995) Enhanced intestinal absorption of an RGD pepti<strong>de</strong> from<br />
water-in-oil microemulsions of different composition and<br />
particle size. J Contr Rel 34: 109-116<br />
6 Gasco MR, Gallarate M, Trotta M, Bauchiero L, Gremmo E,<br />
Chiappero O (1989) Microemulsions as topical <strong>de</strong>livery<br />
vehicles: ocular administration of timolol. J Pharm Biomed Anal<br />
7:433-439<br />
7 Haße A, Keipert S (1997) Development and characterization of<br />
microemulsions for ocular application. Eur J Pharm Biopharm<br />
43:179-183<br />
8 Park K-M, Kim Ch-K (1999) Preparation and evaluation of<br />
flurbiprofen-loa<strong>de</strong>d microemulsion for parenteral <strong>de</strong>livery. Int J<br />
Pharm 181:173-179<br />
9 Trotta M, Gasco MR, Carlotti ME (1990) Study on an o/w<br />
microemulsion carrying diazepam. Acta Technol Legis<br />
Medicamenti 1:137-148<br />
10 Gasco MR, Gallarate M, Pattarino F (1991) In vitro permeation<br />
of azelaic acid from viscosized microemulsions. Int J Pharm<br />
69:193-196<br />
11 Krause SA (2001) Entwicklung und Charakterisierung von<br />
Mikroemulsionen zur <strong>de</strong>rmalen Applikation von Arzneistoffen,<br />
PhD Thesis, Martin-Luther-University Halle-Wittenberg,<br />
Germany<br />
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In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
Microemulsions as drug vehicles for <strong>de</strong>rmal application 185<br />
12 Kemken J, Ziegler A, Mueller BW (1991) Investigations into the<br />
pharmacodynamic effect of <strong>de</strong>rmally administered<br />
microemulsions containing ß-Blockers. J Pharm Pharmacol<br />
43:679-684<br />
13 Lawrence MJ, Rees GD (2000) Microemulsion-based media as<br />
novel drug <strong>de</strong>livery systems. Adv Drug. Del Rev 45: 89-121<br />
(2000)<br />
14 Jahn K, Krause A, Janich M, Neubert RHH (2002) Colloidal<br />
Drug Carrier Systems. In: Bronaugh RL, Maibach HI (eds)<br />
Topical absorption of <strong>de</strong>rmatological products. Marcel Dekker,<br />
New York p 483-493<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
186 Transfersomes® and their Application in Dermatopharmaceutics<br />
Transfersomes ® and their Application in<br />
Dermatopharmaceutics<br />
J. Lehmann, M. Rother<br />
IDEA AG<br />
Frankfurter Ring 193 a<br />
D-80807 München<br />
Germany<br />
What are Transfersomes ® ?.......................................... 186<br />
Therapeutic Applications for the Transfersome ®<br />
Technology.................................................................. 189<br />
Glucocorticoids: Triamcinolone acetoni<strong>de</strong> in<br />
Transfersomes ® ........................................................... 189<br />
Conclusion .................................................................. 193<br />
Acknowledgement ...................................................... 193<br />
References................................................................... 193<br />
What are Transfersomes ® ?<br />
Transfersomes ® are ultraflexible lipid vesicles <strong>de</strong>signed to <strong>de</strong>liver<br />
drugs through the skin barrier [1]. Their membrane consists of a<br />
minimum of two components with different solubility. This enables<br />
Transfersomes ® to rearrange the components in the membrane<br />
according to any external force exerted on them, e.g., the hydration<br />
gradient, to make the membrane locally much more adaptable and<br />
better suited to accommodate to ambient stress (Fig. 1, upper right<br />
panel). This allows Transfersomes ® to cross pores that have a<br />
diametre smaller than their own average diametre.<br />
In or<strong>de</strong>r to characterize the ability of different lipid vesicles to<br />
pe<strong>net</strong>rate a semi-permeable barrier an in vitro assay was <strong>de</strong>veloped.<br />
The method consists of applying a pressure on a suspension of<br />
mixed lipid vesicles on one si<strong>de</strong> of a barrier with 20 nm to 50 nm<br />
pores. As a control, water is pressed through the pores to <strong>de</strong>termine<br />
maximum transfer ability. Such an assay can clearly differentiate<br />
between the liposomes with a stiff membrane that only pass through<br />
a nano-porous barrier un<strong>de</strong>r pressure of >1 MPa, and the highly<br />
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Transfersomes® and their Application in Dermatopharmaceutics 187<br />
shape-adaptable Transfersomes ® that start pe<strong>net</strong>rating such a barrier<br />
at pressures around 0.1 MPa (Fig. 1). As an additional parameter<br />
vesicle integrity is checked by analysing the size of the vesicles that<br />
have passed the barrier. In case of liposomes, the original size is<br />
significantly reduced suggesting passage after vesicle<br />
fragmentation. In contrast, Transfersomes ® maintain their original<br />
size. This proves that the selected mixed lipid vesicles cross pores<br />
in a barrier due to their extremely high membrane adaptability.<br />
Pe<strong>net</strong>ration rel. to water [%]<br />
10 2<br />
10 1<br />
10 0<br />
10 -1<br />
10 -2<br />
10 -3<br />
Water<br />
Pressure [MPa]<br />
r V /r Pore = 3.5<br />
Transfersomes ®<br />
0 0.2 0.4 0.6 0.8<br />
Liposomes<br />
Fig. 1: In vitro assay for <strong>de</strong>termining membrane adaptability of<br />
lipid vesicles. The flexibility of Transfersome ® membranes is much<br />
higher than that of liposome membranes, resulting in pore<br />
pe<strong>net</strong>ration ability of the former that is similar to that of water.<br />
Upper right panel: schematic representation of Transfersome ®<br />
membrane composition and <strong>de</strong>formation during entry in a confining<br />
pore. Lower right panel: schematic representation of liposome<br />
membrane composition and stiffness. rel.: relative; rV/rPore: relative<br />
vesicle/pore size ratio.<br />
In vivo, the driving force for Transfersome ® motion across the skin<br />
is the transepi<strong>de</strong>rmal water gradient. With increasing <strong>de</strong>pth in the<br />
skin the water content of the stratum corneum as the outermost skin<br />
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188 Transfersomes® and their Application in Dermatopharmaceutics<br />
region increases from approximately 15% to nearly 75% [2]. After<br />
an epicutaneous application Transfersome ® suspensions first dry to<br />
the vesicles´ solubility limit. The hydrophilic vesicles are<br />
consequently attracted by the higher water content in the inner skin.<br />
This drives Transfersomes ® through the stratum corneum through<br />
the hydrophilic pores between cells that are opened by the vesicles<br />
themselves. Aguilella et al. [3] estimated the corresponding pore<br />
radius to be approximately 20 nm.<br />
Fig. 2: Left: Schematic drawing of mammalian epi<strong>de</strong>rmis, revealing<br />
the existence of cell clusters and of potential inter-cluster or intercellular<br />
(intra-cluster) pathways in the stratum corneum. Right:<br />
Murine stratum corneum as viewed with confocal laser scanning<br />
microscopy from the top after epicutaneous treatment with<br />
fluorescently labelled Transfersomes ® [4]. The Transfersome ® -<br />
associated label stains intra- as well as inter-cluster pathways.<br />
Using fluorescently labelled Transfersomes ® and confocal laser<br />
scanning microscopy (CLSM) the morphology of the stratum<br />
corneum was investigated by Schätzlein and Cevc [4]. This<br />
revealed the existence of cell clusters, shown in the left panel of<br />
Fig. 2, and of inter-cluster as well as intra-cluster pathways shown<br />
in the right panel of Fig. 2. The inter-cluster pathways are marked<br />
intensively by the dye. The intra-cluster pathway is highlighted in<br />
the superposition of pictures taken at several <strong>de</strong>pths in the stratum<br />
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Transfersomes® and their Application in Dermatopharmaceutics 189<br />
corneum and projected on top of each other. Inter-cluster pathways<br />
appear as thick bands and inter-cellular (intra-cluster) pathways as<br />
thin-bands. Lipid aggregates with stiffer membranes only label the<br />
wi<strong>de</strong>st pathways between the cells and the intercellular space in the<br />
top layers of the stratum corneum [1].<br />
Therapeutic Applications for the Transfersome ®<br />
Technology<br />
The Transfersome ® technology offers a wi<strong>de</strong> range of treatment<br />
opportunities [5]. The molecules to be <strong>de</strong>livered may vary from<br />
small ones like glucocorticoids and antimycotics up to<br />
macromolecules. For optimum performance however each<br />
Transfersome ® formulation must be specifically <strong>de</strong>signed according<br />
to its inten<strong>de</strong>d use, the target indication, the target tissue, and the<br />
drug molecule to be transported. The most obvious application is<br />
Transfersome ® usage for the treatment of skin diseases like<br />
psoriasis, mycoses, keratoses, etc.. In addition, Transfersomes ® are<br />
also suitable for non-invasive treatment of local indications like<br />
pain in the joints or muscle soreness. This is due to the fact that<br />
such carriers are uniquely able to transport the drug into the <strong>de</strong>ep<br />
subcutaneous tissues [6]. This route of administration is especially<br />
interesting for non-steroidal anti-inflammatory drugs as it helps to<br />
avoid si<strong>de</strong> effects caused by systemic application like bleeding of<br />
the gastrointestinal tract. A third area of use for Transfersomes ® is<br />
the non-invasive, systemic application of molecules that currently<br />
require an injection as route of administration like insulin or<br />
interferon.<br />
Glucocorticoids: Triamcinolone acetoni<strong>de</strong> in<br />
Transfersomes ®<br />
Preclinical data obtained in the arachidonic acid-induced mouse ear<br />
oe<strong>de</strong>ma mo<strong>de</strong>l [7] suggest that only one tenth of the triamcinolone<br />
acetoni<strong>de</strong> (TAC) dose applied in Transfersomes ® compared to the<br />
dose applied in commercially available lotion or cream<br />
formulations is nee<strong>de</strong>d.<br />
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190 Transfersomes® and their Application in Dermatopharmaceutics<br />
Based on the preclinical data, a monocentric, placebo-controlled,<br />
observer- and subject-blin<strong>de</strong>d clinical trial was conducted [8]. The<br />
primary objective was to <strong>de</strong>termine the bioequivalence between a<br />
ten-fold lower TAC dosage in Transfersomes ® and a commercially<br />
available cream and ointment. The test fields were randomly<br />
distributed on the skin of the back of 20 healthy volunteers, using<br />
several drug doses to investigate the equipotency. All formulations<br />
were applied epicutaneously in a non-occlusive way. The UVBinduced<br />
erythema test was used for intra-individual comparison.<br />
2.5 µg/cm² TAC in Transfersomes ® proved to be equipotent in<br />
erythema suppression to 25 µg/cm² TAC in a cream and an<br />
ointment. Equipotency was statistically significant with p=0.01 and<br />
p
Transfersomes® and their Application in Dermatopharmaceutics 191<br />
of skin thickness. The results of this monocentric, placebocontrolled,<br />
observer-blin<strong>de</strong>d trial with randomized test field<br />
distribution on the inner forearms and intraindividual comparison<br />
are based on the data obtained from 25 healthy volunteers. Both<br />
formulations studied were applied epicutaneously in a nonocclusive<br />
way. After twice daily applications of either 2.5 µg/cm²<br />
TAC in Transfersomes ® or 25 µg/cm² TAC cream for 6 weeks, 76%<br />
of the test fields treated with TAC cream showed atrophy <strong>de</strong>fined as<br />
a reduction in skin thickness of at least 20% compared to baseline.<br />
In contrast, only 24% of the test fields treated with TAC in<br />
Transfersomes ® fulfilled this criterion. This criterion was only<br />
reached by one subject treated with placebo Transfersomes ® . After<br />
one week there was already a significant reduction in skin thickness<br />
between the TAC containing formulations and placebo<br />
Transfersomes ® (p
192 Transfersomes® and their Application in Dermatopharmaceutics<br />
Table 2 shows the three most frequently reported adverse events:<br />
skin atrophy, telangiectasias and dry skin. For skin atrophy the<br />
highest reports were seen in those fields treated with TAC cream,<br />
while the rates were substantially lower for the Transfersome ®<br />
formulation containing the equipotent dose of TAC and for the<br />
placebo Transfersomes ® . The same effect was observed for<br />
telangiectasias which were consi<strong>de</strong>red signs of skin atrophy. Dry<br />
skin was reported to a similar level in all treatment groups.<br />
skin reduction relative to control + SD<br />
15%<br />
10%<br />
5%<br />
0%<br />
-5%<br />
-10%<br />
-15%<br />
-20%<br />
-25%<br />
-30%<br />
-35%<br />
-12.1%<br />
significance of a simple difference:<br />
p=0.007 **<br />
p=0.007 **<br />
at least a twofold superiority of TAC<br />
p=0.74 n.s.<br />
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-21.1%<br />
2.5 µg/cm² TAC TAC I (2.5 µg/cm²) Transfersomes Volon A Creme<br />
® 25 µg/cm² TAC cream<br />
Fig. 3: Skin thickness reduction relative to untreated control fields<br />
after twice daily treatment with equipotent doses of triamcinolone<br />
acetoni<strong>de</strong> (TAC) in two different formulations, TAC in<br />
Transfersomes ® , and TAC in commercial cream. Ultrasound data<br />
obtained after 6 weeks of treatment revealed a significant difference<br />
in skin thickness reduction (Wilcoxon test of difference). SD:<br />
standard <strong>de</strong>viation.<br />
The majority of the reported adverse events occurred towards the<br />
end of the treatment phase (weeks 5 and 6) and were mainly due to<br />
the <strong>de</strong>sign of the study which was aimed at inducing measurable<br />
atrophy. As neither the duration of treatment nor the dosing<br />
frequency match the customary clinical practice, most of the<br />
adverse events are of limited relevance for the routine use of TAC.
Conclusion<br />
Transfersomes® and their Application in Dermatopharmaceutics 193<br />
Non-invasive drug <strong>de</strong>livery with Transfersomes ® may improve the<br />
efficiency, applicability, safety, and/or targetability of trans<strong>de</strong>rmal<br />
transport. Lower amounts of drug are often nee<strong>de</strong>d for <strong>de</strong>rmal<br />
targets as compared to oral or conventional topical formulations. As<br />
a consequence, a <strong>de</strong>crease in si<strong>de</strong> effects and a better tolerability of<br />
the administered drug can be expected. Administration of drugs in<br />
Transfersomes ® reduces high initial plasma peak levels typically<br />
induced by subcutaneous injection. Furthermore, a <strong>de</strong>pot effect in<br />
the skin can be created in or<strong>de</strong>r to reduce the frequency of<br />
application, thereby improving patient satisfaction and compliance.<br />
Acknowledgement<br />
We thank Prof. Dr. D. Abeck, Dr. H. Fesq, A. Glöckner, and I.<br />
Erdmann for conducting the two clinical trials in the Klinik und<br />
Poliklinik für Dermatologie und Allergologie am Bie<strong>de</strong>rstein,<br />
Technische Universität München, Germany. Many thanks also to<br />
Dr. U. Vierl for the schematic drawing of the stratum corneum<br />
morphology.<br />
References<br />
1 Cevc G (1996) The skin: a pathway for systemic treatment with<br />
patches and lipid-based agent carriers. Adv Drug Deliv Rev 18:<br />
349-378<br />
2 Warner RR, Myers MC, Taylor DA (1988) Electron probe<br />
analysis of human skin: <strong>de</strong>termination of the water concentration<br />
profile. J Invest Dermatol 90: 218-224<br />
3 Aguilella V, Kontturi K, Murtomäki L, Ramírez P (1994)<br />
Estimation of the pore size and charge <strong>de</strong>nsity in human cadaver<br />
skin. J Control Release 32: 249-257<br />
4 Schätzlein A, Cevc G (1998) Non-uniform cellular packing of<br />
the stratum corneum and permeability barrier function of intact<br />
skin: a high-resolution confocal laser scanning microscopy study<br />
using highly <strong>de</strong>formable vesicles (Transfersomes) Br J Dermatol<br />
138: 583-592<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
194 Transfersomes® and their Application in Dermatopharmaceutics<br />
5 Cevc G (1997) Drug <strong>de</strong>livery across the skin. Exp Opin Invest<br />
Drugs 6: 1887-1937<br />
6 Cevc G, Blume B (2001) New, highly efficient formulation of<br />
diclofenac for the topical, trans<strong>de</strong>rmal administration in<br />
ultra<strong>de</strong>formable drug carriers, Transfersomes. Biochim Biophys<br />
Acta 1514: 191-205.<br />
7 Young JM, Spires DA, Bedord CJ, Wagner B, Ballaron SJ, <strong>de</strong><br />
Young LM (1984) The mouse ear inflammatory response to<br />
topical arachidonic acid. J Invest Dermatol 82: 367-371<br />
8 Fesq H, Lehmann J, Glöckner A, Erdmann I, Theiling K, Rother<br />
M, Ring J, Cevc G, Abeck D (2002) Improved risk-benefit ratio<br />
for topical triamcinolone acetoni<strong>de</strong> in Transfersomes ® in<br />
comparison to equipotent cream and ointment. Clin Pharmacol<br />
Ther, submitted.<br />
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In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
Trends in the systemic antibiotic therapy of <strong>de</strong>rmatological infectious diseases 195<br />
Trends in the systemic antibiotic therapy of<br />
<strong>de</strong>rmatological infectious diseases<br />
N. H. Brockmeyer, A. Kreuter<br />
Department of Dermatology<br />
Ruhr-University Bochum<br />
Gudrunstr. 56<br />
D-44791 Bochum<br />
Germany<br />
Systemic antibiotic therapy has acquired an important position in<br />
<strong>de</strong>rmatological routine. An awareness of the spectrum of<br />
appropriate antibiotics, new substances and their characteristic<br />
resistance profiles plays a major role in <strong>de</strong>ciding upon which<br />
therapeutic substances to employ. The choice of an antibiotic is also<br />
<strong>de</strong>termined by its characteristic spectrum of activity as well as its<br />
profile of interaction with other substances.<br />
For this reason, new trends in the systemic antibiotic therapy of<br />
<strong>de</strong>rmatological infectious diseases have to take into account newer<br />
therapeutic strategies and modalities, epi<strong>de</strong>miological <strong>de</strong>velopments<br />
as well as newly appearing antibiotic substances and pathogens.<br />
The most frequent indications for the systemic application of<br />
antibiotics in <strong>de</strong>rmatology inclu<strong>de</strong> erysipelas, impetigo, furuncles,<br />
carbuncles as well as wound, ulcer or soft tissue infections. As a<br />
rule, established substances are resorted to when choosing the<br />
antibiotic; for example cephalosporin with staphylococci,<br />
penicillins for streptococci, doxycycline or penicillin for borrelia,<br />
and tetracycline, doxycycline or minocycline for the therapy of acne<br />
and rosacea. Microorganisms were already shown to <strong>de</strong>velop<br />
resistance to antibiotics immediately after they were introduced in<br />
the 1940s. By 1948, most strains of S.-aureus in British hospitals<br />
were resistant to penicillin. At the latest, the appearance of hospitalrelated<br />
infections due to Methicillin-resistant S.-aureus strains<br />
(MRSA) at the end of the 1960s emphasised the far-reaching<br />
importance of multiresistant strains. The resulting choice of second<br />
class substances, i.e. those with a lower efficacy, resulted again in<br />
the selection of pathogens that <strong>de</strong>veloped resistance. Because of this<br />
vicious cycle it has become increasingly more difficult to treat<br />
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196 Trends in the systemic antibiotic therapy of <strong>de</strong>rmatological infectious diseases<br />
hospital-related infections effectively. One of the most important<br />
mechanisms un<strong>de</strong>rlying the <strong>de</strong>velopment of resistance in<br />
nosocomial pathogens is the appearance of antibiotic inactivating<br />
enzymes. Other modifications involve the permeability and binding<br />
structures of the cellular wall, as well as alterations in the target of<br />
the antibiotic’s action.<br />
Since the introduction of mo<strong>de</strong>rn antituberculosis agents,<br />
tuberculosis has become a well treatable disease with a cure rate of<br />
over 90% (provi<strong>de</strong>d that therapy is a<strong>de</strong>quate and the pathogens are<br />
sensitive). Resistance towards antituberculotic agents is no rarity.<br />
Multiple resistance is the most problematic form, involving<br />
resistance to both isoniazid and rifampicin. In Germany it occurs in<br />
approx. 2 % of cases wherever individuals are treated ina<strong>de</strong>quately<br />
or therapy is prematurely interrupted. Internationally, a<br />
monoresistance rate of approx. 10 % can be expected in nonpretreated<br />
cases, more frequently against isoniazid than rifampicin.<br />
With every case of assumed medication resistance, treatment should<br />
be performed with 4 agents until the results of resistance tests are<br />
available, and in cases of suspected multiresistance, 5<br />
antituberculotic agents should be given. The final antituberculotic<br />
treatment should then be performed with 4-5 resistance-corrected<br />
substances until at least 18 months after sputum conversion.<br />
No infectious disease has displayed such a drastic increase in<br />
inci<strong>de</strong>nce over the last few years as syphilis. The number of new<br />
syphilis infections has increased particularly significantly amongst<br />
HIV-positive individuals in major cities (Hamburg 1997: 19 cases,<br />
1999: 71 cases; Cologne 1997: 13 cases, 2001: 69 cases). In the<br />
USA, a similarly dramatic increase in new infections has been<br />
recor<strong>de</strong>d following the <strong>de</strong>crease that characterised the 1980s. The<br />
inci<strong>de</strong>nce is approximately 10-fold higher than it is in other<br />
industrial countries. In some <strong>de</strong>veloping countries in Africa and<br />
Asia, according to information provi<strong>de</strong>d by the WHO, the inci<strong>de</strong>nce<br />
of syphilis exceeds 360/100,000 inhabitants. Experience has shown<br />
that in cases of concomitantly-existing HIV-infection, the risk of<br />
neurosyphilis appearing is particularly high. For this reason, even in<br />
the absence of neurological or psychiatric symptoms, penicillin<br />
therapy should also be carried out in AIDS-patients (as is also the<br />
case with neurosyphilis) with close surveillance and control<br />
examinations. The generation time for Treponema pallidum is<br />
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Trends in the systemic antibiotic therapy of <strong>de</strong>rmatological infectious diseases 197<br />
approx. 30 hours. The minimum duration of uninterrupted<br />
bactericidal therapy is about 8 days. According to recommendations<br />
from the German Society of Sexually Transmitted Diseases,<br />
syphilis should be treated for an a<strong>de</strong>quate period with intramuscular<br />
clemizole-penicillin. Benzathine-penicillin, which in the USA is<br />
usually employed presumably for patient-compliance and to prevent<br />
premature therapeutic interruption, only enters the cerebrospinal<br />
fluid in part. Although the accompanying meningitis occurring in<br />
the second phase can be treated, levels required to treat neurological<br />
syphilis can not be reached. Here, the intracellularly persisting<br />
pathogens can only be reached poorly by the antibiotics. In<br />
addition, the reproduction time of the pathogen is prolonged in this<br />
phase. Whether comparably high levels can be reached in the CSF<br />
with doxycycline, tetracycline or erythromycin is questionable and<br />
currently the subject of pharmacological investigation.<br />
With cyclic intravenous antibiotic therapy, a new efficient<br />
therapeutic concept has been established for chronically recurring<br />
erysipelas. For this purpose penicillin G is applied intravenously<br />
over a period of 10 days every three months. A mechanical<br />
lymphatic drainage is also performed. In a clinical study within our<br />
clinic, newly occurring episo<strong>de</strong>s of erysipelas could be prevented in<br />
more than 90 % of all patients. A significant reduction in<br />
inflammation parameters such as antistreptolysin-titres, BSG as<br />
well as C-reactive protein was also brought about. It would<br />
therefore appear that elimination of pathogen from the interstitial<br />
and lymphatic spaces is possible in the case of erysipelas through<br />
application of a longer-term antibiotic treatment.<br />
The current expansion of medication resistance and new infections<br />
from bacterially –induced skin infections has ma<strong>de</strong> it vital for<br />
clinically active <strong>de</strong>rmatologists to have knowledge about the correct<br />
administration of currently available systemic antibiotics.<br />
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In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
198 Systemic therapy with immunomodulatory drugs in <strong>de</strong>rmatology<br />
Systemic therapy with immunomodulatory drugs<br />
in <strong>de</strong>rmatology<br />
M. Sticherling<br />
Klinik und Poliklinik für Hautkrankheiten<br />
Abteilung für Klinische und Experimentelle Dermatologie<br />
Universität Leipzig<br />
Stephanstr. 11<br />
D-04103 Leipzig<br />
Germany<br />
Introduction................................................................. 198<br />
Adjuvant drugs............................................................ 201<br />
Immunosuppressive drugs .......................................... 201<br />
Immunomodulatory drugs with suppressive activity.. 202<br />
Immunomodulatory drugs without suppressive<br />
activity......................................................................... 203<br />
References................................................................... 205<br />
Introduction<br />
The progress within experimental and clinical immunology over the<br />
last <strong>de</strong>ca<strong>de</strong>s has grossly changed our attitu<strong>de</strong>s towards<br />
pathogenesis, diagnostic procedures and therapeutic approaches to<br />
various inflammatory diseases. As a result of these advances, new<br />
drugs have been <strong>de</strong>veloped and ma<strong>de</strong> available un<strong>de</strong>r<br />
pathoge<strong>net</strong>ically orientated aspects [1-4]. They may be opposed to<br />
drugs which are clinically used based on either empirical, partly<br />
only anecdotical knowledge of their effectiveness. Thus, current<br />
requirements of evi<strong>de</strong>nce based medicine for therapeutic<br />
approaches are often lacking. Following our advances in<br />
immunological knowledge, however, in many instances the mo<strong>de</strong> of<br />
action of such drugs can now be explained at least in parts as<br />
exemplified for glucocorticosteroids or thalidomi<strong>de</strong>.<br />
Inflammatory processes are resulting from the interaction of various<br />
cellular and humoral parameters and are based on either antigendriven<br />
or non-specific mechanisms. Among cellular components,<br />
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Systemic therapy with immunomodulatory drugs in <strong>de</strong>rmatology 199<br />
apart from antigen-presenting cells and interacting lymphocytes of<br />
both T- and B-cell origin, various resi<strong>de</strong>nt and migratory cells are<br />
involved to result in the tissue inflammatory reaction characteristic<br />
for the individual diseases. These interactive effects are mediated<br />
by cellular proteins like cell surface receptors and adhesion<br />
molecules. In addition to these parameters, cellular functions are<br />
modulated by various cytokines at both systemic and local level<br />
resulting in a <strong>net</strong>work of inflammatory processes which is<br />
intricately regulated.<br />
Within mo<strong>de</strong>rn concepts of inflammatory diseases, T-helper cell<br />
dysbalance has been addressed very extensively over the last years<br />
and resulted in the <strong>de</strong>finition of TH1 and TH2 mediated<br />
responses.[1] A shift of immunological responses to either si<strong>de</strong> is<br />
regar<strong>de</strong>d as pathoge<strong>net</strong>ically relevant. Resulting from these i<strong>de</strong>as,<br />
current therapeutic interventions are targeting such dysbalances by<br />
shifting the T-cell response with appropriate drugs.<br />
With these aspects in mind, immunomodulatory therapy can be<br />
<strong>de</strong>fined as counteracting the dysbalances which can be found at the<br />
various steps of this immunological <strong>net</strong>work (table 1). This may be<br />
effected by targeting pathogenic immune cells and their activation<br />
or by interfering with the cytokine <strong>net</strong>work. The intention is to only<br />
target those elements which are pathoge<strong>net</strong>ically relevant within the<br />
progression of the inflammatory response, however sparing other<br />
parts of the immune system which are necessary for normal<br />
immune responses. Currently available drugs fulfil these criteria to<br />
a variable extent by more or less specifically targeting single or<br />
multiple parameters.<br />
Following this concept, immunomodulatory drugs can be divi<strong>de</strong>d<br />
into those with prominent immunosuppressive or cytotoxic activity,<br />
those with both immunomodulatory and immunosuppressive and<br />
thirdly those with immunomodulatory activity only (table 2). As a<br />
result of current concepts of immunological dysbalance, the effects<br />
of mo<strong>de</strong>rn immunomodulatory drugs are often referred to as<br />
immuno<strong>de</strong>viation, a term which <strong>de</strong>scribes the effects of the<br />
modulation of functional activity rather than physical eradication of<br />
the cells involved. Examples for each of these groups will be given<br />
within the context of this contribution without, however, special<br />
referral to individual diseases and specific therapeutic regimens.<br />
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200 Systemic therapy with immunomodulatory drugs in <strong>de</strong>rmatology<br />
Cellular targets Cell surface molecules Humoral targets<br />
T-cells Cell surface receptors<br />
(T-cell receptor, MHCantigens,<br />
costimulatory cell<br />
surface molecules)<br />
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Cytokines<br />
B-cells Adhesion molecules Chemokines<br />
Macrophages/Antigen-presenting<br />
cells<br />
Resi<strong>de</strong>nt tissue cells<br />
(e.g.fibroblasts, endothelial<br />
cells)<br />
Other inflammatory mediators<br />
(e.g. lipid mediators,<br />
complement factors)<br />
Tab. 1: Cellular and humoral targets of immunomodulatory<br />
treatment<br />
Immunosuppressive /cytotoxic drugs<br />
• Cyclophosphami<strong>de</strong><br />
•<br />
Immunomodulatory drugs with suppressive activity<br />
• Corticosteroids<br />
• Azathioprine<br />
• Methotrexate<br />
• Leflunomi<strong>de</strong><br />
• Mycophenolate mofetile<br />
• Ciclosporin<br />
• Macrolactames<br />
• UVB/PUVA<br />
Immunomodulatory dugs without suppressive activity<br />
• Fumaric acid <strong>de</strong>rivatives<br />
• Intravenous immunoglobulins (IVIG)<br />
• Immunobiologicals<br />
- fusion proteins<br />
- monoclonal antibodies<br />
- cytokines<br />
Tab. 2: Systemic immunomodulatory drugs
Adjuvant drugs<br />
Systemic therapy with immunomodulatory drugs in <strong>de</strong>rmatology 201<br />
Different immunomodulatory agents are often referred to as<br />
adjuvant drugs which refers to their supportive or additive action<br />
when combined with corticosteroids. Due to their <strong>de</strong>layed clinical<br />
effects, they usually have to be combined with corticosteroids in the<br />
initial phase of the disease. In mild disease or after stopping steroids<br />
they may however be used as monotherapy. Apart from e.g.<br />
azathioprine, methotrexate and intravenous immunoglobulins which<br />
will be <strong>de</strong>alt with below, chloroquin and hydroxychloroquin are<br />
used as basic adjuvant drugs for the treatment of rheumatic<br />
disor<strong>de</strong>rs including their skin manifestations as well as lichen<br />
rubber [5-7]. Thalidomi<strong>de</strong> has recently been reintroduced into<br />
clinical practice apart from lepra and is now used for chronic<br />
inflammatory, especially granulomatous skin diseases like<br />
cutaneous lupus erythematosus. Modulation of TNFα release from<br />
macrophages were shown to be a major activity exerted by this drug<br />
[8-11]. Similarly dapsone [12,13] and colchizine can very<br />
effectively used alone or in combination with corticosteroids by<br />
modulating cytokine release as well as leukocyte functions. The<br />
clincial effectiveness of antibiotics beyond their antibiotic activity<br />
un<strong>de</strong>rlines immunological effects and warrants their use as adjuvant<br />
drugs in diseases like bullous pemphigoid (tetracycline) and<br />
sclero<strong>de</strong>rma (penicilline) [6].<br />
Immunosuppressive drugs<br />
A representative of this group relevant within <strong>de</strong>rmatology is<br />
cyclophosphami<strong>de</strong> which may be used in high dose and low dose<br />
regimens <strong>de</strong>pending on both disease entity and activity [14,15]. It<br />
grossly interferes with immunological processes by targeting all<br />
proliferative cells. Among these, cells like T and B cells are<br />
involved in the inflammatory processes and should be the main<br />
target. Accordingly, a range of si<strong>de</strong> effects is seen due to the<br />
involvement of other cells e.g. from the hematopoetical system and<br />
gastrointestinal tract. However, in many clincial cases, alternative<br />
drugs with equal effectiveness are missing and thus warrant the use<br />
of cyclophosphami<strong>de</strong>.<br />
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202 Systemic therapy with immunomodulatory drugs in <strong>de</strong>rmatology<br />
Immunomodulatory drugs with suppressive activity<br />
Allocation to this group can be ma<strong>de</strong> for glucocorticosteroids,<br />
azathioprine, methotrexate, ciclosporin and macrolactame<br />
antibiotics [1,4,16] as well as photochemotherapy regimens<br />
(PUVA) [17]. A gross range of effects on different cells apart from<br />
those immunologically relevant can be found for corticosteroids<br />
[14,18-20]. The resulting distinct si<strong>de</strong> effects often restrict their<br />
short- and long-term use in certain patient groups. However, until<br />
today they are wi<strong>de</strong>ly used as first-line treatment for diverse<br />
inflammatory disor<strong>de</strong>rs due to their timely effects. This is in<br />
contrast to other immunomodulatory drugs which may need several<br />
days to weeks to be effective. Accordingly, for dose-sparing and<br />
minimizing long-term si<strong>de</strong> effects glucocorticosteroids are usually<br />
combined with other drugs which are referred to as adjuvant drugs<br />
and induce their effects by both immunosuppressive and nonimmunosuppressive<br />
action (see above). In cases of low disease<br />
activity or after tappering corticosteroids they may even be used as<br />
single drug. The classical immunosuppressive drug combined with<br />
corticosteroids is azathioprine [21,22] which is able to suppress<br />
lymphocyte activities by interfering with the DNA metabolism. The<br />
effects of methotrexate [23-25] at doses used in <strong>de</strong>rmatology are<br />
beyond cytotoxicity. Functional modulation of lymphocyte activity<br />
by modulation of IL-1ß, IL-6 and TNFα-receptor expression as<br />
well as modulation of chemotaxis, migration and adhesion of<br />
polymorphonuclear leukocytes seem to be main effects [25].<br />
Ciclosporin and macrolactame antibiotics like tacrolimus (FK506)<br />
and pimecrolimus represent drugs targeting distinct subsets of<br />
immunologically relevant cells [1-4]. They have been <strong>de</strong>veloped<br />
and extensively used in transplantation medicine before being<br />
introduced into <strong>de</strong>rmatology for immunologically mediated<br />
diseases. Their effects have been pin-pointed to intracytoplasmic<br />
specific binding proteins which are part of the signaling casca<strong>de</strong> to<br />
interfere with cytokine expression at the the DNA level. Despite<br />
these very specific mechanisms of action, distinct si<strong>de</strong>-effects on<br />
other cell systems and organs are seen and often restrict their<br />
clinical use. Though originally found within the group of<br />
macrolactame antibiotics, their immunological effects are beyond<br />
antibiosis. This highlightens possible effects on inflammatory and<br />
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Systemic therapy with immunomodulatory drugs in <strong>de</strong>rmatology 203<br />
immunological processes by other, classical antibiotics like<br />
penicilline, tetracyclines and minocycline which have been shown<br />
to modulate granulocyte and lymphocyte functions. Though their<br />
effectiveness in inflammatory processes is suggested by clinical<br />
experience, they have, however, been studied only to a limited<br />
extent.<br />
Another group of immunosuppressive drugs which before<br />
introduction into <strong>de</strong>rmatology have extensively been used in other<br />
specialities are represented by mycophenolate mofetil (MMF)<br />
[26,27] and leflunomi<strong>de</strong> [27-29]. Both interfere with DNA<br />
replication by antagonizing purin and pyrimidine metabolism<br />
respectively and thus modulate proliferation and functional activity<br />
of lymphocytes. MMF has already been successfully used in<br />
psoriasis vulgaris and autoimmune bullous skin diseases, especially<br />
bullous pemphigoid and pemphigus. Its comparability to established<br />
drugs in respect to efficacy is currently un<strong>de</strong>r evaluation in clinical<br />
studies. Both drugs do however represent alternatives in cases of<br />
poor response, contraindication or si<strong>de</strong>-effects of established<br />
treatment modalities.<br />
Immunomodulatory drugs without suppressive activity<br />
Within this group, both novel and well-established drugs are found<br />
and inclu<strong>de</strong> fumaric acid <strong>de</strong>rivatives, cytokines, intravenous<br />
immunoglobulins as well as the expanding group of<br />
immunobiologicals. Apart from monoclonal antibodies, fusion<br />
proteins, receptor proteins and pepti<strong>de</strong> fragments a number of<br />
agents are contained within this group which are still in<br />
experimental studies, do however indicate very interesting<br />
therapeutic perspectives. These drugs either induce effects<br />
indirectly by modulating the expression of certain cytokines or<br />
activation parameters. Alternatively, cytokines or proteinaceous<br />
mediators involved are directly applied as therapeutic agents<br />
themselves.<br />
Fumaric acid <strong>de</strong>rivatives have so far been only used for<br />
<strong>de</strong>rmatological diseases, mainly psoriasis [3,30,31]. Apart from<br />
inhibiting both lymphocyte proliferation and differentiation of<br />
<strong>de</strong>ndritic cells mainly through NF-KB <strong>de</strong>pen<strong>de</strong>nt processes,<br />
induction of apoptosis, a shift of TH1 responses characteristic for<br />
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204 Systemic therapy with immunomodulatory drugs in <strong>de</strong>rmatology<br />
psoriasis to TH2 responses could be <strong>de</strong>monstrated. These effects<br />
indicate the effectiveness of fumarates beyond psoriasis and will<br />
have to be <strong>de</strong>monstrated in the near future.<br />
Similarly, two compounds which have so far been used successfully<br />
in <strong>de</strong>rmatology for local application, may be available soon for<br />
systemic application. Vitamin D <strong>de</strong>rivatives [1,4] have been<br />
shown to modulate immunological parameters apart from<br />
keratinocye differentiation as does imiquimod [32] which induces<br />
different cytokines like interferons, IL-6, 8 and 10 when used<br />
locally. Systemic application of these compounds or <strong>de</strong>rivatives<br />
with less pronounced si<strong>de</strong>-effects beyond the indications studied so<br />
far in <strong>de</strong>rmatology may be expected very soon.<br />
Different cytokines have been studied clinically for their<br />
effectiveness in <strong>de</strong>rmatological diseases such as interferons and<br />
interleukins 2, 10 and 12 [1,2,16]. Their main action is regar<strong>de</strong>d as<br />
<strong>de</strong>viating immunological dysbalances in either direction, of<br />
<strong>de</strong>creased or increased immunological responsiveness [33].<br />
However, effectiveness has in many clinical studies been below that<br />
expected from earlier experimental data.<br />
Though intravenous immunoglobulins (IVIG) have successfully<br />
been used for diverse, pathoge<strong>net</strong>ically very heterogenous diseases<br />
they are at the same time licensed only for a limited number of<br />
diseases [34-36]. This is reflected by a wi<strong>de</strong> range of<br />
immunological and inflammatory effects which have been studied<br />
both in vitro and in vivo and are differentially involved within the<br />
different diseases. They inclu<strong>de</strong> specific and non-specific effects on<br />
both humoral and cellular parameters like binding and inhibiting<br />
cytokines, adhesion molecules and complement factors or<br />
modulating macrophage and lymphocyte functions. The low rate of<br />
si<strong>de</strong>-effects and good clinical effectiveness is counteracted by high<br />
costs and short-term effects. Currently, clinical use of IVIG is<br />
recommen<strong>de</strong>d only in combination with other immunomodulatory<br />
drugs [36].<br />
The polyclonal mixture of antibodies against diverse antigens as<br />
contained in IVIG is reduced to single and <strong>de</strong>fined antigens in<br />
preparations of monoclonal antibodies [37,38]. They are directed<br />
against proteinaceous structures which are involved in the<br />
pathogenesis of distinct diseases. Clinical experience shows that<br />
such antibody approaches is still not entirely successful either in<br />
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Systemic therapy with immunomodulatory drugs in <strong>de</strong>rmatology 205<br />
respect to total and long-standing clearance of disease or clearance<br />
in all patients. Possibly an “oligoclonal” mixture of <strong>de</strong>fined<br />
antibodies will in the future increase the effectiveness of such<br />
regimens. Antibody and mediator approaches have been combined<br />
in some fusion proteins (LFA3-TIP or etanercept) and will have to<br />
be further evaluated in clinical studies. Long-term consequences on<br />
the immune system regarding inci<strong>de</strong>nce of tumors as well as<br />
allergological and immunological diseases have to be closely<br />
monitored as therapeutic approaches are ma<strong>de</strong> in chronic or<br />
recidivating diseases which may necessitate repetitive or constant<br />
long-lasting application of these drugs.<br />
Dissection of immunological parameters from a complex,<br />
multifactorial system in an experimental setting <strong>de</strong>monstrated both<br />
their relevance or irrelevance as well as their primary or secondary<br />
involvement within the pathogenesis of individual diseases.<br />
Experimental concepts which focus on single or few parameters<br />
regar<strong>de</strong>d pathoge<strong>net</strong>ically relevant have been established in basic<br />
immunology. Transfered to clinical immunology, many of these<br />
approaches have been disappointing in the complex system of<br />
human diseases. Based on these concepts, however, oligofactorial<br />
approaches by targeting a limited set of <strong>de</strong>fined factors may in the<br />
future allow successful treatment of inflammatory diseases within<br />
<strong>de</strong>rmatology and beyond.<br />
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9 Kyriakis KP, Kontochristopoulos GJ, Panteleos DN (2000)<br />
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11 Warren KJ, Nopper AJ, Crosby DL (1998) Thalidomi<strong>de</strong> for<br />
recalcitrant discoid lesions in a patient<br />
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13 Glied M, Rico MJ (1999) Treatment of autoimmune blistering<br />
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14 Wozel G (1996) Dapson - Pharmakologie, Wirkmechanismus<br />
und klinischer Einsatz. Thieme Stuttgart, New York<br />
15 Becker L, Bastian B, Wesselmann U, Karl S, Hamm H, Bröcker<br />
EB (1998) Paraneoplastic pemphigus treated with<br />
<strong>de</strong>xamethasone/cyclophosphami<strong>de</strong> pulse therapy. Eur J<br />
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16 Fleischli ME, Rachel H, Valek BS, Pandya AG (1999) Pulse<br />
intravenous cyclophosphami<strong>de</strong> therapy in pemphigus. Arch<br />
Dermatol 135: 57-61<br />
17 Thoma-Uszynski S, Hertl M (2001) Novel therapeutic<br />
approaches in autoimmune skin disor<strong>de</strong>rs. In: Hertl M (ed)<br />
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18 Gasparro FP (2000) Photo<strong>de</strong>rmatology: progress, problems and<br />
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19 Werth VP (1993) Management and treatment with systemic<br />
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Vaillant L, D'Incan M, Plantin P, Bedane C, Young P, Bernard<br />
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comparison of oral and topical corticosteroids in patients with<br />
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22 Anstey A (1996) Management of immunobullous disor<strong>de</strong>rs: the<br />
clinical significance of interindividual variation in azathioprine<br />
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24 Jeffes EW 3 rd , McCullough JL, Pittelkow MR, McCormick A,<br />
Almanzor J, Liu G (1995) Methotrexate therapy of psoriasis:<br />
differential sensitivity of proliferating lymphoid and epithelial<br />
cells to the cytotoxic and growth –inhibitory effects of<br />
methotrexate. J Invest Dermatol 104: 184-188<br />
25 Bottomley WW, Goodfield MJ (1995) Methotrexate for the<br />
treatment of discoid lupus erythematosus. Br J Dermatol 133:<br />
655-656<br />
26 Cronstein BN (1996) Molecular therapeutics. Methotrexate and<br />
its mechanism of action. Arthritis Rheum 39: 1951-60<br />
27 Jayne D (1999) Non-transplant uses of mycophenolate mofetil.<br />
Curr Opin Nephrol Hypertens 8: 563-567<br />
28 Furst DE (1999) Leflunomi<strong>de</strong>, mycophenolic acid and matrix<br />
metalloproteinase inhibitors. Rheumatology (Oxford) 38: 14-18<br />
29 Kurtz ES, Bayley SC, Arshad F, Lee AA, Przekop PA (1995)<br />
Leflunomi<strong>de</strong>: an active antiinflammatory and antiproliferative<br />
agent in mo<strong>de</strong>ls of <strong>de</strong>rmatologic disease. Inflamm Res 44: 187-<br />
188<br />
30 Nousari HG, Anhalt GJ (2000) Bullous pemphigoid treated with<br />
leflunomi<strong>de</strong>. Arch Dermatol 136: 1204-1205<br />
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31 Altmeyer P, Matthes U,Pawlak F, Hoffmann K, Frosch PJ,<br />
Ruppert P (1994) Antipsoriatic effect of fumaric acid<br />
<strong>de</strong>rivatives. Results of a multicenter double-blind study in 100<br />
patients. J Am Acad Dermatol 30: 977-981<br />
32 Mrowietz U, Christophers E, Altmeyer P (1999) Treamtent of<br />
severe psoriasis with fumaric acid esters: scientific background<br />
and gui<strong>de</strong>lines for therapeutic use. Br J Dermatol 141: 424-429<br />
33 Sau<strong>de</strong>r DN (2000) Immunomodulatory and pharmacologic<br />
properties of imiquimod. J Am Acad Dermatol 43: S6-11<br />
34 Thivolet J, Nicolas JF, Kanitakis J, Lyon<strong>net</strong> S, Chouvet B<br />
(1990) Recombinant interferon alpha 2a is effective in the<br />
treatment of discoid and subacute cutaneous lupus<br />
erythematosus. Br J Dermatol 122: 405-409<br />
35 De Vita S, Ferraccioli GF, Di Poi E, Bartoli E, Bombardieri S<br />
(1996) High dose intravenous immunglobulin therapy for<br />
rheumatic diseases: clinical relevance and personal experience.<br />
Clin Exp Rheumatol 14: S85-92<br />
36 Jolles S, Hughes J, Whittaker S (1998) Dermatological uses of<br />
high-dose intravenous immunglobulin. Arch Dermatol 134: 80-<br />
86<br />
37 Sacher RA (2001) Intravenous immunoglobulin consensus<br />
statement. J Allergy Clin Immunol 108: 139-146<br />
38 Gelfand EW (2001) Antibody-directed therapy: Past, present and<br />
future. J Allergy Clin Immunol 108: 111-116<br />
39 Isaacs JD (2001) From bench to bedsi<strong>de</strong>: discovering rules for<br />
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In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
Systemic Therapy with Recombinant Antibodies in Dermatology 209<br />
Systemic Therapy with Recombinant Antibodies<br />
in Dermatology<br />
M. Lüftl<br />
Department of Dermatology<br />
University Hospital of Erlangen<br />
Hartmannstr. 14,<br />
D-91052 Erlangen<br />
Germany<br />
Introduction................................................................. 209<br />
Recombinant antibodies – “tailor-ma<strong>de</strong>” therapeutics211<br />
Treatment of skin diseases with monoclonal antibodies<br />
- clinical studies .......................................................... 213<br />
Inflammatory skin diseases......................................... 213<br />
Neoplastic skin diseases ............................................. 214<br />
Limitations .................................................................. 215<br />
Outlook ....................................................................... 215<br />
References................................................................... 216<br />
Introduction<br />
In contrast to high-dose intravenous immunoglobulin therapy (a<br />
mixture of polyclonal antibodies) that unspecifically blocks the<br />
immune system, treatment with recombinant monoclonal antibodies<br />
leads to a selected <strong>de</strong>letion or inhibition of single targets.<br />
Antibodies, e.g. immunoglobulins mediate the humoral arm of<br />
specific immune responses. The primary functions of antibodies are<br />
to bind specifically to antigen and bring about the inactivation or<br />
removal of the offending protein, toxin, microbe or cell. All<br />
immunoglobulins have the basic structure of two heavy and two<br />
light chains structurally divi<strong>de</strong>d into domains (Fig. 1). Lytic<br />
antibodies mediate their effector functions after binding to the<br />
specific antigen via the Fab fragments by recruiting FcR-positive<br />
cells and/or complement components in turn to remove and/or<br />
<strong>de</strong>stroy the target through opsonization, anitibody <strong>de</strong>pen<strong>de</strong>nt<br />
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210 Systemic Therapy with Recombinant Antibodies in Dermatology<br />
cellular cytotoxicity (ADCC), or complement-mediated<br />
cytotoxicity. Non-lytic antibodies act by blocking the function of<br />
the target.<br />
Fv<br />
Fab<br />
Fc<br />
Fig. 1: Structure of an Immunoglobulin: Each immunoglobulin is<br />
structurally divi<strong>de</strong>d into domains of variable (VL, VH) or constant<br />
(CL, CH1-3) regions. The Fab region comprises VL/CL and<br />
VH/CH1, the Fc terminus comprises CH2/CH3. The actual antigenbinding<br />
site is formed by hypervariable loops (complementarity<strong>de</strong>termining<br />
regions, CDR) in the Fv part (VH and VL)<br />
Attempts to an antibody therapy date back to the early 1900s in<br />
patients with cancer, but progress was stalled until discovery in<br />
1975 of a way to produce mouse monoclonal antibodies in vitro by<br />
hybridoma technology (14). These early attempts drew attention to<br />
the potential benefits and limitations of mouse anti-human<br />
monoclonal antibody therapy. Early trials with these antibodies in<br />
patients with cancer, however, found only short lived responses.<br />
Major reasons for the therapeutic failure were shortened circulating<br />
half-life, limited <strong>de</strong>livery to or pe<strong>net</strong>ration into tumor sites,<br />
ina<strong>de</strong>quate recruitment of host leukocyte bearing constant region<br />
receptors (Fc) and, most important, production of neutralizing antimouse<br />
antibodies in treated patients.<br />
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Systemic Therapy with Recombinant Antibodies in Dermatology 211<br />
Recombinant antibodies – “tailor-ma<strong>de</strong>” therapeutics<br />
During the past two <strong>de</strong>ca<strong>de</strong>s, there has been progress in overcoming<br />
many of the above mentioned obstacles due to advances in<br />
molecular and protein biology techniques (Table 1).<br />
• Reduction of the immunogenicity so that antibody therapy can be<br />
used over exten<strong>de</strong>d periods<br />
• Addition of extrinsic effector functions or modification of intrinsic<br />
functions<br />
• Increase of antibody specificity, affinity and avidity<br />
• Increase of half-life<br />
• Generation of novel specificities, using phage antibody technology<br />
• Production of stable recombinant antibodies at high levels in a costeffective<br />
manner<br />
Tab. 1: Advantages of recombinant antibodies<br />
Ge<strong>net</strong>ic engineering offers the possibility to create “<strong>de</strong>signer”<br />
therapeutics, since each antibody domain is enco<strong>de</strong>d by different<br />
exons, and recombinant antibodies can be built by ge<strong>net</strong>ically<br />
fusing the <strong>de</strong>sired exons together. Introducing nucleoti<strong>de</strong> sequences<br />
of human immunoglobulin genes into the genes encoding mouse<br />
monoclonal antibodies results in “humanized” chimeric monoclonal<br />
antibodies containing human Fc region sequences, and antigenbinding<br />
region consisting of frameworks <strong>de</strong>rived from mouse<br />
sequences (17). Since even humanized chimeric monoclonal<br />
antibodies often provoke antibodies that nullify the therapeutic<br />
benefit of engineered immunoglobulins, a way of making fully<br />
human antibodies has been sought and were found in recombinant<br />
DNA technology using bacteriophages containing a library for a<br />
vast number of variable regions (Fv) with high affinity for virtually<br />
any <strong>de</strong>sired antigen. The modular arrangement of antibody domains<br />
(VH and VL bind antigen, while the Fc domains mediate effector<br />
functions) has allowed for a “mix and match” approach to <strong>de</strong>signing<br />
antibody-based therapeutics (Table 2). Thus, functional domains<br />
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212 Systemic Therapy with Recombinant Antibodies in Dermatology<br />
providing specific antigen-binding or effector functions can be<br />
exchanged between antibodies, expressed as separate units with<br />
biological activity (antibody fragments) or used as building blocks<br />
to construct novel fusion proteins (combination of an Ig with a<br />
toxin, a radionucli<strong>de</strong> or an effector protein) and bispecific<br />
antibodies (one arm of the Fab part binds the target, the other Fab<br />
arm binds the effector cell).<br />
Type Description and selected example<br />
Ro<strong>de</strong>nt monclonal Ab<br />
Chimeric<br />
“humanized” Ab<br />
Fully “humanized”<br />
Ab<br />
Ab fragments<br />
Fusion Proteins<br />
Bispecific Ab<br />
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Ig produced by ro<strong>de</strong>nt B-cells<br />
Not in clinical use any more<br />
Framework of the Ig human; variable<br />
region in part ro<strong>de</strong>nt<br />
Infliximab (anti-TNF-α) (4)<br />
Ge<strong>net</strong>ically engineered “human” Ig<br />
D2E7 (anti-TNF-α) (12)<br />
Neutralizing Ab fragments<br />
CDP870 (Fab anti-TNF-α)<br />
clinical trial, not yet published<br />
Combination of an Ig with a toxin, a<br />
radionucli<strong>de</strong> or an effector protein<br />
Etanercept (16)<br />
One arm of the Fab part binds the<br />
target, the other arm binds the effector<br />
cell.<br />
MDX-H210 (anti-HER2 x CD64) (11)<br />
Tab. 2: Antibody types and examples in clinical usage.
Systemic Therapy with Recombinant Antibodies in Dermatology 213<br />
Treatment of skin diseases with monoclonal antibodies -<br />
clinical studies<br />
It was not the intention of the author to review the numerous<br />
clinical studies that have been performed with antibodies. Here are<br />
given examples that emphasize certain themes only.<br />
Inflammatory skin diseases<br />
Most data concerning systemic antibody therapy in <strong>de</strong>rmatology are<br />
gained in psoriasis and psoriatic arthritis. Although no autoantigen<br />
has yet been <strong>de</strong>fined in psoriasis, there is probably enough<br />
circumstantial evi<strong>de</strong>nce to categorise this disease as autoimmune in<br />
nature, and there is direct evi<strong>de</strong>nce of the involvement of T cells.<br />
Systemic antibody treatment approaches in psoriasis may be<br />
divi<strong>de</strong>d as either T cell targeting or cytokine modulating (Table 3).<br />
Most convincing in the treatment of severe psoriasis and proven by<br />
randomized placebo controlled double blind multicenter studies is<br />
blocka<strong>de</strong> of the proinflammatory cytokine TNF-α with an<br />
impressive ability to substantially improve skin manifestation<br />
(including pustular lesions) and arthritis (4, 16, 18, 27).<br />
T cell targeting<br />
Cytokine modulating<br />
OKTcdr4a (anti CD4) (8) Infliximab (anti-TNF-α) (4)<br />
Efaluzimab (hu1124, anti CD11a) (7, 20)<br />
Daclizumab (anti CD25) (15)<br />
Alefacept (LFA-3/IgG1 fusion protein) (6)<br />
CTLA-4-Ig fusion protein (1)<br />
Etanercept (TNF-receptor fused<br />
with the Fc domain of human<br />
IgG1) (16)<br />
Tab. 3: Clinical studies using monoclonal antibodies in the<br />
treatment of psoriasis<br />
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214 Systemic Therapy with Recombinant Antibodies in Dermatology<br />
Several other inflammatory, immune-mediated skin diseases have<br />
been shown to be receptive to antibody therapy including GvHD,<br />
vasculitis and Behcet’s disease (3, 22, 25) as well as autoimmune<br />
bullous disease (5). Case reports for CD4 Ab, CD40-ligand Ab,<br />
CTLA-4-Ig, complement-5 Ab (23, 26) indicated benefit in the<br />
treatment of systemic lupus erythematosus.<br />
An intriguing new treatment approach of allergic disor<strong>de</strong>rs twentyfive<br />
years after the discovery of immunoglobulin E offers a<br />
humanized, non-anaphylactogenic antibody against IgE. RhuMAb-<br />
E25 (omalizumab) is a novel anti-IgE antibody that is directed<br />
against the receptor-binding domain of IgE. This binding is specific<br />
towards free IgE thereby preventing it from attaching to the mast<br />
cell and its subsequent activation. Initial studies <strong>de</strong>monstrated<br />
attenuation of the early and late asthmatic responses when anti-IgE<br />
was administered to asthmatic subjects (2).<br />
Neoplastic skin diseases<br />
Progress in the treatment of cancer with antibody based therapies<br />
has been slower than for their application in immunosuppression.<br />
One reason is that immune reactivity against tumor cells requires<br />
more than blocking of receptor function, as the primary goal is cell<br />
<strong>de</strong>ath.<br />
Clinical trials have been performed using monoclonal antibodies to<br />
treat patients with cutaneous lymphomas. Two antibodies<br />
recognizing lymphocyte differentiation antigens have gained much<br />
attention in the recent years. One is the anti CD20 antibody<br />
rituximab which induced partial remission in patients with<br />
otherwise uncontrollable cutaneous B-cell lymphomas (9, 10).<br />
CD20 expression is usually retained in more than 90% of B-cell<br />
non-Hodgkin lymphoma, including cutaneous B-cell lymphoma.<br />
The other is CAMPATH-1H (anti CD52) which has been rarely<br />
used for B-cell lymphomas but more frequent in advanced T-cell<br />
lymphomas (19).<br />
In patients with advanced squamous cell carcinoma of the head and<br />
neck efficacy of a chimeric anti-epi<strong>de</strong>rmal growth factor receptor<br />
monoclonal antibody, cetuximab, in combination with radiation<br />
therapy has been reported (21) and some therapeutic and<br />
immunologic benefit following R(24) anti-GD3 monoclonal<br />
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Systemic Therapy with Recombinant Antibodies in Dermatology 215<br />
antibody therapy was achieved in 37 patients with metastatic<br />
melanoma (13).<br />
Limitations<br />
Recombinant, humanized monoclonal antibody therapy can be<br />
regar<strong>de</strong>d as safe resulting in only minor toxicity. However,<br />
anaphyllaxis, or other hypersensitivity type symptoms may require<br />
treatment break off. Since chimeric antibodies may induce<br />
neutralizing host antibodies, tachyphyllaxis has to be consi<strong>de</strong>red.<br />
Some antibodies with strong immunosuppressing properties like<br />
TNF blocking agents may induce exacerbation of infections.<br />
Special attention has to be <strong>de</strong>voted to intracellular bacteria<br />
(tuberculosis, listeriosis) or fungal infections. CAMPATH-1H<br />
induced rapid <strong>de</strong>pletion of both B cells and T cells, resulting in an<br />
even more profound immunosuppression. Interestingly, patients<br />
with actinic skin damage <strong>de</strong>veloped invasive squamous cell<br />
carcinomas shortly after initiation of anti-TNF therapy (24),<br />
although clinical trials preceding approval by the Food and Drug<br />
Administration did not show any increase in the inci<strong>de</strong>nce of<br />
malignancies.<br />
Outlook<br />
More than 25 years after the revolutionary <strong>de</strong>scription of<br />
monoclonal antibody production via hybridoma technology,<br />
monoclonal antibodies have fully entered the clinical arena as new,<br />
unique, and important components of the medical armamentarium<br />
for the treatment of a variety of diseases. In fact, some of these<br />
antibodies can be regar<strong>de</strong>d as major breakthroughs in the treatment<br />
of such disor<strong>de</strong>rs as psoriasis/psoriatic arthritis and non-Hodgkin<br />
lymphoma. It is virtually certain that this initial set of agents is but<br />
the first wave of what will become a broad array of therapeutics.<br />
Continuous improvement of the antibody <strong>de</strong>sign or creation of<br />
small-molecule mimetics (for example single chain Fv fragments)<br />
with similar activity will soon permit even better clinical results.<br />
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216 Systemic Therapy with Recombinant Antibodies in Dermatology<br />
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12 Kempeni J (2000). Update on D2E7: a fully human anti-tumour<br />
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14 Kohler G, Milstein C (1975). Continuous cultures of fused cells<br />
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15 Krueger JG, Walters IB, Miyazawa M, Gilleau<strong>de</strong>au P, Hakimi J,<br />
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16 Mease PJ, Goffe BS, Metz J, Van<strong>de</strong>rStoep A, Finck B, Burge DJ<br />
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18 Ogilvie ALJ, Antoni Ch, Dechant C, Manger B, Kal<strong>de</strong>n JR,<br />
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Dedrick RL, Kim SS, White M, Garovoy MR (2001). The<br />
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21 Robert F, Ezekiel MP, Spencer SA, Meredith RF, Bonner JA,<br />
Khazaeli MB, Saleh MN, Carey D, LoBuglio AF, Wheeler RH,<br />
Cooper MR, Waksal HW (2001). Phase I study of anti-epi<strong>de</strong>rmal<br />
growth factor receptor antibody cetuximab in<br />
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head and neck cancer. J Clin Oncol 19:3234-43<br />
22 Robertson LP, Hickling P (2001). Treatment of recalcitrant<br />
orogenital ulceration of Behcet's syndrome with infliximab.<br />
Rheumatology (Oxford) 40:473-4<br />
23 Schulze-Koops H, Lipsky PE (2000). Anti-CD4 monoclonal<br />
antibody therapy in human autoimmune diseases. Curr Dir<br />
Autoimmun 2:24-49<br />
24 Smith KJ, Skelton HG (2001). Rapid onset of cutaneous<br />
squamous cell carcinoma in patients with rheumatoid arthritis<br />
after starting tumor necrosis factor alpha receptor IgG1-Fc<br />
fusion complex therapy. J Am Acad Dermatol 45:953-6<br />
25 Specks U, Fervenza FC, McDonald TJ, Hogan MC (2001).<br />
Response of Wegener's granulomatosis to anti-CD20 chimeric<br />
monoclonal antibody therapy. Arthritis Rheum 44:2836-40<br />
26 Strand V (2001). Monoclonal antibodies and other biologic<br />
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In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
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27 Voigtlän<strong>de</strong>r C, Lüftl M, Schuler G, Hertl M (2001). Infliximab<br />
(anti-tumor necrosis factor α antibody), a novel, highly effective<br />
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In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
220 Current state and perspectives of immunomodulation of the allergic contact <strong>de</strong>rmatitis<br />
Current state and perspectives of<br />
immunomodulation of the allergic contact<br />
<strong>de</strong>rmatitis<br />
H.-D. Göring<br />
Hautklinik und Immunologisches Zentrum<br />
Kühnauer Str. 24<br />
D-06846 Dessau<br />
Germany<br />
Current state and perspectives of immunomodulation of<br />
the allergic contact <strong>de</strong>rmatitis ..................................... 220<br />
References................................................................... 224<br />
The immunomodulating therapy of the allergic contact <strong>de</strong>rmatitis<br />
inclu<strong>de</strong>s the conservative topical and systemic glucocorticosteroid<br />
application. Systemic immunosuppression, <strong>de</strong>sensitization and<br />
tolerance induction are only in the early stage of their introduction<br />
in clinical practice and are studied above all in animals<br />
experiments. Glucocorticoids influence - during concrete case of<br />
illness – the existing inflammatory process of allergic contact<br />
<strong>de</strong>rmatitis by their vasoconstrictoric, anti-inflammatory,<br />
cellmembran-stabilising and anti-proliverative effects. Because of<br />
their immunomodulating effects they slow down the further<br />
immunologically steered disease process (table 1). Potent effective<br />
topically applied glucocorticoids like clobetasol propionate inhibit<br />
the DNCB-contact <strong>de</strong>rmatitis on pigs, while the less potent<br />
flucocinolone acetoni<strong>de</strong> shows no effect [17]. Different<br />
glucocorticoids have different points of attack. Hydrocortisone<br />
leads, after the stimulation of antigen in vitro, to a reduced<br />
expression of MHC class II molecules and of the costimulatory<br />
molecules B 7.1 and B 7.2 as well as of the Langerhans cell (LC)specific<br />
CD 83 and to IL-12 secretion inhibition and reduced T cell<br />
proliferation [3]. Beta-methasone valerate un<strong>de</strong>r comparable<br />
experimental conditions supports the expression of MHC class II<br />
molecules and costimulatory molecules B 7.1 and B 7.2 as well as<br />
IL-2R (CD25) on the LC, but disturbs their allostimulatory activity<br />
and inhibits the <strong>de</strong>ndritic cell (DC)-40- as well as the MHC class I<br />
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Current state and perspectives of immunomodulation of the allergic contact <strong>de</strong>rmatitis 221<br />
molecule-expression [19]. The responsible contact allergen should<br />
be i<strong>de</strong>ntified by epicutaneous testing and if possible should be<br />
avoi<strong>de</strong>d (allergen avoidance). A <strong>de</strong>sensitization (hyposensitization)<br />
might be consi<strong>de</strong>red if the avoidance of the contact allergen is<br />
impossible. Experiments of <strong>de</strong>sensitization have a long history. In<br />
1946 Chase [5] achieved a temporary gradual subsiding of DNCBcontact<br />
<strong>de</strong>rmatitis if DNCB was fed to appropriately sensitized<br />
guinea pigs. In 1968 Polak and Turk [20] only succee<strong>de</strong>d in this in<br />
animal experiments about chromate allergy after feeding subletal<br />
doses of chromate. Among patients with nickel contact allergy a<br />
<strong>de</strong>sensitization with 5 mg nickel sulfate once a week for a period of<br />
7 weeks led to a reduction of the number of circulating<br />
lymphocytes, which reacted against nickel. Skin tests and the<br />
clinical appearance remained unchanged [2].<br />
Among guinea pigs with a contact allergy against urushiol (poison<br />
oak/ivy) only a combination of oral and epicutaneous allergen<br />
application led to <strong>de</strong>sensitization. Un<strong>de</strong>r exclusive oral application<br />
the <strong>de</strong>sensitization was incomplete and un<strong>de</strong>r exclusive<br />
epicutaneous application fully failed [16]. Parthenium<br />
hysterophorus is the most common reason for airborne contact<br />
<strong>de</strong>rmatitis in northern India. Oral application led in 70% of the<br />
patients to a clinical improvement, in 30% it led to an exacerbation<br />
[13]. Belvisto [4] comes to the conclusion that according to current<br />
state of knowledge <strong>de</strong>sensitization is no alternative to conventional<br />
therapy of allergic contact <strong>de</strong>rmatitis. In animal experiments it is<br />
possible to achieve tolerance to nickel by oral application before<br />
percutaneous sensitization with nickel compounds [25]. A long time<br />
tolerance however requires a continuous oral or intraperitoneal<br />
NiCl(2)-application. By spleen- and lymph no<strong>de</strong> cells of orally<br />
tolerized donors tolerance is transferable. The donors showed no<br />
increased IL-2 production. A persisting suppressor cell activity is<br />
assumed [1]. These findings support the clinical observation that the<br />
oral intake of nickel from tooth braces among children could have<br />
led to a lower sensitization rate against nickel by later earpiercing<br />
than for juveniles who did not have any tooth brace treatment [15].<br />
Cyclosporin A causes an inhibition of the transcription of IL-2, IL-<br />
3, IL-4 and other pro-inflammatory cytokines that lead to a<br />
retardation of the auto- and parakrine stimulation of T-lymphocytes<br />
and macrophages [6]. Besi<strong>de</strong>s it also leads to an inhibition of the<br />
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222 Current state and perspectives of immunomodulation of the allergic contact <strong>de</strong>rmatitis<br />
Fas ligands mediated Keratinocyte (KC)-apoptosis. This apoptosis<br />
is caused in the allergic contact <strong>de</strong>rmatitis by IFN-gamma from<br />
activated T-cells. IFN-gamma supports the expression of Fas<br />
ligands on the KC-surface and makes them sensitive for apoptosis.<br />
The same effect on the suppression of apoptosis - in animal<br />
experiments - have intravenous injected immunoglobulines (IVIG)<br />
as well as <strong>de</strong>xamethasone and the macroli<strong>de</strong>s rapamycin and<br />
tacrolimus, the later by the systemic and topical application [24].<br />
Un<strong>de</strong>r systemic application cyclosporin A and tacrolimus suppress<br />
the early mastcell-<strong>de</strong>pen<strong>de</strong>nt and late inflammatory phase of the Tcell<br />
mediated contact sensitization. However the topical application<br />
of cyclosporin has no effect, while tacrolimus suppresses the early<br />
phase more clearly than the late phase [10]. Tacrolimus suppresses<br />
the allergic contact <strong>de</strong>rmatitis in animal experiments and for human<br />
beings. Applicated in form of oinments on the skin, the expression<br />
of IL-2R, B 7.1, CD40 and MHC class II and I molecules is<br />
suppressed, not however of B 7.2. Only freshly from the skin<br />
isolated LC exprime the FK 506 (tacrolimus) binding protein<br />
(FKBP) [10]. During the LC maturing process in the lymph no<strong>de</strong> it<br />
is lost. Un<strong>de</strong>r topical application tacrolimus suppresses the<br />
stimulating function 100 times more than beta-methasone valerate<br />
[19]. In different clinical studies tacrolimus has proven its efficacy<br />
against the allergic contact <strong>de</strong>rmatitis of human beings [18].<br />
A new immunosuppressive agent is the macrolid ascomycin. The<br />
ascomycin macrolactam <strong>de</strong>rivative SDZ ASM 981 suppresses in<br />
vitro the proliferation of T cells after antigen stimulation, regulates<br />
the Th1-cytokine production (IL-2,IFN-gamma) and the Th2cytokine<br />
production (IL-4, IL-10) down after antigen stimulation<br />
and suppresses the liberation of pre-modulated anti-inflammatory<br />
mediators out of mast cells [12]. ABT-281, a macrolactam<br />
ascomycin analogon inhibits likewise the synthesis of cytokines of<br />
Th1 and Th2 cells and suppresses un<strong>de</strong>r topical application as a 0,3<br />
and 1 per cent solution in aceton and olive oil the DNCB-induced<br />
allergic contact <strong>de</strong>rmatitis on the pig up to 90% in comparison to<br />
50% un<strong>de</strong>r topical application of the potent glucocorticoid<br />
clobetasol propionate [17]. Besi<strong>de</strong>s contact allergenes UVB-light<br />
also induces activated KC to IL-10 production [22]. This probably<br />
explains why it comes to an antigen specific tolerance instead of a<br />
contact sensitization in animal experiments after applying a strong<br />
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Current state and perspectives of immunomodulation of the allergic contact <strong>de</strong>rmatitis 223<br />
contact sensitizating substance onto a skin area which was only<br />
shortly before irradiated with UVB. IL-10 also inhibits the IFNgamma-mediated<br />
macrophage activation and the IL-12 production<br />
by macrophages. This suppresses the type IV reaction [22].<br />
IL-10 inhibits the expression of the costimulatory molecules B 7.1<br />
and B 7.2 on LC. Is the costimulatory signal missing, it does not<br />
come to a clonal activation but to clonal inactivation of the T cells<br />
the so-called clonal anergy. Besi<strong>de</strong>s it comes to a check of IL-12<br />
production and to reduced T cell proliferation. IL-10 contribution<br />
before antigen stimulation leads to an inhibition of the Th1- and<br />
Th2-cytokine production [3]. Because of that LC lose their ability<br />
to stimulate Th1 cells. In the end the cytokine pattern of the<br />
epi<strong>de</strong>rmis is changed in such a way that pro-inflammatory<br />
regulation circuits are interrupted and a sensitization can no longer<br />
take place. Therefore IL-10 changes potent immunostimulating LC<br />
into tolerance introducing LC [22]. Epi<strong>de</strong>rmal nerves can be found<br />
in anatomical connection to LC. They contain the neuropepti<strong>de</strong><br />
calcitonin gene-related pepti<strong>de</strong> (CGRP). The local application of<br />
CGRP leads to an mo<strong>de</strong>ration of the contact sensitization. CGRP<br />
inhibits the expression of the costimulatory molecule B 7.2 on LC<br />
[23]. The antigen presenting function of the LC is regulated down<br />
by CGRP. UV-irradiation leads to a reduction of the LC-<strong>de</strong>nsity in<br />
the epi<strong>de</strong>rmis. Beyond this UV-irradiation leads to a CGRP<br />
liberation out of sensoric neurons and supports together with NO<br />
the local immunosuppression. The CGRP content of the epi<strong>de</strong>rmis<br />
<strong>de</strong>creases about 2 hours after the irradiation (UV-dosis 0,5-2,0<br />
J/cm²) and reaches its minimum 6-12 hours later [11]. A further,<br />
however not yet applied possibility to check the allergic contact<br />
<strong>de</strong>rmatitis is represented in the neuropepti<strong>de</strong> vasoactive intestinal<br />
pepti<strong>de</strong> (VIP) and the structural related pituitary a<strong>de</strong>nylate cyclase<br />
activating polypepti<strong>de</strong> (PACAP). They inhibits the expression of<br />
the costimulating molecules B 7.1 and B 7.2, the TNF-alpha, IL-12<br />
and IL-10 production [9]. The biochemical produced<br />
intramembraneous amino-acid sequence of the T-cell receptor chain<br />
(TCR mimic pepti<strong>de</strong>s) inhibits the interaction between Tlymphocytes<br />
and LC. In vitro it comes to the suppression of CD4+<br />
and CD8+ cell-proliferation. TCR-mimic pepti<strong>de</strong>s block, un<strong>de</strong>r<br />
topical application, the ear swelling in mice as an expression of the<br />
failing contactallergic reaction, if chronologically applicated before<br />
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224 Current state and perspectives of immunomodulation of the allergic contact <strong>de</strong>rmatitis<br />
the contact allergen. TCR-mimic pepti<strong>de</strong>s neutralize the T cell<br />
mediated immunoreaction [8].<br />
Further immunological possibilities exist to intervene in a highly<br />
specific way in the induction phase of the type IV reaction. Thus,<br />
the activity of IL-1 beta can be neutralized by monoclonal<br />
antibodies and hence the further course of the sensitization is<br />
prevented [7]. Antibodies against IL-1 and TNF-alpha inhibits their<br />
production and liberation in the skin, whereby a sensitization<br />
against haptene is impe<strong>de</strong>d or prevented [14].<br />
Natural IL-1R-antagonists bind on the IL-1R (receptor block) by<br />
which the receptor released signal and hence the forming of<br />
cytokine is prevented. The use of receptor antagonists is equally<br />
imaginable than this of soluble receptor molecules, which intercept<br />
the cytokine before it binds to the receptor. Here already exists a<br />
prototype of the soluble TNF-alpha-receptor. In vitro-mo<strong>de</strong>ls of<br />
specific cytokine-antagonists, transgene experimental animals,<br />
which exprime certain cytokines and others, whose certain<br />
cytokines are switched off (“gene-knock-out”-technology), already<br />
exist [21]. It is interesting that IVIG contains a series of factors<br />
which can interfere in the antigen presentation and the sensitization<br />
process as well as the release phase of type IV reaction: CD4- and<br />
MHC class II molecules, antibodies against TCR, IL-1 as well as<br />
TNF-alpha and MHC class II molecules, IL-1R-antagonists, soluble<br />
TNF-alpha receptors. IVIG can regulate pro-inflammatory<br />
cytokines down and check the Fas ligands mediated apoptosis [26].<br />
References<br />
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Tolerance to nickel: oral nickel administration induces a high<br />
frequency of anergic T cells with persistent suppressor activity.<br />
Immunol 167: 6794-6803<br />
2 Bagot M, Terki N, Bacha S, Moyse D, Suck C, Revuz J (1999)<br />
Per os <strong>de</strong>sensitization in nickel contact eczema: a double-blind<br />
placebo-controlled clinico-biological study. Ann Dermatol<br />
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3 Bellinghausen I, Brand U, Steinbrink K, Enk AH, Knop J,<br />
Saloga J (2001) Inhibition of human allergic T-cell responses by<br />
IL-10-treated <strong>de</strong>ndritic cells: differences from hydrocortiso<strong>net</strong>reated<br />
<strong>de</strong>ndritic cells. Allergy Clin Immunol 108: 242-249<br />
4 Belsito DV (2000) The diagnostic evaluation, treatment, and<br />
prevention of allergic contact <strong>de</strong>rmatitis in the new millennium.<br />
Allergy Clin Immunol 105: 409-420<br />
5 Chase MW (1946) Inhibition of experimental drug allergy by<br />
prior feeding of the sensitizing agent. Proc Soc Exp Biol Med<br />
61: 257-259<br />
6 Diasio RB, Lo Buglio, AF: Immunmodulators:<br />
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JG, bid,LE, Molinoff, PB, Ruddori RW, Goodman Gilman A<br />
(eds.) Goodman & Gilman’s The pharmacological basis of<br />
therapeutics. edn 9. New York Mc Grawhil1996, p. 1291-1308<br />
7 Enk AH, Katz SI (1992) Early molecular events in the induction<br />
phase of contact sensitivity. Proc Nat Acad Sci 89: 1398-1402<br />
8 Enk AH, Knop J (2000) T cell receptor mimic pepti<strong>de</strong>s and their<br />
potential application in T-cell-mediated disease. Int Arch<br />
Allergy Immunol 123: 275-281<br />
9 Ganea D, Delgado M (2001) Neuropepti<strong>de</strong>s as modulators of<br />
macrophage functions. regulation of cytokine production and<br />
antigen presentation by VIP and PACAP. Arch Immunol et<br />
Therapiae Exp 49: 101-110<br />
10 Geba GP, Ptak W, Askenase PW (2001) Topical tacrolimus and<br />
cyclosporin A differentially inhibit early and late effector phases<br />
of cutaneous <strong>de</strong>layed-type and immunoglobulin E<br />
hypersensitivity. Immunology 104: 235-242<br />
11 Gillardon F, Moll I, Michel S, Benrath J, Weihe E, Zimmermann<br />
M (1995) Calcitonin gene-related pepti<strong>de</strong> an nitric oxi<strong>de</strong> are<br />
involved in ultraviolet radiation-induced immunosuppression.<br />
Eur J Pharmacol 293: 395-400<br />
12 Grassberger M, Baumruker T, Enz A, Hiestand P, Hultsch T,<br />
Kalthoff F, Schuler W, Schulz M, Werner FJ, Winiski A, Wolff<br />
B, Zenke G (1999) A novel anti-inflammatory drug, SDZ ASM<br />
981, for the treatment of skin disease: in vitro pharmacology. Br<br />
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13 Handa S, Sahoo B, Sharma VK (2001) Oral hyposensitization in<br />
patients with contact <strong>de</strong>rmatitis from Parthenium hysterophorus.<br />
Contact Dermatitis 44: 279-182<br />
14 Hauser C (1992) Current topics in Immuno<strong>de</strong>rmatology.<br />
Seminars in Immunopathol 13: 263-454<br />
15 Hoogstraten IMW, An<strong>de</strong>rsen KE, von Blomberg BME et al.<br />
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16 Ikeda Y, Yasuno H, Sato A, Kawai K (1998) Oral and<br />
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guinea pigs sensitized by 2 methods of different sensitizing<br />
potency. Contact Dermatitis 39: 286-292<br />
17 Mollison KW, Fey TA, Gauvin DM, Kolano RM, Sheets MP,<br />
Smith ML, Pong M, Nikolaidis NM, Lane BC, Trevillyan JM,<br />
Cannon J, Marsh K, Carter GW, Or YS, Chen YW, Hsieh GC,<br />
Luly JR (1999) A macrolactam inhibitor of T helper type 1 and<br />
T helper type 2 cytokine biosynthesis for topical treatment of<br />
inflammatory skin diseases. J Invest Dermatol 112: 729-738<br />
18 Nasr IS (2000) Topical tacrolimus in <strong>de</strong>rmatology. Clin Exp<br />
Dermatol 25: 250-254<br />
19 Panhans-Gross A, Novak N, Kraft S, Bieber T (2001) Human<br />
epi<strong>de</strong>rmal Langerhans‘ cells are targets for the<br />
immunosuppressive macroli<strong>de</strong> tacrolimus (FK506). J Allergy<br />
Clin Immunol 107: 345-352<br />
20 Polak L, Turk JL (1968) Studies on the effect of systemic<br />
administration of sensitizers in guinea pigs with contact<br />
sensitivity to inorganic metal compounds. I. The induction of<br />
immunological unresponsiveness in already sensitized animals.<br />
Clin Exp Immunol 3: 245-251<br />
21 Romani N ( 1998) Zytokine. In: Fritsch P: Dermatologie und<br />
Venerologie. Lehrbuch und Atlas. Springer, Berlin Hei<strong>de</strong>lberg,<br />
S 58-70<br />
22 Schuler G (1998) Grundlagen <strong>de</strong>r Immunologie und<br />
Allergologie. In: Fritsch P: Dermatologie und Venerologie.<br />
Lehrbuch und Atlas. Springer, Berlin Hei<strong>de</strong>lberg, S 43-70<br />
23 Torii H, Hosoi J, Asahina A, Granstein RD (1997) Calcitonin<br />
gene-related pepti<strong>de</strong> and Langerhans cell function. J Investig.<br />
Dermatol Symp Proc 2: 82-86<br />
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24 Trautmann A, Akdis M, Schmid-Gren<strong>de</strong>lmeier P, Disch R,<br />
Brocker EB, Blaser K, Addis CA (2001) Targeting keratinocyte<br />
apoptosis in the treatment of atopic <strong>de</strong>rmatitis and allergic<br />
contact <strong>de</strong>rmatitis. J Allergy Clin Immunol 108: 839-846<br />
25 Van <strong>de</strong>r Burg CKH, Bruynzeel DP, Vreeburg KJJ et al. (1986)<br />
Hand eczema in hairdressers and nurses: a prospektive study.<br />
Contact Dermatitis 14: 275-279<br />
26 Wahn V.: Klinischer Einsatz von intravenösen<br />
Immunglobulinen. UNI-MED Verlag, Bremen, 2000, S 61-69<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
228 Therapy of Immediate Type Reactions<br />
Therapy of Immediate Type Reactions<br />
W.Ch. Marsch<br />
Universitätsklinik und Poliklinik für Dermatologie und Venerologie<br />
Martin-Luther-Universität Halle-Wittenberg<br />
Ernst-Kromayer-Str. 5-6<br />
D-06097 Halle (Saale)<br />
Germany<br />
Therapy of Immediate Type Reactions....................... 228<br />
References................................................................... 234<br />
An allergic immediate-type reaction (Type I, Gell and Coombs) is<br />
an acute inflammation in preexisting sensitization. It is usually<br />
elicited locally or regionally at the site of allergen contact by<br />
mediators of sessile, allergen-specific immunoglobulin E-bearing<br />
mast cells and the functions of secondary immigrating eosinophile<br />
granulocytes. This may result primarily or even secondarily in a<br />
systemic effect of released mediators up to and including shock<br />
symptoms of life-threatening character (anaphylaxis). The<br />
immediate-type reaction is essentially <strong>de</strong>termined initially by the<br />
dominating preformed and stored mast-cell mediator histamine<br />
via acute release by <strong>de</strong>granulation. The allergic pathomechanism is<br />
based on a coating established on the mast-cell surface by allergenspecific<br />
IgE-molecules, which elicit the signal to <strong>de</strong>granulation of<br />
the mast cells by bridging of two such molecules with a specific<br />
antigen, such as the birch pollen epitope. Mast cell <strong>de</strong>granulation<br />
and thus release of the preformed mediator histamine <strong>de</strong>termines<br />
the early phase of the Type-I allergic reaction, which begins<br />
seconds or at the latest 30 – 60 minutes after allergen contact. The<br />
visible reaction of the skin is characterized by a <strong>de</strong>rmis/coriume<strong>de</strong>ma<br />
(wheal), erythema (flare) and localized irritation (itch), that<br />
is, Urticaria. In addition to mast cells, the - in its nature similar -<br />
basophilic leukocytes in blood circulation are also involved. Mast<br />
cell <strong>de</strong>granulation leads to synthesis in the membrane of secondary<br />
mast cell mediators, such as tryptase, leukotrien C4, prostaglandin<br />
D2, serotonin, thromboxan A2, and particularly the platelet-<br />
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Therapy of Immediate Type Reactions 229<br />
activating factor (PAF) and the tumor-necrosis-factor-alpha. The<br />
former are essentially proinflammatory mediators with vascular<br />
activity, like especially the dilatation-eliciting serotonin. PAF and<br />
TNF-alpha act as chemo-attractors for eosinophilic granulocytes,<br />
which mature in bone marrow then enter the blood-vascular system<br />
and migrate to the site of mast cell <strong>de</strong>granulation at postcapillary<br />
venules into the area of acute inflammation. This secondary<br />
immigration of eosinophilic granulocytes <strong>de</strong>termines the late<br />
phase of the Type-I allergic reaction, which predominates about<br />
6 to 24 hours after specific antigen contact. The eosinophilic<br />
granulocyte contains preformed basic proteins (dominant: major<br />
basic protein, MBP) as well as eosinophilic cationic protein (ECP),<br />
further eosinophil-<strong>de</strong>rived neurotoxin (EDN), also enzymes like<br />
arylsulfatase for breakdown of leukotrien C4, and histaminase<br />
(breakdown of histamine), phospholipase (breakdown of PAF), also<br />
collagenase and myeloperoxidase, but no lysozyme. Essential is the<br />
realization that specific cytokines (such as Interleukin 3, Interleukin<br />
5, GM-CSF) lead to longer lifetime (persistence) of the eosinophilic<br />
granulocytes (normal: 2 – 3 days, here possibly up to 14 days),<br />
while on the other hand leading to activation of their effector<br />
functions by increasing the formation of oxygen radicals and lipid<br />
mediators secondarily formed on the cytomembranes. In inflamed<br />
tissue, longer-lived and functionally-active eosinophilic<br />
granulocytes are thus present. The type-1 late-phase is<br />
pathophysiologically characterized by erythematous swelling, in the<br />
nasal mucosa by blockage of nasal respiration (nasal congestion).<br />
Which such Type I-Allergy diseases are <strong>de</strong>rmatologically more or<br />
less relevant? These are diseases oriented to the target organs skin<br />
and mucosa and their occupation with mast cells: on the external<br />
skin (integument) within the upper layer of the <strong>de</strong>rmis (corium), the<br />
conjunctiva of the eyes, the mucosae of the nasopharynx, the<br />
oropharynx, the larynx, the bronchial epithelium and the<br />
subepithelial tunica propria of the gastrointestinal tract. Allergy<br />
refers to a state of existing sensitization or sensitizations to one or<br />
more allergens, while the condition “Allergy” and additionally<br />
clinical signs of inflammation form the basis for an allergic<br />
disease. Measured on the different target tissues and organs cited,<br />
the following relevant Type I allergic diseases are the central focus<br />
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230 Therapy of Immediate Type Reactions<br />
of our diagnostics (mostly allergen i<strong>de</strong>ntification) and multibased<br />
therapy mo<strong>de</strong>s (allergen withdrawal, antiallergic<br />
pharmacotherapeutics, hyposensitization):<br />
Allergic Rhinoconjunctivitis (seasonal: mostly pollen; perennial:<br />
mostly in-door allergens like dust mites and animal epithelia). The<br />
rhinitis can manifest as rhinorrhoe (“runners“), “sneezers“ or<br />
blocked nasal respiration (“blockers“). The <strong>de</strong>velopment of chronic<br />
sinusitis and/or bronchial asthma (“level change”) may be promoted<br />
by repetitive or persistent allergic inflammation (“allergic<br />
casca<strong>de</strong>“).<br />
Asthma bronchiale allergicum (usually elicited by animal<br />
epithelia, but also by occupational exposition to aeroallergens,<br />
seasonal also “concurrent asthma“ in pollen-related<br />
rhinoconjunctivitis),<br />
Urticaria, particularly the special form: Contact urticaria of the oral<br />
mucosa (“oral contact urticaria syndrome“ to kernal and stone fruits<br />
among patients allergic to birch pollen). Here, evi<strong>de</strong>nce that a<br />
urticaria can be elicited non-immunologically by non-Ig-Emediated<br />
mast cell <strong>de</strong>granulation is important (=pseudo-allergic<br />
reaction/intolerance reaction, e.g. to acetylsalicylic acid and other<br />
analgesics, food colorants, aromas, <strong>de</strong>xtrane). The illness category<br />
“Urticaria“ inclu<strong>de</strong>s a number of clinically different diseases (such<br />
as diverse physical forms of urticaria, including chronic-recurrent<br />
urticaria with a broad spectrum of eliciting, often even unknown<br />
causes). Frequently histamine is the dominant mediator, but some<br />
urticaria forms are not infrequently refractory to substances with<br />
only an antihistamine effect, and thus apparently characterized by a<br />
different spectrum of mediators.<br />
Immunological Food Intolerances (Food allergy) of the intestinal<br />
mucosa with the predominant symptoms of increased intestinal<br />
motility and diarrhea. Here, too, clinically i<strong>de</strong>ntical pseudoallergic<br />
mechanisms are frequent, due to food-<strong>de</strong>pen<strong>de</strong>nt histamine excess<br />
and intolerances.<br />
Hymenopter-toxin Allergy (wasps, bees), which is associated with<br />
a consi<strong>de</strong>rable risk of <strong>de</strong>ath, is important and there are<br />
exceptionally good therapeutic-preventive possibilities.<br />
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Therapy of Immediate Type Reactions 231<br />
The allergological therapy must first examine in connection with<br />
the history and possibly targeted allergen exposition<br />
(rhinomanometry, bronchial provocation test) which of the<br />
sensitizations <strong>de</strong>termined in the test procedures is currently acute<br />
for the patient (relevance testing), and can thus be consi<strong>de</strong>red the<br />
cause of the <strong>de</strong>fined allergic disease. This is the basis for attempts<br />
at allergen avoidance. Hyposensitization (Hymenopter toxins,<br />
pollen, dust mites, animal epithelia) is consi<strong>de</strong>red to be a<br />
therapeutic method with very <strong>de</strong>finite prophylactic effect.<br />
Pharmacotherapy with <strong>de</strong>fined antiallergic Substances focuses<br />
on the following therapeutic goals: 1. Mediator-receptor blocka<strong>de</strong><br />
for histamine and leukotriens, 2. “Mast cell stabilization“ (release<br />
of histamine becomes more difficult) and reduction of secondary<br />
<strong>de</strong>-novo-synthesis of lipid mediators, 3. Blocking the immigration<br />
of eosinophilic granulocytes (“Eosinophilic Migration“).<br />
1. Histamine-1-Receptor Antagonists: The first generation<br />
antihistamines had a low receptor selectivity, namely a broa<strong>de</strong>ned<br />
spectrum of receptor binding, and thus acted on muscariniccholinergic,<br />
alpha-adrenergic, serotoninergic and tryptaminergic<br />
receptors, and because they are lipophil and pass the blood-brain<br />
barrier, also had an effect on intracerebral H-1-receptors. The<br />
pharmacological advances in antihistamines of the second<br />
generation are due to improved receptor selectivity (minimization<br />
of si<strong>de</strong> effects, especially great reduction or lack of sedation), the<br />
receptor affinity (reduction of both dose and administration<br />
intervals) and hydrophilic character of the active substances<br />
(reduction of passage through the blood-brain barrier).<br />
Several examples of preparations of the 2 nd generation and their<br />
active metabolites (3 rd generation) with the main indications<br />
urticaria (acute and chronic-recurrent forms, some physical urticaria<br />
forms, such as sweat urticaria/cholinergic urticaria) and allergic<br />
rhinoconjunctivitis are given below:<br />
Fexofenadin (Telfast®): a further <strong>de</strong>velopment of Terfenadin<br />
(Teldane®) has no cardiotoxic risk (QT-prolongation, ventricular<br />
fibrillation in AV-block patients).<br />
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232 Therapy of Immediate Type Reactions<br />
Mizolastin (Zolim®): the substance has additional mast cellstabilizing<br />
and antiinflammatory/leukotrien antagonistic effects. It<br />
inhibits 5-lipooxygenase and reduces the afflux of eosinophilic<br />
granulocytes and thus the intensity of the late-phase reaction.<br />
Cetirizin (Zyrtec®,Alerid®): The substance is a mixture of<br />
stereoisomers (racemate), accumulates rapidly in tissues following<br />
oral administration (onset of action after 15-20 minutes) and has a<br />
special partial effect on eosinophilic granulocytes. Cetirizin<br />
apparently blocks their transmural cell passage at the selectin level<br />
of the endothelial adhesion molecule casca<strong>de</strong> and thus the<br />
eosinophil immigration into the inflammatory interstitial tissue. It<br />
also reduces the allergen-related ICAM-1 expression on epithelial<br />
cells of the rhinopharynx and thus the allergic inflammation<br />
casca<strong>de</strong>. The favorable prophylactic-preventive long-term action of<br />
reduction of secondary asthma <strong>de</strong>velopment by Cetirizin in atopic<br />
children may possibly be based on this (Early Treatment of the<br />
Atopic Child :ETAC Study).<br />
Levocetirizin (Xusal®) is a new <strong>de</strong>velopment which represents the<br />
active L-enantiomer of Cetirizin. The stereoisomeric mirror-image<br />
D-(<strong>de</strong>xtro)-enantiomer is, by contrast, not active. Levocetirizin is a<br />
very selective and long-acting antagonist of peripheral H1receptors,<br />
which is twice as potent as the Cetirizin racemate. It can<br />
be given in a lower daily dose (5 mg vs. 10 mg Cetirizin) and is still<br />
found to be more effective than its “pre<strong>de</strong>cessor“ with respect to<br />
clinical items like reduction of the wheal area.<br />
One very important advantage of both substances is their almost<br />
completely unchanged renal excretion and in any event their lack<br />
of hepatic metabolization via the Cytochrome-P-450-Isoenzyme<br />
system. This is why there is no medication interaction with danger<br />
of, for example, accumulation.<br />
Desloratadin (Aerius®), the active metabolite of the precursor<br />
preparation Loratadin(Lisino®), has an even greater affinity than<br />
the precursor for peripheral H1-receptors and increased selectivity,<br />
which is why sedation and anticholinergic effects are entirely<br />
missing. Neither substance is metabolized via the CYP3A4isoenzyme,<br />
but alternatively via the isoenzyme CYP2D6, it has<br />
(unlike the very potent antihistamine Ebastin/Ebastel®, for<br />
example) no risk of interaction with active substances like<br />
erythromycin and ketoconazol with the consequence of cardiac<br />
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Therapy of Immediate Type Reactions 233<br />
arrhythmias. Both also have a broad antiinflammatory effect.<br />
Desloratadin inhibits the release of inflammatory mediators from<br />
mast cells after stimulation of <strong>de</strong>granulation: except preformed<br />
histamine, tryptase, prostaglandin D2 and leukotrien C4, especially<br />
interleukines 3,6,8 and TNF-alpha.<br />
The following are cited as special cases:<br />
Levocabastin (Livocab®) and Azelastin (Allergodil®) are topically<br />
applicable as eyedrops and nasal spray, are fast-acting substances<br />
with very low resorption, and have thus very little systemic effect.<br />
Doxepin is a tricyclic anti<strong>de</strong>pressive with potent H-1-receptor<br />
affinity and is applicable for serious physical forms of urticaria, e.g.<br />
cold urticaria. A topical application form has recently become<br />
available (Xepin®-Creme).<br />
2. Leukotrien-Receptor Antagonist: Montelukast (Singulair®).<br />
This substance blocks cysteinyl-leukotriens, also reduces the<br />
immigration of eosinophilic granulocytes in a histamine-dominated<br />
inflammation area. The substance can be used in combination with<br />
potent H-1 receptor antagonists, probably has a special indication<br />
for non-allergic physical forms of urticaria, which usually have a<br />
different mediator spectrum than conventional urticarial, histaminedominated<br />
inflammatory reactions. Montelukast is especially<br />
suitable for inflammations with eosinophile-rich tissues thanks to its<br />
inhibition of eosinophile migration.<br />
As a substance with anti-inflammatory action, Montelukast is used<br />
these days in long-term combination therapy (beta-2sympathicomimetics,<br />
glucocorticoids) in Asthma bronchiale where<br />
it is replacing the less effective cromons (DNCG,Neocromil),<br />
which, like ketotifen (Zaditen®) stabilize mast cells.<br />
The pharmacological trend has thus brought forth a broad palette<br />
of active substances with the following specific pharmacodynamic<br />
properties for optimized therapy of clinically variable and targetorgan-specific<br />
allergic immediate-type reactions:<br />
1. very strong-binding and receptor-specific Histamine-1 receptorantagonists<br />
with only slight or even no sedative si<strong>de</strong> effects,<br />
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234 Therapy of Immediate Type Reactions<br />
2. their additional potency with respect to “mast cell stabilization”<br />
including in the sense of reduction of the secondary <strong>de</strong>-novosynthesis<br />
of inflammatory lipid mediators and inhibition of the<br />
secondary immigration of eosinophilic granulocytes with<br />
proinflammatory action,<br />
3. antagonists of other mediator receptors, for example with respect<br />
to leukotriens (Montelukast),<br />
4. rapid and effective action of topical H-1-receptor antagonists on<br />
the nasal mucosa and ocular conjunctiva,<br />
5. non-metabolizing active substances (Cetirizin, Levocetirizin)<br />
with no risk of drug interaction or metabolization via an<br />
alternative p-450-isoenzyme (Loratadin, Desloratadin) with no<br />
critical interaction with azoles and macrolid-antibiotics,<br />
6. greater administration comfort (1x pro die ) thanks to longlasting<br />
action but with no essential danger of accumulation.<br />
Mo<strong>de</strong>rn therapy of allergic immediate-type reactions in organvariant<br />
disease patterns thus makes use of potent active substances<br />
with antihistamine and anti-inflammatory properties and a favorable<br />
risk/benefit ratio.<br />
References<br />
1 Ellis AK, Day JH (2000) Second- and third-generation<br />
antihistamines. Dermatol Therapy 13:327-336.<br />
2 Kroegel C, Mock B, Reissig A, Hengst U, Machnik A, Henzgen<br />
M (2001) Therapie <strong>de</strong>s Asthma bronchiale im Erwachsenenalter.<br />
Z ärztl Fortb Qualsich (ZaeFQ) 95:699-706.<br />
3 Llanes S, Grant A (2000) Comparison of the potency of<br />
antihistamines. Dermatol Therapy 13:344-348.<br />
4 Passalacqua G, Bousquet J, Bachert C, Church MK et al (1996)<br />
The clinical safety of H1-receptor antagonists. An EAACI<br />
position paper. Allergy 51:666-675.<br />
5 Sabroe RA, Greaves MW (2000) Chronic idiopathic urticaria<br />
and its management. Dermatol Therapy 13:384-391.<br />
6 Salmun LM (2002) Antihistamines in late-phase clinical<br />
<strong>de</strong>velopment for allergic disease. Expert Opin Investig Drugs<br />
11:259-273.<br />
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In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
Therapy of Immediate Type Reactions 235<br />
7 Simons FE, Simons KJ (1999) Clinical pharmacology of new<br />
histamine H1 receptor antagonists. Clin Pharmacoki<strong>net</strong> 36:239-<br />
352.<br />
8 Spencer CM, Faulds D, Peters DH (1993) Cetirizine. A<br />
reappraisal of its pharmacological properties and therapeutic use<br />
in selected allergic disor<strong>de</strong>rs. Drugs 46:1055-1080.<br />
9 Walsh GM (2000) The anti-inflammatory effects of the secondgeneration<br />
antihistamines. Dermatol Therapy 13:349-360.<br />
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236 In vitro Mo<strong>de</strong>ls for the <strong>de</strong>tection of immunomodulating properties of pharmaceuticals<br />
In vitro Mo<strong>de</strong>ls for the <strong>de</strong>tection of<br />
immunomodulating properties of pharmaceuticals<br />
G. Wichmann, I. Lehmann<br />
Junior Research Group Environmental Immunology<br />
Department of Human Exposure Research and Epi<strong>de</strong>miology<br />
UFZ-Centre for Environmental Research Leipzig-Halle GmbH<br />
Permoserstr. 15<br />
D-04318 Leipzig<br />
Germany<br />
In vitro Mo<strong>de</strong>ls for the <strong>de</strong>tection of immunomodulating<br />
properties of pharmaceuticals ..................................... 236<br />
References................................................................... 245<br />
The immune system is an integrated body system that is comprised<br />
of various organs, tissues, cells, and cell products which mediate<br />
host <strong>de</strong>fense against microorganisms (e.g. bacteria, fungi, parasites,<br />
or viruses), foreign substances (e.g. bacterial or other toxins), or<br />
pathogenic cells (e.g. neoplasms). Protective immune responses<br />
<strong>de</strong>pend on the successful orchestration of individual responses by a<br />
vast array of effector cell types including T- and B-lymphocytes,<br />
NK cells, monocytes and macrophages, <strong>de</strong>ndritic cells, and<br />
granulocytes. These effector cell types arise from precursor cells<br />
that originate from either hematopoietic or primary lymphoid<br />
organs such as the bone marrow and thymus. Analysis of the<br />
activation, growth, proliferation and differentiative processes by<br />
which mature cells become effector cells (e.g. naive-toeffector/memory<br />
B-cell or T-cell conversions or monocyte-tomacrophage<br />
transitions), has led to a <strong>de</strong>epening un<strong>de</strong>rstanding of<br />
the cellular and molecular mechanisms which un<strong>de</strong>rlie immunity<br />
and inflammation. Because of its central importance in providing<br />
host <strong>de</strong>fense, and its intercommunication with other body systems<br />
in health and disease states, it is necessary to investigate (si<strong>de</strong>-)<br />
effects of various noxious agents (e.g. chemicals, toxins, and<br />
pharmaceuticals) on the immune system. As a result, numerous in<br />
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In vitro Mo<strong>de</strong>ls for the <strong>de</strong>tection of immunomodulating properties of pharmaceuticals 237<br />
vivo experimental animal mo<strong>de</strong>l systems have been <strong>de</strong>veloped to<br />
gain crucial information and a better un<strong>de</strong>rstanding of the<br />
physiological basis of immunity and inflammation and on the basis<br />
of the action of pharmaceuticals in this context. In addition, many<br />
in vitro mo<strong>de</strong>ls of the immune system have been established using a<br />
vast array of tissue and cell culture systems. These in vitro systems<br />
permit high-resolution i<strong>de</strong>ntification and experimental scrutiny of<br />
the cellular and molecular mechanisms that un<strong>de</strong>rlie immunity and<br />
inflammation and how noxious agents affect them.<br />
Disadvantages of in vitro test systems Advantages of in vitro test systems<br />
• no assessment of systemic influences<br />
• insufficient assessment of organ-specific effects<br />
• no assessment of complex toxic effects, as in the<br />
reproduction toxicology and testing for cancerogenity<br />
• no assessment of chronic effects<br />
• no assessment of the reversibility or healing of toxic<br />
effects<br />
• no assessment of the interactions between different<br />
tissues, organs and organ systems<br />
• insufficient consi<strong>de</strong>ration of pharmacoki<strong>net</strong>ic and<br />
metabolic aspects<br />
• no official acceptance for the toxicological evaluation of<br />
medicaments<br />
• no international official acceptance for the toxicological<br />
classification and indication of chemical materials and<br />
preparing<br />
• controlled test conditions<br />
• elimination of systemic influences<br />
• check of a large number of different<br />
test systems (cells or tissues) per<br />
dose possible<br />
• time-<strong>de</strong>pen<strong>de</strong>nt repeated and/or<br />
simultaneous samplings possible<br />
• quick and approves of testing<br />
• small quantities of test chemicals<br />
necessary<br />
• small quantities of arrears results<br />
after the experiments<br />
• human cells and tissues can be<br />
tested<br />
• reduction of the number of experi-<br />
ments with animals (especially<br />
vertebrates)<br />
Tab. 1: Disadvantages and advantages of in vitro test systems in<br />
the toxicology (according to [7], modified).<br />
In recent years many substances have been <strong>de</strong>scribed to have<br />
immunotoxic or immunomodulating properties and are therefore<br />
toxicologically relevant. Immunotoxic and immunomodulating<br />
substances are members of different structural classes of chemicals.<br />
An overview of some xenobiotics with immunotoxic properties is<br />
given in table 2. All of the effects of interactions of xenobiotics<br />
with the immune system <strong>de</strong>scribed below were shown in animals<br />
and man. The consequences of the exposure to immunotoxic<br />
substances and pharmaceuticals are various. The immune system is<br />
able to react with these substances or their metabolites and thereby<br />
could be activated or suppressed. Many of the immunotoxic<br />
substances are highly or mo<strong>de</strong>rate electrophilic reagents or could be<br />
activated by a variety of metabolic systems to reactive<br />
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238 In vitro Mo<strong>de</strong>ls for the <strong>de</strong>tection of immunomodulating properties of pharmaceuticals<br />
intermediates. These electrophilic chemicals are able to bind on<br />
macromolecules like nucleic acids and/or proteins and affect their<br />
biological function. In general, electrophilic substances not only<br />
affect the immune system but also other organs or organ systems,<br />
especially those with a higher proliferative activity.<br />
Pharmaceuticals<br />
Neomycin<br />
Procaine<br />
Sulfonami<strong>de</strong><br />
Penicillin<br />
Benzocaine<br />
Thiuram<br />
Cobalt sulfate<br />
Inducers of allergies Immunosuppressors<br />
p-Phenylenediamine<br />
Hydroxybenzoic acid ester<br />
Nickel sulfate<br />
Potassium dichromate Formal<strong>de</strong>hy<strong>de</strong><br />
PCDD and other dioxins<br />
PCB and PCDF<br />
Benzo[a]pyrene and other PAHs<br />
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Azathioprine<br />
Cyclosporin<br />
Glucocorticoids<br />
Cyclophosphami<strong>de</strong><br />
Chlorambucil<br />
Carmustine<br />
Tab. 2: Immunotoxic xenobiotics. The known immunotoxic<br />
relevant substances can be distinguished by their chemical<br />
properties and their mo<strong>de</strong> of action into at least two groups<br />
(according to [8], modified).<br />
On one hand, immunotoxic and immunosuppressive effects could<br />
occur and cause organ failure and toxicity in general. Because such<br />
general toxic effects affect cells with higher proliferating and/or<br />
metabolic activity to a higher <strong>de</strong>gree than resting or fully<br />
differentiated cells, the consequences of general toxic effects on the<br />
immune system are greater than those effects on other body<br />
systems. The resulting suppression of immune responses leads to<br />
impaired resistance against opportunistic pathogens like viruses,<br />
fungi, and bacteria and to a higher risk of oncogene expression and<br />
the <strong>de</strong>velopment of neoplasms and cancer. On the other hand,<br />
ina<strong>de</strong>quate activation by pharmaceuticals or other substances bears<br />
the risk of hyperreactivity of the immune system. The exceeding<br />
immune reactions caused by immunologic dysregulation are<br />
responsible for the different forms of allergic diseases. Allergies are<br />
divi<strong>de</strong>d into four types (type I to type IV). The different types of<br />
allergies differ in their time course and the cell types and immune<br />
reactants involved in the immunologic reactions un<strong>de</strong>rlying this<br />
specific type of allergy. Xenobiotics are able to interfere with the<br />
immune system and to trigger all four types of allergies.<br />
Furthermore, hyperreactivity against chemicals, pharmaceuticals,
In vitro Mo<strong>de</strong>ls for the <strong>de</strong>tection of immunomodulating properties of pharmaceuticals 239<br />
and other substances related to the environment are able to trigger<br />
immunologic dysregulation. These immune reactions which seem to<br />
be out of the physiologic normal regulatory control are often aimed<br />
at structures of the own body and therefore have the potency to<br />
trigger autoimmune reactions and autoimmune diseases.<br />
Additionally, environmental pollutants and diverse pharmaceuticals<br />
have the ability to interact specifically with transcription factors or<br />
are (after binding to specific intracellular receptors) part of<br />
transcription-factor complexes (as shown for the interaction of<br />
polycon<strong>de</strong>nsed aromatic hydrocarbons [PAHs], e.g.<br />
benzo[a]pyrene, with the aromatic hydrocarbon receptor [AhR] and<br />
the aromatic hydrocarbon receptor nuclear translocator [ARNT])<br />
and act on the expression of immune regulatory relevant genes<br />
[1][2]. The result of such interactions could also be suppression or<br />
activation of expression of the respective gene(s). Furthermore,<br />
diverse xenobiotics act on the intracellular level of calcium ions and<br />
affect signal transduction [3][4]. In summary, the interactions of<br />
immunomodulating substances with the immune system might<br />
occur at different checkpoints of immune regulation on the cellular<br />
and sub-cellular level. The resulting effects might be further<br />
amplified and hence lead to pathological situations. Thus the<br />
exposure to immunotoxicants and immunomodulators bears a lot of<br />
risks. Therefore, the <strong>de</strong>tection of immunomodulating potencies of<br />
such substances is very important.<br />
In vitro test systems in the form of cell and tissue cultures are used<br />
for a long time in pharmacological research. Animal experiments<br />
and later on clinical investigations are only carried out following<br />
effect checks of a new medicine material in in vitro systems.<br />
Oppositely to this in the toxicology in vitro tests are only used for<br />
specific questions, e.g. in mutagenicity testing or to get special<br />
information (or supplemental information) for a better basis for risk<br />
assessment. In vitro mo<strong>de</strong>ls for the <strong>de</strong>tection of immunomodulating<br />
properties are used for the estimation of effects of pharmaceuticals<br />
or other chemicals potentially relevant for human beings on specific<br />
immune parameters, e.g. cytokine production, cytotoxicity or<br />
apoptosis. In vitro mo<strong>de</strong>ls for the <strong>de</strong>tection of immunomodulating<br />
properties of pharmaceuticals or other chemicals make use of<br />
isolated and in vitro cultured cells of immunological origin. These<br />
cells used in the in vitro mo<strong>de</strong>ls are from different sources. On one<br />
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240 In vitro Mo<strong>de</strong>ls for the <strong>de</strong>tection of immunomodulating properties of pharmaceuticals<br />
hand, the used indicator cells are primary cell cultures <strong>de</strong>rived from<br />
immune organs of animals, mainly mice or rats, or from the<br />
peripheral blood of animals or humans. On the other hand,<br />
established cell lines or T- and B-cell clones are used for the testing<br />
of chemicals for their immunomodulating properties. In these tests<br />
the used immune cells are stimulated with polyclonal activators like<br />
lipopolysacchari<strong>de</strong> (LPS) or the mitogens phytohemagglutinin<br />
(PHA), concanavalin A (Con A), and pokeweed mitogen (PWM).<br />
Another way is the use of stimulating antibodies against the T-cell<br />
receptor (TCR) or its signal-transducing components (the CD3<br />
complex and associated intracellular proteins), the B-cell receptor<br />
(BCR) or other proteins involved in the immunological stimulation<br />
of immune cells which are expressed on the surface of the cellular<br />
membrane, e.g. CD28 in the case of T cells, or CD40 in the case of<br />
B cells and <strong>de</strong>ndritic cells (DC). Furthermore, there are mo<strong>de</strong>ls<br />
which frequently involve the use of primary cell cultures and<br />
established cell lines that <strong>de</strong>pend upon the presence of (a) particular<br />
cytokine(s) for their growth or survival or that respond to a given<br />
cytokine. Fig. 1 shows a flowchart of a useful procedure for the<br />
<strong>de</strong>tection of immunomodulating properties of pharmaceuticals and<br />
other substances. We use this test system in our laboratory for the<br />
<strong>de</strong>tection of immunomodulating effects of a variety of<br />
environmental pollutants including volatile organic compounds<br />
(VOC), microbial VOC, mycotoxins, pestici<strong>de</strong>s and polycon<strong>de</strong>nsed<br />
aromatic hydrocarbons. In our system freshly prepared peripheral<br />
blood cells of healthy donors are used. These cells (which serve as<br />
indicators for the effects of a given chemical on immune responses)<br />
were adjusted to a useful number of cells per volume (in the<br />
majority of cases 1 to 5 x 10 6 cells per ml) of an appropriate cell<br />
culture medium (mostly RPMI1640 supplemented with fetal calf<br />
serum or autologous serum) and see<strong>de</strong>d into the wells of sterile cell<br />
culture plates (24, 48, or 96 wells per plate) or tubes. The chemicals<br />
to be tested are solved in phosphate buffered saline (PBS) or – if<br />
they are not hydrophilic enough (which is a common problem) – in<br />
appropriate solvents like ethanol, methanol, dimethyl sulfoxi<strong>de</strong><br />
(DMSO), or acetonitrile, <strong>de</strong>pending on their solvability. Following<br />
this the chemicals are serial diluted and then applied into the cell<br />
cultures at least in triplicates. After an appropriate culturing time<br />
the exposure to the chemicals is terminated.<br />
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In vitro Mo<strong>de</strong>ls for the <strong>de</strong>tection of immunomodulating properties of pharmaceuticals 241<br />
Preparation of immune cells<br />
Adjustment to an appropriate<br />
number of cells/ml<br />
Seeding into culturing plates<br />
Application of immune<br />
stimulators<br />
Adjustment to a final number of 1<br />
x 10 6 cells/ml<br />
Solving of the compound to be<br />
tested (appropriate solvent)<br />
Serial dilution (same solvent)<br />
Application of individual<br />
dilutions (or solvent controls) into<br />
the cell culture<br />
Culturing un<strong>de</strong>r appropriate<br />
conditions (37°C, humidified<br />
atmosphere with 5% CO2) Harvesting of culture superna-<br />
Measurement of<br />
cell viability and/or<br />
proliferation using<br />
the MTT assay or<br />
the incorporation of<br />
[ 3 H]thymidine<br />
Harvesting of cells at useful<br />
endpoints<br />
Fixing of cells<br />
Fluorescence labeling of cells<br />
(phenotyping, expression of<br />
activation markers)<br />
Flowcytometric analysis in FACS<br />
tants and storage un<strong>de</strong>r appropriate<br />
conditions until analysis<br />
Measurement of cytokine and/or<br />
immunoglobulin concentrations<br />
with ELISA<br />
Preparation of mRNA<br />
Analysis of mRNA with RT-PCR<br />
Permeabilization of cells<br />
Fluorescence labeling of cells<br />
(intracellular cytokine staining<br />
and phenotyping)<br />
Fig. 1: Flowchart of a useful strategy for the testing of<br />
pharmaceutical compounds and other chemicals in immunological<br />
in vitro mo<strong>de</strong>ls.<br />
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242 In vitro Mo<strong>de</strong>ls for the <strong>de</strong>tection of immunomodulating properties of pharmaceuticals<br />
By doing this it is crucial to analyze the in vitro immune response at<br />
different time-points that are matching the individual ki<strong>net</strong>ic of the<br />
respective parameter. One common strategy inclu<strong>de</strong>s washing steps<br />
after a short-time exposure of the cells to noxious agents to remove<br />
their remaining part outsi<strong>de</strong> the cells. This is then followed by the<br />
culturing of the remaining cells for a period of time sufficient for<br />
the expression of relevant proteins. Other strategies omit on such<br />
washing procedures and additional culturing times and analyze the<br />
direct effects of the agents on immune parameters during the<br />
exposure at different endpoints.<br />
There are different possibilities for the subsequent steps in the<br />
analysis of those effects caused by the chemicals. The first one,<br />
which is usually applied to all in vitro mo<strong>de</strong>ls for the estimation of<br />
immunotoxic effects, is the estimation of cell-viability and/or<br />
proliferation/activation of immune cells in response to mitogens.<br />
Estimations of cell-viability and/or activation of immune cells are<br />
often done using the MTT assay. The MTT assay is a quantitative<br />
colorimetric assay for cell survival and proliferation based on the<br />
ability of live cells to take up the pale yellow compound MTT (3-<br />
(4,5-dimethyl-thiazol-2-yl)-2,5-diphenyl-tetrazoliumbromi<strong>de</strong>) and<br />
to be converted by the mitochondrial succinate-tetrazolium<br />
reductase system to form a blue formazan dye [5]. The amount of<br />
formazan dye produced is proportional to the number of viable<br />
cells. Besi<strong>de</strong> this, the proliferation of mitogene stimulated<br />
lymphocytes is mostly measured by the incorporation of<br />
[ 3 H]thymidine or 5-Bromo<strong>de</strong>soxyuridine into the DNA during<br />
replication before mitosis.<br />
Another possibility of <strong>de</strong>tection of immunomodulating effects is<br />
harvesting of cell-free supernatants that is then followed by the<br />
measurement of e.g. cytokine concentrations by ELISA or in<br />
bioassays. The remaining cells can then be analyzed either on their<br />
content on mRNAs of different immune relevant genes or the<br />
presence of relevant protein components of signal transduction<br />
pathways. Another way is the analysis of cell surface markers<br />
(immune-phenotyping) of the former exposed cells, e.g. combined<br />
with the analysis of cytokine expression using the method of<br />
intracellular cytokine staining. Other mo<strong>de</strong>ls analyze the prior<br />
exposed cells for their ability to trigger cytolysis of target cells and<br />
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In vitro Mo<strong>de</strong>ls for the <strong>de</strong>tection of immunomodulating properties of pharmaceuticals 243<br />
thus to act either as cytotoxic T cells (CTL) or as natural killer<br />
(NK) cells.<br />
One common problem is the use of appropriate controls for the<br />
verification of the effects observed un<strong>de</strong>r the influence of noxious<br />
agents that were applied in solvents. In such cases controls with<br />
i<strong>de</strong>ntical concentrations of solvent are nee<strong>de</strong>d and the effects have<br />
to be calculated according to these controls. Nevertheless, it has to<br />
be taken into account that the data for immune responses obtained<br />
un<strong>de</strong>r the influence of solvents are principally a result of complex<br />
interactions of both the pharmaceutical and solvent with the<br />
immune cells and their biological activity. As an example, DMSO<br />
is an anti-inflammatory substance and acts at concentrations above<br />
5 % v/v in cultures on the expression and the quaternary structure of<br />
tumor-necrosis factor alpha and on its biological effects [6]. With<br />
this in mind, results for some immunologic effects obtained in those<br />
in vitro systems containing DMSO in higher concentrations have to<br />
be interpreted very carefully.<br />
One special topic is the assessment of the data obtained with the<br />
different techniques used for the analysis of immune parameters<br />
resulting after testing in the in vitro mo<strong>de</strong>l. Each of the different<br />
tests used to measure the resulting effects in the in vitro mo<strong>de</strong>l<br />
assays one or more special parameter(s) and offers answers only to<br />
those questions to which the test is addressed. Furthermore, the<br />
individual tests are suitable to a different <strong>de</strong>gree for the<br />
measurement of the individual effect. The MTT assay, for instance,<br />
is suitable for the measurement of cell viability (or cytotoxic<br />
effects) based on the activity of the mitochondrial succinatetetrazolium<br />
reductase system and therefore <strong>de</strong>pends on the number<br />
of viable cells as well as on their respiration activity. However, the<br />
MTT assay gains data about cytotoxic effects. It is very useful to<br />
have these data for a comparison with those concentrations of the<br />
test substance affecting other immunologic parameters. Useful<br />
insights into the immunotoxic or immunomodulating properties of a<br />
substance can be obtained by measurements of cytokine<br />
concentrations in culture supernatants exten<strong>de</strong>d by measurements of<br />
cytokine-mRNA expression in the former exposed cells and the<br />
analysis of cytokine production by flowcytometry. The use of<br />
flowcytometry (which means the measurement of fluorescencelabeled<br />
cells in a fluorescence-activated cell sorter [FACS]) for<br />
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244 In vitro Mo<strong>de</strong>ls for the <strong>de</strong>tection of immunomodulating properties of pharmaceuticals<br />
phenotyping and intracellular cytokine-staining (ICS) of immune<br />
cells offers the possibility of <strong>de</strong>tection of effects on different cell<br />
populations (e.g. subsets of T cells) on the single cell level. The ICS<br />
data therefore provi<strong>de</strong> additional information on the targeted cell<br />
populations and the effects of noxious agents on different T-cell<br />
subsets.<br />
The measurement of culture supernatant concentrations of<br />
cytokines like tumor necrosis factor-alpha (TNF-α), interleukin<br />
(IL)-1β, and IL-6 with immunoassays or bioassays offers the<br />
possibility to <strong>de</strong>tect pro-inflammatory potencies of a given<br />
substance. These three cytokines are known as pro-inflammatory<br />
cytokines and are involved in inflammation processes, regulation of<br />
acute phase reactions and show pyrogenic activity. Furthermore,<br />
these cytokines are growth and differentiation factors for B- and Tlymphocytes.<br />
Other cytokines are immune regulators that<br />
predominantly act on immune cells themselves. Such cytokines are<br />
interferon-gamma (IFN-γ), IL-2, IL-4, IL-13, and IL-5. The<br />
measurement of these cytokines offers the possibility to <strong>de</strong>tect<br />
immunomodulating properties of a given substance targeting<br />
immune regulation. The balance of these cytokines and the balance<br />
of the producing T-cell subsets is crucial in immune regulation.<br />
Dysregulation affecting the balance of IFN-γ and IL-4 is thought to<br />
be related to autoimmunity and allergy. The measurement of IFN-γ<br />
and IL-4 in culture supernatants is therefore very suitable to gain<br />
information on the immunomodulatory activity of a given<br />
substance. Another way to measure cytokine concentrations is the<br />
use of bioassays. Generally the biological responses induced by<br />
cytokines show saturation ki<strong>net</strong>ics which can be used to quantitate<br />
their amounts from dose-response curves. It should be noted that<br />
cytokine assays frequently measure only one single aspect of many<br />
biological activities of a given cytokine. Potential complex<br />
interactions among cytokines must also be consi<strong>de</strong>red when<br />
interpreting data obtained from cytokine bioassays. Furthermore,<br />
there are often differences between measurements of cytokine<br />
concentrations in bioassays and immunoassays (e.g. ELISA). This<br />
is thought to be related in some cases to the presence of different<br />
antigenic forms (including complexes with soluble receptors or<br />
monomeric forms of cytokines) that cannot be <strong>de</strong>tected in<br />
bioassays. Because there are additional difficulties in the<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
In vitro Mo<strong>de</strong>ls for the <strong>de</strong>tection of immunomodulating properties of pharmaceuticals 245<br />
measurement of culture supernatants containing the cytokines to be<br />
measured as well as the substance to be analyzed in the in vitro<br />
mo<strong>de</strong>l (that eventually may further have the ability to act on the<br />
indicator cells used for the cytokine measurement in the bioassay)<br />
we suggest to avoid bioassays for cytokine measurements in such a<br />
background.<br />
In general, in vitro systems and analytical methods like those<br />
presented here are suitable for the analysis of immunomodulating<br />
effects of a broad spectrum of substances including<br />
pharmaceuticals, antibiotics and toxins [9]. This system as well as<br />
other comparable in vitro systems are able to show<br />
immunomodulating potentials of the test compound and therefore<br />
can serve as an inexpensive tool for the <strong>de</strong>tection of<br />
immunomodulating properties. In this context arises the question<br />
about the transmissibility of in vitro data on the situation in vivo and<br />
further on their relevance for integrity of the whole organism and<br />
health. Since in vitro systems only indicate the potentials of a given<br />
substance un<strong>de</strong>r these artificial conditions (see [6]), it remains to be<br />
shown in further investigations that the observed effects are also<br />
real in vivo.<br />
References<br />
1 Reyes H, Reisz-Porszasz S, Hankinson O (1993) I<strong>de</strong>ntification<br />
of the Ah receptor nuclear translocator protein (Arnt) as a<br />
component of the DNA binding form of the Ah receptor.<br />
Science 256: 1193-1195.<br />
2 Safe S, Krishnan V (1995) Cellular and molecular biology of<br />
aryl hydrocarbon (Ah) receptor-mediated gene expression. Arch<br />
Toxicol Suppl 17: 99-115.<br />
3 Archuleta MM, Schieven GL, Ledbetter JA, Deanin GG,<br />
Burchiel SW (1993) 7,12-dimethylbenz[a]anthracene activates<br />
protein-tyrosine kinases Fyn and LCK in the HPB-ALL human<br />
T-cell line and increases tyrosine phosphorylation of<br />
phospholipase C-γ 1, formation of inositol 1,4,5-triphosphate,<br />
and mobilization of intracellular calcium. Proc Natl Acad Sci<br />
USA 90: 6105-6109.<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
246 In vitro Mo<strong>de</strong>ls for the <strong>de</strong>tection of immunomodulating properties of pharmaceuticals<br />
4 Mounho BJ, Davila DR, Burchiel SW (1997)<br />
Characterization of intracellular calcium responses produced by<br />
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Pharmacol 145: 323-330.<br />
5 Mosmann T (1983) Rapid colorimetric assay for cellular<br />
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6 De Groote D, Grau GE, Dehart I, Franchimont P (1993)<br />
Stabilisation of functional tumor necrosis factor-alpha by its<br />
soluble TNF receptors. Eur Cytokine Netw 4: 359-362.<br />
7 Hockertz S (1994) Immunsystem. In: Marquardt H, Schäfer SG<br />
(Hrsg) Lehrbuch <strong>de</strong>r Toxikologie. Spektrum Akad Verl, S 257-<br />
270.<br />
8 Spielmann H (1994) In-vitro-Metho<strong>de</strong>n. In: Marquardt H,<br />
Schäfer SG (Hrsg) Lehrbuch <strong>de</strong>r Toxikologie. Spektrum Akad<br />
Verl, S 814-820.<br />
9 Wichmann G, Herbarth O, Lehmann I (2002) The mycotoxins<br />
citrinin, gliotoxin and patulin affect rather interferon-γ than<br />
interleukin-4 production of human blood cells. Environ<br />
Toxicol 17 (3).<br />
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Wohlrab J, Neubert R, Marsch W (eds): Trends in Dermatopharmacy<br />
In: Trends Clin Exp Dermatol, Aachen, Shaker, 2003, vol 1
VOLUME 1<br />
<strong>TRENDS</strong> <strong>IN</strong> <strong>DERMATOPHARMACY</strong><br />
- UPDATE 2002 -<br />
Volume Editors<br />
J. Wohlrab<br />
R.R.H. Neubert<br />
W.Ch. Marsch