Topical gel made from oral blood pressure drugs shown effective in healing chronic wounds

An international team of researchers led by Johns Hopkins has shown that a topical gel made from a class of common blood pressure pills that block inflammation pathways speeds the healing of chronic skin wounds in mice and pigs.

A report of the findings, published Oct. 16 in the Journal of Investigative Dermatology, marks efforts to seek approval from the U.S. Food and Drug Administration (FDA) to use the gel application in treatment-resistant skin wounds among diabetics and others, particularly older adults.

“The FDA has not issued any new drug approval for wound healing in the past 10 years,” says Peter Abadir, M.D., associate professor of medicine at the Johns Hopkins University School of Medicine and the paper’s first author. “Using medicines that have been available for more than two decades, we think we have shown that this class of medicines holds great promise in effectively healing chronic wounds that are prevalent in diabetic and aged patients.”

Chronic wounds, defined as skin injuries that fail to heal in a timely manner and increase the risk of infection and tissue breakdown, accounted for more than 100 million hospital visits in United States hospitals in 2008, according to Abadir.

In recent years, attention has turned to the skin’s renin-angiotensin system (RAS), which is involved in the skin’s inflammatory response, collagen deposition and signaling necessary for wound healing. Studies show that the RAS system is abnormally regulated in diabetic and older adults.

Abadir and colleagues experimented with gel formulations of angiotensin II receptor antagonists, or blockers, a long-standing class of drugs that includes losartan and valsartan, prescribed to treat hypertension. The drugs block RAS and increase wound blood flow, and the goal was to apply the gels directly to wounds, increasing wound tissue level of the drugs that promote faster healing.

Abadir and colleagues first tested 5 percent topical losartan on mice in three different phases of wound healing: group 1 treatment, for up to three days post-wound infliction to target the inflammatory phase; group 2 treatment, starting on day seven after wound infliction to target the proliferative/remodeling (later) phase of tissue healing; and group 3 treatment, starting the first day of wound infliction until closure to treat all wound healing phases. A fourth group was kept back as a control and given standard care and a placebo. Mice in group 2 experienced the most accelerated wound healing rate.

Next, Abadir and colleagues compared the effects of different concentrations of losartan and valsartan on young diabetic and aged mice during the proliferation/remodeling phase of wound healing, which involves the regrowth of normal tissue.

The results showed that valsartan was more effective in accelerating wound healing than losartan, without any significant difference in healing time between valsartan doses. Overall, 1 percent valsartan had the greatest impact on total closure compared with the other agents, and 10 percent losartan led to the worst wound healing, which Abadir says may be attributed to toxicity.

Final results showed that half of all mice that received 1 percent valsartan achieved complete wound healing, while only 10 percent of the mice given the placebo did.

Driven by 1 percent valsartan’s promising results in mice, the researchers tested its effects on wounds among aged, diabetic pigs, as pig skin has more similar properties to human skin.

Compared with pigs in the placebo group, wounds that received 1 percent valsartan healed much more quickly, and all 12 wounds were closed by day 50, compared with none of the placebo-treated wounds, the researchers say.

Of note, Abadir says, a low concentration (1 to 50 nanomoles) of valsartan was detected in the pigs’ blood near the beginning of treatment, and none was detected later in the treatment course, suggesting that the drug acts locally on the tissues where it’s absorbed, rather than affecting the entire body.

For comparison, oral ingestion of valsartan generally yields 4,000 to 5,000 nanomoles in the blood level for a human. This suggests that topical application of valsartan will not be absorbed into the bloodstream and could have unintended physiological effects, such as those that affected blood pressure, body weight or kidney function.

Finally, to determine the quality of 1 percent valsartan’s biological effects on wound repair–not just rate of repair–Abadir and colleagues examined collagen content and tensile strength in the pigs’ skin. Pigs treated with valsartan had a thicker epidermal layer (the outermost layer of the skin) and dermal collagen layer, as well as a more organized collagen fiber arrangement, all of which indicate 1 percent valsartan application leads to stronger healing skin, Abadir says.

“Our strategy for specifically targeting the biology that underlies chronic wounds in diabetics and older adults differs greatly from other approaches to wound care thus far. The topical gel likely enables a cascade of positive biological effects that facilitates and accelerates chronic wound healing,” says Jeremy Walston, M.D., professor of medicine and the paper’s senior author.

“Now that we’ve proven efficacy in animals, we’re moving on to the next stage of FDA-required testing in humans. Hopefully, this medication will be available for public use in a few years, if further research bears out our results,” adds Walston. Walston and colleagues envision that the medication could one day also be used to treat scars, wrinkles and other skin problems.

Twenty-nine million Americans have diabetes and 1.7 million are newly diagnosed each year. Of this group, approximately 900,000 will develop diabetic foot ulcers annually. With an aging population and incidence of diabetes increasing rapidly across the globe. Abadir estimates the total number of diabetic foot ulcers to be more than 20 million per year, with an estimated total cost of $25 billion annually in the U.S. alone.

New Treatment Shows Promise for Patients with Rare Dermatologic Disease

A new treatment for a rare and often incurable condition called dermatomyositis (DM) reduced the severity of the disease in patients whose DM was resistant to other therapies. As part of a randomized, double-blind study conducted at the Perelman School of Medicine at the University of Pennsylvania, 22 patients were given either a drug called anabasum or a placebo. The 11 patients who got the drug improved during the trial, with less severe skin disease and better patient-reported quality of life and symptom assessments. Researchers will present their findings at the American College of Rheumatology Annual Meeting in San Diego next week.

Dermatomyositis is an inflammatory disease that causes a rash on the skin and is frequently associated with muscle weakness. Some patients are only affected on the skin. Other symptoms can include fevers, shortness of breath due to lung disease, weight loss, and sensitivity to light. While there are fewer than 100,000 cases of DM overall in the United States, treatment is often ineffective and frequently requires drugs that suppress the immune system, which can leave patients susceptible to other illnesses.

“Not only are current treatments limited, but this disease itself is very understudied, so we’ve had to build our understanding of DM from the ground up just to be in a position to run a trial like this,” said the study’s principal investigator Victoria P. Werth, MD, a professor of Dermatology at Penn and the Chief of Dermatology at the Corporal Michael J. Crescenz VA Medical Center in Philadelphia.

One of the first challenges was developing a way to measure the severity of a patient’s DM. In other dermatologic conditions, such as psoriasis or eczema, doctors can measure the percentage of the skin that is affected – a measurement known as body surface area.

“In DM, body surface area is less informative, because even though you may only have DM on a small percentage of your skin, it can still have severe effects,” Werth said. “We needed a way to look for the amount of disease in a given area.”

Werth and her team developed a metric called the Cutaneous Dermatomyositis Disease Area and Severity Index (CDASI). It measures the amount of skin severity as separate activity and damage scores, with a higher score representing more severe disease. The median activity score among Penn’s clinical population is 13, but this trial involved patients with more severe disease, so scores ranged from 33 to 35.

Penn researchers have spent the last decade developing and validating the CDASI, and though it has become standard practice for use in DM research, this is the first placebo-controlled randomized clinical trial to report the score to evaluate the results of a new treatment.

Patients in this trial all had skin-predominant DM and had not responded to standard treatments such as antimalarial or immunosuppressive therapies. Patients received a single 20mg dose of anabasum for a month and then went to two doses per day for two months, or they were assigned to the placebo. All patients were followed for one month post-treatment. The 11 patients who received the drug had a mean decrease of more than six points relative to the placebo during dosing with the higher dose of drug. The most common side effects seen in the study were diarrhea, dizziness, fatigue, and dry mouth, but these were mild and did not cause anyone to stop taking the drug.

Twenty of the 22 patients on this trial have entered a one-year, long-term extension study. Werth says that will be critical to understanding the efficacy and safety of anabasum, but she also says a larger study is warranted based on these results.

This trial was supported by the NIH’s National Institute of Arthritis and Musculoskeletal and Skin Diseases (R21AR066286) and Corbus Pharmaceuticals, which is developing anabasum for a number of rare inflammatory diseases including DM.

Study Unlocks How Changes in Gene Activity Early During Therapy Can Establish the Roots of Drug-Resistant Melanoma

FINDINGS
A UCLA-led study of changes in gene activity in BRAF-mutated melanoma suggests these epigenomic alterations are not random but can explain how tumors are already developing resistance as they shrink in response to treatment with a powerful class of drugs called MAP kinase (MAPK)-targeted inhibitors. The discovery marks a potential milestone in the understanding of treatment-resistant melanoma and provides scientists with powerful targets for drug development and new clinical studies.

BACKGROUND
Approximately 50 percent of advanced melanoma tumors are driven to grow by the presence of BRAF mutations. The use of BRAF inhibitors, both alone and in combination with another MAPK pathway inhibitor called MEK, have shown unprecedented responses as a treatment for these types of tumors, rapidly shrinking them. However, BRAF-mutated tumors frequently show early resistance to treatment and respond only partially to BRAF inhibitors, leaving behind cancer cells that may evolve to cause eventual tumor regrowth.

The findings build upon research by Dr. Roger Lo, professor of medicine (dermatology) and molecular and medical pharmacology at the David Geffen School of Medicine, and lead author of the new study. Previously, he discovered that epigenomic alterations (via a regulatory mechanism called CpG methylation) accounted for a wide range of altered gene activities and behaviors in BRAF-mutant therapy-resistant melanoma tumor cells. The loss of tumor-fighting immune or T-cells in drug-resistant tumors may lead to resistance to subsequent salvage immunotherapy, Lo said, and drug resistance can grow at the same time that anti-tumor immune cells diminish and weaken.

This means that in some patients the melanoma might develop resistance to both MAP kinase-targeted therapy and anti-PD-L1 antibodies, which capitalize on the abundance of immune cells inside the tumor to unleash their anti-cancer activities. Lo concluded that non-genomic, epigenomic, and immunologic evolution of melanoma explain why patients relapse on MAPK-targeted therapies.

Along with co-first authors, Drs. Chunying Song, Marco Piva and Lu Sun, Lo hypothesized that epigenomic and immunologic resistance evident during clinical relapse may be developing already during the first few weeks of therapy as the tumors shrink and clinical responses are viewed as successes. If this proves to be true, then scientists could potentially identify combination treatments that suppress the earliest resistance-promoting activities.

METHOD
Lo’s team utilized state-of-the-art technologies to comprehensively profile recurrent patterns of gene activity changes. They analyzed 46 samples of patients’ melanoma tumors, both before and early during MAPK therapy. They also replicated the process outside of the human body, modeling both non-genomic drug resistance by growing melanoma cell lines from patients’ tumors and immunologic resistance in mouse melanoma. Patient-derived cell lines and mouse melanoma tumors were treated with drugs that block the MAP kinase pathway and sampled at various times over the course of the study to track gene activity changes.

The researchers found that MAPK therapies fostered CpG methylation and gene activity reprogramming of tumors. This reduced the tumor cells’ dependence on the mutated BRAF protein, and switched their growth and survival strategies to rely on proteins called receptor-tyrosine kinases and PD-L2. In addition, PD-L2 gene activity was found to be turned on in immune cells surrounding the tumor cells. They also demonstrated that blocking PD-L2 with an antibody could prevent the loss of T-cells in the tumor’s immune microenvironment and suppressing therapy resistance.

Lo’s team continues to identify other adaptations during this early phase of therapy that could be targets of future combination treatment regiments.

IMPACT
More than 87,000 new cases of melanoma will be diagnosed this year in the United States alone, and more than 9,500 people are expected to die of the disease.

The findings can prompt drug development and new clinical studies based on epigenetic or gene expression and immune targets in combination with mutation-targeted therapies. As scientists learn what these mechanisms of tumor resistance are, they can combine inhibitor drugs that block multiple resistance routes and eventually make the tumors shrink for much longer or go away completely, Lo said.

JOURNAL
The research is published online in Cancer Discovery, the peer-reviewed journal of the American Association of Cancer Research.

AUTHORS
UCLA’s Dr. Roger Lo is senior author. The co-first authors are Drs. Chunying Song, Marco Piva and Lu Sun at the David Geffen School of Medicine at UCLA. Other authors are Drs. Aayoung Hong, Gatien Moriceau, Xiangju Kong, Hong Zhang, Shirley Lomeli, Jin Qian, Clarissa Yu, Robert Damoiseaux, Philip Scumpia, Antoni Ribas and Willy Hugo at UCLA; and Mark Kelley, Kimberly Dahlman, Jeffrey Sosman, Douglas Johnson at Vanderbilt University. Lo, Damoiseaux, Scumpia and Ribas are members of UCLA’s Jonsson Comprehensive Cancer Center.

FUNDING
The research was supported by the National Institutes of Health, the American Cancer Society, the Melanoma Research Alliance, the American Skin Association, the American Association for Cancer Research, the National Cancer Center, the Burroughs Wellcome Fund, the Ressler Family Foundation, the Ian Copeland Melanoma Fund, the SWOG/Hope Foundation, the Steven C. Gordon Family Foundation, the Department of Defense Horizon Award, the Dermatology Foundation, and the ASCO Conquer Cancer Career Development Award.

Autologous Cell Therapy for Epidermolysis Bullosa Gains FDA Breakthrough Therapy Designation

Abeona Therapeutics Inc., a leading clinical-stage biopharmaceutical company focused on developing novel gene therapies for life-threatening rare diseases, announced today that the U.S. Food and Drug Administration has granted Breakthrough Therapy designation status to the Company’s EB-101 gene therapy program for patients with Recessive Dystrophic Epidermolysis Bullosa (RDEB).  The designation from the FDA enables collaborative discussions with senior FDA personnel, priority review and an expedited approval process to drug candidates where preliminary clinical trials indicate that a therapy may offer substantial treatment advantages over existing options for patients with serious or life-threatening diseases.

“EB-101 is an autologous gene-corrected cell therapeutic approach that utilizes a patient’s own cells and genetically engineering them to produce the correct version of collagen, which helps hold skin on to the body, thereby reducing the number of painful blisters caused by injury and improving wound healing,” stated Timothy J. Miller, Ph.D., Abeona’s President and CEO. “We are grateful that the FDA has recognized the promising clinical data from the EB-101 program with Breakthrough Therapy designation and look forward to initiating our pivotal Phase 3 trial as we advance EB-101 for patients with this debilitating disease.”

The Breakthrough Therapy designation is based on data from the Phase 1/2 EB-101 clinical trial, which demonstrated significant wound healing (greater than 50% healed) in treated wounds for over two years. Breakthrough Therapy designation is intended to expedite the development and review of drugs for serious or life-threatening conditions. The criteria for this particular designation require preliminary clinical evidence that demonstrates the drug may have substantial improvement on at least one clinically significant endpoint over available therapy.

A Breakthrough Therapy designation conveys all fast track program features with more intensive FDA guidance on an efficient drug development program, an organizational commitment involving senior managers, and eligibility for rolling review and priority review. This is the first Breakthrough Therapy designation for Abeona since the FDA initiated the program in 2013, highlighting the necessity to develop innovative therapies in diseases where there is a significantly unmet clinical need like RDEB.

The Company continues to engage the FDA on the final Phase 3 clinical trial design, planned to commence early 2018, and will provide an update on the program in the coming months.  Abeona’s EB-101 product is an autologous, ex-vivo gene-corrected cell therapy in which the COL7A1 gene is inserted into a patient’s own skin cells (keratinocytes) for the treatment of the underlying disease in Recessive Dystrophic Epidermolysis Bullosa. The EB-101 program has been granted Orphan Drug and Rare Pediatric Disease Designations from the US Food and Drug Administration (FDA) and Orphan Drug Designation from the European Medicines Agency (EMA).

About EB-101 Phase 1/2 Clinical Trial:
In the recent Phase 1/2 clinical trial, EB-101 was administered to non-healing chronic wounds on each subject and assessed for wound healing at predefined time points. The trial met the primary endpoints safety and efficacy, where wound healing after EB-101 administration was compared to control untreated wounds from a supporting natural history study that evaluated 128 patients. Secondary endpoints included expression of collagen C7 and restoration of anchoring fibrils at three and six-months post-administration. Clinical data were presented at the Society of Investigative Dermatology (SID) conference by Stanford collaborators, and demonstrated that EB-101 treated wounds were significantly healed >50% for more than two years post-administration. The data included:

Wound healing, defined as >50% closure after EB-101 administration, was observed in:
—   100% (36/36 treated wounds, n=6 subjects) at 3 months;
—   89% (32/36 treated wounds, n=6 subjects) at 6 months;
—   83% (20/24 treated wounds, n=4 subjects) at 12 months;
—   88% (21/24 treated wounds, n=4 subjects) at 24 months;
—   100% (6/6 treated wounds, n=1 subject) at 36 months post-administration.

Collagen VII (C7) expression: C7 and morphologically normal NC2 reactive anchoring fibrils were observed in EB-101 treated wounds up to two years post-administration.

Importantly, data from a supportive natural history study of 1,436 wounds from 128 patients with RDEB, established by Stanford and EBCare Registry, were also presented at the conference and to the FDA. Notably, 13 RDEB patients with a total of 15 chronic wounds were treated with an allograft product, including Apligraf® and Dermagraft®. Of these wounds treated with allografts, only 7% (1/15 treated wounds) remained healed after 12 weeks, and 0% (0/15 treated wounds) remained healed after 24 weeks. This is a meaningful finding of the natural history study, as there are no approved therapies for RDEB patients that demonstrate significant wound closure after two months post-application.

Abeona Therapeutics Inc. is a clinical-stage biopharmaceutical company developing gene therapies for life-threatening rare genetic diseases. Abeona’s lead programs include ABO-102 (AAV-SGSH), an adeno-associated virus (AAV) based gene therapy for Sanfilippo syndrome type A (MPS IIIA) and EB-101 (gene-corrected skin grafts) for recessive dystrophic epidermolysis bullosa (RDEB).  Abeona is also developing ABO-101 (AAV-NAGLU) for Sanfilippo syndrome type B (MPS IIIB), ABO-201 (AAV-CLN3) gene therapy for juvenile Batten disease (JNCL), ABO-202 (AAV-CLN1) for treatment of infantile Batten disease (INCL), EB-201 for epidermolysis bullosa (EB), ABO-301 (AAV-FANCC) for Fanconi anemia (FA) disorder and ABO-302 using a novel CRISPR/Cas9-based gene editing approach to gene therapy for rare blood diseases. In addition, Abeona has a proprietary vector platform, AIM™, for next generation product candidates. For more information, visit www.abeonatherapeutics.com

Penn study details impact of antibiotics, antiseptics on skin microbiomes

The use of topical antibiotics can dramatically alter communities of bacteria that live on the skin, while the use of antiseptics has a much smaller, less durable impact. The study, conducted in mice in the laboratory of Elizabeth Grice, PhD, an assistant professor of Dermatology in the Perelman School of Medicine at the University of Pennsylvania, is the first to show the long-term effects of antimicrobial drugs on the skin microbiome. Researchers published their findings today in the journal Antimicrobial Agents and Chemotherapy.

The skin, much like the gut, is colonized by a diverse multitude of microorganisms which generally coexist as a stable ecosystem — many of which are harmless or even beneficial to the host. However, when that ecosystem is disturbed or destabilized, colonization and/or infection by more dangerous microbes can occur. Antiseptics, such as ethanol or iodine, are commonly used to disinfect the skin prior to surgical procedures or following exposure to contaminated surfaces or objects. Topical antibiotics may be used to decolonize skin of specific types of bacteria or for rashes, wounds, or other common conditions.

In the gut, research shows medication that alters microbial communities can lead to complications like Clostridium difficile, or C. diff — which causes diarrhea and is the most common hospital-acquired infection. But when it comes to the skin, the impact of these medications on bacteria strains like Staphylococcus aureus, or S. aureus — the most common cause of skin infections — is still largely unstudied.

“We know antibiotics and antiseptics can be effective in stopping the growth of certain bacteria, but we wanted to know about the larger impact these treatments can have on the resident microbial communities on the skin,” said the study’s lead author, Adam J. SanMiguel, PhD, a researcher in the Grice Laboratory at Penn.

Researchers treated the skin of hairless mice with a variety of antibiotics, including a narrowly targeted mupirocin ointment and a broadly applicable triple-antibiotic ointment (TAO) containing bacitracin, neomycin, and polymyxin B. All of the antibiotics changed the makeup of the microbial communities, and, in a key finding of the study, the impact of that change lasted for days after treatment stopped.

“The problem in this case isn’t antibiotic resistance, but instead, how long the disruption of the skin microbiomes continues,” SanMiguel said. “That disruption opens the door for colonization by an unwanted strain.”

The researchers similarly evaluated antiseptics, using alcohol or povidone-iodine and comparing those treatments with two control groups – mice treated with water and mice entirely untreated. They found neither antiseptic caused responses similar enough to cluster the mice together into groups based on their microbiomes. They also found no clear difference between the treatment groups and the control groups when comparing the relative number of individual bacteria strains.

“We thought antiseptics would be even more disruptive to microbial communities than antibiotics since they are less targeted, but it turns out the opposite is true,” SanMiguel said. “It shows how stable the skin microbiome can be in the face of stress.”

However, both antibiotic and antiseptic treatments removed skin resident bacteria that compete against the pathogenic S. aureus to colonize the skin. Colonization with S. aureus is a risk factor for developing a skin infection.

“This gives us a better understanding of how topical antimicrobials affect the skin microbiome and what kind of impact their disturbance can have in the context of pathogenic colonization,” said Grice, the study’s senior author. “This helps us anticipate their potential effects.”

The researchers say this work can provide the foundation for greater understanding of how the skin defends against infection. They have already begun similar testing in humans.

Cancer therapy shows promise for psoriasis treatment

HDAC inhibitors, already widely used to treat cancer, may be an effective therapy for psoriasis as well, scientists report.

They have shown that HDAC3 inhibitors are particularly adept at increasing expression of aquaporin-3, or AQP3, a channel that transports glycerin, a natural alcohol and water attractor, which helps skin look better and aids healthy production and maturation of high-turnover skin cells.

“We’ve found that HDAC3 normally inhibits expression of AQP3 and we think we can use this knowledge to treat patients with psoriasis,” said Dr. Vivek Choudhary, molecular biologist and physiologist in the Department of Physiology at the Medical College of Georgia at Augusta University.

MCG scientists knew that AQP3 levels were lower in psoriasis than in healthy skin, said Choudhary, corresponding author of the study in the Journal of Investigative Dermatology. The protein helps skin cells proliferate, differentiate into the right kind of cells and get to the right location in the body. It also aids the skin’s hydration, wound recovery and elasticity. Histone deacetylase, which they found suppresses AQP3, helps regulate gene expression and protein function.

Since the immune system is believed to play a key role in psoriasis, many current treatments generally suppress the immune response, which increases the risk of infections, even cancer. MCG scientists hope they can one day instead directly enhance the presence of AQP3 or maybe its key cargo glycerin.

Psoriasis is one of the most common skin disorders, with red, flaky patches most often erupting on the elbows, knees, scalp and back, said Dr. Wendy B. Bollag, cell physiologist in the MCG Department of Physiology and the study’s senior author.

Like cancer, inflammation and excessive proliferation of cells are a psoriasis hallmark. That common ground and other emerging clues got the scientists thinking about the treatment potential of HDAC inhibitors. But first they had to establish a relationship.

When they introduced a broad-acting HDAC inhibitor to normal skin cells, or keratinocytes, – both mouse and human – they found expression of AQP3 went up within 24 hours, the first time the relationship had been noted.

They reiterated that AQP3 was critical because when it was missing, there was no commensurate increase in glycerin. AQP3 knockout mice also further clarified AQP3’s role in skin hydration, elasticity and wound healing and that it is glycerin – rather than water – that is most key to these healthy functions.

They also found that p53, a known, natural tumor suppressor that also supports cell differentiation, helps the HDAC inhibitors enable more AQP3 and ultimately more glycerin, Choudhary said. HDACs also are known to inhibit p53 activity. However overexpressing p53 by itself did not result in increased functional levels of AQP3, the scientists found.

The MCG scientists first used the HDAC inhibitor, suberoylanilide hydroxamic acid, or SAHA, which was approved by the Food and Drug Administration more than a decade ago to treat cutaneous T cell lymphoma, which has symptoms that can include dry, itchy skin as well as enlarged lymph nodes.

“We think this is one of the ways it works,” Bollag said of SAHA and their new findings. They also used several other HDAC inhibitors and found the ones that suppressed HDAC3 were also most effective at increasing AQP3.

AQP3 is adept at hauling glycerin, the backbone of many lipids and typically a key ingredient in skin lotion. Bollag’s lab reported in the Journal of Investigative Dermatology in 2003 that glycerin helps skin cells mature properly. Inside skin cells, phospholipase D – an enzyme that converts fats or lipids in the external protective cell membrane into cell signals – and AQP3 interact. AQP3 hands off glycerin, which produces phosphatidylglycerol, which, in turn, aids skin cell differentiation.

“We think phosphatidylglycerol is the key,” Bollag said of the positive results. “If you don’t have enough, you may have psoriasis.”

The Bollag lab and others also had found that AQP3, which is present in psoriasis, appears rather immature and out of place, largely inside the cell cytoplasm instead of on the protective, outer cell membrane. The inner location puts quite a damper on its normal mature function of transporting glycerin, water and other substances through the membrane.

“If you use antibodies to visualize where AQP3 is in the keratinocytes, you will see it nicely outlining the cells because it’s right there on the plasma membrane,” Bollag said. “So clearly it’s normally expressed in keratinocytes but the fact that we can upregulate it even more with an HDAC3 inhibitor suggests that normally HDAC3 keeps it in check.”

Cambridge, Massachusetts-based biotech company Shape Pharmaceuticals Inc., currently has a topical version of an HDAC inhibitor in clinical trials for cutaneous T cell lymphoma. If psoriasis patients end up taking HDAC inhibitors, low doses or a topical application likely would help avoid some side effects, including nausea, Bollag said.

One way HDAC inhibitors help fight cancer is by temporarily loosening DNA, increasing the expression of tumor-suppressing genes and making the tumor more vulnerable. HDAC inhibitors also are being explored for their potential in treating neurological diseases such as Huntington’s.

Others have provided evidence that dysregulation of AQP3 contributes to psoriasis and AQP3 is linked to other skin diseases as well like atopic dermatitis – the most common type of eczema and vitiligo, which results in white patches on the skin.

Interestingly, even though psoriatic cells are known for their propensity to replicate, it’s hard to grow an adequate number of cells for scientific study: they increase a certain amount then go quiet. There also is no real animal model of psoriasis. Moving forward, the MCG scientists may try developing a model using a topical drug for genital warts since some patients who take it develop psoriasis.

Healing wounds with cell therapy

Diabetic patients frequently have lesions on their feet that are very difficult to heal due to poor blood circulation. In cases of serious non-healing infections, a decision to amputate could be made. A new therapeutic approach, presented recently in the Journal of Investigative Dermatology by Canadian researchers affiliated with the University of Montreal Hospital Research Centre (CRCHUM), could prevent these complications by promoting wound healing.

The solution isn’t what you might expect, not just another antibiotic ointment or other prescription medication. It’s the approach that’s different, a way to heal through personalized medicine. “We discovered a way to modify specific white blood cells — the macrophages — and make them capable of accelerating cutaneous healing,” explained nephrologist Jean-François Cailhier, a CRCHUM researcher and professor at the University of Montreal.

It has long been known that macrophages play a key role in the normal wound healing process. These white cells specialize in major cellular clean-up processes and are essential for tissue repair; they accelerate healing while maintaining a balance between inflammatory and anti-inflammatory reactions (pro-reparation).

“When a wound doesn’t heal, it might be secondary to enhanced inflammation and not enough anti-inflammatory activity,” explained Cailhier. “We discovered that macrophage behaviour can be controlled so as to tip the balance toward cell repair by means of a special protein called Milk Fat Globule Epidermal Growth Factor-8, or MFG-E8.”

Cailhier’s team first showed that when there is a skin lesion, MFG-E8 calls for an anti-inflammatory and pro-reparatory reaction in the macrophages. Without this protein, the lesions heal much more slowly. Then the researchers developed a treatment by adoptive cell transfer in order to amplify the healing process.

Adoptive cell transfer consists in treating the patient using his or her own cells, which are harvested, treated, then re-injected in order to exert their action on an organ. This immunotherapeutic strategy is usually used to treat various types of cancer. This is the first time it has been shown to also be useful in reprogramming cells to facilitate healing of the skin.

“We used stem cells derived from murine bone marrow to obtain macrophages, which we treated ex vivo with the MFG-E8 protein before re-injecting them into the mice, and we quickly noticed an acceleration of healing,” said Dr. Patrick Laplante, Cailhier’s research assistant and first author of the study.

Added Dr. Cailhier, “the MFG-E8 protein, by acting directly upon macrophages, can generate cells that will orchestrate accelerated cutaneous healing.”

The beauty of this therapy is that the patient (in this case the mouse) is not exposed to the protein itself. Indeed, as Dr. Cailhier explained, “if we were to inject the MFG-E8 protein directly into the body there could be effects, distant from the wound, upon all the cells that are sensitive to MFG-E8, which could lead to excess repair of the skin causing aberrant scars named keloids. The major advantage [of this treatment] is that we only administer reprogrammed cells, and we find that they are capable of creating the environment needed to accelerate scar formation. We have indeed discovered the unbelievable potential of the macrophage to make healing possible by simple ex vivo treatment.”

What now remains to be done is to test this personalized treatment using human cells. Thereafter, the goal will be to develop a program of human cell therapy for diabetic patients and for victims of severe burns. It will take several years of research before this stage can be reached.

This advanced personalized treatment could also make all the difference in treating cases of challenging wounds. According to the World Health Organization, diabetes affects 8.5% of the global population, and amputation rates of the lower extremities are 10 to 20 times higher in diabetics. “If, with this treatment, we can succeed in closing wounds and promoting healing of diabetic ulcers, we might be able to avoid amputations,” Dr. Cailhier said.

“Serious burn victims could also benefit,” he added. “By accelerating and streamlining the healing of burns, we may be able to reduce the infections and keloids that unfortunately develop much too often in such patients.” Cancer patients requiring extensive reconstruction surgery could also benefit, he said.

 

Drug Combination Delivered by Nanoparticles May Help in Melanoma Treatment

The first of a new class of medication that delivers a combination of drugs by nanoparticle may keep melanoma from becoming resistant to treatment, according to Penn State College of Medicine researchers.

CelePlum-777 combines a special ratio of the drugs Celecoxib, an anti-inflammatory, and Plumbagin, a toxin. By combining the drugs, the cells have difficulty overcoming the effect of having more than one active ingredient.

Celecoxib and Plumbagin work together to kill melanoma cells when used in a specific ratio. Researchers used microscopic particles called nanoparticles to deliver the drugs directly to the cancer cells. These particles are several hundred times smaller than the width of a hair and can be loaded with medications.

“Loading multiple drugs into nanoparticles is one innovative approach to deliver multiple cancer drugs to a particular site where they need to act and have them released at that optimal cancer cell killing ratio,” said Raghavendra Gowda, assistant professor of pharmacology, who is the lead author on the study. “Another advantage is that by combining the drugs, lower concentrations of each that are more effective and less toxic can be used.”

Celecoxib and Plumbagin cannot be taken by mouth because the drugs do not enter the body well this way and cannot be used together in the ratio needed because of toxicity.

CelePlum-777 can be injected intravenously without toxicity. Because of its small size, it also accumulates inside the tumors where it then releases the drugs to kill the cancer cells. Researchers report their results in the journals Molecular Cancer Therapeutics and Cancer Letters.

“This drug is the first of a new class, loaded with multiple agents to more effectively kill melanoma cells, that has potential to reduce the possibility of resistance development,” said senior author Gavin Robertson, professor of pharmacology, pathology, dermatology, and surgery; director of the Penn State Melanoma and Skin Cancer Center and member of Penn State Cancer Institute. “There is no drug like it in the clinic today and it is likely that the next breakthrough in melanoma treatment will come from a drug like this one.”

The researchers showed the results of CelePlum-777 on killing cancer cells growing in culture dishes and in tumors growing in mice following intravenous injection. The drug prevented tumor development in mice with no detectable side effects and also prevented proteins from enabling uncontrolled cancer cell growth.

More research is required by the Food and Drug Administration before CelePlum-777 can be tested in humans through clinical trials. Penn State has patented this discovery and licensed it to Cipher Pharmaceuticals, which will perform the next series of FDA-required tests.

Penn Medicine Launches First Apple ResearchKit App for Sarcoidosis Patients

App combines patient resources with research

Penn Medicine today launched its first Apple ResearchKit app, focused on patients with sarcoidosis, an inflammatory condition that can affect the lungs, skin, eyes, heart, brain, and other organs. The effort marks Penn’s first time using modules from Apple’s ResearchKit framework, as part of the institution’s focus on mobile health and innovative research strategies.

ResearchKit is an open source software framework designed specifically for medical research that helps doctors and scientists gather data more frequently and more accurately from participants using an iPhone. Since its launch two years ago, valuable data collected from the iPhones of patients with Parkinson’s disease, breast cancer, and asthma who opt in to use these applications, has poured into medical centers investigating better ways to study and treat these diseases.

Developed by Misha Rosenbach, MD, an assistant professor of Dermatology in the Perelman School of Medicine at the University of Pennsylvania, and Daniel O’Connor, a fourth-year Penn medical student, in collaboration with Marc Judson, MD, at Albany Medical College as well as the Foundation for Sarcoidosis Research, the app will deliver informational resources to patients, supplying links to disease information and advocacy groups, and directing them to specialists in their area based on their phone’s GPS. Patients will have the ability to opt in to a research study which can provide researchers with a trove of data about this rare disease. Optional, once-a-month surveys will query users about, for example, their symptoms and flare ups, how sarcoidosis affects their lives, and medications. The app will also optionally pull data naturally tracked through sensors on iPhone – from the weather to physical activity – to help the researchers spot any trends.

Among potential queries the technology will allow investigators to explore: When sarcoidosis is flaring, are patients walking fewer steps? Do they miss work? Does their disease flare after a week’s worth of sunny days? Does geographic location affect symptoms? Is there a seasonal variability? How quickly do patients respond to treatments?

“There’s a great opportunity that has never been done,” Rosenbach said. “In traditional research, you can’t see patients every day, but in app-based research you can suddenly get all this information about the disease in real-time and over time, from many different patients all over the world. It gives us the power to do sarcoidosis research in a way that has never been done.”

One of the biggest challenges in medical research is numbers. Researchers are faced with a shortage of patients for clinical studies. Even in a more common research space like cancer, studies have shown only 3 to 5 percent of patients volunteer to participate. But it’s especially hard in rare disease research because of a much smaller pool of patients. Sarcoidosis, which occurs in the lungs for about 90 percent of patients, is diagnosed in anywhere between 10 to 30 out of 100,000 Americans each year. It can affect nearly anyone, but disproportionately affects African Americans, particularly black women.
The largest study to date, the ACCESS trial (A Case-Control Etiologic Sarcoidosis Study), enrolled about 800 patients over a three-year period across 20 medical centers in the United States, and still failed to completely answer many critical questions, Rosenbach said.
“This new app has the potential to build up a larger cohort of more diverse patients in a shorter amount of time,” he said. “There’s a motivated and engaged group of sarcoidosis patients who are active online, but there’s a whole host of them out there we don’t know about. This app, which can securely, privately, and anonymously collect data, casts a wide net that may engage those people, and funnel valuable, much-needed information to researchers.”

The exact cause of sarcoidosis is unclear, but many researchers agree it starts from an immune response to some foreign material trigger, such as an atypical infection. When the body encounters a foreign material that it can’t fight off, it builds up a protective wall of inflammatory cells called a granuloma – lumps of cells. In sarcoidosis patients, this production never shuts off – it keeps going and going, resulting in numerous granulomas – that can damage organs, particularly the lungs.

With this project, researchers will determine whether the app is an effective method of studying the disease and collecting quality of life measurements used in today’s conventional clinical studies. Survey questions to enrollees can be tweaked throughout the process, if necessary, as new data rolls in or input from health care leaders and the sarcoidosis community emerges.

Data gathered from the app, the researchers said, could impact how tomorrow’s clinical studies are designed.

“We’re excited about future opportunities to repurpose the app for other rare diseases, as well,” O’Connor said. “With a strong app framework in place, ‘sarcoidosis’ could be swapped out for another disease, allowing wide networks of patients all over the country to participate in Penn studies without traveling to Philadelphia.”

Gene therapy for blistering skin disease appears to enhance healing in clinical trial

Grafting sheets of a patient’s genetically corrected skin to open wounds caused by the blistering skin disease epidermolysis bullosa appears to be well-tolerated and improves wound healing, according to a phase-1 clinical trial conducted by researchers at the Stanford University School of Medicine.

The results mark the first time that skin-based gene therapy has been demonstrated to be safe and effective in patients.

The findings will be published Nov. 1 in JAMA. Associate professors of dermatology Peter Marinkovich, MD, and Jean Tang, MD, PhD, share senior authorship of the study. Senior scientist Zurab Siprashvili, PhD, is the lead author.

For the study, four adult patients with recessive dystrophic epidermolysis bullosa, an excruciatingly painful genetic skin disease, received the skin grafts.

“Our phase-1 trial shows the treatment appears safe, and we were fortunate to see some good clinical outcomes,” said Tang. “In some cases, wounds that had not healed for five years were successfully healed with the gene therapy. This is a huge improvement in the quality of life for these people.”

People with epidermolysis bullosa lack the ability to properly produce a protein called type-7 collagen that is needed to anchor the upper and lower layers of the skin together. As a result, the layers slide across one another upon the slightest friction, creating blisters and large open wounds. The most severe cases are fatal in infancy. Other patients with recessive dystrophic EB can live into their teens or early adulthood with supportive care. Often these patients die from squamous cell carcinoma that develops as a result of constant inflammation in response to ongoing wounding.

The Stanford researchers showed that it was possible to restore functional type-7 collagen protein expression in patient skin grafts to stop blistering and allow wounds to heal. They also found that the protein continued to be expressed and that wound healing was improved during a year of follow up.

Looking to build upon results

The researchers seek to build upon these promising early results in a new trial that will include patients ages 13 and older.

“Moving into the pediatric population may allow us to intervene before serious chronic wounds and scars appear,” said Marinkovich, who directs the Stanford Blistering Disease Clinic. Repeated rounds of wounding and scarring on the fingers and palms, for example, often lead to fusion of the skin and the formation of what’s known as a “mitten hand.”

Siprashvili used a virus to deliver a corrected version of the type-7 collagen gene into batches of each patient’s skin cells that had been harvested and grown in the laboratory. He coaxed these genetically corrected cells to form sheets of skin about the size of an iPhone 5. The sheets were then surgically grafted onto the patient’s chronic or new wounds in six locations.

The researchers tracked the status of the grafts at one-, three- and six-month intervals for at least a year, checking to see if they stayed in place and caused wound closure. They also looked for any evidence of an immune reaction to the grafts, and whether the grafts continued to make the corrected type-7 collagen protein.

All 24 grafts were well-tolerated, the researchers found. Furthermore, they could detect expression of the type-7 collagen protein in the correct location of the skin in nine out of 10 tissue biopsies at three months. After 12 months, they were able to detect the collagen protein in five out of 12 biopsies.

Wound healing

Similar results were seen with wound healing. After three months, 21 of the 24 grafts were intact. This number dropped to 12 out of 24 after one year.

“Even a small improvement in wound healing is a huge benefit to the overall health of these patients,” said Tang. “For example, it may reduce the likelihood of developing squamous cell carcinoma that often kills these patients in young adulthood.”

Coupling grafts with hand surgery to break up scarred, fused tissue could help patients maintain the use of their hands, Marinkovich said.

Tang, Marinkovich and their colleagues will continue to monitor the patients in the phase-1 trial throughout their lifetimes to assess any long-term effects of the grafts.

The completion of the phase-1 trial and the potential to improve upon these outcomes is due to a concerted, long-term effort at Stanford to find ways to help young patients with this devastating disease.

The researchers are now starting a phase-2 clinical trial and are looking for new patients. For more information, send an email to tangy@stanford.edu or mpm@stanford.edu.

“This trial represents the culmination of two decades of dedicated clinical and basic science research at Stanford that began with the arrival of the former dean of the School of Medicine, Eugene Bauer, who set up the multidisciplinary EB Center at Stanford,” said Tang. “We have been working for a long time to get to this potential therapy into patients. We had to discover the genes and proteins involved and the responsible mutations. We then had to learn to deliver the corrected gene and grow those cells into sheets suitable for grafting.”

“We could not have reached this point without the support of the EB patients and their families,” said Marinkovich. “Since the time of my research training in the laboratory of Robert Burgeson, PhD, who discovered type-7 collagen, I’ve been deeply motivated to contribute to the EB community, and it is very satisfying to be able to finally see this molecular therapy come to fruition.”

The work is an example of Stanford Medicine’s focus on precision health, the goal of which is to anticipate and prevent disease in the healthy and precisely diagnose and treat disease in the ill.

Stem Cell Study Finds Mechanism That Controls Skin and Hair Color

A pair of molecular signals controls skin and hair color in mice and humans — and could be targeted by new drugs to treat skin pigment disorders like vitiligo, according to a report by scientists at NYU Langone Medical Center.

Finding ways to activate these pathways, researchers say, could lead to therapies that repigment skin cells damaged in vitiligo, a disfiguring illness marked by the loss of skin pigmentation, leaving a blotchy, white appearance. The same pathways could serve as targets for drug therapies that repigment grayed hair cells for people seeking a younger look but who are allergic to cosmetic dyes. Such therapies might even one day reinforce pigment to correct discoloration around scars.

In experiments in mice and human cells, researchers found that control of these skin and early-stage hair cells, known as melanocyte stem cells, is regulated by cell-to-cell signaling reactions. These reactions are part of the endothelin receptor type B (EdnrB) and the Wnt signaling pathways.

Previous research had shown that endothelin proteins and the EdnrB pathway help control blood vessel development, as well as some aspects of cell growth and division, the scientists say. But they believe that their new findings, to be published in the journal Cell Reports online April 28, are the first evidence tying the signaling pathways to the routine growth of cells that produce pigment (melanocytes) and provide color to skin and hair.

They say the study is the first to outline the link between EdnrB and Wnt signaling, confirming that EdnrB coordinates the rapid reproduction of melanocyte stem cells.

“Our study results show that EdnrB signaling plays a critical role in growth and regeneration of certain pigmented skin and hair cells and that this pathway is dependent on a functioning Wnt pathway,” says study senior investigator and cell biologist Mayumi Ito, PhD. Ito is an associate professor in the Ronald O. Perelman Department of Dermatology at NYU Langone and a member of NYU Langone’s Helen L. and Martin S. Kimmel Center for Stem Cell Biology.

Among the study’s key findings, Ito reports, was that mice bred to be deficient in the EdnrB pathway experienced premature graying of their fur.

Study co-lead investigator and postdoctoral fellow Wendy Lee, PhD, says the pathway’s involvement in determination of hair color was “clearly evident” in the mice when she first examined them.

In further experiments in mice, stimulating the EdnrB pathway resulted in a 15-fold increase in melanocyte stem cell pigment production within two months, producing what Ito calls “hyperpigmentation.” Wounded skin in normally white mice became dark upon healing.

In the latest study, Ito and her team found that blocking Wnt signaling stalled stem cell growth and the maturing of stem cells into normally functioning melanocytes, even when endothelin proteins were present. This led to mice with unpigmented grayish coats.

Ito says her team plans further investigations into how other cell repair and signaling pathways interact with EdnrB and melanocyte stem cells.

According to the National Institute of Arthritis and Musculoskeletal and Skin Diseases, vitiligo occurs in about 1 percent of people worldwide.