MXPA05013435A - Treatment and prevention of excessive scarring with 4-hydroxy tamoxifen - Google Patents

Abstract

The present invention provides a method for treating or preventing excessive scarring, including keloid and hypertrophic scars, by administering 4-hydroxy tamoxifen to a patient with excessive scarring or a wound at risk for developing excessive scarring.

Description

TREATMENT AND PREVENTION OF EXCESSIVE CICATRIZATION WITH TAMOXIFEN 4-HIDROXI BACKGROUND OF THE INVENTION The present invention relates to the treatment and prevention of excessive scarring, including hypertrophic and keloid scars, with tamoxifen 4-hydroxy (4-OHT). Keloid scars, or keloids, are overgrowths of dense fibrous tissue resulting from variations in normal wound healing. The dense fibrous tissue of a keloid extends beyond the edges of the original wound, and usually does not return spontaneously. In this way, the keloid scarring is out of proportion to the severity of the inciting wound. Similarly, hypertrophic scars are also overgrowths of dense fibrous tissue resulting from abnormal wound healing. However, hypertrophic scars do not extend beyond the original limits of a wound. Also different from keloids, hypertrophic scars reach a certain size, then stabilize or return. The process of normal healing of wounds extends over a period of one to two years, and conceptually consists of three distinct stages. The first stage, the inflammatory stage, is intensely degrading. It starts immediately after the injury and provides a means to remove damaged tissue and external material from the wound. A few days after the injury, the second stage, the stage of proliferation and matrix synthesis, begins. During this stage, fibroblasts from surrounding tissues move toward the wound and proliferate. Fibroblasts actively produce collagen, which is secreted in the extracellular matrix. The newly synthesized collagen forms degraded fibrils, which provide structural integrity to the wound. After several weeks, the final stage, the remodeling stage, begins. During the remodeling stage, the collagen fibrils, which are previously randomly oriented, align in the direction of mechanical strength, providing additional mechanical intensity to the wound. After the completion of the entire process, the skin regains its physical and chemical barrier functions. Six to eight weeks in the process of normal wound healing, the anabolic and catabolic processes reach a balance. At this time, the scar resistance is approximately 30-40% healthy skin, and the scars are typically hyperemic and thick. During the following several months, the catabolic and anabolic processes are eliminated, and the progressive degradation of the collagen fibers improves the tensile strength of the wound. Also, the hyperemia and thickness decrease until the mature, flexible, white, flat scar develops. Excessive scarring results from an imbalance in the anabolic and catabolic processes of wound healing. In the formation of an excessive scar, more collagen is produced than it degrades. As a result, the scars grow larger than required for wound healing, with an overproduction of cells, collagen and proteoglycan. Keloids that grow in all directions, rise above the skin, and remain hyperemic. The exact mechanisms of excessive scarring are poorly understood, but it is believed that common mechanisms enhance the formation of both keloid and hypertrophic scars. Evidence suggests that the increased transformation growth factor β1 (TGF-β1) plays a role in excessive scarring. TGF-β1 promotes the production of extracellular matrix, and is produced at high levels by keloid fibroblasts. Keloid and hypertrophic scars are primarily of cosmetic interest but can cause contractures, which can result in a loss of function if they cover a joint. Additionally, excessive scars can be painful, pruritic and cause a burning sensation. Once the keloid lesions occur, they tend to continue the growth from weeks to months, even for years. The growth usually progresses slowly, but the keloids occasionally lengthen rapidly, still tripling in size within months. Hypertrophic scars tend to stabilize, and return over time. However, this regression can be very slow, and often incomplete. The administration of hypertrophic and keloid scars continues to be an unsolved clinical problem. Although many forms of treatment have been used, none has proven to be consistently reliable. Current forms of treatment include use of occlusive healing, compression therapy, intralesional corticosteroid injections, radiation therapy, and surgery. Occlusive cures and pressure devices are unpredictable forms of treatment, since a large percentage of patients treated by these means show little or no improvement. Additionally, compliance with these forms of treatment can be impractical. For example, it may be necessary for cures and pressure devices to be used 24 hours for up to 12 months. For a scar in a sensitive or visible location, this simply may not be possible. Intralesional corticosteroids have been the main ones in keloid treatment. Corticosteroids reduce excessive scarring by reducing collagen synthesis, by altering glycosaminoglycan synthesis, and by reducing the production of inflammatory mediators and fibroblast proliferation during wound healing. However, about half of all keloids fail to respond to corticosteroids, and about half of the scars that are resolved completely by corticosteroid therapy recur. Additionally, corticosteroid injections can cause several complications, including atrophy, telangiectasia formation, and skin depigmentation. 'Radiation therapy may be the only predictably effective treatment for keloids that is currently available. It has the potential to cause cancer, however, and for this reason it is not generally recommended or accepted as a keloid treatment. In addition, approximately 20 percent of keloids treated by radiation therapy only occur within a year. Surgical procedures, including excision, cryosurgery and laser therapy, can effectively remove keloid tissue, and are currently the treatment of choice for hypertrophic scars. However, these techniques often cause tissue trauma that results in additional keloid and hypertrophic scars. In fact, keloids recur in more than half of patients treated by surgical excision, cryosurgery, and laser therapy. Additionally, these procedures cause pain and present a risk of infection. Cryosurgery also causes depigmentation of the skin in some patients. As an alternative keloid treatment, some researchers have proposed using the drug for breast cancer, tamoxifen (Hu, 1998; Hu 2002). In vitro, tamoxifen inhibits keloid fibroblast proliferation and decreases collagen production. Apparently, tamoxifen effects this inhibition by downregulating the expression of TGF-β1, which promotes the formation of collagen (Chau 1998; Mikulec, 2001). The in vitro use of tamoxifen to treat scars would have disadvantages, however. Tamoxifen is currently available only for oral administration, and its administration in this way poses serious health risks and causes unwanted, significant side effects. Tamoxifen potentially impacts every estrogen receptor in the body, and, as both an agonist and antagonist, causes a wide range of systemic effects. These effects include the increased risk of cancer, endometrial hyperplasia and polyps, deep vein thromboids and pulmonary embolism, changes in enzyme levels in the liver, and eye disturbances, including cataracts. Additionally, patients treated with oral tamoxifen reported hot flushes, vaginal discharge, depression, amenorrhea, and nausea (Fentiman 1986, Fentiman 1988, Fentiman 1989, and Ibis 2002). Tamoxifen locally administered, which may possess few risks, could eliminate liver metabolism from the first step, which changes tamoxifen into its active metabolites. Without a liver mechanism, tamoxifen would be less effective. In this way, despite the wide range of available treatments, there are no widely accepted and predictably effective means to prevent or treat excessive scars. Therefore, an effective approach to reduce hypertrophic scars and keloids would offer significant benefit if it also causes systemic side effects.

BRIEF DESCRIPTION OF THE INVENTION This invention relates to a method for minimizing or preventing excessive scarring, including keloid scars and hypertrophic scars. The method comprises administering an effective amount of tamoxifen 4-hydroxy for a period of time sufficient to minimize the scar or prevent its formation. This treatment approach offers several advantages over other treatments for scars, including (1) few systemic side effects, (2) a better safety profile, (3) easy patient compliance. Additionally, tamoxifen 4-hydroxy can be administered to a wound prophylactically to prevent or minimize excessive scar formation. To perform the inventive method, tamoxifen 4-hydroxy can be administered by any means that delivers it to a wound or scar tissue in vivo. Preferably, the administration is carried out by means which deliver tamoxifen 4-hydroxy locally, limiting the systemic exposure to the medicament. Examples of such modes include (1) topical administration at the site of a wound or scar, (2) direct injection at a scar or wound site, and (3) implementation of a controlled release polymer or other delivery device incorporating tamoxifen 4-hydroxy. The inventive method can be performed as the only form of therapy or prophylaxis, or it can be combined with other forms. A wide range of topical formulations are suitable for carrying out the invention, but hydroalcoholic solutions and hydroalcoholic gels are preferred. The concentration of tamoxifen 4-hydroxy in these formulations may vary, but a dose should result in local concentrations of tamoxifen 4-hydroxy that effectively inhibit fibroblast proliferation and collagen production.

BRIEF DESCRIPTION OF THE FIGURES Figure 1 shows the extensive metabolism of tamoxifen in humans. Figure 2 shows a plasma concentration-time curve, after cutaneous administration of tamoxifen 4-hydroxy gel to healthy women.

DETAILED DESCRIPTION OF THE PREFERRED MODALITIES The present inventors have discovered that, by administering tamoxifen 4-hydroxy in a pharmaceutically effective amount, one can treat or prevent excessive scars with fewer desired side effects. In this way, the approach of the invention provides a superior safety profile and easier compliance of the patient, compared to other prophylactic and treatment methods. According to the present invention, the term "excessive scar" or "excessive scarring" refers to overgrowths of dense fibrous tissue resulting from normal wound healing. Excessive scars have developed larger than what is necessary for normal wound healing, and are characterized by overproduction of cells, collagen and / or proteoglycan. "Keloid scars" are excessive scars in which the dense fibrous tissue extends beyond the edges of the original incision or wound, and usually does not return spontaneously. The determination of whether a scar is a keloid can be difficult, since keloids often superficially resemble other hypertrophic scars. However, keloids have distinguished histological features. Such a feature is the collagen nodule, which contains a high density of unidirectional fibroblasts and collagen fibrils in a distinct and highly organized orientation. Additionally, keloids have a rich vasculature, a high mesenchymal cell density, and a thick epidermal cell layer. Genetics and skin color, which correlate with keloid formation, also help in determining if a scar is a keloid. Since no less than 16% of black Africans have keloids, while Polynesians, Chinese, Indians and Malians have less. Albino whites have even less. Patients with keloid scars tend to have a strong family history associated; Both modes of transmission, autosomal dominant and autosomal recessive, have been reported. Factors that correlate with keloid formation are also useful for the determination of whether a patient will benefit from prophylactic administration of tamoxifen 4-hydroxy. According to one aspect of the invention, tamoxifen 4-hydroxy is administered to a patient having a wound, when the patient presents a high risk of keloid formation. The factors specifically useful for determining a high risk are a family and individual keloid history. "Hypertrophic scars" are excessive scars in which the dense fibrous tissue does not extend beyond the edges of the original wound or incision. They tend to be wider than necessary for normal wound healing to occur. Histologically, hypertrophic scars have more organized collagen fibers than keloids, and sparse mucoid matrix. Hypertrophic lesions are characterized by randomly distributed tissue groups consisting of cells and uniaxially oriented extracellular matrix. The compound tamoxifen 4-hydroxy, or 1 - [4- (2-N-dimethylaminoethoxy) phenyl] -1- (4-hydroxyphenyl) -2-phenylbut-1-ene, constitutes an active metabolite of the well-characterized anti-estrogen compound , tamoxifen. There are both isomers, E and Z, any of which, alone or in combination, are useful according to the present invention. The Z isomer is preferred. It is well known that tamoxifen 4-hydroxy acts as a selective estrogen receptor modulator (SERM) that shows tissue specificity for estrogen receptor tissues. Studies have shown that tamoxifen 4-hydroxy can regulate the transcription activity of estrogen-related receptors, which may contribute to its tissue-specific activity. In vitro, tamoxifen 4-hydroxy shows more potency than tamoxifen, as measured by affinity binding to estrogen receptors, or Ers, and a binding affinity similar to estradiol for estrogen receptors (Robertson et al., 1982; Kuiper ef al., 1997). Z-tamoxifen 4-hydroxy inhibits the growth in culture of normal human epithelial sinus cells 100 times more than Z-tamoxifen (Malet et al., 1988). Although tamoxifen 4-hydroxy is a metabolite of tamoxifen, its usefulness in treating and preventing excessive scarring is not presaged by prior experience with tamoxifen by itself. Tamoxifen is extensively metabolised in humans, as shown in Figure 1. In this way, its in vivo action is the net result of individual actions by the compound of origin and its metabolite compounds competing for the occupation of receptors within target tissues. For example, see Jordán, 1982. Each of these compounds manifests different and unpredictable biological activities in different cells, determined in part by each individual effect of the compound in conformation of the receptor. That is, the receptor binding of each compound generates a single receptor-ligand conformation that recruits different cofactors, and results in variable pharmacologies for the different compounds (Wijayaratne et al., 1999; Giambiagi et al., 1988). Several examples of these variable effects have been documented. For example, tamoxifen but not tamoxifen 4-hydroxy is a potent rat liver carcinogen. (Carthew ef al., 2001; Sauvez ef al., 1999). Additionally, tamoxifen but not tamoxifen 4-hydroxy initiates apoptosis in mammary epithelial cells of normal human (Dietze et al., 2001). . In contrast, tamoxifen 4-hydroxy shows a significant inhibitory effect on estrone suitate activity in breast cancer cell lines, although tamoxifen has little or no effect in this regard (Chetrite et al., 1993). The methods for preparing tamoxifen 4-hydroxy are well known. For example, U.S. Pat. UU No. 4,919,937 for Mauvais-Jarvis et al., Describes a synthesis derived from Robertson and Katzenellenbogen, 1982. This synthesis occurs in several stages: Stage 1 - Reaction between bromide of 4- (β-dimethylaminoethoxy) -a-ethyldeoxibenzoin and p- (2-tetrahydropyranyloxy) phenylmagnesium; Stage 2 - Separately from stage 1, the formation of 1 - . 1- (4-hydroxyphenyl) -2-phenyl-1-butanone by hydroxylation of 1,2-diphenyl-1-butanone; Step 3 - Reaction between the products of steps 1 and 2 to form 1- (4-dimethylaminoethoxyphenyl) -1 - [p-2-tetrahydropyranyloxy) phenyl] -2-phenylbutan-1-ol; Step 4 - Dehydration with methanol / hydrochloric acid produces 1 - [p- (β-dimethylaminoethoxy) phenyl] -Z-1 - (p-hydroxyphenyl) -2-phenyl-1-but-1-ene = 4-OH-tamoxifen , a mixture of E and Z isomers; Step 5 - Separation of the E and X isomers by chromatography and crystallization for constant specific activity. According to the present invention, tamoxifen 4-hydroxy can be administered in any dosage form and through any system that delivers the active compound to a wound or scar in vivo. Preferably, the administration is carried out by a medium that delivers tamoxifen 4-hydroxy locally, limiting systemic exposure to the drug. For example, tamoxifen-4-hydroxy, alone or in combination with a pharmaceutically acceptable carrier, can be applied topically to the surface of a scar or wound site, can be injected at a scar or wound site, or can be incorporated into a release polymer controlled and surgically implanted in a region to be treated. The optimal method to administer an acceptable dose to minimize scarring will depend on the location of the scar and the degree of scarring. Preferably, tamoxifen 4-hydroxy is delivered topically, such as by "cutaneous administration", a phrase denoting any way to deliver a medicament from the surface of a patient's skin, through layers of stratum corneum, epidermis, and dermis, and in the microcirculation. This is typically done by diffusion under a concentration gradient. Diffusion can occur through intracellular penetration (through cells), intercellular penetration (between cells), transapendageal penetration (through hair follicles, sebaceous glands and sweat glands), or any combination of these. Topical administration offers the distinct advantage of not being invasive. An appropriate dose for administration should result in local 4-hydroxy tamoxifen concentrations that effectively inhibit fibroblast proliferation and collagen production, without causing significant side effects. Although the invention is not limited to any particular theory, clinically significant side effects of anti-estrogen agents occur when agents displace estradiol in non-target tissues. Because tamoxifen 4-hydroxy and estradiol have similar binding affinities for estrogen receptors, a competition between them for receptor binding would be approximately equal when the concentration of each compound approximates that of the other. If the concentration of tamoxifen 4-hydroxy exceeds the concentration of estradiol, then the former should preferentially bind to the estrogen receptors, and vice versa. Accordingly, doses of tamoxifen-4-hydroxy which result in plasma concentrations lower than the estradiol concentration are preferred. The daily doses to be administered can be estimated initially based on the absorption coefficients of tamoxifen 4-hydroxy, the concentration of tissue that is desired, and the concentration of plasma that should not be exceeded. By administering tamoxifen 4-hydroxy locally, high concentrations can be achieved in the target tissue without simultaneously elevating plasma levels of tamoxifen 4-hydroxy to a point where significant systemic competition occurs for estradiol receptors. Of course, the initial dose can be optimized in each patient, depending on individual responses. In a topical formulation, doses in the order of 0.25 to 3 ug of tamoxifen 4-hydroxy / cm / day should achieve the desired result, with doses of approximately 0.5 to 2.5 ug / cm2 / day being preferred. Doses of approximately 1.0 and 2.0 ug / cm2 / day are more highly preferred. Cutaneous administration can be carried out mainly in two different ways: (i) by mixing a therapeutically active compound or its non-toxic pharmaceutically acceptable salt with pharmaceutically suitable carriers and, optionally, penetration enhancers to form ointments, emulsions, lotions, solutions, creams, gels or the like, wherein a quantity of said preparation is applied over a scar or wound site, or (ii) by incorporating the therapeutically active substance in patches or transdermal delivery systems according to known technology. The effectiveness of cutaneous drug administration depends on many factors, including drug concentration, surface area of application, time and duration of application, skin hydration, physicochemical properties of the drug, division of the drug between the formulation and the skin. Drug formulations proposed for cutaneous use take advantage of these factors to achieve optimal delivery. Such formulations often contain penetration enhancers that improve skin absorption by reducing the resistance of the stratum corneum by reversibly altering its physicochemical properties, by changing hydration in the stratum corneum, acting as a co-solvent, or by changing the organization of lipids and proteins in the stratum corneum. Intercellular spaces. Such skin absorption enhancers include surfactants, D SO, alcohol, acetone, propylene glycol, polyethylene glycol, fatty acids, fatty alcohols and related molecules, pyrrolidones, urea, and essential oils. In addition to chemical enhancers, physical methods can increase skin absorption. For example, occlusive bandages induce skin hydration. Other physical methods include iontophoresis and sonophoresis, which use electric fields and high frequency ultrasound, respectively, to increase the absorption of drugs that are poorly absorbed due to their size and ionic characteristics. The many factors and methods relating to cutaneous drug delivery are reviewed in REMI NGTON: THE SCI ENCE AND PRACTICE OF PHARMACY, Alfonso R. Gennaro (Lippincott Williams &; Wilkins, 2000), on pages 836-58, and in PERCUTANEOUS ABSORPTION: DRUGS COSMETICS MECHANISM METHODOLOGY, Bronaugh and Maibach (Marcel Dekker, 1999). As this publication demonstrates, those in the pharmaceutical field can manipulate the various factors and methods to achieve effective skin delivery. Tamoxifen 4-hydroxy is a large and very lipophilic molecule; therefore, without assistance penetration enhancers penetrates poorly into the skin. Accordingly, the tamoxifen 4-hydroxy formulations used in the present invention preferably contain one or more penetration enhancers. Alcohols are preferred enhancers because tamoxifen 4-hydroxy is soluble in alcohol. Isopropyl myristate is also a preferred intensifier. For cutaneous administration, tamoxifen 4-hydroxy can be supplied in an ointment, cream, gel, emulsion (lotion), powder, oil or similar formulation. For this purpose, the formulation may comprise common excipient additives, including vegetable oils such as almond oil, olive oil, peach seed oil, peanut oil, castor oil and the like, animal oils, DMSO, fat and substances similar to fat, lanolin lipoids, phosphatides, hydrocarbons such as paraffins, gelatinous petroleum, waxes, detergent emulsifying agents, lecithin, alcohols, carotin, glycerol, glycerol ethers, glycols, glycol ethers, polyethylene glycol, polypropylene glycol, non-volatile fatty alcohols, acids, esters, volatile alcohol compounds, urea, talc, cell derivatives and preservatives. To practice the present invention, the preferred formulations contain tamoxifen 4-hydroxy in a hydroalcoholic gel. The amount of tamoxifen 4-hydroxy per 100 grams of gel can vary from about 0.001 gram to about 1.0 gram. Preferably, it ranges from about 0.01 gram to about 0.1 gram. Table 1 describes the composition of two highly preferred 4-hydroxy tamoxifen gel formulations.

Table 1: Composition of Tamoxifen Gel Formulations 4- Hydroxy In accordance with the present invention, tamoxifen 4-hydroxy is also delivered through the transdermal patch. In one embodiment, the patch comprises a container for the tamoxifen 4-hydroxy formula. The patch may comprise (a) a backing sheet impervious to the solution, (b) an element similar to a layer having a cavity, (c) a permeable microporous-semipermeable membrane, (d) a self-adhesive layer, and ( e) optionally, a backup film. The element similar to a layer having a cavity can be formed by the backing sheet and the membrane. Alternatively, the patch may comprise (a) a backing sheet impermeable to the solution, (b) an open-pored foam, a closed-pored foam, a tissue-like layer or a fibrous network-like layer as a container, (c) if the layer according to (b) is not self-adhesive, a self-adhesive layer and (d) optionally a removable backing film. It is contemplated that the administration of tamoxifen 4-hydroxy may be combined with other keloid therapies. According to the present invention, therefore, administration of tamoxifen-4-hydroxy can be accompanied by the use of cures, compression therapy, intralesional corticosteroid injections, radiation therapy and surgery, including cryotherapy and laser therapy. Reference will now be made to the following illustrative examples that will help to provide a more complete understanding of the invention. Example 1: Demonstration of Skin Delivery of Tamoxifen 4-Hydroxy Four patients with breast cancer received [3H] -tamoxifen 4-hydroxy in an alcohol solution applied directly to the sinuses at specific intervals between 12 hours to 7 days before surgery to Remove the diseased tissue. After surgery, both the excised tissue and the normal breast tissue surrounding the tumor contained radioactivity (Kuttenn et al., 1988). In a subsequent study, 9 of 12 patients scheduled for surgical removal of hormone-dependent breast cancer received Z- [3H] -tamoxyphene 4-hydroxy (80 μCi) in 60% alcohol solution, and 3 patients received Z- [ 3H] -tamoxifen (80 μCi) for comparison. Patients received medication marked with [3H] applied directly to the affected sinuses at specific intervals ranging from 12 hours to 7 days before surgery to remove the diseased tissue. The breast tissue of three regions: the tumor, tissue immediately surrounding the tumor, and normal tissue, is immediately excised and frozen in liquid nitrogen.

Additionally, plasma and urine samples are obtained at scheduled intervals and frozen until analysis. Table 2 shows results of the analyzes performed. Tamoxifen 4-hydroxy concentrated predominantly in the cytosolic and nuclear fractions of breast tissue, where estrogen receptors are present. In these intracellular sites, tamoxifen 4-hydroxy remained unmetabolized except for limited somerization from form Z to E. Retention in the breast lasted approximately 4 days in the tamoxifen 4-hydroxy group, but was shorter and weaker in the tamoxifen group. Table 2: [3H] -tamoxifen 4-hydroxy and metabolites identified in breast tumor tissue after cutaneous administration of Z- [3H] -tamoxifen 4-hydroxy to the affected breast Time after administration of Z- [H] -tamoxifen 4-hydroxy The percentage of radioactivity identified as [3H] -tamoxyphene 4-hydroxy in breast tissue after cutaneous administration decreased slowly over seven days (from 97% to 65%). During this period, a progressive isomerization of the Z isomer in the E-isomer occurred, with similar percentages observed on day 7 (32% and 33%).

The radioactivity in the blood due to [3H] -tamoxyphen-hydroxy increased gradually, with an interval of 4 to 6 days. This contrasts with [3H] -tamoxifen, which appeared quickly in the blood, interval in 2 days. 36 hours after cutaneous administration of [3 H] -tamoxyphen 4-hydroxy, only 0.5% of the radioactivity administered was shown in the blood. Marked metabolism of tamoxifen 4-hydroxy occurred in the blood, in contrast to the next absence of such metabolism in the breast tissue. 24 hours after the administration, 68% of the radioactivity in the blood represented tamoxifen 4-hydroxy, 18% represented N-demethyl-tamoxifen 4-hydroxy, and 1 1% represented bisphenol. The maximum urinary elimination occurred a later time after cutaneous administration of tamoxifen 4-hydroxy compared with cutaneous tamoxifen. After the application of tamoxifen 4-hydroxy, a progressive increase of metabolites, mostly N-demethyl-tamoxifen 4-hydroxy and bisphenol, is observed in the urine. This example demonstrates that the cutaneous application of tamoxifen 4-hydroxy results in a substantial and durable local tissue concentration of the drug, with minimal metabolism, very low and stable plasma concentrations, and slow elimination through the urine. Example 2: Demonstration of the Pharmacokinetics and Pharmacodynamics of 4-OH-Tamoxifen cutaneously administered compared to 20 mg of oral tamoxifen This study compared tissue and plasma concentrations of tamoxifen 4-hydroxy after cutaneous administration through a hydroalcoholic gel with tissue and plasma concentrations of tamoxifen 4-hydroxy after oral administration of tamoxifen. (Pujol ef al.,). Thirty-one patients scheduled for breast cancer surgery are randomly assigned to 1 of 5 groups. They received treatment with either tamoxifen oral or tamoxifen 4-hydroxy cutaneous as outlined in Table 3. The treatment was daily and hard for 3-4 weeks before surgery. The study evaluated three different doses of tamoxifen 4-hydroxy (0.5, 1, or 2 mg / day) and two application areas (either to breasts or to large areas of skin including arms, forearms and shoulders). A group of patients received 20 mg / day (10 mg b. I.d) of oral tamoxifen (Nolvadex®). Table 3; Treatment groups to 10 mg b.i.d. b divided into 2 daily applications; 1 mg in the morning and 1 mg in the afternoon The tamoxifen 4-hydroxy gel (20 mg of tamoxifen 4- hydroxy / 100 g of hydroalcoholic gel, Besins-lsovesco Laboratories) is packed in a pressurized dose measuring pump that supplies 1.25 g of gel / measured dose (ie, 0.25 mg of tamoxifen 4-hydroxy / dose). During surgery, two samples (1 cm3 each) of breast tissue are removed, one tumor and the other macroscopically normal. They are immediately frozen in liquid nitrogen until analyzed. Blood samples are obtained on the day and the day before surgery. All tissue and plasma samples are analyzed for tamoxifen 4-hydroxy concentration by gas chromatography / mass spectrometry (GC-MS). Pre and post-treatment blood samples are analyzed for blood counts (CBC), bilirubin, serum glutamic-pyruvic transaminase (SGPT), serum glutamic-oxaloacetic transaminase (SGOT), alkaline phosphatase, creatinine, estradiol, follicle stimulating hormone (FSH), luteinizing hormone (LH), sex hormone binding globulin (SHBG), cholesterol, high density lipoprotein (HDL), low density lipoprotein (LDL), triglycerides, fibrinogen, and anti-thrombin I II. Table 4 below summarizes the concentration of tamoxifen 4-hydroxy found in breast and plasma tissue. Normal and tumor breast tissues contained similar concentrations of tamoxifen 4-hydroxy in five treatment groups. Tamoxifen 4-hydroxy was concentrated in higher amounts in breast tissue when the gel is applied directly to the breasts, unlike other large surfaces of the skin. Side effects do not have a significant problem. The cutaneous treatment does not cause any local irritation. A woman in Group 2 (0.5 mg / day of tamoxifen 4-hydroxy gel) reported rest due to dizziness, cystitis, and medium vaginitis occurring on the seventh day of treatment. A woman in Group 1 (oral tamoxifen) reported hot flushes and vaginites on the fifth day of treatment. There are no differences between pre-and post-treatment blood samples for any of the hematology or serum chemistry evaluations in patients receiving tamoxifen 4-hydroxy gel. However, a statistically significant decrease in anti-thrombin I I I and fibrinogen and a statistically significant increase in lymphocyte and platelet contents are observed in the oral tamoxifen group, consistent with the biological effects of this drug observed in other studies.

Table 4: Concentrations of tamoxifen 4-hydroxy an = 5 bn = 4 c Four patients had undetectable levels of tamoxifen-4-hydroxy (LOQ = 20 pg / ml) d Three patients had undetectable levels of tamoxifen-4-hydroxy and 2 patients had undetectable levels of tamoxifen-4-hydroxy f 1 patient had undetectable levels of tamoxifen 4-hydroxy Example 3: Demonstration of tolerance and pharmacokinetics of 4- OH-tamoxifen cutaneously administered in healthy women This study demonstrates the tolerance and pharmacokinetics of tamoxifen 4-hydroxy gel topically applied in healthy premenopausal women, aged 18-45 years. Each participant was given daily gel for the duration of two menstrual cycles. Three doses and two gel concentrations were tested, as summarized in Table 5. For AC groups, the gel, containing 20 mg of tamoxifen 4-hydroxy / 100 g, is distributed from a pressurized dose-measuring pump that supplies 0.25 mg of tamoxifen 4-hydroxy / dose. The Group C study is suspended because the amount of gel was too large to be applied to a single breast, Groups D and E received a more concentrated gel that contained almost 3 times more of tamoxifen 4-hydroxy: 57 mg of tamoxifen 4-hydroxy / 100 g, or 50 mg of tamoxifen 4-hydroxy / 100 mL of gel. This more concentrated gel was also supplied by a dose measuring pump that delivered 0.25 mg tamoxifen 4-hydroxy / dose. Table 5: Treatment groups At the end of the menstrual cycle, each patient received a single dose, after which the serial blood samples are collected at 0, 0.5, 1, 1 .5, 2, 3, 4, 6, 12, 18, 24, 36, 48 and 72 hours. The first day of the next menstruation, the treatment, which consisted of daily application of the gel during two menstrual cycles, begins. The blood samples are collected 24 hours after the morning application of gel on days 7, 20 and 25 of the first and second cycles. The last day of administration, day 25 of the second menstrual cycle, blood samples are collected before application and in 0.5, 1, 1 .5, 2, 3, 4, 6, 12, 18, 24, 36, 48 and 72 hours after the application of the gel. -The samples are analyzed by tamoxifen 4-hydroxy, estradiol, progesterone, FSH and LH. The plasma concentrations of tamoxifen 4-hydroxy remained detectable 72 hours after the last gel application. Therefore, to ensure that the data points are obtained until tamoxifen 4-hydroxy becomes undetectable in the blood, additional blood samples are collected from some participants at intervals up to 92 days after the last gel application. Table 6 displays plasma concentrations of mean + standard deviation (SD) of tamoxifen 4-hydroxy, with ranges in parentheses. A single dose of 0.5 mg does not produce detectable plasma concentrations of tamoxifen 4-hydroxy, but 6 of 12 patients had detectable plasma concentrations (> 5 pg / ml) after a single dose of 1 mg.

Tabia 6: Concentrations in average plasma + SD of tamoxifen 4-hydroxy in healthy women after daily cutaneous administration for two menstrual cycles.

LOQ = quantification method (<5pg / mL) Gel concentration was 20 mg tamoxifen 4-h? Drox? per 100 g of gel 2 Gel concentration was 57 mg of tamoxifen 4-h? drox? per 100 g of gel 3 Point at time 0 is 24 hours after application on day 24 before the final application on day 25 Figure 2 shows a plasma concentration-time curve, after the last administration on day 25 of the second menstrual cycle. Table 7 shows average pharmacokinetic parameters that are related to the last administration on day 25 of the second menstrual cycle. Table 7: Average pharmacokinetic parameters of tamoxifen 4-hydroxy in healthy women after the last administration 1 Gel concentration was 20 mg of tamoxifen 4-hydroxy per 100 g of ge 3. 2 Gel concentration was 57 mg of tamoxifen 4-hydroxy per 100 g of gel AUC0.24 = area under the concentration-time curve for 0 -24 hours; Cav = Calculation of area under the curve for 24 hours (AUC0-24) divided by 24 hours; Cmax = maximum concentration in plasma; t / 2 = average life; T (1 erC <LOQ) = first point in time at which the plasma concentration is below the limit of quantification; tmax = time of maximum concentration in plasma.

The data were consistent with a dose response across the three doses tested (0.5, 1, and 2 mg). The more concentrated gel is better absorbed, by approximately twice, than the less concentrated gel, based on AUC and Cav. The biological tolerance was excellent in the 36 patients. The treatment did not affect FSH, LH, estradiol, or progesterone hormone levels during menstrual cycles. In addition, the ultrasound examination of the ovaries at the end of the treatment was normal in all patients, showing normal size development follicles. One patient developed an allergic reaction to the gel, and 10 reported facial acne. In summary, this study indicates that exposure to tamoxifen 4-hydroxy after topical application increased with dose, that plasma concentrations of tamoxifen 4-hydroxy were lower than typical estradiol concentrations (80 pg / ml) and that there is no clinical or laboratory evidence to detect systemic effects. Example 4: Study to demonstrate efficacy for cutaneous 4-hydroxy tamoxifen to treat keloid scars The main objective of this study is to demonstrate that tamoxifen 4-hydroxy is administered cutaneously, effectively treat keloid scars. Patients diagnosed with a keloid scar receive either placebo or 4-hydroxy tamoxifen gel for a period of 6 months. For the treatment group, between 1 and 2 mg of gel-g / cm2 (57 mg 4-OHT / 100 g gel) is administered twice a day, that is, between 0.5 and 1 μg 4-OHT / cm2. Multiple endpoints of clinical efficacy are evaluated: (1) each patient assesses pain, discomfort, and itching due to keloid, (2) scars are classified into stages using the Vancouver scars scale, (3) biopsies are compared in the baseline and after 6 months of treatment by histological analysis, (4) molecular analysis of the TGF-β isoform and collagen expression are performed. Patients in the treatment group show statistically significant improvement in endpoints against patients in the placebo group. Publications cited Bronaugh and Maibach, Percutaneous Absorption: Drugs Cosmetics Mechanisms Methodology, Marcel Dekker 1999. Carthew, P., Lee PN, R. E Edwards, RT Heydon, BM Nolan, EA Martin, Cumulative exposure to tamoxifen: DNA adducts and liver cancer in the rat, Arch Toxicol, 75: 375 -80 (2001). Chetrite, G., C. Varin, L. Delalonde, J. R. Pasqualini, Effect of promegestone, tamoxifen, 4-hydroxytamoxifen and ICT 164,384 on the oestrone sulphatase activity of human breast cancer ceils, Anticancer Res, 1 3 (4) 931-4 (Jul-Aug. 1993). Chau, D., J. S. Mancoll, S. Lee, J. Zhao, L.G. Philips, G. I. Gittes, M. T. Longaker, Tamoxifen downregulates TGB-beta production in keloid fibroblasts, Ann. Plast. Surg. , 40 (5): 490-3 (1998). Dietze, E. C, LE Caldwell, SL Grupin, M. Mancini, and VL Seewald, Tamoxifen, but not 4-hydroxytamoxifen initiates apoptosis in p53 (-) normal human mammary epithelial cells by inducing mitochondrial depolarization, J. Biol. Chem. , 276 (7): 5384-94 (Feb. 16, 2001). Fentiman, I.S. , Tamoxifen and mastalgia. An emerging indication, Drugs 32: 477-80 (1986). Fentiman, I.S. , M. Caleffl, H. Hamed, and M. A. Chaudary, Dosage and duration of tamoxifen treatment for mastalgia: a controlled trial, British Journal of Surgery 75: 845-46 (1988). Fentiman, I.S. , M. Caleffi, H. Hamed, and MA Chaudary, Studies of tamoxifen in women with mastalgia, British Journal of Clinical Practice, Supplement 68, 43 (11): 34-36 (1989)) Giambiagi, N. and JR Pasqualini, I mmunologica! Differences between the estradiol-, tamoxifen and 4-hydroxy-tamoxifen estrogen receptor complexes detected by two monoclonal antibodies, J. Steroid Biochem, 30 (1-6): 213-7 (1988). Hu, D., M. Hughes, G. W. Cherry, Topical tamoxifen- a potential therapeutic regimen in treating excessive dermal scarring ?, Br. J. Plast. Surg. , 50 (6): 462-9 (1998). Hu, D., X. Zhu, M. Xu, B. Chen, AH Margaret, WC George, The inhibitory effect of tamoxifen on human dermal fibroblast-populated collagen lattices, Zhonghua Zheng Xing Wai Ke Za Zhi, (18 (3) : 160-2 (2002), IBIS Investigators, First results from the International Breast Cancer Intervention Study (IBIS-1): a randomized prevention trial, Lancet, 360 (9336): 817-24 (2002). C, Metabolites of tamoxifen in animáis and man: identification, pharmacology, and significance, Breast Cancer Res. Treat., 2 (2) 123-38 (1982) Kuiper, GGJM, B. Carlsson, K. Grandien, E. Enmark , J. Heggblad, S. Nilsson, J. Gustafsson, Comparison of the ligand binding specificity and transcript tissue distribution of estrogen receptors a and p, Endocrinology, 138: 863-870 (1 997) Kuttenn, F. and P. Mauvais -Jarvis, Intratumoral levéis and metaboMsm of 4- hydroxytamoxifen after percutaneous admi- nistration at the breast level, CR Acad. Sci. III. 300: 457-462 (1 985) (French) Malet C, A. Gompel, P. Spritzer, N Bricourt, NH Yaneva, I.

Mowszowicz, F. Kutten and P Mauvais Jarvis, Tamoxifen and hydroxytamoxifen isomers versus estradiol effects on normal human breast cells in culture, Cancer Research, 48: 71 93-71 99 (1988). Mauvais-Jarvis, P., N. Baudot, D. Castaigne, P. Banzet, and F. Kuttenn, Z-4- hydroxytamoxifen concentration and metabolism after local percutaneous administration to human breast, Cancer Research, 46: 1521 -1 525 ( 1986). Mikulec, A. A., M. Hanasono M., J. Lum, J. M. Kadleck, M. Kita, R. J. Koch, Effect of tamoxifen on transforming growth factor betal production by keloid and fetal fibroblasts, Arch. Facial Plast. Surg. , 3 (2): 1 1 1 (2001). Pujol, H. , J. Girault, P. Rouanet, S. Fournier, J. Grenier, J. Simony, J. B. Fourtillan, and J. L. Pujol, Phase 1 study of percutaneous 4-hydroxy-tamoxifen with analyses of 4- hydroxy-tamoxifen concentrations in breast cancer and normal breast tissue, Cancer Chemother. Pharmacol. , 36: 493-498 (1995). Remington: The Science and Practice of Pharmacy, Alfonso R. Gennaro, Lippincott Williams & Wilkins, 2000, pp. 836-858. Robertson and Katzenellenbogen, J. Org. Chem., 47: 2387 (1982). Robertson, D.W., J.A. Katzenellenbogen, D.J. Long, E.

A. Rorke and B. S. Katzenellenbogen, Tamoxifen antiestrogens. A comparison of the activity, pharmacokinetics, and metabolic activation of the E and Z isomers of tamoxifen, J. Steroid Biochemistry, 16 (1): 1-13 (1982). Sauvez, F., D. Salin-Drouin, M. Attia, H. Bertheux, and R. Forster, Cutaneously applied 4-hydroxytamoxien is not carcinogenic in female rats. Carcinogenesis, 20: 843-50 (1999). Wijayaratne, A.L., S.C. Nagel, L.A. Paige, D.J. Christensen, J. D. Norris, D. M. Fowlkes, and D. P. McDonnell, Comparative Analyzes of Mechanistic Difference among Antiestrogens, Endocrinology, 140 (12): 5828-5840 (1999).

Claims (9)

1. CLAIMS 1. Use of tamoxifen 4-hydroxy for the preparation of a pharmaceutical composition for treating or preventing scarring, or a wound or incision at risk of developing excessive scarring.
2. 2. A use according to claim 1, characterized in that said scar is a keloid scar.
3. 3. A use according to claim 1, characterized in that said scar is at risk of developing into a keloid scar.
4. 4. A use according to claim 1, characterized in that said scar is a hypertrophic scar.
5. 5. A use according to claim 1, characterized in that said scar is at risk of developing a hypertrophic scar.
6. 6. A use according to any of claims 1 to 5, characterized in that said tamoxifen 4-hydroxy is in a form capable of being administered cutaneously.
7. 7. A use according to any of claims 1 to 5, characterized in that said tamoxifen 4-hydroxy is in a form capable of being administered by injection.
8. 8. A use according to any of claims 1 to 6, characterized in that said tamoxifen 4-hydroxy is in a vehicle containing a penetration enhancer. 9. A use according to any of claims 1 to 8, characterized in that said tamoxifen 4-hydroxy is a mixture of Z and E isomers. A use according to any of claims 1 to 8, characterized in that said tamoxifen 4-hydroxy is predominantly a Z. 1 1 isomer. A use according to any of claims 1 to 10, characterized in that between approximately 0.25 and 3.0 ug of said tamoxifen 4-hydroxy per cm2 of scar is administered per day. 12. A use according to claim 1, characterized in that said pharmaceutical composition is capable of administering between about 0.5 and 2.5 ug of said tamoxifen 4-hydroxy per cm2 of scar that is administered per day. 3. A use according to claim 12, characterized in that said pharmaceutical composition is capable of administering between approximately 1.0 μg of said tamoxifen 4-hydroxy per cm2 of scar that is administered per day. 14. A use according to claim 13, characterized in that said pharmaceutical composition is capable of administering between about 2.0 ug of said tamoxifen 4-hydroxy per cm2 of scar that is administered per day. 15. A use according to any of claims 1 to 6 or 8 to 14, characterized in that said tamoxifen 4-hydroxy is formulated in a percutaneous administration form selected from the following list: an ointment, a cream, a patch, a gel, an emulsion, a powder and an oil. 16. A use according to any of claims 1 to 6 or 8 to 14, characterized in that said tamoxifen 4-hydroxy is formulated in a hydroalcoholic gel. 17. A use according to claim 16, characterized in that said hydroalcoholic gel comprises ethyl alcohol, isopropyl myristate, and hydroxypropylcellulose. 18. A use according to any of claims 1 to 6 or 8 to 14, wherein said tamoxifen 4-hydroxy is formulated in a hydroalcoholic solution.
9. 9. Use according to claim 18, characterized in that said hydroalcoholic solution comprises ethyl alcohol, isopropyl myristus and hydroxypropylcellulose.