WO2022204587A1 - Compositions and methods for treating dermal infections - Google Patents

Abstract

Provided herein is a method of treating a bacterial infection in a disorder characterized by scaly skin in patient in need thereof. In embodiments, the method comprises: (a) administering to an affected area of the patient's skin a pharmaceutically acceptable composition comprising a therapeutically effective amount of aloe emodin, or a pharmaceutically acceptable salt thereof, and a skin softening agent; and then (b) applying a combination of blue light and ultrasound.

Description

COMPOSITIONS AND METHODS FOR TREATING DERMAL INFECTIONS

CROSS-REFERENCE TO RELATED APPLICATIONS

[0001] This application claims the benefit of priority to U.S. Provisional Application No. 63/166,584, filed March 26, 2021, the entire contents of which is hereby incorporated by reference in their entirety.

BACKGROUND

[0002] Bacterial infections commonly occur with scaly skin disorders. Congenital ichthyosis identifies a group of rare scaly skin disorders present at birth characterized by varying degrees of skin scaling and hardening. Treatments are aimed at both reducing and softening the ichthyotic scales and addressing the threat of bacterial infection.

[0003] Harlequin ichthyosis is a rare, life-threatening pediatric disease in which the serious or life-threatening manifestations primarily affect neonates and infants. The skin forms large, diamond-shaped plates over an infant’s entire body that are separated by deep fissures. The plates affect the shape of the eyelids, nose, mouth, and ears, and limit movement of the arms and legs, restrict breathing, constrict circulation, and the fissures leave the patient extremely susceptible to infection and dehydration. It affects about 1 per 300,000 births or 7 births per year in the U.S. Due to the severe complications and lack of skin barrier function, only about one half (56%) of infants survive, with death occurring at day 1 to day 52.

[0004] Because of the severe skin barrier dysfunction in harlequin ichthyosis, there is a constant threat of dermal infections, which can become life threatening and a major source of mortality in these patients. Indeed, infants suffer recurrent skin infections which may include S. aureus , methicillin resistant S. aureus (MRSA), S. pyogenes and Klebsiella. Currently there are no effective medical therapies for harlequin ichthyosis. The patients are treated in the neonatal intensive care unit with an array of moisturizing cream, antibiotics, and retinoids. However, studies suggest that antibiotic prophylaxis in children with compromised skin barrier does not reduce the rate of infection may actually be detrimental by favoring the growth of P. aeruginosa , which may lead to systemic infections and possibly death.

[0005] The present disclosure addresses these needs.

BRIEF DESCRIPTION OF THE DRAWINGS

[0006] FIG. l is a schematic illustration of photo-activation process.

[0007] FIG. 2 shows the results of separate or simultaneous energy exposures of P. acnes planktonic cultures.

[0008] FIG. 3 shows the results of sequential or simultaneous treatment of P. acnes biofilm.

[0009] FIG. 4 shows a reduction of S. aureus (MRSA) by treatment with light/ultrasound energy (CLENS) alone, IX Aloe Vera alone, or IX Aloe Vera with CLENS.

[0010] FIG. 5 shows a reduction of S. aureus (MRSA) by treatment with 3ppm aloe emodin (AE) only, diluent (DMSO) only with CLENS, 3ppm AE with CLENS, or 3ppm AE suspended in IX aloe vera (AV), with CLENS.

[0011] FIG. 6 shows reduction of a suspension of freshly collected facial bacteria by treatment with light/ultrasound energy (CLENS) or CLENS plus aloe emodin (AE).

DETAILED DESCRIPTION

[0012] The present disclosure provides for pharmaceutical compositions and methods of treating diseases characterized by scaly skin that are susceptible to bacterial infections, such as, but not limited to ichthyosis disorders. The methods comprise administering a pharmaceutical composition comprising aloe emodin, or a pharmaceutically acceptable salt thereof, and a skin softening agent, to the affected area of the patient’s skin, wherein after administration, blue light and ultrasound are applied.

Definitions

[0013] Unless otherwise stated, the following terms used in the specification and claims have the following meanings set out below.

[0014] References to “compound”, “aloe emodin,” and the like include a pharmaceutically acceptable salts, solvates, hydrates, polymorphs, tautomers, and prodrugs. [0015] It is to be understood that, throughout the description, where compositions are described as having, including, or comprising specific components, it is contemplated that compositions also consist essentially of, or consist of, the recited components Similarly, where methods or processes are described as having, including, or comprising specific process steps, the processes also consist essentially of, or consist of, the recited processing steps. Further, it should be understood that the order of steps or order for performing certain actions is immaterial so long as the invention remains operable. Moreover, two or more steps or actions can be conducted simultaneously.

[0016] As used herein, the term “pharmaceutically acceptable salts” refer to derivatives of the compounds of the present disclosure wherein the parent compound is modified by making acid or base salts thereof. Examples of pharmaceutically acceptable salts include, but are not limited to, mineral or organic acid salts of basic residues such as amines, alkali or organic salts of acidic residues such as carboxylic acids, and the like. The pharmaceutically acceptable salts include the conventional non-toxic salts or the quaternary ammonium salts of the parent compound formed, for example, from non-toxic inorganic or organic acids. For example, such conventional non-toxic salts include, but are not limited to, those derived from inorganic and organic acids selected from 2- acetoxybenzoic, 2-hydroxyethane sulfonic, acetic, ascorbic, benzene sulfonic, benzoic, bicarbonic, carbonic, citric, edetic, ethane disulfonic, 1,2-ethane sulfonic, fumaric, glucoheptonic, gluconic, glutamic, glycolic, glycollyarsanilic, hexylresorcinic, hydrabamic, hydrobromic, hydrochloric, hydroiodic, hydroxymaleic, hydroxynaphthoic, isethionic, lactic, lactobionic, lauryl sulfonic, maleic, malic, mandelic, methane sulfonic, napsylic, nitric, oxalic, pamoic, pantothenic, phenylacetic, phosphoric, polygalacturonic, propionic, salicylic, stearic, subacetic, succinic, sulfamic, sulfanilic, sulfuric, tannic, tartaric, toluene sulfonic, and the commonly occurring amine acids, e.g ., glycine, alanine, phenylalanine, arginine, etc.

[0017] In some embodiments, the pharmaceutically acceptable salt is a sodium salt, a potassium salt, a calcium salt, a magnesium salt, a diethylamine salt, a choline salt, a meglumine salt, a benzathine salt, a tromethamine salt, an ammonia salt, an arginine salt, or a lysine salt. [0018] Other examples of pharmaceutically acceptable salts include hexanoic acid, cyclopentane propionic acid, pyruvic acid, malonic acid, 3-(4-hydroxybenzoyl)benzoic acid, cinnamic acid, 4-chlorobenzenesulfonic acid, 2-naphthalenesulfonic acid, 4- toluenesulfonic acid, camphorsulfonic acid, 4-methylbicyclo-[2.2.2]-oct-2-ene-l- carboxylic acid, 3-phenylpropionic acid, trimethylacetic acid, tertiary butylacetic acid, muconic acid, and the like. The present disclosure also encompasses salts formed when an acidic proton present in the parent compound either is replaced by a metal ion, e.g. , an alkali metal ion, an alkaline earth ion, or an aluminum ion; or coordinates with an organic base such as ethanolamine, diethanolamine, triethanolamine, tromethamine, N- methylglucamine, and the like. In the salt form, it is understood that the ratio of the compound to the cation or anion of the salt can be 1 : 1, or any ratio other than 1:1, e.g., 3:1, 2:1, 1:2, or 1:3.

[0019] It is to be understood that all references to pharmaceutically acceptable salts include solvent addition forms (solvates) or crystal forms (polymorphs) as defined herein, of the same salt.

[0020] As used herein, the term “treating” or “treat” describes the management and care of a patient for the purpose of combating a disease, condition, or disorder and includes the administration of the compound disclosed herein to alleviate the symptoms or complications of a disease, condition or disorder, to eliminate the disease, condition or disorder, or to prevent the disease, condition or disorder. The term “treat” can also include treatment of a cell in vitro or an animal model. It is to be appreciated that references to “treating” or “treatment” include the alleviation of established symptoms of a condition. “Treating” or “treatment” of a state, disorder or condition therefore includes: (1) preventing or delaying the appearance of clinical symptoms of the state, disorder or condition developing in a human that may be afflicted with or predisposed to the state, disorder or condition but does not yet experience or display clinical or subclinical symptoms of the state, disorder or condition, (2) inhibiting the state, disorder or condition, i.e., arresting, reducing or delaying the development of the disease or a relapse thereof (in case of maintenance treatment) or at least one clinical or subclinical symptom thereof, or (3) relieving or attenuating the disease, i.e., causing regression of the state, disorder or condition or at least one of its clinical or subclinical symptoms. [0021] As used herein, the term “pharmaceutically acceptable” refers to those compounds, anions, cations, materials, compositions, carriers, and/or dosage forms which are, within the scope of sound medical judgment, suitable for use in contact with the tissues of human beings and animals without excessive toxicity, irritation, allergic response, or other problem or complication, commensurate with a reasonable benefit/risk ratio.

[0022] As used herein, the term “pharmaceutically acceptable excipient” means an excipient that is useful in preparing a pharmaceutical composition that is generally safe, non-toxic and neither biologically nor otherwise undesirable, and includes excipient that is acceptable for veterinary use as well as human pharmaceutical use. A “pharmaceutically acceptable excipient” as used in the specification and claims includes both one and more than one such excipient.

[0023] As used herein, the term “therapeutically effective amount” refers to an amount of a pharmaceutical agent to treat, ameliorate, or prevent an identified disease or condition, or to exhibit a detectable therapeutic or inhibitory effect. The effect can be detected according to the examples herein, or any appropriate assay method known in the art. The precise therapeutically effective amount for a subject may depend upon the subject’s body weight, size, and health; the nature and extent of the condition; and the therapeutic or combination of therapeutics selected for administration.

[0024] All publications and patent documents cited herein are incorporated herein by reference as if each such publication or document was specifically and individually indicated to be incorporated herein by reference. Citation of publications and patent documents is not intended as an admission that any is pertinent prior art, nor does it constitute any admission as to the contents or date of the same.

Drug Substance

[0025] The disclosure provides for compositions comprising aloe emodin and methods of treating bacterial infections comprising administering and photo-sonically activating aloe

emodin. Aloe emodin (l,8-dihydroxy-3-(hydroxymethyl)anthraquinone) is an anthraquinone. The empirical formula of aloe emodin is C15H10O5 and the molecular mass is 270.24 g-mol ¹. The structural formula for aloe emodin is:

[0026] Aloe emodin is a component of aloe vera, which is an product of Aloe barbadensis Miller leaves. In some embodiments, aloe emodin is present in the pharmaceutical compositions described herein in a substantially pure form. As used herein, “substantially pure” and the like refer to an extract in which other components of aloe vera are removed, and the extract contains at least about 90%, about 91%, about 92%, about 93%, about 94%, about 95%, about 96%, about 97%, about 98%, about 99%, or about 100% aloe emodin. In some embodiments, aloe emodin is synthetic. In some embodiments, the pharmaceutical composition comprises aloe vera, which comprises a therapeutically effective amount of aloe emodin. In some embodiments, the aloe vera is enriched with aloe emodin, such that the amount of aloe emodin is increased by 1.5, 2, 2.5, 3, 3.5, 4, 4.5, 5, 5.5, 6, 6.5, 7, 7.5, 8, 8.5, 9, 9.5, or 10 fold or more. Non-limiting examples of the components in aloe vera are provided in Table 1. In some embodiments, the pharmaceutical composition comprises aloe emodin and one or more components of aloe vera listed in Table 1. For example, aloe vera contains polysaccharides which possess antimicrobial activity believed to be mediated by stimulation of phagocytosis of bacteria.

Table 1.

[0027] In some embodiments, aloe emodin is present in the pharmaceutical composition at about 0.1 ppm, about 0.5 ppm, about 1 ppm, about 1.5 ppm, about 2 ppm, about 2.5 ppm, about 3 ppm, about 3.5 ppm, about 4 ppm, about 4.5 ppm, about 5 ppm, about 5.5 ppm, about 6 ppm, about 6.5 ppm, about 7 ppm, about 7.5 ppm, about 8 ppm, about 8.5 ppm, about 9 ppm, about 9.5 ppm, about 10 ppm, about 10.5 ppm, about 10.5 ppm, about 11, about 11.5 ppm, about 12 ppm, about 12.5 ppm, about 13 ppm, about 13.5 ppm, about 14 ppm, about 14.5 ppm, about 15 ppm, about 15.5 ppm, about 16 ppm, about 16.5 ppm, about 17 ppm, about 17.5 ppm, about 18 ppm, about 18.5 ppm, about 19 ppm, about 19.5 ppm, about 20 ppm, about 20 5 ppm, about 21, about 21.5 ppm, about 22 ppm, about 22.5 ppm, about 23 ppm, about 23.5 ppm, about 24 ppm, about 24.5 ppm, about 215 ppm, about 25.5 ppm, about 26 ppm, about 26.5 ppm, about 27 ppm, about 27.5 ppm, about 28 ppm, about 28.5 ppm, about 29 ppm, about 29.5 ppm, about 30 ppm, or more, including all values and ranges therein.

Methods of Treatment

[0028] The compositions and methods provide the therapeutic effects described herein by photosonic activation of aloe emodin. Photosonic activation, as used herein, refers to the application of blue light and ultrasound to aloe emodin. In some embodiments, the aloe emodin is administered in to the affected area of the patient’s skin and then blue light and ultrasound are applied. In some embodiments, the blue light and ultrasound are applied simultaneously. Blue light and ultra sound may be applied contemporaneously with applying the aloe emodin to the patient’s epidermis, e g., within about 5 sec, about 10 sec, about 15 sec, about 20 sec, about 25 sec, about 30 sec, about 40 sec, about 45 sec, about 50 sec, about 55 sec, about 60 sec, about 1.5 min, about 2 min, about 3 min, about 4 min, about 5 min, about 6 min, about 7 min, about 8 min, about 9 min, about 10 min, about 15 min or about 30 min, including all values and ranges therein. In some embodiments, after epidermal application of the pharmaceutical composition comprising aloe emodin, the patient’s skin patient is exposed to blue light and ultra sound for about 5 sec, about 10 sec, about 15 sec, about 20 sec, about 25 sec, about 30 sec, about 40 sec, about 45 sec, about 50 sec, about 55 sec, about 60 sec, about 1.5 min, about 2 min, about 3 min, about 4 min, about 5 min, about 6 min, about 7 min, about 8 min, about 9 min, or about 10 min, including all values and ranges therein. Without being bound by theory, the concomitant application of the ultrasound serves the dual role of rendering the bacteria more vulnerable to antibacterial attack and driving the pharmaceutical composition into the hardened scales to enhance the pliability of the dermis. [0029] Figure 1 below illustrates the process of photoactivation of aloe emodin, which produces Reactive Oxygen Species (ROS) or singlet Oxygen ( ¹02). Aloe emodin is the PhotoSensitizer (PS) in the diagram.

[0030] Without being bound by theory, aloe emodin, in the presence of light, absorbs a photon that excites it to the first excited singlet state, which then relaxes to the more long lived triplet state. This triplet state can interact with molecular oxygen in two pathways, namely Type I or Type II, leading to the formation of reactive oxygen species (ROS) or singlet oxygen respectively. These products then react with bacteria macromolecules to produce oxidative stress and cellular damage leading to bacterial death. At the energy level used to produce photosonically activated aloe emodin, Type II decay of aloe emodin is expected.

[0031] In some embodiments, light and ultrasound energies will be applied to the epidermis using the dual-energy CLENS (Combined Light Energy and Non-focused ultraSound) system. This system combines LED-based light stimulation with simultaneous low-level ultrasound energy. The combination of ultrasound and light provides synergistic efficacy. Ultrasound mechanically stimulates bacteria, causing an increase in trans membrane oxygen transport and enhanced metabolic levels. Additionally, the ultrasound drives the skin softening agent into the affected area, but not so deep that it results in systemic administration. Simultaneously, light energy photo-stimulates aloe emodin, allowing it to react with newly available oxygen. This reaction creates highly localized toxic oxygen products that kill bacteria, as illustrated in Figure 1. In some embodiments, aloe emodin is photo-stimulated with blue light. Advantageously, the methods of the disclosure reduce bacteria levels without inducing bacterial drug resistance [0032] In some embodiments, the CLENS system provides: (i) the ultrasound comprising one or more of a frequency ranging from about 350-550kHz, pressure ranging from about 180-380kPa, intensity from 50-100mW/cm²(I_satao.o), and a wavelength from 2.3-4.3mm; and (ii) blue light comprising energy ranging from 20-60J/cm², intensity ranging from 40- 50 W/cm², and a wavelength ranging from 395-415nm.

[0033] In some embodiments, the CLENS device comprises the following major components:

1. 405nm LED light source to specifically photo-activate aloe emodin. 2. Ultrasound emitting elements to mechanically stimulate bacteria, causing an increase in trans-membrane oxygen transport and enhanced metabolic levels. The oxygen interacts with the photo-stimulated aloe emodin, producing toxic oxygen products that kill the bacteria.

3. Control Electronics

4. Medical grade power supply.

[0034] The unit has a single functional mode during which the ultrasound and light energies are alternately pulsed on and off (that is, one is off while the other is on, alternating back and forth). The two energies alternate 200 times a second. Importantly, the energy distribution of the light and the ultrasound spatially overlap to provide a combination treatment from a single device. This simplifies the treatment procedure by requiring only a single device with both modalities. Table 1 below summarizes the characteristics of the ultrasound and light.

Table 1. Light and ultrasound characteristics.

* Ultrasound output meets low therapeutic level per IEC60601-2-5.

**The light output falls within the EXEMPT GROUP of Photobiological Risk per IEC62471

[0035] The CLENS device is also designed to meet the following:

• Electrical safety per IEC60601-1

• Electromagnetic Compatibility per IEC60601-1-2

• Software Validation per IEC62304

• Biocompatibility per ISO10993-1

• Usability per IEC62336

[0036] The range of CLENS energy emission is generally considered safe and gentle. The light levels are similar to those already in commercial use in both home and healthcare settings; the ultrasound levels are also currently in commercial use in home settings. A to. critical key to the effectiveness of the CLENS applicator is the complete overlap of the light and the ultrasound at the patient contact surface.

[0037] In some embodiments, the methods comprises administering the pharmaceutical composition of the present disclosure 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 ,19, 20, 21, 22, 23, or 24 times a day. In some embodiments, the pharmaceutical composition is administered about every hour, 2 hours, 3 hours, 4 hours, 5 hours, 6 hours, 8 hours, 10 hours, 12 hours, 16 hours, 20 hours, 24 hours, 30 hours, 36 hours, 42 hours, or 48 hours. In some embodiments, the pharmaceutical composition of the present disclosure is administered about every 12 hours or about every 24 hours (e.g., once daily or twice daily).

Conditions and Diseases

[0038] In some embodiments, the compositions of the disclosure are used to treat disease characterized by scaly skin that are susceptible to bacterial infections. Non-limiting examples include ichthyosis vulgaris, X-linked ichthyosis, congenital ichthyosiform erythroderma, harlequin ichthyosis, syndromes that include ichthyosis, non-bullous ichthyosiform erythroderma, bullous ichthyosiform erythroderma, lamellar ichthyosis, psoriasis characterized by scaly skin, guttate psoriasis, seborrheic dermatitis, discoid lupus erythematosus, pityriasis versicolor, keratosis pilaris, annular erythema, palmoplantar keratoderma, crusted scabies, lichen planus, pitariasis lichenoides, tinea corporis, piyriasis rubra pilaris, atopic dermatitis, dermatitis, collodion baby, and erthrokeratoderma.

[0039] In some embodiments, the compositions of the disclosure are used to treat ichthyosis. Ichthyosis is a disorder of comification, characterized by persistently dry, thickened, scaling skin. There are at least 20 varieties of ichthyosis, including inherited (i.e., congenital) and acquired forms.

[0040] In some embodiments, ichthyosis disorder is a congenital ichthyosis. Congenital ichthyosis include CHILD syndrome, collodion baby, congenital ichthyosform erythroderma, Conradi-flunermann, epidermolytic hyperkeratosis, erythrokeratoderma variabilis, KID syndrome, lamellar ichthyosis, Netherton syndrome, neutral lipid storage disease, Sjorgren-Larsson syndrome, trichothiodystrophy, X-linked ichthyosis, or harlequin ichthyosis. In some embodiments, the congenital ichthyosis is harlequin ichthyosis.

[0041] In congenital ichthyosis disorders, such as harlequin ichthyosis, premature birth is typical, leaving the infants at risk for complications from early delivery. These infants are also at high risk for difficulty breathing, low body temperature, dehydration, hypernatremia (elevated levels of sodium in the blood). Constriction and swelling of the mouth may interfere with the suck response and infants may need tube feeding. Due to the severe complications and lack of skin barrier function, only about one half (56%) of infants survive, with death occurring at day 1 to day 52. In some embodiments, the methods of the disclosure reduce the risk of mortality at 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, or 12 months of life (compared to an otherwise identical patient that is not treated according to the methods of the disclosure or compared to baseline levels measured before treatment according to the methods of the disclosure). In some embodiments, the risk of mortality is reduced by about 5%, about 10%, about 15%, about 20%, about 25%, about 30%, about 35%, about 40%, about 45, about 50%, about 55%, about 60%, about 65%, about 70%, about 75%, about 80%, about 85%, about 90%, about 95%, about 99%, or about 100%, including all values and ranges therein (compared to an otherwise identical patient that is not treated according to the methods of the disclosure). In some embodiments, survival rate at 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, or 12 months of life is improved by about 5%, about 10%, about 15%, about 20%, about 25%, about 30%, about 35%, about 40%, about 45, about 50%, about 55%, about 60%, about 65%, about 70%, about 75%, about 80%, about 85%, about 90%, about 95%, about 99%, or about 100%, including all values and ranges therein (compared to an otherwise identical patient that is not treated according to the methods of the disclosure).

[0042] Infants with congenital ichthyosis disorders, such as harlequin ichthyosis, are susceptible to microbial infections, such as bacterial and functional infections. In some embodiments, the methods of the disclosure reduce the risk of microbial infections. The skin of infants with congenital ichthyosis disorders. Infant skin contains erythematous fissures which penetrate into the dermis, exposing the skin to greatly increased chances of infection. In some embodiments, the methods of the disclosure reduce the risk of dermal infections. Non-limiting examples of dermal infections includes include those caused by S. aureus , methicillin resistant S. aureus (MRSA), S. pyogenes , Klebsiella Propionibacterium, Staphylococcus, Micrococcus, Corynebacterium and Acinetobacter. In some embodiments, the risk of such infections is reduced by about 5%, about 10%, about 15%, about 20%, about 25%, about 30%, about 35%, about 40%, about 45, about 50%, about 55%, about 60%, about 65%, about 70%, about 75%, about 80%, about 85%, about 90%, about 95%, about 99%, or about 100%, including all values and ranges therein (compared to an otherwise identical patient that is not treated according to the methods of the disclosure or compared to baseline levels measured before treatment according to the methods of the disclosure). In some embodiments, the methods and compositions of the disclosure reduce total bacteria counts (CFU, Colony Forming Units) by about 1.5, 2, 2.5,

3, 3.5, 4, 4.5, 5, 5.5, 6, 6.5, 7, 7.5, 8, 8.5, 9, 9.5, or 10 fold or more, including all values and ranges therein (compared to an otherwise identical patient that is not treated according to the methods of the disclosure or compared to baseline levels measured before treatment according to the methods of the disclosure).

[0043] In some embodiments, the methods and compositions of the disclosure reduce ichthyotic scales, e.g., by about 5%, about 10%, about 15%, about 20%, about 25%, about 30%, about 35%, about 40%, about 45, about 50%, about 55%, about 60%, about 65%, about 70%, about 75%, about 80%, about 85%, about 90%, about 95%, about 99%, or about 100%, including all values and ranges therein (compared to an otherwise identical patient that is not treated according to the methods of the disclosure or compared to baseline levels measured before treatment according to the methods of the disclosure).

[0044] In some embodiments, the methods and compositions of the disclosure soften ichthyotic scales, e.g., by about 5%, about 10%, about 15%, about 20%, about 25%, about 30%, about 35%, about 40%, about 45, about 50%, about 55%, about 60%, about 65%, about 70%, about 75%, about 80%, about 85%, about 90%, about 95%, about 99%, or about 100%, including all values and ranges therein (compared to an otherwise identical patient that is not treated according to the methods of the disclosure or compared to baseline levels measured before treatment according to the methods of the disclosure).

[0045] In some embodiments, the methods and compositions of the disclosure provide at least a 2 point improvement in overall severity of disease as measured by IGS (e.g., 2, 3,

4, 5 point improvement) compared to the IGS score measured at baseline before treatment according to the methods of the disclosure. The IGA score is a static evaluation of the overall or "average" degree of severity of a subject's disease, taking into account all of the subject's scaling, erythema, and Assuring in the Treatment Area. The IGA is described in Langley, R. G. B., et al, J. of Dermatological Treatment, 2015, Vol. 26(1), 23-31. https://doi.org/10.3109/09546634.2013.865009, which is incorporated by reference herein in its entirety.

[0046] Efficacy can also be measured using animal models described in, e.g., Lee, Kiho J. Mol. Cell. Biol. 2019 Dec 19; 11(12): 1027-1028 (doi: 10.1093/jmcb/mjz034) and Zhang, Lei, et al., PLOS ONE, 11(8): e0161465. doi: 10.1371/joumal. pone.0161465, the contents of which are incorporated by reference herein in its entirety.

Compositions

[0047] In some embodiments, the pharmaceutical compositions of the disclosure are formulated with a skin softening agent. The skin softening agent suitable for use in the compositions and methods of the present disclosure are those which moisturize outer layer of the skin (strum corneum and possibly the epidermis) but are not driven deep into the skin such when ultrasound is applied at the below conditions. This prevents the aloe emodin and/or the skin softening agent from being absorbed systemically.

[0048] In some embodiments, the skin softening agent is aloe emodin stays in the strum corneum. There may be some penetration into the epidermis, but does not result in significant systemic administration of aloe emodin. In some embodiments, the skin softening agent is a lipid, urea, or an emollient. In some embodiments, the skin softening agent is an emollient. Generally, emollients that help hydrate the skin are more preferred than volatile vehicles, such as ethanol, that dry the skin. Non-limiting examples of suitable emollients include petrolatum, petrolatum based oil, vegetable based oil, lanolin, mineral oil, dimethicone, fatty esters, glycerol esters, propylene glycol esters, alkoxylated carboxylic acids, alkoxylated alcohols, fatty alcohols, fatty acids, cold cream (USP), and hydrophilic ointment (USP).

[0049] In some embodiments, the compositions include topical numbing agents, such as lidocaine, benzocaine, pramoxine, dibucaine, and tetracaine

[0050] For topical application to the skin, the pharmaceutical compositions of the present disclosure may be combined with one or a combination of carriers for topical formulations, which can include, but are not limited to, an aqueous liquid, an alcohol base liquid, a water soluble gel, a lotion, an ointment, a nonaqueous liquid base, a mineral oil base, a blend of mineral oil and petrolatum, lanolin, liposomes, proteins carriers such as serum albumin or gelatin, powdered cellulose carmel, carbomer polymers such as carbomer homopolymers, carbomer copolymers, and Carbopol® polymers, and combinations thereof. Carbopol® polymers are polymers of acrylic acid cross-linked e.g., with polyalkenyl ethers or divinyl glycol. In some embodiments, the Carbopol® polymer is Carbopol® 71G, Carbopol® 97 IP, Carbopol® 974P, Carbopol® 980, Carbopol® 981, Carbopol® 5984, Carbopol® 934, Carbopol® 934P, Carbopol® 940, Carbopol® 941, and Carbopol® 1342.

[0051] Carriers for topical formulations may comprise semi-solid and/or gel-like vehicles, which may include a polymer thickener, water, preservatives, active surfactants, emulsifiers, and/or a solvent or mixed solvent system. U.S. Pat. No. 5,863,560 discloses a number of different carrier combinations that can aid in the exposure of skin to a medicament, and its contents are incorporated herein by reference. The carrier may or may not involve a controlled-release formulation, e.g., as disclosed in US 2008/0260697, the contents of which are incorporated herein by reference. In some embodiments, the carrier may or may not involve a viscous formulation, e.g., a gel, e.g., as disclosed in US 2009/0191254, the contents of which are incorporated herein by reference.

[0052] Compositions can also be formulated so as to provide slow or controlled release of the active ingredient therein using, for example, hydroxypropylmethyl cellulose in varying proportions to provide the desired release profile, other polymer matrices, liposomes and/or microspheres. They can be sterilized by, for example, filtration through a bacteria-retaining filter, or by incorporating sterilizing agents in the form of sterile solid compositions that can be dissolved in sterile water, or some other sterile injectable medium immediately before use. [0053] Liquid dosage forms useful for topical administration include pharmaceutically acceptable emulsions, lyophiles for reconstitution, microemulsions, solutions, suspensions, gels, syrups and elixirs. In addition to the active ingredient, the liquid dosage forms can contain inert diluents commonly used in the art, such as, for example, water or other solvents, cyclodextrins and derivatives thereof, solubilizing agents and emulsifiers, such as ethyl alcohol, isopropyl alcohol, ethyl carbonate, ethyl acetate, benzyl alcohol, benzyl benzoate, propylene glycol, 1,3-butylene glycol, oils (such as cottonseed, groundnut, corn, germ, olive, castor and sesame oils), glycerol, tetrahydrofuryl alcohol, polyethylene glycols and fatty acid esters of sorbitan, and mixtures thereof. Besides inert diluents, the topical compositions can also include adjuvants such as wetting agents, emulsifying and suspending agents, and preservative agents.

[0054] Suspensions, in addition to the active compounds, can contain suspending agents as, for example, ethoxylated isostearyl alcohols, polyoxyethylene sorbitol and sorbitan esters, microcrystalline cellulose, aluminum metahydroxide, bentonite, agar-agar and tragacanth, and mixtures thereof.

[0055] Wetting agents, emulsifiers and lubricants, such as sodium lauryl sulfate and magnesium stearate, as well as coloring agents, release agents, coating agents, sweetening, flavoring and perfuming agents, preservatives and antioxidants can also be present in the compositions.

[0056] Examples of pharmaceutically acceptable antioxidants include: (1) water-soluble antioxidants, such as ascorbic acid, cysteine hydrochloride, sodium bisulfate, sodium metabi sulfite, sodium sulfite and the like; (2) oil-soluble antioxidants, such as ascorbyl palmitate, butylated hydroxyanisole (BHA), butylated hydroxytoluene (BHT), lecithin, propyl gallate, alpha-tocopherol, and the like; and (3) metal-chelating agents, such as citric acid, ethylenediamine tetraacetic acid (EDTA), sorbitol, tartaric acid, phosphoric acid, and the like.

[0057] Dosage forms for the topical administration include powders, sprays, ointments, pastes, creams, lotions, gels, solutions, and patches. The active compound can be mixed under sterile conditions with a pharmaceutically acceptable carrier, and with any preservatives or buffers that can be required. [0058] The ointments, pastes, creams and gels can contain, in addition to an active compound, one or more excipients or carriers, such as animal and vegetable fats, oils, waxes, paraffins, starch, tragacanth, cellulose derivatives, polyethylene glycols, silicones, bentonites, silicic acid, talc, polymers, salts, and zinc oxide, or mixtures thereof. In some embodiments, the BT composition is in the form of an aqueous solution. In some embodiments, the excipient comprises a salt selected from sodium chloride or potassium chloride. In some embodiments, the excipient comprises sodium chloride.

[0059] In some cases, in order to prolong the effect of a drug, it is desirable to slow the absorption of the drug. This can be accomplished by the use of a liquid suspension of crystalline or amorphous material having poor water solubility. The rate of absorption of the drug then depends upon its rate of dissolution, which, in turn, can depend upon crystal size and crystalline form. Alternatively, delayed absorption of a parenterally administered drug form is accomplished by dissolving or suspending the drug in an oil vehicle.

[0060] In some embodiments, topical pharmaceutical compositions of the present disclosure are provided in a hermetically sealed container. The container may a vial, syringe, tube, bottle, ampoule (e.g. blow-fill-seal polypropylene ampules), sachet, or the like; and may comprise or consist of glass, plastic, or other suitable material. Ampoules, for example, generally are produced industrially from short lengths of glass tubing, shaped by heating with gas torches and gravity. Computer vision techniques often are employed, e.g., for quality control. The filling and sealing of ampoules may be done by automated machinery. Blank ampoules can be purchased from scientific glass supply houses and sealed, e.g., with a small gas torch, preferably under inert atmospheres. In some embodiments, the container also may be filled with an inert gas, in addition to the pharmaceutical composition. In some embodiments, the composition is provided in an ampoule, or other suitable container, and transferred for use to a vehicle suitable for direct contact with non-intact skin, e.g., a patch, wipe, bandage, dressing, as described below. [0061] The topical mode of delivery may include a smear (e.g. finger swipe or with an applicator), a spray, a foam, a bandage, a time-release patch, a liquid-absorbed wipe, and combinations thereof. In some embodiments, the compositions of the present disclosure are provided, either directly or in a carrier(s), in a patch, wipe, bandage, dressing, or other vehicle suitable for direct contact with the skin, in particular, non-intact skin. [0062] In some embodiments, topical administration of a pharmaceutical composition of the present disclosure comprises use of a dressing. The pharmaceutical composition of the present disclosure may be incorporated into a dressing and/or applied separately along with the use of a dressing. A dressing promotes healing by keeping a wound moist, creating a barrier against infection, and/or keeping the surrounding skin dry.

[0063] In some embodiments, the dressing comprises a moist wound dressing. Moist wound therapy, comprising use of moist wound dressings, represents a standard therapy in the treatment and control of non-healing wounds. In moist wound therapy, wounds are dressed with materials that offer protection from outside contaminants, prevent wound desiccation, and provide an environment conducive to wound closure. The degree of moisture in a wound is to be considered when treating a diabetic ulcer. High levels of exudate warrant the choice of a moisture-absorbing material, including but not limited to alginates, foams, collagen-alginate combinations, carboxymethylcellulose materials, or gauze. Low exudate and desiccated wounds generally respond well to hydrogels. Hydrogel sheets often comprise three-dimensional networks of cross-linked hydrophilic polymers. Amorphous hydrogels are similar in composition to hydrogel sheets but lack the cross- linking. The gel also may comprise additional ingredients, such as collagens, alginate, or complex carbohydrates.

[0064] The pharmaceutical compositions may conveniently be presented in unit dosage form and can be prepared by any methods well known in the art of pharmacy. The amount of active ingredient which can be combined with a carrier material to produce a single dosage form will vary depending upon the subject being treated, the particular mode of administration. The amount of active ingredient that can be combined with a carrier material to produce a single dosage form will generally be that amount of the compound which produces a therapeutic effect.

[0065] Actual dosage levels of the active ingredients in the pharmaceutical compositions can be varied so as to obtain an amount of the active ingredient that is effective to achieve the desired therapeutic response for a particular patient, composition, and mode of administration, without being toxic to the patient.

[0066] The selected dosage level will depend upon a variety of factors including the activity of the particular compound or combination of compounds employed, or the ester, salt or amide thereof, the route of administration, the time of administration, the rate of excretion of the particular compound(s) being employed, the duration of the treatment, other drugs, compounds and/or materials used in combination with the particular compound(s) employed, the age, sex, weight, condition, general health and prior medical history of the subject being treated, and like factors well known in the medical arts.

EXAMPLES

Example 1. Bactericidal Activity of Blue Light and Ultrasound

[0067] A custom laboratory dual-energy exposure system (also referred to as CLENS) was designed with energy output equivalent to proposed clinical dosage levels in the following table.

*The above values may vary by ± 10%

[0068] The exposure system is designed to provide uniform, controlled levels of both light and ultrasound to a Millicell® hanging insert with a polyethylene terephthalate (PET) membrane (4.45 cm2, 0.4 pm, PIHT30R48, EMD Millipore). The test system allows the two energies to pass unhindered through the bacteria sample and the PET membrane below to be absorbed in castor oil below the membrane. Using the laboratory exposure system, first, planktonic bacteria and secondly, biofilms (cultured on the membrane), were treated with either light or low intensity ultrasound, or both simultaneously. Planktonic P. acnes bacteria were assessed first (Figure 2). Note that P. acnes has abundant endogenous porphyrin, which is a naturally occurring photosensitive molecule, like aloe emodin [0069] Low intensity ultrasound did not induce observable bactericidal activity when planktonic bacteria were exposed for 20 min. Light at 405nm was bactericidal . Importantly, in combination, the light plus low intensity ultrasound induced a synergistic bactericidal effect, that is, the reduction of bacteria CFU was greater than just adding the effects of the two single energy sources (p<0.05).

[0070] The same synergistic bactericidal effect was observed when exposing P. acnes biofilm to CLENS. An experiment to demonstrate that the two energies were only synergistic upon simultaneous delivery was conducted. For this experiment, exposure was either sequential (ultrasound first, then light, or light first, then ultrasound) or simultaneous (both ultrasound and light together). There was a dramatic increase in killing effectiveness when both energies were delivered simultaneously (Figure 3). The mechanism of action of the compounds and methods of the disclosure takes advantage of this synergistic effect, with the addition of ultrasound providing a boost to the bactericidal effect of photo activation. Evidence suggests that ultrasound acts to improve the availability of oxygen needed for Type II photo-activation (Figure 1), as well as additional mechanical effects which increase the susceptibility of bacteria to killing.

Example 2. Photosonically Activated Aloe Emodin

[0071] Experiments were conducted using the same custom exposure system described above in Example 1. Each reaction contained lmL of bacteria culture re-suspended in a total of 10 mL phosphate buffered saline (PBS). For the first experiment, S. aureus planktonic stationary culture (ATCC 700699; MRSA) were treated under various conditions. Aloe emodin (Selleckchem, S2259) was dissolved in DMSO (Sigma) to give 3 mg/mL and then further diluted in PBS to the desired concentration. Final concentrations were 3ppm (i.e. 3 pg/mL). Decolorized aloe vera gel was obtained as a powder (AloeCorp, ACTIV aloe®QM200X) and re-suspended in PBS to a 20X concentration as per the manufacturer’s directions. Note decolorized aloe vera would have nearly all of the anthraquinones removed, leaving approximately lOppm total of the anthraquinone fraction in a IX concentration of aloe vera. This level of anthraquinones is the industry standard for ingested products. It is estimated that <lppm aloe emodin remained in the aloe vera. Final concentration of the aloe vera gel in the reaction mixture was IX.

[0072] Test samples were exposed to different treatment combinations as listed in Table 3 below. All tests involved the same handling of samples and contact with the experimental treatment system, even for those cases which did not involve energy exposure. [0073] After exposure, 100 pL of the 10 rtiL test samples was serially diluted in PBS/0.1% Tween-80. The dilutions were plated onto reinforced clostridial agar (RCA, Oxoid) plates, 2 plates/dilution, and incubated for 2 days at 37°C Plates were then assessed for total bacteria counts (CFU, Colony Forming Units). The results are shown in Figure 5 and Figure 6.

[0074] The data indicate that there was some S. aureus killing with CLENS alone (Figure 5). Exposure of bacteria to aloe vera gel alone had no detected bactericidal activity in this test system, however importantly aloe vera gel in combination with CLENS had a 1.51ogio bacteria kill compared to baseline (Figure 3). The likely photo-activated molecule in aloe vera gel, aloe emodin, was then tested for efficacy (Figure 3).

Table 2. In-vitro bacteria reduction conditions

[0075] Aloe emodin without CLENS was not bactericidal. Diluent used to re-suspend the aloe emodin contained DMSO and was tested for background activity. Bacteria reduction was approximately equivalent to CLENS alone. Aloe emodin in combination with CLENS exhibited significant bactericidal activity, reducing bacteria by several orders of magnitude. It was not known precisely how much aloe emodin was contained in the IX aloe vera gel concentrate mixture used in Figure 4. Industry standards target <10ppm for the total anthraquinone fraction in aloe vera mixtures intended for oral ingestion, thus the IX concentrate had approximately lOppm of total anthraquinone, with aloin likely making up the majority of the anthraquinone fraction. When aloe emodin was added back to IX aloe vera gel to a concentration of 3ppm, significant bactericidal activity was observed, reducing bacteria by orders of magnitude. Demonstration of bactericidal activity of IX aloe vera gel plus 3ppm aloe emodin indicates that photo-activation of aloe vera may be greatly enhanced by enriching the aloe emodin (Figure 5).

[0076] To ensure the bactericidal effect of aloe emodin in combination with light+ultrasound (CLENS) was not restricted to a lab strain of Staph, a suspension of freshly isolated facial bacteria was tested. Resident facial bacteria include Propionibacterium, Staphylococcus, Micrococcus, Corynebacterium and Acinetobacter. Samples were obtained by swabbing a healthy adult volunteer’s face with 0.1% Triton X- 100 in PBS. In this case, the CLENS alone showed little to no bactericidal activity. The bactericidal effect of aloe emodin plus CLENS increased bacteria killing by ~2 log 10 over the control, using 0.45ppm, to essentially non-detectable (~51ogio) with 4.5ppm (Figure 6). Therefore, CLENS photo-sonically activated aloe emodin to significantly enhance bactericidal activity against the bacteria normally resident on human facial skin.

Claims

CLAIM

1. A method of treating a bacterial infection in a disorder characterized by scaly skin in patient in need thereof comprising:

(a) administering to an affected area of the patient’s skin a pharmaceutically acceptable composition comprising a therapeutically effective amount of aloe emodin, or a pharmaceutically acceptable salt thereof, and a skin softening agent; and then

(b) applying a combination of blue light and ultrasound.

2. The method of claim 1, wherein the ultrasound comprises at least one of (i) a frequency ranging from about 350 kHz to about 550 kHz, (ii) a pressure ranging from about 180 kPa to about 380 kPa, (iii) an intensity from about 50 mW/cm²(I_satao.o) to about 100 mW/cm²(I_Satao o), or (iv) a wavelength ranging from about 2.3 mm to about 4.3 mm.

3. The method of claim 1 , wherein the blue light comprises at least one of (i) an energy ranging from 20 J/cm²to about 60 J/cm², (ii) an intensity ranging from about 40 W/cm² to about 50 W/cm², or (iii) a wavelength ranging from about 395 nm to about 415 nm.

4. The method of claims 1-3, wherein the ultrasound and blue light comprises:

5. The method of any one of claims 1-4, wherein the ultrasound and blue light are applied within about 0.5, 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 minutes of administering the pharmaceutical composition to the affected area.

6. The method of any one of claims 1-5, wherein the ultrasound and blue light are applied simultaneously.

7. The method of any one of claims 1-6, wherein the ultrasound and blue light are applied to the affected area for about 10 sec, about 20 sec, about 30 sec, about 40 sec, about 50 sec, about 1 min, about 1.5 min, about 2 min, about 3 min, about 4 min, or about 5 min.

8. A method of any one of claims 1-7, wherein the disorder characterized by scaly skin is an ichthyosis disorder

9. The method of claim 8, wherein the ichthyosis disorder is a congenital ichthyosis.

10. The method of claim 9, wherein the congenital ichthyosis is CHILD syndrome, collodion baby, congenital ichthyosform erythroderma, Conradi-flunermann, epidermolytic hyperkeratosis, erythrokeratoderma variabilis, KID syndrome, lamellar ichthyosis, Netherton syndrome, neutral lipid storage disease, Sjorgren-Larsson syndrome, trichothiodystrophy, X-linked ichthyosis, or harlequin ichthyosis.

11. The method of any one of claims 8-10, wherein the congenital ichthyosis is harlequin ichthyosis.

12. The method of any one of claims 8-11, wherein ichthyotic scales are reduced.

13. The method of any one of claims 8-12, wherein ichthyotic scales are soften.

14. The method of any one of claims 1-13, wherein a risk of a bacterial infection is reduced.

15. The method of any one of claims 1-12, wherein the patient has a bacterial infection, and the bacterial infection is treated.

16. The method of claim 15, wherein the bacterial infection is in the form of a biofilm.

17. The method of any one of claims 1-16, wherein the bacterial infection is caused by S. aureus , methicillin resistant S. aureus (MRSA), S. pyogenes , Klebsiella, Propionibacterium, Staphylococcus, Micrococcus, Corynebacterium or Acinetobacter.

18. The method of any one of claims 8-16, wherein the risk of mortality during the first 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, or 12 months of life is reduced.

19. A method of treating harlequin ichthyosis in a patient in need thereof, comprising:

(a) administering to the affected area of the patient a pharmaceutical composition comprising a therapeutically effective amount of aloe emodin and a skin softening agent; and then

(b) applying ultrasound and blue light.

20. The method of claim 19, wherein the ultrasound comprises at least one of (i) a frequency ranging from about 350 kHz to about 550 kHz, (ii) a pressure ranging from about 180 kPa to about 380 kPa, (iii) an intensity ranging from about 50 mW/cm²(I_satao.o) to about 100 mW/cm²(I_satao.o), or (iv) a wavelength ranging from about 2.3 mm to about 4.3 mm.

21. The method of claim 19, wherein the blue light comprises at least one of (i) an energy ranging from 20 J/cm² to about 60 J/cm², (ii) an intensity ranging from about 40 W/cm² to about 50 W/cm², or (iii) a wavelength ranging from about 395 nm to about 415 nm.

22. The method of claims 20-22, wherein the ultrasound and blue light comprises:

23. The method of any one of claims 19-22, wherein the ultrasound and blue light are applied within about 0.5, 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 minutes of administering the pharmaceutical composition to the affected area.

24. The method of any one of claims 19-23, wherein the ultrasound and blue light are applied simultaneously.

25. The method of any one of claims 19-24, wherein the within ultrasound and blue light are applied to the affected area for about 10 sec, about 20 sec, about 30 sec, about 40 sec, about 50 sec, about 1 min, about 1.5 min, about 2 min, about 3 min, about 4 min, or about 5 min.

26. A pharmaceutical composition comprising a therapeutically effective amount of aloe emodin, or a pharmaceutically acceptable salt thereof, and a skin softening agent wherein the aloe emodin, or pharmaceutically acceptable salt thereof, and the skin softening agent have no systemic effect after ultrasound and blue light are applied.

27. The pharmaceutical composition of claim 26, wherein the ultrasound comprises at least one of (i) a frequency ranging from about 350 kHz to about 550 kHz, (ii) a pressure ranging from about 180 kPa to about 380 kPa, (iii) an intensity from about 50 mW/cm²(Isa_tao_.o) to about 100 mW/cm²(I_satao_.o), or (iv) a wavelength ranging from about 2.3 mm to about 4.3 mm.

28. The pharmaceutical composition of claim 26, wherein the blue light comprises (i) at least one of energy ranging from 20 J/cm² to about 60 J/cm², (ii) intensity ranging from about 40 W/cm² to about 50 W/cm², or (iii) a wavelength ranging from about 395 nm to about 415 nm.

29. The pharmaceutical composition of claims 27 and 28, wherein the ultrasound and blue light comprises:

30. The method of any one of claims 1-25 or the pharmaceutical composition of claim 26, wherein the pharmaceutical composition is a gel, cream, ointment, emulsion, liquid, or spray.

31. The pharmaceutical composition of any one of claims 26-30, comprising at least 3 ppm aloe emodin.

32. The pharmaceutical composition of any one of claims 26-31, comprising from about 3 ppm to about 30 ppm aloe emodin.

33. The method of any one of claims 1-25, wherein the therapeutically effective amount of aloe emodin is at least 3 ppm.

34. The method of any one of claims 1 -25, wherein the therapeutically effective amount of aloe emodin is from about 3 ppm to about 30 ppm aloe emodin.

35. The pharmaceutical composition of any one of claims 26-31, or the method of any one of claims 1-25, wherein the skin softening agent is an emollient.