United States Patent (19)
`Reinmuller
`
`54 METHOD FOR THE TREATMENT OF
`SCARS AND KELODS
`
`76 Inventor: Johannes Reinmuller,
`Gustav-Frcytag-Strasse 27, 65189
`Wiesbaden, Germany
`21 Appl. No.:
`256,040
`22 PCT Filed:
`Dec. 24, 1992
`86 PCT No.:
`PCT/EP92/O2990
`S371 Date:
`Aug. 15, 1994
`S 102(e) Date: Aug. 15, 1994
`87 PCT Pub. No.: WO93/12801
`PCT Pub. Date:Jul. 8, 1993
`Foreign Application Priority Data
`30
`Jan. 3, 1992 DEl Germany .......................... 42 OOO8O.7
`(51)
`int. Cl. .......................... A61K 31/715; C08B 37/00
`(52) U.S. C. ................................ 514/54; 514/55; 514/56;
`514/62; 536/53: 536/20:536/21; 536/55.2;
`536,123.1
`58 Field of Search ................................. 514/54, 55, 56,
`514/62; 536/20, 21, 55.2, 53, 123.1
`
`56
`
`References Cited
`U.S. PATENT DOCUMENTS
`4,350,629 9/1982 Yannas et al. .......................... 530/356
`4,582,865 4/1986 Balazs et al. ............................. 524/29
`4,613,502 9/1986 Turková et al. ....................... 424/94.3
`4,863,907
`9/1989 Sakurai et al. ............................ 514/56
`4,947,840 8/1990 Yannas et al. ...
`-
`-
`-
`- 602A50
`5,093,319 3/1992 Higham et al. ........................... 514/55
`
`
`
`USOO5731298A
`Patent Number:
`11
`45 Date of Patent:
`
`5,731,298
`Mar. 24, 1998
`
`FOREIGN PATENT DOCUMENTS
`2129300 5/1984 United Kingdom.
`89,04172 5, 1989 WIPO.
`
`OTHER PUBLICATIONS
`
`Yannas et al. J. Biomed. Mater: Res. 1980, 14, 65-81. month
`not available.
`Friderich Z. Allgemeinemedizin 1985, 61,1101-1103. month
`not available.
`Dockery et al. Clinics Podiatric Med. Surg, 1986 3(3),
`473–485. month not available.
`Nicolai et al. Aesth. Plast. Surg, 1987. 11, 29-32. month not
`available.
`Davidson et al. Clin. Mater 1991, 8, 171-177. month not
`available.
`Biagini et al. Biomaterials 1991, 12, 281-286. month not
`available.
`Sorrone et al. Riy, Ital. Chiv Plastica 1986, 18, 205-207.
`month not available.
`
`Primary Examiner-Kathleen K. Fonda
`Attorney, Agent, or Firm-Felfe & Lynch
`57
`ABSTRACT
`A method and a pharmaceutical composition for non-topical
`wound, scar and keloid treatment is described which con
`tains cross-linked glycosaminoglycans and conventional
`pharmaceutical auxiliary and/or carrier substances. The
`pharmaceutical composition is preferably administered
`intralesionally e.g. by injection in the form of a gel contain
`ing water. The cross-linked glycosaminoglycans are also
`suitable for use as cosmetics and skin care products.
`
`3 Claims, No Drawings
`
`Exhibit 1059
`Prollenium v. Allergan
`
`

`

`5,731.298
`
`1.
`METHOD FOR THE TREATMENT OF
`SCARS AND KELODS
`
`This is in an application under 35 U.S.C. S371 of
`PCT/EP92/O2990 having an international filing date of Dec.
`24, 1992.
`
`2
`ment of scars and cicatricial keloids is heparin (cf. e.g.
`“Pharmazie in unserer Zeit" 10 (1981), page 168 to 181).
`All preparations of active substances for external appli
`cations have the same inherent disadvantage, namely that
`the external application, i.e. spreading on the skin over the
`keloid, does not ensure an adequate tissue concentration in
`the keloid itself which can reach a thickness of up to several
`centimetres. Due to the excessively increased blood circu
`lation within the keloids, the active substances-provided
`that they can penetrate the skin barriers at all-are rapidly
`transported away via the blood and lymph stream. The
`diffusion of the active substances in the tissue therefore only
`plays a subordinate role in the distribution.
`It is also known that the active substance heparin cannot
`penetrate the epidermal layers. Thus the effect of externally
`applied preparations, such as e.g. ointments based on
`heparin, on connective tissue cells is doubtful. It cannot
`therefore be excluded that the successes achieved with scar
`ointments containing heparin could be ascribed to sponta
`neous healing.
`Derivatives of the hormone cortisol (hydrocortisone) are
`used in the invasive methods of treatment for keloids; due to
`the known increased blood circulation withinkeloids and the
`concomitant rapid transport of pharmaceutical agents, the
`crystalline poorly soluble forms are preferably used with
`which a depot effect can be achieved. Since cortisol and its
`derivatives strongly inhibit the cells of connective tissue, the
`quantitatively and qualitatively strongest changes in keloids
`can be achieved at present with the invasive administration
`(injection) of pharmaceutical preparations based on crystal
`line corticoids (corticosteroids).
`However, a decisive disadvantage of this therapy with
`corticoids is the lack of control of the reaction. Therefore in
`the practical application this can either result in an undesired
`scar atrophy i.e. a divergence and sinking of the scar with
`corresponding disfigurement or in an inadequate reaction of
`the tissue with an unsatisfactory therapeutic result.
`Afurther disadvantage of corticoid therapy is the systemic
`action of the dissolved active substance which prevents its
`use in the case of keloids of large area or in children.
`SUMMARY OF THE INVENTION
`The object of the invention is to provide a pharmaceutical
`composition for the treatment of wounds, scars and keloids
`with which the aforementioned disadvantages that occur in
`previous methods of treatment can be avoided, in particular
`the undesired side-effects of corticoid therapy such as e.g.
`local over-reactions, that can be administered easily and
`successfully and is degraded by the organism.
`This object is achieved by the pharmaceutical composi
`tion of the invention which contains cross-linked glycosami
`noglycans and conventional pharmaceutical auxiliary and/or
`carrier substances.
`Practical embodiments thereof are the subject matter of
`this invention.
`A further subject matter is also a process for the produc
`tion of the pharmaceutical compositions according to the
`invention.
`It is possible using the compositions according to the
`invention to avoid the undesired properties of corticoid
`therapy. Namely it was found that the cross-linked gly
`cosaminoglycans (GAG, mucopolysaccharides) used
`according to the invention have an inhibitory effect on keloid
`formation when they are administered non-topically
`(intralesionally). In this case no local over-reactions occur as
`
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`BACKGROUND OF THE INVENTION
`The invention concerns a pharmaceutical composition for
`the treatment of wounds, scars and keloids.
`Excess new growth of scar tissue occurs in many people
`during healing of skin wounds. In medical terminology this
`new formation of tissue is referred to as cicatricial hyper
`trophy or as keloid in severe cases. These are unpredictable
`reactions during wound healing caused by a predisposition.
`Up to now the reasons for excess cicatrisation are not
`known. Thus at present there is also no scientifically based
`causal method of treatment.
`Numerous methods have been described for keloid treat
`ment (cf. e.g. McCarthy/Convers "Plastic Surgery", volume
`1. pages 732-747, W.B. Saunders, 1990). However, they are
`all more or less empirically based and do not have a secure
`foundation in a strict scientific sense. This is due on the one
`hand to a lack of basic knowledge and is also due to the fact
`that a spontaneous tendency of untreated keloids to regress
`is often observed
`As a consequence there is an extremely large number of
`competing methods of treatment whose effectiveness is,
`however, doubtful and of which the most important are
`briefly described in the following.
`It is necessary to differentiate between mechanical
`(physical) and medicinal (chemical) methods of treatment.
`The mechanical methods of treatment encompass the
`application of pressure on the keloid by external compres
`sion bandages and the application of foils made of silicon
`elastomers. A major disadvantage in this case is that the
`application has to be carried out over months and years. It
`can also not be used to the same extent in all body regions;
`thus for example an adequate degree of compression cannot
`be achieved on the neck. In addition extensive compression
`bandages always mean a considerable restriction in the
`freedom of movement and quality of life for the carrier.
`Moreover they also create considerable problems of
`hygiene, in particular in the warm period of the year and in
`hot countries. Compression bandages can also again lead to
`renewed tissue lesions by the mechanical strain on the
`sensitive scar skin and thus again promote keloid formation.
`The physical methods also include cold treatment
`(cryotherapy) and laser therapy. Both methods produce
`tissue necroses by cold or heat by which means the active
`connective tissue cells and the fibrous substance within the
`keloid are destroyed. The keloids temporarily collapse and
`tissue defects are formed. During the subsequent healing of
`these defects, connective tissue cells again immigrate by
`which means the formation of keloid starts again. Conse
`quently this method of treatment can thus always only
`achieve short-term improvements but no final healing.
`In the case of the medicinal methods it is necessary to
`differentiate between preparations for external application
`and for injection.
`In the case of the agents for external application, these are
`usually ointments with a great variety of active substances
`such as e.g. hormones, amino acids, mucopolysaccharides.
`55
`Plant extracts such as from the thorn-apple are also used. A
`preferred component of preparations for the external treat
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`is the case with the corticoids and also no systemic effects.
`A further advantage is the biological degradability in the
`organism.
`Moreover the compositions according to the invention
`also allow the successful treatment of deep scar formations
`in connective tissue such as e.g. Dupuytren's disease of the
`palmar surfaces or the so-called Induratio penis plastica
`(IPP) which form without prior injury (cross-section).
`DETALED DESCRIPTION OF THE
`INVENTION
`Cross-linked glycosaminoglycans according to the inven
`tion are understood to be those in which two or several of the
`same and/or different glycosaminoglycans are linked
`together to form a molecular unit. The cross-linking is
`preferably carried out by chelate formation, complex for
`mation and/or salt formation and in particular by a chemical
`cross-linking.
`Natural or synthetic glycosaminoglycans and also sub
`stances that are chemically related thereto can be used as
`glycosaminoglycans. They can be of an anionic or cationic
`character.
`Natural glycosaminoglycans that are preferably used are
`those that occur in human connective tissue in particular e.g.
`hyaluronic acid, heparin, heparin sulfate, chondroitin sul
`fate. Sulfated polysaccharides are preferably used as syn
`thetic glycosaminoglycans. Substances that are chemically
`related to glycosaminoclycans that are used according to the
`invention are preferably those of biological origin and in
`particular chitosamine and chitosan or their derivatives such
`as e.g. N-carboxybutlychitosan (cf. R. Muzzarelli et al.,
`Carbohydrate Polymers 11 (1989) 307-320). The formation
`of chelates, poorly soluble salts or complexes of glycosami
`noglycans which also represent a cross-linking within the
`sense of the invention is achieved by a holding-together
`through ionic forces as is common for such chelates, salts or
`complexes.
`The cross-linked glycosaminoglycans used according to
`the invention can be produced in a well-known manner. The
`chemical cross-linking in this process is usually carried out
`by cross-linking with bifunctional reactive agents such as
`e.g. glutaraldehyde or carbodiimide; it is, however, also for
`example possible to produce cross-linking via amide bonds
`by means of bifunctional amino acids such as lysine, prota
`mines or albumins. If glycosaminoglycans or analogues
`thereof that have been produced synthetically are used
`according to the invention then these can already be prima
`rily cross-linked during production so that a further treat
`ment for cross-linking is not necessary. Such glycosami
`noglycans are partly commercially available already in a
`cross-linked state and can be used directly according to the
`invention (e.g. "Hylon" and "Hylagel", a cross-linked hyalu
`ronic acid from the Biomatrix Company NJ. USA; for the
`production c.f. also U.S. Pat. Nos. 4.713448, 4.605.691).
`It is preferable to cross-linkidentical glycosaminoglycans
`are preferably and then use them according to the invention
`but it is also possible according to the invention to use a
`combination of two or more different or partially different
`glycosaminoglycans. In a particularly preferred
`embodiment, glycosaminoglycans with an extremely long
`chain (molecular weight preferably between 100,000 and
`1,000,000) are used; in this case the degree of cross-linking
`can then remain low. The products are practically free of
`protein.
`In a particularly preferred embodiment of the invention
`intermolecularly cross-linked heparin is used as the cross
`linked glycosaminoglycan.
`
`4
`The intermolecular cross-linking of heparin can for
`example be carried out in the following manner: commer
`cially available heparin is treated with dilute nitric acid by
`which means reactive aldehyde groups are formed on the
`heparin; subsequently areductive animation is carried out by
`means of NaBHCN. Covalent bonds are formed between
`the individual heparin chains (end and side chains) via the
`free amino functional groups of heparin.
`A cross-linking of heparin by complex formation is pref
`erably carried out with protamines, gentamycin or
`vancomycin, metal ions such as e.g. Fe, Zn".
`The pharmaceutical compositions according to the inven
`tion contain the cross-linked glycosaminoglycans preferably
`in amounts of 0.1 to 20% by weight in relation to the total
`pharmaceutical composition and in particular in an amount
`of 0.5 to 10% by weight and especially preferably in an
`amount of 1 to 5% by weight.
`The pharmaceutical compositions according to the inven
`tion can be present in the form of preparations that can be
`administered intralesionally and in particular in the form of
`injectable gels preferably with a water content of 80 to 99%
`by weight and also as an anhydrous precursor e.g. lyo
`philized powder in the form of a powder. The pharmaceu
`tical auxiliary and carrier substances that can be used are
`those that are conventionally used for this purpose and are
`suitable for the application according to the invention and
`are compatible with the cross-linked glycosaminoglycans.
`The preferred carrier substance is water.
`The pharmaceutical compositions according to the inven
`tion can for example contain agents to set the pH value,
`stabilizers, antioxidants, solubilizers, agents that promote
`penetration, preservatives and/or gel formers as pharmaceu
`tical auxiliary substances as they are usually used in such
`compositions. They are used in the usual amounts for such
`preparations.
`The pharmaceutical compositions according to the inven
`tion can in addition to the actual active substances (cross
`linked glycosaminoglycans) also contain further pharmaceu
`tically active substances that are compatible with the cross
`linked glycosaminoglycans within the scope of the
`application e.g. active substances for the therapy of skin
`diseases (dermatoses), antibiotics (in particular antibiotics
`with a charge of opposite polarity such as e.g. gentamycin
`and vancomycin with a positive charge for e.g. cross-linked
`heparin, or e.g. penicillins or cephalosporins with a negative
`charge for e.g. cross-linked chitosamine), sulfonamides,
`disinfectants, hormones (e.g. corticoids) and hormone
`derivatives (e.g. cortisol), local anaesthetics e.g. of the
`lidocaine or novocaine type, vasoactive substances for vas
`cular constriction (avoidance of bleeding), adrenalin,
`enzymes such as e.g. hyaluronidase, interleukins, growth
`factors e.g. EGF, PDGF and/or IGF, skin care agents and/or
`agents that stimulate blood flow (hyperaemising agents).
`These substances can be present bound firmly to the gly
`cosaminoglycans such as e.g. antibiotics with a heteropolar
`charge of opposite polarity i.e. as a component of the
`cross-linked glycosaminoglycans and are then released dur
`ing the degradation of the cross-linked glycosaminoglycans
`or they can be released by a controlled release type of
`system.
`In the preferred application according to the invention in
`the form of an injection, the preparations can for example
`contain local anaesthetics to avoid pain when the injection
`cannula is inserted. The preparations preferably contain an
`anionically or cationically charged molecule such as genta
`mycin as an antibiotic which is bound as a counter-ion to the
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`cross-linked glycosaminoglycans and thus remains immo
`bilized in loco which prolongs the action accordingly.
`The compositions according to the invention can be
`produced in a conventional, generally known manner for the
`production of such compositions. In this process the order of
`mixing of the individual components is usually not critical.
`The invention also concerns a process for the production
`of the compositions which is characterized in that the
`cross-linked glycosaminoglycan and the other components
`are dissolved in the pharmaceutical carrier. Water is prefer
`ably used as the pharmaceutical carrier and it is expedient to
`carry out the process while heating and subsequently cool
`ing. For protection against oxidation it may be expedient to
`work under an inert gas atmosphere in particular under
`nitrogen.
`The type, dose and frequency with which the composition
`according to the invention is administered depends in par
`ticular on the severity of the disease and the general state of
`the patient and also quite generally on the state and the
`sensitivity of the skin scar. If the compositions according to
`the invention are administered in the form of preparations
`that can be applied topically then the administration is as a
`rule in accordance with the usual conditions for such con
`positions.
`The type of treatment and frequency of administration
`also depends in particular on the individual response of the
`person to be treated. An application of gels is preferably
`carried out at intervals of 1 to 2 months.
`If the compositions according to the invention in the form
`of injectable gels are applied intralesionally which is pri
`marily the case then this is preferably carried out by injec
`tion with the aid offine cannulae and with pressure-resistant
`syringes. The gels according to the invention can also be
`shot percutaneously with the aid of compressed air instru
`ments; compressed air instruments such as those that are
`known in medicine for such an application can be used for
`this.
`In a particularly preferred embodiment of the invention
`the pharmaceutical preparation in the form of an injectable
`gel contains cross-linked heparin as the cross-linked gly
`cosaminoglycan. Whereas for example the injection of non
`cross-linked heparin does not come into consideration
`because heparin inhibits blood coagulation and is addition
`ally rapidly transported out of the lesion via the vascular
`system and then has a systemic effect similar to the
`corticoids, heparin loses its inhibitory properties on blood
`coagulation in the cross-linked form according to the inven
`tion and cannot be transported away via the blood and lymph
`stream. It therefore remains active at the site of application
`in the keloid tissue for weeks and months after injection.
`Degradation is primarily via phagocytosis by special cell
`populations.
`When the compositions according to the invention are
`used which contain cross-linked glycosaminoglycans there
`is also no occurrence of local over-reactions and no systemic
`effects such as is the case for corticoids. A further advantage
`is the biological degradability in the organism. Thus for
`example the intralesional application by injection can be
`repeated at intervals of 4 to 8 weeks.
`An advantage of the preferred preparations according to
`the invention in the form of injectable gels and their intrale
`sional application is also that no additional hygienic mea
`sures whatsoever are necessary after the injection sites have
`healed. All regions of the body can be treated in the same
`manner and the mobility of the patients is not restricted by
`bandages. Treatment with the preparations according to the
`
`6
`invention can also prevent an occurrence or reoccurrence of
`keloids which demonstrates its preventive effect.
`The invention therefore also concerns the use of cross
`linked glycosaminoglycans for the treatment of wounds,
`scars and primarily keloids and for the production of a
`pharmaceutical composition for wound, scar and keloid
`treatment. In this case the aforementioned glycosaminocly
`cans that were stated as being preferred are preferably used
`as the cross-linked glycosaminoglycan.
`A particular method of application for the prevention of
`keloids or contract scars is the administration of anhydrous
`precursors of cross-linked glycosaminoglycans (e.g. as a
`lyophilisate) in the form of a wound powder into fresh
`wounds. In this case the powder is sprinkled into the open
`wound or wound cavity before wound closure. The wound
`is then closed by a suture, clamps etc. In the wound the
`powder takes up water from the tissue and then corresponds
`to the preparation according to the invention in the form of
`a gel or itself represents a preparation according to the
`invention.
`The powder or gel form can also be introduced into large
`body cavities to prevent undesired adhesions e.g. into the
`abdominal cavity or thoracic cavity during a surgical opera
`tion on the intestine or the lung, into the pericardium, or after
`operative procedures via indwelling drainages. In the case of
`inflammatory effusions into large body cavities, the prepa
`ration according to the invention can also be introduced via
`the indwelling cannula after puncturing and emptying the
`effusion.
`The preparation according to the invention which may be
`on a suitable carrier (e.g. tampon) can also be introduced
`into cavities and ducts of the body that are accessible from
`the outside e.g. into the main nasal cavities and paranasal
`sinuses or into the meati of the nose or into the tear ducts to
`prevent scarred adhesions.
`It is known from U.S. Pat. No. 4605,691 that cross-linked
`gels of hyaluronic acid can be use alone or together with
`other hydrophilic polymers in cosmetic formulations. R.
`Muzzarelli et al. (1.c) also describe the use of
`N-carboxybutylchitosan for cosmetic preparations.
`It was now surprisingly found that the cross-linked gly
`cosaminoglycans according to the invention that are
`described above are excellently suitable as a carrier or
`component of cosmetics and skin care products.
`The present invention therefore also concerns the use of
`the cross-linked glycosaminoglycans described above with
`the exception of cross-linked hyaluronic acid or cross-linked
`N-carboxybutylchitosan for cosmetics or as skin care prod
`ucts. In particular the cross-linked glycosaminoglycans that
`were previously stated as being preferred and distinctively
`described are used for this.
`The cosmetic preparations and skin care products can be
`present in the usual forms for such preparations e.g. as
`creams, ointments, lotions and in particular as gels that can
`be applied topically. They can also contain other auxiliary
`and/or carrier substances that are conventionally used for
`this that are compatible with the cross-linked glycosami
`noglycans according to the invention. In addition they can
`also contain the auxiliary substances and/or further active
`substances described previously in connection with the
`pharmaceutical preparations, provided that they are compat
`ible with the cross-linked glycosaminoglycans within the
`scope of the application and are practical.
`It is intended to elucidate the invention in more detail by
`the following examples without limiting it thereto.
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`7
`EXAMPLE 1.
`Production of an injectable gel from the following com
`ponents:
`
`5,731,298
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`8
`The keloids were treated several times using conservative
`methods (topical preparations) and repeatedly excised. After
`the last excision, cross-linked hyaluronic acid was injected
`during the operation into the wound edges on the right side.
`Then both sides were sutured identically. The sutures were
`removed on the right and left side after two weeks. After four
`weeks the untreated scar on the left side was raised consid
`erably more and was more reddened than the scar on the
`right side treated with hyaluronic acid. In addition it was
`possible to successfully prevent the reoccurrence of a keloid
`on the right-hand side. This also demonstrates the preventive
`effect of the pharmaceutical preparation according to the
`invention.
`I claim:
`1. Amethod for treating a pre-existing scar or pre-existing
`keloid comprising injecting a composition comprising a
`pharmaceutically effective amount of a cress-linked hyalu
`ronic acid in combination with a pharmaceutically accept
`able carrier into the pre-existing scar or pre-existing keloid,
`wherein the pharmaceutically effective amount of a cross
`linked hyaluronic acid is 0.1% to 20% by weight of the
`composition.
`2. A method for treating a scar or keloid according to
`claim 1, wherein said cross-linked hyaluronic is cross-linked
`by chemical cross-linking, chelate formation, complex for
`mation or salt formation.
`3. A method for treating a scar or keloid according to
`claim 1, wherein said cross-linked hyaluronic acid is cross
`linked by chemical cross-linking.
`
`Component
`cross-linked hyaluronic acid
`("Hylager" Biomatrix Co., NJ, USA)
`lidocaine hydrochloride
`water, purified
`(DAB 9)
`
`Amount
`0.004g
`0.02 g
`
`to 1.0 g
`
`The components are dissolved under a nitrogen atmo
`sphere while stirring and briefly heating; a colourless clear
`gel is obtained after cooling; pH value: 7.00-0.1.
`The gel is dispensed into pressure-resistant piercable
`ampoules and sealed. Afterwards a heat sterilization is
`carried out and the gel is stored protected from light.
`Application example 1
`The treatment of a ca. 3 cmx5 cm dark-red raised keloid
`is described which was present on the back of a 30 year old
`woman after a tangential cut by a broken pane of glass.
`The patient complained about itching in the area of the
`keloid. The keloid was infiltrated with cross-linked hyalu
`ronic acid (Hylon) by injection for a total of four times at
`intervals of 4 to 8 weeks. The itching had already disap
`peared a few hours after the first injection. The keloid
`became considerably paler within two weeks and aflattening
`was already recognizable after four weeks. After ca. 6
`months there was a pale, only slightly raised scar.
`Application example 2
`The treatment of a keloid in the lower fold of the breast
`(right and left) is described which occurred in a female
`patient after surgical breast correction.
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