Europaisches Patentamt European Patent Office © Publication number: 0 357 646 B1 Office europeen des brevets © EUROPEAN PATENT SPECIFICATION © Date of publication of patent specification: 22.03.95 © Int. CI.6: A61 K 31/07, A61 K 31/20 © Application number: 88903704.0 @ Date of filing: 05.04.88 © International application number: PCT/US88/01103 © International publication number: WO 88/07857 (20.10.88 88/23) The file contains technical information submitted after the application was filed and not included in this specification © TREATMENT OF AGED SKIN WITH ORAL 13-CIS-RETINOIC ACID. ® Priority: 06.04.87 US 35544 © Proprietor: DALTEX MEDICAL SCIENCES, INC. 50 Kulick Road @ Date of publication of application: Second Floor 14.03.90 Bulletin 90/11 Fairfield, NJ 07006 (US) © Publication of the grant of the patent: @ Inventor: PLEWIG, Gerd 22.03.95 Bulletin 95/12 Cecilienallee 38 D-4000 Dusseldorf 30 (DE) © Designated Contracting States: Inventor: KLIGMAN, Albert, M. AT BE CH DE FR GB IT LI LU NL SE 637 Pine Street Philadelphia, PA 19106 (US) © References cited: GB-A- 1 335 867 Representative: Koepsell, Helmut, Dipl. Ing. Retinoids, ED.; C.E. ORFANOS et al., pub- Mittelstrasse 7 lished 29 July 1981, pp. 219-223, 232-235, see D-50672 Koln (DE) entire document 00 CO CO m Note: Within nine months from the publication of the mention of the grant of the European patent, any person may give notice to the European Patent Office of opposition to the European patent granted. Notice of opposition shall be filed in a written reasoned statement. It shall not be deemed to have been filed until the opposition fee has been paid (Art. 99(1) European patent convention). Rank Xerox (UK) Business Services (3. 10/3.09/3.3.3) EP 0 357 646 B1 DRUGS, vol. 28, 1984, pages 6-37, ADIS Press Ltd.; A. WARD et al.: "Isotretinoin. A review of Its pharmacological properties and thera- peutic efficacy In acne and other skin dis- orders" HAUTARTZT, vol. 35, 1984, pages 623-629, C. Sprlnger-Verlag, DE; R. CORLIN et al.: "13-cis-retin-saure. Nledrlg doslerte orale Anwendung bel Acne papulopustulosa" DERMATOLOGICA, vol. 171, 1985, pages 213-219, S. KARGER AG, Basel, CH; J. GAR- IQUE et al.: "Action de I'acide 13-cls-re- tlnolque et du retlnolde aromatlque sur divers para metres cutanes, chez le rat rendu hyperseborrhelque" MAYO CLINICAL PROC., vol. 57, 1982, pages 51-57, CH. DICKEN et al.: "Systemic re- tinoids In dermatology" Z. HAUTKR., vol. 57, no. 15, 1982, pages 1137-1143, Grosse Verlag, Berlin, DE; E. HOT- ING et al.: "Systemische Retlonoldtheraple - Wlrkprlnzlplen und kllnlsche Erfahrungen bel erythematosquamosen und anderen Der- matosen" INT. J. DERMATOL, vol. 25, no. 10, December 1986, pages 660-663; E. HOTING et al.: "Treat- ment of Rosacea with Isotretinoin" J. AM. ACAD. DERMATOL, vol. 6, no. 4, 1982, pt 2, suppl., pages 766-785; G. PLEWIG et al.: "Action of Isotretinoin In acne rosacea and gramnegatlve folliculitis" ACTA VITAMINOL. ENZYMOL, vol. 6, no. 4, 1984, pages 325-337; M. GANDOLA: "La terapla dell'acne grave e della Rosacea con acldo 13-cls-retlnolco (Isotretinoin) per via orale" 2 1 EP 0 357 646 B1 2 Description skin of adults, usually starting about middle age, which acts to reverse and retard the effects of Field of the Invention photoaging through its actions on the damaged connective tissue and abnormal epidermis. Further, The present invention relates to the treatment 5 pending U.S. Patent Application Serial No. 886,595 of various associated disorders of the skin which of Albert M. Kligman for "Methods for Treatment of are typical of many elderly persons. More particu- Sundamaged Human Skin with Retinoids" dis- larly, the invention is directed to the treatment of closes the topical use of various retinoic acid de- such disorders with low oral doses of 13-cis-re- rivatives, including 13-cis-retinoic acid, for treating tinoic acid. io photoaged skin. 13-cis-retinoic acid, more commonly referred to Background of the Invention simply as cis-retinoic acid or isotretinoin or by the trademarks "ACCUTANE" (in U.S.) or "ROAC- Many older persons (i.e., generally over 50 CUTAN" (in Europe), is an FDA-approved oral years of age and referred to herein as "the el- 75 medication for the treatment of severe, refractory derly") have "problem" skin deriving from multiple acne vulgaris, in particular acne conglobata. Cis- influences. These increase steadily with age, and retinoic acid is also used, but not FDA-approved, all are worsened by years of earlier excessive for the treatment of certain chronic, uncurable in- exposure to sunlight. The sun is a significant contri- flammatory and scaling disorders, viz, psoriasis, butor to chronic skin problems which are very 20 ichthyosis, Darier's disease, lupus erythematosus, prevalent in the aging population. These skin prob- granulomatous rosacea, etc. Orally administered lems are most vividly expressed in the most ex- isotretinoin also has anti-tumor activity in very high posed areas of the skin, and especially on the face, doses and can bring about at least partial regres- an area rich in blood vessels, follicles, and seba- sion of actinic keratoses, keratoacanthomas, and ceous glands. The face is also a highly permeable 25 basal cell carcinomas. region with a poor barrier layer, allowing ready In such prior art treatments the recommended penetration of potentially toxic chemicals originat- oral doses for acne are generally in the range of 40 ing in soaps, cosmetics, fragrances, toiletries, etc. to 80 mg daily (0.5-2.0 mg/kg body weight per The face is under continuous chemical assault, as day), and higher doses, sometimes as much as well as radiation insults. The end result is abnormal 30 200 mg per day, are often given for other chronic, skin, a consequence of multiple factors acting in disabling disorders. At these high dosages adverse combination. One can recognize the following clini- side reactions occur in all patients and are recog- cal disorders: nized as the general signs of hypervitaminosis A, 1) Rosacea-like syndromes with persistent red- namely dry skin, conjunctivitis, cheilitis, nasal ness, papules, and solid edema-like swellings; 35 bleeding, fragile skin, hair loss, pruritus, muscle 2) Hyperplasia of the sebaceous glands; pains, hyperostosis of bone, calcification of liga- 3) A seborrheic-like dermatitis, peculiar to the ments, gastrointestinal upsets, pseudotumor cerebri elderly; and others. 4) Pityrosporon-induced folliculitis; In a certain proportion of patients taking oral 5) Infestation by Demodex mites, with mite-as- 40 isotretinoin, blood tests show potentially serious sociated folliculitis, erythema, and scaling; abnormalities, viz, increased cholesterol, reduction 6) Enlarged, roughened nose (rhinophyma ; of high density lipoproteins (which protect against 7) Overgrowth of P. acnes, an anaerobic bac- coronary heart disease), increased levels of teria living in the follicles; triglycerides, elevation of hepatic enzymes, xan- 8) Flat, keratotic and pigmented seborrheic 45 thoma formation and others. Moreover, cis-retinoic keratoses; acid has been found to be extremely teratogenic. 9) Rough, scaly lesions of the actinic keratoses Lower doses of cis-retinoic acid in the range of type; 0.05 or 0.1 mg/kg body weight per day, have been 10) Scaly, flaky, dandruff-like conditions of the reported to be beneficial in acne conglobata scalp; and 50 (nodulo-cystic acne). Corlin, R. et al., "13-cis-re- 11) Trichostasis spinulosa-follicular impactions tinoic acid. Low Dosage Oral Use in Acne on nose, cheeks, temples and nape of the neck. Papulopustulosa. Results of a Multicenter Study," Changes take place against a background of Hautarzt 35:623-629 (1984); Ward, A. et al., photoaged skin showing yellowing, wrinkling, dry- "Isotretinoin. A Review of its Pharmaceutical Prop- ness, dilated vessels and comedones. 55 erties and Therapeutic Efficacy in Acne and Other U.S. Patent 4,603,146 of Albert M. Kligman Skin Disorders," Drugs 28:6-37. (1984). The latter discloses the use of vitamin A acid (retinoic acid or publication notes that the pharmacological profile of tretinoin) as a topical medication for sun-damaged isotretinoin suggests that it acts primarily by reduc- 3 3 EP 0 357 646 B1 4 ing sebaceous gland size and sebum production, yeast-like fungi Pityrosporon species and espe- and as a result alters the composition of the sur- cially anaerobic P. acnes, producing papules face lipids. The follicular microflora are also re- and pustules. Unlike acne, these do not originate duced, owing to diminished sebum production. The from ruptured comedones. This reaction is a reference also reports encouraging preliminary re- 5 folliculitis due to sebum leakage; sults in small numbers of patients with rosacea, 5) Flushing and redness, associated with dilated gram-negative folliculitis, Darier's disease, ich- vessels, resembling rosacea, accompanied by thyosis and pityriasis rubra pilaris. The response in sensitive skin which stings and burns; keratinizing disorders resembles that of the related 6) Scaling and redness along the sides of the drug etretinate, another retinoic acid derivative. io nose and cheeks, also the eyebrows, mimicking Plewig, G. et al., "Effects of Two Retinoids in and related to seborrheic dermatitis of younger Animal Experiments and After Clinical Application persons; in Acne Patients: 13-Cis-Retinoic Acid Ro4-3780 7) Flat, brown pigmented keratotic lesions of the and Aromatic Retinoid Ro1 0-9359," Retinoids, seborrheic keratosis variety; Pages 219-235 (Springer-Verlag 1981) discloses is 8) Rough, scaly lesions of the actinic keratosis clinical studies of sixty patients with severe ("un- type; treatable") acne using oral doses of 13-cis-retinoid 9) Scaly, flaky, dandruff-like conditions of the acid ranging from 0.05 to 2.0 mg/kg body weight. scalp; The authors reported a dramatic but dose-depen- 10) Fine wrinkles caused by dryness or loss of dent response in all patients, where with lower 20 moisture from the aged skin; and doses the improvement showed delayed onset.