<clinical_study>
  <!-- This xml conforms to an XML Schema at:
    https://clinicaltrials.gov/ct2/html/images/info/public.xsd -->
  <required_header>
    <download_date>ClinicalTrials.gov processed this data on September 20, 2023</download_date>
    <link_text>Link to the current ClinicalTrials.gov record.</link_text>
    <url>https://clinicaltrials.gov/ct2/show/NCT03012191</url>
  </required_header>
  <id_info>
    <org_study_id>HS-16-00788</org_study_id>
    <nct_id>NCT03012191</nct_id>
  </id_info>
  <brief_title>Gentamicin for RDEB</brief_title>
  <official_title>Gentamicin Therapy for Recessive Dystrophic Epidermolysis Bullosa Patients With Nonsense Mutations</official_title>
  <sponsors>
    <lead_sponsor>
      <agency>University of Southern California</agency>
      <agency_class>Other</agency_class>
    </lead_sponsor>
  </sponsors>
  <source>University of Southern California</source>
  <oversight_info>
    <is_fda_regulated_drug>Yes</is_fda_regulated_drug>
    <is_fda_regulated_device>No</is_fda_regulated_device>
    <is_us_export>No</is_us_export>
  </oversight_info>
  <brief_summary>
    <textblock>
      Recessive dystrophic epidermolysis bullosa (RDEB) is an incurable, devastating, inherited&#xD;
      skin disease caused by mutations in the COL7A1 gene that encodes for type VII collagen (C7),&#xD;
      the major component of anchoring fibrils (AFs), structures that mediate epidermal-dermal&#xD;
      adherence. Thirty percent of RDEB patients have nonsense mutations. The investigators&#xD;
      recently demonstrated in 5 such patients that intradermal and topical gentamicin induced&#xD;
      &quot;read-through&quot; of their nonsense mutations and created robust and sustained new C7 and AFs at&#xD;
      the dermal-epidermal junction (DEJ) of their skin and also stimulated wound closure and&#xD;
      reduced new blister formation. No untoward side effects occurred. Herein, the investigators&#xD;
      propose evaluating the safety and efficacy of intravenous gentamicin in these patients. In&#xD;
      theory, this intravenous administration has the possibility of treating simultaneously all of&#xD;
      the patients' skin wounds. The investigators also propose optimizing the concentration and&#xD;
      manner of delivery of topical gentamicin. The unambiguous milestones will be increased C7 and&#xD;
      AFs in the patients' DEJ, improved EB Disease Activity Scores, and absence of significant&#xD;
      gentamicin side effects.&#xD;
    </textblock>
  </brief_summary>
  <detailed_description>
    <textblock>
      Aim 1. Evaluate the Safety and Efficacy of Short Term Intravenous Gentamicin for RDEB&#xD;
      Patients.&#xD;
&#xD;
      Overview &amp; Rationale: The rationale for short-term systemic intravenous gentamicin in these&#xD;
      patients is outlined in the sections above, namely the drug could treat multiple skin sites&#xD;
      simultaneously including the esophagus. This approach has proven safe and efficacious in&#xD;
      other genetic diseases such as CF and DMD22-25 Our HYPOTHESIS is that intravenous gentamicin&#xD;
      will, like topical and intradermal gentamicin, create new C7 and AFs at the patient's DEJ,&#xD;
      improve multiple skin sites simultaneously, improve the patient's clinical disease and&#xD;
      improve his or her quality of life. In accordance with the enclosed letters from two&#xD;
      experienced pediatricians, we believe this therapy will be safe. Because C7 and AFs are&#xD;
      incredibly stable, we further hypothesize that newly induced C7 and AFs will persist for many&#xD;
      months in the patient's skin. Using dosing regimens of gentamicin that have proven to be&#xD;
      safe, we will: 1) determine the percentage increase of C7 expression in the patients' skin&#xD;
      before and after treatment, 2) determine how durable and sustainable the new C7 and AFs are&#xD;
      in the patients' skin after treatment, 3) determine if this treatment is safe in this patient&#xD;
      population, 4) determine if this treatment improves the patients clinically and improves&#xD;
      their quality of life and 5) generate data for a multi-centered Phase III study using a&#xD;
      larger number of patients.&#xD;
&#xD;
      Patients/Intervention: We have already lined up 3 well-characterized, adult RDEB patients&#xD;
      with nonsense mutations who wish to participate in this study. These patients had positive&#xD;
      responses to topical and intradermal gentamicin in our clinical trial (Table II). The&#xD;
      patients will receive intravenous gentamicin (7.5 mgs per kilogram), in 100 ml of 5% dextrose&#xD;
      in saline, for 14 consecutive days, a dose proven to not cause ototoxicity or&#xD;
      neprhotoxicity28 and to be efficacious in inducing PTC read-through in DMD patients.22 The&#xD;
      first few infusions will be done in the Infusion Center of the Keck Hospital of USC. We will&#xD;
      measure gentamicin trough levels (24 hours after infusion) and gentamicin peak levels (30&#xD;
      minutes after the infusion) during the second day and, if needed, adjust the gentamicin doses&#xD;
      such that the peak level is between 20 and 40 μg/ml and the trough level &lt;2 μg/ml. If no&#xD;
      untoward side effects occur, the patients will then have their infusions in their home via a&#xD;
      commercial infusion service.&#xD;
&#xD;
      Safety Evaluation: Patients will be consented, enrolled and evaluated on Day 0 and then&#xD;
      evaluated on post-treatment days 30, 90, and 180. On Day 0, the patients will have a complete&#xD;
      medical history, review of systems (ROS), physical examination, vital signs, and weight. They&#xD;
      will also have baseline urine analysis, complete blood count (CBC), electrolytes, glucose,&#xD;
      comprehensive metabolic panel (CMP), and calculated creatinine clearance. Pure tone&#xD;
      audiometry and a calculated creatinine clearance will be done on Days 0, 7, 14 and 30&#xD;
      post-treatment. Stop criteria will be a decline of &gt;15 dB on pure tone audiometry at 2&#xD;
      consecutive frequencies and a creatinine clearance &lt;60ml/min.28 Whenever there is new protein&#xD;
      created in a patient, there is the possibility that the patient's immune system will raise&#xD;
      autoantibodies against it. This did not occur in our clinical trial with topical and&#xD;
      intradermal gentamicin, but it behooves us to evaluate this again with intravenous gentamicin&#xD;
      and potentially more auto-antigenic protein created. Using indirect immunofluorescence and&#xD;
      our anti-C7 ELISA, we will test the subject's serum for anti-C7 antibodies at each visit.&#xD;
&#xD;
      Efficacy: A. Clinical Evaluations: At baseline Day 0 and at each follow-up visit, (days 30,&#xD;
      90 and 180) the patients will complete a Quality of Life Assessment tool, a Pruritus Score&#xD;
      tool, and a validated epidermolysis bullosa disease activity index (EBDASI)29,30. Patients&#xD;
      will keep a daily diary using a self-ROS questionnaire. Patients will be telephoned weekly by&#xD;
      a USC study member inquiring about any new signs, symptoms or ROS changes since the advent of&#xD;
      the study. At baseline Day 0, we will identify four Test Sites at least 25 cm2 in size to&#xD;
      follow sequentially. Two will be from areas that at baseline have blisters or erosions and&#xD;
      the other two from intact skin areas. The two Test Sites with active blisters and erosions&#xD;
      will be traced using a transparency sheet and the areas of the lesions calculated on a&#xD;
      digitizing tablet. Likewise, all of the Test Sites will have standardized photographs and the&#xD;
      lesional areas calculated by computer-assisted morphometry, as previously published.29-31&#xD;
      Within the context of their daily diary, patients will note the number of new blisters and&#xD;
      erosions that occur in the Test Sites. A USC study member will telephone the patient each&#xD;
      week and inquire about the Test Sites and ask the patient to estimate the percentage area of&#xD;
      the Test Site consumed by erosions and blisters. Also, at each follow-up visit, three&#xD;
      dermatologists will observe the four Test Sites and count the number of bullae and erosions&#xD;
      in each. The intact Test Site areas will be scored at each follow-up visit using the&#xD;
      following 3-point scale: 0 = no lesions; +1 = any active lesions; +2 = active lesions&#xD;
      consuming over 50% of the Test Site area. Tracings to evaluate the areas of blisters or open&#xD;
      erosions will be done, and standardized photographs paired with computer-assisted morphometry&#xD;
      to calculate the areas of any lesions will be performed. B. Evaluations of C7 and AF&#xD;
      Expression: At each post-treatment time point, 8 mm punch biopsies from the four Test Sites&#xD;
      will be divided into three parts for (i) H&amp;E histology and quantitation of epidermal-dermal&#xD;
      adherence, (ii) the expression of C7 at the DEJ relative to that of normal human skin using&#xD;
      anti-C7 antibodies to the NC1 and NC2 domains of C7 and NIH J Image software. One major&#xD;
      &quot;milestone&quot; of the study will be the expression of NC2 since this would clearly indicate&#xD;
      restoration of full-length C7 and (III) evaluation of newly created AFs by immuno-EM and AF&#xD;
      enumeration by computer-assisted morphometry. Performing these evaluations out to 6 months&#xD;
      will determine how durable the newly created C7 and AFs are. In our recent clinical trial&#xD;
      outlined above, it was surprising that gentamicin-induced C7 remained at a similar level at 3&#xD;
      months post-treatment as that of 1 month for Patient #3 (Please see Figure 1 and Table II).&#xD;
&#xD;
      Aim 2: Evaluate the Safety and Efficacy of Higher Dose Topical Gentamicin for RDEB Patients.&#xD;
&#xD;
      Overview and Rationale: In our gentamicin clinical trial outlined earlier, there was&#xD;
      significant variation in the production of new C7 and AFs, as shown in Table II. Patients #2&#xD;
      and #5 only restored C7 to 20% of normal skin in response to gentamicin. We only used one&#xD;
      concentration of gentamicin, 0.1% ointment, and our in vitro studies with RDEB fibroblasts&#xD;
      from these same two patients showed that the C7 response to gentamicin was dose-dependent.26&#xD;
      In these patients, there could have been sub-optimal dosing or sub-optimal access of the&#xD;
      gentamicin to the patient's dermal fibroblasts and basal keratinocytes. In this aim, we will&#xD;
      use 0.5% gentamicin ointment rather than 0.1% and determine if the C7 response is more robust&#xD;
      in these two patients. Based on our encouraging data shown in Figure 2, we will also treat&#xD;
      intact skin and determine if higher dose gentamicin can prophylactically prevent frank skin&#xD;
      blisters and erosions from forming.&#xD;
&#xD;
      Patients/Intervention: We will study two RDEB children tested in our previous trial for this&#xD;
      study. In addition, we also have 2 other children and 2 other adult patients who have&#xD;
      contacted us and wish to participate in this study (Table III). Two of these patients share&#xD;
      the same mutations (R578X and R2814) as our current patients. We will select a total of four&#xD;
      Test Sites (two with open wounds of at least 3 cm by 3 cm and two areas of intact skin nearby&#xD;
      the Test Sites with blisters or erosions) and apply 0.5% gentamicin ointment two times a day&#xD;
      under an occlusive dressing of the patients' choice for two weeks. This dose was used in&#xD;
      combination with 15% paromomycin to ulcerative cutaneous leishmaniasis lesions once daily for&#xD;
      20 days in two publications without renal or ototoxicity detected.32,33 Safety and Efficacy:&#xD;
      We will essentially assess in these patients the safety and efficacy parameters outlined in&#xD;
      Aim #1 at months 1, 3 and 6 after topical application. Potential renal toxicity and&#xD;
      ototoxicity will be monitored by creatinine clearance and pure tone audiometry at day 0 and&#xD;
      at each follow up visit.&#xD;
&#xD;
      Aim 3: Evaluate the Safety and Efficacy of Intradermal Administration of Gentamicin with a&#xD;
      MR2 Micro-needle Roller Device.&#xD;
&#xD;
      Overview and Rationale: In our current clinical trial outlined above, there were excellent C7&#xD;
      responses to intradermal injections of gentamicin solution in several patients (Table II).&#xD;
      Nevertheless, these injections were very localized with diffusion of the drug probably less&#xD;
      than an inch from the single injection site. Recent evidence has shown that a MR2 microneedle&#xD;
      roller device can readily deliver lidocaine into the lower epidermis and upper papillary&#xD;
      dermis over a wide area of skin with good efficacy, safety and excellent patient tolerance.34&#xD;
      This may be an opportunity to deliver intradermal gentamicin solution (40 mg/ml) to wide&#xD;
      areas of skin in a simple manner that can be done in an outpatient office with minimal&#xD;
      logistical issues and avoidance of systemic exposure to the drug. Advantages include the&#xD;
      possibility of delivering in a &quot;pulse &quot; fashion significant levels of gentamicin to the&#xD;
      papillary dermis over wide areas of skin with minimal discomfort and minimal systemic&#xD;
      exposure of gentamicin. Avoiding systemic exposure would be valuable for RDEB patients who&#xD;
      have ototoxicity or renal compromise, poor venous access or cannot tolerate intravenous&#xD;
      infusions.&#xD;
&#xD;
      Patients &amp; Interventions: We will enroll two new RDEB patients (either adults or children)&#xD;
      shown in Table III in this &quot;proof-of-principle&quot; study. Skin Test Sites will be areas&#xD;
      measuring at least 40 cm2, and we will test one site of intact unwounded skin and one site of&#xD;
      skin with lesions (blisters or erosions). The areas will be cleansed with 4% Hibiclens and&#xD;
      then the MR2 Microneedle Roller Device passed over the area in two directions at 90 degrees.&#xD;
      This device induces tiny micro-wounds in the skin to the depth of the papillary dermis.&#xD;
      Gentamicin sterile solution (40 mg/ml) will then be liberally applied over the area and the&#xD;
      area immediately occluded with a polyrurethane membrane (Opsite). Another equal sized Test&#xD;
      Site of intact skin will be tested without prior intervention with the Microneedle Roller.&#xD;
      The same gentamicin solution will be applied to the site and immediately occluded with&#xD;
      Opsite. This will determine if the gentamicin solution can penetrate intact skin.&#xD;
&#xD;
      Safety and Efficacy: We will measure gentamicin in the serum of these patient 30 minutes&#xD;
      after the microneedle delivery to determine if there is any systemic exposure when gentamicin&#xD;
      is administered in this manner. Efficacy of the gentamicin administration will be assessed&#xD;
      identically to those in Aim#1 by IF and immuno-EM analysis in conjunction with the patients&#xD;
      keeping a daily diary of the treatment sites, weekly photographs of Test Sites, weekly staff&#xD;
      interviews of the patients, and physician assessments at patient visits at months 1, 3 and 6&#xD;
      after administration of gentamicin. Potential renal toxicity and ototoxicity will be&#xD;
      monitored by creatinine clearance and pure tone audiometry at day 0 and each follow up visit.&#xD;
    </textblock>
  </detailed_description>
  <overall_status>Completed</overall_status>
  <start_date type="Actual">February 2, 2017</start_date>
  <completion_date type="Actual">August 31, 2018</completion_date>
  <primary_completion_date type="Actual">May 5, 2018</primary_completion_date>
  <phase>Phase 1/Phase 2</phase>
  <study_type>Interventional</study_type>
  <has_expanded_access>No</has_expanded_access>
  <study_design_info>
    <allocation>N/A</allocation>
    <intervention_model>Single Group Assignment</intervention_model>
    <primary_purpose>Treatment</primary_purpose>
    <masking>None (Open Label)</masking>
  </study_design_info>
  <primary_outcome>
    <measure>Increased Expression of Full-length Type VII Collagen as Assessed by Immunofluorescence</measure>
    <time_frame>6 months</time_frame>
    <description>The expression of type VII collagen at the patients' dermal-epidermal junction was assessed by immunofluorescence (IF) using an antibody specific to type VII collagen. The expression was semi-quantitated using NIH Image J software. The IF expression of type VII collagen was assessed before treatment and at one and three months after treatment. At each assessment time point, type VII collagen expression was also measured in normal human skin. The expression of type VII collagen was then expressed as a percentage of the type VII collagen expressed in normal human skin.</description>
  </primary_outcome>
  <primary_outcome>
    <measure>Number of Participants With New or Increased Numbers of Anchoring Fibrils as Assessed by Immuno-electron Microscopy</measure>
    <time_frame>6 months</time_frame>
    <description>The expression of anchoring fibril structures at the patients' dermal-epidermal junction was assessed by immuno-electron microscopy (IEM) using an antibody specific to type VII collagen. The IEM expression of anchoring fibrils was assessed before treatment and at one and three months after treatment. At each assessment time point, anchoring fibrils were compared with normal human skin. Baseline pre-treatment and one and three month post-treatment sites were compared for the presence of anchoring fibrils after gentamicin treatment (or increase if anchoring fibrils were detected at baseline in patients).</description>
  </primary_outcome>
  <primary_outcome>
    <measure>Number of Participants With Absence of Gentamicin Side Effects Especially the Detection of Any Ototoxicity or Nephrotoxicity</measure>
    <time_frame>6 months</time_frame>
    <description>Prolonged exposure to systemic gentamicin is associated with ototoxicity and nephrotoxicity. Specific tests (creatinine clearance and gold-tone audiometry) are performed throughout the study in order to detect any drug-specific adverse events as a result of systemic exposure to gentamicin. Additionally, we test patient skin and serum throughout the study to look for increase of autoantibodies to C7. Since some of these patients may have never had C7 expressed in their bodies, gentamicin-induced C7 may cause in auto-immune response.</description>
  </primary_outcome>
  <secondary_outcome>
    <measure>Improved EBDASI Scores</measure>
    <time_frame>6 months</time_frame>
    <description>EBDASI - Epidermolysis Bullosa Disease Activity and Scarring Index Scale - Minimum (0) to Maximum (506) A lower score indicates a better outcome (less disease activity and/or damage) A clinical tool for evaluating the disease activity and damage associated with bullous patients. To be administered by a licensed dermatologist.</description>
  </secondary_outcome>
  <number_of_arms>1</number_of_arms>
  <enrollment type="Actual">6</enrollment>
  <condition>Recessive Dystrophic Epidermolysis Bullosa</condition>
  <arm_group>
    <arm_group_label>Gentamicin</arm_group_label>
    <arm_group_type>Experimental</arm_group_type>
    <description>Topical gentamicin; Topical gentamicin with microneedle roller assistance; IV gentamicin. While the intervention is the same drug, the topical gentamicin is compounded into a 0.5% ointment and the IV gentamicin is prepared to 7.5 mg/kg body weight and administered over a 30 minutes.</description>
  </arm_group>
  <intervention>
    <intervention_type>Drug</intervention_type>
    <intervention_name>Gentamicin Sulfate</intervention_name>
    <description>Participants will be divided into three cohorts: topical gentamicin; Topical gentamicin with microneedle roller assistance; IV gentamicin. While the intervention is the same drug, the topical gentamicin is compounded into a 0.5% ointment and the IV gentamicin is prepared to 7.5 mg/kg body weight and administered over a 30 minutes.</description>
    <arm_group_label>Gentamicin</arm_group_label>
    <other_name>Gentamicin, Garamycin</other_name>
  </intervention>
  <eligibility>
    <criteria>
      <textblock>
        Inclusion Criteria:&#xD;
&#xD;
        (i) RDEB patients with a nonsense mutation in COL7A1 in either one or two alleles (ii) An&#xD;
        absence or decrease in C7 expression at their DEJ when compared to that of normal human&#xD;
        skin.&#xD;
&#xD;
        Exclusion Criteria:&#xD;
&#xD;
        (i) Pre-existing renal or auditory impairment (ii) Allergies to aminoglycosides or sulfate&#xD;
        compounds (iii) Pregnancy (iv) Exposure to gentamicin within the past 6 weeks.&#xD;
      </textblock>
    </criteria>
    <gender>All</gender>
    <minimum_age>N/A</minimum_age>
    <maximum_age>N/A</maximum_age>
    <healthy_volunteers>No</healthy_volunteers>
  </eligibility>
  <overall_official>
    <last_name>David Woodley, MD</last_name>
    <role>Principal Investigator</role>
    <affiliation>University of Southern California Department of Dermatology</affiliation>
  </overall_official>
  <location>
    <facility>
      <name>University of Southern California</name>
      <address>
        <city>Los Angeles</city>
        <state>California</state>
        <zip>90033</zip>
        <country>United States</country>
      </address>
    </facility>
  </location>
  <location_countries>
    <country>United States</country>
  </location_countries>
  <verification_date>July 2019</verification_date>
  <study_first_submitted>January 4, 2017</study_first_submitted>
  <study_first_submitted_qc>January 5, 2017</study_first_submitted_qc>
  <study_first_posted type="Estimate">January 6, 2017</study_first_posted>
  <results_first_submitted>June 3, 2019</results_first_submitted>
  <results_first_submitted_qc>July 22, 2019</results_first_submitted_qc>
  <results_first_posted type="Actual">July 23, 2019</results_first_posted>
  <last_update_submitted>July 22, 2019</last_update_submitted>
  <last_update_submitted_qc>July 22, 2019</last_update_submitted_qc>
  <last_update_posted type="Actual">July 23, 2019</last_update_posted>
  <responsible_party>
    <responsible_party_type>Principal Investigator</responsible_party_type>
    <investigator_affiliation>University of Southern California</investigator_affiliation>
    <investigator_full_name>David Woodley</investigator_full_name>
    <investigator_title>Professor</investigator_title>
  </responsible_party>
  <condition_browse>
    <!-- CAUTION:  The following MeSH terms are assigned with an imperfect algorithm            -->
    <mesh_term>Epidermolysis Bullosa</mesh_term>
    <mesh_term>Epidermolysis Bullosa Dystrophica</mesh_term>
  </condition_browse>
  <intervention_browse>
    <!-- CAUTION:  The following MeSH terms are assigned with an imperfect algorithm            -->
    <mesh_term>Gentamicins</mesh_term>
  </intervention_browse>
  <provided_document_section>
    <provided_document>
      <document_type>Study Protocol</document_type>
      <document_has_protocol>Yes</document_has_protocol>
      <document_has_icf>No</document_has_icf>
      <document_has_sap>No</document_has_sap>
      <document_date>March 2, 2017</document_date>
      <document_url>https://ClinicalTrials.gov/ProvidedDocs/91/NCT03012191/Prot_000.pdf</document_url>
    </provided_document>
    <provided_document>
      <document_type>Statistical Analysis Plan</document_type>
      <document_has_protocol>No</document_has_protocol>
      <document_has_icf>No</document_has_icf>
      <document_has_sap>Yes</document_has_sap>
      <document_date>March 2, 2017</document_date>
      <document_url>https://ClinicalTrials.gov/ProvidedDocs/91/NCT03012191/SAP_001.pdf</document_url>
    </provided_document>
  </provided_document_section>

  <clinical_results>

    <participant_flow>
      <group_list>
        <group group_id="P1">
          <title>Topical Gentamicin</title>
          <description>0.5% Gentamicin ointment</description>
        </group>
        <group group_id="P2">
          <title>Intravenous Gentamicin</title>
          <description>IV gentamicin is prepared to 7.5 mg/kg body weight and administered over a 30 minutes.</description>
        </group>
        <group group_id="P3">
          <title>Intradermal Gentamicin</title>
          <description>0.5% Gentamicin ointment applied after microneedle roller assistance</description>
        </group>
      </group_list>
      <period_list>
        <period>
          <title>Overall Study</title>
          <milestone_list>
            <milestone>
              <title>STARTED</title>
              <participants_list>
                <participants group_id="P1" count="2"/>
                <participants group_id="P2" count="2"/>
                <participants group_id="P3" count="2"/>
              </participants_list>
            </milestone>
            <milestone>
              <title>COMPLETED</title>
              <participants_list>
                <participants group_id="P1" count="2"/>
                <participants group_id="P2" count="2"/>
                <participants group_id="P3" count="2"/>
              </participants_list>
            </milestone>
            <milestone>
              <title>NOT COMPLETED</title>
              <participants_list>
                <participants group_id="P1" count="0"/>
                <participants group_id="P2" count="0"/>
                <participants group_id="P3" count="0"/>
              </participants_list>
            </milestone>
          </milestone_list>
        </period>
      </period_list>
    </participant_flow>

    <baseline>
      <group_list>
        <group group_id="B1">
          <title>Topical Gentamicin</title>
          <description>0.5% Gentamicin ointment</description>
        </group>
        <group group_id="B2">
          <title>Intravenous Gentamicin</title>
          <description>IV gentamicin is prepared to 7.5 mg/kg body weight and administered over a 30 minutes.</description>
        </group>
        <group group_id="B3">
          <title>Intradermal Gentamicin</title>
          <description>0.5% Gentamicin ointment applied after microneedle roller assistance</description>
        </group>
        <group group_id="B4">
          <title>Total</title>
          <description>Total of all reporting groups</description>
        </group>
      </group_list>
      <analyzed_list>
        <analyzed>
          <units>Participants</units>
          <scope>Overall</scope>
          <count_list>
            <count group_id="B1" value="2"/>
            <count group_id="B2" value="2"/>
            <count group_id="B3" value="2"/>
            <count group_id="B4" value="6"/>
          </count_list>
        </analyzed>
      </analyzed_list>
      <measure_list>
        <measure>
          <title>Age</title>
          <units>Participants</units>
          <param>Count of Participants</param>
          <class_list>
            <class>
              <category_list>
                <category>
                  <title>&lt;=18 years</title>
                  <measurement_list>
                    <measurement group_id="B1" value="2"/>
                    <measurement group_id="B2" value="0"/>
                    <measurement group_id="B3" value="1"/>
                    <measurement group_id="B4" value="3"/>
                  </measurement_list>
                </category>
                <category>
                  <title>Between 18 and 65 years</title>
                  <measurement_list>
                    <measurement group_id="B1" value="0"/>
                    <measurement group_id="B2" value="2"/>
                    <measurement group_id="B3" value="1"/>
                    <measurement group_id="B4" value="3"/>
                  </measurement_list>
                </category>
                <category>
                  <title>&gt;=65 years</title>
                  <measurement_list>
                    <measurement group_id="B1" value="0"/>
                    <measurement group_id="B2" value="0"/>
                    <measurement group_id="B3" value="0"/>
                    <measurement group_id="B4" value="0"/>
                  </measurement_list>
                </category>
              </category_list>
            </class>
          </class_list>
        </measure>
        <measure>
          <title>Age</title>
          <units>years</units>
          <param>Mean</param>
          <dispersion>Full Range</dispersion>
          <class_list>
            <class>
              <category_list>
                <category>
                  <measurement_list>
                    <measurement group_id="B1" value="9" lower_limit="1" upper_limit="17"/>
                    <measurement group_id="B2" value="28.5" lower_limit="27" upper_limit="30"/>
                    <measurement group_id="B3" value="22" lower_limit="17" upper_limit="27"/>
                    <measurement group_id="B4" value="19.8" lower_limit="1" upper_limit="30"/>
                  </measurement_list>
                </category>
              </category_list>
            </class>
          </class_list>
        </measure>
        <measure>
          <title>Sex: Female, Male</title>
          <units>Participants</units>
          <param>Count of Participants</param>
          <class_list>
            <class>
              <category_list>
                <category>
                  <title>Female</title>
                  <measurement_list>
                    <measurement group_id="B1" value="0"/>
                    <measurement group_id="B2" value="1"/>
                    <measurement group_id="B3" value="1"/>
                    <measurement group_id="B4" value="2"/>
                  </measurement_list>
                </category>
                <category>
                  <title>Male</title>
                  <measurement_list>
                    <measurement group_id="B1" value="2"/>
                    <measurement group_id="B2" value="1"/>
                    <measurement group_id="B3" value="1"/>
                    <measurement group_id="B4" value="4"/>
                  </measurement_list>
                </category>
              </category_list>
            </class>
          </class_list>
        </measure>
        <measure>
          <title>Race (NIH/OMB)</title>
          <units>Participants</units>
          <param>Count of Participants</param>
          <class_list>
            <class>
              <category_list>
                <category>
                  <title>American Indian or Alaska Native</title>
                  <measurement_list>
                    <measurement group_id="B1" value="0"/>
                    <measurement group_id="B2" value="0"/>
                    <measurement group_id="B3" value="0"/>
                    <measurement group_id="B4" value="0"/>
                  </measurement_list>
                </category>
                <category>
                  <title>Asian</title>
                  <measurement_list>
                    <measurement group_id="B1" value="0"/>
                    <measurement group_id="B2" value="0"/>
                    <measurement group_id="B3" value="0"/>
                    <measurement group_id="B4" value="0"/>
                  </measurement_list>
                </category>
                <category>
                  <title>Native Hawaiian or Other Pacific Islander</title>
                  <measurement_list>
                    <measurement group_id="B1" value="0"/>
                    <measurement group_id="B2" value="0"/>
                    <measurement group_id="B3" value="0"/>
                    <measurement group_id="B4" value="0"/>
                  </measurement_list>
                </category>
                <category>
                  <title>Black or African American</title>
                  <measurement_list>
                    <measurement group_id="B1" value="0"/>
                    <measurement group_id="B2" value="0"/>
                    <measurement group_id="B3" value="0"/>
                    <measurement group_id="B4" value="0"/>
                  </measurement_list>
                </category>
                <category>
                  <title>White</title>
                  <measurement_list>
                    <measurement group_id="B1" value="2"/>
                    <measurement group_id="B2" value="2"/>
                    <measurement group_id="B3" value="2"/>
                    <measurement group_id="B4" value="6"/>
                  </measurement_list>
                </category>
                <category>
                  <title>More than one race</title>
                  <measurement_list>
                    <measurement group_id="B1" value="0"/>
                    <measurement group_id="B2" value="0"/>
                    <measurement group_id="B3" value="0"/>
                    <measurement group_id="B4" value="0"/>
                  </measurement_list>
                </category>
                <category>
                  <title>Unknown or Not Reported</title>
                  <measurement_list>
                    <measurement group_id="B1" value="0"/>
                    <measurement group_id="B2" value="0"/>
                    <measurement group_id="B3" value="0"/>
                    <measurement group_id="B4" value="0"/>
                  </measurement_list>
                </category>
              </category_list>
            </class>
          </class_list>
        </measure>
        <measure>
          <title>Region of Enrollment</title>
          <units>participants</units>
          <param>Number</param>
          <class_list>
            <class>
              <title>United States</title>
              <category_list>
                <category>
                  <measurement_list>
                    <measurement group_id="B1" value="2"/>
                    <measurement group_id="B2" value="2"/>
                    <measurement group_id="B3" value="2"/>
                    <measurement group_id="B4" value="6"/>
                  </measurement_list>
                </category>
              </category_list>
            </class>
          </class_list>
        </measure>
        <measure>
          <title>Expression of C7 in Skin</title>
          <units>C7 Expression (percent of normal skin)</units>
          <param>Mean</param>
          <dispersion>Full Range</dispersion>
          <class_list>
            <class>
              <category_list>
                <category>
                  <measurement_list>
                    <measurement group_id="B1" value="0" lower_limit="0" upper_limit="0"/>
                    <measurement group_id="B2" value="6.8" lower_limit="2" upper_limit="11.6"/>
                    <measurement group_id="B3" value="5.8" lower_limit="0" upper_limit="11.6"/>
                    <measurement group_id="B4" value="4.2" lower_limit="0" upper_limit="11.6"/>
                  </measurement_list>
                </category>
              </category_list>
            </class>
          </class_list>
        </measure>
        <measure>
          <title>Presence of Anchoring Fibrils in Skin</title>
          <units>Participants</units>
          <param>Count of Participants</param>
          <class_list>
            <class>
              <category_list>
                <category>
                  <measurement_list>
                    <measurement group_id="B1" value="0"/>
                    <measurement group_id="B2" value="1"/>
                    <measurement group_id="B3" value="1"/>
                    <measurement group_id="B4" value="2"/>
                  </measurement_list>
                </category>
              </category_list>
            </class>
          </class_list>
        </measure>
      </measure_list>
    </baseline>

    <outcome_list>
      <outcome>
        <type>Primary</type>
        <title>Increased Expression of Full-length Type VII Collagen as Assessed by Immunofluorescence</title>
        <description>The expression of type VII collagen at the patients' dermal-epidermal junction was assessed by immunofluorescence (IF) using an antibody specific to type VII collagen. The expression was semi-quantitated using NIH Image J software. The IF expression of type VII collagen was assessed before treatment and at one and three months after treatment. At each assessment time point, type VII collagen expression was also measured in normal human skin. The expression of type VII collagen was then expressed as a percentage of the type VII collagen expressed in normal human skin.</description>
        <time_frame>6 months</time_frame>
        <group_list>
          <group group_id="O1">
            <title>Topical Gentamicin</title>
            <description>0.5% Gentamicin ointment</description>
          </group>
          <group group_id="O2">
            <title>Intravenous Gentamicin</title>
            <description>IV gentamicin is prepared to 7.5 mg/kg body weight and administered over a 30 minutes.</description>
          </group>
          <group group_id="O3">
            <title>Intradermal Gentamicin</title>
            <description>0.5% Gentamicin ointment applied after microneedle roller assistance</description>
          </group>
        </group_list>
        <measure>
          <title>Increased Expression of Full-length Type VII Collagen as Assessed by Immunofluorescence</title>
          <description>The expression of type VII collagen at the patients' dermal-epidermal junction was assessed by immunofluorescence (IF) using an antibody specific to type VII collagen. The expression was semi-quantitated using NIH Image J software. The IF expression of type VII collagen was assessed before treatment and at one and three months after treatment. At each assessment time point, type VII collagen expression was also measured in normal human skin. The expression of type VII collagen was then expressed as a percentage of the type VII collagen expressed in normal human skin.</description>
          <units>C7 Expression (percent of normal skin)</units>
          <param>Mean</param>
          <dispersion>Full Range</dispersion>
          <analyzed_list>
            <analyzed>
              <units>Participants</units>
              <scope>Measure</scope>
              <count_list>
                <count group_id="O1" value="2"/>
                <count group_id="O2" value="2"/>
                <count group_id="O3" value="2"/>
              </count_list>
            </analyzed>
          </analyzed_list>
          <class_list>
            <class>
              <category_list>
                <category>
                  <measurement_list>
                    <measurement group_id="O1" value="31.8" lower_limit="13.7" upper_limit="54.0"/>
                    <measurement group_id="O2" value="28.4" lower_limit="4.0" upper_limit="59.0"/>
                    <measurement group_id="O3" value="65.6" lower_limit="2" upper_limit="134"/>
                  </measurement_list>
                </category>
              </category_list>
            </class>
          </class_list>
        </measure>
      </outcome>
      <outcome>
        <type>Primary</type>
        <title>Number of Participants With New or Increased Numbers of Anchoring Fibrils as Assessed by Immuno-electron Microscopy</title>
        <description>The expression of anchoring fibril structures at the patients' dermal-epidermal junction was assessed by immuno-electron microscopy (IEM) using an antibody specific to type VII collagen. The IEM expression of anchoring fibrils was assessed before treatment and at one and three months after treatment. At each assessment time point, anchoring fibrils were compared with normal human skin. Baseline pre-treatment and one and three month post-treatment sites were compared for the presence of anchoring fibrils after gentamicin treatment (or increase if anchoring fibrils were detected at baseline in patients).</description>
        <time_frame>6 months</time_frame>
        <group_list>
          <group group_id="O1">
            <title>Topical Gentamicin</title>
            <description>0.5% Gentamicin ointment</description>
          </group>
          <group group_id="O2">
            <title>Intravenous Gentamicin</title>
            <description>IV gentamicin is prepared to 7.5 mg/kg body weight and administered over a 30 minutes.</description>
          </group>
          <group group_id="O3">
            <title>Intradermal Gentamicin</title>
            <description>0.5% Gentamicin ointment applied after microneedle roller assistance</description>
          </group>
        </group_list>
        <measure>
          <title>Number of Participants With New or Increased Numbers of Anchoring Fibrils as Assessed by Immuno-electron Microscopy</title>
          <description>The expression of anchoring fibril structures at the patients' dermal-epidermal junction was assessed by immuno-electron microscopy (IEM) using an antibody specific to type VII collagen. The IEM expression of anchoring fibrils was assessed before treatment and at one and three months after treatment. At each assessment time point, anchoring fibrils were compared with normal human skin. Baseline pre-treatment and one and three month post-treatment sites were compared for the presence of anchoring fibrils after gentamicin treatment (or increase if anchoring fibrils were detected at baseline in patients).</description>
          <units>Participants</units>
          <param>Count of Participants</param>
          <analyzed_list>
            <analyzed>
              <units>Participants</units>
              <scope>Measure</scope>
              <count_list>
                <count group_id="O1" value="2"/>
                <count group_id="O2" value="2"/>
                <count group_id="O3" value="2"/>
              </count_list>
            </analyzed>
          </analyzed_list>
          <class_list>
            <class>
              <category_list>
                <category>
                  <measurement_list>
                    <measurement group_id="O1" value="1"/>
                    <measurement group_id="O2" value="2"/>
                    <measurement group_id="O3" value="1"/>
                  </measurement_list>
                </category>
              </category_list>
            </class>
          </class_list>
        </measure>
      </outcome>
      <outcome>
        <type>Primary</type>
        <title>Number of Participants With Absence of Gentamicin Side Effects Especially the Detection of Any Ototoxicity or Nephrotoxicity</title>
        <description>Prolonged exposure to systemic gentamicin is associated with ototoxicity and nephrotoxicity. Specific tests (creatinine clearance and gold-tone audiometry) are performed throughout the study in order to detect any drug-specific adverse events as a result of systemic exposure to gentamicin. Additionally, we test patient skin and serum throughout the study to look for increase of autoantibodies to C7. Since some of these patients may have never had C7 expressed in their bodies, gentamicin-induced C7 may cause in auto-immune response.</description>
        <time_frame>6 months</time_frame>
        <group_list>
          <group group_id="O1">
            <title>Topical Gentamicin</title>
            <description>0.5% Gentamicin ointment</description>
          </group>
          <group group_id="O2">
            <title>Intravenous Gentamicin</title>
            <description>IV gentamicin is prepared to 7.5 mg/kg body weight and administered over a 30 minutes.</description>
          </group>
          <group group_id="O3">
            <title>Intradermal Gentamicin</title>
            <description>0.5% Gentamicin ointment applied after microneedle roller assistance</description>
          </group>
        </group_list>
        <measure>
          <title>Number of Participants With Absence of Gentamicin Side Effects Especially the Detection of Any Ototoxicity or Nephrotoxicity</title>
          <description>Prolonged exposure to systemic gentamicin is associated with ototoxicity and nephrotoxicity. Specific tests (creatinine clearance and gold-tone audiometry) are performed throughout the study in order to detect any drug-specific adverse events as a result of systemic exposure to gentamicin. Additionally, we test patient skin and serum throughout the study to look for increase of autoantibodies to C7. Since some of these patients may have never had C7 expressed in their bodies, gentamicin-induced C7 may cause in auto-immune response.</description>
          <units>Participants</units>
          <param>Count of Participants</param>
          <analyzed_list>
            <analyzed>
              <units>Participants</units>
              <scope>Measure</scope>
              <count_list>
                <count group_id="O1" value="2"/>
                <count group_id="O2" value="2"/>
                <count group_id="O3" value="2"/>
              </count_list>
            </analyzed>
          </analyzed_list>
          <class_list>
            <class>
              <category_list>
                <category>
                  <measurement_list>
                    <measurement group_id="O1" value="2"/>
                    <measurement group_id="O2" value="2"/>
                    <measurement group_id="O3" value="2"/>
                  </measurement_list>
                </category>
              </category_list>
            </class>
          </class_list>
        </measure>
      </outcome>
      <outcome>
        <type>Secondary</type>
        <title>Improved EBDASI Scores</title>
        <description>EBDASI - Epidermolysis Bullosa Disease Activity and Scarring Index Scale - Minimum (0) to Maximum (506) A lower score indicates a better outcome (less disease activity and/or damage) A clinical tool for evaluating the disease activity and damage associated with bullous patients. To be administered by a licensed dermatologist.</description>
        <time_frame>6 months</time_frame>
        <population>EBDASI is a system-wide disease activity score used for participants in the Intravenous Gentamicin phase of the study. Participants receiving Topical and Intradermal Gentamicin were not administered the EBDASI.</population>
        <group_list>
          <group group_id="O1">
            <title>Intravenous Gentamicin</title>
            <description>IV gentamicin is prepared to 7.5 mg/kg body weight and administered over a 30 minutes.</description>
          </group>
        </group_list>
        <measure>
          <title>Improved EBDASI Scores</title>
          <description>EBDASI - Epidermolysis Bullosa Disease Activity and Scarring Index Scale - Minimum (0) to Maximum (506) A lower score indicates a better outcome (less disease activity and/or damage) A clinical tool for evaluating the disease activity and damage associated with bullous patients. To be administered by a licensed dermatologist.</description>
          <population>EBDASI is a system-wide disease activity score used for participants in the Intravenous Gentamicin phase of the study. Participants receiving Topical and Intradermal Gentamicin were not administered the EBDASI.</population>
          <units>Scores on a scale</units>
          <param>Mean</param>
          <dispersion>Full Range</dispersion>
          <analyzed_list>
            <analyzed>
              <units>Participants</units>
              <scope>Measure</scope>
              <count_list>
                <count group_id="O1" value="2"/>
              </count_list>
            </analyzed>
          </analyzed_list>
          <class_list>
            <class>
              <category_list>
                <category>
                  <measurement_list>
                    <measurement group_id="O1" value="171.3" lower_limit="161" upper_limit="187"/>
                  </measurement_list>
                </category>
              </category_list>
            </class>
          </class_list>
        </measure>
      </outcome>
    </outcome_list>

    <reported_events>
      <time_frame>6 months</time_frame>
      <group_list>
        <group group_id="E1">
          <title>Topical Gentamicin</title>
          <description>0.5% Gentamicin ointment</description>
        </group>
        <group group_id="E2">
          <title>Intravenous Gentamicin</title>
          <description>IV gentamicin is prepared to 7.5 mg/kg body weight and administered over a 30 minutes.</description>
        </group>
        <group group_id="E3">
          <title>Intradermal Gentamicin</title>
          <description>0.5% Gentamicin ointment applied after microneedle roller assistance</description>
        </group>
      </group_list>
      <serious_events>
        <category_list>
          <category>
            <title>Total</title>
            <event_list>
              <event>
                <sub_title>Total, all-cause mortality</sub_title>
                <counts group_id="E1" subjects_affected="0" subjects_at_risk="2"/>
                <counts group_id="E2" subjects_affected="0" subjects_at_risk="2"/>
                <counts group_id="E3" subjects_affected="0" subjects_at_risk="2"/>
              </event>
              <event>
                <sub_title>Total, serious adverse events</sub_title>
                <counts group_id="E1" subjects_affected="0" subjects_at_risk="2"/>
                <counts group_id="E2" subjects_affected="0" subjects_at_risk="2"/>
                <counts group_id="E3" subjects_affected="0" subjects_at_risk="2"/>
              </event>
            </event_list>
          </category>
        </category_list>
      </serious_events>
      <other_events>
        <frequency_threshold>0</frequency_threshold>
        <category_list>
          <category>
            <title>Total</title>
            <event_list>
              <event>
                <sub_title>Total, other adverse events</sub_title>
                <counts group_id="E1" subjects_affected="0" subjects_at_risk="2"/>
                <counts group_id="E2" subjects_affected="0" subjects_at_risk="2"/>
                <counts group_id="E3" subjects_affected="0" subjects_at_risk="2"/>
              </event>
            </event_list>
          </category>
        </category_list>
      </other_events>
    </reported_events>

    <certain_agreements>
      <pi_employee>Principal Investigators are NOT employed by the organization sponsoring the study.</pi_employee>
      <restrictive_agreement>There is NOT an agreement between Principal Investigators and the Sponsor (or its agents) that restricts the PI's rights to discuss or publish trial results after the trial is completed. </restrictive_agreement>
    </certain_agreements>
    <limitations_and_caveats>Small number of subjects analyzed due to rarity of the disease and experimental plan.</limitations_and_caveats>
    <point_of_contact>
      <name_or_title>Dr. David Woodley</name_or_title>
      <organization>University of Southern California Department of Dermatology</organization>
      <phone>(323)442-0084</phone>
      <email>dwoodley@med.usc.edu</email>
    </point_of_contact>
  </clinical_results>
</clinical_study>


download date: ClinicalTrials.gov processed this data on September 20, 2023
link text: Link to the current ClinicalTrials.gov record.
url: https://clinicaltrials.gov/ct2/show/NCT03012191
org study id: HS-16-00788
nct id: NCT03012191
lead sponsor: 
is fda regulated drug: Yes
is fda regulated device: No
is us export: No
Recessive dystrophic epidermolysis bullosa (RDEB) is an incurable, devastating, inherited
      skin disease caused by mutations in the COL7A1 gene that encodes for type VII collagen (C7),
      the major component of anchoring fibrils (AFs), structures that mediate epidermal-dermal
      adherence. Thirty percent of RDEB patients have nonsense mutations. The investigators
      recently demonstrated in 5 such patients that intradermal and topical gentamicin induced
      "read-through" of their nonsense mutations and created robust and sustained new C7 and AFs at
      the dermal-epidermal junction (DEJ) of their skin and also stimulated wound closure and
      reduced new blister formation. No untoward side effects occurred. Herein, the investigators
      propose evaluating the safety and efficacy of intravenous gentamicin in these patients. In
      theory, this intravenous administration has the possibility of treating simultaneously all of
      the patients' skin wounds. The investigators also propose optimizing the concentration and
      manner of delivery of topical gentamicin. The unambiguous milestones will be increased C7 and
      AFs in the patients' DEJ, improved EB Disease Activity Scores, and absence of significant
      gentamicin side effects.
Aim 1. Evaluate the Safety and Efficacy of Short Term Intravenous Gentamicin for RDEB
      Patients.

      Overview & Rationale: The rationale for short-term systemic intravenous gentamicin in these
      patients is outlined in the sections above, namely the drug could treat multiple skin sites
      simultaneously including the esophagus. This approach has proven safe and efficacious in
      other genetic diseases such as CF and DMD22-25 Our HYPOTHESIS is that intravenous gentamicin
      will, like topical and intradermal gentamicin, create new C7 and AFs at the patient's DEJ,
      improve multiple skin sites simultaneously, improve the patient's clinical disease and
      improve his or her quality of life. In accordance with the enclosed letters from two
      experienced pediatricians, we believe this therapy will be safe. Because C7 and AFs are
      incredibly stable, we further hypothesize that newly induced C7 and AFs will persist for many
      months in the patient's skin. Using dosing regimens of gentamicin that have proven to be
      safe, we will: 1) determine the percentage increase of C7 expression in the patients' skin
      before and after treatment, 2) determine how durable and sustainable the new C7 and AFs are
      in the patients' skin after treatment, 3) determine if this treatment is safe in this patient
      population, 4) determine if this treatment improves the patients clinically and improves
      their quality of life and 5) generate data for a multi-centered Phase III study using a
      larger number of patients.

      Patients/Intervention: We have already lined up 3 well-characterized, adult RDEB patients
      with nonsense mutations who wish to participate in this study. These patients had positive
      responses to topical and intradermal gentamicin in our clinical trial (Table II). The
      patients will receive intravenous gentamicin (7.5 mgs per kilogram), in 100 ml of 5% dextrose
      in saline, for 14 consecutive days, a dose proven to not cause ototoxicity or
      neprhotoxicity28 and to be efficacious in inducing PTC read-through in DMD patients.22 The
      first few infusions will be done in the Infusion Center of the Keck Hospital of USC. We will
      measure gentamicin trough levels (24 hours after infusion) and gentamicin peak levels (30
      minutes after the infusion) during the second day and, if needed, adjust the gentamicin doses
      such that the peak level is between 20 and 40 μg/ml and the trough level <2 μg/ml. If no
      untoward side effects occur, the patients will then have their infusions in their home via a
      commercial infusion service.

      Safety Evaluation: Patients will be consented, enrolled and evaluated on Day 0 and then
      evaluated on post-treatment days 30, 90, and 180. On Day 0, the patients will have a complete
      medical history, review of systems (ROS), physical examination, vital signs, and weight. They
      will also have baseline urine analysis, complete blood count (CBC), electrolytes, glucose,
      comprehensive metabolic panel (CMP), and calculated creatinine clearance. Pure tone
      audiometry and a calculated creatinine clearance will be done on Days 0, 7, 14 and 30
      post-treatment. Stop criteria will be a decline of >15 dB on pure tone audiometry at 2
      consecutive frequencies and a creatinine clearance <60ml/min.28 Whenever there is new protein
      created in a patient, there is the possibility that the patient's immune system will raise
      autoantibodies against it. This did not occur in our clinical trial with topical and
      intradermal gentamicin, but it behooves us to evaluate this again with intravenous gentamicin
      and potentially more auto-antigenic protein created. Using indirect immunofluorescence and
      our anti-C7 ELISA, we will test the subject's serum for anti-C7 antibodies at each visit.

      Efficacy: A. Clinical Evaluations: At baseline Day 0 and at each follow-up visit, (days 30,
      90 and 180) the patients will complete a Quality of Life Assessment tool, a Pruritus Score
      tool, and a validated epidermolysis bullosa disease activity index (EBDASI)29,30. Patients
      will keep a daily diary using a self-ROS questionnaire. Patients will be telephoned weekly by
      a USC study member inquiring about any new signs, symptoms or ROS changes since the advent of
      the study. At baseline Day 0, we will identify four Test Sites at least 25 cm2 in size to
      follow sequentially. Two will be from areas that at baseline have blisters or erosions and
      the other two from intact skin areas. The two Test Sites with active blisters and erosions
      will be traced using a transparency sheet and the areas of the lesions calculated on a
      digitizing tablet. Likewise, all of the Test Sites will have standardized photographs and the
      lesional areas calculated by computer-assisted morphometry, as previously published.29-31
      Within the context of their daily diary, patients will note the number of new blisters and
      erosions that occur in the Test Sites. A USC study member will telephone the patient each
      week and inquire about the Test Sites and ask the patient to estimate the percentage area of
      the Test Site consumed by erosions and blisters. Also, at each follow-up visit, three
      dermatologists will observe the four Test Sites and count the number of bullae and erosions
      in each. The intact Test Site areas will be scored at each follow-up visit using the
      following 3-point scale: 0 = no lesions; +1 = any active lesions; +2 = active lesions
      consuming over 50% of the Test Site area. Tracings to evaluate the areas of blisters or open
      erosions will be done, and standardized photographs paired with computer-assisted morphometry
      to calculate the areas of any lesions will be performed. B. Evaluations of C7 and AF
      Expression: At each post-treatment time point, 8 mm punch biopsies from the four Test Sites
      will be divided into three parts for (i) H&E histology and quantitation of epidermal-dermal
      adherence, (ii) the expression of C7 at the DEJ relative to that of normal human skin using
      anti-C7 antibodies to the NC1 and NC2 domains of C7 and NIH J Image software. One major
      "milestone" of the study will be the expression of NC2 since this would clearly indicate
      restoration of full-length C7 and (III) evaluation of newly created AFs by immuno-EM and AF
      enumeration by computer-assisted morphometry. Performing these evaluations out to 6 months
      will determine how durable the newly created C7 and AFs are. In our recent clinical trial
      outlined above, it was surprising that gentamicin-induced C7 remained at a similar level at 3
      months post-treatment as that of 1 month for Patient #3 (Please see Figure 1 and Table II).

      Aim 2: Evaluate the Safety and Efficacy of Higher Dose Topical Gentamicin for RDEB Patients.

      Overview and Rationale: In our gentamicin clinical trial outlined earlier, there was
      significant variation in the production of new C7 and AFs, as shown in Table II. Patients #2
      and #5 only restored C7 to 20% of normal skin in response to gentamicin. We only used one
      concentration of gentamicin, 0.1% ointment, and our in vitro studies with RDEB fibroblasts
      from these same two patients showed that the C7 response to gentamicin was dose-dependent.26
      In these patients, there could have been sub-optimal dosing or sub-optimal access of the
      gentamicin to the patient's dermal fibroblasts and basal keratinocytes. In this aim, we will
      use 0.5% gentamicin ointment rather than 0.1% and determine if the C7 response is more robust
      in these two patients. Based on our encouraging data shown in Figure 2, we will also treat
      intact skin and determine if higher dose gentamicin can prophylactically prevent frank skin
      blisters and erosions from forming.

      Patients/Intervention: We will study two RDEB children tested in our previous trial for this
      study. In addition, we also have 2 other children and 2 other adult patients who have
      contacted us and wish to participate in this study (Table III). Two of these patients share
      the same mutations (R578X and R2814) as our current patients. We will select a total of four
      Test Sites (two with open wounds of at least 3 cm by 3 cm and two areas of intact skin nearby
      the Test Sites with blisters or erosions) and apply 0.5% gentamicin ointment two times a day
      under an occlusive dressing of the patients' choice for two weeks. This dose was used in
      combination with 15% paromomycin to ulcerative cutaneous leishmaniasis lesions once daily for
      20 days in two publications without renal or ototoxicity detected.32,33 Safety and Efficacy:
      We will essentially assess in these patients the safety and efficacy parameters outlined in
      Aim #1 at months 1, 3 and 6 after topical application. Potential renal toxicity and
      ototoxicity will be monitored by creatinine clearance and pure tone audiometry at day 0 and
      at each follow up visit.

      Aim 3: Evaluate the Safety and Efficacy of Intradermal Administration of Gentamicin with a
      MR2 Micro-needle Roller Device.

      Overview and Rationale: In our current clinical trial outlined above, there were excellent C7
      responses to intradermal injections of gentamicin solution in several patients (Table II).
      Nevertheless, these injections were very localized with diffusion of the drug probably less
      than an inch from the single injection site. Recent evidence has shown that a MR2 microneedle
      roller device can readily deliver lidocaine into the lower epidermis and upper papillary
      dermis over a wide area of skin with good efficacy, safety and excellent patient tolerance.34
      This may be an opportunity to deliver intradermal gentamicin solution (40 mg/ml) to wide
      areas of skin in a simple manner that can be done in an outpatient office with minimal
      logistical issues and avoidance of systemic exposure to the drug. Advantages include the
      possibility of delivering in a "pulse " fashion significant levels of gentamicin to the
      papillary dermis over wide areas of skin with minimal discomfort and minimal systemic
      exposure of gentamicin. Avoiding systemic exposure would be valuable for RDEB patients who
      have ototoxicity or renal compromise, poor venous access or cannot tolerate intravenous
      infusions.

      Patients & Interventions: We will enroll two new RDEB patients (either adults or children)
      shown in Table III in this "proof-of-principle" study. Skin Test Sites will be areas
      measuring at least 40 cm2, and we will test one site of intact unwounded skin and one site of
      skin with lesions (blisters or erosions). The areas will be cleansed with 4% Hibiclens and
      then the MR2 Microneedle Roller Device passed over the area in two directions at 90 degrees.
      This device induces tiny micro-wounds in the skin to the depth of the papillary dermis.
      Gentamicin sterile solution (40 mg/ml) will then be liberally applied over the area and the
      area immediately occluded with a polyrurethane membrane (Opsite). Another equal sized Test
      Site of intact skin will be tested without prior intervention with the Microneedle Roller.
      The same gentamicin solution will be applied to the site and immediately occluded with
      Opsite. This will determine if the gentamicin solution can penetrate intact skin.

      Safety and Efficacy: We will measure gentamicin in the serum of these patient 30 minutes
      after the microneedle delivery to determine if there is any systemic exposure when gentamicin
      is administered in this manner. Efficacy of the gentamicin administration will be assessed
      identically to those in Aim#1 by IF and immuno-EM analysis in conjunction with the patients
      keeping a daily diary of the treatment sites, weekly photographs of Test Sites, weekly staff
      interviews of the patients, and physician assessments at patient visits at months 1, 3 and 6
      after administration of gentamicin. Potential renal toxicity and ototoxicity will be
      monitored by creatinine clearance and pure tone audiometry at day 0 and each follow up visit.
allocation: N/A
intervention model: Single Group Assignment
primary purpose: Treatment
masking: None (Open Label)
measure: Increased Expression of Full-length Type VII Collagen as Assessed by Immunofluorescence
time frame: 6 months
description: The expression of type VII collagen at the patients' dermal-epidermal junction was assessed by immunofluorescence (IF) using an antibody specific to type VII collagen. The expression was semi-quantitated using NIH Image J software. The IF expression of type VII collagen was assessed before treatment and at one and three months after treatment. At each assessment time point, type VII collagen expression was also measured in normal human skin. The expression of type VII collagen was then expressed as a percentage of the type VII collagen expressed in normal human skin.
measure: Number of Participants With New or Increased Numbers of Anchoring Fibrils as Assessed by Immuno-electron Microscopy
time frame: 6 months
description: The expression of anchoring fibril structures at the patients' dermal-epidermal junction was assessed by immuno-electron microscopy (IEM) using an antibody specific to type VII collagen. The IEM expression of anchoring fibrils was assessed before treatment and at one and three months after treatment. At each assessment time point, anchoring fibrils were compared with normal human skin. Baseline pre-treatment and one and three month post-treatment sites were compared for the presence of anchoring fibrils after gentamicin treatment (or increase if anchoring fibrils were detected at baseline in patients).
measure: Number of Participants With Absence of Gentamicin Side Effects Especially the Detection of Any Ototoxicity or Nephrotoxicity
time frame: 6 months
description: Prolonged exposure to systemic gentamicin is associated with ototoxicity and nephrotoxicity. Specific tests (creatinine clearance and gold-tone audiometry) are performed throughout the study in order to detect any drug-specific adverse events as a result of systemic exposure to gentamicin. Additionally, we test patient skin and serum throughout the study to look for increase of autoantibodies to C7. Since some of these patients may have never had C7 expressed in their bodies, gentamicin-induced C7 may cause in auto-immune response.
measure: Improved EBDASI Scores
time frame: 6 months
description: EBDASI - Epidermolysis Bullosa Disease Activity and Scarring Index Scale - Minimum (0) to Maximum (506) A lower score indicates a better outcome (less disease activity and/or damage) A clinical tool for evaluating the disease activity and damage associated with bullous patients. To be administered by a licensed dermatologist.
arm group label: Gentamicin
arm group type: Experimental
description: Topical gentamicin; Topical gentamicin with microneedle roller assistance; IV gentamicin. While the intervention is the same drug, the topical gentamicin is compounded into a 0.5% ointment and the IV gentamicin is prepared to 7.5 mg/kg body weight and administered over a 30 minutes.
intervention type: Drug
intervention name: Gentamicin Sulfate
description: Participants will be divided into three cohorts: topical gentamicin; Topical gentamicin with microneedle roller assistance; IV gentamicin. While the intervention is the same drug, the topical gentamicin is compounded into a 0.5% ointment and the IV gentamicin is prepared to 7.5 mg/kg body weight and administered over a 30 minutes.
arm group label: Gentamicin
other name: Gentamicin, Garamycin
criteria: 
gender: All
minimum age: N/A
maximum age: N/A
healthy volunteers: No
last name: David Woodley, MD
role: Principal Investigator
affiliation: University of Southern California Department of Dermatology
facility: 
country: United States
responsible party type: Principal Investigator
investigator affiliation: University of Southern California
investigator full name: David Woodley
investigator title: Professor
mesh term: Epidermolysis Bullosa
mesh term: Epidermolysis Bullosa Dystrophica
mesh term: Gentamicins
provided document: 
provided document: 
participant flow: 
baseline: 
outcome list: 
reported events: 
certain agreements: 
limitations and caveats: Small number of subjects analyzed due to rarity of the disease and experimental plan.
point of contact: 