Robert S. Kirsner

A new recombinant proteolytic enzyme, isolated from maggot saliva, with fibrinolytic action has been investigated through a series of non‐clinical toxicology and in‐vitro/in‐vivo pharmacology studies to explore its potential safety and efficacy as an enzymatic debridement agent for use in chronic wounds. Studies indicate that the enzyme has a good safety profile. When locally administered, it is not detrimental to wound healing, is non‐sensitising and is rapidly inactivated in the systemic circulation. Adverse effects are limited, at very high concentrations, to transient erythema at the site of application. In‐vitro testing indicates that the enzyme, whilst selective for fibrin, has additional proteolytic action against collagen and elastin, with enzymatic action for all three substrates being dose dependent. In‐vivo, we used an established MRSA biofilm model, in which microbiological counts were used as a surrogate for debridement efficacy. Here, we showed that higher concentrations of the enzyme in a formulated proprietary gel, significantly reduced MRSA counts over a period of 2 to 14 days, and significantly improved the vascularity of the wound at 14 days. Together, these data support the potential for this maggot‐derived proteolytic enzyme as a clinically effective debriding agent.

Non‐biologic immunosuppressive therapies are a mainstay in the treatment of various dermatologic conditions. However, the use of these therapies has been scrutinized for potentially increasing risk of haematologic or solid‐organ malignancies. Currently, there are no evidence‐based guidelines stratifying the risk of malignancy in patients receiving these immunosuppressive agents for the treatment of dermatologic disease. In our review, we evaluate the risk of solid organ and haematologic malignancies in patients receiving non‐biologic immunosuppressant therapy for dermatologic indications. A literature search was conducted on PubMed/MEDLINE. Search terms included commonly prescribed non‐biologic immunosuppressants and common dermatologic conditions for which non‐biologic immunosuppressants are typically prescribed. Levels of evidence and grades of recommendation were used for guidelines. All immunosuppressants evaluated, with the exception of cyclophosphamide, demonstrated low solid‐organ or haematologic malignancy potential. Co‐morbidities may play a role in malignancy risk in the context of immunosuppressant treatment, including autoimmune disease, which have been associated with increased risk of malignancy and confound overall risk. Duration and/or dosage of treatment may influence this risk as well. Limitations of the review include that the majority of studies were of small sample size, retrospective in nature, and there was lack of direct comparison trials.