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Phase I Study of a Topical Skin Protectant Against Chemical Warfare Agents

Authors:
  • The Faculty of Medicine, The Hebrew University, Jerusalem, Israel

Abstract

Vesicants and some nerve agents penetrate exposed skin, mainly through the sensitive integration areas of the personal protective equipment. Therefore, improving dermal barrier with a topical agent should reduce the threat of exposure. A topical skin protectant lotion (IB1) was developed to improve protection against chemical warfare agents. Preclinical studies in several animal models have proven the protective efficacy of IB1. Here we present the results of a randomized placebo-controlled, double-blind phase I clinical study, performed with 34 healthy volunteers. The study tested the safety of repeated applications, including ruling out transdermal permeation of magnesium, which may lead to a dangerous blood magnesium level, since the lotion contains magnesium sulfate. Other objectives included detection of dermatological adverse effects, assessment of application convenience, and effect on daily activities. Importantly, no serious adverse effects were recorded and the lotion did not interfere with daily tasks. There were no significant differences in magnesium levels between the placebo and the study groups in any of the applications. No toxic levels of magnesium were found in either group. We conclude that IB1 is probably safe, easily self-applied, and does not cause any significant inconvenience. Therefore, IB1 can be considered as an adjunctive chemical, biological, and radio-nuclear (CBRN) protective aid to field soldiers.
MILITARY MEDICINE. 174. 1:47. 2009
Phase I Study of a Topical Skin Protectant Against
Chemical Warfare Agents
Major Arik
Eisenkrañ*f;
Major Amir Krivoy*; Major Aviv
Vidan*;
Captain Eyal Robenshtok*t;
Col Ariel Hourvitz*; LTC
Tsvika
Dushnitsky*; Leut Gal Marker§
ABSTRACT Vesicants and .some nerve agents penetrate exposed skin, mainly through the sensitive integration areas
of the personal protective equipment. Therefore, improving dermal harrier with a topical agent .should reduce the threat
of
exposure.
A topical skin protectant lotion (IBI
)
was developed lo improve protection against chemical warfare agents.
Preclinical studies in several animal models have proven the protective efficacy of IBI. Here we present the results of
a randomized placebo-controlled, double-hlind phase I clinical study, performed with 34 healthy volunteers. The study
tested the safety of repeated applications, including ruling out transdemial permeation of magnesium, which may lead
to a dangerous blood magnesium level, since the lotion contains magnesium sulfate. Other objectives included detec-
tion of dermalological adverse effects, assessment of application convenience, and effect on daily activities. Importantly,
no serious adverse effects were recorded and the lotion did not interfere with daily lasks. There were no significant
differences in magnesium levels between the placebo and the study groups in any of the applications. No toxic levels of
magnesium were found in either group. We conclude that IBI is probably safe, easily self-applied, and does nol cause
any significant inconvenience. Therefore. IBl can be considered as an adjunctive chemical, biological, and radio-nuclear
(CBRN) protective aid to field soldiers.
INTRODUCTION
SuHur mustard is a potetit vesicant that penetrates the human
skin easily and although blisters appear within hours after
exposure, the molecular damage occurs within minutes.'"^
Despite continuing efforts there are still no antidotes avail-
able.'*'^'*
Several nerve agents (e.g., VX) have the ability to
penetrate the human skin, thus exerting their toxic effects. VX
specifically is considered as one of the most potent chemical
warfare agents (CWAs).''' Current chemical, biological, and
radio-nuclear (CBRN) personal protection equipment includes
a mask, protective clothing, gloves, and overboots. Any pene-
tration of
the
above mentioned CWAs through gaps in the pro-
tective equipment entails a potential life-threatening risk.
A topically applied pretreatment may act as a dermal barrier,
preventing the absorption of these agents through the skin and
thus their respective toxicity.'" Such skin protectant may serve
as an additional means of protection in conjunction with other
physical protection components. Towards this end, the primary
application areas should include the integration areas of the per-
sonal protective equipment, i.e., the neck, armpits, groin, waist,
wrists, and ankles, which arc also considered to be relatively
sensitive skin areas.'-' The "topical skin protectant" strategy
has been adopted by several countries so far, including Israel.'"
*CBRN Medicine Branch. Medical Corps. Israel Defense Forces. Tel
Hashomer. Israel.
f.Sarru Children's Hnspifal. Sheba Medical Center. Tel Hashomer. Israel.
^Internal Medicine E, Rabin Medical Center. Bellinson Campus. Petach-
Tikva. Israel.
§Sheba Cancer Research Center. Sheba Medical Center. Tel Hashomer.
Israel.
This manuscript was received for review in Oclober 2007. The revised
manuscript was accepted for publication in September 2008.
Reprint & Copyright © by Association of Military Surgeons of
U.S..
2009.
IBI,
a topical skin protectant resistant to CWAs that
was developed at the Israel Institute for Biological Research
(IIBR),
was successfully tested in various animal models."^
Using the well-established primary skin irritation Draize
test," the protectant was demonstrated to be nonirritating
in guinea pigs and in rabbits. No adverse dermatotogical
or systemic effects were found in a long-term toxicologi-
cal study in pigs following an overdose application of the
protectant (covering >209'c of the skin surface, applied three
times per day for 2 weeks). Evaluation included a clinical
follow-up for I month, blood and urine biochemistry, includ-
ing magnesium (Mg) levels, and pathology. No detectable
levels of the protectant ingredients were found in blood
and urine during the entire monitoring period.'' Also, blood
and urine Mg levels were not increased. Irritation and sen-
sitivity tests were performed on 50 human volunteers (U
males,
39 females; 10 at the ages of 18-35 years, 14 at the
ages of 36-45, 26 at the ages of 46-65) and were not found
to be associated with any skin irritation or with any allergic
sensitization.'^
Here we tested the medical safety of repeated topical
application of the IBI lotion in a randomized placebo-
controlled double-blind phase
I
clinical study in young healthy
volunteers. Since the lotion includes a relatively high content
of magnesium sulfate, potential changes in serum Mg
levels were monitored, as well as other hematological and
biochemical parameters, local dermatological adverse effects,
and convenience of use.
MATERIALS AND METHODS
The study was approved by the review board of the Israeli
Defense Force's (IDF) Medical Corps and was conducted
MILITARY MEDICINE, Vol. 174. January 2009
Phase I Study of a Topical Skin Protectant Against Chemical
Warfare
Agents
according to the Declaration of Helsinki. All volunteers gave
their written informed consent.
Preiiminary Application Test
To determine ihe amount of IB
1
lotion needed for each appli-
cation, an application test was performed before the main
study. In this preliminary study 10 volunteers received small
glass vials containing 20 m! of the IB
I
and were asked to
cover relevant areas as described in Figure 1. The applica-
tion was performed in the presence of the researchers. After
application, the remaining lotion was weighed. On average,
-10 ml (containing 0.37 g of Mg) were required to cover all
relevant areas, and this amount was thus determined as the
experimental dose.
Voiunteers
Volunteers were recruited from a medic's course in the
IDF's military medical school. Inclusion criteria allowed
only healthy soldiers with normal physical examination,
normal baseline complete blood count, liver function tests,
and renal function tests to participate. Soldiers with any
chronic or acute disease (especially dermatological dis-
eases) or receiving any medical treatment were excluded.
This excluded soldiers with asthma, atopic dermatitis, previ-
ously known allergy, allergic rhinitis, allergic conjunctivitis,
sun burns, skin lesions at the application areas, and soldiers
that for any reason could not replace contact lenses with
eyeglasses. Every volunteer had the right to stop participa-
tion at any time during the study. In addition, each volunteer
tilled and signed an informed consent form and a medical
questionnaire.
Blinding Procedures
The study was designed as a randomized placebo-controlled
double-blind study. The
IB I
and the placebo lotions were pre-
pared at the IIBR and were coded by medical personnel at the
IDF's Medical Corps, who were not involved in any other part
of
the
experiment, including design, performance, or analysis.
Codes were locked throughout the experiment. The research-
ers,
who enrolled the volunteers, drew the blood, took vital
signs,
examined the volunteers, and were present in every
application, as well as a dermatologist, were blinded to the
lotion composition throughout the experiment until after al!
analyses were completed. Coding was revealed only at the end
of the study by the same personnel that coded them before the
study.
The placebo was the vehicle of the IBl lotion, consi.st-
ing of 87% glycerin (Merck. Israel) and \3% Aqua with-
out any magnesium. Both placebo and IBl lotions were
indistinguishabiy odorless, colorless, and with the same
consistency. Both were supplied in identical vials. The
researchers received a single box containing batches of
coded vials that were randomly assigned to the volun-
teers during the preparation day of the study (see below
"Experimental Protocol"). Each volunteer was assigned
one vial per application.
Experimental Protocol
A preparation day preceded the actual study by
1
week. Study
protocol included 4 consecutive days in which a total of
nine applications were carded out, once every 8 hours.
The preparation day included signing an informed consent
form, full medical examination, assigning the coded batches
to the volunteers, and obtaining baseline blood tests (base-
line Mg levels, complete blood count, renal functions, and
liver functions). The dosing schedule was defmed on the
basis of the pre-clinical experiments.^ The lotion was applied
on six body areas: the neck, axillae, waist, groin, wrists,
and ankles (Fig. 1). Volunteers were instructed to evenly
apply the lotion on these areas and use all 10 ml supplied.
All application sessions were performed in the presence of
the researchers to verify that all of the volunteers followed
the instructions by marking relevant checklists and draw-
ings.
Volunteers washed their hands after every application,
and only after several minutes during which the lotion was
absorbed into the skin surface did they re-dress. Worth not-
ing, the vials were collected by the researchers after each
application.
Complete blood counts and liver function tests were
obtained in baseline and poststudy assessments. The baseline
test was required for inclusion and exclusion criteria. Further,
since the IB
1
lotion contains magnesium sulfate, renal func-
tion tests were taken as baseline and at the end of the study,
and blood Mg levels were monitored daily to verify that repet-
itive IBl application does not lead to a dangerous increase.
Because of the diurnal changes in Mg levels.'- '^ blood sam-
ples were drawn at the same time every day between 12:30pm
and
1:30pm,
except for the baseline tests, which were obtained
between 10:30am and 11:00am. Ba.seline test results were
used for inclusion/exclusion of candidates. Hence, a total of
four blood samples were obtained from each volunteer. The
first and the last included a complete blood count, plasma Mg
level (total serum level), and liver and renal functions. Two
additional samples for plasma Mg levels were obtained from
each volunteer on days 2 and 3. Bloud samples were trans-
ferred immediately in a chilled receptacle to a medical labora-
tory facility adjacent to the base for analysis.
The volunteers were allowed to have one shower a day,
before the night application. No restrictions on any activ-
ity, including physical trainings, or on any clothing, includ-
ing uniforms, were placed on the voiunteers. Each volunteer
was fully examined by a dermatologist every day. The aim of
this examination was to identify any topical adverse effects
consistent with either allergic contact dermatitis or other local
toxic dermal effect. These were documented in a daily chart,
including an image similar to Figure 1, on which the exact
area involved could be marked.
Each volunteer filled out a daily questionnaire concerning
adverse effects. At the end of the study they all filled out a
48MILITARY MEDICINE, VtiL 174, January 200*-)
Phase I Study of a
Topical
Skin Protectant Against Chemical
Warfare
Agents
FIGURE 1. Areas of lotion application.
second questionnaire on the influence of the lotion on daily
activities and their comments about the product (data not
shown).
Statisticai
Analysis
The minimal number of subjects for the study was decided on
the basis of the following considerations: significance level
(a) 0.05; statistical power (\-ß) 0.8; anticipated effect size
(/-) 0.4. The minimal number accordingly was calculated to
be 22
( 11
in eacb group); however, since several dropouts were
expected, the study was started with 51 subjects (of which 17
indeed dropped out).
Statistical analyses were performed using SAS for Windows
version 9.1 (SAS Institute. Inc. Cary. NC). Normality of vari-
ables distribution was tested with the Smimov-Klimigorov
test. Plasma Mg levels of the two groups (ÏB1 lotion and pla-
cebo) were compared for each day of lotion application with
the Mann-Whitney nonparametric test. In addition, differ-
ences between Mg levels at each stage and the baseline lev-
els were calculated and compared between the two groups.
Analysis of variation with repeated measures was fitted for
each group, using Proc Mixed in SAS. Statistical significance
was set at 0.05. Data are shown as mean (±SD).
RESULTS
Of 130 soldiers approached, only 51 had volunteered. After
screening, 2 volunteers were excluded because of a history of
asthma.
2
other volunteers were diagnosed with mild anemia at
the baseline complete blood count
(
iO.2 mg/dL and 10,6 mg/
dL).
I volunteer had a high bilirubin level (3.2 mg/dL), and 1
volunteer had a relatively high baseline Mg level (2.9 mg/dL).
The remaining 45 volunteers were randomized for treatment
groups. During the study, an additional 2 volunteers dropped
out because of acute tonsillitis with fever that appeared on the
second and third days of the study, and an additional 9 volun-
teers dropped out of the study at various stages because of non-
medical reasons according to their request. The 34 volunteers
who completed the full study protocol were ages 18-20 (mean
18.9 ± 0.7). Decoding revealed that
21
volunteers received the
IBl and 13 received placebos; 26 males (17 in the IBI group,
9 in the placebo group) and 8 females (4 in each application
group).
The effect of gender on the results could not be mea-
sured because of small sample size.
No serious adverse effects were reported throughout the
study. Forty percent of the male volunteers in the IBI group
and 60% of the male volunteers in the placebo group reported
a short-lasting (up to 30 minutes) burning sensation when
applying the lotion after shaving, with no residual or apparent
dermal irritation upon examination by the dermatologist and
no pathological findings in their daily medical examinations.
No significant differences were found in the complete blood
counts between baseline and poststudy samples, except for a
slight increase in the white blood count, which was observed
in both groups (Table I). The mild increase was statistically
significant in the placebo group (;;-value = 0.04) and showed
a strong trend in the IBI group (p-value = 0.06). There were
no significant differences among renal and liver function tests
between the baseline and the poststudy analy.ses (Table I).
After completion of the experimental protocol all volun-
teers reported that there was no interference with any daily
activity or performance, except for very mild interference
in wearing clothing and performing power drills, which was
reported by the volunteers in the IBI group mainly (Table II).
However, these interferences did not seem to impair the
soldiers' overall physical performance and hence may not
have any practical implication. All volunteers stated that the
instructions were clear and simple, there was no need for
buddy aid, and that it had no effect on their ability to concen-
trate during lectures (Table II).
Blood Mg levels were within the normal range in all sam-
ple points in both groups (1.53 mg/dL-2.6 mg/dL). except
for two sporadic samples from two different volunteers in
the IBI group (2.9 mg/dL in the third sample in one volun-
teer and 2.7 mg/dL in the fourth sample in the other). No
significant differences in Mg levels were found between
the placebo group and the IB
I
group in any of the tested
time points (Table III). Individual analysis of each volunteer
did not reveal any clinically significant change over time in
the Mg levels (data not shown). Differences between mean
Mg levels at each time point and ba.seline levels were calcu-
lated and compared between the two groups. The differences
were found to be insignificant (Table III). Of note, analysis
of variation with repeated measurement revealed that Mg
levels on day I were significantly lower than other measure-
ments in the same group in both placebo and IBI groups
(/i-value < 0.001 and /j-value < 0.01, respectively). However,
these differences were very small and within the normal
Mg range.
MILITARY MEDICINE,
Vol.
174,
January 2009
Phase I Study of a
Topical
Skin Protectant Against Chemical
Warfare
Agents
Placebo (.N= 13) Baseline
(
mean
)
Poststudy
(mean)
p-value
IBl(Af=21) Baseline
(mean)
Poststudy
(meati)
p-value
TABLE 1.
Renal Functions
Creattnine
1.0
1.0
0-70
I.O
I.I
0.88
Urea
25.8
26.0
0.91
26.9
26.9
1.00
Various Hematological and Biochemtcal Parameters
Liver Functions
T-Bil
0.7
0.7
0.78
0.8
0.7
0.35
SGOT
19.8
19.5
0.89
23.6
23.8
0.53
SGPT
15.5
17.4
0.37
16.6
17.1
0.69
Hb
13.5
13.8
0.12
13.8
13.8
0.97
WBC
6.6
7.4
0.04
7.2
7.9
0.06
Complete Blood Count
PLT
243.0
256.5
0.19
244
249
0.16
Neut
56.7
57.9
0.45
59
60
0.53
Mono
8.7
8.1
0.09
8.6
15.9
0.11
Lymph
31.8
31.4
0.81
27.7
29.0
0.50
Eos
2.2
2.3
0.52
2.6
2.4
0.56
The mean values of
an
entire group for each of
the
various parameters are shown, as indicated. Results are presented for baseline blood test and for poststtidy blood
test, as well as the /»-value of a paired Student's /-test. The units used were: creatinine, mg/dL: urea, mg/dL: bilirubine, mg/dL; SGOT, lU/L; SGPT, lU/L; Hb.
g/dL; WBC. K/microL: PLT, K/microL; neutrophiles(neut). montxrytes (mono), lymphocytes (lymph), and eositiophils (eos), percentage out of white blixid cells.
TABLE II. No Signiftcant Effect of Lotion on Everyday Life
Question
On what level of ditViculty would you define the
application of the lotion?
How much help was needed for the application?
Were there any areas that were more difficult to
apply than others?
Estimate the time needed to complete the whole
application
Wiis the application appalling?
Were the instructions clear?
Were there signs of irregularities
(liquefaction, peeling, etc.)?
Was there a difference in application after having a
shower?
How did it influence your ability to
perform power drills?
How did il inlluence your ability to
perform jogging?
How did il intluence your ability to dress?
How did it induence your ability to concentrate in
class?
How did it influence your ability to eat?
How did it influence the ability to move your
fingers?
How did it influetice the ability to move your
hands?
How did it influence the ability to move your neck?
Did it influence any other tnovements of other body
parts?
How difficult was it to remove ihe lotion at the end
of the study?
How long did it take to remove the lotion?
Did you feel it was possible to remove the lotion?
IBl
1.14
1.00
1.10
2.24
1.95
1.00
O.IO
0.25
1.67
1.81
1.95
1.00
1.24
1.10
1.10
1.05
1.00
0.95
1.90
1.18
Placebo
1.27
1.00
1.09
2.18
1.64
1.00
0.00
0.27
1.18
1.73
1.27
1.00
1.09
1.09
1.00
1.00
1.00
1.00
1.60
1.00
The results of the questionnaire filled in at the end of the study are presented
as the mean score for each question.
DISCUSSION
Mitny highly loxic CWAs exert their effect through the dermal
exposure route, either by vapors or droplets.'"'^''* Consensus
protective measures include mainly physical protection with
specialized outfits. Yet, integration areas, such as neck, armpits,
groin, waist, wrists, and ankles are a weak link for penetration
and exposure to CWAs. Previous preclinical studies indicated
that IBl lotion, a passive protective lotion against CWAs, sig-
nificantly reduced the toxicity of sulfur mustard and VX.''
The IBl lotion contains ingredients approved for human use
and has successfully passed the safety testing on animals and
humans."" A major concern regarding future use of the topical
skin protectant was the possibility, although faint, that danger-
ous amounts of magnesium might accumulate in plasma when
applying the lotion repeatedly. Thus, the main goals of the cur-
rent study were to test the dermatological and systemic safety
of this product in repeated applications and especially to rule
out ihe possibility of reaching dangerous levels of plasma Mg.
Magnesium is the fourth most common cation in the
body and the third most common intracellular cation (mainly
in muscle and liver).'^'"' The normal plasma concentra-
tion ranges between 1.5 and 2.3 mg/dL (1.2-1.9 mEq/L;
0.62-0.94 mmol/L), with some variation between clinical
laboratories. Only 1-2% of body magnesium is extra-
cellular (60% ionized; 15% complexed; 25% protein bound).
Magnesium is a necessary cofactor for hundreds of enzymes.
It is important for membrane stabilization and nerve conduc-
tion.''^ Renal excretion is tbe principal regulator of magne-
sium balance. Clinically significant hypermagnesemia. albeit
unusual, is almost always secondary to excessive intake. Tbe
kidneys' ability to excrete excessive magnesium is dimin-
ished in patients with chronic renal failure. Massive paren-
teral infusions of magnesium salts, which overwhelm renal
excretory mechanisms, have been reported with inadvertent
intravenous infusion, urologie procedures involving irriga-
tion with magnesium salts, and ingestion of large quantities of
magnesium-containing antacids and cathartics."' To tbe best
of our knowledge, there is no published scientific evidence
on transdermal absorption of magnesium. The symptoms of
bypermagnesemia correlate roughly with serum concentra-
tions but depend on the rate of increase and host factors.'^
50MILITARY MEDICINE, Vol.
174,
January 2009
Phase I Study of a
Topical
Skin Protectant Against Chemical
Warfare
Agents
TABLE III. Magnesiutn Levels of the Placebo atid Drug Groups
Sample A Placebo Mean Mg Leve! (mg/dL) n = 13
1 (Baseüne) 2.06(±0.ll)
2 2.33 (±0-17)
3 2.!6(±O.12)
4 2.25 (±0.15)
Samp!e B Placebo Mean difference from baseline tmg/dLj n = 13
2 0.27 (±0.14)
3 O.!O(±O.l)
4 0.19 (±0.16)
IBI Mean Mg Levels (mg/dL%)rt =
21
p-Value
2.08 (±0.08) 0.8
2.26(±0.16) 0.24
2.18 (±0.20) 0.75
2.I8(±O.19) 0.16
IB
I. Mean difference from baseline (mg/dL) n
=
2[ /)-Value
O.I8(±O.18) 0.15
0.10 (±0.21) 0.94
0.10 (±0.23) 0.20
(A) Results show the mean Mg va!ues of each group in al! individual time points, as indicated. (B) Differences between magnesium concentrations in the two
groups, relative to baseline values.
Usually, symptoms do not appear when plasma magnesium
levels are <4.5 mg/dL.'"^ Hypermagnesemia impairs neuromus-
cular junction transmission by decreasing ucetylcholine release
from the presynaptic membrane, thus producing hypotonia,
hyporeflexia. and weakness.''^ Paralysis occurs at high concen-
trations. Direct central nervous system depression causes leth-
argy and sleepiness. It is also associated with hypotension and
flushing owing to vascular dilation. Hypotension can be pro-
found at plasma levels of 4-5 mEq/L because of
a
direct effect
on cardiac function. At the same levels hypermagnesemia
typically results in loss of deep tendon reflexes. At levels >5
[TiEq/L central nervous system depression may range from
drowsiness to coma. Electrocardiogram changes occur at lev-
els of 5-10 mEq/L. including prolonged P-R. QRS. and Q-T
intervals. Serum levels of 9-12 mEq/L may cause apnea and
cardiovascular collapse.'' Severe hypermagnesemia includes
nausea, vomiting, hypocalcaemia. and can cause parasym-
pathetic blockade, fixed dilated pupils, and neuromuscular
blockade mimicking a midbrain syndrome.'^
We found no significant rise in blood Mg levels during
repetitive applications. Allegedly, a significant rise could be
observed between the first test obtained a week before the
study and the other tests obtained during the study. However,
this difference was very small and within the normal Mg range
(no clinical relevance) and may be attributed to the different
hour in which the samples were obtained. Indeed, baseline
samples were obtained at IO:3Oam-l
1:00am
and the other tests
at 12:30pm-l:30pm. Two sampîes in which a higher than nor-
mal level of Mg was recorded in two volunteers applying the
IBl lotion might be explained by the normal diurnal change
in blood Mg levels, although blood samples were drawn at the
same time every day tluring the application study. Our main
concern was from tnuch higher blood Mg levels that might
cause dangerous symptoms, even if only transiently elevated.
Itnportantly. these slightly above normal values were far from
being considered dangerous, especially in young healthy indi-
viduals with normal renal functions. Although there is a possi-
bility that a larger sample size will uncover a group of subjects
with a significant rise in blood Mg levels, we tbink that the
existing evidence supported by animal studies"* is sufficient to
conclude that the use of IB
1
lotion does not lead to increased
serum Mg levels and is safe to use from this perspective.
Members of the review board of the Israeli Defense
Force's Medical Corps raised concerns of a potential effect
of IBl application on liver functions, as well as on complete
blood count, because of an inflammatory response, although
there was no evidence of any such changes in animal stud-
ies.
Hence, complete blood counts and liver function tests
were taken as part of the screening procedures and to rule out
clues for inflatntTiation that might follow dermal application
of the lotion. There was no evidence of any such changes in
the animal studies, and as estimated, there were also no sig-
nificant changes in the complete blood count and liver func-
tion measurements in either group in our study, except for a
very mild increase in white blood count ob.served post study
in both groups. However, as the difference was very small
and absolute values were within the normal range, it was
probably unrelated to the chemical composition of the IBl
and might reflect a mild stress, perhaps because of repeated
drawing of blood. No significant values could be observed
in the volunteers who complained of a transient burning
sensation (data not shown). Renal function tests were obtained
to make sure the basic status of the volunteers was normal and
was not altered during the study. No significant changes were
recorded in renal function tests, in either group. We conclude
that repetitive application of IBl does not cause measurable
inflammatory changes or renal or liver abnormalities.
Before this study, irritation and sensitivity tests were per-
formed in a well-recognized medical institute in the country,
which showed neither irritation nor sensitivity among 50 par-
ticipants.^ Here, however, several volunteers reported a short-
lasting burning sensation when applying the lotion on freshly
shaved skin, yet there were no persistent signs of irritation as
deñned by a dermatologist. The volunteers noted that it was
present for only a short period of time and resembled the feel-
ing of applying an aftershave. No difference could be identified
between the placebo and the IB
1
groups. As was mentioned
earlier, no changes were found in the complete blood count of
these volunteers, as might appear in an inflammatory reaction.
The second goal of the study was to find out whether the
topical skin protectant interferes with routine daily tasks. The
volunteers' impression was that repetitive applications do
not interfere with various daily activities, including writing,
jogging, and other sports activities, as detailed in Table IL
MILITARY MEDICINE, Vol.
174,
Jatiuary 200951
Phase I Study of a Topical Skin Protectant Against Chemical
Warfare
Agents
We have no explanation for the difference concerning the
wearing of clothing and performing power drills, especially as
there was no difference in the consistency of
the
IB
I
lotion and
the placebo. These differences may not reflect any practical
difficulties or differences. Alternatively, the study eventually
included a limited number of subjects. To attain confidently
significant results a larger group of volunteers is needed.
The limited number of volunteers in our study is one of
its major limitations. Though the final number of volunteers
participating in the study was statistically sufficient, it was
advisable to have a larger sample size. Unfortunately, >80%
of potential volunteers on the base did not want to take part
in this study, most of them because of the requirement of
drawing several blood samples during the study.
CONCLUSIONS
With the combination of previous animal studies, irritation and
sensitivity tests, and results that show safety and convenience,
we believe that the IBI lotion should be considered as a safe
adjunct to other CBRN protective measures of field soldiers.
ACKNOWLEDGMENTS
We thank Dr. Tamar Kadar and the teams of the Pharmacology and Organic
Chemistry Departments at the Israel Institute for Biological Research, for
their invaluable help in performing this study.
REFERENCES
1.
Sidell FR. Urbanetti JS. Smith WJ. Hursi CG; Vesicants. In: Textbook of
Mlliiary Medicine: Medical Aspects of Chemical and Biological Warfare.
PP 197-228. Edited by Sideli FR. Takafuji ET. Franz DR. Washington.
DC.
Borden In.stilute and Walter Reed Army Medical Center. 1997.
2.
U.S. Army Medical Research Institute of Chemical Defense: Vesicants.
In; Chemical Casualty Care Division, Ed 3. pp 56-86. Aberdeen Proving
Ground, MD. Medical Management of Chemical Casualties Handbook,
3.
Hurst CG. Smith WJ: Chronic effects of acute, low-level exposure to the
chemical warfare agent sulfur mustard. In: Chemical Warfare Agents:
Toxicity m Low Levels, pp 245-260. Edited by Somani SM, Romano JA:
Boca Raton, FL. CRC Press. 2001.
4.
KadarT, FishbineE. Meshulam J.Sahar R. Amir A. Bamess I: A lopicai
skin protectant against chemical warfare agents. Isr Med Assoc J
2003;
5:717-9.
5.
Eisenkraft A. Tashma Z, Luria S; Mustard gas: clinical implications and
management. In; Terror and Medicine; Medical Aspects of Biological.
Chemical and Radiological Terrorism, pp 172-182. Edited by Shemer J,
Shoenfeld Y: Germany. Pabst Science Publishers,
2003.
6. Sidell FR. Hurst CG: Clinical considerations in mustard poisoning. In:
Chemical Warfare Agents, p 51. Edited by Somani SM: New York,
Academic Press, 1992.
7.
Babin MC, Ricketis K. Skvorak JP. Gazaway M. Mitchkree LW. Casillas
RP;
Systemic administration of candidate antivesicants to protect
against topically applied sulfur mustard in the mouse ear vesicant model
(MEVM). J Appl ToxiccI 2000; 20:
SI4]^.
8. Dachir S. Fishbeine E, Meshulam Y, Shahar R. Amir A. Kadar T;
Screening of potential anti-inflammatory Ireatments against cutaneous
sulfur mustard injury using the mouse ear vesicant model. Hum Exp
Toxicol2002;21:
197-203.
9. Munro NB. Ambrose KR. Watson AP: Toxicity ol'the organophosphate
chemical warfare agents GA. GB and VX: implications for public protec-
tion. Environ Health Perspect 1994; 102: 18-38.
10.
Braue EH: Development of a reactive topical skin protectant. J Appl
Toxicol 1999; 19(Suppl 1): S47-53.
11.
Draize JH. Woodward G. Calvery HO: Methods for the study of irrita-
tion and toxicity of substances applied topically to the skin and mucous
membranes. J Pharmacol Exp Ther 1944; 83: 377-90.
12.
Touitou Y. Touitou C. Bogdan A. Beck H. Reinberg A: Serum mag-
nesium circadian rhythm in human adults with respect to age. sex and
mental status. Clin Chim Acta 1978: 87;
35-41.
13.
Newhouse U, Johnson KP. Montelpare WJ. McAulifte JE: Variability
within individuals of plasma ionic magnesium concentrations. BMC
Physiology. 2(K)2. Available at http://www.biomedcenlral.com/1472-
6793/2/6; accessed October 10, 2007.
14.
Moore DH. Alexander SM; Emergency response to a chemical warfare
agent incident: domestic preparedness, first response, and public health
considerations. In: Chemical Warfare Agents: Toxicity at Low Levels,
pp 409-435. Edited by Somani SM, Romano JA; Boca Raton. FL, CRC
Press.
2001.
15.
Schonwald S; Magnesium. In; Section 9: Electrolytes and Diuretics.
Medical Toxicology, Ed 3. pp 901-903. Edited by Dart RC: Philadelphia.
Lippincott Williams & Wilkin.s, 2004.
16.
Charney AN. Hoffman RS: Fluid, electrolyte, and acid-base principles.
In: Section II: Pathophysiologic Basis: Organ Systems. Goldfrank's
Toxicologie Emergencies. Ed 8. pp 278-295. Edited by Flomenbaum
NE.
Howtand MA. Goldfrank LR. Lewin NA. Hoffman RS, Nelson LS:
New York, NY, McGraw-Hill, 2006.
52MILITARY MEDICINE, Vol. 174, January 2009
... We have developed a topical skin protectant that is applied onto the skin before exposure and prevents the penetration of warfare agents such as SM and VX through the skin and thus confers a highly efficient protection against the hazard they pose [2]. The formulation coded IB1 is a hydrophilic water-based solution comprised of magnesium sulfate and glycerin and it was shown to be safe in preclinical and phase I studies [3]. IB1 was registered and approved by the Israel Ministry of Health as Dermostyx protective solution and is commercially available (Rekah Pharm, Israel). ...
... The longest pretreatment duration that was tested for the efficacy of SERPACWA, the TSP used by the US military, was 5 h [23,24]. IB1 is absorbed into the stratum corneum of the skin and remains there and we have shown that the ingredients are not absorbed into the circulation [3]. The protective mechanism of this preparation seemed to be primarily due to alterations in the physico-chemical properties of the stratum corneum that turned hydrophilic by the glycerin. ...
... When using glycerin, the hydration effect was long-lasting and the lipophilic stratum corneum turned hydrophilic as demonstrated by the histochemical staining of phospholipids. Another advantage of glycerin is that it does not penetrate from the stratum corneum into the circulation as shown in preclinical [2] and Phase I clinical [3] studies. The addition of magnesium sulfate into the glycerin solution decreased the solubility of the toxic agents in the stratum corneum water phase, a process known as " salting out " . ...
... IB1 (Dermostyx), a topical skin lotion protectant resistant to chemical agents, was developed at the Israel Institute for Biological Research (IIBR). It was successfully tested in a pig model, showing a significant reduction of sulfur mustard and VX toxicity, and has also passed successfully Phase I safety testing [24,25]. ...
... IB1 is effective immediately upon application and remains efficient for hours (tested up to 12 hours) in reducing the toxicity of sulfur mustard and VX in dermal exposure [25]. IB1 has successfully passed the safety testing in both animals and humans [24,25], and is approved by the Israel Ministry of Health and in Europe for skin application on up to 25% of body surface area, currently aimed for C-PPE integration areas or for relatively susceptible skin areas (Neck, armpits, and groin). ...
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We aimed to evaluate the performance of medical personnel in using the IB1 topical protective lotion on their hands and wrists together with standard disposable medical gloves, compared to standard-issued medical chemical protective gloves. This randomized cross-over study included 144 medical personnel. Primary endpoints were time-to-completion of autoinjection; success rate, number of attempts, and time-to-achieve successful endotracheal intubation; time-to-achieve satisfactory tube fixation; time-to-draw and inject the content of an ampoule; and the total time-to-perform all medical procedures. Secondary endpoints included the subjective assessment of convenience to perform these four procedures with each protective measure. Mean time was significantly shorter using IB1 compared to chemical protective gloves for tube fixation, ampoule drawing, and the total time-to-perform all procedures (58.6±22.7 seconds vs. 71.7±29.7; 31.5±21.8 vs. 38.2±19.4; 137.4±56.1 vs. 162.5±63.6, respectively; P<.001 for all). For all medical procedures, the use of IB1 was reported as significantly more convenient than the use of chemical protective gloves (P<.001 for all comparisons). IB1 with standard medical gloves significantly shorten the time-to-perform medical procedures requiring fine motor dexterities and is subjectively more convenient than chemical protective gloves. IB1 should be considered as an appropriate alternative for medical teams in a chemical event.
... There were no significant differences in magnesium levels between the placebo and the study groups in any of the applications. No toxic levels of magnesium were found in either group [20]. ...
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Clinical considerations in mustard poisoning
  • F R Sidell
  • C G Hurst
Sidell FR. Hurst CG: Clinical considerations in mustard poisoning. In: Chemical Warfare Agents, p 51. Edited by Somani SM: New York, Academic Press, 1992.
Emergency response to a chemical warfare agent incident: domestic preparedness, first response, and public health considerations
  • D H Moore
  • S M Alexander
Moore DH. Alexander SM; Emergency response to a chemical warfare agent incident: domestic preparedness, first response, and public health considerations. In: Chemical Warfare Agents: Toxicity at Low Levels, pp 409-435. Edited by Somani SM, Romano JA;