Topical Rapamycin PI: Mary Kay Koenig, MD Co-PIs:Adelaide Hebert, MD Joshua Samuels, MD, MPH John Slopis, MD Hope Northrup, MD Coordinator:Joan Roberson, RN

The Skin The most superficial layer of the skin is the epidermis. The epidermis is composed of five cellular layers.

The Skin The stratum corneum consists of dead, keratinized cells that are sloughed off by friction and motion. As the stratum corneum sloughs its surface cells, they are replaced by cells derived from the stratum basale. Continual sloughing and replacement results in complete turnover of the skin surface approximately every three weeks.

The Skin in TSC In TSC, the epidermal basal cells contain a mutant copy of either the TSC1 or TSC2 gene. Loss of heterozygosity results in constitutive activation of mTOR leading to production of the epidermal cells at a faster rate than the ability to slough the dead cells by the stratum corneum.

The Skin in TSC Cells with non-functional TSC genes also secrete vascular growth factors that induce angiogenesis. The overproduction of skin cells, in conjunction with angiogenesis, results in the formation of visible facial angiofibromas.

The Skin in TSC Many treatments have been developed to alleviate the appearance of facial angiofibromas: o Curettage o Cryosurgery o Chemical peels o Dermabrasian o Shave excisions o Laser therapy Even though the majority of these treatments are effective, they are uncomfortable and need to be repeated at periodic intervals to treat recurrence.

Rapamycin Recent investigations have demonstrated the complex involvement of the TSC1 and TSC2 gene products in cell signaling. In particular their involvement in the mammalian target of rapamycin (mTOR) signaling pathway Studies also suggest the potential benefit of rapamycin for many tumor types in TSC.

Rapamycin Systemically administered rapamycin has a side effect profile that could limit it’s use as a cosmetic treatment. o Oral ulcers o Hyperlipidemia o Thrombocytopenia o Acneiform rash o Immunosuppression o impaired wound healing

Topical Rapamycin Rapamycin has a molecular weight of grams/mol, allowing for its absorption through the superficial layers of the epidermis. With an appropriate delivery system, topically applied rapamycin should be able to penetrate the skin and reach the deep epidermal basal cells implicated in development of facial angiofibromas without significant absorption.

Trial Design Inclusion criteria: o 13 years or older o Clinical diagnosis of TSC with visible facial angiofibromas Exclusion criteria: o Current use of any immunosuppressive agent, including oral rapamycin o Current participation in another drug trial o Pregnant or nursing o Known sensitivity to the vehicle or to rapamycin o Subject had received dermabrasion, cryotherapy, or laser therapy to their face within the preceding 6 months

Trial Design Subjects were randomized to one of thee topical therapy groups: o placebo o low dose topical rapamycin (0.01%) o high dose topical rapamycin (0.05%) Subjects and investigators were blinded to treatment arms The study product was applied nightly and washed off in morning by study subjects for 6 months

Trial Objectives Screen for systemic uptake of topically applied rapamycin Monitor for adverse effects Determine if the application of topical rapamycin minimizes appearance of facial angiofibromas in TSC

SubjectFlow

Withdrawn Subjects Total Withdrawn = 5 o 2 - Discomfort with product application (burning sensation with application) o 2 - Poor compliance with study protocols o 1 - Prolonged hospitalization unrelated to the study product Total Completing Study = 23 o 8 placebo o 8 high dose o 9 low dose

Subject Demographics Number (%) Age, years (29) (39) (11) >30 6 (21) SexMale 15 (54) Female 13 (46) RaceWhite, non-Hispanic 20 (72) White, Hispanic 2 (7) African American 3 (10) Asian 2 (7) Native American 1 (4)

Rapamycin Levels Blood was drawn at each study visit to measure rapamycin levels. Levels were analyzed at the University of Texas Medical School at Houston Rapamycin lab using the Architect i1000 analyzer (Abbott Laboratories, Abbott Park, IL). The limit of detection of the assay is 1.0 ng/mL and no subject reached that level during treatment.

Lesion Appearance Upon completion of the trial, subjects were asked if the formulation improved the appearance of their facial angiofibromas Of the 23 subjects who completed the study, 73% in the treatment arms reported a reduction in the appearance of their facial angiofibromas versus 38% of subjects in the placebo arm p = % vs 38%

Lesion Appearance

Adverse Events Among the study subjects, a single adverse event occurred in a patient on the low dose arm of the study. This subject aspirated during a seizure and developed pneumonia that progressed to septic shock. His rapamycin levels were undetectable at the time of hospital admission and he was immediately withdrawn from the study. His illness required a prolonged hospitalization, but he has now made a full recovery.

Conclusions Topically applied rapamycin can be applied safely to the surface of the skin and is effective in decreasing the appearance of facial angiofibromas in patients with TSC

Thanks To The Pediatric Dermatology Society, Cheniere Energy, Inc., Sponsors of Kirk and Meg Gentle of the Cheniere Race Across America Team, The University of Texas Medical School at Houston Department of Pediatrics, and The University of Texas Tuberous Sclerosis Center of Excellence at the University of Texas Medical School at Houston.

Research Team Adelaide Hebert, MD Joshua Samuels, MD, MPH John Slopis, MD Hope Northrup, MD Joan Roberson, RN

TREATMENT Trial Multi-center evaluation of topical rapamycin for facial angiofibromas Funding secured from the CDMRP Anticipate enrollment to begin in January 2011 Primary Site: University of Texas Houston TSC Center of Excellence

Collaborating Sites Clinic Without Walls o Site PI: Michael Frost, MD University of Alabama Birmingham o Site PI: Martina Bebin, MD, MPA Texas Scottish Rite Hospital o Site PI: Steven P. Sparagano, MD Herscot Center for Adults and Children with TSC at Massachusetts General Hospital o Site PI: Elizabeth Thiele, MD, PhD Children’s National Medical Center o Site PI: William McClintock, MD University of Pennsylvania Medical Center o Site PI: Peter Crino, MD, PhD Miami Children’s Hospital o Site PI: Ian Miller, MD The TSC Clinic at Loma Linda University Medical Center & Children’s Hospital o Site PI: Stephen Ashwal, MD The Jack & Julia Center for TSC at Children’s Hospital and Research Center at Oakland o Site PI: Rachel Kuperman, MD