disease (EMPD) is a frequently recurring malignant neoplasm with metastatic potential that presents in older adults on the genital, perianal, and axillary skin. Extramammary Paget disease can precede or occur along with internal malignant neoplasms. OBJECTIVE To develop recommendations for the care of adults with EMPD.EVIDENCE REVIEW A systematic review of the literature on EMPD from January 1990 to September 18, 2019, was conducted using MEDLINE, Embase, Web of Science Core Collection, and Cochrane Libraries. Analysis included 483 studies. A multidisciplinary expert panel evaluation of the findings led to the development of clinical care recommendations for EMPD. FINDINGSThe key findings were as follows: (1) Multiple skin biopsies, including those of any nodular areas, are critical for diagnosis. (2) Malignant neoplasm screening appropriate for age and anatomical site should be performed at baseline to distinguish between primary and secondary EMPD. (3) Routine use of sentinel lymph node biopsy or lymph node dissection is not recommended. (4) For intraepidermal EMPD, surgical and nonsurgical treatments may be used depending on patient and tumor characteristics, although cure rates may be superior with surgical approaches. For invasive EMPD, surgical resection with curative intent is preferred. ( 5) Patients with unresectable intraepidermal EMPD or patients who are medically unable to undergo surgery may receive nonsurgical treatments, including radiotherapy, imiquimod, photodynamic therapy, carbon dioxide laser therapy, or other modalities. (6) Distant metastatic disease may be treated with chemotherapy or individualized targeted approaches. (7) Close follow-up to monitor for recurrence is recommended for at least the first 5 years.CONCLUSIONS AND RELEVANCE Clinical practice guidelines for EMPD provide guidance regarding recommended diagnostic approaches, differentiation between invasive and noninvasive disease, and use of surgical vs nonsurgical treatments. Prospective registries may further improve our understanding of the natural history of the disease in primary vs secondary EMPD, clarify features of high-risk tumors, and identify superior management approaches.

Chemical penetration enhancers are widely used in transdermal pharmaceuticals as well as cosmetic products. Selection of suitable enhancers in topical formulations requires an understanding of the mechanism of action of these enhancers. The objective of the present study was to evaluate the enhancement effects of a number of commonly known enhancers and cosmetic ingredients on permeation across human epidermal membrane (HEM). The potencies of these chemical enhancers -maximum enhancement, E max -were compared at their highest thermodynamic activity in equilibrium with HEM (i.e., solubility equilibrium). This was achieved by the treatment of HEM with the enhancer or phosphate buffered saline (PBS) saturated with the enhancer. Passive transport experiments were then conducted with a model permeant corticosterone to determine the effects of these enhancers on the lipoidal pathway of HEM. The results suggest that E max of an enhancer is related to its octanol/water partition coefficient and its solubility in the HEM lipid domain. A relationship between enhancer E max and its solubility in silicone elastomer was also observed, suggesting the use of silicone solubility to predict enhancer potency. Based on the E max results, some common topical ingredients were found to be more potent enhancers than a number of well-known chemical enhancers.

Purpose The present study evaluated the effects of fatty acids commonly present in cosmetic and topical formulations on permeation enhancement across human epidermal membrane (HEM) lipoidal pathway when the fatty acids saturated the SC lipid domain without cosolvents (Emax). Methods HEM was treated with neat fatty acids or fatty acid suspensions to determine Emax. A volatile solvent system was used to deposit fatty acids on HEM surface to compare fatty acid enhancer efficiency in topical volatile formulations with Emax. To elucidate permeation enhancement mechanism(s), estradiol (E2β) uptake into fatty acid-treated SC lipid domain was determined. Results Emax of fatty acids was shown to increase with their octanol solubilities and decrease with their lipophilicities, similar to our previous findings with other enhancers. Emax of solid fatty acids was shown to depend on their melting points, an important parameter to the effectiveness of the enhancers. The E2β uptake results suggest that enhancer-induced permeation enhancement across HEM is related to enhanced permeant partitioning into the SC lipid domain. Conclusions The results suggest Emax as a model for studying the permeation enhancement effect of the fatty acids and their structure enhancement relationship.

Previously, chemical enhancer-induced permeation enhancement on human stratum corneum (SC) lipoidal pathway at enhancer thermodynamic activities approaching unity in the absence of cosolvents (defined as Emax) was determined and hypothesized to be related to the enhancer solubilities in the SC lipid domain. The objectives of the present study were to (a) quantify enhancer uptake into SC lipid domain at saturation, (b) elucidate enhancer mechanism(s) of action, and (c) study the SC lipid phase behavior at Emax. It was concluded that direct quantification of enhancer uptake into SC lipid domain using intact SC was complicated. Therefore a liposomal model of extracted human SC lipids was used. In the liposome study, enhancer uptake into extracted human SC lipid liposomes (EHSCLL) was shown to correlate with Emax. Attenuated total reflectance Fourier transform infrared spectroscopy (ATR-FTIR) and differential scanning calorimetry (DSC) were used to evaluate lipid phase alterations in enhancer-treated intact SC. IR spectra demonstrated an increase in the lipid domain fluidity and DSC thermograms indicated a decrease in the phase transition temperature with increasing Emax. These results suggest that the enhancer mechanism of action is through enhancer intercalation into SC intercellular lipids and subsequent lipid lamellae fluidization related to enhancer lipid concentration.

Many topical pharmaceuticals such as aerosols, topical sprays, and hydro-alcoholic and polymer based gels contain chemical enhancers. The objectives of the present study were to (a) determine the enhancement effects induced by enhancers deposited from a volatile solvent on human epidermal membrane (HEM) upon transdermal permeation enhancement, (b) compare these enhancement factors with Emax, and (c) examine the relationship between enhancer-induced permeation enhancement and stratum corneum equilibrium uptake enhancement. In this study, HEM was treated with enhancer/ethanol (enhancer dissolved in ethanol). After the evaporation of ethanol, passive transport experiments were conducted using corticosterone (CS) as the model permeant. The uptake of another model corticosteroid, estradiol (E2β), into the intercellular lipid domain of stratum corneum after enhancer/ethanol treatment was also determined. The results show a correlation between Emax and the enhancement effect of most enhancers when the enhancers were deposited on the skin using the volatile solvent ethanol. The data suggest that the CS transport rate limiting domain was likely the same as the intercellular lipid domain probed by E2β uptake. The correlation between steady-state permeation enhancement and uptake enhancement into the intercellular lipid domain suggests that the permeation enhancement mechanism is primarily due to enhancement of permeant partitioning into the transport rate limiting domain.

TSS is easily applied, delivering flexible drug dosage and associated with lower incidence of skin irritation. TSS provides a fast-drying product where the volatile solvent enables uniform drug distribution with minimal vehicle deposition on skin. TSS ensures precise dose administration that is aesthetically appealing and eliminates concerns of residual drug associated with transdermal patches. Furthermore, it provides a better alternative to traditional transdermal products due to ease of product development and manufacturing.

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Objective To evaluate the evidence upon which standards for hospital accreditation by The Joint Commission on Accreditation of Healthcare Organizations (the Joint Commission) are based. Design Cross sectional study. Setting United States. Participants Four Joint Commission R3 (requirement, rationale, and reference) reports released by July 2018 and intended to become effective between 1 July 2018 and 1 July 2019. Interventions From each R3 report the associated standard and its specific elements of performance (or actionable standards) were extracted. If an actionable standard enumerated multiple requirements, these were separated into distinct components. Two investigators reviewed full text references, and each actionable standard was classified as either completely supported, partly supported, or not supported; Oxford evidence quality ratings were assigned; and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) was used to assess the strength of recommendations. Main outcome measure Strengths of recommendation for actionable standards. Results 20 actionable standards with 76 distinct components were accompanied by 48 references. Of the 20 actionable standards, six (30%) were completely supported by cited references, six were partly supported (30%), and eight (40%) were not supported. Of the six directly supported actionable standards, one (17%) cited at least one reference of level 1 or 2 evidence, none cited at least one reference of level 3 evidence, and five (83%) cited references of level 4 or 5 evidence. Of the completely supported actionable standards, strength of recommendation in five was deemed GRADE D and in one was GRADE B. Conclusions In general, recent actionable standards issued by The Joint Commission are seldom supported by high quality data referenced within the issuing documents. The Joint Commission might consider being more transparent about the quality of evidence and underlying rationale supporting each of its recommendations, including clarifying when and why in certain instances it determines that lower level evidence is sufficient.