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Transdermal drug delivery with a pressure

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Article in Advanced Drug Delivery Reviews April 2004
DOI: 10.1016/j.addr.2003.10.031 Source: PubMed

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Advanced Drug Delivery Reviews 56 (2004) 559 579

www.elsevier.com/locate/addr

Transdermal drug delivery with a pressure wave

Apostolos G. Doukas a,*, Nikiforos Kollias b
a

Department of Dermatology, Wellman Laboratories of Photomedicine, Massachusetts General Hospital, Harvard Medical School,
Boston, MA 02114, USA
b
Johnson & Johnson Consumer and Personal Products Worldwide, 199 Grandview Road, Skillman, NJ 08558, USA
Received 9 September 2003; accepted 13 October 2003

Abstract
Pressure waves, which are generated by intense laser radiation, can permeabilize the stratum corneum (SC) as well as the cell
membrane. These pressure waves are compression waves and thus exclude biological effects induced by cavitation. Their
amplitude is in the hundreds of atmospheres (bar) while the duration is in the range of nanoseconds to a few microseconds. The
pressure waves interact with cells and tissue in ways that are probably different from those of ultrasound. Furthermore, the
interactions of the pressure waves with tissue are specific and depend on their characteristics, such as peak pressure, rise time
and duration. A single pressure wave is sufficient to permeabilize the SC and allow the transport of macromolecules into the
epidermis and dermis. In addition, drugs delivered into the epidermis can enter the vasculature and produce a systemic effect.
For example, insulin delivered by pressure waves resulted in reducing the blood glucose level over many hours. The application
of pressure waves does not cause any pain or discomfort and the barrier function of the SC always recovers.
D 2004 Elsevier B.V. All rights reserved.
Keywords: Photomechanical waves; Shock waves; Stratum corneum barrier; Stress waves; Transdermal delivery

Contents
1.
2.
3.
4.
5.
6.
7.
8.

Introduction . . . . . . . . . . . . . . . . . . . . . . . .
Generation and propagation of pressure waves . . . . . . . .
Biological effects of pressure waves . . . . . . . . . . . . .
Experimental arrangement . . . . . . . . . . . . . . . . . .
Transdermal drug delivery . . . . . . . . . . . . . . . . . .
The synergy of pressure waves and sodium lauryl sulfate . . .
The mechanism of the permeabilization of the stratum corneum
Examples of transdermal drug delivery . . . . . . . . . . . .
8.1.
Delivery of allergens. . . . . . . . . . . . . . . . .
8.2.
Systemic delivery of insulin . . . . . . . . . . . . .
9. Conclusions . . . . . . . . . . . . . . . . . . . . . . . .
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . .

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* Corresponding author.
E-mail address: adoukas@partners.org (A.G. Doukas).
0169-409X/$ - see front matter D 2004 Elsevier B.V. All rights reserved.
doi:10.1016/j.addr.2003.10.031

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560

A.G. Doukas, N. Kollias / Advanced Drug Delivery Reviews 56 (2004) 559579

1. Introduction
In clinical drug therapies, topical application allows
localized drug delivery to the site of interest. This
enhances the therapeutic effect of the drug while
minimizing systemic side effects. Furthermore, topical
application of drugs bypasses systemic deactivation or
degradation and minimizes gastrointestinal incompatibility and potential toxicological risk.
The stratum corneum (SC) of the skin is an effective
barrier to molecular transport. It is composed of
corneocytes (f 30 Am by 0.5 0.8 Am thick cells)
which are filled with keratin and lack nuclei and
cytoplasmic organelles. There are 10 50 cell layers
in the human SC with an intercellular spacing of the
order of 20 nm [1]. The intercellular volume is 5 21%
of the SC volume [2]. The intercellular regions are
composed mainly of neutral lipids, which originate
from the membrane-coating granules in the stratum
granulosum [3]. These granules are 0.15 0.5 Am by
0.3 0.7 Am and are composed of stacks of 7.5 8 nm
disks thick in a triple-layered membrane [3]. They fuse
with the plasma membrane and release their contents
into the intercellular matrix as the cells in the stratum
granulosum progress into the SC. Elias [4] has proposed a heterogeneous two-compartment model of the
SC which attributes a special role to the intercellular
lipids in the regulation of the SC barrier function.
Three possible pathways, transappendageal, transcellular, and intercellular have been suggested for
molecular transport through the SC [5]. The transappendageal pathway is primarily through hair follicles. However, the transappendageal skin transport
in humans is limited by the small surface area available. The fractional area of hair follicles relative to the
skin area is 10! 2 10! 5 [6]. The transcellular pathway requires the substrates to travel through the
corneocytes while the intercellular pathway is via
the extracellular matrix between the corneocytes.
For intercellular skin transport, hydrophilic substrates
are rate limited by the lipid environment of the
intercellular matrix of the SC [7]. On the other hand,
lipophilic substrates partition into the intercellular
lipids of the SC. However, the rate-limiting step is
the partition into the epidermis, which is practically an
aqueous environment. Molecular transport through
the skin has been described by a solubility diffusion
model [8] and a transfer free energy model [9]. Skin

penetration depends on anatomical site, age, sex, skin

care, hydration, and temperature as well as contact
with organic solvents or surfactants [10]. In addition,
the molecular weight (MW) of the substrate affects
percutaneous absorption. The diffusion through the
SC follows the expression D~(MW)! b where the
value of b varies between 0.3 and 0.6 [11].
Depending on the substrate, there may be several
orders of magnitude difference in the rate of transport
through the SC [12]. Nevertheless, even the most
rapidly penetrating drugs actually diffuse very slowly
through the SC [5]. Once a substrate has diffused into
the epidermis and dermis it can enter the vasculature,
thus producing a systemic effect. For transdermal
delivery to be effective, the drugs have to enter into
the viable skin in sufficient quantities to produce a
therapeutic effect. There are a number of ways, which
can be utilized to enhance transdermal delivery. For
example, the drug can be mixed with a formulation
that promotes the delivery of the drug through the SC
over a period of hours [13]. Occlusion has also been
used together with formulations to enhance skin
penetration [14]. However, the dependence of the
molecular penetration on hydration is unclear because
hydration changes several parameters at the same
time. For example, diffusivity and skin thickness
increase with water content while the partition coefficient decreases. In general, the amount of drug
absorbed through the skin increases with longer
contact time, larger contact area on the surface of
the skin, higher drug concentration in the formulation
and occlusion. However, high substrate concentration
can cause saturation of the transdermal absorption
pathways and extended exposure can increase the risk
of allergic contact skin sensitivity [15]. Furthermore,
these techniques usually require prolonged contact
and do not work for all substances.
Transdermal drug delivery has been the subject of
extensive research [16]. In addition to vehicle formulations and chemical enhancers [13,17], physical
methods such as the application of continuous electrical current (iontophoresis) [18,19], electrical pulses
(electroporation) [20,21] and ultrasound (phonophoresis) [22 24] have been used to facilitate the transport of a variety of molecules across the SC. Physical
methods have the advantage of decreased skin irritant/
allergic responses, as well as no interaction with the
drugs being delivered.

A.G. Doukas, N. Kollias / Advanced Drug Delivery Reviews 56 (2004) 559579

561

Pressure waves (high amplitude pressure transients) generated by lasers is, perhaps, one of the latest
platforms for drug delivery. A pressure wave (PW)
was first shown to permeabilize the cell plasma
membrane and allow macromolecules to diffuse
through it into the cytoplasm [25]. Pressure waves
have been used to permeabilize the SC and facilitate
the transport of macromolecules into the viable skin
[26]. They have also been shown to facilitate drug
delivery into microbial biofilms [27]. Last, we have
recently demonstrated that PW can permeabilize the
nuclear envelope and facilitate the delivery of macromolecules into the cell nucleus [28]. The many
diverse applications of pressure waves exemplify the
potential of this platform for drug delivery in many
different biological systems.
The applications of PW for drug delivery rest on
extensive studies of the interactions of laser-induced
pressure waves with cells [29 33] and tissue [34
39]. Shock waves generated by extracorporeal shock
wave lithotripters [40,41] and to a lesser extent
ultrasound [42] have also contributed to our understanding of the effects of waves on cells and tissues.

2. Generation and propagation of pressure waves

Pressure waves, stress waves and shock waves are
terms that have been used to describe high amplitude
pressure transients generated by laser [43] extracorporeal shockwave lithotripters [40], shock wave tubes
[44], and energetic material [45]. In addition, the term
photomechanical waves has often been used for lasergenerated pressure waves. Pressure waves should be
distinguished from ultrasound, which has been extensively used for transdermal and cytoplasmic molecular
delivery. Fig. 1 shows the waveforms of an ultrasound
wave and a PW. The amplitude of the ultrasound
oscillates equally between positive and negative pressure. The negative pressure (tensile component) is
responsible for the cavitation associated with lowfrequency ultrasound. On the other hand, the PW is
mostly a unipolar compression wave (positive pressure), which does not show a measurable tensile
component and thus exclude biological effects induced by cavitation [42]. Fig. 2 shows the bandwidth
of the PW generated by Fourier Transform. The
bandwidth depends on the rise time, decay and

Fig. 1. (A) Typical ultrasound waveform and (B) a typical PW used

in transdermal drug delivery and its characteristics, (PP) the peak
pressure, (RT) the rise time defined as the time from 10% to 90% of
the peak pressure, the duration (FWHM) defined as the full width at
half maximum and (D) the decay defined as the time from 90% to
10% of the peak pressure.

duration. The shorter the rise time the broader the

bandwidth will be.
It should be emphasized that the operating parameters (amplitude and duration) of the two types of
waves are very different. For example, the peak
pressure of the PW, used in our experiments, has been
between 300 and 1000 bar (1 bar = 105 Pa = 0.987
atm.) while the amplitude of the ultrasound is usually
between 1 and 5 bar. Furthermore, the duration of the
PW, depending on the application, has been between
100 ns and 10 As. On the other hand, typical applica-

562

A.G. Doukas, N. Kollias / Advanced Drug Delivery Reviews 56 (2004) 559579

Fig. 2. The bandwidth of the PW shown in Fig. 1B produced by

Fourier Transform. In this scale the bandwidth of an ultrasound
wave (e.g., 300 kHz) would be represented by the vertical line.

tions of ultrasound for transdermal delivery are of the

order of tens of minutes. So there are many orders of
magnitude difference both in the pressure amplitude
and duration. What may be more important is the rate
at which the pressure is applied onto the skin. The rise
time of a PW is between 10 and 200 ns which, for a
500 bar PW, produced a rate of pressure increase
between 50 " 109 and 2.5 " 109 bar s! 1, a rate of
increase of billion atmospheres per second. It is
reasonable to assume that the application of this kind
of physical force onto the skin can produce novel
effects.
The generation of PW by lasers was demonstrated
in 1964 [46], shortly after the invention of the Qswitched laser. The interactions of lasers with matter
that can generate pressure waves has been extensively
reviewed in the literature [47 50]. Pressure waves
can be generated by one of the following mechanisms:
optical breakdown, ablation, and rapid heating of an
absorbing medium (thermoelastic generation) [43].
These three modes of PW generation allow the
investigation of interactions of cells and tissue with
PW under a variety of conditions. It should be pointed
out that PW is only one of the phenomena under the
general category of photomechanical effects. Other
photomechanical effects include plasma formation,

cavitation, microstreaming and formation of jets.

The diversity of the phenomena involved during the
application of short pulsed lasers has hindered the
understanding of the PW effects and potential therapeutic uses until it was technologically possible to
separate and control these phenomena independently.
Ablation is a reliable method for generating PW
with consistent characteristics [51 53]. In ablation,
the laser radiation causes decomposition of the target
material into small fragments, which move away from
the surface of the target at supersonic speed [54].
Although the amount of material ejected is small, a
PW of high amplitude can be generated by the
imparted recoil momentum [55]. The characteristics
of the PW (peak pressure, rise time and duration)
depend on the laser parameters (wavelength, pulse
duration and fluence) and the optical and mechanical
properties of the target material. The efficiency of the
PW generation, conversion of light energy to the
mechanical energy of the PW, is given by the coupling
coefficient. The coupling coefficient is defined as the
total momentum transfer to the target during ablation
divided by the laser pulse energy. From the coupling
coefficient the peak pressure can be calculated. Eq. (1)
gives the peak pressure generated during ablation of
polymers and metals as a function of irradiance,
wavelength and pulse duration [52]:

P0 b

I 0:7
p 0:3
k s

where P0 is the peak pressure of the wave, b the

proportionality constant which depends on the material properties, I the laser irradiance, k the laser
wavelength and s the laser pulse duration. Eq. (1)
has been shown to hold over a wide range of laser
irradiance (3 MW cm! 2 70 TW cm! 2), wavelength
(248 nm 10.6 Am), pulse duration (500 ps 1.5 ms)
and pulse energy (100 mJ 10 kJ). During ablation,
most of the energy of the incident light is absorbed by
the plasma and only a small fraction of the irradiance
is converted into the mechanical energy of the PW.
However, by designing stratified targets and overlays
(confined ablation) the momentum transfer to the
target can be increased and thus create PW more
efficiently or of higher peak pressure [56]. The
presence of the overlay also changes the other char-

A.G. Doukas, N. Kollias / Advanced Drug Delivery Reviews 56 (2004) 559579

acteristics of the PW, such as the rise time, duration

and decay.
The PW rise time depends on the optical penetration depth of the target material, the dynamics of the
plasma, and the interactions of the plasma with the
surface of the target. There is no simple mathematical
formula, which can predict the rise time from the laser
parameters and properties of the target. Nevertheless,
PW with different rise times have been generated by
appropriate selection of laser wavelength and target
material. Fig. 3 shows five different waveforms produced by different combinations of laser wavelength,
target material, and confinement. The waveforms were
measured using a polyvinylidene fluoride (PVDF)
transducer. The rise time of the PW can be varied from

Fig. 3. Examples of PW waveforms generated by combination of

laser wavelengths, target material and confinement. Mode-locked
Nd:YAG (1064 nm) on aluminum foil (Al), ArF (193 nm) on black
polystyrene (PS), KrF (248 nm) on polyimide (PI), Q-switched ruby
(694 nm) on PS under direct ablation and under confined ablation
(Conf). The peak pressure of the waveforms has been normalized to
the same value for clarity.

563

5 ns (ablation of an aluminum foil by a mode-locked

Nd:YAG laser) to f 200 ns (ablation of a polystyrene
target by a Q-switched ruby laser under confinement).
In addition, the rise time can also be modified by taking
advantage of the steepening of the leading edge of the
PW that occurs naturally during non-linear propagation
of the PW in a medium.
From the point of view of hydrodynamics, pressure
waves, the type we have used for drug delivery, is
finite-amplitude waves. The difference from smallamplitude or infinitesimal-amplitude waves is that the
sound velocity (c) is not constant (independent of
pressure). The sound velocity is given by Eq. (2):
s
dP
c
2
dq
where P is the pressure and q is the density of the
material. For normal fluids, the curve of pressure
versus density is a concave upward (adiabatic compression) and the slope increases with increasing
compression. This can affect significantly the propagation of the PW. The rise time of a PW propagating
through a medium is altered by the linear and nonlinear propagation [47]. The linear attenuation, which
increases as a function of frequency, attenuates predominantly the high frequency components and
causes the rise time to increase. On the other hand,
in non-linear propagation the leading edge of the PW
becomes steeper as the PW propagates through the
medium. This is the result of the dependence of both
the sound and particle velocity (the bulk displacement
velocity) on pressure. The local velocity, which is the
sum of the sound and particle velocity, increases along
the leading edge of the PW which causes the leading
edge of the waveform to steepen that is the rise time to
decrease. The relative strength of the linear attenuation and non-linear coefficient of the medium as well
as the initial peak pressure, the initial rise time, and
the distance traveled in the medium will determine the
final value of the rise time. Thus, we can take
advantage of the non-linear propagation to produce
PW with continuously adjustable rise times. Fig. 4
shows the shortening of the rise time, which occurs
after propagation of a distance of 800 Am in water.
The rise time decreased from the original value of 100
ns, behind the target, to 60 ns at 800 Am. The nonlinear propagation of the PW has been recently

564

A.G. Doukas, N. Kollias / Advanced Drug Delivery Reviews 56 (2004) 559579

Fig. 4. The rise time of a PW emerging from the target and after
propagation of a distance of 800 Am in water. The rise time
decreased from the original value of 100 ns, behind the target, to
60 ns.

applied to generate shock waves in order to induce

permeabilization of the nuclear envelope [28]. The
permeabilization of the nuclear envelope required a
higher pressure gradient (higher peak pressure, shorter
rise time or both) than the permeabilization of the cell
plasma membrane.
Eventually, a PW becomes a shock wave. The
salient feature of a shock wave is a very fast rise
time, which for all practical purposes amounts to a
discontinuity in pressure, density, particle velocity
and internal energy [57,58]. In water, the rise time of
a shock wave is of the order of a few picoseconds,
corresponding to a shock front thickness of a few
nanometers [59]. The large pressure gradients and
the high translational velocity of the molecules
within the shock front account for the unique interactions of the shock waves with matter. The propagation distance (L) required for the formation of a
shock wave as well as the rise time can be determined from the theory of non-linear acoustics [47],
Eqs. (3) and (4):
L

lqc2
eP

qcm
eP

where l is the spatial width of the pressure transient

(temporal duration multiplied by the sound velocity),
q the density of the medium, c the sound velocity, e
the non-linear coefficient, P the peak pressure, s the
rise time and m the dissipative coefficient.
There are a number of different ways to produce
PW, such as extracorporeal shock wave lithotripters,
shock wave tubes as well as the use of energetic
materials. They all produce high amplitude PW. The
specific characteristics can vary over a large range of
values and depend on the design of the particular
device. Extracorporeal shock wave lithotripters and
shock tubes, in particular, have been used for drug
delivery. The former to permeabilize the cell membrane and facilitate the delivery of macromolecules
into the cytoplasm [60,61], the latter for both transdermal and cytoplasmic drug delivery [44,62,63].
Finally, the use of energetic materials could potentially be useful in disposable devices for transdermal drug
delivery.

3. Biological effects of pressure waves

The research on drug delivery with PW is grounded
on the extensive investigations of the biological effects
of PW carried out in the last four decades. How do
pressure waves interact with cells and tissue? Surprisingly, the mechanisms of these interactions are not well
known. The study of the effects of forces, whether
compression tension or shear, on cells has been the
subject of many investigations [64]. In the case of
pressure waves, however, the additional complication
is that the applied forces act on a very short time scale,
tens or hundreds of nanoseconds. Therefore, the
mechanisms of interactions of pressure waves with
cells and tissue are not expected to be the same. In
the past, most of the studies on the photomechanical
effects were phenomenological and focused on the
damage induced by pressure waves. Nevertheless,
they provide some background information of the
damage thresholds of cells and tissue. The use of
high power lasers in medicine over the last 20 years
has yielded a wealth of information on side effects,
collateral damage, potential hazards and safety
issues.
The first observations of lesions from exposure to
PW produced by high power lasers were reported in

A.G. Doukas, N. Kollias / Advanced Drug Delivery Reviews 56 (2004) 559579

the 1960s [65]. Of particular interest were observations that showed tissue injury in the brain and the
abdomen of mice located some distance from the
irradiated site. The injury was attributed to the pressure waves generated during the irradiation of tissue.
Many investigations were undertaken in the ensuing
years. The interpretation of the observations, however,
was difficult because in many cases tissue injury was
mediated by other mechanical effects, such as plasma,
cavitation and streaming produced during laser irradiation. Over the last decade, we have developed a
methodology for the study of the effects induced by
PW on cells and tissue. This methodology eliminates
problems associated with direct laser irradiation. The
basic idea is to generate the PW by irradiation of
appropriate targets and launch them into the cell
cultures or tissue. In this approach cells or tissue are
not exposed directly to laser radiation [26,29,31].
The most interesting finding of the studies on the
interactions of PW with biological systems is that
these interactions depend on the characteristics of the
PW. Traditionally, it has been thought that the interactions of PW with tissue were non-specific. We have
found that those interactions are specific and depend
on the PW parameters, such as peak pressure, rise
time or duration [30,44,66 68]. We have not fully
explored the extent of the specificity of the interactions of the PW with different biological systems. This
is clearly a very important issue since, perhaps for the
first time, PW can be used to target tissues, cells or
even subcellular sites. The main target of the PW
(though not necessarily the only one) appears to be the
cell plasma membrane. These studies have elucidated
some of the modes of interactions of PW with cells
and subcellular structures and have led to the development of methods for drug delivery. Interestingly,
both membrane permeabilization [66] and cell injury
depend on the rise time [30]. However, the pressure
threshold for cell injury appears to be higher than the
threshold for cell permeabilization, at least for the cell
lines that have been investigated [31].
Our conjecture is that the PW interact the strongest
with those cell structures that are of the same dimensions as the spatial length of the PW. For example,
PW of a short rise time are effective in permeabilizing
the cell membrane [66]. In this case, there are indications that the membrane permeabilization is mediated
by membrane proteins (aquaporins) which form a

565

water-filled channel and are present in most mammalian cells [69]. On the other hand, PW of long duration
generated can also permeabilize the cell membrane
[44]. The mechanisms of permeabilization in this case
are not known but since the membrane permeabilization correlates with the impulse of the PW it is
possible that cell deformation might be responsible
for the permeabilization of the cell membrane.

4. Experimental arrangement
The experimental device for transdermal delivery
is shown in Fig. 5. A flexible washer, f 1.5 mm thick
and f 7 mm inner diameter, was used as a reservoir
for the solution to be delivered through the SC. A
target made out of black polystyrene f 1 mm thick
was used to generate the PW by ablation. The target
was placed in contact with the solution, which also
acted as the acoustic coupling medium. The PW
propagated from the target to the solution and impinged on the surface of skin. A Q-switched ruby laser
(694 nm wavelength and f 28 ns pulse duration) was
used in the experiments. Pressure waves were generated by either direct or confined ablation. For confined ablation, a thin overlay made of transparent
plastic (f 1 mm thick) was bonded on top of the
polystyrene target. In confined ablation, the expansion
of the generated plasma is delayed by the overlay. The

Fig. 5. Schematic of the washer-target contraption. The laser

radiation was totally absorbed by the target and produced a single
PW. The PW propagated through drug solution, which also acted as
the acoustic coupling medium, impinged on the skin and permeabilized the SC. The molecules diffused into the viable epidermis under
the concentration gradient until the barrier function of the SC
recovered.

566

A.G. Doukas, N. Kollias / Advanced Drug Delivery Reviews 56 (2004) 559579

plasma maintains the applied pressure even after the

laser is switched off. This results in generation of PW
with higher peak pressure and longer duration, for a
given radiant exposure, than those generated by direct
ablation.
Peak pressures up to 1000 bar have been generated
by ablation of plastic targets in our lab. The PW were
measured using a piezoelectric transducer, with a 9Am thick PVDF film as the active element, and
recorded by a digital oscilloscope using a 1 MV
termination. The transducer was calibrated by measuring the signal generated by a known momentum
transfer. A small steel ball bearing was dropped on the
transducer and allowed to bounce. The impact force
was calculated from the conservation of momentum,
the mass of the ball bearing and the time between
bounces [53]. The temporal resolution depends on the
thickness of the active element. The 9-Am thickness of
the PVDF film corresponds to a temporal resolution of
f 5 ns. The resolution was validated by measuring
the rise time of a PW with a known rise time [53]. The
peak pressure on the skin ( PS) was calculated from
the measured peak pressure in the water ( PW) and the
known acoustic impedance of water (ZW = 1.48 " 106
kg m! 2 s! 1) and skin (ZS = 1.54 " 106 kg m! 2 s! 1)
using Eq. (5):
PS
2ZW

PW ZS ZW

Fig. 6 shows the sequence of steps for the application of a PW for transdermal drug delivery on the
forearm of a volunteer. (A) A rubber washer was
attached to the skin with grease. (B) The washer was
filled with the drug solution to be delivered into the
skin. (C) The target material, black polystyrene, was
placed on top of the washer in contact with the
solution. (D) The articulating arm of the laser was
positioned over the target and the laser fired. The laser
radiation was totally absorbed by the target and
produced a single PW. The PW propagated through
Fig. 6. (A) A rubber washer was attached to the skin with grease.
(B) The washer was filled with the drug solution to be delivered into
the skin. (C) The target material was placed on top of the washer in
contact with the solution. (D) The articulating arm of the laser was
positioned over the target and the laser fired once to generate a
single PW. (E) The target and the washer were removed and the skin
was wiped clean.

A.G. Doukas, N. Kollias / Advanced Drug Delivery Reviews 56 (2004) 559579

the solution, which also acted as the acoustic coupling

medium, impinged on the skin and permeabilized the
SC. The permeabilization of the SC was strictly due to
the PW. Molecules diffused into the viable skin under
the concentration gradient until the barrier function of
the SC was recovered. (E) The target and the washer
were removed and the skin was wiped clean. There
was no change in the appearance of the skin after the
application of a PW. The same procedure was also
followed in the animal studies.

5. Transdermal drug delivery

There are a number of advantages of transdermal
drug delivery with PW:
1. The PW is only applied for a very short time (100
ns 1 As). The PW does not transport the drug
through the SC. It only transiently permeabilizes
the SC. The delivery of the drug takes place by
diffusion under the concentration gradient.
2. The recovery of the barrier function can be easily
modulated by changing the characteristics of the
PW or using chemical enhancers, such as sodium
lauryl sulfate (SLS). This allows to control the
amount of the drug delivered into the viable skin.
3. The size of the probe that has been delivered into
the epidermis, to this date, is 100 nm latex
particles. This is, to the best of our knowledge,
the largest size probe that has ever been delivered
by any transdermal delivery method.
4. Pressure waves have been shown to transiently
permeabilize the plasma membrane as well as the
nuclear envelope of cells. Furthermore, different
PW parameters are required for each of these
applications. Therefore, it is conceivable to apply
one type of PW to permeabilize the SC for
transdermal delivery and follow with a second
PW of different characteristics for delivery into the
cytoplasm or even into the cell nucleus.
5. Pressure waves can be thought of as a generic
technology platform for drug delivery into many
different biological systems (skin, cells, microbial
biofilms).
A very useful probe for human transdermal measurements is y-aminolevulinic acid (ALA). ALA has

567

been approved by FDA and is currently used in

photodynamic therapy. ALA can be delivered by
iontophoresis and its pharmacokinetics for humans
as well as for a number of experimental animals are
known [70]. ALA is a small charged molecule and
therefore the rate of penetration is limited in normal
SC. It is the precursor of protoporphyrin IX (PpIX),
which is an intermediate in heme biosynthesis [71].
The synthesis of PpIX is the rate-limiting step in the
synthesis of heme and is regulated by the inhibition of
ALA synthase by the heme. However, application of
exogenous ALA enables the cells to bypass this ratelimiting step and produce excess amounts of PpIX
because the rate of PpIX production is faster than the
rate of conversion of PpIX to heme. Furthermore,
since PpIX is produced in the viable skin, the presence
of ALA in the SC does not interfere with the measurements of PpIX. The peak of PpIX fluorescence is at
634 nm (excitation 405 nm) while ALA does not
absorb or fluoresce at this wavelength. Therefore, the
transport of ALA through the SC can be followed by
monitoring the PpIX fluorescence. A fiber-based
spectrofluorometer can be used to measure the PpIX
fluorescence over time. Fig. 7 shows the fluorescence
emission spectrum of PpIX of a site on the forearm of
a volunteer exposed to a single PW in the presence of
ALA solution (5% w/v in water). The fluorescence
emission of a control site (treated in an identical
manner but without exposure to a PW) is also shown
for comparison.
The following is a summary of the results:
1. A single PW was sufficient to increase the
permeability of the SC and produce a strong
fluorescence signal from PpIX.
2. The amount of ALA transported across the SC increased with the ALA concentration (5 20% w/v).
3. The permeabilization of the SC was transient. The
barrier function of the SC always recovered.
4. The permeabilization of the SC depended on the
peak pressure. The onset of the permeabilization of
the SC was observed at f 350 bar and increased
with increasing pressure.
The observation of PpIX fluorescence from the
skin indicates that the epidermis was still viable after
the application of a PW. It has been shown previously
that the keratinocytes are a sensitive indicator of tissue

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A.G. Doukas, N. Kollias / Advanced Drug Delivery Reviews 56 (2004) 559579

Fig. 7. The fluorescence emission spectrum obtained from human

skin (the inner volar forearm) exposed to a single PW in the
presence of ALA. The fluorescence emission of PpIX peaks at 634
nm (excitation 405 nm). The fluorescence emission spectra were
recorded before the application of PW baseline (BL) as well at 3 and
5 h post-treatment (3PW and 5PW). The fluorescence emission
spectra of a control site, a site treated in an identical manner except
that no PW was applied, at 3 and 5 h (3C and 5C) are also shown for
comparison. The 5 h control overlaps with the baseline.

injury caused by PW [37]. However, transmission

electron microscopy of biopsies taken either immediately [72] or 24 h after the application of a PW [67]
showed that there was no observable injury to the
keratinocytes. Therefore, it appears again that the
pressure threshold for the permeabilization of the SC
is lower than that for injury of the viable skin.
Interestingly, when three PW were applied on the
skin the level of PpIX fluorescence was lower than
that of the single PW (unpublished observations).
Since the permeabilization of the SC could not be
lower with three PW than with one, the conversion of
ALA to PpIX had to be lower. This implies that
multiple PW might have caused some cell injury,
though this injury could not be seen in biopsies with
transmission electron microscopy. The conversion of
ALA to PpIX may prove to be a simple assay of cell
injury.
Fig. 8 shows the fluorescence intensity of PpIX at
634 nm from a volunteer as a function of time after the
application of a single PW, for three different peak

pressures. It should be kept in mind that the fluorescence intensity of PpIX reflects the kinetics of the
conversion of ALA to heme. The fluorescence intensity
of PpIX does not yield the instantaneous production of
PpIX but the accumulation of PpIX over time minus the
conversion of PpIX to heme. It is also possible that
some of the ALA that entered the viable skin was taken
up by the vasculature and removed from the epidermis.
The peak of the fluorescence intensity versus time
shifts toward the longer times with increased accumulation of PpIX. This is not surprising because as the
accumulation of PpIX increases it may take a longer
time to clear it from the skin.
The permeabilization of the SC and subsequent
delivery of ALA depended on the peak pressure. The
pressure threshold for the SC permeabilization was
observed at approximately 350 bar and increased
dramatically at the highest peak pressure. It should
be pointed out that this pressure threshold value is for
a particular site (inner volar forearm) and volunteer. In
fact, the threshold pressure varied among sites, indi-

Fig. 8. The fluorescence intensity of PpIX at 634 nm as a function

of time following the application of a single PW. The three sites on
the forearm were exposed to a PW of different peak pressure
(diamond) 390 bar, (squares) 440 bar, and (circles) 500 bar.

A.G. Doukas, N. Kollias / Advanced Drug Delivery Reviews 56 (2004) 559579

viduals and skin conditions. In addition, the pressure

threshold for SC permeabilization depends on the
other characteristics of the PW. For example, it
appears that the pressure threshold for the permeabilization of the SC is lower for long duration PW [62].
The application of PW did not cause any pain or
discomfort [67]. Pressure waves of 300 ns duration
did not produce any sensation whatsoever. On the
other hand, PW of 1 As duration generated a sensation
but not pain. With respect to skin changes after the
application of a PW, the 300 ns PW did not produce
any changes of the skin, while the 1 As PW produced
a minor erethyma, which disappeared within 10 15
min. One interesting observation was that the amount
of ALA delivered through the SC correlated with the
transepidermal water loss (TEWL). The higher the
TEWL the more ALA was delivered into the viable
skin (unpublished observations). Higher rates of
TEWL may indicate higher levels of hydration, which
would be consistent with our current understanding of
the mechanism of permeabilization of the SC.
Fig. 9 shows the results of transdermal delivery of
40-kDa rhodamine-B dextran with a single PW in a rat
animal model. The reservoir on the rat skin was filled
with an aqueous solution of rhodamine-B dextran
(500 AM) and a single PW (f 730 bar peak pressure,
f 490 ns pulse duration FWHM, and f 190 ns rise
time) was applied. The solution remained in contact
with the skin for 5 min and then was removed. Full
thickness skin biopsies were obtained approximately 1
h post-treatment, embedded in OCT and frozen in dry
ice. Control sites were treated in the same way except
that no PW was applied. The fluorescence image from
a frozen biopsy and the corresponding transmission
image of a site exposed to a single PW are shown in
Fig. 9A, B, respectively [68]. There is a broad band of
fluorescence from the rhodamine-B dextran that
extends from the SC to a depth of f 300 Am into
the dermis. The thickness of the SC, epidermis and
dermis in the rat are 9 15, 8 18 Am and f 1 mm,
respectively. For comparison, the thickness for the
human skin is 10 15 Am for the SC, 50 100 Am for
the epidermis and 2 3 mm for the dermis. Fig. 9C, D
show the fluorescence and transmission images from
the frozen biopsy of a control site, respectively. The
fluorescence of the control site originates in the SC.
The fluorescence images of the sites exposed to a
PW show that the probe was distributed uniformly

569

into the epidermis and dermis. This implies that the

permeabilization of the SC was uniform rather than
limited to a few sites. There are a number of dark
areas (low concentration of the fluorescent probe) in
the fluorescence images. Comparison with the transmission micrographs show that they coincide with
hair follicles. The reduced delivery in the hair follicles
is probably due to the difference of the acoustic
impedance between the dermis and the hair follicle
cavity. In addition to the 40-kDa dextran molecules,
fluorescent latex particles 20 and 100 nm in diameter
have been transported through the SC with a PW
[26,73]. The transdermal delivery of 100-nm particles
is, to the best of our knowledge, the largest size probe
that has ever been delivered by any transdermal
delivery method. Thus, PW can facilitate the delivery
into the epidermis of very large molecules such as
proteins and DNA plasmids. In addition, novel probes
such as quantum dots could be delivered into the
epidermis and dermis. Another potential application is
the transdermal delivery of encapsulated drugs. Drugs
can be incorporated in time-release microspheres and
delivered over an extended period of time.
As we have mentioned earlier, the biological
effects of PW depend on their characteristics. In
transdermal delivery, the permeabilization of the
SC depends on the duration of the PW. Fig. 10
shows a comparison of the penetration depth of the
40-kDa rhodamin-B dextran in a rat by PW of
different duration [68]. The two types of PW used
in these experiments had different temporal characteristics shown in Fig. 11. The fluorescence photomicrograph shows the transdermal delivery with the
long duration (490 ns FWHM) PW. The transdermal
delivery of the short duration (110 ns FWHM) PW is
shown in the insert. The fluorescence photomicrograph and the insert are shown under the same
magnification. There is a dramatic difference in the
penetration depth of the 40-kDa dextran produced by
the two types of PW. The penetration of the dextran,
when the long duration PW was used, reached to a
depth of f 300 Am into the dermis. In comparison,
the penetration depth, when the short duration PW
was applied, was only f 50 Am.
It is of interest to compare the permeabilization
pattern produced by the PW with that of ultrasound. Mitragotri and coworkers [74] have shown
that as the frequency of the ultrasound increased

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A.G. Doukas, N. Kollias / Advanced Drug Delivery Reviews 56 (2004) 559579

Fig. 9. The fluorescence photomicrographs from (A) the biopsy of the rat skin exposed to a PW and (C) a control site. An aqueous solutions of
rhodamine-B dextran (40-kDa) at 500 AM concentration was used for transdermal delivery. The corresponding transmission photomicrographs
from (B) the site exposed to a PW and (D) the control site. Scale bar 200 Am.

from 19.6 to 58.9 kHz, the pattern of permeabilization of the SC changed from a single spot to
multiple foci, thus, presenting a more uniform
pattern. Furthermore, the permeabilization threshold

Fig. 10. Transdermal delivery of the 40 kDa rhodamin-B dextran

with PW of different characteristics. The fluorescence photomicrograph shows the transdermal delivery with the long duration (490 ns
FWHM) PW. The transdermal delivery of the short duration (110 ns
FWHM) PW is shown in the insert. Scale bar 200 Am.

Fig. 11. (A) A long duration PW generated by confined ablation.

The pulse duration is f 490 ns FWHM and (B) a PW generated by
direct (unconfined) ablation. The pulse duration is f 110 ns
FWHM. The two waveforms have been normalized to the same
peak pressure for clarity. The actual peak pressures are (A) 730 bar;
(B) 600 bar.

A.G. Doukas, N. Kollias / Advanced Drug Delivery Reviews 56 (2004) 559579

increased with frequency. These observations are

consistent with the fact that PW with a frequency
bandwidth, which covers the range from kHz to
tens of MHz, can produce a uniform permeabilization of the SC and subsequent uniform delivery
into the epidermis and dermis. It appears, therefore,
that the two technologies of transdermal delivery,
namely ultrasound and PW, may converge at high
frequencies.
Transdermal drug delivery with PW has been
reported by Ogura et al. [75]. The photosensitizer,
Photofrin II, was delivered by a PW (520 bar peak
pressure, 1 As duration) in a rat animal model. What is
worth mentioning is that when the skin was heated
prior to the application of the PW to a surface
temperature of 47 jC the penetration depth increased
from 75 to 100 Am. This was probably caused by the
increased fluidity of the lipids at the elevated temperature. This observation is consistent with the view
that the PW target the weaker lipid domains rather
than the corneocytes which are protected by the
cornified envelope and the covalently bound lipid
envelope.

571

spectra of the exposed and control sites were collected

while the animal (rat) was alive under anesthesia.
Fluorescence emission spectra (excitation 488 nm,
emission 498 600 nm) were obtained using a fiberbased spectrofluorimeter. Fluorescence emission spectroscopy allows the investigation of transdermal delivery quickly and non-invasively. The fluorescence
intensity depends on the concentration of the molecules in the tissue and the scattering properties of the
tissue. However, because all experiments were carried
out in adjacent sites on the dorsal side of the rat, the
optical properties of the skin sites were expected to be
comparable. The experimental procedure for measuring the recovery of the barrier function of the SC was
to apply the PW with water or SLS solution (2% w/v)
in the reservoir. Subsequently, the contents of the
reservoir were removed within 1 min and the reservoir
was filled, at different time points, with an aqueous
solution of the 40-kDa rhodamine-B dextran. The
presence or the absence of rhodamine-B dextran in
the epidermis at the particular time point indicated

6. The synergy of pressure waves and sodium

lauryl sulfate
The permeabilization of the SC depends on the PW
parameters. Both the PW peak pressure as well as the
duration can modulate the efficiency of the SC permeabilization. In addition, molecular transport through
the SC increases dramatically when SLS, an anionic
surfactant, is administered together with a PW [76].
Therefore, the use of SLS may have the same effect as
higher peak pressure or longer duration. The use of
SLS and surfactants, in general, allow greater flexibility in the choice of parameters for the optimization of
drug delivery which can result in simpler PW generation schemes and reduced collateral damage. The use
of SLS has been shown to enhance drug delivery in
phonophoresis as well [77].
The use of SLS delayed the recovery of the SC
barrier from < 2 min to >30 min [26,76]. This increased substantially the amount of dextran that was
delivered into the epidermis and dermis. The presence
of the dextran in the skin was measured by fluorescence emission spectroscopy. Fluorescence emission

Fig. 12. The recovery of the SC barrier with ( + SLS) and without
( ! SLS) sodium lauryl sulfate. The SC recovery was measured by
monitoring the fluorescence intensity at 596 nm (excitation 568 nm).
The fluorescence intensity was measured after tape-stripping to
reduce the fluorescence of dextran in the SC. The fluorescence of the
skin without dextran (baseline) was also subtracted. The fluorescence
intensity (average F S.D.) at time points of 2, 30 and 60 min postexposure are shown. The measurements of the recovery of the SC
without the use of SLS are shown for comparison. For the time point 0
min, the PW was applied with the reservoir filled with an aqueous
solution of dextran. For the time points 2, 10, 15, and 30 min postexposure, the PW was applied with the reservoir filled with water.

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A.G. Doukas, N. Kollias / Advanced Drug Delivery Reviews 56 (2004) 559579

whether the SC was still permeable or its barrier

function had recovered. Fig. 12 shows the fluorescence
intensity at 596 nm (the peak fluorescence intensity of
rhodamine-B dextran) at different time points posttreatment with and without SLS.
The SC recovery as measured in these experiments
was the recovery time that corresponded to the particular probe used. In the present case, the 40 kDa dextran
with a diameter of approximately 9 nm. This recovery
time is not the same as the absolute recovery time of
the barrier function of the SC. In fact, TEWL measurements gave a recovery time of f 15 min when water
was used as the coupling medium (unpublished observations). This contrasts to < 2 min recovery time for
the 40 kDa dextran. This apparent discrepancy is not
surprising. If the PW creates transient channels in the
SC, as we hypothesize, the transport of molecules

through the SC will continue until the size of the

channels becomes smaller than the size of the molecules. Therefore, large molecules will be blocked from
going through the SC earlier in the recovery process
than small molecules.
The fluorescence images from the frozen biopsies
(Fig. 13) are shown in pseudocolor intensity scale.
The fluorescence intensity is a measure of the
concentration of rhodamine-B dextran in the epidermis and dermis. The use of the SLS in combination
with the PW increased substantially both the amount
of dextran in the viable skin and the penetration
depth. The use of SLS also increased the concentration of the dextran in the SC as shown in the control.
Fig. 14 shows the fluorescence intensity profile of
the 40-kDa rhodamine-B dextran as a function of the
penetration depth for transdermal delivery with and

Fig. 13. The fluorescence images obtained from frozen biopsies of (A) a site exposed to a single PW and (B) a control site. SLS was used in both
sites. The fluorescence images were obtained under identical conditions but without the use of SLS from frozen biopsies of (C) a site exposed to
a PW and (D) a control site. The PW used in both experiments were identical. The images are shown in pseudocolor intensity scale. The
fluorescence intensity increases from violet (lowest intensity) to red (highest intensity). Scale bar 200 Am.

A.G. Doukas, N. Kollias / Advanced Drug Delivery Reviews 56 (2004) 559579

573

(Fig. 15). The lacunae have been defined as electron

lucent areas embedded within the lipid bilayers spanning the SC extracellular domains, and considered as
the putative pores [78]. These domains were not
present at every level, i.e. between every corneocyte,
as normal bilayers could be seen in the extracellular
spaces of corneocytes that were immediately below.
However, it should be kept in mind that the lacunae
seen in electron micrographs are in essence cross
sections of the three dimensional trabecular network
which may form a continuous, permeable lacunar
system. No ultrastructural changes were seen in the
morphology of individual corneocytes. When SLS was
used as the coupling medium to enhance transdermal
delivery the expansion of the lacunae system was
significantly larger. Fig. 16 shows the low magnificaFig. 14. The fluorescence intensity profile of the 40-kDa rhodamineB dextran as a function of the penetration depth for transdermal
delivery with or without SLS. The fluorescence intensity was
measured along the lines shown in Fig. 12A, C. The intensity for
each profile was normalized to its maximum value.

without SLS. The fluorescence intensity was measured along the lines shown in Fig. 12A, C. The
intensity for each profile was normalized to its
maximum value.

7. The mechanism of the permeabilization of the

stratum corneum
Transdermal delivery can occur whether the molecules are present during the application of the PW or
introduced after the PW [67]. Given the short duration
of the PW, a few microseconds at the most, the effect of
the PW is probably limited to the permeabilization of
the SC. The diffusion of the drug occurs under the
concentration gradient through the channels produced
by the PW. The barrier function of the SC always
recovers.
In a series of in vivo experiments, sites on the inner
volar forearm of volunteers were exposed to a single
PW with water as the acoustic coupling medium [72].
Skin biopsies were obtained immediately after the
experiments and fixed in Karnovskys fixative for 1
h at room temperature. The exposed sites, post-fixed
with RuO4, showed many highly expanded SC extracellular domains near continuous lacunar domains

Fig. 15. High magnification electron micrograph of the SC (A) from

a control site and (B) exposed to a single PW with water as the
coupling medium. The expanded lacunar domains within the
intercellular lamellae can be seen.

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A.G. Doukas, N. Kollias / Advanced Drug Delivery Reviews 56 (2004) 559579

Fig. 16. Low magnification electron microscopy of the SC stratum

granulosum junction (A) with water as the coupling medium and
(B) with SLS as the coupling medium. The lacunae system of the
site where SLS was used is noticeably larger.

tion electron microscopy of the SC stratum granulosum

(SG) junction with water and SLS as the coupling
medium, respectively. The lacunar system of the site
where SLS was used was noticeably larger.
The expansion of the lacunar domains could possibly create transient channels, which enable drug
delivery through the SC and into the epidermis and
dermis. We hypothesize that under the action of a PW
the lacunar system forms a continuous pathway that
allows the passive diffusion of the drug under the
concentration gradient. The actual physical mechanism is not known. Our conjecture is that the free
water within the SC [79] is involved in the permeabilization process. Water can be considered incompressible in the time scale of the duration of the PW. The

free water has to go somewhere. It is possible that

under the high pressure gradient generated by the PW,
the free water is forced in the constricted domains of
the lacunar system expanding them and thus, forming
a continuous pathway.
As it evolved, the mammalian SC is designed to
function as a barrier in diverse and specialized
environments (low and high humidity, extremes of
temperature, UV radiation and other physical factors), while functioning as a sensory transducer as
well. As a composite biopolymer of proteins and
lipids, arranged in a brick and mortar organization, the corneocytes provide the scaffolding for the
waterproofing lipid bilayers. Physical forces, such as
PW, ultrasound and electric fields, target the weaker
lipid domains rather than the tough corneocytes
protected by the cornified envelope and the covalently bound lipid envelope. The recent observations
by Ogura et al. [75] that the combination of heating
the skin and PW enhances transdermal delivery is
consistent with this view. Again, within the lipid
domains, it is the hydrophilic regions such as the
lacunae that contain water that are susceptible to
most physical and chemical agents used for permeability enhancement.
Surprisingly, we have been unable to permeabilize
the SC ex vivo, although the same PW would permeabilize the SC in vivo. It should be pointed out that
low-frequency ultrasound has been applied successfully to cadaver skin for transdermal drug delivery
[24]. However, ultrasound may interact with the SC
differently than the PW. Low-frequency ultrasound
works predominantly through cavitation induced by
the tensile component. Confocal micrographs show
significant bleaching of fluorescein-loaded SC after
ultrasound exposure [80]. The bleaching was attributed to the oxidation of fluorescein by cavitation-generated free radicals.
Routine electron microscopy (OsO4 post-fixed) did
not reveal any noticeable differences between the
control sites and the PW exposed sites. The nucleated
epidermis as well as the dermis maintained their
typical ultrastructural features with no indication of
damage either in the extracellular matrix or the
cellular components [72]. In addition, transmission
electron microscopy of human biopsies taken 24
h following the exposure of a PW showed no damage
to the subcellular organelles [67].

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575

8. Examples of transdermal drug delivery

8.1. Delivery of allergens
Pressure waves can be applied for rapid delivery
of allergens and thus, make it possible to differentiate irritant from allergic contact dermatitis [81].
Presently, the suspect allergen is applied at sub-irritant
concentrations to the skin under occlusion (Finn
chamber) for a period of up to 48 h to maximize
penetration [82]. Once the patch is removed, the site is
clinically examined for morphologic evidence of an
eczematous response. If the subject develops such a
response at a concentration below the irritant threshold
concentration, the eczematous lesion is considered to
be an allergic response to the tested substance. Pressure waves allow the rapid transdermal delivery of
allergens and thus, improve the optimal penetration of
the allergen across the SC. This has the potential to
reduce the exposure time for the clinical manifestation
of the challenge and improve the accuracy of the
procedure.
The allergic skin reaction using PW delivery was
compared to 5 min and 21 h occlusion in a
sensitized hairless albino guinea pig model. The
pigs were sensitized by intradermal injection of
(0.01%) dinitrochlorobenzene and topical administration (0.1%, 1 week later) of the hapten. One
month later, testing for the allergic response was
performed by the administration of 10 Al of 0.1%
dinitrochlorobenzene with a PW. The picture of the
back of a pig (Fig. 17) shows two skin sites treated
under occlusion for 21 h and 5 min using the Finn
chamber, respectively. In addition, a single PW was
applied to one site with water as the coupling
medium followed by the application of the allergen
for 5 min. The skin site treated with the Finn
chamber under occlusion for 21 h showed an
erythematous and edematous skin reaction, which
in some cases resulted in skin maceration and
necrosis. These reactions always extended beyond
the contact site of the skin with the allergen. On the
other hand, skin sites treated with a PW showed a
pink, well demarcated erythematous area confined
to the beam diameter at 24 and 48 h after delivery.
The control sites, exposed to the allergen under
occlusion for 5 min, showed no clinically perceptible reaction.

Fig. 17. The picture of the back of a guinea pig treated with the
allergen dinitrochlorobenzene with (A) the Finn chamber under
occlusion for 21 h, (B) a single PW with water as the coupling
medium followed by the application of the allergen for 5 min and
(C) the Finn chamber under occlusion for 5 min as a control.

8.2. Systemic delivery of insulin

Pressure waves can also facilitate the transdermal
delivery of drugs for systemic treatment [83]. Insulin
was used as the probe for systemic delivery because
transport through the SC can be easily monitored by
measuring the glucose level in the blood. The animal
model was the streptozotocin diabetic rat. A two-step
procedure was used in order to increase the amount of
insulin delivered into the viable skin [83]. For the first
step, the reservoir was filled with 2% w/v aqueous
solution of SLS. The SLS was allowed to remain in
contact with the skin for 2 min. This step was intended
to enhance the permeabilization of the SC. For the
second step, the SLS solution was removed and the
reservoirs was filled with a solution of porcine insulin
400 U ml! 1 adjusted to pH 4. The second target was
driven by the laser pulse into the reservoir like the
plunger of a syringe. Therefore, the first laser pulse in
this procedure produced a PW, which permeabilized
the SC while the second laser pulse drove the target
into the reservoir by exerting a hydrodynamic pulse
on the insulin solution. Fig. 18 shows the glucose
level of three diabetic rats over time after the proce-

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A.G. Doukas, N. Kollias / Advanced Drug Delivery Reviews 56 (2004) 559579

skin, we can estimate that between 0.3 and 0.9 Al of

insulin solution was transported through the SC. This
corresponds to an average value of skin permeability
between 4 " 10! 4 and 1.2 " 10! 3 cm h! 1.
The application of the PW did not affect the activity
of insulin. In addition, in experiments where DNA
solutions were exposed to PW no strand breaks were
observed (unpublished observations). This is not surprising, a review of the literature shows that the
pressure required to have any effect on molecules or
induce any chemistry is two orders of magnitude higher
than that used in our experiments [84 86]. Furthermore, in those particular cases the waves were truly
shock waves with rise times of the order of 10 100 ps.
That means that the pressure gradients in our experiments were five to six orders of magnitude lower than
the pressure gradients that are required to produce
chemical reactions.

9. Conclusions
Fig. 18. Blood glucose kinetics following PW delivery of insulin in
diabetic rats. Shown for comparison is the blood glucose kinetics
following intramuscular injection of insulin (0.1 and 0.3 U).

dure. The blood glucose of the diabetic rat dropped

from >350 to < 100 mg dl! 1 or f 80% of the initial
glucose level. Overall, the blood glucose remained
within the normal range for f 3 h. These experiments
suggest that the amount of a drug that can be delivered
through the SC can reach therapeutic levels. Comparison of glucose kinetics after the application of PW
with the kinetics of intramuscular injection of insulin
indicated that the total amount of insulin delivered
through the SC was between 0.1 and 0.3 U [83]. From
the insulin concentration, the skin area treated, and the
time the insulin solution remained in contact with the

A PW can effectively deliver drugs through the SC,

the cell plasma membrane as well as into microbial
biofilms. Furthermore, the PW parameters required for
efficient drug delivery are different for different biological systems. In the case of transdermal drug delivery, the permeabilization of the SC is transient and its
barrier function always recovers. A PW can facilitate
the delivery of macromolecules, the size of proteins and
DNA plasmids, in the epidermis and deep into the
dermis. Furthermore, the drug delivery can be of
sufficient quantity to produce systemic treatment. The
mechanism of permeabilization is probably caused by
the disruption of the hydrophilic domains of the SC.
Although the PW can be characterized as broadband pulsed ultrasound, we have tended to retain the

Fig. 19. The design concept of a disposable transdermal patch based on the use of energetic material. (A) The energetic material provides the
energy for the generation of the PW, (B) once the SC is permeabilized the drug can diffuse into the epidermis and dermis.

A.G. Doukas, N. Kollias / Advanced Drug Delivery Reviews 56 (2004) 559579

term pressure wave because its characteristics are so

different from the ultrasound that has been traditionally used in phonophoresis. Furthermore, it is highly
probable that the interactions of PW with tissue, cells
and subcellular structures are fundamentally different
than those of ultrasound.
The laser has been the preferred method of generation of PW in our work. The laser has proven a
unique tool for the study and development of methods
of drug delivery. However, the laser itself is not a
necessary component of drug delivery systems. In fact,
our current concept for transdermal drug delivery is
based on the use of energetic material, which can
produce efficiently high pressure transients with small
amounts of energetic material [45]. Fig. 19 shows the
design concept of a disposable transdermal patch
based on the use of energetic material. The patch
roughly the size of a bandage contains the energetic
material and the drug to be delivered through the SC.
The energetic material provides the energy for the
generation of the PW. Once the SC is permeabilized
the drug can diffuse into the epidermis and dermis.
This scheme of delivery avoids the substantial cost of
the laser system. Furthermore, makes possible a delivery device, which could be appropriate for home use.

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Acknowledgements
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The work on drug delivery at the Wellman

Laboratories of Photomedicine was supported by the
DoD Medical Free Electron Program under contracts
N00014-94-1-0927 and F4 9620-01-1-0014.

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