title: The Effect and Mechanism of Transdermal Penetration Enhancement of Fu's Cupping Therapy: New Physical Penetration Technology for Transdermal Administration with Traditional Chinese Medicine (TCM) Characteristics.
abstract: BACKGROUND
  In this paper, a new type of physical penetration technology for transdermal administration with traditional Chinese medicine (TCM) characteristics is presented. Fu's cupping therapy (FCT), was established and studied using in vitro and in vivo experiments and the penetration effect and mechanism of FCT physical penetration technology was preliminarily discussed.
  
  
  METHODS
  With 1-(4-chlorobenzoyl)-5-methoxy-2-methylindole-3-ylacetic acid (indomethacin, IM) as a model drug, the establishment of high, medium, and low references was completed for the chemical permeation system via in vitro transdermal tests. Furthermore, using chemical penetration enhancers (CPEs) and iontophoresis as references, the percutaneous penetration effect of FCT for IM patches was evaluated using seven species of in vitro diffusion kinetics models and in vitro drug distribution; the IM quantitative analysis method in vivo was established using ultra-performance liquid chromatography-tandem mass spectrometry technology (UPLC-MS/MS), and pharmacokinetic parameters: area under the zero and first moment curves from 0 to last time t (AUC0-t, AUMC0-t), area under the zero and first moment curves from 0 to infinity (AUC0-∞, AUMC0-∞), maximum plasma concentration (Cmax) and mean residence time (MRT), were used as indicators to evaluate the percutaneous penetration effect of FCT in vivo. Additionally, we used the 3Kfactorial design to study the joint synergistic penetration effect on FCT and chemical penetration enhancers. Through scanning electron microscopy (SEM) and transmission electron microscope (TEM) imaging, micro- and ultrastructural changes on the surface of the stratum corneum (SC) were observed to explore the FCT penetration mechanism.
  
  
  RESULTS
  In vitro and in vivo skin permeation experiments revealed that both the total cumulative percutaneous amount and in vivo percutaneous absorption amount of IM using FCT were greater than the amount using CPEs and iontophoresis. Firstly, compared with the control group, the indomethacin skin percutaneous rate of the FCT low-intensity group (FCTL) was 35.52%, and the enhancement ratio (ER) at 9 h was 1.76X, roughly equivalent to the penetration enhancing effect of the CPEs and iontophoresis. Secondly, the indomethacin percutaneous ratio of the FCT middle-intensity group (FCTM) and FCT high-intensity group (FCTH) were 47.36% and 54.58%, respectively, while the ERs at 9 h were 3.58X and 8.39X, respectively. Thirdly, pharmacokinetic data showed that in vivo indomethacin percutaneous absorption of the FCT was much higher than that of the control, that of the FCTM was slightly higher than that of the CPE, and that of the FCTM group was significantly higher than all others. Meanwhile, variance analysis indicated that the combination of the FCT penetration enhancement method and the CPE method had beneficial effects in enhancing skin penetration: the significance level of the CPE method was 0.0004, which was lower than 0.001, meaning the difference was markedly significant; the significance level of the FCT was also below 0.0001 and its difference markedly significant. The significance level of factor interaction A × B was lower than 0.0001, indicating that the difference in synergism was markedly significant. Moreover, SEM and TEM images showed that the SC surfaces of Sprague-Dawley rats treated with FCT were damaged, and it was difficult to observe the complete surface structure, with SC pores growing larger and its special "brick structure" becoming looser. This indicated that the barrier function of the skin was broken, thus revealing a potentially major route of skin penetration.
  
  
  CONCLUSIONS
  FCT, as a new form of transdermal penetration technology, has significant penetration effects with TCM characteristics and is of high clinical value. It is worth promoting its development.
authors.affiliation: School of Pharmacy, Guiyang College of Traditional Chinese Medicine, No. 50 Shi Dong Road, Guiyang 550002, China. xwjginseng@126.com.
authors.forename: Wei-Jie
authors.initials: WJ
authors.lastname: Xie
authors.affiliation: School of Pharmacy, Guiyang College of Traditional Chinese Medicine, No. 50 Shi Dong Road, Guiyang 550002, China. zgygpg@126.com.
authors.forename: Yong-Ping
authors.initials: YP
authors.lastname: Zhang
authors.affiliation: School of Pharmacy, Guiyang College of Traditional Chinese Medicine, No. 50 Shi Dong Road, Guiyang 550002, China. twt8489@126.com.
authors.forename: Jian
authors.initials: J
authors.lastname: Xu
authors.affiliation: Institute of Medicinal Plant Development, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100193, China. ginseng123@163.com.
authors.forename: Xiao-Bo
authors.initials: XB
authors.lastname: Sun
authors.affiliation: School of Pharmacy, Guiyang College of Traditional Chinese Medicine, No. 50 Shi Dong Road, Guiyang 550002, China. yff19771128@126.com.
authors.forename: Fang-Fang
authors.initials: FF
authors.lastname: Yang
mesh_terms: D000279:Administration, Cutaneous; D000818:Animals; D007213:Indomethacin / Q000008:administration & dosage* / Q000493:pharmacokinetics; D008297:Male; D008516:Medicine, Chinese Traditional / Q000295:instrumentation*; D051381:Rats; D017207:Rats, Sprague-Dawley; D012867:Skin / Q000737:chemistry*; D012869:Skin Absorption; D057968:Transdermal Patch
chemical_list: D007213:Indomethacin
keywords: Fu’s cupping therapy; mechanism; pharmacokinetics; scanning electron microscopy (SEM); stratum corneum; transdermal physical penetration technology; transmission electron microscope (TEM)