Double Blind, Single-Center, Randomized, Within Subject Placebo, Phase I Study Evaluating the Effects of Novel Topical Gel in Prevention of Hypertrophic Scar Formation
Phase: PHASE1
Conditions: Hypertrophic Scar
Sponsor: Mayo Clinic

 
 
Double Blind, Single-Center, Randomized, 
Within-Subject Placebo, Phase I Study 
Evaluating the Effects of Novel Topical Gel in 
Prevention of Hypertrophic Scar Formation 
 
NCT03403621 
 
October 25, 2019 

Topical Pentamidine for Hypertrophic Scarring 
 
Version 7.0 
 
 
Revised July 5, 2018 
Page 1 of 40 
Alexander Meves, MD 
 
CONFIDENTIAL 
 
Double Blind, Single-Center, Randomized, Within-Subject Placebo,  
Phase I Study Evaluating the Effects of Novel Topical Gel in  
Prevention of Hypertrophic Scar Formation 
 
Regulatory Sponsor: 
Alexander Meves, M.D. 
Department of Dermatology 
Mayo Clinic 
200 First Street SW 
Mayo Clinic, Rochester, MN USA 
507-284-2511 
Co-investigator 
 
Steven Moran, M.D. 
Division of Plastic Surgery 
Mayo Clinic 
200 First Street SW 
Mayo Clinic, Rochester, MN USA 
507-284-2511 
 
Saranya Wyles, M.D., Ph.D. 
Department of Dermatology 
Mayo Clinic 
200 First Street SW 
Mayo Clinic, Rochester, MN USA 
507-284-2511 
 
Study Product: 
Pentamidine 2% cream 
Protocol Number: (IRBe) 
17-005230  
IND Number: 
136556 
 
 
Initial version: 8/14/2017 Version (1.0) 
Revised: 9/12/2017 Version (2.0)  
Revised: 10/30/2017 Version (3.0) 
Revised: 12/21/2017 Version (4.0) 
Revised: 3/16/2018 Version (5.0) 
Revised: 3/26/2018 Version (6.0) 
Revised 8/21/2018 Version (7.0) 
Revised 8/19/2019 Version (8.0) 
Revised 9/18/2019 Version (9.0) 
Revised 10/25/2019 Version (10.0) 
 

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Table of Contents 
 
STUDY SUMMARY ...................................................................................................................................... 5 
1 
INTRODUCTION ................................................................................................................................. 6 
1.1 
BACKGROUND .................................................................................................................................... 6 
1.2 
INVESTIGATIONAL AGENT .................................................................................................................... 7 
1.3 
PRECLINICAL DATA ............................................................................................................................. 7 
1.4 
CLINICAL DATA TO DATE..................................................................................................................... 8 
1.5 
DOSE RATIONALE................................................................................................................................ 9 
1.6 
STUDY RISKS AND BENEFITS ................................................................................................................ 9 
1.6.1 
Anticipated Risks ....................................................................................................................... 9 
1.6.2 
Overall Study Risk Management ................................................................................................ 10 
1.6.3 
Scar Excision and Skin Biopsy Risk Management ....................................................................... 10 
1.6.4 
Adverse Reaction Risk Management .......................................................................................... 10 
1.6.5 
Potential Benefits ..................................................................................................................... 11 
2 
STUDY OBJECTIVES ........................................................................................................................ 11 
3 
STUDY DESIGN ................................................................................................................................. 11 
3.1 
GENERAL DESCRIPTION ..................................................................................................................... 11 
3.2 
NUMBER OF SUBJECTS ....................................................................................................................... 13 
3.3 
DURATION OF PARTICIPATION ............................................................................................................ 13 
3.4 
PRIMARY STUDY ENDPOINTS .............................................................................................................. 14 
3.5 
SECONDARY STUDY ENDPOINTS ......................................................................................................... 14 
3.6 
IDENTIFICATION OF SOURCE DATA ...................................................................................................... 14 
4 
SUBJECT SELECTION ENROLLMENT AND WITHDRAWAL ...................................................... 15 
4.1 
INCLUSION CRITERIA ......................................................................................................................... 15 
4.2 
EXCLUSION CRITERIA ........................................................................................................................ 15 
4.3 
SUBJECT RECRUITMENT, ENROLLMENT AND SCREENING ....................................................................... 16 
4.4 
EARLY WITHDRAWAL OF SUBJECTS .................................................................................................... 17 
4.4.1 
When and How to Withdraw Subjects ........................................................................................ 17 
4.4.2 
Data Collection and Follow-up for Withdrawn Subjects .............................................................. 17 
5 
STUDY DRUG .................................................................................................................................... 17 
5.1 
DESCRIPTION .................................................................................................................................... 17 
5.2 
TREATMENT REGIMEN ....................................................................................................................... 19 
5.3 
PREPARATION AND ADMINISTRATION OF STUDY DRUG ......................................................................... 19 
5.4 
SUBJECT COMPLIANCE MONITORING ................................................................................................... 19 
5.4.1 
Prior and Concomitant Therapy ................................................................................................ 20 
5.5 
PACKAGING ...................................................................................................................................... 20 
5.6 
MASKING/BLINDING OF STUDY........................................................................................................... 21 
5.7 
RECEIVING, STORAGE, DISPENSING AND RETURN ............................................................................... 211 
5.7.1 
Receipt of Drug Supplies .......................................................................................................... 21 
5.7.2 
Storage ................................................................................................................................... 22 
5.7.3 
Dispensing of Study Drug ......................................................................................................... 22 
5.7.4 
Return or Destruction of Study Drug ......................................................................................... 23 
6 
STUDY PROCEDURES ...................................................................................................................... 23 

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6.1 
VISIT 0 (PREOPERATIVE PERIOD) .................................................................................................................... 23 
6.2 
VISIT 1 (PREOPERATIVE PERIOD) .................................................................................................................... 23 
6.3 
VISIT 2 (DAY OF PROCEDURE) ....................................................................................................................... 24 
6.4 
PHONE INTERVIEW #1 (WEEK 0, DAY 1 POSTOP) ........................................................................................... 24 
6.5 
PHONE INTERVIEW #2 (WEEK 1 POSTOP) ....................................................................................................... 24 
6.6 
VISIT 3 (WEEK 2 POSTOP) .............................................................................................................................. 24 
6.7 
PHONE INTERVIEW#3 (WEEK 3 POSTOP) ....................................................................................................... 25 
6.8 
VISIT 4(WEEK 4 POSTOP) ............................................................................................................................... 25 
6.9 
PHONE INTERVIEW #4: (MONTH 2)................................................................................................................. 25 
6.10 VISIT #5: (MONTH 3) ...................................................................................................................................... 25 
6.11  
SCHEDULE OF EVENTS ............................................................................................................................... 26 
7 
STATISTICAL PLAN ......................................................................................................................... 27 
7.1 
SAMPLE SIZE DETERMINATION ........................................................................................................... 27 
7.2 
STATISTICAL METHODS ..................................................................................................................... 27 
7.3 
SUBJECT POPULATION(S) FOR ANALYSIS ............................................................................................. 27 
8 
SAFETY AND ADVERSE EVENTS ................................................................................................... 27 
8.1 
DEFINITIONS ..................................................................................................................................... 27 
8.2 
RECORDING OF ADVERSE EVENTS ....................................................................................................... 30 
8.3 
REPORTING OF SERIOUS ADVERSE EVENTS AND UNANTICIPATED PROBLEMS .......................................... 30 
8.3.1 
Sponsor-Investigator reporting: notifying the Mayo IRB ............................................................. 31 
8.3.2 
Sponsor-Investigator reporting: Notifying the FDA ..................................................................... 32 
8.4 
UNMASKING/UNBLINDING PROCEDURES ............................................................................................. 33 
8.5 
STOPPING RULES ............................................................................................................................... 33 
8.6 
MEDICAL MONITORING ..................................................................................................................... 34 
9 
DATA HANDLING AND RECORD KEEPING .................................................................................. 34 
9.1 
CONFIDENTIALITY ............................................................................................................................. 34 
9.2 
SOURCE DOCUMENTS ........................................................................................................................ 34 
9.3 
CASE REPORT FORMS ........................................................................................................................ 35 
9.4 
RECORDS RETENTION ........................................................................................................................ 35 
10 
STUDY MONITORING, AUDITING, AND INSPECTING ................................................................ 36 
10.1 
STUDY MONITORING PLAN ............................................................................................................ 36 
10.2 
AUDITING AND INSPECTING ........................................................................................................... 36 
11 
ETHICAL CONSIDERATIONS ......................................................................................................... 36 
12 
STUDY FINANCES ............................................................................................................................ 37 
12.1 
FUNDING SOURCE ......................................................................................................................... 37 
13 
PUBLICATION PLAN ....................................................................................................................... 37 
14 
REFERENCES ................................................................................................................................... 38 
 
 
 
 
 
 
 
 

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List of Abbreviations 
 
AE 
Adverse Event/Adverse Experience 
CFR 
Code of Federal Regulations 
CRF 
Case Report Form 
DSMB 
Data and Safety Monitoring Board 
ECM 
Extracellular Matrix 
ECG 
Electrocardiogram 
FDA 
Food and Drug Administration 
GCP 
Good Clinical Practice 
HIPAA 
Health Insurance Portability and Accountability Act 
IB 
Investigator’s Brochure 
IDS 
Investigational Drug Services 
IND 
Investigational New Drug Application 
IRB 
Institutional Review Board 
LSR 
Local Skin Reaction 
PCCA PP 
Professional Compounding Centers of America Pracasil™-Plus 
PHI 
Protected Health Information 
PI 
Principal Investigator 
RCT 
Randomized Clinical Trial 
SAE 
Serious Adverse Event/Serious Adverse Experience 
SOP 
Standard Operating Procedure 
SPP1 
Osteopontin 
SSE 
Surgical Scar Excision 
TP 
Topical Pentamidine + PCCA Pracasil™-Plus 
US 
Ultrasound 
VAS 
Visual Analog Scale 
VSS 
Vancouver Scar Scale 
POSAS 
Patient and Observer Scar Assessment Scale 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Topical Pentamidine for Hypertrophic Scarring 
 
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Study Summary 
 
Title 
Double Blind, Single-Center, Randomized, Within-Subject Placebo, 
Phase I Study Evaluating the Effects of Topical Pentamidine in 
Prevention of Hypertrophic Scar Formation 
Running Title 
Novel Topical Gel for Hypertrophic Scar Prevention 
IRB Protocol Number 
17-005230 
Phase 
Pilot Study 
Methodology 
Double Blind, Single-Center, Randomized, Within-Subject Placebo 
Phase I Study  
Overall Study Duration 
3 months 
Subject Participation 
Duration 
3 months 
Single or Multi-Site  
Single site 
Objectives 
Evaluate safety of topical pentamidine (TP) as an adjuvant to surgical 
scar excision (SSE) in the treatment of hypertrophic scar formation. 
Safety will be measured by serial monitoring for adverse events 
following the procedure and during treatment duration. Secondarily, 
study will evaluate drug quality and standardizations as well as 
investigate initial signs of efficacy. 
Number of Subjects 
10 
Diagnosis and Main 
Inclusion Criteria 
Hypertrophic scar diagnosed in Mayo Clinic Department of 
Dermatology or Division of Plastic Surgery, Rochester, Minnesota. 
Study Product, Dose, 
Route, Regimen 
Pentamidine, delivered as topical formulation containing 2% TP in 
silicone-containing base, PCCA Pracasil™-Plus (PP), versus placebo 
base alone. Approximately 1.8 mL of product in allotted single dose 
containers will be applied every 48 hours for 4 weeks following 
surgical scar excision.  
Duration of 
Administration 
Once every 48 hours for 4 weeks. 
Reference therapy 
SSE with silicone compounding base only (PCCA PP). 
Statistical Methodology 
The primary analysis will use descriptive statistics to document adverse 
events between treated and untreated lesions. The secondary analysis 
will use paired t-test or Wilcoxon signed rank test to compare the 
change in lesion height and characteristics between the treated and 
placebo groups following SSE (TP + PCCA PP vs. PCCA PP alone). In 
addition, two-factor analysis of variance (ANOVA) with repeated 
measures on both factors will be used to evaluate the effect of treatment 
and follow-up time for other continuous measures such as Vancouver 
Scar Scale (VSS) and Patient and Observer Scar Assessment Scale 
(POSAS). 
 

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1 Introduction 
This document is a protocol for a human research study. This study will be carried out in 
accordance with applicable United States government regulations and Mayo Clinic research 
policies and procedures.  
1.1 
Background 
Hypertrophic scars are formed by an excessive tissue response to dermal injury characterized by 
local fibroblast proliferation and overproduction of collagen [1, 2]. With an incidence of 
hypertrophic scarring occurring at rates of 40-70% post-surgery and up to 91% following burn 
injury [3, 4], an effective topical treatment would offer immense benefits to a patient's quality of 
life. Current treatments for hypertrophic scars rely on management via surgical intervention [5], 
compression therapy [6], silicone gel sheeting [7], laser [8, 9] or corticosteroid injection [10, 11]. 
While these may offer temporary relief, interventions such as corticosteroid therapy have 
recurrence rate of up to 50% after 5 years [12, 13] and various skin complications including dermal 
atrophy, skin ulceration and hypo/hyperpigmentation [14].  
 
The use of silicone gel sheeting to prevent and treat hypertrophic scarring is still relatively new, 
and started in 1981 with treatment of burn scars [15]. Topical silicone gel sheet and silicone cream 
have been evaluated as efficacious in treating keloids and hypertrophic scars due to their hydrating 
effect on the stratum corneum [16-18]. Silicone-based therapies are currently being investigated 
in several clinical trials for hypertrophic abdominal scar (NCT01078428), hypertrophic and keloid 
scar (NCT00754247), and post-surgical hypertrophic scarring (NCT01861119; NCT00849004) 
(http://clinicaltrials.gov/) [19]. Preliminary results from the Investigation of a Novel Silicone 
Dressing to Maximize the Outcomes of Scar Revision Procedures (IMPROVE) trial 
(NCT01430130) showed improvement in the visual analog scale (VAS) in the silicone dressing 
cohort. This proof-of-concept demonstration suggests that silicone-based therapy may provide a 
solution for hypertrophic scar prevention. Despite these findings, treatment of hypertrophic 
scarring varies and management targeting the root cause of abnormal wound healing is warranted.  
 
Early inflammation following dermal injury is essential in the progression of normal wound 
healing; in contrast, chronic or excessive inflammation leads to pathological scarring and fibrosis 
[20, 21].  Our recent preliminary findings show that osteopontin (SPP1), a secreted chemokine-
like protein [22] involved in intracellular signaling [23], modulates extracellular matrix (ECM) 
remodeling [24]; this interaction plays a role in scar formation as SPP1 is known to drive tissue 
fibrosis and aging [25]. Previous studies have shown that SPP1 local knockdown leads to 
accelerated repair and decreased granulation tissue and scar formation [26]. Thus, SPP1 expressed 
by wound fibroblasts as a consequence of signals from inflammatory cells may hinder the rate of 
wound repair and regeneration. Screening pharmaceutically active compounds that inhibit the 
SPP1 promoter led to the discovery of pentamidine isethionate, which inhibited SPP1 promoter 
activity by ≥80% with minimal in vitro cell toxicity. 
 
Here we investigate a novel topical agent, SPP1 inhibitor, pentamidine isethionate, compounded 
in silicone-containing base, as an adjuvant therapy to surgical scar excision (SSE) to prevent 
adverse scarring and enhance skin rejuvenation by upregulating anti-fibrotic and anti-aging 
processes. Initial studies in rabbit ear hypertrophic scar formation model (n=18 rabbits) showed 
significantly reduced scar elevation index following 4 weeks of topical pentamidine (TP) treatment 

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compared to silicone base, PCCA Pracasil™-Plus (PP), versus no treatment. As such, TP serves 
as a primed agent for trial as a clinical-grade product for human use.  
1.2 
Investigational Agent 
SPP1 is a pro-inflammatory inducer of skin fibrosis and aging. Screening pharmaceutically active 
compounds that inhibit the SPP1 promoter led to the discovery of pentamidine isethionate, which 
inhibited SPP1 promoter activity by ≥80% with minimal in vitro cell toxicity. Mayo Clinic 
Compounding Pharmacy was utilized to produce pentamidine isethionate, delivered as topical 
cream formulation containing 2% TP in PCCA PP base. 
1.3 
Preclinical Data 
Pre-clinical testing (animal and biocompatibility) of TP in silicone base (PCCA PP) demonstrated 
safety and biocompatibility across numerous rabbit models of hypertrophic scar formation. Pre-
clinical animal and biocompatibility data are provided below. 
 
We developed a hypertrophic scar formation rabbit ear model following IACUC approval 
(A00001970-16). Surgical ligation of leporine auricular vessels induced an ischemic landscape for 
hypertrophic scar production. Specifically, cranial artery and vein were ligated; caudal artery and 
vein were preserved; and central artery was ligated but central vein was preserved in the rabbit ear 
(Figure 1A). Following vascular ligation, one linear full-thickness skin wound was created on the 
ventral side of each ear with a surgical blade. The skin and perichondrium were removed and 
wound edges were closed with 4-0 Nylon sutures, generating tension for hypertrophic scarring.  
 
Following ischemic wounding, we assessed the relative ischemia created in the ear at time of 
surgery and time of sacrifice with a fluorescent light assisted angiography (Spy Elite, LifeCell) 
(Figure 1B). Ischemic perfusion coupled with mechanical suture tension yielded hypertrophic scar 
formation. 
 
 

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Following vascular ligation and linear wounding, rabbits were assigned to treatment groups: (1) 
control group with synthetic bandage (no treatment), (2) PCCA PP (base only), or (3) TP in PCCA 
PP. Treatment with 2% TP in PCCA PP demonstrated scar reduction following 4 weeks of topical 
gel application (Figure 2). These results provide proof-of-concept for the proposed trial using 2% 
TP in PCCA PP for hypertrophic scar reduction.  
 
 
 
1.4 
Clinical Data to Date 
There is no available clinical research data to date on topical application of pentamidine isethionate 
to treat hypertrophic scarring.  
 
Figure 1. Ischemic Rabbit Ear for Hypertrophic Scar Model. Surgical Ligation of 
Leporine Auricular Blood Vessels, A. Fluorescent light-assisted angiography (Spy 
Elite) with and without Doppler, B. 
Figure 2. Hypertrophic Scar Reduction. 

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1.5 
Dose Rationale 
Drug titration testing with 1%, 2% and 5% pentamidine isethionate identified 2% as the optimal 
active dose for wound healing.  
1.6 
Study Risks and Benefits 
1.6.1 Anticipated Risks 
Although the risk is extremely small, subjects are theoretically at increased risk of infection 
through participation in this study. In addition to standard of care with surgical scar excision (SSE), 
patients in this study will have skin biopsied from their scar site. There also exists a potential risk 
for adverse skin reactions following topical drug application and/or concomitant drug interactions. 
The type of infections and adverse skin reactions that are theoretically possible and how we will 
monitor and address are listed below: 
 
• Acute soft tissue infection: 
 
Risk of infection from scar excision alone is extremely low. In Dr. Moran’s practice, there has 
been very limited instance of infection. However, we will contact patients by phone at 24 hours 
post-discharge as well as at 2 months and 3 months to address any of the following symptoms: 
increasing pain at the wound site, redness around the wound or fever [defined as body temperature 
above 100.4°F (38.0°C)], as deemed appropriate by the primary investigator. In addition, the 
study subjects will be asked to self-monitor for symptoms of pain or fever and contact the study 
investigators immediately if they have any of above symptoms.  
 
• Adverse skin reactions: 
 
In its use as an antifungal treatment, topical pentamidine (TP) has been proven to have minimal to 
no adverse skin reactions (Patent Publication# US5230897-A). We will be monitoring patients 
weekly during the first month. Follow-up visits at week 2and week 4 will assess change in physical 
exam or pattern of pain. Patients will also be encouraged to self-monitor for symptoms of pain or 
fever. Patients will seek immediate medical attention for fever above 103°F (39.4°C). 
 
With the proposed protocol, acute risks exist and are as follows: 
o Pain 
o Itching 
o Urticaria 
o Infection 
o Inflammation 
o Bruising 
o Crusting/Scabbing 
o Hyper/hypo/depigmentation 
o Thickening of the skin 
o Change in vascularization  
 
 
 

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1.6.2 Overall Study Risk Management 
The following measures implemented by Mayo Clinic will minimize the risks associated with 
patients’ participation in the clinical study: 
 
 Mayo Clinic selects personnel with extensive experience in conducting clinical studies and 
in performing procedures involved in the protocol including skin biopsies and surgical 
procedures. 
 All examinations, treatment procedures and interpretation of clinical data generated during 
the study is directed, overseen and analyzed by an appropriately licensed and credentialed 
physician who has been trained to the clinical study protocol. 
 Mayo Clinic developed the clinical protocol and training programs to ensure that the study 
personnel at Mayo Clinic have a strong knowledge and understanding of the clinical 
protocol, including patient selection criteria and procedure requirements.  
 Mayo Clinic carefully developed patient eligibility criteria for the investigation including 
clearly defined inclusion and exclusion criteria to ensure that only properly selected 
patients will be enrolled in the clinical study. 
 The protocol is designed so that patient treatment and follow-up procedures will be 
consistent with those of the clinically established standard of care. 
1.6.3 Scar Excision and Skin Biopsy Risk Management 
Investigators and all study personnel will be trained in the details of all aspects of the study 
procedures. To minimize risks and increase the chances of a favorable clinical outcome the 
following measures are required: 
 
 Enrollment of subjects who qualify per the inclusion/exclusion criteria in the protocol 
 Strict adherence to the study protocol 
 Use sterile technique throughout the procedure  
 Use standard of care for the monitoring of and treatment of possible adverse events 
following scar excision and biopsy procedure  
 Depending on the site of the scar, the surgeon will explain the types of activities to avoid 
 Close surgical incision and biopsy site with appropriate suture 
1.6.4 Adverse Reaction Risk Management 
Investigators and all study personnel will be trained in the details of all aspects of the study 
procedures. Standardization of topical drug and placebo application techniques is critical to a good 
clinical outcome. To minimize risks and increase the chances of a favorable clinical outcome the 
following measures are required: 
 
 Subjects will be educated on treatment application during pre-operative visit  
 Potential risks will be listed in the patient consent form and quantified during the course of 
treatment via patient questionnaires (VSS and POSAS) 
 Follow-up will continue for 3 months following surgery:  in-person appointments with 
study staff will occur during treatment period at 2 weeks and4 weeks after surgery.  A final 
visit will be encouraged at 3 months after surgery.  A follow-up phone call will be made 
by study staff 24 hours after surgery and postoperative weeks 1 and 3, and month 2 (and 3 
if the patient is unable to return for in-clinic follow-up)2. 

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1.6.5 Potential Benefits 
Each patient will receive both treatment and within subject placebo following SSE. Either the 
distal or proximal portion of the wound will receive the investigative treatment (TP) versus placebo 
(PCCA PP) with adjuvant SSE. Our preclinical data suggests that topical treatment with 
pentamidine may provide an improved environment for lesion healing in the setting of 
hypertrophic scar. However, this has not been formally tested for safety or efficacy in a RCT within 
the United States. As far as cosmetic benefits, patients will have the potential for the reduction of 
visible scarring. Hypertrophic scarring can cause patients to experience physical pain, as well as 
psychological and social costs that can be emotionally and financially difficult. The proposed 
topical treatment aims to reduce the thickness, redness and altered pigmentation of scar tissue by 
targeting the root cause of pathological scarring and fibrosis. Thus, the focus of this pilot study 
will be procedural safety and preliminary efficacy.  
2 Study Objectives 
The primary goal of this randomized clinical trial will be to directly evaluate safety of topical scar 
prevention product and placebo base control in patients with hypertrophic scarring. Patients with 
known diagnosis of hypertrophic scar will be enrolled. Secondarily, we will evaluate initial signs 
of treatment efficacy using topical product. 
3 Study Design 
3.1 
General Description 
This study is a double-blind pilot study of scar excision procedure followed by treatment with 
either TP in PCCA PP versus PCCA PP silicone base only. Current management for patients with 
hypertrophic scar includes silicone-based treatment. At our institution we treat patients with scar 
excision surgery without topical scar cream following the procedure. However, a significant 
proportion of patients continue to fail this treatment modality leading to scar recurrence. Indeed, 
individual patient response to therapy varies based on patient characteristics including ethnicity. 
As such, we plan to treat the same patient with both TP in PCCA PP and PCCA PP alone at 
different ends of their scar. In this way, we can better determine efficacy of these topical agents in 
biologically controlled setting with reduced response variability. We plan to enroll patients with 
minimum hypertrophic scar length ≥ 3 cm.   
 
Those patients who successfully qualify based on inclusion and exclusion criteria will be invited 
to participate in the trial. Following informed consent, eligible subjects will undergo pre-operative 
tests to include blood work and EKG.  Preoperative photographs of the scar site will be taken.  
Scar quality questionnaires (VSS and POSAS) will be completed and a scar ultrasound performed..  
A 5-mm skin punch biopsy will be obtained from the lateral edge of the scar at both the proximal 
and distal ends of the scars, under local anesthesia. Alternatively, the first punch biopsy may occur 
prior to the surgical procedure while the patient is under anesthesia. Part of the sample will be 
stored in formalin and prepared for histological staining. The other portion will be frozen and 
prepared for molecular analysis. All participants will receive both treatments to be applied either 
at the proximal end or the distal end of the scar.  Treatment application will be randomized. For 
example, topical agent A will be applied to the proximal end of the scar and will contain either TP 

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in PCCA PP or PCCA PP.  Topical agent B will treat the distal portion of the scar  and contain 
either TP in PCCA PP or PCCA PP alone.  1-2cm in the middle of the scar will remain untreated 
as the border zone. It is known that blood perfusion influences scar formation; thus to reduce 
potential bias from distal scar site receiving reduced blood flow compared to proximal scar site, 
treatment application will be randomized to scar site. Prior to treatment initiation, patients will 
undergo scar excision procedure with a 24-hour recovery period. Treatments will be provided in 
single dose containers for application every 48 hours following surgical recovery (total of 14-16 
applications; total treatment duration of 4 weeks). 
 
Patient Treatment Schema 
 
Visit 0: (Preoperative screening) 
• Informed consent 
 
Visit 1: (Preoperative period) 
• Pre-operative evaluation including history, clinical exam with baseline neuropsychiatric 
assessment, and laboratory studies to include hepatic and renal function, complete blood 
count with differential, blood glucose level and calcium.  The specific laboratory tests for 
hepatic and renal function will include ALT, AST, Bilirubin, BUN and Creatinine. Any 
abnormal value twice the upper limit of normal will meet exclusion criteria: AST (Normal: 
8-48 U/L); ALT (Normal: 7-55 U/L); Bilirubin, Total (Normal <= 1.2 mg/dL); BUN 
(Normal 8-24 mg/dL); Creatinine (0.8-1.3 mg/dL). 
• Baseline cardiac monitoring (ECG) 
• Scar photography 
• Quality questionnaires (VSS and POSAS) 
• Pre-operative US and/or 3D imaging 
• Treatment application patient education 
• 5-mm skin punch biopsy under local anesthesia from distal and proximal sites 
(Alternatively, the first punch biopsy may occur prior to the surgical procedure while under 
anesthesia.) 
 
Visit 2: (Day of procedure) 
• Surgical scar excision under local or general anesthesia depending on size of scaring and 
surgeon preference for excision  
• Provide single dose containers with de-identified treatment agents (TP in PCCA PP and 
PCCA PP alone) and treatment recording log for two weeks 
 
Phone Interview #1: (Week 0, Day 1 postop)  
• Assessment of adverse events 
 
Phone Interview #2 (Week 1 postop) 
• Assessment of adverse events 
 
Visit3: (Week 2 postop) 
• Scar photography 
• Quality questionnaires (VSS and POSAS) 

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• Post-operative evaluation including clinical exam with local safety evaluation to assess 
tolerability (e.g. erythema, edema, vesicle formation, necrosis, ulceration etc.) and 
neuropsychiatric adverse event assessment 
• Laboratory studies (including hepatic and renal function, complete blood count with 
differential, blood glucose level and calcium)  
• Post-operative cardiac monitoring (ECG) 
• Post-operative US and/or 3D imaging 
• Provide single dose containers with de-identified treatment agents (TP in PCCA PP and 
PCCA PP alone) and treatment recording log for two weeks 
 
Phone Interview #3 (Week 3 postop) 
• Assessment of adverse events 
 
Visit4: (Week 4 postop) 
• Scar photography 
• Quality questionnaires (VSS and POSAS) 
• Post-operative evaluation including clinical exam with local skin reaction evaluation and 
neuropsychiatric adverse event assessment 
• Laboratory studies will include hepatic and renal function, complete blood count with 
differential, blood glucose level and calcium.  Post-operative US and/or 3D imaging 
• 5-mm skin punch biopsy under local anesthesia from distal and proximal sites 
 
Phone Interview #4: (Month 2 postop)  
• Assessment of adverse events 
 
Visit #5: (Month 3 postop)  
• Scar photography 
• Quality questionnaires (VSS and POSAS) 
• Assessment of adverse events 
• Note:  if the patient is unable to return for an in-clinic appointment, a phone interview will 
be conducted 
3.2 
Number of Subjects 
Ten subjects will be enrolled in this trial.  
3.3 
Duration of Participation 
Length of study treatment will be 4 weeks. Per treatment schema, patients will have 5 total visits 
including initial pre-operative evaluation (visit 1); surgical excision procedure (visit 2) and follow-
up visits at postoperative week 2 and 4, and month 3. Patients will receive a phone call 24 hours 
following their surgical excision to assess adverse events.  Another phone call will be made at 
postoperative weeks 1 and 3, and postoperative month 2.   
 

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3.4 
Primary Study Endpoints 
Aim #1: Identify the type and number of serious adverse events related to TP in PCCA PP 
compared to PCCA PP base alone following surgical scar excision. While we do not anticipate 
any severe adverse events, we will monitor for the following: 
 
• Skin infection 
• Skin irritation 
• Wound dehiscence 
• Clinically significant abnormalities in physical examination and vital signs. 
3.5 
Secondary Study Endpoints 
Aim #2: Evaluate initial signals of efficacy as measured by US dimensions (length, width and 
height) and volume quantification, skin biopsy histological features (semi-quantitative assessment 
of skin fibrosis) and patient-reported outcome metrics (per VSS and POSAS). Preoperative US as 
well as 2 week and 4 week postoperative US will be compared based on formal quantification of 
the hypertrophic scar lesion volume size (unit of measure: cm3). Preoperative 5-mm skin biopsy 
and 4 week postoperative skin biopsy will be used for histological evaluation (including epidermal 
hyperplasia/hyperkeratoses, hair follicles, apocrine glands, smooth muscles, fibroplasia, vascular 
proliferation and collagen orientation) [27] and epidermal scar thickness calculation. Quality of 
life and scar elevation scores will also be assessed at serial follow-up as measured by VSS and 
POSAS. 
3.6 
Identification of Source Data 
The following source data will be directly recorded on the Case Report Form (CRF): 
• Patient demographic data: 
o Age 
o Sex 
o Ethnicity 
o Indication for scar excision 
o Concomitant medications 
• Inclusion criteria 
• Exclusion criteria 
• Physical examination 
• Trial medication administration 
o Date of dosing 
o Time of dosing 
• Assessment 

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o POSAS 
o VSS 
• Adverse events 
o Pain 
o Rash 
o Skin Ulcer 
o Erythema 
o Pruritus  
o Urticaria  
o Erosions 
o Scabbing 
o Infection 
o Depigmentation 
o Hypopigmentation 
o Hyperpigmentation 
 
The following source data will not be directly collected in the Case Report Form (CRF), but will 
be captured in supportive documentation (EMR): 
• Photographs of lesion area 
• Ultrasound 3D radiographic images 
• Histology report from 5-mm skin biopsy 
4 Subject Selection Enrollment and Withdrawal 
4.1 
Inclusion Criteria 
• 
Males and females 18 years of age or older. 
• 
Diagnosis of hypertrophic scar by a Mayo Clinic plastic surgeon or dermatologist   
• 
Target disease or condition: Hypertrophic scar 
• 
Subject with a hypertrophic scar that meet all of the following criteria: 
- 
Linear scar  ≥3 cm to ≤40 cm in length  
- 
Present for minimum 6 months  
- 
Located anywhere in the body except on the face or front of neck 
- 
Resulting from surgical or traumatic injury, or other scar considered 
appropriate for surgical excision 
• 
Ability to safely undergo scar excision surgery 
• 
Capacity to provide informed consent  
• 
Ability to comply with protocol 
• 
Subject is judged, by the clinical investigator, to be healthy as evidenced by lack of 
clinically significant abnormal findings on medical history, physical examination, 
electrocardiogram, vital signs, and clinical laboratory tests.  
4.2 
Exclusion Criteria 
• 
Subjects identified as having a keloid or a scar not appropriate for surgical excision 

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• 
Subjects who are positive for hepatitis B surface antigen (HbsAg), hepatitis C 
antibody and HIV as determined in screening the subject’s electronic medical 
record. 
• 
Concurrent use of systemic corticosteroids (excludes inhaled or topical steroids), 
COX-2 inhibitors and/or drugs that are strong inhibitors and inducers of CYP 
enzymes 
• 
Are immuno-compromised (HIV infected, cancer and other disease affecting the 
basal immune response) 
• 
Clinically significant cardiovascular, pulmonary, renal, endocrine, hepatic, 
neurological, psychiatric, immunological, gastrointestinal, hematological, or 
metabolic disease that is, in the opinion of the investigator, not stabilized or may 
otherwise impact the results of the study. 
• 
Subjects with renal and hepatic impairment.   
• 
Known allergy or hypersensitivity to the study drug(s) or one of the ingredients of 
the formulation. 
• 
Any infection or wound in the area to treat including photosensitive dermatosis or 
inflammatory acne. 
• 
Existence of any surgical, medical or laboratory condition that, in the judgment of 
the clinical investigator, might interfere with the safety, distribution, metabolism or 
excretion of the drug 
• 
Participation in another clinical study in the past 30 days or concurrent participation 
in another clinical trial. 
• 
Patients with poorly controlled diabetes mellitus (HbA1C ≥ 8%), peripheral 
neuropathy, or known concomitant vascular problems. 
• 
Pregnant or lactating female patients. 
• 
Prisoners.  
• 
Subjects who smoke cigarettes and/or use other tobacco products. 
4.3 
Subject Recruitment, Enrollment and Screening 
Prior to discussing study enrollment with the patient, principal investigator, Alexander Meves, MD 
and/or Steven Moran, MD, will discuss with study coordinator to ensure that that target enrollment 
has not yet been met.. Subjects will be recruited at Mayo Clinic Department of Dermatology and 
Division of Plastic Surgery in Rochester, Minnesota. 
 
At the time of patient enrollment in the trial the following must be verified: 
 
1. IRB approval of the trial and open enrollment status with both Mayo Clinic and 
clinicaltrials.gov.  
2. Open  place  on  the  enrollment log  (confirmation  from  the  PI  and  study coordinator). 
3. Patient is willing and able to travel to the Mayo Clinic, Rochester for all tests, treatment 
and follow up required in the protocol. 
 
At the time of patient enrollment the following will be confirmed and documented: 
 
1. A signed consent form. 

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2. The existence of a signed authorization for use and disclosure of protected health 
information. 
3. A completed inclusion/exclusion enrollment checklist. 
4.4 
Early Withdrawal of Subjects 
4.4.1 When and How to Withdraw Subjects 
Subjects may withdraw from the study for any of the following reasons: safety issues, inability or 
unwillingness to adhere to protocol requirements, or if the subject desires to withdraw from the 
study. A single subject withdrawn from the study will not be replaced. If two or more patients have 
withdrawn (with the exception of safety reasons) one of the subjects will be replaced with a new 
enrollee. The decision to withdraw subjects and the responses below will occur under the following 
circumstances. 
 
 Patients wishing to withdraw from the study: Patients wishing to withdraw from the study 
should provide written indication of these wishes. 
 Patients unable or uncooperative to continue in the study: If possible, patients should be 
contacted in an attempt to determine the reasons for the inability to complete the study. 
After at least three attempts and failure to complete required testing the patient will be 
considered out of the study. 
 Withdrawn from study due to safety reasons: See section below for the response to drug 
related adverse events and patient withdrawal from the study. Generally, even patients with 
a drug related adverse event will continue with the test schedule as the test schedule 
includes minimal risk tests and is used to monitor and gauge continued long term effects 
of the treatment. 
4.4.2 Data Collection and Follow-up for Withdrawn Subjects 
The sponsor of the study is responsible for following up on patients who develop adverse reactions 
to treatment. All study participants will undergo risk-appropriate follow-up until study-related 
adverse events have been fully treated and resolved. 
5 Study Drug  
5.1 
Description 
Pentam 300 (pentamidine isethionate), an anti-protozoal agent, is a sterile, nonpyrogenic, 
lyophilized product. Pentamidine isethionate is a white crystalline powder soluble in water and 
glycerin, slightly soluble in alcohol and insoluble in ether, acetone, and chloroform. Currently used 
as an oral inhalation/intramuscular/intravenous antifungal agent.  
Pentamidine isethionate, an aromatic diamidine, is known to have activity against Pneumocystis 
carinii.  The mode of action of pentamidine is not fully understood.  In vitro studies indicate that 
the drug interferes with protozoal nuclear metabolism by inhibition of DNA, RNA, phospholipid 
and protein synthesis. 
It is chemically designated as 4,4-[1,5-pentanediylbis(oxy)]bis-benzenecarboximidamid with the 
following structural formula: 

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Each vial contains:  
Pentamidine isethionate . . . . . . . . . . . . . 300 mg 
Pharmacokinetics 
Biotransformation of pentamidine in humans is unknown. At least six metabolites have been 
identified in rats. Elimination of systemic drug is primarily renal, and half-life is increased in 
patients with renal dysfunction. Half-lives vary, depending on the route of administration. The 
terminal half-life is 2—4 weeks. Urinary excretion may persist for up to 8 weeks after 
discontinuation. Multiple dosing may result in drug accumulation, even in patients with normal 
renal function. No information on fecal excretion in humans is available. 
 
Affected cytochrome P450 isoenzymes and drug transporters: CYP3A5, CYP2D6, CYP2C19, 
CYP1A1, CYP4A11. Previous data suggest that pentamidine was metabolized by the CYP2C19 
isoenzyme; however, this has not been confirmed. In vitro data suggest that the CYP1A1, 3A5, 
and 4A11 isoenzymes may contribute to the metabolism of pentamidine, but data from healthy 
volunteers show that the CYP1A1 and 2D6 are the mediating enzymes in humans. Drug 
interactions with pentamidine are not well studied. Given these interactions, clinicians should be 
cautious using concurrent drugs that have similar toxicities. 
 
 
 
Base 
The vehicle used in this study is Pracasil™-Plus (PCCA #30-4655; PCCA PP). This non-aqueous 
silicone-based compounding agent contains the following ingredients: 
• Cyclopentasiloxane 
• Polysilicone-11 
• PEG-16 Macadamia Glycerides 
• Dimethicone 
• C30-45 Alkyl Cetearyl Dimethicone Crosspolymer 
• Pentaclethra Macroloba Seed Oil 

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• Oenocarpus Bataua Pulp Oil 
• Phosphatidylcholine 
• Tocopheryl Acetate 
• BHT 
5.2 
Treatment Regimen 
First dose will be applied 24 hours post-surgical scar excision, then scheduled every 48 hours. 
Approximately 1.8 mL (0.06 oz) of topical pentamidine (TP) or PCCA PP control will be topically 
applied via single dose containers provided the day of surgery and at their 2-week postoperative 
follow-up visit. Participants will receive two sets of single dose containers (set A and set B). One 
set will be randomized to contain TP with de-identified label; the other set will be randomized to 
contain PCCA PP with de-identified label. Each set (A and B) will contain 8 single dose containers, 
all with a de-identified label. The study drug will be applied every 48 hours. Specifically, topical 
agent (either TP or PCCA PP) will be applied to either the distal or the proximal end of the wound. 
Study participants will receive treatment application education during their pre-operative visit; 
further details provided in Section 6.1. Treatment duration is 4 weeks. 
5.3 
Preparation and Administration of Study Drug 
Standard USP 40-NF 35, Chapter 795 compounding techniques will be followed. The compounder 
is responsible for compounding preparations of acceptable strength, quality, and purity and in 
accordance with the prescription or medication order. The compounder is also responsible for 
dispensing the finished preparation, with appropriate packaging and labeling, and in compliance 
with the requirements established by the applicable state agencies, state boards of pharmacy, 
federal law, and other regulatory agencies where appropriate.  
 
Professional Compounding Centers of America Pracasil™-Plus (PCCA PP) is a topical silicone-
based compounding base agent. Mayo Clinic Compounding Laboratory produced topical gel 
pentamidine (Pentam-300) in PCCA PP in USP (U.S. Pharmacopeial Convention)-grade facility. 
This gel will be sent to the Research Facility and stored at controlled room temperature (20-25˚C) 
and stable until the end of the study period (4 weeks). Contact Melissa Wendling, Pharm.D., R.Ph. 
507-293-1157 in the Research Pharmacy for more information. 
 
Treatments will be provided in single dose containers for application every 48 hours following 
surgical recovery window (total 14 applications); total duration will be 4 weeks. Approximately 
1.8 mL (0.06 oz) of pentamidine and within-patient placebo control will be topically applied to the 
designated scar region. Single dose containers will ensure each patient receives the same dosage. 
5.4 
Subject Compliance Monitoring 
Subjects will be seen in the outpatient clinic as part of their follow-up (total of three follow-up 
visits in addition to four follow-up phone calls) during study duration. To ensure that study subjects 
are qualified in treatment application, each subject will complete an education session with the RN 
study coordinator. Subject compliance will be monitored during the follow-up visits and phone 
calls. Subjects will also receive a treatment log to record the date and time of treatment application 
as well as record any adverse events. 

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5.4.1 Prior and Concomitant Therapy 
No topical therapies other than either TP or placebo PCCA PP are permitted for the duration of 
the study. 
5.5 
Packaging  
The research pharmacy will order 300 mg Pentam vials via Rochester Methodist Campus (RMC) 
pharmacy purchasing specialists from APP Pharmaceuticals. Pentam vials will be stored within 
the research pharmacy (20-25˚C) and sent to the compounding pharmacy when the study drug 
order is placed. The study drug order will be initiated by the study coordinator following patient 
consent, and as needed based on the date of surgery and 2 week postoperative visit. The Principle 
Investigator will sign the order which is then forwarded to the research pharmacy to be filled. For 
production, 300 mg Pentam (pentamidine isethionate) product will be compounded into non-
aqueous silicone base vehicle (Pracasil™-Plus (PCCA #30-4655; PCCA PP) for 2% topical gel.  
 
The compounding pharmacy will prepare the single containers for storage and dispensation by the 
research pharmacy. The research pharmacy will dispense a specified quantity of containers 
according to patient-specific prescription signed by IRB-authorized prescriber.  The study 
coordinator will pick up the prescription from the research pharmacy and provide to the patient on 
visit 2 (day of surgery) and visit 3 (2 week postop clinic visit). Each dispensation will contain 8 
active and 8 placebo containers to be applied every 48 hours; all containers (used and unused) will 
be returned by the patient at their next follow-up visits.  
 
The research pharmacy will perform randomization schema to determine treatment to dispense for 
proximal versus distal scar areas. The research pharmacy maintains electronic records of 
investigational medication inventory and dispensation activities for the study; thus randomization 
will be performed for enrolled patients electronically via Medidata and Scientific Data 
Management System (SDMS). All Mayo Clinic Research Pharmacy staff members are required 
by policy to complete the Mayo Clinic Human Subject Protection and CITI Good Clinical Practice 
Training once every 3 years. The designated Research Pharmacy staff member assigned primary 
responsibilities for the study reviews all sponsor documents and prepares instruction sheets 
outlining storage, handling, electronic order entry and preparation of all investigational agents as 
indicated in the study protocol and pharmacy manual. 
 
Following randomization, the distal location randomized treatment group (TP or PCCA PP) will 
be placed into a light-resistant bag with the below label on the exterior. Similar label will be 
provided for the proximal treatment group.  Label will include caution statement: “Caution: New 
Drug--Limited by Federal (or United States) law to investigational use."   
 
 
 
 
 
 
 
 
 

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Example of label: 
 
 
5.6 
Masking/Blinding of Study  
This is a double-blinded study; subjects and clinical investigators (physicians, nurse practitioners 
and study delegates) will be blinded to the treatment. Study treatments (either TP or control PCCA 
PP base) will be packaged at the Mayo Clinic Compounding Pharmacy as described above. 
Compounding pharmacists will be aware of the study drug and will provide an unidentified label 
(please see example in Section 5.5) with lot number only for each treatment application. At the 
completion of the study, investigators will be unmasked following data interpretation and 
statistical analysis.   
5.7 
Receiving, Storage, Dispensing and Return 
Per Mayo Clinic Research Pharmacy policy, investigational product(s) are received by study 
personnel acting on behalf of the investigator. Research pharmacy staff verifies information on the 
packing slip matches the contents of the shipment. The following are verified by receiving 
personnel upon receipt of shipment: product identification, sponsor product label, quantity of items 
received, package size(s), lot numbers, expiration dates if available, product condition, and 
maintenance of storage conditions in transit. Any discrepancies in shipment are communicated 
immediately to study sponsor. Investigational products that do not contain an expiration date are 
deemed in date and acceptable to use until notice of expiration is received from sponsor or supplier. 
Research staff contacts sponsors and/or suppliers quarterly to determine if retest date or expiration 
is available. After shipment has been checked and verified, IP is immediately placed in appropriate 
storage conditions as indicated in study documentation. For product delivered with a temperature 
recording device which may be electronically interrogated, data will be downloaded and saved in 
PDF format in the Investigational Drug Services (IDS) electronic management application if the 
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Invoices are dated, signed, scanned, and uploaded electronically into the IDS electronic 
management application at time of receipt. Signed/dated hard copies of invoices are double 
checked per page against scanned uploaded images to ensure scanned image represents a true copy 
of the original document. Once accuracy of the scanned image has been verified, hard copies of 
invoices/shipping documents are discarded.  
 
Product 
No  
NDC  
No.  
11310 
63323-
113-10   
PENTAM® 300 (pentamidine isethiionate for injection) 300 mg, 
lyophilized product in single-dose vials, packages of 10. 
Store dry product at 20° to 25°C (68° to 77°F) [see USP Controlled Room Temperature]. Protect 
from light. Preservative Free.  Discard unused portion. 
 
Mayo Clinic compounding pharmacy will produce the topical gel pentamidine (Pentam-300) in 
PCCA PP in USP (U.S. Pharmacopeial Covention)-grade facility. This gel is then sent to the 
research pharmacy in single dose containers and stored at controlled room temperature (20-25˚C) 
and stable until the end of the study period (4 weeks). 
 
Study coordinators will pick up study drug containers from the research pharmacy for dispensation 
to the patient. Any unused doses will be returned to the research pharmacy to be discarded 
properly.  
5.7.1 Receipt of Drug Supplies 
All drug formulation and compounding will be performed in the Mayo Clinic Compounding 
Laboratory. Pentam-300 and PCCA PP will be purchased from their respective manufacturers and 
shipped to the Research Pharmacy. Purchase will occur via Mayo Clinic Rochester Methodist 
Campus (RMC) pharmacy purchasing specialists from APP Pharmaceuticals. Further production 
details in Section 5.5. This is a single-site study conducted in Mayo Clinic Rochester, MN. 
5.7.2 Storage 
The compounded drug will be stored at controlled room temperature (20-25˚C) in light resistant 
containers placed in amber Ziploc bags. These will be kept secure in the Research Pharmacy until 
receipt of compounding request from the clinical trial coordinator. Special access is required to 
access this location to prevent unintended or unauthorized use of the drug. No special handling is 
required. Since the drug is formulated from a lyophilized, stable product and compounded with a 
non-aqueous base, the topical formulation will be stable for up to 180 days. 
 
Per Mayo Clinic Research Pharmacy policy, the Investigational Pharmacy is a secure, badge access 
area accessible to authorized pharmacy personnel only. Investigational products are stored as per 
study documentation. Temperature monitoring is recorded via a continuous electronic monitoring 
system. All storage areas and devices that contain investigational products are monitored by this 
system. Temperature sensor devices are calibrated per local policy and calibration certificates are 
available upon request. Sponsor specific temperature monitoring devices are not utilized. 
Temperature data from the continuous electronic temperature monitoring system is stored 

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electronically in a dedicated server and is readily retrievable upon request. Local procedures are 
followed in the event of an out of range condition reported by the continuous electronic monitoring 
system. 
5.7.3 Dispensing of Study Drug 
Per Mayo Clinic Research Pharmacy policy, pharmacists and/or pharmacy technicians under the 
supervision of a pharmacist will prepare and dispense investigational products per study protocol. 
Lot numbers and expiration dates of commercial supplies utilized in the preparation of 
investigational products such as syringes, needles, IV bags, tubing, diluents, and standard of care 
products are not tracked. 
 
Single dose containers will help to ensure accurate and consistent dosing across all patients 
participating in the trial. Approximately 1.8 mL (0.06 oz) of TP and placebo PCCA PP will be 
topically applied to the designated scar region. The randomized treatment group (TP versus PCCA 
PP) will be assigned to subjects in a double-blinded manner by the research pharmacist; details in 
Section 5.5. Patients will be educated on topical drug application during the pre-operative clinic 
visit.  The patient will be instructed to apply enough study drug to thoroughly cover the area to be 
treated. It is not necessary to use the entire dose for each treatment application, but a minimum of 
at least half should be used. The patient will be asked to administer a sample product in the 
presence of a study coordinator to verify their application technique and amount. Once the patient 
demonstrates understanding and skill, the patient may personally administer the remaining 
treatments during the trial.  
 
Single dose containers will be distributed to patients at visit 2 and visit 3. Each treatment set will 
contain 8 active and 8 placebo containers to be applied every 48 hours.  Any unused containers 
will be returned by the patient at their next follow-up visit (return bag for used containers will be 
provided). Randomized treatment label will contain instructions for site-specific application. 
Patients are held accountable for keeping track of dispensed drug at all times. If a dose of the drug 
is lost due to unforeseen circumstances, a single replacement may be available.  
 
Regular study drug reconciliation will be performed to document drug assigned, drug dispensed, 
drug returns, and drug remaining.  This reconciliation will be logged on the drug reconciliation 
form, and signed and dated by the study team. 
5.7.4 Return or Destruction of Study Drug 
Per Mayo Clinic Research Pharmacy policy, investigational product and associated wastes 
generated on site as a consequence of participation in a sponsor’s study are disposed of via 
placement in a designated, appropriate waste container per local policy and regulation. Empty 
containers, vials, or empty injectable syringes of investigational products generated from 
preparation and subsequent administration of an investigational product to a patient are not 
retained for monitor inspection following dose preparation; instead these items are disposed of by 
placement in an appropriate waste container based on the hazard risk of the investigational product 
(e.g. hazardous, chemotherapeutic, biohazardous). Disposition is documented in the IDS electronic 
management application. Unless pharmacy is the only unblinded party in a study, IDS pharmacy 
staff will not document investigational product destruction or drug returns within sponsor 
electronic systems. In addition, all investigational products (i.e. tablets, capsules, injections, and/or 

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containers) that are returned by subjects, as well as any returned empty boxes and cartons are 
disposed of in the manner described above immediately after appropriate documentation of such 
return has occurred in the IDS electronic management application. 
 
At the completion of the study, there will be a final reconciliation of amounts of cream 
manufactured, dispensed, returned (if applicable), destroyed and any drug remaining.  This 
reconciliation will be documented, signed and dated.  Any discrepancies noted will be documented 
and investigated, prior to return or destruction of unused study drug.  Drug destroyed on site will 
be documented in the study files. 
6 Study Procedures 
6.1 
Visit 0 (Preoperative screening)  
Patients will provide written consent if they are interested in participating in this trial and meet 
appropriate inclusion and exclusion criteria. 
6.2 
Visit 1 (Preoperative period) 
Patients will receive a comprehensive pre-operative evaluation. This evaluation will gather 
information relating to medical history as well as include a standard clinical exam and necessary 
laboratory studies. Once consent is provided and patient meets inclusion criteria as a qualified 
participant for the study, photographs will be taken of the lesion area with a digital camera and/or 
photography service. Pre-operative ultrasound and/or 3D imaging will also be performed to 
determine initial scar height and morphology. The scar will be assessed using the Vancouver Scar 
Scale (VSS) [28] and the Patient and Observer Scar Assessment Scale (POSAS) [29]. These scales 
will determine the initial level of hypertrophy and scar attributes before treatment initiation. Safety 
evaluation will include assessment of systemic and local safety and thus baseline clinical exam 
with neuropsychiatric evaluation, laboratory studies (including hepatic and renal function, 
complete blood count with differential, blood glucose level and calcium) and baseline cardiac 
monitoring with electrocardiogram (ECG) will be performed. 
 
This visit will include two 5-mm skin punch biopsy (one from distal site and one from proximal 
scar site) performed under local anesthesia in a dedicated procedure room. Alternatively, the first  
punch biopsy may occur prior to the surgical procedure while under anesthesia. This sample will 
be processed by the study staff for histological/molecular evaluation to analyze scar characteristics. 
 
Patients will also be educated on proper treatment application. Treatment regimen and duration 
will be summarized. For example, following their surgical scar excision procedure, they will be 
provided single dose containers with topical study agents. There will be two different formulations 
given to patients; one is the placebo control (PCCA PP) and the other is the active treatment (TP). 
Patients and providers blinded to treatment regions but their treatment label will have appropriate 
instructions for application either at the distal or proximal region. 
 
Based on the distal or proximal region assigned to each formulation by the pharmacist and 
appropriately labeled single dose containers, patients will apply the unit dose.  Compound A (either 
TP or PCCA PP)) will be applied to proximal site and Compound B (either TP or PCCA PP) will 
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The study coordinator will provide a demonstration of application using a sample container 
containing petroleum gel or similar non-therapeutic agent. Prior to treatment application, site 
preparation and wound care techniques will be reviewed (patient education hand-out provided). 
Patients will be advised to carefully clean the skin around the wound using either normal saline 
solution or mild soapy water. Using medical gloves, topical gel will be applied to either the 
proximal or distal wound. Gloves will be changed between each treatment application. Patients 
will then practice topical gel application and wound dressing to verify their understanding. 
Regarding total surface area to be treated, the following guidelines are recommended: 
• Scar length 3 cm to 8 cm: Treat 2 cm proximal (site A) and 2 cm distal (site B)  
• Scar length 8 cm to 10 cm: Treat 3 cm proximal (site A) and 3 cm distal (site B)  
• Scar length 10 cm to 15 cm: Treat 4 cm proximal (site A) and 4 cm distal (site B) 
• Scar length >15cm: Treat 5 cm proximal (site A) and 5 cm distal (site B) 
 
After each treatment application, the treated area will be covered with a non-adherent dressing 
(which will be provided to the patient). There will be a 1-2 cm  untreated gap  between the two 
scar treatment sites (proximal and distal to prevent cross contaminations. 
 
At this visit, a detailed schedule will be provided including date of surgery and follow-up 
visits/phone calls. All procedures, surveys, imaging and testing will be explained. 
6.3 
Visit 2 (Day of Procedure) 
Patients will be undergoing surgical scar excision using local or general anesthesia depending on 
the size of scarring and surgeon preference for excision. Dr. Steven Moran and/or his surgical staff 
will perform the surgical scar excision. Patients will receive their first 2 weeks of study drug with 
de-identified treatment agents to be applied either distal or proximal region of surgical site. 
6.4 
Phone Interview #1 (Week 0, Day 1 postop) 
Patients will be contacted at 24 hours following scar excision. Any adverse effects present will be 
assessed and noted. Measures to address these effects will be taken on a per-patient basis.  
6.5 
Phone Interview #2 (Week 1 postop) 
 Patients will be contacted 1 week following scar excision. Any adverse effects present will be 
assessed and noted. Measures to address these effects will be taken on a per-patient basis.  

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6.6 
Visit 3 (Week 2 postop) 
The scar will be photographed and quality questionnaires (VSS and POSAS) will be filled out. 
Patients will receive their third and fourth week of study drug with de-identified treatment agents 
to be applied either distal or proximal region of surgical site. Post-operative ultrasound and/or 3D 
imaging will be performed to assess scar height. Post-operative safety testing with laboratory 
studies (including hepatic and renal function, complete blood count with differential, blood 
glucose level and calcium) and cardiac monitoring (ECG) will be performed. Additional safety 
evaluation including clinical exam with local safety evaluation to assess tolerability (e.g. erythema, 
edema, vesicle formation, necrosis, ulceration etc.) and neuropsychiatric adverse event assessment 
will be completed. 
6.7 
Phone Interview #3 (Week 3 postop) 
 Patients will be contacted 3 weeks following scar excision. Any adverse effects present will be 
assessed and noted. Measures to address these effects will be taken on a per-patient basis.  
6.8 
Visit 4(Week 4 postop) 
The scar will be photographed and quality questionnaires (VSS and POSAS) will be filled out. 
Post-operative ultrasound and/or 3D imaging will be performed to assess scar height. This visit 
will include two 5-mm skin punch biopsy (one from distal site and one from proximal scar site) 
performed under local anesthesia in a dedicated procedure room. This sample will be processed 
by the study staff for histological/molecular evaluation to analyze scar characteristics. Post-
treatment safety testing with laboratory studies (including hepatic and renal function, complete 
blood count with differential, blood glucose level and calcium) and cardiac monitoring (ECG) 
will be performed. Additional safety evaluation including clinical exam with local safety 
evaluation to assess tolerability (e.g. erythema, edema, vesicle formation, necrosis, ulceration 
etc.) and neuropsychiatric adverse event assessment will be completed.  
 
Follow-up visits may be scheduled per patient request. 
6.9 
Phone Interview #4: (Month 2 post op) 
Patients will be contacted 2 months following scar excision. Any adverse effects present will be 
assessed and noted. Measures to address these effects will be taken on a per-patient basis.  
6.10 Visit #5: (Month 3 post op) 
The scar will be photographed and quality questionnaires (VSS and POSAS) will be completed.  
Patients will be assessed for any adverse events.  
 
Range for phone interviews for call 2 and 3: +/- 1 day 
Range for phone interview for call 4: +/- 1 week 
Range for study visits   3 and 4: +/- 1-3 days 
Range for study visit 5: +/- 2 weeks 
 
 

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6.11 Schedule of Events 
Schedule of Events 
 
Study Activity 
Visit 0 
Pre-op 
Visit 1 
Pre-op 
Visit 2, 
Week 0, Day 0 
Surgery 
 Phone 1, 
  Week 0, 
 Day 1 
Phone 2 
Week 1 
Visit 3, 
Week 2 
Phone 3 
Week 3 
Visit 4, 
Week 4 
Phone 4, 
Month 2 
Visit 5 
Month 3 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
Randomization 
 
X 
 
 
 
 
 
 
 
 
General evaluation, physical exam and vital signsa 
 
X 
 
 
 
 
 
 
 
 
Scar photography 
 
X 
X 
 
 
X 
 
X 
 
X 
Neuropsychiatric exam and local safety evaluation 
(baseline and adverse event assessment)b 
 
X 
 
 
 
X 
 
X 
 
 
Laboratory studiesc  
 
X 
 
 
 
X 
 
X 
 
 
Quality questionnaires (VSS and POSAS)d 
 
X 
 
 
 
X 
 
X 
 
X 
US and/or 3D imaginge 
 
X 
 
 
 
X 
 
X 
 
 
Cardiac monitoring (ECG)f 
 
X 
 
 
 
X 
 
X 
 
 
Treatment application patient education 
 
X 
 
 
 
 
 
 
 
 
Dispense study drug g 
 
 
X 
 
 
X 
 
 
 
 
Surgical scar excision 
 
 
    X 
 
 
 
 
 
 
 
5-mm skin punch biopsy   
 
X 
     
 
 
 
 
X 
 
 
Phone interview 
 
 
 
X 
X 
 
X 
 
X 
 
Adverse event evaluation 
 
 
 
X 
X 
X 
X 
X 
X 
X 
 a: Vital signs include blood pressure, pulse, temperature and respiratory rate. Physical exam includes skin check.  
 b: Clinical exam for neuropsychiatric exam will include evaluation for confusion and hallucination. 
 c: Hepatic and renal function, complete blood count with differential, blood glucose level and calcium 
 d: Quality questionnaires: Vancouver Scar Scale (VSS) and Patient Observer Scar Assessment Scale (POSAS). 
 e: Ultrasound (US) and/or 3D-scanner imaging used to evaluate scar height. 
 f: Safety evaluation will include cardiac monitoring with electrocardiogram (ECG).  
 g: Single dose containers  with de-identified treatment agents (active topical drug and silicone-base only). 
 

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7 Statistical Plan 
7.1 
Sample Size Determination 
This is a first in-human exploratory study to determine the efficacy of topical pentamidine. There 
will be 80% power to detect an effect size of 1.3 standard deviations for the comparison of MED 
between any two treatment groups. This calculation is based a two-sided unpaired t-test with a 
type I error of 0.05. 
7.2 
Statistical Methods 
 
Primary Hypothesis 
This primary hypothesis will be evaluated by paired t-test.  
7.3 
Subject Population(s) for Analysis 
This study will include only subjects who completed ALL study-related procedures and follow up.  
8 Safety and Adverse Events 
8.1 
Definitions 
Unanticipated Problems Involving Risk to Subjects or Others (UPIRTSO) 
Any unanticipated problem or adverse event that meets the following three criteria:  
• Serious: Serious problems or events that results in significant harm, (which may be physical, 
psychological, financial, social, economic, or legal) or increased risk for the subject or 
others (including individuals who are not research subjects). These include: (1) death; (2) 
life threatening adverse experience; (3) hospitalization - inpatient, new, or prolonged; (4) 
disability/incapacity - persistent or significant; (5) birth defect/anomaly; (6) breach of 
confidentiality and (7) other problems, events, or new information (i.e. publications, DSMB 
reports, interim findings, product labeling change) that in the opinion of the local 
investigator may adversely affect the rights, safety, or welfare of the subjects or others, or 
substantially compromise the research data, AND 
• Unanticipated: (i.e. unexpected) problems or events are those that are not already described 
as potential risks in the protocol, consent document, not listed in the Investigator’s 
Brochure, or not part of an underlying disease. A problem or event is "unanticipated" when 
it was unforeseeable at the time of its occurrence. A problem or event is "unanticipated" 
when it occurs at an increased frequency or at an increased severity than expected, AND 
• Related: A problem or event is "related" if it is possibly related to the research procedures. 
Drug Interactions 
No drug interaction studies with Pentam 300 have been conducted. 
Because the nephrotoxic effects may be additive, the concomitant or sequential use of pentamidine 
isethionate and other nephrotoxic drugs such as aminoglycosides, amphotericin B, cisplatin, 
foscarnet, or vancomycin should be closely monitored and avoided, if possible. 
 

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Adverse Event 
An untoward or undesirable experience associated with the use of a medical product (i.e. drug, 
device, biologic) in a patient or research subject. 
The safety evaluation of this topical drug product during the conduct of a clinical trial includes an 
assessment of systemic safety as well as evaluation of local safety.  Evaluation of systemic safety 
addresses warnings, precautions, and adverse events from approved product labeling for 
pentamidine isethionate (e.g., laboratory studies including renal and hepatic function, hematology, 
blood glucose, and calcium; periodic cardiac monitoring with electrocardiogram [ECG], and 
assessment for neuropsychiatric adverse events [including confusion and hallucinations].  The 
evaluation of systemic safety will be conducted at baseline (Visit 1, pre-operative), during 
treatment (Visit 3, Week 2), and after treatment (Visit 4, Week 4) and extended follow-up (Visit 
5, Month 3). The local safety evaluation includes an active assessment of local tolerability (e.g. 
erythema, edema, vesiculation, necrosis, ulceration etc.) using an acceptable scale called the local 
skin reaction (LSR) grading scale [30]. The LSR grading scale uses a 0-4 numerical rating, with 
clinical descriptor and representative photographic images for each rating. The scale provides the 
ability to 
rate 
each 
LSR 
category 
(erythema, 
flaking/scaling, 
crusting, 
swelling, 
vesiculation/postulation and erosion/ulceration) and generate a composite objective LSR score 
[30]. 
Serious Adverse Events 
Adverse events are classified as serious or non-serious.  Serious problems/events can be well 
defined and include; 
• death 
• life threatening adverse experience 
• hospitalization 
• inpatient, new, or prolonged; disability/incapacity 
• persistent or significant disability or incapacity 
• birth defect/anomaly 
• tissue necrosis 
 
and/or per protocol may be problems/events that in the opinion of the sponsor-investigator 
may have adversely affected the rights, safety, or welfare of the subjects or others, or 
substantially compromised the research data. 
 
All adverse events that do not meet any of the criteria for serious, should be regarded as non-
serious adverse events.  
 
Non-serious Adverse Events 
• skin ulcers 
• erythema 
• reaction at site of administration 
• rash 
Routine monitoring of safety evaluation includes an active assessment of local tolerability (e.g. 
erythema, edema, vesiculation, necrosis, ulceration etc.) using an acceptable scale called the 
local skin reaction (LSR) grading scale as outlined below [30].  

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Adverse Event Reporting Period 
For this study, the study treatment follow-up period is defined as 3 months following the last 
administration of study treatment. 

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Preexisting Condition 
A preexisting condition is one that is present at the start of the study.  A preexisting condition is 
recorded as an adverse event if the frequency, intensity, or the character of the condition worsens 
during the study period. 
 
General Physical Examination Findings 
At screening, any clinically significant abnormality is recorded as a preexisting condition.  At the 
end of the study, any new clinically significant findings/abnormalities that meet the definition of 
an adverse event is recorded and documented as an adverse event.  
 
Post-study Adverse Event 
All unresolved adverse events are followed by the sponsor-investigator until the events have 
resolved, the subject is lost to follow-up, or the adverse event is otherwise explained.  At the last 
scheduled visit, the sponsor-investigator instruct each subject to report, to the sponsor-investigator, 
any subsequent event(s) that the subject, or the subject’s personal physician, believes might 
reasonably be related to participation in this study.  
 
Hospitalization, Prolonged Hospitalization or Surgery 
Any adverse event that results in hospitalization or prolonged hospitalization should be 
documented and reported as a serious adverse event unless specifically instructed otherwise in this 
protocol.  Any condition responsible for surgery should be documented as an adverse event if the 
condition meets the criteria for an adverse event.  
8.2 
Recording of Adverse Events 
At each contact with the subject, the study team must seek information on adverse events by 
specific questioning and, as appropriate, by examination.  Information on all adverse events should 
be recorded immediately in the source document, and also in the appropriate adverse event section 
of the case report form (CRF).  All clearly related signs, symptoms, and abnormal diagnostic, 
laboratory or procedure results should recorded in the source document. 
 
All adverse events occurring during the study period must be recorded.  The clinical course of each 
event should be followed until resolution, stabilization, or until it has been ultimately determined 
that the study treatment or participation is not the probable cause.  Serious adverse events that are 
still ongoing at the end of the study period must be followed up, to determine the final outcome.  
Any serious adverse event that occurs during the Adverse Event Reporting Period and is 
considered to be at least possibly related to the study treatment or study participation should be 
recorded and reported immediately. 
8.3 
Reporting of Serious Adverse Events and Unanticipated Problems 
When an adverse event has been identified, the study team will take appropriated action necessary 
to protect the study participant and then complete the Study Adverse Event Worksheet and log.  
The sponsor-investigator will evaluate the event(s) and determine the necessary follow-up and 
reporting required. 

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8.3.1 Sponsor-Investigator reporting: notifying the Mayo IRB 
The sponsor-investigator will report to the Mayo IRB any UPIRTSOs and Non-UPIRTSOs 
according to the Mayo IRB Policy and Procedures. 
 
According to Mayo IRB Policy any serious adverse event (SAE) which the Principal Investigator 
has determined to be a UPIRTSO must be reported to the Mayo IRB as soon as possible but no 
later than 5 working days after the investigator first learns of the problem/event. 
 
Information collected on the adverse event worksheet (and entered in the research database):  
• Subject’s name:  
• Medical record number:  
• Disease/histology (if applicable):  
• The date the adverse event occurred:  
• Description of the adverse event:  
• Relationship of the adverse event to the research (drug, procedure, or intervention*):  
• If the adverse event was expected:  
• The severity of the adverse event: (use a table to define severity scale 1-5**) 
• If any intervention was necessary:  
• Resolution: (was the incident resolved spontaneously, or after discontinuing treatment) 
• Date of Resolution:  
 
All adverse events will be recorded in the Case Report Form. The sponsor-investigator will review 
all adverse events to determine if reports need to be made to the IRB and FDA.  The sponsor-
investigator will sign off on any adverse events that are reported in the Case Report Form within 
24 hours.  For this protocol, only directly related SAEs/UPIRTSOs will be reported to the IRB. 
 
We will use of a table to define Relationship of an Event to the Research and to define the severity 
of each event. 
 
* Relationship Index  
The relationship of an AE to the Investigational Drug is a clinical decision by the sponsor-
investigator (PI) based on all available information at the time of the completion of the CRF and 
is graded as follows: 
 
1. Not related: a reaction for which sufficient information exists to indicate that the etiology is 
unrelated to the study drug; the subject did not receive the study medication or the temporal 
sequence of the AE onset relative to administration of the study medication is not reasonable or 
the event is c1early related to other factors such as the subject's clinical state, therapeutic 
intervention or concomitant therapy. 
 
2. Unlikely: a clinical event, including laboratory test abnormality, with a temporal relationship to 
drug administration which makes a causal relationship improbable and in which other drugs, 
chemicals, or underlying disease provide plausible explanations. 
 

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3. Possible: a clinical event, including laboratory test abnormality, with a reasonable time sequence 
to administration of the drug but which could also be explained by concurrent disease or other 
drugs or chemicals; information on drug withdrawals may be lacking are unclear. 
 
4. Probable: a clinical event including laboratory test abnormality, with a reasonable time sequence 
to administration of the drug, unlikely to be attributed to concurrent disease or other drugs or 
chemicals and which follows a clinically reasonable response on withdrawal (de-challenge): re-
challenge information is not required to fulfi1 this definition. 
 
5. Definite: a reaction that follows a reasonable temporal sequence from administration of the drug, 
or in which the drug level has been established in body fluids or tissues, that follows a known or 
expected response pattern to the suspected drug, and that is confirmed by improvement on stopping 
or reducing the dosage of the drug, and reappearance of the reaction on repeated exposure (re-
challenge). 
 
** Severity Index  
The maximum intensity of an AE during a day should be graded according to the definitions below 
and recorded in details as indicated on the CRF. If the intensity of an AE changes over a number 
of days, then separate entries should be made having distinct onset dates.  
 
1. Mild: AEs are usually transient, requiring no special treatment, and do not interfere with 
patient’s daily activities. 
 
2. Moderate: AEs typically introduce a low level of inconvenience or concern to the patient and 
may interfere with daily activities, but are usually ameliorated by simple therapeutic measures. 
 
3. Severe: AEs interrupt a patient's usual daily activity and traditionally require systemic drug 
therapy or other treatment. 
8.3.2 Sponsor-Investigator reporting: Notifying the FDA 
The sponsor-investigator will report to the FDA all serious, unexpected and suspected adverse 
reactions according to the required IND Safety Reporting timelines, formats and requirements. 
 
Unexpected fatal or life threatening suspected adverse reactions where there is evidence to suggest 
a causal relationship between the study drug/placebo and the adverse event, will be reported as a 
serious suspected adverse reaction.  This will be reported to the FDA on FDA Form 3500A, no 
later than 7 calendar days after the sponsor-investigator’s initial receipt of the information about 
the event. 
 
Other unexpected serious suspected adverse reactions where there is evidence to suggest a causal 
relationship between the study drug/placebo and the adverse event, will be reported as a serious 
suspected adverse reaction.  This will be reported to the FDA on FDA Form 3500A, no later than 
15 calendar days after the sponsor-investigator’s initial receipt of the information about the event. 
 
Any clinically important increase in the rate of serious suspected adverse reactions over those 
listed in the protocol or product insert will be reported as a serious suspected adverse reaction.  

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This will be reported to the FDA on FDA Form 3500A no later than 15 calendar days after the 
sponsor-investigator’s initial receipt of the information about the event. 
 
Findings from other studies in human or animals that suggest a significant risk in humans exposed 
to the drug will be reported.  This will be reported to the FDA on FDA Form 3500A, no later than 
15 calendar days after the sponsor-investigators initial receipt of the information about the event. 
8.4 
Unmasking/Unblinding Procedures 
 
The study statistician will be responsible for revealing the treatment assignments (i.e. unblinding) 
when necessary. Since no interim analysis is planned for this study, unblinding will occur only 
when 1) a serious adverse event is observed and the treatment assignment must be made known 
and/or 2) at the conclusion of the study at the time of data analysis to evaluate treatment safety and 
preliminary efficacy. 
8.5 
Stopping Rules  
The stopping rules specified below are based on the knowledge available at study development. 
We note that the Adverse Event Stopping Rule may be adjusted at any time during the conduct 
of the trial and in consideration of newly acquired information regarding the adverse event 
profile of the treatment under investigation. The study team may choose to suspend accrual 
because of unexpected adverse event profiles that have not crossed the specified rule below. 
 
Accrual will be temporarily suspended to this study if at any time we observe events considered 
at least possibly related to study treatment (i.e. an adverse event with attribute specified as 
“possible”, “probable”, or “definite”) that satisfy either of the following: 
 
• 
If the first two patients or 3 consecutive at any point experience a SAE deemed related to 
study drug as defined in section 8.3. 
• 
If a patient death considered related to the agent occurs. 
 
The protocol will be reviewed by the study team. It will not be re-opened without proper 
protocol modification. If no modifications are possible then the study will close and be 
permanently stopped. 
 
If a subject experiences an adverse event assessed as ≥ Grade 2 in the System Organ Classes 
(SOCs) of Cardiac Disorders and Blood and Lymphatic System disorders, or ≥ Grade 3 for all 
other SOCs, according to Common Terminology Criteria for Adverse Events (CTCAE v4), the 
subject will not receive additional doses.  Subjects should remain in the study and be followed 
until the adverse event resolves or stabilizes. 
 
We note that we will review grade 4, and 5 adverse events deemed “unrelated” or “unlikely to be 
related” to verify their attribution and to monitor the emergence of a previously unrecognized 
treatment-related adverse event. 

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8.6 
Medical Monitoring 
It is the responsibility of the Principal Investigator to oversee the safety of the study at his/her site.  
This safety monitoring will include careful assessment and appropriate reporting of adverse events 
as noted above, as well as the construction and implementation of a site data and safety-monitoring 
plan (see section 10  “Study Monitoring, Auditing, and Inspecting”).  Medical monitoring will 
include a regular assessment of the number and type of serious adverse events. 
9 Data Handling and Record Keeping 
9.1 
Confidentiality 
Information about study subjects will be kept confidential and managed according to the 
requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).  Those 
regulations require a signed subject authorization informing the subject of the following:  
• What protected health information (PHI) will be collected from subjects in this study 
• Who will have access to that information and why 
• Who will use or disclose that information 
• The rights of a research subject to revoke their authorization for use of their PHI.  
 
In the event that a subject revokes authorization to collect or use PHI, the investigator, by 
regulation, retains the ability to use all information collected prior to the revocation of subject 
authorization.  For subjects that have revoked authorization to collect or use PHI, attempts should 
be made to obtain permission to collect at least vital status (long term survival status that the 
subject is alive) at the end of their scheduled study period. 
9.2 
Source Documents 
Source data is all information, original records of clinical findings, observations, or other activities 
in a clinical trial necessary for the reconstruction and evaluation of the trial.  Source data are 
contained in source documents.  Examples of these original documents, and data records include: 
hospital records, clinical and office charts, laboratory notes, memoranda, subjects’ diaries or 
evaluation checklists, pharmacy dispensing records, recorded data from automated instruments, 
copies or transcriptions certified after verification as being accurate and complete, microfiches, 
photographic negatives, microfilm or magnetic media, x-rays, subject files, and records kept at the 
pharmacy, at the laboratories, and at medico-technical departments involved in the clinical trial. 
9.3 
Case Report Forms 
The study case report form (CRF) is the primary data collection instrument for the study.  All data 
requested on the CRF must be recorded.  All missing data must be explained.  If a space on the 
CRF is left blank because the procedure was not done or the question was not asked, write “N/D”.  
If the item is not applicable to the individual case, write “N/A”.  All entries should be printed 
legibly in black ink.  If any entry error has been made, to correct such an error, draw a single 
straight line through the incorrect entry and enter the correct data above it.  All such changes must 
be initialed and dated.  Do not erase or use “white-out” for errors.  For clarification of illegible or 
uncertain entries, print the clarification above the item, then initial and date it.  If the reason for 
the correction is not clear or needs additional explanation, neatly include the details to justify the 
correction. 
 

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Data Management 
 
Validation of source data will be performed by the investigator or his delegates. 
 
Data Processing 
 
Raw data will be recorded in case report form and then transferred into a password-secured 
electronic database. 
 
Data Security and Confidentiality 
 
Data will be stored on the secure Mayo Clinic network, which is backed up nightly. 
 
Data Quality Assurance 
 
Data will be audited internally by the study investigator and co-investigators to rule out errors in 
data entry and data collection. MED data will be cross-validated by images of skin obtained during 
the course of the study. 
9.4 
Records Retention 
The sponsor-investigator will maintain records and essential documents related to the conduct of 
the study for at least 2 years.  These will include subject case histories and regulatory documents. 
 
The sponsor-investigator will retain the specified records and reports for the longer of these 
periods; 
1. Up to 2 years after the marketing application is approved for the drug; or, if a marketing 
application is not submitted or approved for the drug, until 2 years after shipment and 
delivery of the drug for investigational use is discontinued and the FDA has been so 
notified. OR 
2. As outlined in the Mayo Clinic Research Policy Manual –“Retention of and Access to 
Research Data Policy” http://mayocontent.mayo.edu/research-policy/MSS_669717   
10 Study Monitoring, Auditing, and Inspecting 
10.1 Study Monitoring Plan 
This study will be monitored on a routine basis during the conduct of the trial.  The Mayo Clinic 
Office of Research Regulatory Support will provide clinical monitoring for the trial as a service 
for the sponsor-investigator.  Clinical trial monitoring requires review of the study data generated 
throughout the duration of the study to ensure the validity and integrity of the data along with the 
protection of human research subjects.  This will assist sponsor-investigators in complying with 
Food and Drug Administration regulations. 
  
The investigator will allocate adequate time for such monitoring activities.  The Investigator will 
also ensure that the monitor or other compliance or quality assurance reviewer is given access to 
all the study-related documents and study related facilities (e.g. pharmacy, diagnostic laboratory, 
etc.), and has adequate space to conduct the monitoring visit. 

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Data and safety monitoring provides a clinical investigation with a system for appropriate 
oversight and attention to the protection of human subjects by the investigator, research team, or 
an independent reviewer. A Data and Safety Monitoring Plan is a quality assurance plan for a 
research study.  A written Data and Safety Monitoring Plan (DSMP) prospectively identifies and 
documents monitoring activities intended to protect the safety of the subjects, the validity of the 
data and the integrity of the research study. The DSMP may also identify when to terminate a 
subject’s participation (i.e. individual stopping rules) and/or the appropriate termination of a study 
(i.e. study stopping rules). 
10.2 Auditing and Inspecting 
The investigator will permit study-related monitoring, audits, and inspections by the IRB, the 
sponsor, and government regulatory agencies, of all study related documents (e.g. source 
documents, regulatory documents, data collection instruments, study data etc.).  The investigator 
will ensure the capability for inspections of applicable study-related facilities (e.g. pharmacy, 
diagnostic laboratory, etc.). 
 
Participation as an investigator in this study implies acceptance of potential inspection by 
government regulatory authorities and applicable compliance offices. 
11 Ethical Considerations 
This study is to be conducted according to United States government regulations and Institutional 
research policies and procedures. 
 
This protocol and any amendments will be submitted to a properly constituted local Institutional 
Review Board (IRB), in agreement with local legal prescriptions, for formal approval of the study.  
The decision of the IRB concerning the conduct of the study will be made in writing to the sponsor-
investigator before commencement of this study. 
 
All subjects for this study will be provided a consent form describing this study and providing 
sufficient information for subjects to make an informed decision about their participation in this 
study.  This consent form will be submitted with the protocol for review and approval by the IRB 
for the study.  The formal consent of a subject, using the Approved IRB consent form, must be 
obtained before that subject undergoes any study procedure.  The consent form must be signed by 
the subject or the subject’s legally authorized representative, and the individual obtaining the 
informed consent. 
12 Study Finances 
12.1 Funding Source 
This study is financed through a grant from the Mayo Clinic. 
13 Publication Plan 
The sponsor-investigator has the primary responsibility for publication of the results of the study.  
The trial will be registered on clinicaltrials.gov prior to enrollment and results published, as 
applicable. 

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14 References 
 
1. 
Nemeth, A.J., Keloids and hypertrophic scars. J Dermatol Surg Oncol, 1993. 19(8): p. 
738-46. 
2. 
Teofoli, P., et al., Expression of Bcl-2, p53, c-jun and c-fos protooncogenes in keloids 
and hypertrophic scars. J Dermatol Sci, 1999. 22(1): p. 31-7. 
3. 
Deitch, E.A., et al., Hypertrophic burn scars: analysis of variables. J Trauma, 1983. 
23(10): p. 895-8. 
4. 
Lewis, W.H. and K.K. Sun, Hypertrophic scar: a genetic hypothesis. Burns, 1990. 16(3): 
p. 176-8. 
5. 
Berman, B., et al., Prevention and management of hypertrophic scars and keloids after 
burns in children. J Craniofac Surg, 2008. 19(4): p. 989-1006. 
6. 
Chang, P., et al., Prospective, randomized study of the efficacy of pressure garment 
therapy in patients with burns. J Burn Care Rehabil, 1995. 16(5): p. 473-5. 
7. 
O'Brien, L. and D.J. Jones, Silicone gel sheeting for preventing and treating hypertrophic 
and keloid scars. Cochrane Database Syst Rev, 2013(9): p. CD003826. 
8. 
Wittenberg, G.P., et al., Prospective, single-blind, randomized, controlled study to assess 
the efficacy of the 585-nm flashlamp-pumped pulsed-dye laser and silicone gel sheeting 
in hypertrophic scar treatment. Arch Dermatol, 1999. 135(9): p. 1049-55. 
9. 
Alster, T., Laser scar revision: comparison study of 585-nm pulsed dye laser with and 
without intralesional corticosteroids. Dermatol Surg, 2003. 29(1): p. 25-9. 
10. 
Roques, C. and L. Teot, The use of corticosteroids to treat keloids: a review. Int J Low 
Extrem Wounds, 2008. 7(3): p. 137-45. 
11. 
Mustoe, T.A., et al., International clinical recommendations on scar management. Plast 
Reconstr Surg, 2002. 110(2): p. 560-71. 
12. 
Shaffer, J.J., S.C. Taylor, and F. Cook-Bolden, Keloidal scars: a review with a critical 
look at therapeutic options. J Am Acad Dermatol, 2002. 46(2 Suppl Understanding): p. 
S63-97. 
13. 
Arno, A.I., et al., Up-to-date approach to manage keloids and hypertrophic scars: a 
useful guide. Burns, 2014. 40(7): p. 1255-66. 
14. 
Lumenta, D.B., E. Siepmann, and L.P. Kamolz, Internet-based survey on current practice 
for evaluation, prevention, and treatment of scars, hypertrophic scars, and keloids. 
Wound Repair Regen, 2014. 22(4): p. 483-91. 
15. 
Perkins, K., R.B. Davey, and K.A. Wallis, Silicone gel: a new treatment for burn scars 
and contractures. Burns Incl Therm Inj, 1983. 9(3): p. 201-4. 
16. 
Suetak, T., et al., Effects of silicone gel sheet on the stratum corneum hydration. Br J 
Plast Surg, 2000. 53(6): p. 503-7. 
17. 
Ahn, S.T., W.W. Monafo, and T.A. Mustoe, Topical silicone gel for the prevention and 
treatment of hypertrophic scar. Arch Surg, 1991. 126(4): p. 499-504. 
18. 
Sawada, Y. and K. Sone, Hydration and occlusion treatment for hypertrophic scars and 
keloids. Br J Plast Surg, 1992. 45(8): p. 599-603. 
19. 
Murison, M. and W. James, Preliminary evaluation of the efficacy of dermatix silicone 
gel in the reduction of scar elevation and pigmentation. J Plast Reconstr Aesthet Surg, 
2006. 59(4): p. 437-9. 

Topical Pentamidine for Hypertrophic Scarring 
 
Version 7.0 
 
 
Revised July 5, 2018 
Page 40 of 40 
Alexander Meves, MD 
 
CONFIDENTIAL 
20. 
Ud-Din, S., S.W. Volk, and A. Bayat, Regenerative healing, scar-free healing and scar 
formation across the species: current concepts and future perspectives. Exp Dermatol, 
2014. 23(9): p. 615-9. 
21. 
Gauglitz, G.G., et al., Hypertrophic scarring and keloids: pathomechanisms and current 
and emerging treatment strategies. Mol Med, 2011. 17(1-2): p. 113-25. 
22. 
El-Tanani, M.K., et al., The regulation and role of osteopontin in malignant 
transformation and cancer. Cytokine Growth Factor Rev, 2006. 17(6): p. 463-74. 
23. 
Shinohara, M.L., et al., Osteopontin expression is essential for interferon-alpha 
production by plasmacytoid dendritic cells. Nat Immunol, 2006. 7(5): p. 498-506. 
24. 
Heim, J.B., et al., Myosin-1E interacts with FAK proline-rich region 1 to induce 
fibronectin-type matrix. Proc Natl Acad Sci U S A, 2017. 114(15): p. 3933-3938. 
25. 
Kural, K.C., et al., Pathways of aging: comparative analysis of gene signatures in 
replicative senescence and stress induced premature senescence. BMC Genomics, 2016. 
17(Suppl 14): p. 1030. 
26. 
Mori, R., T.J. Shaw, and P. Martin, Molecular mechanisms linking wound inflammation 
and fibrosis: knockdown of osteopontin leads to rapid repair and reduced scarring. J Exp 
Med, 2008. 205(1): p. 43-51. 
27. 
Singer, A.J., H.C. Thode, Jr., and S.A. McClain, Development of a histomorphologic 
scale to quantify cutaneous scars after burns. Academic emergency medicine : official 
journal of the Society for Academic Emergency Medicine, 2000. 7(10): p. 1083-8. 
28. 
Baryza, M.J. and G.A. Baryza, The Vancouver Scar Scale: an administration tool and its 
interrater reliability. J Burn Care Rehabil, 1995. 16(5): p. 535-8. 
29. 
Draaijers, L.J., et al., The patient and observer scar assessment scale: a reliable and 
feasible tool for scar evaluation. Plast Reconstr Surg, 2004. 113(7): p. 1960-5; discussion 
1966-7. 
30. 
Rosen, R., et al., A new, objective, quantitative scale for measuring local skin responses 
following topical actinic keratosis therapy with ingenol mebutate. Dermatol Ther 
(Heidelb), 2014. 4(2): p. 207-19.