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Sonophoresis in Transdermal Drug Deliverys

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 Ultrasonics 54 (2014) 5665

Contents lists available at SciVerse ScienceDirect

Ultrasonics
journal homepage: www.elsevier.com/locate/ultras

Sonophoresis in transdermal drug deliverys

Donghee Park a, Hyunjin Park b, Jongbum Seo a,, Seunghun Lee c
a
Department of Biomedical Engineering, Yonsei University, Wonju 220-710, Republic of Korea
b
School of Electronic and Electrical Engineering, Sungkyunkwan University, Suwon 440-746, Republic of Korea
c
Department of Dermatology, YongdongSeverance Hospital, Yonsei University College of Medicine, Seoul 135-720, Republic of Korea

a r t i c l e i n f o a b s t r a c t

Article history: Transdermal drug delivery (TDD) has several signicant advantages compared to oral drug delivery,
Received 23 February 2013 including elimination of pain and sustained drug release. However, the use of TDD is limited by low skin
Received in revised form 1 June 2013 permeability due to the stratum corneum (SC), the outermost layer of the skin. Sonophoresis is a tech-
Accepted 2 July 2013
nique that temporarily increases skin permeability such that various medications can be delivered non-
Available online 16 July 2013
invasively. For the past several decades, various studies of sonophoresis in TDD have been performed
focusing on parameter optimization, delivery mechanism, transport pathway, or delivery of several drug
Keywords:
categories including hydrophilic and high molecular weight compounds. Based on these various studies,
Sonophoresis
Inertia Cavitation
several possible mechanisms of sonophoresis have been suggested. For example, cavitation is believed to
Microstreaming be the predominant mechanism responsible for drug delivery in sonophoresis. This review presents
details of various studies on sonophoresis including the latest trends, delivery of various therapeutic
drugs, sonophoresis pathways and mechanisms, and outlook of future studies.
2013 Elsevier B.V. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
1.1. The use of ultrasound in transdermal drug delivery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
2. Mechanisms of sonophoresis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
2.1. Thermal effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
2.2. Cavitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
2.2.1. Stable cavitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
2.2.2. Inertial cavitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
3. Transport pathway in the skin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
3. Transport pathway in the skin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
4. Synergistic effects ofsonophoresis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
5. Applications of sonophoresis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
6. New trends in sonophoresis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
7. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

1. Introduction

1.1. The use of ultrasound in transdermal drug delivery

Transdermal drug delivery (TDD) is a non-invasive, topical

Corresponding author. Address: Department of Biomedical Engineering, Yonsei
University, 304 Medical Industry Techno Tower, Wonju, Gangwon 220-710,
Republic of Korea. Tel.: +82 (0)33 760 2961; fax: +82 (0)33 765 5483.
E-mail address: jongbums@yonsei.ac.kr (J. Seo).
administration method for therapeutic agents. TDD represents a
considerable technological advance compared to oral delivery be-
cause gastrointestinal degradation and rst-pass metabolism
through the liver are avoided [1]. Despite these advantages, the

0041-624X/$ - see front matter 2013 Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.ultras.2013.07.007
 D. Park et al. / Ultrasonics 54 (2014) 5665
use of TDD has been limited by innate barrier functions of the skin
[2]. The skin, which consists of several layers including the stratum
corneum (SC), epidermis, and dermis, is the primary defense sys-
tem of the body [3,4] (Fig. 1). The functions of skin include main-
tenance of body temperature, blockage of ultra-violet radiation,
and providing a defense against harmful external pathogens such
as bacteria and toxins. The most important layer of the skin that
provides substantial protection from pathogens is the SC [5]. The
SC is composed of corneocytes interspersed in a laminate of com-
pressed keratin and intercorneocyte lipid lamellae, functions to
conserve water and electrolytes, and is selectively permeable to
certainsubstances such as drugs (see Fig. 1). Naturally, the SC has
a very low permeability to foreign molecules and is thus the main
obstacle of TDD [6]. Because of this barrier, available transdermal
medicines are small molecules (<500 Da) that are active at low
blood concentrations of a few ng/ml or less [7,8]. A number of
methods have been proposed to overcome the natural barrier func-
tion of the skin, such as skin patches [9,10], iontophoresis [1113],
use of chemical enhancers [14,15], and ultrasound methods
[1618]. The traditional TDD systemincludes an impermeable
patch and allows for controlled drug release over time. Occlusion
of the skin traps the natural epidermal moisture and causes an
increase in the water content and skin membrane swelling, which
result in a compromise of the skin barrier function [19]. Iontopho-
resis, which utilizes small electric currents, can enhance transport
across the skin by a number of possible mechanisms such as elec-
trophoretic and electro-osmotic driving forces [20,21]. Chemical
enhancers such as Azone (1-dodecylazacycloheptan-2-one or
laurocapram), DMSO (dimethyl sulphoxide), and surfactants in-
crease transdermal drug transport via several mechanisms such
as increased drug solubility in the donor formulation and drug par-
titioning into the SC because of the solvent properties of these
compounds [2224]. Specically, DMSO, a commonly used topical
analgesic, anti-inammatory, and antioxidant, has been used in
studies of skeletal muscle as a selective antioxidant or as a solvent
for numerous drugs [25]. Lastly, sonophoresis, which uses ultra-
sound as a physical enhancer for systemic drug delivery, has also
been shown to effectively deliver various types of drugs regardless
of their electrical characteristics and can easily be coupled with
other TDD methods to enhance drug delivery rates [2628]. Histor-
ically, sonophoresis was rst reported in the 1950s along with
other therapeutic ultrasound applications such as noninvasive
treatment of neurological disorders including Parkinsons disease
[29,30]. Sonophoresis operates at frequencies in the range of
20 kHz16 MHz and intensities up to 14 W/cm2 (spatial average
pulse average intensity, ISAPA) to enhance skin permeability
[17,31]. Numerous studies of sonophoresis have been shown to in-
crease skin permeability to various drugs and therapeutic com-
pounds, including hydrophilic and large molecular weight
compounds, especially under low frequency sonophoresis.
Fig. 1. Cross section of human skin (left). Barrier function of the stratum corneum (right). This gure is reproduced from Ref. [3].
57
In this review, we focused on sonophoresis among TDD meth-
ods. The remainder of this article is divided into six sections. The
mechanism of sonophoresis is explained in section two, and sec-
tion three covers the transport pathway of sonophoresis. In section
four, a number of applications using various drugs are introduced.
Section ve introduces new approaches to enhance sonophoresis.
The nal section summarizes sonophoresis and provides an out-
look of future studies.
2. Mechanisms of sonophoresis
Although sonophoresis is known to increase skin permeability,
the fundamental mechanism is still not clearly understood or char-
acterized. Several proposed mechanisms of sonophoresis include
thermal effects by absorption of ultrasound energy and cavitation
effects caused by collapse and oscillation of cavitation bubbles in
the ultrasound eld. Between these two effects, cavitation is be-
lieved to be the predominant mechanism responsible for sonopho-
resis [3234].
2.1. Thermal effects
When ultrasound passes through a medium, energy is partially
absorbed [35]. In the human body, ultrasound energy absorbed by
tissue causes a local temperature increase that is dependent upon
ultrasound frequency, intensity, area of the ultrasound beam, dura-
tion of exposure, and the rate of heat removal by blood ow or con-
duction [36]. The resultant temperature increase of the skin may
enhance permeability due to an increase in diffusivity of the skin.
Merino et al. reported enhanced transdermal permeability caused
by this temperature increase [37]. The skin temperature was in-
creased by 20 C with low frequency ultrasound (20 kHz), and
the delivery of mannitol was enhanced 35-fold. However, the
delivery of mannitol was only 25% when the skin was heated to
a similar level without ultrasound. These contradictory results sug-
gest that thermal energy alone may not play a signicant role in
TDD, even though the temperature increase may affect the skin
permeability.
2.2. Cavitation
Cavitation refers to the creation of cavities as well as expansion,
contraction, and distortion of pre-existing gaseous bubbles in a li-
quid medium [38]. Acoustic cavitation occurs due to the nucleation
of small gaseous cavities during acoustic pressure cycles. The like-
lihood of cavitation occurrence is closely related to ultrasound fre-
quency as well as bubble characteristics such as size and shape.
Since cavitation nuclei in biologic environments are random in
size, type, and shape, the likelihood of cavitation is unpredictable.
Cavitation can be further classied into two categories, stable and
58 D. Park et al. / Ultrasonics 54 (2014) 5665
Fig. 2. Illustration of the differences between uniform shear and surface diver-
gence. (a) Uniform, high shear stress, no divergence and thus no stretch of cell
surface, (b) high rate of positive divergence (as well as shear stress), cell/cell
membrane in stretch-activated state, (c) high rate of negative divergence (as well as
shear stress), and cell/cell membrane compressed together. This gure is repro-
duced from Ref. [43].
inertial cavitation, according to the activity of gaseous bubbles in
relation to the acoustic eld [16].
2.2.1. Stable cavitation
Stable cavitation corresponds to a continuous oscillation of bub-
bles around the equilibrium radius in response to relatively lower
acoustic pressures in an acoustic eld [39]. Bubble oscillation
around asymmetric boundary conditions by stable cavitation leads
to a phenomenon called microstreaming, which can generate
high velocity gradients and hydrodynamic shear stresses [40].
Microstreaming results from the unidirectional ow of uid in re-
sponse to bubble dynamics in an acoustic eld. The characteristics
of microstreaming are determined by uid properties such as
acoustic attention, viscosity, and density, as well as the ultrasound
characteristics including temporal average intensity, frequency,
transducer aperture size, and pressure amplitude [41]. The velocity
of microstreaming decreases with increasing uid viscosity and in-
creases with increasing acoustic attenuation [42]. Collis et al. stud-
ied several patterns of microstreaming and showed that many
patterns are possible around a microbubble. Each microstreaming
pattern also generated different shear stress with distributions of
compression and stretch in the vicinity of a bubble[43]. The states
of uniform shear stress and two types of divergence are illustrated
in Fig. 2. Theoretical and experimental studies have shown that
microstreaming near a cell boundary can affect a cell membrane
Fig. 3. Schematic sketching of cavitation occurring in a variety of sites such as coupling medium, skin surface, and skin tissue. Cavitation occurs preferentially at the interface
between keratinocytes and lipid bilayers.
[44,45]. Second-order microstreaming ow may generate ow
elds that develop shear stresses over a cell membrane, resulting
in tension and stretching on membrane walls that cause channel
activation, allowing delivery of compounds such as DNA for thera-
peutic purposes [46,47]. Fig. 3 shows possible sites in which the
cavitation effect may occur. Cavitation nuclei and air pockets in
TDD can be formed in intracellular and/or intercellular structures.
In addition, bubbles can be formed on the skin and coupling med-
ium at the skin surface. However, small gaseous nuclei are more
resistant to oscillation within densely packed tissue. This becomes
especially apparent during high frequency (P1 MHz) sonophoresis
when skin density variations occur rapidly due to relatively short
wavelengths in comparison to that at low frequency. Therefore,
cavitation may preferentially occur within the coupling medium
between the ultrasound transducer and skin surface and may
locally increase skin permeability[40,43,48,49].
2.2.2. Inertial cavitation
Inertial cavitation corresponds to the violent growth and col-
lapse of bubbles that can occur within a period of a single cycle
or a several cycles and is dependent on acoustic pressure as well
as frequency and the size of bubble [40,50,51]. Apfel and Holland
derived a mechanical index (MI) to represent the likelihood of iner-
tial cavitation [52]. Organizations such as the AIUM, NEMA, and
FDA have adopted the MI equation (see following equation:)
Pneg MPa
MI p 1
f0 MHz
In the MI equation, Pneg represents the maximum negative pres-
sure in the region of interest divided by the square root of the cen-
ter frequency. The likelihood of inertial cavitation increases with
decreasing frequency and increasing peak negative pressure [53].
For inertial cavitation, lower frequencies give bubbles more time
to grow in the expansion cycle and consequently produce a more
violent collapse during the compression cycle. The violent collapse
of cavitation bubbles may generate either shock waves in the bulk
of the liquid or a micro-jet near a boundary, which is referred to as
asymmetric bubble collapse. Fig. 4 schematically shows the shock
wave and micro-jet produced by inertial cavitation events. A
 D. Park et al. / Ultrasonics 54 (2014) 5665 59

Fig. 4. Three possible modes through which inertial cavitation may enhance SC
permeability. (a) Spherical collapse near the SC surface emits shock waves, (b)
impact of an acoustic micro-jet on the SC surface, and (c) micro-jets physically
penetrating into the SC. The gure is reproduced from Ref. [32].

spherical bubble collapse yields high-pressure cores that emit

shock waves with amplitudes exceeding 10 kbar [54]. The disrup-
tion of a target exposed to such a pressure wave may occur through
relative particle displacement, compressive failure, tensile stress,
or shear strain [55]. When a bubble collapses asymmetrically near
a boundary, it generally produces a welldened, high velocity mi-
cro-jet [56,57]. Micro-jet distortion due to bubble collapse depends
on the surface encountered by the bubble. If the surface is larger
than the resonant size of the bubble (radius of 1150 lm at
approximately 5 MHz20 kHz), the resulting collapse will be in
the form of a micro-jet (Fig. 4) [33,52]. As shown in Fig. 3, inertial
cavitation has the potential to take place in keratinocytes, lipid bi-
layer regions, and crevices of hair follicles lled with coupling
medium [47]. Shock waves generated by inertial cavitation can
cause structural alterations in the surrounding keratinocyte-lipid Fig. 5. Ultra-structural changes of the SC after treatment with low frequency
interface regions, resulting in the creation of diffusion channels sonophoresis. (a) After 5 min of treatment with low frequency sonophoresis, 1- to
2-lm-sized pores (b, arrowheads) were observed on the SC surfaces that were not
through which drugs may be potentially delivered. Furthermore,
observed on the normal SC surface. (b) Scanning electron microscopy ndings on
impact pressure of the micro-jet on the skin surface may enhance the SC surface of mouse skin treated with low frequency sonophoresis. Scale
SC permeability by disrupting SC lipid bilayers [58]. A micro-jet bar = 2 lm. The gure is reproduced from Ref. [59].
possessing a radius approximately one-tenth of the maximum
bubble diameter impacts the SC surface without penetrating.
When combined, these factors lead to lipid bilayer disorder and
formation of aqueous channels in the skin through which drugs
can permeate [17]. Lee et al. used scanning electron microscopy
to demonstrate ultra-structural changes of the SC surface after
treatment with low frequency sonophoresis [59]. Approximately
1- to 2-lm-sized pores were observed in scanning electron micros-
copy images of corneocyte surfaces after low frequency sonophore-
sis (frequency: 25 kHz, intensity: 800 mW/cm2, pulse duration:
continuous, sonication time: 5 min) (Fig. 5). Although skin damage
due to cavitation needs to be researched further, some of the prim-
itive in vitro studies may provide further information. Zhong et al.
presented evidence of cavitation damage and cell membrane
recovery after ultrasound exposure using scanning electron
microscopy [60]. In normal cells, morphologic changes were not
observed in overall shape, but randomly positioned pores
0.10.5 lm in diameter appeared on cell membranes exposed to
sonicated ultrasound. Cells allowed 1 min recovery times after
ultrasound sonication showed evidence that membranes were
mostly resealed. Additionally, sonicated cells xed 1 h after ultra-
sound exposure showed minimal evidence of pores on the mem- Fig. 6. Schematic, cross-sectional drawing of skin. Skin is composed of a dermis and
brane surface. These results suggest that cell membranes an epidermis. Cells proliferate in the basal layer of the epidermis. Upon leaving the
exposed to sonicated ultrasound may eventually recover to normal basal layer, cells begin to differentiate and migrate toward the skin surface. At the
stratum granulosum and stratum corneum interface, nal differentiation occurs,
intact forms. Although this observation was limited to temporary
during which viable cells transform into dead cells lled with keratin (corneocytes).
damage and recovery of cells by ultrasound sonication, it could The corneocytes are surrounded by a cell envelope composed of cross-linked
provide a general idea of temporal responses of various biologic proteins and a covalently bound lipid envelope (see arrow). The corneocytes are
barriers to cavitation. embedded in lipid lamellar regions, which are orientated parallel to the corneocyte
In addition, cavitation effects can occur at high and low surface. Substances diffuse across the skin following the tortuous pathway in the
intercellular lamellar regions (a) or other sites of structural disorganization caused
frequency sonophoresis in TDD. The correlation between the
by enhancer compounds (b). C = corneocyte lled with keratin. Bar = 100 nm. This
appliedultrasound frequency and resonant frequency of cavitation gure is reproduced from Ref. [63].
60 D. Park et al. / Ultrasonics 54 (2014) 5665

nuclei on the skin plays a major role in enhancing cavitation
effects. However, resonant frequencies of cavitation nuclei on the
skin cannot be predicted. Therefore, adopting low frequency (e.g.,
100 kHz) ultrasound is considered suitable to increase cavitation
effects in TDD [61].
3. Transport pathway in the skin
Signicant efforts have been made to unveil skin penetration
pathways in sonophoresis. The passive transdermal transport of
drugs occurs mostly through lipid bilayers of the SC. Due to the
inhomogeneous and anisotropic nature of the bilayer, permeation
properties such as drug partitioning and diffusion coefcients dif-
fer considerably for different compounds [62,63]. As a result, drugs
are believed to diffuse across the skin following a tortuous path-
way within either bilayerbilayer interfaces (Fig. 6a) or other sites
of structural disorganization by enhancer compounds (Fig. 6b).
Passive permeability through the SC lipid bilayer is proportional
to the lipid partition coefcient of the drug [64]. Transdermal
transport of hydrophilic drugs can occur through hair follicles
and sweat ducts, which may allow for diffusion of solutes not only
across the stratum corneum, but also the epidermis [1]. On the
other hand, permeability caused by sonophoresis is not propor-
tional to the lipophilicity of drugs but is rather dependent on the
creation of aqueous pathways across the SC (the trans-keratinocyte
route). This thought is supported by recent research using nano-
particles to show the importance of the penetration pathway in
TDD. Lee et al. studied the ultra-structural changes on the SC sur-
face and the penetration pathway of lanthanum nitrate (LaNO3)
tracer in viable epidermis after combined treatment with low fre-
quency sonophoresis and tape stripping (Fig. 7) [46]. After the
application of sonophoresis, LaNO3 was distributed within the cor-
neocytes of the two uppermost layers of the SC, as shown in the
transmission electron microscopy images. In the tightly packed li-
pid bilayers of the SC, discrete elongated defects (dilated lacunae)
were found after sonophoresis.
4. Synergistic effects ofsonophoresis
A number of enhancers for TDD have been studied and devel-
oped including micro-needles, chemicals, iontophoresis, and
sonophoresis, each of which has been shown to increase skin per-
meability. Furthermore, their combination has been considered to
be more effective than each enhancer alone. Chen et al. evaluated
the synergistic effects of low-frequency ultrasound (20 kHz) with
microneedles for delivery of two drug types [65]. For delivery of

Fig. 7. The penetration pathways of lanthanum nitrates after treatment with low frequency sonophoresis, and TEM images of SC after treatment with low frequency
sonophoresis using ruthenium tetroxide xation. (a) TEM ndings in the SC after application of LaNO3. In the absence of low frequency sonophoresis, LaNO3 was found to be
restricted to the intercellular spaces of the upper SC. (b) In contrast, after 5 min of treatment with low frequency sonophoresis, LaNO3 was found in the intercellular and
intracellular domains of the corneocytes in the upper SC. (c, arrow) After 5 min of treatment of low frequency sonophoresis, 2- to 4-lm expansions in lacunae were observed
in the widened intercellular spaces of the SC. (d, arrow) In some sections, rolled-up lipids were also observed in the dilated lacunae. Scale bar = 2 lm. Thisgure is reproduced
from Ref. [59].
 D. Park et al. / Ultrasonics 54 (2014) 5665
calcein, they observed that skin permeability was enhanced up to 5
times by microneedles in comparison with passive diffusion, 7
times for sonophoresis, and 9 times by a combination low fre-
quency ultrasound with microneedles. Similar results were
achieved with bovine serum albumin. Increment ratios of TDD
were increased 7 times by microneedles, 8.5 times by sonophore-
sis, and 12 times by a combination of low frequency ultrasoundand
microneedles. These results showed the combination of sonopho-
resis and microneedles greatly enhanced TDD rates compared to
passive diffusion and either microneedles or ultrasound alone.
Sonophoresis also exhibited a synergistic effect with iontophoresis
[66]. Le et al. investigated the synergistic effects of sonophoresis
and iontophoresis using heparin as a model drug in the SC of pig
skin. The penetration ux of heparin applied with sonophoresis
(20 kHz) was 13 times higher than passive ux over 24 h. Ionto-
phoresis increased the ux of heparin by 10 times compared to
the ux of the passive control. Transdermal haparin ux during
iontophoresis across skin pretreated with ultrasound is approxi-
mately 2-fold higher compared to either ultrasound or iontophore-
sis alone. In addition, a synergistic effect of sonophoresis and
chemical treatment has been shown to enhance transdermal trans-
port.Meidan et al. reported a synergistic effect with a combination
technique of sonophoresis (1.1 MHz and 3.3 MHz) and Azone as
chemical enhancer [67]. Synergistic effects between phonophore-
sis and Azone treatment was observed for enhancement of percu-
taneous hydrocortisone transport. Pretreatment using Azone
enhancer increased the hydrocortisone permeability almost 6-fold.
Additionally, sonication of Azone-pretreated skin enhanced hydro-
cortisone permeation by a further 2.5-fold compared to Azone pre-
treatment alone. Synergistic effects of sonophoresis and various
enhancers of TDD have been conrmed through several studies.
Combining certain technologies and techniques with sonophoresis
may offer an advantageous method for TDD. The practicality and
usefulness of combinations of these techniques will require further
research.
5. Applications of sonophoresis
Numerous studies have been performed to conrm an enhance-
ment of permeability by sonophoresis. Various applications of
sonophoresis in TDD are summarized in Table 1, including param-
eter optimization, mechanisms, and delivery of numerous drugs
such as hydrophilic and large molecules. Since the initial treatment
of polyarthritis with hydrocortisone ointment by Fellingher and
Schmidt in the 1950s, the transdermal delivery of therapeutic
drugs such as fentanyl, caffeine, heparin, ketoprofen and insulin
has become a major concern for clinical medicine. Borcaud et al.
evaluated effects of sonophoresis at 20 kHz with 2.5 W/cm2 on
transdermal transport of fentanyl and caffeine across both hairless
rat and human skin [72]. Fentanyl is generally used to relieve pain
in either surgery or cancer patients, while caffeine is the most com-
mon stimulant used for treatment of lipodystrophy [100,101]. The
results showed that sonophoresis enhanced TDD of fentanyl (about
35-fold greater than control) and caffeine (about 4-fold greater
than control) across human and hairless rat skin. In general, hepa-
rin, which is a commonly used anticoagulant, is administered by
intravenous or subcutaneous injections for the treatment and pre-
vention of venous thromboembolism. Mitragotri et al. performed
in vitro experiments with sonophoresis of 20 kHz with 7 W/cm2
(ISAPA) to deliver heparin or low-molecular weight heparin across
the skin [79]. Biologic activity of transdermally delivered heparin
was measured using activated clotting time assays and by measur-
ing anti-Xa (aXa) activity. Transdermally delivered low molecular
weight heparin resulted in raised aXa levels in the blood. The
transdermal ux of heparin was found to be approximately 21-fold
61
higher through sonicated skin compared to non-sonicated skin.
This result was in strong contrast to subcutaneous or intravenous
injections of LMWH, which resulted in only temporary elevations
of aXa levels. Mitragotri et al. proposed that patients might use a
product based on this technology throughout the day to provide
sustained heparin concentration in the blood. The dose of heparin
may be controlled through skin permeability, treatment area, or
LMWH concentration in the reservoir of the patch system under
the effects of sonophoresis. Ketoprofen is a non-steroidal anti-
inammatory drug predominantly used for treatment of rheuma-
toid arthritis and osteoarthritis [88] as well as to relieve minor
aches and menstrual pain [102]. Herwadkar et al. tested the effects
of sonophoresis at 20 kHz with 6.9 W/cm2 for delivery of ketopro-
fen across the skin [89]. In vitro experiments were performed on
excised hairless rat skin over a period of 24 h using Franz diffusion
cells. Sonophoresis signicantly enhanced the permeation of keto-
profen from 74.87 5.27 lg/cm2 with passive delivery to
491.37 48.78 lg/cm2 with sonophoresis. Furthermore, drug level
in skin layers increased from 34.69 7.25 lg following passive per-
meation to 212.62 45.69 lg following sonophoresis. These re-
sults show that sonophoresis at a frequency of 20 kHz is an
effective enhancement technique to improve transdermal and top-
ical delivery of ketoprofen.
Among the therapeutic drugs used in TDD, noninvasive trans-
dermal delivery of insulin has received great attention because of
the increasing incidence of diabetes, one of the most costly dis-
eases in all patient populations and age groups [103]. Management
of diabetes often requires painful, repetitive insulin injections up
to three or four times daily [86]. Non-invasive insulin delivery
through the skin may be a preferable technique for diabetic pa-
tients over traditional invasive and painful subcutaneous insulin
injections. Insulin, a hormone produced by the pancreas, plays a
central role in the regulation of carbohydrate and fat metabolism
in the body. Numerous studies of transdermal insulin delivery have
been performed by many researchers [3,16,83,84,86,87]. The feasi-
bility of sonophoresis for insulin delivery has been evaluated by
Smith et al. [84] in an effort to enhance the in vitro transport of
insulin across human skin. Specically, experiments were carried
out with two types of lightweight cymbal transducer arrays, a
stack array with an intensity (ISPTP) of 15.4 0.6 mW/cm2 and a
standard array with an intensity (ISPTP) of 173.7 1.2 mW/cm2 at
20 kHz. Compared with passive transmission (4.1 0.5U) over an
exposure period of 1 h, the standard array facilitated a greater than
7-fold increase in the non-invasive transdermal transport of
Humulin R insulin (45.9 12.9U). The results using Humalog
insulin with the standard array showed a 4-fold increase in the
sonophoresis-facilitated transmission over that seen in the control
group.
Additionally, Mitragotri et al. tested the recovery of the skin
barrier properties after short (1 h) as well as long (5 h) ultrasound
exposures (20 KHz, 125 mW/cm2, 100 ms pulses applied every sec-
ond). They measured the electrical resistance and transdermal ux
of water for up to 12 h after ultrasound exposure. After a 1 h expo-
sure, the epidermal permeability to water measured within 2 h
postexposure was comparable to the passive epidermal permeabil-
ity to water. Within 2 h of ultrasound treatment, resistance in-
creased by a factor of 1.2 compared to the value immediately
after ultrasound treatment. In the case of a 5 h exposure, the
permeability was approximately 6 times higher than the passive
permeability to water. This value continued to decrease to a factor
of 2 times the passive permeability of water at 12 h post-exposure.
In this case, 2 h after discontinuation of the ultrasound, the resis-
tance increased by approximately 2-fold compared to that at the
end of ultrasound exposure. This result suggests that the sonopho-
retic ux of permeants exhibited signicant recovery after ultra-
62 D. Park et al. / Ultrasonics 54 (2014) 5665

Table 1
Research on sonophoresis in TDD.

Compound M.W (Dalton) Skin tissue Ultrasound parameter Ref No.

Frequency Intensity Sonication time Duty
Aldosterone 360 Human (in vitro) 20 kHz 125mW/cm2 10% [40]
Arnica Montana Rat (in vitro) 1 MHz 0.5 W/cm2 3 min 33% [68]
Ascorbic acid 176 Pig ear (in vitro) 1 MHz 2.3, 3.2 W/cm2 1,10,20 min CW mode [69]
Butanol 74 Human (in vitro) 20 kHz 125 mW/cm2 10% [40]
Bovine serum albumin 66000 Rat (in vivo) (in vitro) 20 kHz 30% amplitude 2 min 50% [70]
Caffeine 194 Pig (in vitro) 3 MHz 0.2 W/cm2 240 min CW mode [71]
Caffeine 194 Human (in vitro), Rat (in vitro) 20 kHz 2.5 W/cm2 10 min, 1 h CW mode 10% [72]
Caffeine 194 Pig (in vitro) 20 kHz 0.373.7 W/cm2 51200 s 10, 33, 100% [73]
Calcein 623 Pig(in vitro) 20, 40, 60 kHz 7.5 W/cm2 20 min 50% [74]
Calcium 40 Rat (in vivo) 20 kHz 1 W/cm2 Less than 5 min 50% [31]
Corticosterone 346 Human (in vitro) 20 kHz 125 mW/cm2 10% [40]
Dexamethasone 392 Human (in vivo) 1, 3 MHz 1 W/cm2 10 min CW mode [75]
Diclofenac 296 Human (in vivo) 1 MHz 0.5 W/cm2 5 min [76]
Estradiol 272 Human (in vitro) 20 kHz 125 mW/cm2 10% [40]
Fentanyl 336 Human (in vitro), Rat (in vitro) 20 kHz 2.5 W/cm2 10 min, 1 h CW mode10% [72]
FITC-dextran 4000, 20,000, 150,000 Rat (in vivo) 1.12, 2.47 MHz 330 mW/cm2 30 min 1% [77]
Glycerol 92 Pig (in vitro) 1.1 MHz 600 kPa 60 min 10% [78]
Heparin Average MW of 18,000 Pig (in vitro) 20 kHz 7 W/cm2 10 min 50% [79]
Histamine 184 Human (in vivo) 36 kHz 2.7, 3.50 W/cm2 5 min 28.6, 37.5% [80]
Hyaluronan 1000 Rabbit (in vivo) 1 MHz 400 mW/cm2 10 min CW mode [81]
Hydrocortisone 362 Human (in vitro) 20 kHz 3.7 W/cm2 30, 45 s 10% [82]
Insulin 5807 Rabbit (in vivo) 105 kHz 5 kPa 90 min 50% [83]
Insulin 5807 Human (in vitro) 20 kHz 12.5225 mW/cm2 4h 10% [16]
Insulin 5807 Human (in vitro) 20 kHz 173.7 1.2 mW/ 1h 20% [84]
cm2
Insulin 5807 Rabbit (in vivo) 20 kHz 100 mW/cm2 20% [85]
Insulin 5807 Pig (in vivo) 20 kHz 100 mW/cm2 60 min 20% [86]
Insulin 5807 Rabbit (in vivo) 225.8 1016 kHz 10 min [87]
Ketoprofen 254 Human (in vivo) 100 Hz 1.5 W/cm2 5 min CW mode 20% [88]
1 MHz
Ketoprofen 254 Rat (in vitro) 20 kHz 6.9 W/cm2 0.52 min 50, 100% [89]
Ketorolac- 376 Rat(in vitro) 1 MHz 13 W/cm2 30 min CW mode [90]
tromethamine
Lanthanum nitrate 433 Mouse (in vivo) 25 kHz 800 m W/cm2 5 min CW mode [59]
Mannitol 183 Pig(in vitro) 20 kHz 1.614 W/cm2 1.5 h 10, 50% [31]
Mannitol 183 Rat (in vivo) 1 MHz 1.5.3 W/cm2 35 min CW mode [69]
Morphine 285 Mouse (in vitro) 40 kHz 0.130.44 W/cm2 1218 min CW mode [91]
Oligonucleotides Second generation Pig (in vitro) 20 kHz 2.4 W/cm2 10 min 50% [92]
chemistries
Peptide dendrimer Human (in vitro) 20 kHz 78 W/cm2 30 min 50% [93]
Quantum dot 20 nm diameter Pig (in vitro) 20 kHz 2.4 W/cm2 50% [94]
Salicylic acid 138 Rat (in vivo) 20 kHz 125 mW/cm2 10% [40]
Salicylic acid 138 Guinea pig (in vivo) 2, 10, 16 MHz 0.2 W/cm2 520 min [17]
Sodium lauryl sulfate 288 Pig (in vitro) 20, 40, 60 kHz 7.5 W/cm2 20 min 50% [95]
Sucrose 342 Human (in vitro) 20 kHz 125 mW/cm2 10% [40]
Sucrose 342 Pig (in vitro) 20 kHz 7.5 mW/cm2 2 min 50% [96]
Tetanus toxoid 150,000 Mouse (in vivo) 20 kHz 2.4 W/cm2 80 s 50% [97]
Triamcinolone- 434 Mouse (in vitro) 1, 3 MHz 1.0, 2.5 mW/cm2 10 h CW mode [98]
acetonide Pulse mode
Urea 60 Human (in vitro) 20 kHz 7.2 mW/cm2 78 min 50% [99]
Water 18 Human (in vitro) 20 kHz 125 mW/cm2 10% [40]

sound was discontinued, and sonophoresis does not cause long-
term changes in the epidermal barrier properties of skin [40].
Maruani et al. surveyed adverse effects that were systematically
recorded by the research engineer and a dermatologist [80]. The
most frequent adverse effects reported during or after sonophore-
sis included skin erythema, pain, and tinnitus. These events in-
creased with increasing ultrasound intensity, which generates
relatively high thermal and cavitation effects on the skin. However,
erythema and purpura quickly regressed after sonophoresis was
stopped. In addition, tinnitus, reported in 23.5% of cases, also re-
solved after ultrasound was terminated. The pain associated with
ultrasound was not constant and showed large variations among
subjects. The pain disappeared with the use of a discontinuous
ultrasound mode. These results suggest that optimization of ultra-
sound parameters is essential to reduce adverse effects of
sonophoresis.
6. New trends in sonophoresis
Under the assumption that cavitation is the principal mecha-
nism in sonophoresis due to the formation of intercellular lipid
channels and disordering of lipid bilayers, enhancement of sono-
phoresis cavitation activity has been recently attempted. MI, which
was developed as a method to express the likelihood of cavitation,
increases with decreasing center frequency and increasing peak
rarefaction pressure [53]. Adopting low frequency sonophoresis
is one way to increase existing cavitation bubbles [18,31,32]. When
the frequency is low enough, a quasi-static eld of sufciently
small bubbles can be assumed. Given that small bubbles rapidly
grow and collapse with exposure to quasi-static rarefaction pres-
sure, this observed activity may be related to inertial cavitation
or asymmetric bubble collapse [104,105]. Low-frequency sonopho-
resis has thus been the topic of extensive research over the last
20 years. The effects of low frequency sonophoresis have been
 D. Park et al. / Ultrasonics 54 (2014) 5665
studied by Mitragotri et al. [16,31,40,79] in an effort to enhance the
transport of various drugs of low molecular weight (including
aldosterone, butanol, calcium, corticosterone, estradiol, histamine,
mannitol, salicylic acid, and sucrose) as well as high molecular
weight (including heparin and insulin). They also found that the
enhancement ratio induced by low frequency sonophoresis
(20 kHz) is as much as 1000-fold higher than that induced by high
frequency sonophoresis (13 MHz). The results of several studies
suggest that the greater efciency of low frequency sonophoresis
compared with high frequency sonophoresis originates from the
increasedincidence of cavitation events [1,34,40,61]. Another ap-
proach to increasing cavitation activity is to take advantage of a
narrow bubble size distribution. In recent years, Park et al.
[77,78] hypothesized that, if specic bubbles with a certain reso-
nance frequency, such as ultrasound contrast agent (UCA), are uni-
formly added, cavitation may be generated more uniformly and
predictably over the skin area. In their rst study, the efcacy of
glycerol as an optical clearing agent with 0.1% UCA (Denity)
using sonophoresis at 1 MHz was quantitatively evaluated using
optical measurement in an in vitro experiment. The results indi-
cated that the proposed TDD method increased transparence of
skin by approximately 80% compared to traditional sonophoresis.
In a second study, Park et al. evaluated the efcacy of Fluorescein
isothiocyanatedextran (FITC-dextrans, molecular weight of 4 k,
20, 150 k Dalton) with UCAs (Denity, Sonovue) using high fre-
quency sonophoresis (1.12 MHz, 2.47 MHz) with in vivo experi-
ments. Their results indicated that the addition of small amounts
of UCA could increase skin permeability up to 2-times in sonopho-
resis without any visible skin damage, while UCAs without ultra-
sound sonication do not enhance skin permeability. In addition,
the sonication energy used in the experiments was low enough
that it did not cause a signicant temperature increase (<1.2 C)
or injury to the skin layers. Accordingly, the mechanical interaction
between UCAs and ultrasound is the main mechanism of the signif-
icant increase in TDD at the frequency range tested for molecular
weights up to 40 kD FITC-dextran. Since then, Park et al. have pre-
sented new alternatives to increase cavitation using a narrow bub-
blesize distribution. Another sonophoresis interest area in clinical
studies is non-invasive transdermal monitoring. Sonophoresis in-
creases transdermal permittivity to interstitial uid and enables
glucose extraction at the skin surface. Because traditional glucose
meters require frequent painful nger punctures to obtain samples
several times a day, the development of rapid, convenient, accu-
rate, non-invasive, painless methods for glucose monitoring may
be desirable. Sonophoresis can enhance skin permeability so that
sufcient quantities of analyte can be obtained for glucose mea-
surement [106,107]. Mitragotri et al. reported a potential method
for non-invasive diagnostics based on ultrasonic skin permeabili-
zation and subsequent extraction of interstitial uid across the skin
in which serum and interstitial uid concentrations of various ana-
lytes were measured [108].Specically, this study achieved rates of
vacuum extracted glucose in an in vivo rat skin model of
52 30 lg/cm2/h. Further, the average serum C of the rat was
183 mg/dl, and glucose ux was approximately 100 times higher
than passive glucose ux across non-treated skin. Glucose concen-
trations in the extracted uid correlated well with blood glucose
concentration over a rage of 50250 mg/dl. The results demon-
strate that sonophoresis has the potential to enhance skin perme-
ability to obtain sufcient quantities of analyte after application of
a vacuum for a short time.
7. Conclusion
Due to the advantages of TDD compared to oral drug delivery,
there is a growing interest in TDD and studies continue to evaluate
63
TDD methods for the enhancement of percutaneous drug absorp-
tion. Over the past few decades, the efcacy of sonophoresis in
enhancing transdermal transport has been veried through signif-
icant studies that have looked at the mechanisms and penetration
pathways of sonophoresis and the drugs that may be used in sono-
phoresis. Based on these studies, cavitation is believed to be the
main mechanism of sonophoresis in TDD, and drugs are believed
to diffuse across the skin following a tortuous pathway within
either bilayerbilayer interfaces or other sites of structural disor-
ganization caused by sonophoresis. In addition, the ability of sono-
phoresis to deliver drugs transdermally without causing skin
damage has been veried. In recent decades, studies on enhance-
ment of cavitation activity have also been performed. One
approach to increase cavitation activity involves the use of low fre-
quency sonophoresis. This method may be preferred over rela-
tively high frequency sonophoresis due to the potential for
enhanced cavitation activity and efcacy, which has been con-
rmed through comparison studies of transdermal and topical
drug delivery. More recently, high frequency sonophoresis with
UCAs was used to enhance TDD and demonstrated that the pres-
ence of engineered bubbles such as UCAs with resonant frequency
may increase skin permeability by actively inducing cavitation
without causing skin damage.
In future work, the safety of sonophoresis used in clinical treat-
ment should be established through a wide variety of experiments.
In addition, development of portable and easy-to-use sonophoresis
will be required in order develop this technology as a possibility for
home healthcare. Although sonophoresis systems have been devel-
oped for laboratory use, systems with clinical approval are rarely
found in clinics. SonoPrep (Echo Therapeutics, Franklin, MA,
USA), a commercially available tool, has received US FDA approval
as a specialized sonophoresis device [109]. Furthermore, parame-
ters such as lag time, intensity, and duty factor have not yet been
optimized. Because the skin characteristics of each body part and
the viscosity of the drug affects efciency of drug delivery, specic
protocols and ultrasound parameters will differ according to appli-
cation site and drug used. Parameter optimization related to ef-
ciency of drug delivery is also another challenge that must be
addressed prior to the development of clinical applications. Sono-
phoresis is expected to be a useful tool for both diagnosis and
treatment of diseases, such as diabetes in the near future.
Acknowledgements
This work was supported by grants from the Leading Foreign
Research Institute Recruitment Program and by the Global Frontier
R&D Program on <Human-centered Interaction for Coexistence>
through the National Research Foundation of Korea (NRF) funded
by the Ministry of Education, Science and Technology (MEST)
(2010-00757) and (2011-0032035).
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