Dermatology: Practical and Conceptual Original Article | Dermatol Pract Concept. 2025;15(1):4905 1 Prebiotic- and Panthenol-Containing Multipurpose Healing Dermocosmetics Post-Cryotherapy for Actinic Keratoses: Results of a Randomized Controlled Trial Cesare Ariasi1, Carola Romanò1, Cesare Tomasi1, Simone Soglia1, Gaetano Licata2, Luca Rubelli1, Piergiacomo Calzavara-Pinton1, Marina Venturini1, Mariachiara Arisi1 1 Department of Dermatology, University of Brescia, Brescia, Italy 2 Department of Dermatology, San Antonio Abate Hospital, Trapani, Italy Key words: Dermocosmetic formulation, Actinic keratosis, Cryotherapy, Local skin reactions Citation: Ariasi C, Romanò C, Tomasi C, et al. Prebiotic- and Panthenol-Containing Multipurpose Healing Dermocosmetics Post Cryotherapy for Actinic Keratoses: Results of a Randomized Controlled Trial. Dermatol Pract Concept. 2025;15(1):4905. DOI: https:// DOI.org/10.5826/dpc.1501a4905 Accepted: November 15, 2024; Published: January 2025 Copyright: ©2024 Ariasi et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing Interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding Author: Dr. Carola Romanò, Piazzale Spedali Civili 1, Brescia, Italy. Phone: 0039 0303995300. E-mail: c.romano016@unibs.it Introduction: Actinic keratosis (AKs) is a precancerous skin lesion that can progress to keratinocyte carcinoma. Objective: The objective of the study was to evaluate the efficacy of a dermocosmetic (DC) formu- lation containing prebiotic active ingredients (Aqua Posae Filiformis, a complex made of ferments, sugars, plant extracts, panthenol, madecassoside, and zinc) on healing time and local skin reactions (LSR) following cryotherapy of AKs and to compare the application of DC and boric acid 3% solution soaks (BA) vs. BA alone. Methods: Seventy-five adult patients presenting with a maximum of five isolated AKs on the face and/or scalp and who underwent cryotherapy (T0) were enrolled. Post-treatment, patients initiated the application of BA only or BA followed by DC once daily for 30 days (unblinded 1:1 randomization). The evaluation of efficacy in healing time and cosmetic outcomes was assessed 30 days post-treatment (T2); LSR was evaluated three days post-treatment (T1). Results: There was a gain of 4.5 days (40%) in healing time in the BA+DC group compared to the BA group, with a median time of seven days versus 11.5 days (P <0.0005). Additionally, 50% of lesions in complete response had an excellent cosmetic outcome with BA+DC vs. 20% with BA only. The ma- jority of patients treated with BA+DC had mild LSR vs. moderate LSR with BA, with a median value of two vs three, respectively (P <0.0001). ABSTRACT 2 Original Article | Dermatol Pract Concept. 2025;15(1):4905 Introduction Actinic keratosis (AKs) presents as a prevalent precancerous skin condition, with its prevalence escalating due to aging demographics and heightened ultraviolet exposure. Its onset is linked to the accumulation of genotoxic DNA damage, necessitating prompt removal to mitigate the risk of evolv- ing into invasive squamous cell carcinoma [1]. Numerous treatment modalities exist for AKs, each with distinct mer- its and drawbacks. This variety poses a challenge for clini- cians in determining the optimal, well-tolerated treatment for individual patients [2]. Treatment for AKs may target either individual lesions or the entire affected area, known as field-directed therapy. Among treatments for individual lesions, cryotherapy is one of the most widespread and com- monly used. Liquid nitrogen cryotherapy is classified as a destructive procedure and is today considered a standard first-line approach in cases of single Aks [3]. The destructive impact of freezing encompasses two primary mechanisms: a direct mechanism entails the immediate destruction of cells through intense freezing, leading to cell rupture due to os- motic shock and the formation of intracellular ice crystals, while an indirect mechanism operates through vascular and immune-mediated processes [4]. Despite its benefits, cryo- therapy procedures carry inherent risks, with infections be- ing a notable complication in the short term post-treatment. Infections following cryotherapy can lead to delayed wound healing, prolonged recovery periods, and potentially more severe complications if left untreated [5]. Given the potential for infections, proper management of the treated site is paramount to minimize this risk. Sev- eral strategies are commonly employed in clinical practice to prevent infections following cryotherapy. Antiseptics such as chlorhexidine, povidone-iodine, hydrogen peroxide, or boric acid are commonly utilized to disinfect the treated area and reduce microbial colonization [6]. Cryotherapy is also accompanied by pain and burning during the procedure and by the subsequent appearance of blisters that result in erosions and crusts. Furthermore, as a consequence of me- lanocytes’ susceptibility to freezing, dyspigmentation is the most common and unpleasant long-term complication of cryosurgery in patients with fair skin, while darker skinned individuals can develop hyperpigmentation [4]. At present, there are no post-treatment care standards aimed at reducing procedure- related pain, minimizing infection risk, or acceler- ating skin repair. In recent times, various dermocosmetic (DC) formula- tions with repairing and anti-inflammatory properties have become available on the market. These formulations owe their efficacy to active ingredients with direct functions as well as to components that regulate the cutaneous micro- biome. They represent a promising alternative and support antiseptic solutions and are often preferred by patients due to their superior cosmetic characteristics [7]. Aqua Posae Filiformis is a skincare complex comprising prebiotic ingredients like ferments, sugars, and plant extracts, alongside panthenol, madecassoside, and zinc. It nurtures the skin’s microbiome, promoting a healthy barrier. Panthenol moisturizes and soothes, madecassoside reduces inflamma- tion and aids in healing, while zinc offers antimicrobial and anti-inflammatory benefits, making it versatile for various skin concerns, from hydration to soothing and repair [8]. Objective The objective of the study was to evaluate the efficacy of a DC formulation containing prebiotic active ingredients (Aqua Posae Filiformis, a prebiotic complex made of fer- ments, sugars and plant extracts, panthenol, madecassoside, and zinc) on healing time, cosmetic outcome, and local skin reactions (LSR) following cryotherapy of actinic keratosis. Methods Adult patients able to understand the modalities of the study and provide informed consent to the study who presented with a maximum of five isolated actinic keratoses on the face and/or scalp and undergoing cryotherapy were enrolled in the study. The diagnosis of AKs was confirmed visually and through dermoscopy. Exclusion criteria were as follows: subjects under 18 years of age, pregnancy or lactation, chemical dependency or alcoholism, likelihood of poor compliance, therapy with drugs known to possess anti-inflammatory, immunosuppres- sive, vasoactive, or phototoxic activities, presence of con- comitant pathologies, metabolic dysfunctions, and clinical data that could reasonably raise doubts about the subject’s eligibility for the study, pose a risk to the subject, or act as a confounding factor in data interpretation; concomitant sys- temic treatment that may impact skin repair (e.g., chemo- therapy, corticosteroids, immunosuppressants); concomitant or previous local physical or chemical treatment at the site of Conclusion: The addition of a prebiotic DC significantly reduced healing time, improved cosmetic outcomes, and minimized LSR post-cryotherapy. No adverse event was reported with this treatment. Original Article | Dermatol Pract Concept. 2025;15(1):4905 3 the evaluated skin (e.g., radiotherapy, 5-FU, imiquimod, tir- banibulin); systemic diseases that may influence skin repair (e.g., diabetes, immunodeficiencies, autoimmune diseases); smoking or dietary restrictions that may affect skin repair (e.g., vegan or vegetarian diet); other dermatological diseases apparent at the site of the evaluated skin. For cryotherapy performed at baseline (T0), lesions were treated with a liquid nitrogen unit (CRY-AC; Brymill Cryogenic Systems) using a standard spray technique. Two freeze–thaw cycles were applied. The area was frozen for 15 to 30 seconds each time, with a thawing period of 2–4 minutes, depending on the size of the lesion. Cryotherapy was performed by the same clinician. Following a 6–8-hour interval post-treatment, patients initiated the application of BA or the application of BA followed by the application of DC, based on an unblinded 1:1 randomization. The products were applied once daily for 30 consecutive days. The evaluation of local inflammation induced by cryo- therapy  through the LSR score resulting from erythema, desquamation, crust formation, edema, presence of vesicles/ pustules, and/or erosions/ulcerations was assessed at three days post-treatment (T1). To each complication was given a score from 0 (absent) to 4 (severe), with a maximum achiev- able score of 24 [9,10]. The evaluation of efficacy in terms of healing time in days was reported by the patient, and the cosmetic outcomes were assessed at 30 days post-treatment (T2); at the same timepoint assessment of the overall cosmetic outcome by the investigators was graded into four categories: excellent (no or mild redness or pigmentation changes); good (moderate redness or pigmentation changes); fair (slight-to-moderate scarring, atrophy, and induration); poor (extensive scarring, atrophy, or induration). Clinical photographs were taken for a single target actinic keratosis lesion at baseline, T1, and T2. In addition, as a pilot evaluation, basal architectural evaluation of treated skin with in vivo confocal microscopy (RCM) (Vivascope 3000, Lucid Inc.) and line-field optical confocal tomography (LC-OCT) (OCTAV V3, DAMAE Medical) was performed at baseline and at T2 for 30 out of the 75 patients (15 from each treatment group). The RCM and OCT images collected at T0 and T2 were evaluated and compared in terms of acanthosis, fibrosis, keratinocyte atypia, and inflammatory infiltrate. The study was conducted in accordance with the Decla- ration of Helsinki, and it was evaluated by the Local Ethics Committee (Protocol Number 3718). All patients were given verbal and written information on the nature of the study, and they signed an informed consent form before enrolment. Statistical Analysis The study was a randomized single-center controlled clin- ical trial. The statistical analysis started with a database formatted in Excel© for use in importing versus IBM-SPSS© software ver. 26.1. The continuously expressed variables were subjected to the Kolmogorov-Smirnov test to assess their normality. Categorical variables were summarized by using percentages and continuous variables by calculating medians and range (minimum and maximum values). Me- dians and continuous variables were compared by using the Mann-Whitney test. Chi-square test was used for percentage comparisons. The comparison of the parameters analyzed in RCM and OCT was performed by general linear model with repeated measures and tests of within-subjects effects (arms; T0 vs T2). All tests were considered at an alpha significance level of 5%. For the calculation of sample size and formalization of the design, the following was assumed: from preliminarily data collected, the hypothesis was that DC product would reduce the LSR score by at least 45% compared with BA alone; the mean of the aforementioned post-treatment score was assumed to be 20 (DS 15.5) for BA treatment and 11 (DS 8.5) with the use of BA+DC. To achieve a statistical power of at least 80%, the sample size for each treatment arm turned out to be 32 subjects. Results Seventy-five patients were enrolled and completed the study. Thirty-six (48%) patients were treated with BA+DC and 39 (52%) patients with BA alone. Characteristics of the pop- ulation are summarized in Table 1. All patients completed Table 1. Characteristics of the Population. Total BA group BA+ DC group Patients N (%) 75 (100) 39 (52) 36 (48) Age [median (range)] (years) 78 (60-91) 79 (60-89) 77 (62-91) Sex:   Males N (%) Females N (%) 57 (76) 18 (24) 30 (52.6) 9 (50) 27 (47.4) 9 (50) Skin phototype: N (%) I II III IV 2 (2.7) 45 (60) 28 (37.3) 0 (0) 1 (2.6) 24 (61.5) 14 (35.9) 0 (0) 1 (2.8) 21 (58.3) 14 (38.9) 0 (0) Body site treated: N (%) • Head • Forehead • Nose • Cheek • Chin 23 (30.7) 24 (32) 11 (14.7) 16 (21.3) 1 (1.3) 11 (47.8) 13 (54.2) 6 (54.5) 9 (56.2) 0 (0) 12 (52.2) 11 (45.8) 5 (45.5) 7 (43.8) 1 (100) Abbreviations: BA: boric acid 3% solution; DC: dermocosmetic. 4 Original Article | Dermatol Pract Concept. 2025;15(1):4905 agreement or standardization regarding the application methods. Various treatment regimens have been proposed [4], and there is also variability in the management of the treated site in the post-procedural period. It is well-known that the procedure is generally accompanied by inflam- mation and edema along with the appearance of blisters, leading to erosions and crust formation. Furthermore, there are a number of expected outcomes following cryosurgery such as scar formation and hypopigmentation or hyperpig- mentation results that can impact the cosmetic outcome of the procedure. All these factors can be mitigated by proper management of the treatment site during the post- procedure period. The majority of the available literature asserts that no special care is required during the healing phase. The use of specific topical formulations aimed at proper tissue re- pair represents an additional strategy in the management of outcomes following cryotherapy procedure [11]. The wound microbiota can affect various phases of healing, including hemostasis, inflammation, and cell proliferation. Specifically microbiota points out the role of commensal bacteria in in- fluencing immune responses, keratinocyte growth, and blood vessel development [12]. From the results obtained in our study, the addition of Aqua Posae Filiformis with a prebiotic complex helps to restore the healthy skin microbiota [13] promoting tissue repair, thus reducing the average healing time and decreasing LSR. The use of products containing panthenol or its stabi- lized derivatives is a widely employed strategy to promote tissue repair and reduce potential aesthetic outcomes [14] the study; 100% of patients exhibited a complete response of actinic keratoses treated with cryotherapy without experi- encing significant adverse events. There was a gain of 4.5 days (40%) in healing time in the group treated with BA+DC compared to the group treated with BA alone, with a median time of seven days (range 2–14) versus 11.5 days (range 5–20), respectively (P <0.0005). Moreover, a trend of improved cosmetic out- come was observed in the group treated with BA+DC com- pared to the group treated with BA alone. Among lesions in complete response, 50% of them had an excellent cosmetic outcome with BA+DC treatment compared to 20% of excel- lent cosmetic outcome among lesions in complete response in patients treated with BA only. The majority of patients treated with BA+DC had mild LSR compared to moder- ate with BA, median value 2 vs 3, respectively (P <0.0001; Figure 1). The comparison of images acquired in RCM and OCT at T0 and T2 revealed a trend of greater reduction in fibrosis at T2 in the BA+DC-treated group compared to the BA-only treated group. Additionally, a trend of correlation was observed between the reduction in keratinocyte atypia and acanthosis components and the efficacy of cryotherapy treatment in both groups (P <0.0001; Figures 2 and 3). Discussion Cryotherapy is the most widespread and utilized treatment for single AK due to its speed and simplicity of use. While there is substantial consensus in the literature regarding its indication for treating actinic keratosis [3], there is no Figure 1. Clinical evaluation of AK of the face before cryotherapy (A) BA+DC; (D) BA; LSR assessment at T1 (B) BA+DC; (E) BA and final result at T2 (C) BA+DC; (F) BA. Abbreviations: AK: actinic keratosis; BA: boric acid 3% solution; DC: dermocosmetic. Original Article | Dermatol Pract Concept. 2025;15(1):4905 5 Figure 2. Noninvasive evaluation of AK before cryotherapy by (A) OCTand RCM (C) and at T2 by OCT (B) and RCM (D) in a patient treated with BA+DC: hyperkeratosis (blue arrow); keratinocytes with pleomorphic nuclei (white circle); fibrosis (red arrow); and acanthosis (blue arrows). Abbreviations: AK: actinic keratosis; BA: boric acid 3% solution; DC: dermocosmetic; LC-OCT: line-field confocal optical coherence tomography. Figure 3. Noninvasive evaluation of AK before cryotherapy by OCT (A) and RCM (C) and at T2 by OCT (B) and RCM (D) in a patient treated with BA only: hyperkeratosis (blue arrow); keratinocytes with pleomorphic nuclei (white circles); atypical honeycomb pattern (red arrows); mid follicular dilatation (blue arrows). Abbreviations: AK: actinic keratosis; BA: boric acid 3% solution; DC: dermocosmetic; LC-OCT: line-field confocal optical coherence tomography. 6 Original Article | Dermatol Pract Concept. 2025;15(1):4905 6. Roberts CD, Leaper DJ, Assadian O. The Role of Topical An- tiseptic Agents Within Antimicrobial Stewardship Strategies for Prevention and Treatment of Surgical Site and Chronic Open Wound Infection. Adv Wound Care (New Rochelle). 2017 Feb 1;6(2):63-71. DOI: 10.1089/wound.2016.0701. PMID: 28224049; PMCID: PMC5286547. 7. Al-Smadi K, Leite-Silva VR, Filho NA, et al. Innovative Approaches for Maintaining and Enhancing Skin Health and Managing Skin Diseases through Microbiome-Targeted Strate- gies. Antibiotics (Basel). 2023 Dec 4;12(12):1698. DOI: 10.3390 /antibiotics12121698. PMID: 38136732; PMCID: PMC10741029. 8. Mahe YF, Perez MJ, Tacheau C, et al. A new Vitreoscilla fili- formis extract grown on spa water-enriched medium activates endogenous cutaneous antioxidant and antimicrobial defenses through a potential Toll-like receptor 2/protein kinase C, zeta transduction pathway. Clin Cosmet Investig Dermatol. 2013 Aug 30;6:191-6. DOI: 10.2147/CCID.S47324. PMID: 24039440; PMCID: PMC3770492. 9. Arisi M, Rossi MT, Spiazzi L, et al. A randomized split-face clin- ical trial of conventional vs indoor-daylight photodynamic ther- apy for the treatment of multiple actinic keratosis of the face and scalp and photoaging. J Dermatolog Treat. 2022 Jun;33(4): 2250-2256. DOI: 10.1080/09546634.2021.1944594. Epub 2021 Jun 28. PMID: 34152936. 10. Zane C, Facchinetti E, Rossi MTet al. A randomized clinical trial of photodynamic therapy with methyl aminolaevulinate vs. diclofenac 3% plus hyaluronic acid gel for the treatment of multiple actinic keratoses of the face and scalp. Br J Dermatol. 2014 May;170(5):1143-50. DOI: 10.1111/bjd.12844. PMID: 24506666. 11. Cranwell WC, Sinclair R. Optimising cryosurgery technique. Aust Fam Physician. 2017;46(5):270-274. PMID: 28472571. 12. Zielińska M, Pawłowska A, Orzeł A, et al. Wound Micro- biota and Its Impact on Wound Healing. Int J Mol Sci. 2023 Dec 10;24(24):17318. DOI: 10.3390/ijms242417318. PMID: 38139146; PMCID: PMC10743523. 13. Seité S, Zelenkova H, Martin R. Clinical efficacy of emollients in atopic dermatitis patients - relationship with the skin micro- biota modification. Clin Cosmet Investig Dermatol. 2017 Jan 12;10:25-33. DOI: 10.2147/CCID.S121910. PMID: 28138262; PMCID: PMC5238811. 14. Gorski J, Proksch E, Baron JM, et al. Dexpanthenol in Wound Healing after Medical and Cosmetic Interventions (Postproce- dure Wound Healing). Pharmaceuticals (Basel). 2020 Jun 29; 13(7):138. DOI: 10.3390/ph13070138. PMID: 32610604; PMCID: PMC7407203. 15. Wang H, Duan C, Keate RL, et al. Panthenol Citrate Biomate- rials Accelerate Wound Healing and Restore Tissue Integrity. Adv Healthc Mater. 2023 Dec;12(31):e2301683. DOI: 10.1002 /adhm.202301683. Epub 2023 Jun 25. PMID: 37327023; PMCID: PMC11468745. after medical and cosmetic interventions in post-procedure wound healing. Panthenol and derivatives of vitamin B5 in general exhibit antioxidant, antibacterial, anti-inflammatory, and pro-angiogenic properties and promote keratinocyte and dermal fibroblast migration and proliferation [15], resulting in effectiveness in reducing healing time and improving cos- metic outcomes following cryotherapy treatment. Conclusions The addition of a prebiotic and panthenol-containing multi- purpose healing DC is able to significantly reduce healing time, with a better cosmetic outcome, and local skin reac- tions post-cryotherapy for AK. Such capability was appre- ciated both clinically and in terms of reduction in fibrosis as observed on RCM and OCT. The limitation of the study is that the DC formulation contains many active ingredi- ents, and we did not consider a third arm of patients treated with main active ingredient alone (the prebiotic Aqua Posae Filiformis). Further studies will be necessary to identify the optimal standard of care to be applied in the treatment of patients undergoing cryotherapy. References 1. Ortonne JP. From actinic keratosis to squamous cell carcinoma. Br J Dermatol. 2002 Apr;146 Suppl 61:20-3. DOI: 10.1046 /j.1365-2133.146.s61.6.x. PMID: 11966728. 2. Heppt MV, Leiter U, Steeb T, et al. 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