Assessment of pruritus intensity: prospective study on validity and reliability of the visual analogue scale, numerical rating scale and verbal rating scale in 471 patients with chronic pruritus

A Phase 3 Trial of Difelikefalin in Hemodialysis Patients with Pruritus

BACKGROUND

Difelikefalin is a peripherally restricted and selective agonist of kappa opioid receptors that are considered to be important in modulating pruritus in conditions such as chronic kidney disease.

METHODS

In this double-blind, placebo-controlled, phase 3 trial, we randomly assigned patients undergoing hemodialysis who had moderate-to-severe pruritus to receive either intravenous difelikefalin (at a dose of 0.5 μg per kilogram of body weight) or placebo three times per week for 12 weeks. The primary outcome was the percentage of patients with an improvement (decrease) of at least 3 points from baseline at week 12 in the weekly mean score on the 24-hour Worst Itching Intensity Numerical Rating Scale (WI-NRS; scores range from 0 to 10, with higher scores indicating greater itch intensity). The secondary outcomes included the change from baseline in itch-related quality-of-life measures, the percentage of patients with an improvement of at least 4 points in the WI-NRS score at week 12, and safety.

RESULTS

A total of 378 patients underwent randomization. A total of 82 of 158 patients (51.9%) in the difelikefalin group had a decrease of at least 3 points in the WI-NRS score (primary outcome), as compared with 51 of 165 (30.9%) in the placebo group. The imputed percentage of patients with a decrease of at least 3 points in the WI-NRS score was 49.1% in the difelikefalin group, as compared with 27.9% in the placebo group (P<0.001). Difelikefalin also resulted in a significant improvement from baseline to week 12 in itch-related quality of life as measured by the 5-D itch scale and the Skindex-10 scale. The imputed percentage of patients with a decrease of at least 4 points in the WI-NRS score at week 12 was significantly greater in the difelikefalin group than in the placebo group (37.1% [observed data: 64 of 158 patients] vs. 17.9% [observed data: 35 of 165 patients], P<0.001). Diarrhea, dizziness, and vomiting were more common in the difelikefalin group than in the placebo group.

CONCLUSIONS

Patients treated with difelikefalin had a significant reduction in itch intensity and improved itch-related quality of life as compared with those who received placebo. (Funded by Cara Therapeutics; KALM-1 ClinicalTrials.gov number, NCT03422653.).

Generalized chronic itch induced by small-fibre neuropathy: clinical profile and proposed diagnostic criteria

BACKGROUND

Small-fibre neuropathy (SFN) is a known cause for pain, however, it may be also associated with chronic itch. The clinical profile of chronic itch due to SFN is poorly defined and accordingly under-diagnosed in clinical care.

OBJECTIVES

To establish the clinical profile of patients with SFN and to propose diagnostic criteria for this patient population.

METHODS

Clinical data from patients diagnosed with SFN [chronic generalized itch and reduced intraepidermal nerve fibre density (IENFD)] were analysed retrospectively.

RESULTS

A total of 142 patients (60 females, median age: 62.5 years) were included. Patients reported daily, moderate to severe itch intensity scores occurring mostly in attacks (62.5%). Only 11 patients experienced exclusively itch, while the remaining patients (92%) reported pruralgia (itch along with painful sensations). Burning (50%), a sensation like needle pricks (46%) and tingling (45%) were the sensory symptoms reported by most patients. Cold or ice application led to an alleviation of the symptoms. The IENFD did not correlate with itch intensity; however, patients with a severely reduced IENFD (<30% of the normative cut-off value) reported more frequently sharp, spiky and drilling sensations compared to the remaining patients. The quality of life was moderately impaired and correlated with itch intensity, whereas anxiety and depression scores were low.

CONCLUSIONS

Onset of pruralgia on normal appearing skin, occurrence in attacks and symptomatic alleviation with cold/ice application should alert physicians for a possible neuropathic SFN-related origin of itch. A reduced IENFD can confirm the diagnosis of SFN.

The patient-reported disease burden in adults with atopic dermatitis: a cross-sectional study in Europe and Canada

Background

Cross‐sectional data on patient burden in adults with atopic dermatitis (AD) from real‐world clinical practice are limited.

Objective

This study compared patient‐reported burden associated with adult AD across severity levels from clinical practices in Canada and Europe.

Methods

This study included adults (18–65 years) diagnosed with AD by dermatologists, general practitioners or allergists. Participants categorized as mild (n = 547; 37.3%), moderate (n = 520; 35.4%) or severe (n = 400; 27.3%) based on Investigator's Global Assessment completed a questionnaire that included pruritus and pain numerical rating scales, Patient‐Oriented‐Scoring of Atopic Dermatitis (PO‐SCORAD) itch and sleep visual analogue scales, Dermatology Life Quality Index (DLQI), and the Hospital Anxiety and Depression Scale (HADS). Participants were also stratified by inadequate efficacy/intolerance/contraindication to cyclosporine [Cyclo; n = 62 (4 mild, 18 moderate, 40 severe)] and any systemic immunomodulatory agent [IMM; n = 104 (13 mild, 31 moderate, 60 severe)] and compared with the severe group excluding participants identified as Cyclo/IMM.

Results

Age was similar across severity groups; the proportion of women was higher in the mild group relative to severe (61.2% vs. 50.5%; P < 0.001). Compared with moderate and mild, participants with severe AD had more comorbidities, higher itch and pain severity, worse sleep and higher levels of anxiety and depression (all P < 0.001). Mean ± SD DLQI score among participants with severe AD (16.2 ± 6.9) showed a large effect on quality of life that was higher than those with moderate (10.2 ± 6.3) and mild (5.5 ± 4.9) (both P < 0.001). The burden among Cyclo and IMM subgroups was generally similar to that of participants with severe AD.

Conclusions

Adults with AD reported a substantial burden across multiple domains that was significantly higher in those with severe disease. The burden among participants in the Cyclo/IMM subgroups was similar to those with severe AD.

Effects of skin care education for care staff at elderly care facilities on skin conditions of the residents

Asteatosis is common in elderly people due to a decrease in the moisture content of the epidermal stratum corneum through a loss of skin barrier function caused by aging. Because itching often accompanies asteatosis, this condition may cause a decrease in quality of life. Care staff in elderly care facilities have many opportunities to provide care for residents. In this study, we examined how educational training on skin care changed the thoughts and actions of care staff in these facilities and how these changes impacted the skin conditions of residents. The subjects for the training were all care staff in facilities because these staff work most closely with facility residents. We performed skin care training for the subjects and investigated changes in the skin conditions of the residents before and after the training. The training promoted the understanding of skin care among the care staff and improved the skin symptoms of residents with asteatosis. However, there were no changes in the severity of itchiness based on a verbal rating scale and in interviews of residents. This study showed that skin care training for the care staff in facilities is effective to improve skin conditions of residents. In addition, it was suggested that a full grasp of the residents’ skin symptoms based upon an interview on itching alone was difficult, and thus there is a need to observe skin conditions directly.

Itching as the onset of pain (part 1)

PAIN is a psychophysiological reaction of an organism that occurs with severe irritation of the sensitive nerve endings embedded in organs and tissues. And also pain is the body’s protective reaction. It is signaling about a discomfort and triggers an appropriate response by the body to eliminate the cause of the pain. Pain is one of the earliest symptoms of some diseases [84]. ITCHING – an unpleasant sensation of irritation, heartburn and tingling in any area of the skin caused by various factors (exposure to chemicals, bacteria, parasites). This feeling is often manifested by the urgent need to rub or scratch some areas of the skin (or mucous membrane) [85]. When considering the pathogenesis of these concepts, a sufficiently large resemblance to the realization of mechanisms of origin, or a certain identity thereof is revealed. The question naturally arises whether itching is an early manifestation of pain, especially in those groups of diseases that are not characterized by pain. Pathology of the hematopoietic system is not accompanied by a symptom such as pain. But for conditions such as iron overload, iron deficiency or polycythemia, itching is a clear symptom. The unknown etiology of chronic itching of the skin is indicative of histological examination of the skin in order to exclude skin lymphoma. One of the least understood mechanisms of itching is itching associated with malignant solid tumors. What pain that itching is a subjective sensation that can have an acute or chronic course, a clear intensity and a very significant impact on quality of life, especially in the case of comorbidity. In addition, the question arises whether itching is an early manifestation of pain, especially in those groups of diseases that are not characterized by pain. How can a doctor manage itching effectively to prevent complications? To these and other questions, we have attempted to systematize the manifestations of itching in pathologies of organs and systems that are not traditionally accompanied by pain.

Clinical practice guidelines for the management of atopic dermatitis 2018

Atopic dermatitis (AD) is a disease characterized by relapsing eczema with pruritus as a primary lesion. The current strategies to treat AD in Japan from the perspective of evidence-based medicine consist of three primary measures: (i) the use of topical corticosteroids and tacrolimus ointment as the main treatment for the inflammation; (ii) topical application of emollients to treat the cutaneous barrier dysfunction; and (iii) avoidance of apparent exacerbating factors, psychological counseling and advice about daily life. The guidelines present recommendations to review clinical research articles, evaluate the balance between the advantages and disadvantages of medical activities, and optimize medical activity-related patient outcomes with respect to several important points requiring decision-making in clinical practice.

2019 Consensus Korean Diagnostic Guidelines to Define Severity Classification and Treatment Refractoriness for Atopic Dermatitis: Objective and Subjective Assessment of Severity

Background

Systemic immunomodulatory treatment is actively recommended in the treatment for moderate to severe atopic dermatitis (AD) patients. However, consensus criteria for the classification of AD severity or treatment refractoriness have not been established yet.

Objective

To establish consensus criteria on the definition of severity classification and treatment refractoriness of AD to provide a basis for proper treatment strategy.

Methods

The Korean Atopic Dermatitis Association (KADA) comprised a task force team to establish a definition of moderate to severe AD. A draft of definition of moderate to severe AD was made on the basis of evidence. The recommendation was confirmed by KADA members through a web-based survey.

Results

KADA approved that AD with 16≤eczema area and severity index (EASI)<23 should be basically defined as moderate AD whereas AD with EASI score ≥23 should be considered as severe AD. They agreed that it would be reasonable to raise the severity level if patient's daytime or nighttime pruritus numerical rating scale is equal to or higher than 7 (≥7) or dermatology life quality index score exceeds 10. AD patients who do not reach EASI 50 after appropriate treatment for three months should be considered as a non-responder. Patients with recurrence (EASI ≥16) within three months after cessation of treatment should be considered as a recurrent AD.

Conclusion

KADA built a consensus of definition of moderate and severe AD and treatment-refractoriness. These guidelines are expected to help physicians determine proper treatment options in need.

Diagnostic Workup and Evaluation of Patients with Prurigo Nodularis

Prurigo nodularis (PN) is a chronic inflammatory skin disease characterized oftentimes by symmetrically distributed, severely pruritic nodules. Currently, the pathophysiology of PN remains to be fully elucidated, but emerging evidence suggests that neuroimmune alterations play principal roles in the pathogenesis of PN. There are several associated etiologic factors thought to be associated with PN, including dermatoses, systemic, infectious, psychiatric, and neurologic conditions. We conducted a systematic literature review to evaluate the clinical presentation, diagnosis, and etiologic factors of PN. In this review, we discuss common differential diagnoses of PN and recommend an evidence-based, standardized diagnostic evaluation for those with suspected PN.

The Effect of Olea Ointment on Post-Episiotomy Pain Severity in Primiparous Women: A Paralleled Randomized Controlled Clinical Trial

Background:

Episiotomy is the most commonly performed surgical procedure during delivery, and its associated pain is a major problem in obstetrics. This study aimed to determine the effect of Olea ointment on the severity of post-episiotomy pain in primiparous women.

Materials and Methods:

This paralleled randomized controlled clinical trial was performed on 73 primiparous women in Al-Zahra hospital in Rasht, Iran in 2017-2018. Women were randomly allocated into intervention (n = 39) and control (n = 34) groups. The first intervention was performed 4 h after the episiotomy. This continued every 8 h for 10 days. The pain intensity of episiotomy was assessed by the Visual Analogue Scale (VAS) before intervention, 2 and 24 h after the beginning of intervention, and 5 and 10 days after childbirth. Descriptive and inferential statistics (Mann-Whitney, Fisher exact test, Independent t-test, Friedman test, and Chi-square) were performed for statistical analysis.

Results:

There were no significant differences among two groups in terms of demographic and obstetrics characteristics. The severity of pain in intervention and control group before the intervention was not statistically significant, but the variable depicted a meaningful difference between the groups 2 h after the intervention (U = 483.50, p = 0.021), 24 h after the intervention (U = 489.50, p = 0.019), as well as the 5^th day (U = 112.50, p < 0.001) and 10^th day postpartum (U = 136.50, p < 0.001).

Conclusions:

Based on the findings, Olea ointment could be used effectively for reducing of episiotomy pain. Similar studies are recommended.

Association of Inadequately Controlled Disease and Disease Severity With Patient-Reported Disease Burden in Adults With Atopic Dermatitis

Importance

Real-world data are limited on the patient-reported burden of adult atopic dermatitis (AD).

Objective

To characterize the patient-reported burden of AD with regard to impact of disease severity and inadequate control in adults from clinical settings.

Design, Setting, and Participants

In this cross-sectional study using data from 6 academic medical centers in the United States collected by a self-administered internet-based questionnaire, 1519 adult patients with AD were stratified by AD severity as mild or moderate/severe using the Patient-Oriented Scoring Atopic Dermatitis (PO-SCORAD). Patients with moderate/severe disease using systemic immunomodulators/phototherapy were further stratified as having adequate or inadequate disease control. Strata were compared for all outcomes.

Main Outcomes and Measures

Outcomes included validated measures and stand-alone questions assessing itch (pruritus numerical rating scale; PO-SCORAD itch visual analog scale), pain (numerical rating scale), sleep (PO-SCORAD sleep visual analog scale; sleep interference with function), anxiety and depression (Hospital Anxiety and Depression Scale), and health-related quality of life (Dermatology Life Quality Index).

Results

Among the 1519 adult patients with AD, relative to mild AD (n = 689, 64% women; mean [SD] age, 46.5 [18.0] years), patients with moderate/severe AD (n = 830, 66.8% women; mean [SD] age, 45.1 [16.9] years) reported more severe itching and pain, greater adverse effects on sleep, higher prevalence of anxiety and depression (417 [50.2%] vs 188 [27.3%]), and greater health-related quality-of-life impairment. The 103 patients with moderate/severe AD with inadequate disease control despite treatment with systemic immunomodulators or phototherapy (55.7%) reported higher burdens of itch and sleeping symptoms vs patients with controlled disease including more days per week with itchy skin (5.7 vs 2.7) and higher proportions with itch duration greater than half a day (190 [22.8%] vs 20 [2.9%]). Sleep symptoms included trouble sleeping (3.9 vs 1.1 on the PO-SCORAD VAS), longer sleep latency (38.8 vs 21.6 minutes), more frequent sleep disturbances (2.6 vs 0.4 nights in past week), and greater need for over-the-counter sleep medications (324 [39%] vs 145 [21%]).

Conclusions and Relevance

Inadequate disease control was common among patients with moderate/severe AD, and was associated with a higher patient-reported burden than patients with controlled disease. Regardless of disease control, the burden of moderate/severe AD was higher than mild AD, suggesting a need for more effective therapies for moderate/severe disease.

Exploring content and psychometric validity of newly developed assessment tools for itch and skin pain in atopic dermatitis

Background

Atopic dermatitis (AD) is a common skin disorder characterized by chronic inflammation, altered skin barrier function, and inflammatory cell skin infiltration that decreases health-related quality of life (HRQoL). The study objective was to understand the patient perspective of AD burden and determine suitable patient-reported outcome (PRO) measures.

Methods

This mixed methods study involved the collection of qualitative and quantitative information from adults (≥ 18 years old) and adolescents (12 – 17 years old) with clinician-confirmed AD regarding their experiences of AD symptoms and its impact on HRQoL. The first part of the study included three stages: in-person concept elicitation (CE) interviews, a 2-week daily electronic diary (eDiary) study, and in-person cognitive debriefing (CD) interviews. An Itch numeric rating scale (NRS) (v1.0) and a Skin Pain NRS (v1.0) evaluation during CD interviews required participants to think about their ‘worst’ itch and ‘worst’ skin pain in the past 24 h. Other PRO measures allowed for psychometric testing. The second part of the study involved telephone-depth interviews (TDIs) and qualitative feedback from participants who had not participated in the CD interviews. Qualitative data were thematically analyzed. Psychometric evaluation of NRS measures was performed using eDiary data.

Results

In the CE interviews, itch and/or itching and skin pain were the most prevalent symptoms consistently discussed by participants. Both NRS measures demonstrated strong psychometric reliability and were applicable across ages with suitable concurrent validity. During the CD interviews, some participants focused their answers on their ‘average’ itch/itching in the past 24 h, rather than their ‘worst’ itch. Some participants answered the Skin Pain NRS thinking about general pain or other types of pain, rather than skin pain specifically. Consequently, modifications to both measures addressed these issues and re-tested as paper-and-pen versions in subsequent TDIs. Itch NRS (v2.0) modifications helped participants focus on their worst itching. Most participants preferred Skin Pain NRS v2.0b, which included skin pain descriptors.

Conclusions

Itching and skin pain are the most important and relevant AD symptoms. The Itch NRS (v2.0) and Skin Pain NRS (v2.0b) appear to be appropriate endpoints for the assessment of itching and skin pain severity for clinical trials with adults and adolescents with AD.

Effects of combination therapy and infrared radiation on pain, physical function, and quality of life in subjects with knee osteoarthritis: A randomized controlled study

Background:

Knee osteoarthritis (KOA) is a common degenerative articular disease that causes disability and poor quality of life (QoL) of the individuals. Electrotherapeutic agents such as therapeutic ultrasound (US), interferential current (IFC), and infrared radiation are used in the treatment. It is not clear which of these agents is the best in improving these variables.

Objective:

The study aimed to compare the effects of the combined application of US and IFC therapies and infrared radiation on pain, functional activities, and QoL in people with KOA.

Methods:

In a randomized controlled study, 60 participants were randomized into two groups, the combination therapy group (CTG) and the infrared radiation group (IRG). Each group received 15-min treatment three times per week for 12 weeks. The visual analog scale (VAS) was used to assess the pain, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) for functional activities and the Short Form Health Survey questionnaire for QoL.

Results:

Participants in the CTG had a significant (p<0.05) reduction in pain and significant (p<0.05) improvement in functional activities and QoL compared to the IRG.

Conclusion:

The results of this study support the use of the combination of IFC and US therapies to reduce pain and improve function and QoL for KOA patients.

PRURITUS CHARACTERISTICS IN A LARGE ITALIAN COHORT OF PSORIATIC PATIENTS

BACKGROUND

Psoriasis (Ps) is a chronic systemic autoimmune disease associated with pruritus in 64-98% of patients. However, few modestly sized studies assess factors associated with psoriatic pruritus.

OBJECTIVE

To investigate factors associated with Ps pruritus intensity.

METHODS

Psoriasis patients 18 years or older seen in one of 155 centers in Italy between September 2005 and 2009 were identified from the Italian PsoCare registry. Patients without cutaneous psoriasis and those with missed information on pruritus were excluded.

RESULTS

We identified 10,802 patients, with a mean age 48.8±14.3 years. Mild itch was present in 33.2% of patients, moderate in 34.4%, severe in 18.7% and very severe in 13.7%. Higher itch intensity was associated with female gender, lower educational attainment compared to university degree, pustular psoriasis, psoriasis on the head, face, palmoplantar areas, folds and genitalia, more severe disease, disease duration <15 years, and no or few prior systemic treatments.

LIMITATIONS

Effects of specific medication on itch were not assessed.

CONCLUSIONS

Pruritus should be evaluated during psoriasis visits, and physicians should be aware of patients at higher risk for itch. Further studies are needed to assess the effects of medications on itch, and establish therapy for psoriasis patients with persistent itch.

Validity and reliability of itch assessment scales for chronic pruritus in adults: A prospective multicenter study

BACKGROUND

Several tools can provide a reliable and accurate evaluation of pruritus, including the visual analog scale (VAS), numeric rating scale (NRS), verbal rating scale (VRS), and multidimensional questionnaires such as the Itch Severity Scale (ISS). However, no single method is considered a gold standard.

OBJECTIVE

We evaluated the validity and reliability of VAS, NRS, VRS, and ISS and their correlation with a pruritus-specific quality of life instrument, ItchyQoL.

METHODS

A total of 419 patients (215 men and 204 women) with chronic pruritus (mean age, 46.58 years) recorded their pruritus intensity on VAS, NRS, VRS, and ISS. Retest reliability was analyzed in a second assessment 3 hours after the initial assessment. All participants answered ItchyQoL.

RESULTS

A strong correlation between VAS, NRS, and VRS was found. ISS showed a low intercorrelation validity with these tools. However, ISS was more strongly correlated with ItchyQoL. The retest reliability scores were similar for VAS, NRS, and VRS but lower than the scores obtained for ISS.

LIMITATIONS

Limitations include patient heterogeneity and recall bias.

CONCLUSION

The assessment of pruritus is challenging because of the subjective symptoms and the multifactorial nature. Therefore, more studies are needed to determine the best strategy to assess itch intensity.

TREatment of ATopic eczema (TREAT) Registry Taskforce: consensus on how and when to measure the core dataset for atopic eczema treatment research registries

Background

Comparative, real‐life and long‐term evidence on the effectiveness and safety of phototherapy and systemic therapy in moderate‐to‐severe atopic eczema (AE) is limited. Such data must come from well‐designed prospective patient registries. Standardization of data collection is needed for direct comparisons and data pooling.

Objectives

To reach a consensus on how and when to measure the previously defined domain items of the TREatment of ATopic eczema (TREAT) Registry Taskforce core dataset for research registries for paediatric and adult patients with AE.

Methods

Proposals for the measurement instruments were based on recommendations of the Harmonising Outcome Measures for Eczema (HOME) initiative, the existing AE database of TREATgermany, systematic reviews of the literature and expert opinions. The proposals were discussed at three face‐to‐face consensus meetings, one teleconference and via e‐mail. The frequency of follow‐up visits was determined by an expert survey.

Results

A total of 16 experts from seven countries participated in the ‘how to measure’ consensus process and 12 external experts were consulted. A consensus was reached for all domain items on how they should be measured by assigning measurement instruments. A minimum follow‐up frequency of initially 4 weeks after commencing treatment, then every 3 months while on treatment and every 6 months while off treatment was defined.

Conclusions

This core dataset for national AE research registries will aid in the comparability and pooling of data across centres and country borders, and enables international collaboration to assess the long‐term effectiveness and safety of phototherapy and systemic therapy used in patients with AE.

What's already known about this topic?

Comparable, real‐life and long‐term data on the effectiveness and safety of phototherapy and systemic therapy in patients with atopic eczema (AE) are needed.

There is a high diversity of outcomes and instruments used in AE research, which require harmonization to enhance comparability and allow data pooling.

What does this study add?

Our taskforce has reached international consensus on how and when to measure core domain items for national AE research registries.

This core dataset is now available for use by researchers worldwide and will aid in the collection of unified data.

What are the clinical implications of this work?

The data collected through this core dataset will help to gain better insights into the long‐term effectiveness and safety of phototherapy and systemic therapy in AE and will provide important information for clinical practice.

Standardization of such data collection at the national level will also allow direct data comparisons and pooling across country borders (e.g. in the analysis of treatment‐related adverse events that require large patient numbers).

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Efficacy and safety of topical OPA-15406, a new phosphodiesterase 4 inhibitor, in Japanese patients with atopic dermatitis for 8 weeks: A phase 2, randomized, double-blind, placebo-controlled study

The efficacy and safety of topical OPA-15406, a new phosphodiesterase 4 inhibitor, were examined in Japanese patients aged 15-70 years with atopic dermatitis in a phase 2, randomized, double-blind, vehicle-controlled study. Two hundred patients were randomized to three treatment groups at a 1:1:1 ratio to receive OPA-15406 0.3%, OPA-15406 1% or vehicle ointment twice daily for 8 weeks. The OPA-15406 1% group was superior to the vehicle group in terms of the incidence of success based on the Investigator Global Assessment score at week 4 (P = 0.0328), which was the primary end-point, while the OPA-15406 0.3% group showed a trend toward improvement in the primary end-point. The mean Eczema Area and Severity Index total score and subscale (erythema, induration/papulation, excoriation and lichenification) scores, the Visual Analog Scale pruritus score and the Patient-Oriented Eczema Measure score were significantly improved and the percentage of affected body surface area was significantly decreased in both OPA-15406 groups relative to the vehicle group as early as week 1, and the improved scores and decreased percentages were generally maintained until week 8. No deaths or serious treatment-emergent adverse events occurred in the OPA-15406 treatment groups. Treatment-emergent adverse events frequently observed across treatment groups were worsening of atopic dermatitis, viral upper respiratory tract infection and pruritus, all of which were mild or moderate in severity in the OPA-15406 groups. OPA-15406 1% ointment showed favorable efficacy and safety profiles, indicating a promising treatment option for patients with atopic dermatitis.

Emerging Treatments and Novel Pathways in Pruritus

Itch treatment is a major challenge in the dermatologist’s practice. We encounter patients suffering from pruritus on a regular basis, and often lack diverse treatment options to adequately respond to the patients’ needs. In the last 20 years, novel pathways have been investigated that were beyond the scope of histamine. Although most did not result in a molecule available on the Canadian market, it is interesting and important as health care providers to stay up to date with new neuronal pathways involved in itch transmission and potential new therapeutic options. In this review, we will discuss pathways targeted in new topical treatments such as antagonist of proteinase-activated receptor-2, the endocannabinoid system, neurotrophins and tropomyosin-related kinase A receptor, the transient receptor potential-vanilloid or transient receptor potential-melastatine ion channels. New systemic therapies are now focusing on antagonizing the neurokinin receptor, modulating the opioidergic system, or targeting itch cytokines such as interleukin-31.

Canine Pruritus Visual Analog Scale: how does it capture owners' perception of their pet's itching level?

BACKGROUND

Accurate measurement of pruritus severity is difficult in veterinary medicine.

OBJECTIVES

To determine how the changes in Pruritus Visual Analog Scale (PVAS) scores at follow-up visits agree with the owners' perceptions of improvement of their pet's pruritus.

ANIMALS

One hundred and ninety two pruritic dogs were included in the prospective study and 196 in the retrospective study.

METHODS AND MATERIALS

Owners were randomly assigned into five groups and PVAS scores were recorded during two consecutive visits. Group A: previous scores were shown before completing the PVAS; Group B: PVAS was completed then owners were shown previous scores and asked to repeat the PVAS; Group C: PVAS was completed as reported previously; Group D: PVAS and a 0-10 verbal scale (VS) were completed. Retrospectively, PVAS scores were analysed during at least three consecutive visits. The average percentage and kappa agreements were calculated for all groups. In addition, PVAS and VS scores were compared in Group D.

RESULTS

The average percentage and kappa agreements were higher in groups A (96%; 0.81), B [before (80%; 0.54), after (82%; 0.59) previous score] and D (85%; 0.47). Group C (79%; 0.37) had the lowest agreement. PVAS and VS scores were not significantly different (P = 0.56) in Group D. The average percentage and kappa agreements for the retrospective study were 50.8% and 0.25. The highest values (63%; 0.355) were noted at 30-60 day visit intervals.

CONCLUSIONS AND CLINICAL IMPORTANCE

Showing owners previous scores could improve how PVAS captures the owner's perception of their dog's itching level.

Itch: an under-recognized problem in psoriasis

Psoriasis has historically been considered a nonpruritic dermatosis, in contrast with atopic dermatitis. Thus, itch has often been underappreciated and overlooked in psoriasis. However, increasing evidence over the past decade has shown that itch can be one of the most prevalent and burdensome symptoms associated with psoriasis, affecting almost every patient to some degree. Itch can involve the entire body, although it predominantly affects the legs, hands, back, body and especially the scalp. Uncontrolled itch can significantly impact all aspects of the well-being and quality of life of the patient. While there has been some progress in trying to better understand the pathophysiology of itch in psoriasis, more research effort and interest are needed. This under-recognition of itch in psoriasis is clearly reflected in the dearth of treatment options targeting itch despite significant advancement in treating the lesions themselves. Recently, however, clinical studies have begun to include itch as a study outcome. The resulting data have demonstrated concomitant antipruritic benefits and improved Psoriasis Area and Severity Index (PASI) scores with mainstay treatments for psoriasis, such as topical corticosteroids and vitamin D analogs, phototherapies, and various systemics and biologics. This article takes a closer look at this debilitating symptom, reviewing the available epidemiology data for psoriatic itch, presenting the current understanding of psoriatic itch pathophysiology and highlighting important clinical data for various treatment options for itch. Practical considerations for increasing the recognition of itch as well as improving its management in psoriasis are also provided.

Peak Pruritus Numerical Rating Scale: psychometric validation and responder definition for assessing itch in moderate-to-severe atopic dermatitis

BACKGROUND

Moderate-to-severe atopic dermatitis (AD) is a chronic disease characterized by intense, persistent and debilitating itch, resulting in sleep deprivation, signs of anxiety and depression, impaired quality of life and reduced productivity. The Peak Pruritus Numerical Rating Scale (NRS) was developed and validated as a single-item, patient-reported outcome (PRO) of itch severity.

OBJECTIVES

To describe the content validity and psychometric assessment (test-retest reliability, construct validity, known-groups validity, sensitivity to change) of the Peak Pruritus NRS, and to derive empirically a responder definition to identify adults with a meaningful change in itch.

METHODS

Content validity was assessed through in-depth patient interviews. Psychometric assessments used data from phase IIb and phase III dupilumab clinical trials and included test-retest reliability, construct validity, known-groups validity and sensitivity to change in patients with moderate-to-severe AD.

RESULTS

Interview participants indicated that the Peak Pruritus NRS was a relevant, clear and comprehensive assessment of itch severity. Peak Pruritus NRS scores showed large, positive correlations with existing PRO measures of itch, and weak or moderate correlations with clinician-reported measures assessing objective signs of AD. Peak Pruritus NRS score improvements were highly correlated with improvements in other itch PROs, and moderately correlated with improvements in clinician-reported measures assessing objective signs of AD. The most appropriate threshold for defining a clinically relevant, within-person response was ≥ 2-4-point change in the Peak Pruritus NRS.

CONCLUSIONS

The Peak Pruritus NRS is a well-defined, reliable, sensitive and valid scale for evaluating worst itch intensity in adults with moderate-to-severe AD.

The Itch-Scratch Cycle: A Review of the Mechanisms

Background

Despite being one of the most common presenting dermatological symptoms, itching continues to perplex health care professionals because it is notoriously difficult to control.

Objective

This review gathers evidence to answer the 2-part question, "Why do we itch and scratch?" by exploring the history of itchy disease, the neurobiology of itch, and the 4 different clinical origins of itch: pruritogenic, neurological, neuropathic, and psychological.

Results

The automated scratching reflex and its biological and psychological reasons for existence are complicated and poorly understood. Currently, there are a myriad of treatments available for individuals suffering from this condition; however, many remain symptomatic.

Conclusions

The itch-scratch cycle is a complex pain-like sensation with a reflex-like response. In the future, continued exploration into the mechanisms behind itch and scratch may open the doors for new therapeutic interventions.

Woad extract containing cream improves significantly dry, irritated, and pruritic skin

Objective of this open, noninterventional, noncontrolled study was to investigate the tolerability and performance of a woad extract containing cream in subjects with dry, pruritic skin after twice daily application over 2 weeks. Assessments included sensorial characteristics, skin condition, pruritus (numeric rating scale [NRS], dynamic pruritus score [DPS]), skin dryness (itch-controlled days [ItchCD], overall dry skin [ODS]), transepidermal water loss (TEWL), skin hydration and quality of life (5PLQ, DLQI). All sensorial characteristics were well perceived (>4), with tolerability (4.77 ± 0.47) and no negative skin feelings (4.73 ± 0.74) achieving the highest scores (0-5 scale). Dry skin and symptoms improved significantly (p < .001) for all variables: NRS (from 4.8 ± 1.74 to 1.83 ± 2.18), ItchCD (from 8.23 ± 4.40 to 4.81 ± 4.07), ODS (from 1.80 ± 0.85 to 0.65 ± 0.65), hydration (23.33 ± 1.33 to 40.70 ± 1.86), and quality of life (5PLQ: from 7.12 ± 4.25 to 4.24 ± 3.67; DLQI: from 5.29 ± 4.79 to 3.00 ± 3.98). The DPS revealed a moderate antipruritic effect. The TEWL decreased slightly (p = .511). No side effects were reported. The study suggests that, the cream is effective, and well tolerated in treating dry, irritated, and pruritic skin.

Efficacy and safety of dupilumab for the treatment of moderate-to-severe atopic dermatitis in adults: A pooled analysis of two phase 2 clinical trials

BACKGROUND AND PURPOSE

There is a need for new treatment options for moderate-to-severe atopic dermatitis (AD) in adults. Dupilumab, a fully human anti-interleukin-4 receptor α monoclonal antibody, has recently been approved for this indication.

METHODS

A pooled analysis of a phase 2a (NCT01548404) and a phase 2b (NCT01859988) study and a subanalysis of the 2b study evaluated the efficacy and safety of subcutaneous dupilumab 300 mg once weekly (qw) and every 2 weeks (q2w) in adults with moderate-to-severe AD.

RESULTS

Dupilumab significantly improved clinical outcomes in both analyses at week 12. Itch was significantly improved in the pooled analysis as measured by peak pruritus Numerical Rating Scale, 5-dimension pruritus scale, and SCORing Atopic Dermatitis (SCORAD) Visual Analog Scale (VAS) pruritus scores (all p < .0001 vs. placebo at week 12). Sleep loss was significantly improved (SCORAD VAS sleep loss score; p < .0001 vs. placebo at week 12); similar results were shown for the q2w dose. Dupilumab had an acceptable safety profile.

CONCLUSIONS

Consistent with previous studies, dupilumab qw and q2w significantly improved signs and symptoms of AD at week 12, including improvements in itch and sleep loss.

IMPLICATIONS FOR PRACTICE

Subcutaneous dupilumab is an effective new treatment option for adults with moderate-to-severe AD.

The 1470 nm diode laser with an intralesional fiber device: a proposed solution for the treatment of inflamed and infected keloids

Background

Keloids are the result of abnormal wound healing and often are subject to infections and recurrent inflammation. We present a study conducted with a 1470 nm diode laser using an intralesional optical fiber device for the treatment of inflamed keloid scars. We evaluate its efficacy as a novel alternative method to decrease keloid infection and inflammation.

Methods

The patients who underwent 1470 nm laser treatment from February 2016 to February 2018 at the plastic and reconstructive surgery department of the Shanghai Ninth People’s Hospital Affiliated to Shanghai Jiao Tong University with keloid accompanying serious local infection and fester were included. Patients took curative effect evaluation before and 1 year after the treatment. The test items included infection frequency in each year; pain, by visual analogue scale (VAS); itch, using VAS; quality of life (QOL), using QOL scale; and blood supply, using PeriCam PSI.

Results

A total of 19 patients (mean age 35.21 years, range 11–66) with history of inflamed keloids with episodes of infection or abscess were enrolled. Patients underwent to a 1470 nm laser therapy for average of 1.16 times. After treatment, infection frequency and blood supply in keloids were reduced (p < 0.001). Pain, itching, and QOL were improved (p < 0.001).

Conclusion

The present study shows that 1470 nm fiber laser treatment could improve inflamed keloids fairly well by decreasing inflammation, and a relative stabilization of collagen composition. Therefore, it is an effective minimally invasive scar therapy, but further studies are essential to confirm the present results.

Flaminal® versus Flamazine® in the treatment of partial thickness burns: A randomized controlled trial on clinical effectiveness and scar quality (FLAM study)

Although partial thickness burns are the most frequently reported burn injuries, there is no consensus on the optimal treatment. The objective of this study was to compare the clinical effectiveness and scar quality of Flaminal® Forte to silver sulfadiazine (Flamazine®) in the treatment of partial thickness burns. In this two‐arm open label multicenter randomized controlled trial, adult patients with acute partial thickness burns and an affected total body surface area of less than 30% were randomized between Flaminal® Forte and Flamazine® and followed for 12 months. Dressing changes in the Flamazine® group were performed daily, and in the Flaminal® group during the first 3 days post burn and thereafter every other day until complete wound healing or surgery. Forty‐one patients were randomly allocated to Flaminal® Forte and 48 patients to Flamazine®. The primary outcome was time to wound healing, which did not differ between the groups: median 18 days with Flaminal® Forte (range 8–49 days) versus 16 days with Flamazine® (range 7–48 days; p = 0.24). Regarding the secondary outcomes during hospital admission, there were no statistically significant differences between the groups concerning need for surgery, pain scores, pruritus, or pain‐related and anticipatory anxiety. More patients in the Flaminal® group developed wound colonization (78% versus 32%, p < 0.001), but the treatment groups did not differ regarding the incidence of local infections and use of systemic antibiotics. In terms of scar quality, no statistically significant differences between both treatment groups were found regarding subjective scar assessment (Patient and Observer Scar Assessment Scale (POSAS)), scar melanin and pigmentation (DermaSpectrometer®), and scar elasticity and maximal extension (Cutometer®) during 12 month postburn. In conclusion, time to wound healing did not differ, but the use of Flaminal® Forte seemed favorable because less dressing changes are needed which lowers the burden of wound care.

Meaningfulness of landmark pictograms reduces visual salience and recognition performance

Landmarks, objects in the environment used for orientation, navigation and the formation of cognitive maps are often represented in maps as pictograms. In order to support these tasks effectively and efficiently, landmark pictograms also need to be salient, as the map user needs to identify and process them quickly and easily. Two additional relevant characteristics for the usability of landmark pictograms are their meaningfulness and recognition performance. Meaningfulness is required to understand which categories of objects are represented by the pictograms. Ease of recognition prevents the necessity to consult a map repetitively and may support the formation of a cognitive map of the environment. In the present study, we investigated the relation between salience, meaningfulness and recognition performance of OpenStreetMap (OSM) pictograms and the potential effects of the visual complexity of pictograms on these usability characteristics. Salience was measured via eye fixations on specific pictograms, meaningfulness with an explicit continuous scale and recognition performance with a yes/no recognition memory paradigm. Statistical analyses showed that pictograms drew more visual attention if they were visually complex or if their meaning was inapprehensible or ambiguous. Less apprehensible pictograms were also recognized more often. Interestingly, the data indicated that longer fixations could lead to worse recognition performance. Long fixations on a pictogram may increase the likelihood of false recognition in subsequent situations where the pictogram is no longer valid or relevant. Based on the findings, we suggest balancing the meaningfulness and visual complexity of contiguous pictograms to enhance their recognition and to provide an optimal level of salience of single objects.

Approach to the Assessment and Management of Adult Patients With Atopic Dermatitis: A Consensus Document. Section II: Tools for Assessing the Severity of Atopic Dermatitis

Clinicians rely on clinical measures to define the severity of atopic dermatitis and assess outcomes of therapy. These measures can be objective (ie, physician assessments of disease severity) or subjective (ie, patient-reported symptoms and quality of life outcomes). In this review, the most commonly used tools for assessing atopic dermatitis severity in adult patients are presented and compared. These include Eczema Area and Severity Index (EASI); SCORing Atopic Dermatitis (SCORAD); Physician Global Assessment (PGA); body surface area (BSA); Atopic Dermatitis Severity Index (ADSI); Six Area, Six Sign Atopic Dermatitis (SASSAD); Patient Oriented Eczema Measure (POEM); Dermatology Life Quality Index (DLQI); and pruritus Numerical Rating Scale (NRS). Available severity strata for the tools are summarized, although the use of severity strata in clinical practice is not recommended. Since both objective and subjective assessments of disease severity are important to assess, consideration of clinical characteristics such as disease recurrence or persistence, as well as location of the affected areas, should be considered in the overall judgement of disease severity and consideration of therapy choice.

Humanistic burden of chronic pruritus in patients with inflammatory dermatoses: Results of the European Academy of Dermatology and Venereology Network on Assessment of Severity and Burden of Pruritus (PruNet) cross-sectional trial

BACKGROUND

Chronic pruritus is a multifactorial, challenging symptom of global relevance.

OBJECTIVE

The European Academy of Dermatology and Venereology Network on Assessment of Severity and Burden of Pruritus (PruNet) investigation aimed to analyze the severity and humanistic burden of chronic pruritus in patients suffering from inflammatory dermatoses across Europe.

METHODS

Prospectively collected routine data on 552 patients (with atopic dermatitis, contact dermatitis, prurigo nodularis, psoriasis vulgaris, lichen planus, or mycosis fungoides [pruritus numeric rating scale score ≥3]) from 9 European centers (in Austria, France, Germany, Italy, Poland, Russia, Spain, Switzerland, and Turkey) were analyzed by univariate and multivariate variance analyses of various itch characteristics and quality of life (as measured by the Dermatology Life Quality Index and the ItchyQoL).

RESULTS

Duration, frequency, and intensity of pruritus (according to a numeric rating scale and visual analog scale) and related impairment of quality of life differed between European centers and dermatologic diagnoses (P < .05). The country in which the center was located had a greater impact on how patients evaluated pruritus intensity and quality of life than diagnosis did (P < .001).

LIMITATIONS

One center per country was included.

CONCLUSION

The humanistic burden of chronic pruritus in patients with inflammatory dermatoses is high. European cross-cultural factors may have a stronger influence than a specific dermatologic diagnosis on how patients rate intensity of pruritus and quality of life.

Efficacy and safety of rupatadine in Japanese adult and adolescent patients with chronic spontaneous urticaria: A double-blind, randomized, multicenter, placebo-controlled clinical trial

BACKGROUND

Rupatadine, a novel nonsedating second-generation H1-antihistamine with antiplatelet-activating factor activity, has been used in the treatment of allergic rhinitis and urticaria in European countries since 2003. However, its efficacy and safety in Japanese patients with chronic spontaneous urticaria (CSU) are unknown.

METHODS

We conducted a prospective, multicenter, randomized, placebo-controlled, double-blind study in adolescent and adult CSU outpatients aged 12 to < 65 years (JAPIC-CTI No. 152786). Overall, 94, 91, and 92 eligible patients orally received placebo, rupatadine 10 mg, and 20 mg once daily for 2 weeks, respectively. The primary endpoint was change from baseline to the second week of treatment in total pruritus score (TPS, sum of daytime and nighttime pruritus scores).

RESULTS

The results yielded a least squares mean TPS difference of -1.956 between rupatadine 10 mg versus placebo, and -2.121 between rupatadine 20 mg versus placebo (analysis of covariance, both P < 0.001). The incidence of adverse events was 8.5% for placebo, 20.9% for rupatadine 10 mg, and 17.4% for rupatadine 20 mg. Somnolence was the only adverse drug reaction to rupatadine reported in 2 or more subjects. No serious or clinically significant adverse events were observed.

CONCLUSIONS

The primary and secondary efficacy endpoints consistently favored rupatadine 10 and 20 mg doses over the placebo. No noteworthy dose-related increase in the incidence of adverse drug reactions was observed. Rupatadine is safe and effective at a dose of 10 mg once daily, and can be safely increased to 20 mg once daily, as necessary.

Cross-cultural validation of the Itch Man Scale in pediatric burn survivors in a South African setting

INTRODUCTION

Pruritus or itch is a common symptom after burn injuries. The Itch Man Scale has been recommended to assess itch severity in children. The aim of this prospective observational study was to perform a cross-cultural validation of the Itch Man Scale by comparing it with the Numeric Rating Scale (NRS) and the Toronto Pediatric Itch Scale.

METHOD

At Red Cross War Memorial Children's Hospital in Cape Town, South Africa, parents of pediatric burn patients assessed their child's itch with the Itch Man Scale, NRS and Toronto Pediatric Itch Scale. Children from the age of 6years also rated the Itch Man Scale and NRS themselves. The Spearman rank order correlation between the different scales was calculated to determine construct validity.

RESULTS

Over a two-month period, 255 pediatric burn survivors with a median age of 2.3years (IQR 1.4-4.0) were included; 35 of them were aged 6-13years. Parents' Itch Man Scale ratings correlated significantly with parents' NRS ratings (0.82, 95% CI 0.78-0.86) and with the Toronto Pediatric Itch Scale of the parent (0.80, 95% CI 0.75-0.84). The correlation between the older children's Itch Man Scale rating and those of their parents was 0.66 (95% CI 0.37-0.83).

CONCLUSION

We concluded that the Itch Man Scale has promising validity and is a user-friendly tool to use in clinical practice to determine the itch intensity in children younger than 13years in a South African setting.