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Kwatra SG, Ständer S, Yosipovitch G, Kim BS, Levit NA, O'Malley JT. Pathophysiology of Prurigo Nodularis: Neuroimmune Dysregulation and the Role of Type 2 Inflammation. J Invest Dermatol 2024:S0022-202X(24)01875-X. [PMID: 39217537 DOI: 10.1016/j.jid.2024.06.1276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Accepted: 06/18/2024] [Indexed: 09/04/2024]
Abstract
Prurigo nodularis (PN) is a chronic, inflammatory skin condition characterized by multiple, intensely pruritic, distinctive nodular lesions. Subsequent scratching can further intensify the pruritus, culminating in a self-reinforcing itch-scratch cycle, which drives lesion development. The latest data indicate dysregulation of the neuroimmune axis in PN pathogenesis, including the involvement of sensory neurons, key effector immune cells, proinflammatory cytokines, dermal fibroblasts, and pruritogens. In this review, we highlight evidence supporting the role of type 2 immune axis dysregulation in driving the clinical presentation of PN and discuss how related signaling pathways may offer effective therapeutic targets to control PN signs and symptoms.
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Affiliation(s)
- Shawn G Kwatra
- Department of Dermatology, University of Maryland School of Medicine, Baltimore, Maryland, USA; Maryland Itch Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Sonja Ständer
- Department of Dermatology and Center for Chronic Pruritus, University Hospital Münster, Münster, Germany
| | - Gil Yosipovitch
- Miami Itch Center, Dr. Philip Frost Department of Dermatology & Cutaneous Surgery, University of Miami, Miami, Florida, USA
| | - Brian S Kim
- Mark Lebwohl Center for Neuroinflammation and Sensation, Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Noah A Levit
- Dermatology Physicians of Connecticut, Fairfield, Connecticut, USA
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Liao V, Cornman HL, Ma E, Kwatra SG. Prurigo nodularis: new insights into pathogenesis and novel therapeutics. Br J Dermatol 2024; 190:798-810. [PMID: 38345154 PMCID: PMC11099982 DOI: 10.1093/bjd/ljae052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 01/30/2024] [Accepted: 02/02/2024] [Indexed: 05/18/2024]
Abstract
Prurigo nodularis (PN) is an inflammatory skin condition characterized by intensely pruritic nodules on the skin. Patients with PN suffer from an intractable itch-scratch cycle leading to impaired sleep, psychosocial distress and a significant disruption in quality of life. The pathogenesis of PN is associated with immune and neural dysregulation, mediated by inflammatory cytokines [such as interleukin (IL)-4, -13, -17, -22 and -31] and neuropeptides (such as substance P and calcitonin gene-related peptide). There is a role for type 2 inflammation in PN in addition to T-helper (Th)17 and Th22-mediated inflammation. The neuroimmune feedback loop in PN involves neuropeptides released from nerve fibres that cause vasodilation and further recruitment of inflammatory cells. Inflammatory cells, particularly mast cells and eosinophils, degranulate and release neurotoxins, as well as nerve growth factor, which may contribute to the neuronal hyperplasia seen in the dermis of patients with PN and neural sensitization. Recent studies have also indicated underlying genetic susceptibility to PN in addition to environmental factors, the existence of various disease endotypes centred around degrees of type 2 inflammation or underlying myelopathy or spinal disc disease, and significant race and ethnicity-based differences, with African Americans having densely fibrotic skin lesions. Dupilumab became the first US Food and Drug Administration-approved therapeutic for PN, and there are several other agents currently in development. The anti-IL-31 receptor A inhibitor nemolizumab is in late-stage development with positive phase III data reported. In addition, the oral Janus kinase (JAK) 1 inhibitors, abrocitinib and povorcitinib, are in phase II trials while a topical JAK1/2 inhibitor, ruxolitinib, is in phase III studies.
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Affiliation(s)
- Viviane Liao
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hannah L Cornman
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Emily Ma
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Shawn G Kwatra
- Department of Dermatology
- Maryland Itch Center, University of Maryland School of Medicine, Baltimore, MD, USA
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Cornman HL, Manjunath J, Reddy SV, Adams J, Rajeh A, Samuel C, Bao A, Zhao R, Ma EZ, Shumsky J, Pritchard TW, Imo BU, Kollhoff AL, Lee KK, Lu W, Yossef S, Kwatra MM, Kwatra SG. Comprehensive plasma cytokine and chemokine profiling in prurigo nodularis reveals endotypes in Type 2 inflammation. Sci Rep 2024; 14:8098. [PMID: 38582943 PMCID: PMC10998852 DOI: 10.1038/s41598-024-58013-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 03/25/2024] [Indexed: 04/08/2024] Open
Abstract
Prurigo nodularis (PN) is a chronic inflammatory skin disease that is associated with variability in peripheral blood eosinophil levels and response to T-helper 2 targeted therapies (Th2). Our objective was to determine whether circulating immune profiles with respect to type 2 inflammation differ by race and peripheral blood eosinophil count. Plasma from 56 PN patients and 13 matched healthy controls was assayed for 54 inflammatory biomarkers. We compared biomarker levels between PN and HCs, among PN patients based on absolute eosinophil count, and across racial groups in PN. Eleven biomarkers were elevated in PN versus HCs including interleukin (IL)-12/IL-23p40, tumor necrosis factor-alpha (TNF-α), Thymic stromal lymphopoietin (TSLP), and macrophage-derived chemokine (MDC/CCL22). Additionally, PN patients with AEC > 0.3 K cells/μL had higher Th2 markers (eotaxin, eotaxin-3, TSLP, MCP-4/CCL13), and African American PN patients had lower eosinophils, eotaxin, and eotaxin-3 versus Caucasian and Asian PN patients (p < 0.05 for all). Dupilumab responders had higher AEC (p < 0.01), were more likely to be Caucasian (p = 0.02) or Asian (p = 0.05) compared to African Americans, and more often had a history of atopy (p = 0.08). This study suggests that blood AEC > 0.3 K and Asian and Caucasian races are associated with Th2 skewed circulating immune profiles and response to Th2 targeted therapies.
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Affiliation(s)
- Hannah L Cornman
- Department of Dermatology, University of Maryland School of Medicine, Baltimore, MD, USA
- Maryland Itch Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jaya Manjunath
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD, 21231, USA
| | - Sriya V Reddy
- Department of Anesthesiology, Duke University School of Medicine, Durham, USA
| | - Jackson Adams
- Department of Anesthesiology, Duke University School of Medicine, Durham, USA
| | - Ahmad Rajeh
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD, 21231, USA
| | - Christeen Samuel
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD, 21231, USA
| | - Aaron Bao
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD, 21231, USA
| | - Ryan Zhao
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD, 21231, USA
| | - Emily Z Ma
- Department of Dermatology, University of Maryland School of Medicine, Baltimore, MD, USA
- Maryland Itch Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jason Shumsky
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD, 21231, USA
| | - Thomas W Pritchard
- Department of Dermatology, University of Maryland School of Medicine, Baltimore, MD, USA
- Maryland Itch Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Brenda Umenita Imo
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD, 21231, USA
| | - Alexander L Kollhoff
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD, 21231, USA
| | - Kevin K Lee
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD, 21231, USA
| | - Weiying Lu
- Department of Anesthesiology, Duke University School of Medicine, Durham, USA
| | - Selina Yossef
- Department of Anesthesiology, Duke University School of Medicine, Durham, USA
| | - Madan M Kwatra
- Department of Anesthesiology, Duke University School of Medicine, Durham, USA
| | - Shawn G Kwatra
- Department of Dermatology, University of Maryland School of Medicine, Baltimore, MD, USA.
- Maryland Itch Center, University of Maryland School of Medicine, Baltimore, MD, USA.
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Nilforoushzadeh MA, Heidari N, Ghane Y, Heidari A, Hajikarim-Hamedani A, Hosseini S, Jaffary F, Najar Nobari M, Tavakolzadeh P, Najar Nobari N. A systematic review of interleukin-31 inhibitors in the treatment of prurigo nodularis. Inflammopharmacology 2024; 32:991-1003. [PMID: 38332383 DOI: 10.1007/s10787-024-01436-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Accepted: 01/15/2024] [Indexed: 02/10/2024]
Abstract
BACKGROUND Prurigo nodularis (PN) is a neuroimmunological skin disease. Severe itching is the most challenging symptom which affects patients' quality of life. T helper 2-derived cytokines, such as interleukin-31 and oncostatin M (OSM), play a crucial role in PN pathogenesis. Nemolizumab and vixarelimab are two biologics acting as IL-31 inhibitors. Vixarelimab also suppresses the OSM activity. This systematic review evaluates the efficacy and safety of nemolizumab and vixarelimab in PN management. METHODS A systematic search was conducted in PubMed/Medline, Ovid Embase, and Web of Science up to September 17th, 2023. Clinical trials and cohort studies published in English were included. RESULTS Among a total of 96 relevant records, five were included. The results of four studies with 452 patients using nemolizumab showed that a significantly higher percentage of patients treated with nemolizumab demonstrated a reduction in peak pruritus numerical rating scale (PP-NRS) and investigator's global assessment along with improved sleep disturbance (SD) and quality of life than the placebo group. Moreover, one study administered vixarelimab to 49 PN patients, and their finding illustrated a higher rate of subjects who received vixarelimab experienced ≥ 4-point diminution in worst itch NRS, visual analog scale, healing of representative lesions, and SD quality compared to the placebo group. CONCLUSIONS IL-31 inhibitors suggest distinct advantages in improving pruritus, sleep quality, and overall quality of life in subjects with moderate-to-severe PN. Further clinical studies are recommended to compare the effectiveness of these biologics to other therapeutic choices.
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Affiliation(s)
- Mohammad Ali Nilforoushzadeh
- Skin Repair Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Skin and Stem Cell Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Nazila Heidari
- Skin Repair Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Skin and Stem Cell Research Center, Tehran University of Medical Sciences, Tehran, Iran
- School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Yekta Ghane
- Skin Repair Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Skin and Stem Cell Research Center, Tehran University of Medical Sciences, Tehran, Iran
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Amirhossein Heidari
- Skin Repair Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Skin and Stem Cell Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Faculty of Medicine, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
| | - Arman Hajikarim-Hamedani
- Skin Repair Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Faculty of Medicine, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
| | - SeyedAyin Hosseini
- Skin Repair Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fariba Jaffary
- Skin Repair Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Skin and Stem Cell Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Minou Najar Nobari
- Department of Orofacial Pain and Dysfunction, UCLA School of Dentistry, Los Angeles, CA, USA
| | - Pegah Tavakolzadeh
- Skin Repair Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Niloufar Najar Nobari
- Skin Repair Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
- Skin and Stem Cell Research Center, Tehran University of Medical Sciences, Tehran, Iran.
- Department of Dermatology, Rasool Akram Medical Complex Clinical Research Development Center (RCRDC), School of Medicine, Iran University of Medical Sciences, Tehran, Iran.
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Tietz J, Gunde T, Warmuth S, Weinert C, Brock M, Simonin A, Hess C, Johansson M, Spiga F, Muntwiler S, Wickihalder B, Mahler D, Diem D, Zeberer J, Heiz R, Flückiger N, Shiraishi N, Miyake Y, Takahashi N, Fehrholz M, Bertolini M, Lichtlen P, Urech D, Snell D. A Bispecific, Tetravalent Antibody Targeting Inflammatory and Pruritogenic Pathways in Atopic Dermatitis. JID INNOVATIONS 2024; 4:100258. [PMID: 38375189 PMCID: PMC10875227 DOI: 10.1016/j.xjidi.2024.100258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 12/21/2023] [Accepted: 12/26/2023] [Indexed: 02/21/2024] Open
Abstract
Inhibition of IL-4/IL-13 signaling has dramatically improved the treatment of atopic dermatitis (AD). However, in many patients, clinical responses are slow to develop and remain modest. Indeed, some symptoms of AD are dependent on IL-31, which is only partially reduced by IL-4/IL-13 inhibition. Thus, there is an unmet need for AD treatments that concomitantly block IL-4/IL-13 and IL-31 pathways. We engineered NM26-2198, a bispecific tetravalent antibody designed to accomplish this task. In reporter cell lines, NM26-2198 concomitantly inhibited IL-4/IL-13 and IL-31 signaling with a potency comparable with that of the combination of an anti-IL-4Rα antibody (dupilumab) and an anti-IL-31 antibody (BMS-981164). In human PBMCs, NM26-2198 inhibited IL-4-induced upregulation of CD23, demonstrating functional binding to FcγRII (CD32). NM26-2198 also inhibited the secretion of the AD biomarker thymus and activation-regulated chemokine (TARC) in blood samples from healthy human donors. In male cynomolgus monkeys, NM26-2198 exhibited favorable pharmacokinetics and significantly inhibited IL-31-induced scratching at a dose of 30 mg/kg. In a repeat-dose, good laboratory practice toxicology study in cynomolgus monkeys, no adverse effects of NM26-2198 were observed at a weekly dose of 125 mg/kg. Together, these results justify the clinical investigation of NM26-2198 as a treatment for moderate-to-severe AD.
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Affiliation(s)
| | - Tea Gunde
- Numab Therapeutics AG, Zürich, Switzerland
| | | | | | | | | | | | | | | | | | | | | | - Dania Diem
- Numab Therapeutics AG, Zürich, Switzerland
| | | | - Robin Heiz
- Numab Therapeutics AG, Zürich, Switzerland
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Shao Y, Wang D, Zhu Y, Xiao Z, Jin T, Peng L, Shen Y, Tang H. Molecular mechanisms of pruritus in prurigo nodularis. Front Immunol 2023; 14:1301817. [PMID: 38077377 PMCID: PMC10701428 DOI: 10.3389/fimmu.2023.1301817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 11/13/2023] [Indexed: 12/18/2023] Open
Abstract
Pruritus is the most common symptom of dermatological disorders, and prurigo nodularis (PN) is notorious for intractable and severe itching. Conventional treatments often yield disappointing outcomes, significantly affecting patients' quality of life and psychological well-being. The pathogenesis of PN is associated with a self-sustained "itch-scratch" vicious cycle. Recent investigations of PN-related itch have partially revealed the intricate interactions within the cutaneous neuroimmune network; however, the underlying mechanism remains undetermined. Itch mediators play a key role in pruritus amplification in PN and understanding their action mechanism will undoubtedly lead to the development of novel targeted antipruritic agents. In this review, we describe a series of pruritogens and receptors involved in mediating itching in PN, including cytokines, neuropeptides, extracellular matrix proteins, vasculogenic substances, ion channels, and intracellular signaling pathways. Moreover, we provide a prospective outlook on potential therapies based on existing findings.
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Affiliation(s)
| | | | | | | | | | | | | | - Hui Tang
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, China
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Rajeh A, Cornman HL, Gupta A, Szeto MD, Kambala A, Oladipo O, Parthasarathy V, Deng J, Wheelan S, Pritchard T, Kwatra MM, Semenov YR, Gusev A, Yegnasubramanian S, Kwatra SG. Somatic mutations reveal hyperactive Notch signaling and racial disparities in prurigo nodularis. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.09.25.23295810. [PMID: 37808834 PMCID: PMC10557842 DOI: 10.1101/2023.09.25.23295810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
Prurigo nodularis (PN) is a chronic inflammatory skin disease that disproportionately affects African Americans and is characterized by pruritic skin nodules of unknown etiology. Little is known about genetic alterations in PN pathogenesis, especially relating to somatic events which are often implicated in inflammatory conditions. We thus performed whole-exome sequencing on 54 lesional and nonlesional skin biopsies from 17 PN patients and 10 atopic dermatitis (AD) patients for comparison. Somatic mutational analysis revealed that PN lesional skin harbors pervasive somatic mutations in fibrotic, neurotropic, and cancer-associated genes. Nonsynonymous mutations were most frequent in NOTCH1 and the Notch signaling pathway, a regulator of cellular proliferation and tissue fibrosis, and NOTCH1 mutations were absent in AD. Somatic copy-number analysis, combined with expression data, showed that recurrently deleted and downregulated genes in PN lesional skin are associated with axonal guidance and extension. Follow-up immunofluorescence validation demonstrated increased NOTCH1 expression in PN lesional skin fibroblasts and increased Notch signaling in PN lesional dermis. Finally, multi-center data revealed a significantly increased risk of NOTCH1-associated diseases in PN patients. In characterizing the somatic landscape of PN, we uncover novel insights into its pathophysiology and identify a role for dysregulated Notch signaling in PN.
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Affiliation(s)
- Ahmad Rajeh
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hannah L. Cornman
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Anuj Gupta
- The Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | - Mindy D. Szeto
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Anusha Kambala
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Olusola Oladipo
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Varsha Parthasarathy
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Junwen Deng
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sarah Wheelan
- Present affiliation: National Human Genome Research Institute, National Institute of Health, Bethesda, MD, USA
| | - Thomas Pritchard
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Madan M. Kwatra
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC, USA
| | - Yevgeniy R. Semenov
- Department of Dermatology, Massachusetts General Hospital, Boston, MA, USA
- Department of Systems Biology, Harvard Medical School, Boston, MA, USA
| | - Alexander Gusev
- Division of Genetics, Brigham & Women’s Hospital, Boston, MA, USA
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Srinivasan Yegnasubramanian
- The Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Shawn G. Kwatra
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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