Association of prurigo nodularis and lichen simplex chronicus with hospitalization for mental health disorders in US adults

Depression, Anxiety and Suicidal Ideation in Prurigo Nodularis: A Systematic Review and Meta-analysis

Abstract is missing (Short communication)

Efficacy and safety of nemolizumab and topical corticosteroids for prurigo nodularis: results from a randomized double-blind placebo-controlled phase II/III clinical study in patients aged ≥ 13 years

BACKGROUND

Prurigo nodularis (PN), a chronic inflammatory skin condition, adversely affects the quality of life of affected individuals. Current treatment options for PN in Japan are limited.

OBJECTIVES

To evaluate the optimal dose, efficacy and safety of long-term treatment with nemolizumab in patients with PN in Japan.

METHODS

In a 16-week double-blind phase II/III study, patients aged ≥ 13 years with PN were randomly assigned (1 : 1 : 1) to nemolizumab 30-mg, 60-mg or placebo groups, with concomitant topical corticosteroids, every 4 weeks. The primary efficacy endpoint was the percentage change in the weekly mean Peak Pruritus Numerical Rating Scale (PP-NRS) score (range 0-10, with higher scores indicating worse itching) from baseline to week 16. Secondary efficacy endpoints assessed the impact of treatment on pruritus, PN severity, sleep and quality of life.

RESULTS

At week 16, the least-squares mean percentage change from baseline in the PP-NRS score was -61.1% in the nemolizumab 30-mg group (n = 77), -56.0% in the 60-mg group (n = 76), and -18.6% in the placebo group (n = 76). Differences between both nemolizumab groups and placebo were significant; the difference between the 30-mg and placebo groups was -42.5% [95% confidence interval (CI) -51.9 to -33.1; P < 0.0001], and between the 60-mg and placebo groups was -37.4% (95% CI -46.7 to -28.1; P < 0.0001). Patients treated with nemolizumab also had greater improvements in the number and severity of prurigo nodules, and in sleep and quality of life compared with the placebo group. Both nemolizumab doses were well tolerated.

CONCLUSIONS

Improvements in PN were greater following nemolizumab treatment, despite continuation of topical corticosteroids in both groups.

Increased cardiovascular risks and mortality in prurigo nodularis: a global cohort study

BACKGROUND

Prurigo nodularis (PN) presents with intensely itchy hard nodules. Despite being limited to the skin, PN was noted to be associated with systemic diseases including diabetes and chronic renal failure. In previous smaller retrospective studies, several cardiac and vascular diseases were found more frequently in patients with PN. However, small cohort sizes, partially discrepant outcomes, missing data, and incomplete risk assessment limit these findings.

METHODS

Electronic health records (EHR)s of 64,801 patients (59.44% females) with PN and an equal sized propensity-matched control group were retrieved. In these cohorts, the risks to develop cardiac and vascular diseases and mortality following the diagnosis of PN were determined. Sub-analyses included stratification for sex, ethnicity, and treatments.

FINDINGS

PN was associated with a higher risk for a broad range of acute cardiac events including heart failure and myocardial infarction. For example, the hazard ratio of myocardial infarction was 1.11 (95%-CI: 1.041-1.184, p = 0.0015) following PN diagnosis. Also, all-cause mortality was higher in patients with PN. Further, chronic vascular as well as structural heart diseases, e.g., peripheral arterial disease, chronic ischaemic heart disease and valval disorders were found more frequently following a PN diagnosis. Risks were more pronounced in white and female patients. Having established an increased risk for death and cardiovascular disease, we next addressed if dupilumab that has been recently licenced for use in this indication can modulate these risks. The risk of death but not of any cardiovascular disease was slightly reduced in patients with PN treated with dupilumab as opposed to those treated with systemic therapies other than dupilumab. The study is limited by retrospective data collection and reliance on ICD10-disease classification.

INTERPRETATION

PN is associated with higher mortality and an increased risk for the development of a wide range of cardiac and vascular diseases. Health care professionals should take this into account when managing patients with PN.

FUNDING

This work was supported by the University of Lübeck, the Deutsche Forschungsgemeinschaft and the State of Schleswig-Holstein.

Incident Comorbidity, Resource Use, and All-Cause Mortality Associated with Prurigo Nodularis: A United Kingdom Retrospective Database Analysis

We described comorbidity, resource utilization, and mortality for patients with prurigo nodularis (PN) using data from the Clinical Practice Research Datalink. Patients with incident PN (2008-2018) were selected and matched to controls. Of 2,416 patients with PN, 2,409 (99.7%) were matched to controls. Prevalence of atopic dermatitis (relative risk [RR] = 2.571; 95% confidence interval [CI] = 2.356-2.806), depression (RR = 1.705; 95% CI = 1.566-1.856), anxiety (RR = 1.540; 95% CI = 1.407-1.686), coronary heart disease (RR = 1.575; 95% CI = 1.388-1.787), chronic kidney disease (RR = 1.529; 95% CI = 1.329-1.759), and type 2 diabetes mellitus (RR = 1.836; 95% CI = 1.597-2.111) was significantly higher for patients with PN. Subsequent risk of atopic dermatitis (hazard ratio = 6.58; 95% CI = 5.17- 8.37), depression (hazard ratio = 1.61; 95% CI = 1.30-1.99), and coronary heart disease (hazard ratio = 1.37; 95% CI = 1.09-1.74) were significantly increased. Resource utilization was increased in all settings: incidence rate ratio = 1.48 (95% CI = 1.47-1.49) for primary care, incident rate ratio = 1.80 (95% CI = 1.75-1.85) for inpatients, incident rate ratio = 2.15 (95% CI = 2.13-2.18) for outpatients, and incidence rate ratio = 1.32 (95% CI = 1.27-1.36) for accident and emergency. Respective cost ratios were 1.78 (95% CI = 1.67-1.90), 1.52 (95% CI = 1.20-1.94), 2.34 (95% CI = 2.13-2.58), and 1.55 (95% CI = 1.33-1.80). Total primary and secondary healthcare costs were £2,531 versus £1,333, a cost ratio of 1.62 (95% CI = 1.36-1.94). The adjusted hazard ratio for mortality was 1.37 (95% CI = 1.14-1.66). Patients with PN had significantly increased rates of comorbidity, healthcare resources utilization, and mortality compared with matched controls.

Non-Atopic Chronic Nodular Prurigo (Prurigo Nodularis Hyde): A Systematic Review of Best-Evidenced Treatment Options

BACKGROUND

Chronic nodular prurigo (CNPG) is a chronic, inflammatory skin disease, characterized by intense and debilitating pruritus. The pathophysiology is not fully understood, and the condition is difficult to treat with no targeted therapies. The aim of this systematic review was to review the evidence of therapies for non-atopic CNPG and conduct a meta-analysis of the results.

SUMMARY

We conducted a systematic review of the literature concerning effect of treatment for non-atopic CNPG. Due to few randomized controlled trials (RCTs) and case series, the literature was unfortunately too sparse to conduct a meta-analysis of the results. Instead, we thoroughly report important data from the three existing RCTs and 6 case studies with more than 15 patients. Evaluated therapies include nemolizumab, aprepitant, topical therapy with hydrocortisone and pimecrolimus, thalidomide, UVA phototherapy, pregabalin, and naltrexone. Included RCTs and case studies all had a heterogeneous methodology making direct comparison almost impossible.

KEY MESSAGES

There is sparse evidence for the currently used therapies for non-atopic CNPG. Several RCTs on new therapies are running or in the pipeline, hopefully providing new, effective, and targeted treatment possibilities for CNPG patients both with and without an atopic predisposition.

Epidemiology of prurigo nodularis in England: a retrospective database analysis

OBJECTIVES

Prurigo nodularis is a debilitating skin condition that is classified as rare by the Genetic and Rare Diseases Information Center (GARD) and National Organization for Rare Diseases (NORD). There are no estimates of the prevalence of prurigo nodularis in England. We aimed to address this data gap by describing the epidemiology of prurigo nodularis in a representative dataset derived from the English National Health Service.

METHODS

The study utilised data from the Clinical Practice Research Datalink linked to Hospital Episode Statistics inpatient data. Patients with a diagnosis of prurigo nodularis were selected by clinical code in the primary care or inpatient datasets. Case definition was based on a minimum of two distinct diagnoses to maximize specificity. Point prevalence was calculated for the midpoint of 2018 and incidence rates from 2008-2018 presented. For those classified as incident cases, demographic and clinical characteristics were reported. In sensitivity analyses the case definition was modified to relax the multiple diagnosis criteria and to restrict cases to those diagnosed within a maximum of four or ten years of the midpoint prevalence date.

RESULTS

11,656 patients within the dataset had at least one prurigo nodularis diagnosis. Following application of the relevant inclusion criteria 2,743 patients formed the point prevalent cohort; an estimated prevalence of 3.27 patients per 10,000 (95% CI 3.15-3.40). In sensitivity analyses the estimated prevalence ranged from 2.24 (2.14-2.34) to 6.98 (6.8-7.16). Incidence over the study period was 2.88 per 100,000 patient years. Comorbidity was relatively high in this population notably for atopic dermatitis (52.2%), depression (41.1%) and anxiety (35.4%).

CONCLUSION

This study supports the NORD/GARD classification of prurigo nodularis as a rare disease with a prevalence of 3.27 patients per 10,000 equating to 18,471 patients living with the disease in England in 2018. The relatively high prevalence of comorbidity observed for these patients may increase the complexity of management.

Vulvar Neurodermatitis in a Postmenopausal African-American Patient: A Case Report

Lichen simplex chronicus commonly presents as a distressing vaginal lesion caused by severe, cyclical itch-scratch behavior. Lichen simplex chronicus is diagnosed by obtaining a detailed medical history, performing a physical exam, and recording of self-reported symptoms. Lichen simplex chronicus can be treated by corticosteroids, immunomodulators, antiepileptics, antihistamines, antidepressants, and phototherapy. Our case describes a 55-year-old female patient who presented to a clinic with recurrent vaginal itching, combined with compulsive scratching behavior that disrupted daily functioning. Physical examination revealed hypertrophic nodules located on the labia minora with scaling and hyperpigmentation. And the patient was diagnosed with lichen simplex chronicus. Empirical treatment with behavioral modifications and clobetasol propionate cream with an occlusive dressing produced significant improvements in symptoms at a six-month follow-up. Lichen simplex chronicus can have unusual presentations and; therefore, must be carefully differentiated from infectious and malignant skin lesions.

More than a skin disease: stress, depression, anxiety levels, and serum neurotrophins in lichen simplex chronicus

BACKGROUND

Lichen simplex chronicus is a dermatological condition due to excessive scratching, with few studies on psychoneuroimmunology.

OBJECTIVE

We aimed to estimate the levels of stress, depression, and anxiety, and to measure serum levels of neurotrophins in patients with lichen simplex chronicus, and to correlate these parameters with the severity of the disease and pruritus.

METHODS

Thirty-six patients with lichen simplex chronicus and 36 age- and sex-matched healthy controls were included. Each participant was administered the Hospital Anxiety and Depression Scale and Perceived Stress Scale questionnaires, along with a visual analog scale for pruritus. Levels of neurotrophins (brain-derived neurotrophic factor, neurotrophin-3, nerve growth factor, glial cell line-derived neurotrophic factor) were determined by ELISA assays.

RESULTS

The scores of Perceived Stress Scale-10, Hospital Anxiety and Depression Scale were statistically higher in patients (p < 0.05 for all). The serum levels of all neurotrophins were significantly lower in patients compared to healthy controls (p < 0.05 for all). Disease severity showed no correlation with all four neurotrophins. In linear regression models applied for increased visual analog scale-pruritus scores and disease severity these two variables were statistically significant predictors (p = 0.043).

STUDY LIMITATIONS

A direct causal relationship was not addressed.

CONCLUSION

Lichen simplex chronicus patients are at risk of increased levels of stress, anxiety, depression, and present decreased levels of neurotrophins, that may suggest a role in the pathophysiology of this disorder.

Cognitive Impairment in Inpatients with Prurigo Nodularis and Psychiatric Comorbidities

BACKGROUND

Prurigo nodularis (PN) is a chronic refractory itchy dermatosis. Although psychiatric comorbidity is known, research in cognitive impairment is lacking. We evaluated the occurrence and types of cognitive impairment in a series of inpatients with PN.

METHODS

This was a retrospective chart review of all the patients with PN admitted to a referral neurological institute from September 2018 to March 2021. Any neurological and psychiatric disorder, along with neuroactive drugs taken, were concomitantly assessed.

RESULTS

A total of 16 patients with PN (median age: 70 years, two males) were selected from a total of 1806 hospital admissions. Most of them had a neurodegenerative cognitive disorder, from mild cognitive impairment (8) to Alzheimer's disease (1), followed by mixed disorder (degenerative and vascular) in six and vascular dementia in one. Comorbid psychiatric diseases (anxiety and depression) were more common than either individual condition, followed by bipolar disorder, whereas two patients did not show psychiatric manifestations. Most patients were on combined treatment with benzodiazepines and antidepressants.

CONCLUSION

Cognitive impairment can be observed in PN. In addition to screening for psychiatric comorbidity and initiating appropriate treatment or referral, clinicians may also consider the presence of cognitive impairment in PN of both degenerative and vascular origin.

Cognitive Impairment in Inpatients with Prurigo Nodularis and Psychiatric Comorbidities

BACKGROUND

Prurigo nodularis (PN) is a chronic refractory itchy dermatosis. Although psychiatric comorbidity is known, research in cognitive impairment is lacking. We evaluated the occurrence and types of cognitive impairment in a series of inpatients with PN.

METHODS

This was a retrospective chart review of all the patients with PN admitted to a referral neurological institute from September 2018 to March 2021. Any neurological and psychiatric disorder, along with neuroactive drugs taken, were concomitantly assessed.

RESULTS

A total of 16 patients with PN (median age: 70 years, two males) were selected from a total of 1806 hospital admissions. Most of them had a neurodegenerative cognitive disorder, from mild cognitive impairment (8) to Alzheimer's disease (1), followed by mixed disorder (degenerative and vascular) in six and vascular dementia in one. Comorbid psychiatric diseases (anxiety and depression) were more common than either individual condition, followed by bipolar disorder, whereas two patients did not show psychiatric manifestations. Most patients were on combined treatment with benzodiazepines and antidepressants.

CONCLUSION

Cognitive impairment can be observed in PN. In addition to screening for psychiatric comorbidity and initiating appropriate treatment or referral, clinicians may also consider the presence of cognitive impairment in PN of both degenerative and vascular origin.

Cupping for neurodermatitis: A protocol of systematic review and meta-analysis

BACKGROUND

Neurodermatitis is a common inflammatory and allergic disease, characterized by itching and lichenification plaque. Some studies have reported cupping therapy (CT) for the treatment of neurodermatitis. However, the effectiveness and safety are still uncertain. This study aims to evaluate the efficacy and safety of CT for the treatment of patients with neurodermatitis.

METHODS

We will retrieve the following electronic databases systematically: Pubmed, Web of Science, Embase, the Cochrane Library, Chinese Scientific Journal Database, China National Knowledge Infrastructure Database, Chinese Biomedical Literature Database, and Wanfang database from their inception to December 2020. Other literature resources will be manually searched. Published randomized controlled trials (RCTs) and quasi-randomized controlled trials (q-RCTs) on the topic will be retrieved by 2 investigators independently. We will apply a fixed-effect model or random effect model basis on the heterogeneity test and employ with RevMan 5.3 software for data synthesis. The total clinical effective rate will be selected as the primary outcome, skin disease quality of life index score, recurrence rate, and adverse events as secondary outcomes.

RESULTS

This study will comprehensively summarize the high-quality trials to determine the efficacy and safety of CT for the treatment of patients with neurodermatitis.

CONCLUSION

Our systematic review will present evidence for the efficacy and safety of CT to neurodermatitis patients.

OSF REGISTRATION NUMBER

DOI 10.17605/OSF.IO/6DCM3.

Prurigo nodularis: Epidemiology and clinical features

Prurigo nodularis (PN) is a chronic inflammatory skin disease characterized by intensely pruritic, hyperkeratotic nodules that favor the extensor surfaces of the extremities and the trunk. In addition to its significant impact on quality of life, many patients with PN are recalcitrant to therapy because there are currently no therapies approved by the US Food and Drug Administration. In the first article of this 2-part continuing medical education series, we describe the broader epidemiology, patient demographics, physical examination findings, and symptoms to aid in the timely recognition and diagnosis of PN. Furthermore, we quantify the burden of comorbidities in PN by discussing the broad spectrum of systemic diseases and mental health conditions that have been associated with this condition. The second article of this 2-part series focuses on the pathogenesis of PN and provides detailed algorithms for comprehensive work-up and management.