Causes, pathophysiology, and treatment of pruritus in the mature patient

Unmet needs in treating itch: reaching beyond eczema

PURPOSE

Pruritus is an unpleasant sensation that creates the urge to scratch. In many chronic conditions, relentless pruritus and scratching perpetuates a vicious itch-scratch cycle. Uncontrolled itch can detrimentally affect quality of life and may lead to sleep disturbance, impaired concentration, financial burden, and psychological suffering. Recent strides have been made to develop guidelines and investigate new therapies to treat some of the most common severely pruritic conditions, however, a large group of diseases remains underrecognized and undertreated. The purpose of this article is to provide a comprehensive review of the challenges hindering the treatment of pruritus.

METHODS

An online search was performed using PubMed, Web of Science, Google Scholar, and ClinicalTrials.gov from 1994 to 2024. Included studies were summarized and assessed for quality and relevance in treating pruritus.

RESULTS

Several barriers to treating pruritus emerged, including variable presentation, objective measurement of itch, and identifying therapeutic targets. Itch associated with autoimmune conditions, connective tissue diseases, genodermatoses, cutaneous T-cell lymphoma, and pruritus of unknown origin were among the etiologies with the greatest unmet needs.

CONCLUSION

Treating pruritus poses many challenges and there are many itchy conditions that have no yet been addressed. There is an urgent need for large-scale controlled studies to investigate potential targets for these conditions and novel therapies.

A Retrospective Review of Chronic Non-Communicable Dermatoses Among Older Adults at a Tertiary Healthcare Facility in Southwestern Nigeria

INTRODUCTION

Aging is a ubiquitous human trait that predisposes older persons to chronic diseases. Compared with systemic non-communicable diseases, a significant gap exists in literature on the burden of non-communicable dermatoses (NCDs) amongst older adults particularly in low and middle-income countries.

OBJECTIVES

The aim of this study was to document the epidemiology and clinical pattern of non-communicable skin diseases among older adults at a tertiary healthcare facility in Southwestern Nigeria.

METHODS

We conducted a retrospective review of medical records of ambulant adults aged ≥60 years referred for dermatological care at a teaching hospital in ile-ife, South-Western Nigeria between February 2017 and February 2022. The frequency and pattern of NCDs were recorded for descriptive statistical analysis using SPSS 20 statistics software. The level of statistical significance was set at 0.05.

RESULTS

A total 553 medical records were reviewed with a female: male ratio of 1.3:1 The mean age of the study population was 68.85 ±7.87. Six out of every 10 patients (60.6%) had at least one chronic NCD. The incidence of chronic NCDs declined with increasing age. Chronic eczemas (22.4%), pigmentary dermatoses (9.4%) and skin tumors (8.7%) were the most frequent chronic non-communicable dermatoses recorded. Older males had a significantly higher incidence of chronic eczemas while chronic urticarias and skin tumors demonstrated significant female preponderance.

CONCLUSIONS

There is a high burden of chronic NCDs with significant gender disparities among older adults with skin problems in Nigeria. Pre-emptive planning and resource allocation towards specialist geriatric-dermatology services are needed to address skin-health needs of the growing geriatric population.

[Management of pruritus in the elderly]

BACKGROUND

Chronic pruritus (CP), a frequent (20.3%) symptom in the elderly, increases with age. It has a significant impact on the quality of life, ranking among the 50 most burdensome diseases worldwide (Global Burden of Disease Study).

OBJECTIVES

The aim is to provide an overview of the symptom CP in the elderly and to improve differentiation of underlying conditions and management of this entity.

MATERIALS AND METHODS

A literature search in PubMed was performed, using the terms 'pruritus', 'elderly' and 'gerontodermatology'.

RESULTS

The main causes of CP in the elderly are the physiologic aging process (xerosis cutis, immunosenescence, neuropathy), the increase in potentially pruritic diseases with increasing age (diabetes mellitus, chronic renal failure), and polypharmacy. Therapeutic options relate to causes, severity of pruritus, and individual patient factors (multimorbidity, impaired organ function). The recently updated S2k guideline 'Diagnosis and therapy of chronic pruritus' is helpful.

CONCLUSION

CP in the elderly is challenging for both patients and physicians. Not only the difficulty of identifying the underlying cause, but the complexity of treatment and its tolerability and practicability determines these patients' further burden.

Immunosenescence and Skin: A State of Art of Its Etiopathogenetic Role and Crucial Watershed for Systemic Implications

Immunosenescence is a complex multifactorial phenomenon consisting of wide-ranging remodeling of the immune system during the life span, resulting in an age-related qualitative-quantitative decline of immune cells and cytokines. A growing body of evidence in the international literature is highlighting the etiopathogenetic role of skin immunosenescence in the onset of various dermatologic conditions. Skin immunosenescence also serves as an interesting watershed for the onset of system-wide conditions in the context of allergic inflammation. Moreover, in recent years, an increasingly emerging and fascinating etiopathogenetic parallelism has been observed between some mechanisms of immunosenescence, both at cutaneous and systemic sites. This would help to explain the occurrence of apparently unconnected comorbidities. Throughout our review, we aim to shed light on emerging immunosenescent mechanisms shared between dermatologic disorders and other organ-specific diseases in the context of a more extensive discussion on the etiopathogenetic role of skin immunosenescence. A promising future perspective would be to focus on better understanding the mutual influence between skin and host immunity, as well as the influence of high inter-individual variability on immunosenescence/inflammaging. This can lead to a more comprehensive "immunobiographic" definition of each individual.

Prevalence of Pruritus and Association with Anxiety and Depression in Patients with Nonalcoholic Fatty Liver Disease

Patient-reported outcomes are important in nonalcoholic fatty liver disease (NAFLD). Pruritus is of special interest for evolving therapies with farnesoid X receptor (FXR) agonists. The aim of this study was to investigate the prevalence of pruritus in a real-life NAFLD cohort and analyze associations with anxiety and depression. Pruritus was assessed using a visual analogue- (VAS) and 5-D itch-scale (5-D). Anxiety and depression were evaluated by Beck’s-Depression-Inventory (BDI) and the Hospital Anxiety and Depression Scale (HADS-A, HADS-D). An optimal logistic regression model was found with a stepwise procedure to investigate variables associated with pruritus. In total, 123 NAFLD patients were recruited. VAS and 5-D were highly correlated (Spearman’s correlation coefficient 0.89). Moderate/severe pruritus was reported in 19% (VAS) and 21% (5-D) of patients. Anxiety and depression were present in 12% and 4% (HADS-A and HADS-D, respectively) and 12% (BDI) of cases. There was a significant association between VAS and BDI (p = 0.019). The final multivariate model for 5-D included diabetes mellitus (OR 4.51; p = 0.01), BDI (OR 5.98; p = 0.024), and HADS-A (OR 7.75; p = 0.011). One-fifth of NAFLD patients reported moderate or severe pruritus. 5-D was significantly associated with diabetes mellitus, depression, and anxiety. These findings should be tested in larger populations and considered in candidates for treatment with FXR agonists.

Scalp dysesthesia: a neuropathic phenomenon

Scalp dysesthesia is an abnormal sensation of the scalp in the absence of cutaneous disease. It is characterized by a burning and/or itching sensation and can be related to a variety of neurogenic or psychogenic causes. This condition is extremely bothersome and is also common- especially amongst the geriatric population, in women, in patients with diabetes mellitus and patients with psychiatric history. However, despite its prevalence in many populations, there is limited data about its causes and characteristics. Given its limited cutaneous manifestations it is also easily misdiagnosed and an underrecognized cause of scalp pruritus in the dermatological community. Therefore, education on scalp dysesthesia is paramount to helping physicians identify and provide appropriate treatment for these patients. This review focuses predominately on the neurogenic causes (with a brief review of psychogenic itch) of scalp dysesthesia and the therapeutics that have been found to be effective for this condition. Neurogenic causes of scalp dysesthesia occur with damage to the central or peripheral pathways of itch sensation, resulting in modification and heightened sensitivity of nerves that result in abnormal sensations in the absence of or out of proportion to external stimuli. A comprehensive review of etiologies is provided here, ranging from lesions to the central nervous system caused by cervical spine disease, trigeminal trophic syndrome, tumor, stroke, and multiple sclerosis, to small fiber neuropathies caused by diabetes, brow lifts, keloid and burn scarring. Recently, there have also been reports of scalp dysesthesias associated with post-infectious COVID-19. Treatment options tailored towards disease severity and different causes of disease will also be discussed. By elucidating the different mechanisms and therapeutic treatments of scalp dysesthesia, we hope to provide clinicians with the tools to identify and treat this condition as well as encourage further research into its etiologies and therapeutics.

Chronic itch in African Americans: an unmet need

Chronic pruritus carries a significant burden of disease and is associated with a negative impact on quality of life. African Americans are disproportionately burdened by chronic pruritic disorders, including but not limited to atopic dermatitis, prurigo nodularis, inflammatory scalp dermatoses, pathologic scarring, and HIV-related dermatoses. Racial differences in skin structure and function may contribute to the pathogenesis of itch in African Americans. Itch perception and response to treatment in African Americans remain understudied and not well understood. As such, there is a large unmet need with regard to the knowledge and management of pruritus in African Americans. This review highlights notable differences in the epidemiology, pathophysiology, genetic predisposition, clinical presentation, and response to treatment for select pruritic skin conditions. By addressing itch as an unmet need in African Americans, we hope to improve patient outcomes and lessen disparities in dermatologic care.

Longitudinal association between polypharmacy and development of pruritus: a Nationwide Cohort Study in a Japanese Population

BACKGROUND

Although polypharmacy is known to cause side-effects due to drug-drug interactions, dermatological symptoms triggered by polypharmacy are not fully addressed.

OBJECTIVE

To investigate whether polypharmacy is associated with the risk of pruritus.

METHOD

A cohort study was performed to examine cross-sectional and longitudinal relationships between polypharmacy and pruritus in a general population. Data were collected from the Norm Study conducted in 2016 and 2017, which is a nationwide survey based on a self-administered questionnaire with Japanese representative participants aged 16-84 years. Presence of polypharmacy which was defined as concurrent use of ≥5 prescribed drugs. Primary outcomes were the presence of severe pruritus at baseline for the cross-sectional analysis and the development of severe pruritus after one year for the longitudinal analysis. Multivariable modified Poisson regression analyses were performed to estimate risk ratios (RRs) and 95% confidence intervals (95%CIs) with adjustment for potential confounders (age, gender, smoking habits, drinking habits, depressive symptoms, moderate activities based on IPAQ score and presence of 11 comorbid conditions including skin disease).

RESULTS

The study included 3126 participants (mean age, 48.7 years); nearly half (49.8%) were male. In all, 332 participants (10.3%) had polypharmacy in the cross-sectional analysis. Participants with polypharmacy were more likely to present with severe pruritus at baseline than those who were not using drugs (adjusted RR = 1.52 [95%CI 1.15-2.01, P = 0.003]). The longitudinal analysis (n = 1803) was limited to those without severe pruritus at baseline; participants with polypharmacy at baseline were more likely to develop severe pruritus after a one-year follow-up period than those not using drugs (adjusted RR = 1.46 [95%CI 1.14-1.87, P = 0.002]).

CONCLUSION

Polypharmacy was associated with the presence of pruritus at baseline and may predict the future risk of developing pruritus.

Antihistamine safety in older adult dermatologic patients

Twenty percent of Americans will be older than 65 years by 2030, and without a dedicated geriatrics curriculum in many residency trainings programs, dermatologists may be less familiar with age-associated adverse effects of common dermatologic medications. Herein, we provide a practical guide and clinical safety pearls for the use of antihistamines in older adults. This Review aims to address the risks of antihistamines, anticholinergic burden and polypharmacy, pertinent preexisting medical conditions, and safe alternatives for aging adult patients.

Pathophysiology and Treatment of Pruritus in Elderly

Pruritus is a relatively common symptom that anyone can experience at any point in their life and is more common in the elderly. Pruritus in elderly can be defined as chronic pruritus in a person over 65 years old. The pathophysiology of pruritus in elderly is still unclear, and the quality of life is reduced. Generally, itch can be clinically classified into six types: Itch caused by systemic diseases, itch caused by skin diseases, neuropathic pruritus, psychogenic pruritus, pruritus with multiple factors, and from unknown causes. Senile pruritus can be defined as a chronic pruritus of unknown origin in elderly people. Various neuronal mediators, signaling mechanisms at neuronal terminals, central and peripheral neurotransmission pathways, and neuronal sensitizations are included in the processes causing itch. A variety of therapies are used and several novel drugs are being developed to relieve itch, including systemic and topical treatments.

Manifestaciones dermatológicas de la diabetes: clasificación y diagnóstico

Se estima que en Colombia hay 2.836.500 adultos con diabetes, una enfermedad con una prevalencia del 8,4 %. La exposición a niveles elevados de glucosa afecta los procesos de proliferación y diferenciación en las células de todos los órganos y tejidos, así mismo en los queratinocitos, fibroblastos y demás células presentes en la piel, alteraciones que ocurren en más de un tercio de los diabéticos y que pueden ser la manifestación inicial de la enfermedad. La frecuencia y presentación de estas dermatosis varía según la población estudiada. La dermopatía diabética, la acantosis nigricans, los fibromas laxos, el prurito y la xerosis son las formas más comunes y se consideran marcadores cutáneos de la diabetes. La presente revisión se enfoca en las manifestaciones dermatológicas específicas y no específicas de la diabetes, así como en las relacionadas con su tratamiento. Estas pueden ser un reflejo del estado metabólico actual o previo del paciente diabético y su oportuna identificación permite orientar el diagnóstico primario, sospechar un estado rediabético u optimizar el tratamiento de la enfermedad en los individuos ya diagnosticados.

Management of Itch in the Elderly: A Review

Chronic itch is common in the elderly patient and may be caused by a variety of known dermatologic and non-dermatologic conditions and can have a significant effect on quality of life. Age-related changes in barrier function, immunosenescence, and neuronal changes and neuropathies are common predisposing factors to chronic itch in this age group. Certain primary dermatologic conditions are more common in the elderly and can cause chronic itch. Also, co-morbid diseases particularly of the renal, hepatobiliary, or hematologic systems, psychologic conditions, or medications may contribute to chronic itch in this population. Thus, medical workup for an elderly patient with chronic itch requires special attention to the patient's medical history, current health status, and medications. Topical treatments and emollients may be recommended for elderly patients, with consideration of specific adverse effects and alternatives. Systemic medications pose a higher risk of adverse effects and many are contraindicated in the elderly for this reason. In addition, management in the elderly may be complicated by differential pharmacokinetics of medications, the presence of co-morbid health conditions, cognitive disorders, physical limitations, and polypharmacy. New and emerging treatment modalities hold promise for use in the elderly due to these special considerations.

Chronic Pruritus Responding to Dupilumab-A Case Series

Background: Chronic pruritus is defined as itch lasting for greater than six weeks. Pruritus is a burdensome manifestation of several internal and external disease states with a significant impact on quality of life. Dupilumab has shown promise in treating a number of conditions including atopic dermatitis (AD) and asthma. Its success in reducing pruritus in AD has generated interest regarding its potential application in other pruritic conditions, such as chronic pruritus of unknown origin, uremic pruritus, and pruigo nodularis. Methods: In this retrospective analysis, we present a series of 20 recalcitrant pruritus patients seen at a tertiary center treated with off-label dupilumab at standard AD dosing. Results: Dupilumab was successful at reducing itch in all treated patients, leading to complete resolution in 12/20 patients and an overall mean NRSi reduction of 7.55. Dupilumab was well tolerated with no significant adverse effects. Conclusions: Our case series suggests dupilumab may be a safe and efficacious therapeutic option in several pruritic conditions and demonstrates the need for further studies to better ascertain its place in the pruritus treatment armamentarium.

Qingpeng Ointment Ameliorates Inflammatory Responses and Dysregulation of Itch-Related Molecules for Its Antipruritic Effects in Experimental Allergic Contact Dermatitis

The pathogenesis of itchy skin diseases including allergic contact dermatitis (ACD) is complicated and the treatment of chronic itch is a worldwide problem. One traditional Tibetan medicine, Qingpeng ointment (QP), has been used in treatment of ACD in China for years. In this study we used HPLC and LC/MS analysis, combined with a BATMAN-TCM platform, for detailed HPLC fingerprint analysis and network pharmacology of QP, and investigated the anti-inflammatory and antipruritic activities of QP on ACD induced by squaric acid dibutylester (SADBE) in mice. The BATMAN-TCM analysis provided information of effector molecules of the main ingredients of QP, and possible chronic dermatitis-associated molecules and cell signaling pathways by QP. In ACD mice, QP treatment suppressed the scratching behavior induced by SADBE in a dose-dependent manner and inhibited the production of Th1/2 cytokines in serum and spleen. Also, QP treatment reversed the upregulation of mRNAs levels of itch-related genes in the skin (TRPV4, TSLP, GRP, and MrgprA3) and DRGs (TRPV1, TRPA1, GRP, and MrgprA3). Furthermore, QP suppressed the phosphorylation of Erk and p38 in the skin. In all, our work indicated that QP can significantly attenuate the pathological alterations of Th1/2 cytokines and itch-related mediators, and inhibit the phosphorylation of MAPKs to treat the chronic itch.