1
|
Pereira MP, Metz M. [Neuropathy in pruritus medicine : Recommended diagnostics and therapy]. DERMATOLOGIE (HEIDELBERG, GERMANY) 2024:10.1007/s00105-024-05374-z. [PMID: 38869846 DOI: 10.1007/s00105-024-05374-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/22/2024] [Indexed: 06/14/2024]
Abstract
Chronic itch is a frequent and debilitating condition that greatly affects the quality of life of those affected. In a subset of patients, damage to the peripheral or central nervous system constitutes the cause of the itch. Small-fiber neuropathy, nerve compression syndromes, post-herpetic neuralgia, scars and burns are possible conditions affecting the peripheral nervous system potentially causing itch, whereas space-occupying lesions affecting the spinal cord and stroke are examples of conditions that may induce central itch. Neuropathic itch starts on normal appearing skin, is often accompanied by pain sensations and other dysesthesias, and usually relieved by local cold application. Its distribution depends on the affected site of the somatosensory system. A comprehensive medical history is paramount to reach the diagnosis, while complementary diagnostics with skin biopsies for the investigation of cutaneous neuromorphological alterations or medical imaging to rule out nerve impingement may be advised in selected cases. Topical agents such as capsaicin or local anesthetics as well as systemic drugs such as gabapentinoids, antidepressants and opioid receptor modulators are used in the treatment of neuropathic itch. This review article provides an overview of the clinical features, underlying causes, diagnostic workup and therapeutic approach in neuropathic itch.
Collapse
Affiliation(s)
- Manuel P Pereira
- Institut für Allergieforschung, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 27, 12203, Berlin, Deutschland.
- Immunologie und Allergologie, Fraunhofer Institut für Translationale Medizin und Pharmakologie ITMP, Berlin, Deutschland.
| | - Martin Metz
- Institut für Allergieforschung, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 27, 12203, Berlin, Deutschland
- Immunologie und Allergologie, Fraunhofer Institut für Translationale Medizin und Pharmakologie ITMP, Berlin, Deutschland
| |
Collapse
|
2
|
Hernandez NS, Rogers JL, Pham MH. Brachioradial Pruritus Caused by Cervical Disc Herniation Precipitated by Trauma Treated with Anterior Cervical Discectomy and Fusion: Report of Two Cases and Review of the Literature. Asian J Neurosurg 2024; 19:101-104. [PMID: 38751391 PMCID: PMC11093638 DOI: 10.1055/s-0043-1772760] [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] [Indexed: 05/18/2024] Open
Abstract
Brachioradial pruritis (BRP) is a rare form of dermatomal pruritis that appears to be caused both by cervical radiculopathy and exposure to ultraviolet-light, although the exact pathophysiology for the manifestation of these symptoms remains to be determined. A diagnosis of BRP is typically confirmed with the "ice-pack" test and evidence of cervical spine pathology using magnetic resonance imaging. Treatment options consist of application of ice, reduction in sun exposure, and topical capsaicin, antiepileptics, or tricyclic antidepressants. Patients with refractory symptoms and cervical spine pathology may be candidates for surgical decompression, particularly at the C5 and C6 levels. However, there are currently no established guidelines to treat BRP, or surgical procedures that have shown to be superior. Here, we report two cases of cervical disc herniations after traumatic events that presented as BRP. Both cases were successfully treated with anterior cervical discectomy and fusion with complete resolution of symptoms.
Collapse
Affiliation(s)
| | | | - Martin H. Pham
- Address for correspondence Martin H. Pham, MD Assistant Professor of Neurological Surgery9300 Campus Point Drive, MC7893, La Jolla, CA 92037United States
| |
Collapse
|
3
|
Hamzoian H, Alkhayat M, Abdelmasih M, Choudry S. Management of Brachioradial Pruritus With Cervical Epidural Steroid Injection: A Case Report. Cureus 2023; 15:e48060. [PMID: 38046482 PMCID: PMC10688763 DOI: 10.7759/cureus.48060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2023] [Indexed: 12/05/2023] Open
Abstract
Brachioradial pruritus (BRP) is a neuropathic dysesthesia described as itching over the dorsolateral forearm. The etiology of BRP has not been fully identified but is hypothesized to be multifactorial, including sun exposure and cervical spine disease. Management of BRP is challenging, and conservative measures often fail to provide notable improvement. We present a case of a 71-year-old woman with BRP refractory to topical and oral treatment, with radiographic evidence of cervical spinal canal and neuroforaminal stenosis. Two rounds of cervical epidural steroid injections (CESI) were performed at the C6-C7 epidural space resulting in a marked improvement of symptoms. With this case report, we would like to add to the current scientific knowledge of BRP management and the potential utilization of CESIs to provide symptomatic relief to patients suffering from refractory pruritus.
Collapse
Affiliation(s)
| | - Maha Alkhayat
- Neurology, Orlando Regional Medical Center, Orlando, USA
| | | | - Shehzad Choudry
- Pain Management, Orlando Regional Medical Center, Orlando, USA
| |
Collapse
|
4
|
Kwatra SG, Kambala A, Cornman H, Reddy SV, Cohen SP. Ketamine Infusions for Treatment-Resistant Neuropathic Pruritus. JAMA Dermatol 2023; 159:1011-1012. [PMID: 37531125 DOI: 10.1001/jamadermatol.2023.1772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2023]
Abstract
This case report describes a patient in her 50s with a 4-year history of brachioradial pruritus with bilateral pruritus on her upper arms and forearms.
Collapse
Affiliation(s)
- Shawn G Kwatra
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Anusha Kambala
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Hannah Cornman
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sriya V Reddy
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Steven P Cohen
- Departments of Anesthesiology and Critical Care Medicine, Physical Medicine and Rehabilitation, Neurology, and Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
| |
Collapse
|
5
|
Baka P, Birklein F. [Neuropathic pruritus-Evidence-based treatment recommendations]. DER NERVENARZT 2023; 94:136-141. [PMID: 35951052 PMCID: PMC9898430 DOI: 10.1007/s00115-022-01369-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 07/11/2022] [Indexed: 02/06/2023]
Abstract
Neuropathic pruritus is a previously neglected symptom of a wide range of neurological diseases. Peripheral nerve or root compression syndromes, space-occupying lesions of the central nervous system, chronic inflammatory neurological diseases and polyneuropathy can cause neuropathic pruritus. Even when the identification of the underlying neurological disease is successful, a direct causal treatment is not always possible, hence an effective symptomatic treatment remains the only therapeutic option. The purpose of this review article is to present the current literature on various therapeutic agents and options in the treatment of neuropathic pruritus.
Collapse
Affiliation(s)
- Panoraia Baka
- Klinik für Neurologie, Universitätsmedizin Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland.
| | - Frank Birklein
- Klinik für Neurologie, Universitätsmedizin Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland
| |
Collapse
|
6
|
Shields LB, Iyer VG, Zhang YP, Shields CB. Brachioradial Pruritus: Clinical, Electromyographic, and Cervical MRI Features in Nine Patients. Cureus 2022; 14:e21811. [PMID: 35291549 PMCID: PMC8896843 DOI: 10.7759/cureus.21811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2022] [Indexed: 11/05/2022] Open
|
7
|
Roh YS, Choi J, Sutaria N, Kwatra SG. Itch: Epidemiology, clinical presentation, and diagnostic workup. J Am Acad Dermatol 2022; 86:1-14. [PMID: 34428534 PMCID: PMC8678917 DOI: 10.1016/j.jaad.2021.07.076] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 07/24/2021] [Accepted: 07/28/2021] [Indexed: 01/03/2023]
Abstract
Itch, or pruritus, is the uncomfortable sensation underlying the desire to scratch. Itch is a very common complaint in the general population that can result from dermatologic, systemic (eg, renal, hepatobiliary, endocrine), paraneoplastic, neuropathic, and psychogenic etiologies. Chronic itch is associated with significant sleep disturbances and profoundly reduces overall quality of life. Certain populations, including elderly and African Americans, are at increased risk of experiencing heightened burden of itch. Because of the variable clinical presentation and wide-ranging etiologies, itch presents a challenge for clinicians. The initial evaluation should include a complete blood count, with differential, hepatic, renal, and thyroid function testing along with diabetes screening. Further testing should be guided by history and physical examination findings. There should be a heightened concern for underlying malignancy in individuals older than 60 years of age who have a history of liver disease and diffuse itch less than 12 months of duration. For individuals with chronic pruritus of unknown origin, increased blood eosinophils may serve as a biomarker of T helper cell type 2 polarization and response to immunomodulator therapies. In this first part of a 2-part continuing medical education series, we describe the broader epidemiology and specific conditions associated with itch and the clinical presentation and diagnostic workup for patients with itch.
Collapse
Affiliation(s)
- Youkyung S. Roh
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Justin Choi
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nishadh Sutaria
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Shawn G. Kwatra
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| |
Collapse
|
8
|
Miller LHGSV, Akita J, Martelli ACC, Kirchner DR, Salgado MH, Garbino JA. Neurophysiological assessment of brachioradial pruritus patients. ARQUIVOS DE NEURO-PSIQUIATRIA 2021; 79:900-903. [PMID: 34706020 DOI: 10.1590/0004-282x-anp-2020-0333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 11/29/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Pruritus is a common complaint in dermatology. Wartenberg, in 1943, associated pruritus with neuropathy, relating it to the "posterior antebrachial cutaneous nerve neuropathy". In 1968, Waisman described patients with frequent pruritus complaints in the upper limb during the summer, which he named "brachioradial summer pruritus". Currently, this pruritus is named brachioradial pruritus (BRP). BRP is characterized by a chronic pruritus, usually localized, with a long duration, and without apparent cutaneous abnormalities. Neurological disorders both from the central and peripheral nervous systems, including multiple sclerosis, are associated with pruritus. OBJECTIVE To investigate correlations between symptomatic dermatomes and alterations in the myotomes, as evidenced by electroneuromyography (ENMG). METHODS Forty-six patients with BRP dermatological diagnoses were subjected to upper limb ENMG. RESULTS Among 46 patients with C5 to C8 dermatomal pruritus, we evaluated 113 symptomatic dermatomal areas. Overall, 39 (85%) patients had radicular involvement and 28 (60%) had agreement between complaint and the ENMG findings (p=0.015). A total of 80% of the patients with complaints at C7 and 47% at C6 had radicular involvement at the same level. CONCLUSIONS Among the patients who presented complaints, 47 and 80%, respectively, had ENMG alterations in the C6 and C7 myotomes. We conclude that peripheral nervous system involvement is associated with BRP.
Collapse
Affiliation(s)
| | - Juliana Akita
- Instituto Lauro de Souza Lima, Departamento de Neurofisiologia Clínica, Bauru SP, Brazil
| | | | - Daniel Rocco Kirchner
- Instituto Lauro de Souza Lima, Departamento de Neurofisiologia Clínica, Bauru SP, Brazil
| | - Manoel Henrique Salgado
- Universidade Estadual Paulista, Faculdade de Engenharia, Engenharia de Produção, Bauru SP, Brazil
| | - José Antonio Garbino
- Instituto Lauro de Souza Lima, Departamento de Neurofisiologia Clínica, Bauru SP, Brazil
| |
Collapse
|
9
|
Sutaria N, Adawi W, Goldberg R, Roh YS, Choi J, Kwatra SG. Itch: Pathogenesis and treatment. J Am Acad Dermatol 2021; 86:17-34. [PMID: 34648873 DOI: 10.1016/j.jaad.2021.07.078] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 07/22/2021] [Accepted: 07/23/2021] [Indexed: 12/19/2022]
Abstract
Itch pathogenesis is broadly characterized into histaminergic and nonhistaminergic pathways and transmitted via 2 main receptor families: G protein-coupled receptors and transient receptor potential channels. In the skin, itch is primarily transmitted by unmyelinated type C and thinly myelinated type Aδ nerve fibers. Crosstalk between the immune and neural systems modulates itch transmission at the skin, spinal cord, and brain. Among the many known pruritogens, Th2 cytokines, such as interleukin-4, interleukin-13, interleukin-31, and thymic stromal lymphopoietin, are particularly important mediators that signal through shared Janus kinase pathways, representing novel targets for novel itch therapeutics. Emerging evidence has also revealed that the opioidergic system is a potent modulator of itch transmission, with increased μ-opioid activity and decreased κ-opioid activity contributing to itch pathogenesis. Optimal management of itch requires that treatment approaches be tailored to specific etiologic itch subtypes. When the etiology is unknown and patients are given a diagnosis of chronic pruritus of unknown origin, treatment should be guided by the presence of Th2 polarization, often reflected by increased blood eosinophils. In the second article of this 2-part series, we outline our current understanding of itch pathogenesis and discuss available and emerging treatments for itch.
Collapse
Affiliation(s)
- Nishadh Sutaria
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Waleed Adawi
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rebecca Goldberg
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Youkyung S Roh
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Justin Choi
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Shawn G Kwatra
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| |
Collapse
|
10
|
Wermelt J, Ständer S, Pereira MP, Mannil M. [Chronic brachioradial pruritus in cervical spine meningioma]. Hautarzt 2021; 73:485-487. [PMID: 34609536 DOI: 10.1007/s00105-021-04897-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2021] [Indexed: 12/01/2022]
Abstract
We report a case of a 57-year-old slightly obese woman with localized itch on the arms accompanied by stinging and burning sensations. A few excoriations were observed upon clinical examination. The MRI examination of the cervical spine revealed a meningioma at C5/C6 level. The diagnosis of brachioradial pruritus due to compression of the cervical myelon was further supported by a positive ice-pack sign. Disc herniation or prolapse, foraminal stenosis and degenerative alterations constitute other possible causes of brachioradial pruritus.
Collapse
Affiliation(s)
- Julia Wermelt
- Kompetenzzentrum chronischer Pruritus (KCP), Klinik für Hautkrankheiten, Universitätsklinikum Münster, Von-Esmarch-Str. 58, 48149, Münster, Deutschland.
| | - Sonja Ständer
- Kompetenzzentrum chronischer Pruritus (KCP), Klinik für Hautkrankheiten, Universitätsklinikum Münster, Von-Esmarch-Str. 58, 48149, Münster, Deutschland
| | - Manuel P Pereira
- Kompetenzzentrum chronischer Pruritus (KCP), Klinik für Hautkrankheiten, Universitätsklinikum Münster, Von-Esmarch-Str. 58, 48149, Münster, Deutschland
| | - Manoj Mannil
- Kompetenzzentrum chronischer Pruritus (KCP), Klinik für Hautkrankheiten, Universitätsklinikum Münster, Von-Esmarch-Str. 58, 48149, Münster, Deutschland
| |
Collapse
|
11
|
Gupta D, Shetty N, Shivaprasad A, Javali M, Pradeep R, Mehta A, Acharya PT, Srinivasa R. Rash Decisions in Neurology: A Case Report of Brachioradial Pruritus Secondary to Cervical Intramedullary Lesion. Neurol India 2021; 69:1034-1036. [PMID: 34507438 DOI: 10.4103/0028-3886.325376] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Brachioradial pruritus (BRP) is an enigmatic condition often encountered by dermatologists and passed off as a benign itch. It is an "idiopathic" pruritus, presenting as severe itching on the radial aspect of the elbow. The physical examination may be unremarkable except for mild pruritic lesions. Hence, the patient is treated with local applications of sunscreens, anti-inflammatory agents, anti-histamines and steroids, most of which prove to be ineffective. Dermatomal localization of localization of pruritis has suggested cervical myeloradiculopathy as a novel aetiology and this has been elucidated in recent studies. Here we report a young man, who presented with brachioradial pruritus and was diagnosed to have a C6-7 intramedullary cervical cord lesion.
Collapse
Affiliation(s)
- Dhananjay Gupta
- Department of Neurology, Ramaiah Medical College, Bengaluru, Karnataka, India
| | - Nikith Shetty
- Department of Neurology, Ramaiah Medical College, Bengaluru, Karnataka, India
| | - Akhil Shivaprasad
- Department of Neurology, Ramaiah Medical College, Bengaluru, Karnataka, India
| | - Mahendra Javali
- Department of Neurology, Ramaiah Medical College, Bengaluru, Karnataka, India
| | - Rangaiah Pradeep
- Department of Neurology, Ramaiah Medical College, Bengaluru, Karnataka, India
| | - Anish Mehta
- Department of Neurology, Ramaiah Medical College, Bengaluru, Karnataka, India
| | | | | |
Collapse
|
12
|
Pereira MP, Wiegmann H, Agelopoulos K, Ständer S. Neuropathic Itch: Routes to Clinical Diagnosis. Front Med (Lausanne) 2021; 8:641746. [PMID: 33732722 PMCID: PMC7959783 DOI: 10.3389/fmed.2021.641746] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 02/03/2021] [Indexed: 01/08/2023] Open
Abstract
Neuropathic itch occurs due to damage of neurons of the peripheral or central nervous system. Several entities, including metabolic, neurodegenerative, orthopedic, infectious, autoimmune, malignant, and iatrogenic conditions, may affect the somatosensory system and induce neuropathic itch. Due to the complex nature of neuropathic itch, particularly concerning its clinical presentation and possible etiological factors, diagnostic work-up of this condition is challenging. A detailed medical history, especially in regard to the itch, and a comprehensive physical examination are relevant to detect characteristic signs and symptoms of neuropathic itch and to rule out other possible causes for chronic itch. Complementary diagnostic exams, especially laboratory tests, determination of the intraepidermal nerve fiber density via a skin biopsy and radiological examinations may be indicated to confirm the diagnosis of neuropathic itch and to identify underlying etiological factors. Functional assessments such as quantitative sensory testing, nerve conduction studies, evoked potentials, or microneurography may be considered in particular cases. This review article provides a comprehensive overview of the diagnostic work-up recommended for patients with neuropathic itch.
Collapse
Affiliation(s)
- Manuel Pedro Pereira
- Department of Dermatology and Center for Chronic Pruritus, University Hospital Münster, Münster, Germany
| | - Henning Wiegmann
- Department of Dermatology and Center for Chronic Pruritus, University Hospital Münster, Münster, Germany
| | - Konstantin Agelopoulos
- Department of Dermatology and Center for Chronic Pruritus, University Hospital Münster, Münster, Germany
| | - Sonja Ständer
- Department of Dermatology and Center for Chronic Pruritus, University Hospital Münster, Münster, Germany
| |
Collapse
|
13
|
Wang T, Tao J, Fang Y, Ma C. The role of pruriceptors in enhancing sensitivity to pruritogens in a murine chronic compression model of dorsal root ganglion. Mol Brain 2021; 14:15. [PMID: 33468207 PMCID: PMC7814616 DOI: 10.1186/s13041-021-00730-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 01/04/2021] [Indexed: 11/30/2022] Open
Abstract
Chronic pruritus is a symptom that commonly observed in neurological diseases. It has been hypothesized that the chronic pruritus may result from sensitization of itch-signaling pathways but the mechanisms remain obscure. In this study, we established a mouse model of chronic compression of dorsal root ganglion (CCD) and injected various pruritogenic and algogenic agents intradermally to the calf skin ipsilateral to the compressed dorsal root ganglion (DRG). Compared to the naïve mice, a significant increase in itch-related behaviors was observed in the CCD mice after the injection of pruritogens including histamine and BAM8-22, but not after the injection of capsaicin, although all the above agents evoked enhanced pain-related behaviors toward the injected site. In addition, we investigated if pruritogen-evoked activities of DRG neurons were enhanced in this model. In vivo calcium imaging revealed that compressed DRG neurons exhibited enhanced responses to histamine and BAM8-22. Immunoflorescent staining also showed that the histamine receptor H1 and the capsaicin receptor TRPV1 were significantly upregulated in DRG neurons. Our findings indicated that the sensitization of primary pruriceptive neurons may underlie the enhanced itch sensation after chronic compression of DRG in the mice, and may play a role in chronic pruritus in neurological diseases.
Collapse
MESH Headings
- Animals
- Calcium/metabolism
- Capsaicin/adverse effects
- Cattle
- Chronic Disease
- Disease Models, Animal
- Ganglia, Spinal/diagnostic imaging
- Ganglia, Spinal/pathology
- Histamine/adverse effects
- Male
- Mice, Inbred C57BL
- Mice, Transgenic
- Nerve Compression Syndromes/complications
- Nerve Compression Syndromes/metabolism
- Nerve Compression Syndromes/pathology
- Neurons/metabolism
- Pain/pathology
- Peptide Fragments/adverse effects
- Pruritus/metabolism
- Pruritus/pathology
- RNA, Messenger/genetics
- RNA, Messenger/metabolism
- Receptors, G-Protein-Coupled/genetics
- Receptors, G-Protein-Coupled/metabolism
- Receptors, Histamine H1/metabolism
- Receptors, Histamine H4/metabolism
- TRPV Cation Channels/metabolism
- Up-Regulation/genetics
- Mice
Collapse
Affiliation(s)
- Tao Wang
- Institute of Basic Medical Sciences, Neuroscience Center, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, 100005, China
- Department of Human Anatomy, Histology and Embryology, School of Basic Medicine, Peking Union Medical College, Beijing, 100005, China
- Joint Laboratory of Anesthesia and Pain, Peking Union Medical College, Beijing, 100730, China
| | - Jin Tao
- Institute of Basic Medical Sciences, Neuroscience Center, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, 100005, China
- Department of Human Anatomy, Histology and Embryology, School of Basic Medicine, Peking Union Medical College, Beijing, 100005, China
- Joint Laboratory of Anesthesia and Pain, Peking Union Medical College, Beijing, 100730, China
| | - Yehong Fang
- Institute of Basic Medical Sciences, Neuroscience Center, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, 100005, China
- Department of Human Anatomy, Histology and Embryology, School of Basic Medicine, Peking Union Medical College, Beijing, 100005, China
- Joint Laboratory of Anesthesia and Pain, Peking Union Medical College, Beijing, 100730, China
| | - Chao Ma
- Institute of Basic Medical Sciences, Neuroscience Center, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, 100005, China.
- Department of Human Anatomy, Histology and Embryology, School of Basic Medicine, Peking Union Medical College, Beijing, 100005, China.
- Joint Laboratory of Anesthesia and Pain, Peking Union Medical College, Beijing, 100730, China.
| |
Collapse
|
14
|
Lipman ZM, Magnolo N, Golpanian RS, Storck M, Yosipovich G, Zeidler C. Comparison of itch characteristics and sleep in patients with brachioradial pruritus and notalgia paresthetica: A retrospective analysis from 2 itch centers. JAAD Int 2020; 2:96-97. [PMID: 34409357 PMCID: PMC8362268 DOI: 10.1016/j.jdin.2020.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Zoe M Lipman
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, Miami Itch Center, University of Miami, Florida
| | - Nina Magnolo
- Department of Dermatology and Center for Chronic Pruritus, University Hospital Münster, Germany
| | - Rachel S Golpanian
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, Miami Itch Center, University of Miami, Florida
| | - Michael Storck
- Institute for Medical Informatics and Center for Chronic Pruritus, University Hospital Münster, Germany
| | - Gil Yosipovich
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, Miami Itch Center, University of Miami, Florida
| | - Claudia Zeidler
- Department of Dermatology and Center for Chronic Pruritus, University Hospital Münster, Germany
| |
Collapse
|
15
|
Chung BY, Um JY, Kim JC, Kang SY, Park CW, Kim HO. Pathophysiology and Treatment of Pruritus in Elderly. Int J Mol Sci 2020; 22:ijms22010174. [PMID: 33375325 PMCID: PMC7795219 DOI: 10.3390/ijms22010174] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 12/16/2020] [Accepted: 12/24/2020] [Indexed: 12/21/2022] Open
Abstract
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.
Collapse
|
16
|
Ständer S, Schmelz M. [Neuropathic pruritus]. Schmerz 2020; 34:525-535. [PMID: 33025226 DOI: 10.1007/s00482-020-00502-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 07/14/2020] [Accepted: 07/15/2020] [Indexed: 11/26/2022]
Abstract
In the past 10 years specific pathways for pruritus have been characterized on a cellular and molecular level but their exact role in the pathophysiology of neuropathic pruritus remains unclear. This also applies to the question which of the competing theories for pruritus, e.g. specificity, temporal/spatial pattern or intensity, would best apply. While experimental trials on mice have mostly confirmed the theory of specificity, the results on humans indicate a role of spatial and temporal patterns. The skin innervation is greatly reduced by the neuropathy and could provide a "spatial contrast pattern" and the axotomy could induce a de novo expression of gastrin-releasing peptide (GRP) in primarily afferent nociceptors and thus modulate spinal pruritus processing. In addition, the overlap of pruritus and pain in neuropathy patients complicates the direct translation from animal experiments and requires collaboration at the clinical level between pain medicine and dermatology.
Collapse
Affiliation(s)
- Sonja Ständer
- Kompetenzzentrum Chronischer Pruritus, Universitätsklinikum Münster, Münster, Deutschland
| | - Martin Schmelz
- Experimentelle Schmerzforschung, MCTN, Medizinische Fakultät Mannheim, Universität Heidelberg, Ludolf-Krehl-Str. 13-17, 68167, Mannheim, Deutschland.
| |
Collapse
|
17
|
Klinische Shortcuts in der Differenzialdiagnostik von Pruritus. Hautarzt 2020; 71:493-499. [DOI: 10.1007/s00105-020-04606-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
18
|
Disabling Pruritus in a Patient With Cervical Stenosis. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2020; 4:JAAOSGlobal-D-19-00178. [PMID: 32440634 PMCID: PMC7209791 DOI: 10.5435/jaaosglobal-d-19-00178] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 02/11/2020] [Indexed: 11/18/2022]
Abstract
Brachioradial pruritus is a rare condition characterized by chronic localized itching of the dorsolateral upper extremities. Although the exact pathophysiology is still unknown, cervical nerve compression is thought to be a cause. We present the case of a 56-year-old man with a 6-year history of disabling chronic bilateral upper extremity pruritus and pain as well as concurrent neck pain. The patient presented to our office after multiple inconclusive diagnostic evaluations (dermatology, rheumatology, neurology, and psychiatry) and unsatisfactory multimodal conservative treatment attempts. His symptoms markedly impeded his ability to get restful sleep. Imaging of the cervical spine revealed multilevel cervical spondylosis, spinal stenosis with cord compression, and multilevel foraminal stenosis. The patient underwent successful multilevel anterior cervical decompression and fusion and was instantly symptom-free. The present case highlights that patients complaining of itching of the dorsolateral forearms of seemingly unknown etiology should undergo a workup of the cervical spine. If conservative treatment fails, surgical decompression may be considered in select patients.
Collapse
|
19
|
Fourzali KM, Yosipovitch G. Management of Itch in the Elderly: A Review. Dermatol Ther (Heidelb) 2019; 9:639-653. [PMID: 31549284 PMCID: PMC6828892 DOI: 10.1007/s13555-019-00326-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Indexed: 02/07/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Kayla M Fourzali
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery and Miami Itch Center, University of Miami, Miami, 33136, USA
| | - Gil Yosipovitch
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery and Miami Itch Center, University of Miami, Miami, 33136, USA.
| |
Collapse
|
20
|
Weinberg BD, Amans M, Deviren S, Berger T, Shah V. Brachioradial pruritus treated with computed tomography-guided cervical nerve root block: A case series. JAAD Case Rep 2018; 4:640-644. [PMID: 30094306 PMCID: PMC6080634 DOI: 10.1016/j.jdcr.2018.03.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Brent D Weinberg
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia
| | - Matthew Amans
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
| | - Sibel Deviren
- Department of Orthopedics, University of California, San Francisco, California
| | - Timothy Berger
- Department of Dermatology, University of California, San Francisco, California
| | - Vinil Shah
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
| |
Collapse
|
21
|
Steinhoff M, Schmelz M, Szabó IL, Oaklander AL. Clinical presentation, management, and pathophysiology of neuropathic itch. Lancet Neurol 2018; 17:709-720. [PMID: 30033061 DOI: 10.1016/s1474-4422(18)30217-5] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 05/15/2018] [Accepted: 06/01/2018] [Indexed: 12/19/2022]
Abstract
Unlike conventional itch, neuropathic itch develops in normal skin from excess peripheral firing or dampened central inhibition of itch pathway neurons. Neuropathic itch is a symptom of the same central and peripheral nervous system disorders that cause neuropathic pain, such as sensory polyneuropathy, radiculopathy, herpes zoster, stroke, or multiple sclerosis, and lesion location affects symptoms more than aetiology. The causes of neuropathic itch are heterogeneous, and thus diagnosis is based primarily on recognising characteristic, disease-specific clinical presentations. However, the diagnosis of neuropathic itch is challenging, different subforms exist (eg, focal vs widespread, peripheral vs central), and the mechanisms of neuropathic itch are poorly understood, resulting in reduced treatment availability. Currently available strategies include treating or preventing causal diseases, such as diabetes or herpes zoster, and topical or systemic medications that calm excess neuronal firing. Discovery of itch mediators such as gastrin releasing peptide, receptors (eg, neurokinin-1), and pathways (eg, Janus kinases) might encourage much needed new research into targeted treatments of neuropathic itch.
Collapse
Affiliation(s)
- Martin Steinhoff
- Department of Dermatology and Venereology, Hamad Medical Corporation, Doha, Qatar; HMC Translational Research Institute, Hamad Medical Corporation, Doha, Qatar; Weill Cornell Medicine-Qatar, Doha, Qatar; College of Medicine, Qatar University, Medical School, Doha, Qatar.
| | - Martin Schmelz
- Department of Experimental Pain Research, CBTM Mannheim, Heidelberg University, Mannheim, Germany
| | - Imre Lőrinc Szabó
- Department of Dermatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Anne Louise Oaklander
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Neuropathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
22
|
Zagarella S. Nerve entrapment syndromes in dermatology: Review and practical approach to treatment. Australas J Dermatol 2018; 59:286-290. [PMID: 29676437 DOI: 10.1111/ajd.12822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 03/07/2018] [Indexed: 11/28/2022]
Abstract
A good understanding of cutaneous nerve entrapment syndromes is important for physicians to provide early and accurate diagnosis and treatment. These syndromes have traditionally been managed with analgesics, antidepressants or antiepileptic medication but this approach is often inadequate and causes frequent adverse medication effects. With early diagnosis and treatment, many nerve entrapment syndromes can be successfully managed with physical, non-pharmacological approaches including stretches, exercises and physiotherapy.
Collapse
Affiliation(s)
- Samuel Zagarella
- Department of Dermatology, Concord Hospital, University of Sydney Medical School, Sydney, New South Wales, Australia
| |
Collapse
|
23
|
Pereira M, Lüling H, Dieckhöfer A, Steinke S, Zeidler C, Agelopoulos K, Ständer S. Application of an 8% capsaicin patch normalizes epidermal TRPV1 expression but not the decreased intraepidermal nerve fibre density in patients with brachioradial pruritus. J Eur Acad Dermatol Venereol 2018; 32:1535-1541. [DOI: 10.1111/jdv.14857] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 01/11/2018] [Indexed: 11/30/2022]
Affiliation(s)
- M.P. Pereira
- Department of Dermatology and Center for Chronic Pruritus; University Hospital Münster; Münster Germany
| | - H. Lüling
- Department of Dermatology and Center for Chronic Pruritus; University Hospital Münster; Münster Germany
| | - A. Dieckhöfer
- Department of Dermatology and Center for Chronic Pruritus; University Hospital Münster; Münster Germany
| | - S. Steinke
- Department of Dermatology and Center for Chronic Pruritus; University Hospital Münster; Münster Germany
| | - C. Zeidler
- Department of Dermatology and Center for Chronic Pruritus; University Hospital Münster; Münster Germany
| | - K. Agelopoulos
- Department of Dermatology and Center for Chronic Pruritus; University Hospital Münster; Münster Germany
| | - S. Ständer
- Department of Dermatology and Center for Chronic Pruritus; University Hospital Münster; Münster Germany
| |
Collapse
|
24
|
|
25
|
Pinto ACVD, Wachholz PA, Masuda PY, Martelli ACC. Clinical, epidemiological and therapeutic profile of patients with brachioradial pruritus in a reference service in dermatology. An Bras Dermatol 2017; 91:549-51. [PMID: 27579762 PMCID: PMC4999125 DOI: 10.1590/abd1806-4841.201644767] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 08/25/2015] [Indexed: 11/22/2022] Open
Abstract
This is a cross-sectional study, conducted from May to November/2014, in a
dermatology reference unit, through review of medical records and interviews. In
a sample of 49 patients with brachioradial pruritus, we observed higher
prevalence of Caucasian (81.6%) and women (73.5 %), with a mean age of 56.1
years. Pruritus occurred in the topography of brachioradialis muscle in 87.8% of
cases; 59.2% of the sample reported worsening of pruritus with sun exposure; the
mean intensity of this symptom before treatment was 8.63. Therapy effectiveness
was described as "very good/good" in 79.2% of cases, and for 55.3% relapses were
categorized as "uncommon".
Collapse
|
26
|
Atış G, Bilir Kaya B. Pregabalin treatment of three cases with brachioradial pruritus. Dermatol Ther 2017; 30. [DOI: 10.1111/dth.12459] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 10/26/2016] [Accepted: 11/29/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Güldehan Atış
- Department of Dermatology; Haydarpaşa Numune Training and Research Hospital, İstanbul, Turkey
| | - Başak Bilir Kaya
- Department of Physical Medicine and Rehabilitation; Dr. Siyami Ersek Thorax and Cardiaovascular Surgery Training and Research Hospital, İstanbul, Turkey
| |
Collapse
|
27
|
Rajagopalan M, Saraswat A, Godse K, Shankar DSK, Kandhari S, Shenoi SD, Tahiliani S, Zawar VV. Diagnosis and Management of Chronic Pruritus: An Expert Consensus Review. Indian J Dermatol 2017; 62:7-17. [PMID: 28216719 PMCID: PMC5286757 DOI: 10.4103/0019-5154.198036] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
The aim of this study is to formulate the best clinical practice in the diagnosis and management of chronic pruritus (CP). We searched PubMed, EMBASE, Scopus, Web of Science, and the WHO's regional databases, for studies on "Diagnosis and management of chronic pruritus" from January 1, 2014, to July 31, 2015. We included programmatic reports and hand-searched references of published reviews and articles. Two independent reviewers screened articles and extracted data. We screened 87 of 95 studies that contained qualitative data. Avoid: Dry climate, heat, alcohol compress, ice packs, frequent bathing and washing, intake of very hot and spicy food, intake of alcohol, contact with irritant substances, excitement, strain and stress, and allergens. Using: Mild nonalkaline soaps, moisturizers, bathing oils, lukewarm water while bathing, soft cotton clothing and night creams/lotions, relaxation therapy, autogenic training, psychosocial education, educating patients to cope with itching and scratching, and educational programs. Especially use of moisturizers is considered important. In addition, symptomatic treatment options include systemic H1 antihistamines and topical corticosteroids. Symptomatic therapy directed toward the cause (hepatic, renal, atopic, polycythemia, etc.). If refractory or cause is unknown, consider capsaicin, calcineurin inhibitors for localized pruritus and naltrexone, pregabalin, ultraviolet therapy, Cyclosporine for generalized itching. CP is quite frequent finding associated with skin and systemic diseases in the overall population. It is known to significantly affect quality life score of an individual and also adds burden on the health-care cost. A specific recommendation for treatment of CP is difficult as a result of varied and diverse possibility of underlying diseases associated with CP.
Collapse
Affiliation(s)
| | - Abir Saraswat
- Indushree Skin Clinic, Lucknow, Uttar Pradesh, India
| | - Kiran Godse
- Department of Dermatology, D. Y. Patil Hospital and School of Medicine, Navi Mumbai, Maharashtra, India
| | | | - Sanjiv Kandhari
- Dermatiologist, Dr. Kandhari's Skin Clinic, New Delhi, India
| | - Shrutakirthi D Shenoi
- Department of Dermatology, Kasturba Medical College and Hospital, Manipal, Karnataka, India
| | - Sushil Tahiliani
- Department of Dermatology, Hinduja Healthcare Surgical Hospital, Mumbai, Maharashtra, India
| | | |
Collapse
|
28
|
Gabapentin and pregabalin for the treatment of chronic pruritus. J Am Acad Dermatol 2016; 75:619-625.e6. [DOI: 10.1016/j.jaad.2016.02.1237] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 02/26/2016] [Accepted: 02/26/2016] [Indexed: 01/23/2023]
|
29
|
Skelton F, Frontera JE. Brachioradial Pruritus as a Harbinger of Syrinx in Chronic Spinal Cord Injury: A Case Report. PM R 2016; 9:311-313. [DOI: 10.1016/j.pmrj.2016.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Revised: 08/03/2016] [Accepted: 08/10/2016] [Indexed: 11/29/2022]
|
30
|
Abstract
Chronic itch in the elderly is a common problem, with a significant impact on quality of life and sleep in elderly patients. Chronic itch may be attributable to several causes, including dry skin, immunosenescence and neural degeneration. Itch may also be caused by skin diseases, such as seborrhoeic dermatitis and stasis dermatitis; systemic conditions, such as end-stage renal disease and diabetes; and psychogenic conditions, such as depression and anxiety. The use of polypharmacy may also cause itch, with or without a rash. Specifically, thiazides and calcium channel blockers have been known to cause itch in elderly patients. Management should be tailored according to the underlying dermatological or systemic aetiology of itch. Topical treatment is the mainstay of therapy, providing special emphasis on skin hydration and barrier repair. In addition, topical and oral medications that target the nervous system and reduce neuronal hypersensitization, such as gabapentin and selective antidepressants, have a role in treating patients with severe chronic itch. Furthermore, management must account for changes in metabolism and pharmacokinetics of drugs in the aging population in order to prevent the occurrence of adverse effects.
Collapse
|
31
|
Ständer S, Zeidler C, Magnolo N, Raap U, Mettang T, Kremer AE, Weisshaar E, Augustin M. Clinical management of pruritus. J Dtsch Dermatol Ges 2016; 13:101-15; quiz 116. [PMID: 25631127 DOI: 10.1111/ddg.12522] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The care of patients with chronic pruritus as a symptom of a wide variety of underlying diseases continues to confront dermatologists with diagnostic and therapeutic challenges. However, a structured history and a physical examination may already substantially help in narrowing down the number of potential differential diagnoses. Apart form reducing the intensity of pruritus, identification and appropriate treatment of the underlying disease are important needs of patients. If these goals doesn't lead to improvement of itch, current guidelines provide a number of topical and systemic therapies for symptomatic treatment. Various skin lesions (for example, xerosis caused by irritant substances, secondary scratch lesions) prompt patients to consult a dermatologist, but most cases require an interdisciplinary therapeutic approach to identify potential internal medicine, neurologic, or psychosomatic aspects. Although great strides have been made in basic research, specific therapies are still rare, and a precise knowledge of the legal framework for the implementation of guidelines (for example, off-label use) is essential. This CME article gives an overview of the causes of and treatment options for chronic pruritus and discusses both advances in basic research as well as progress in clinical knowledge.
Collapse
Affiliation(s)
- Sonja Ständer
- Competence Center Chronic Pruritus, Department of Dermatology, University Hospital Muenster, Germany
| | | | | | | | | | | | | | | |
Collapse
|
32
|
Wang T, Hurwitz O, Shimada SG, Qu L, Fu K, Zhang P, Ma C, LaMotte RH. Chronic Compression of the Dorsal Root Ganglion Enhances Mechanically Evoked Pain Behavior and the Activity of Cutaneous Nociceptors in Mice. PLoS One 2015; 10:e0137512. [PMID: 26356638 PMCID: PMC4565551 DOI: 10.1371/journal.pone.0137512] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 08/18/2015] [Indexed: 11/29/2022] Open
Abstract
Radicular pain in humans is usually caused by intraforaminal stenosis and other diseases affecting the spinal nerve, root, or dorsal root ganglion (DRG). Previous studies discovered that a chronic compression of the DRG (CCD) induced mechanical allodynia in rats and mice, with enhanced excitability of DRG neurons. We investigated whether CCD altered the pain-like behavior and also the responses of cutaneous nociceptors with unmyelinated axons (C-fibers) to a normally aversive punctate mechanical stimulus delivered to the hairy skin of the hind limb of the mouse. The incidence of a foot shaking evoked by indentation of the dorsum of foot with an aversive von Frey filament (tip diameter 200 μm, bending force 20 mN) was significantly higher in the foot ipsilateral to the CCD surgery as compared to the contralateral side on post-operative days 2 to 8. Mechanically-evoked action potentials were electrophysiologically recorded from the L3 DRG, in vivo, from cell bodies visually identified as expressing a transgenically labeled fluorescent marker (neurons expressing either the receptor MrgprA3 or MrgprD). After CCD, 26.7% of MrgprA3+ and 32.1% MrgprD+ neurons exhibited spontaneous activity (SA), while none of the unoperated control neurons had SA. MrgprA3+ and MrgprD+ neurons in the compressed DRG exhibited, in comparison with neurons from unoperated control mice, an increased response to the punctate mechanical stimuli for each force applied (6, 20, 40, and 80 mN). We conclude that CCD produced both a behavioral hyperalgesia and an enhanced response of cutaneous C-nociceptors to aversive punctate mechanical stimuli.
Collapse
Affiliation(s)
- Tao Wang
- Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Neuroscience Center, Department of Anatomy, Histology and Embryology, Beijing, China
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut, United States of America
| | - Olivia Hurwitz
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut, United States of America
| | - Steven G. Shimada
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut, United States of America
| | - Lintao Qu
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut, United States of America
- Department of Neurosurgery, Neurosurgery Pain Research Institute, Johns Hopkins University, Baltimore, Maryland
| | - Kai Fu
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut, United States of America
| | - Pu Zhang
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut, United States of America
| | - Chao Ma
- Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Neuroscience Center, Department of Anatomy, Histology and Embryology, Beijing, China
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut, United States of America
| | - Robert H. LaMotte
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut, United States of America
- * E-mail:
| |
Collapse
|
33
|
Zeidler C, Lüling H, Dieckhöfer A, Osada N, Schedel F, Steinke S, Augustin M, Ständer S. Capsaicin 8% cutaneous patch: a promising treatment for brachioradial pruritus? Br J Dermatol 2015; 172:1669-1671. [PMID: 25354282 DOI: 10.1111/bjd.13501] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- C Zeidler
- Department of Dermatology, Competence Center Chronic Pruritus, University Hospital of Münster, Münster, Germany
| | - H Lüling
- Department of Dermatology, Competence Center Chronic Pruritus, University Hospital of Münster, Münster, Germany
| | - A Dieckhöfer
- Department of Dermatology, Competence Center Chronic Pruritus, University Hospital of Münster, Münster, Germany
| | - N Osada
- Institute for Medical Informatics, University Hospital of Münster, Münster, Germany
| | - F Schedel
- Department of Dermatology, Competence Center Chronic Pruritus, University Hospital of Münster, Münster, Germany
| | - S Steinke
- Department of Dermatology, Competence Center Chronic Pruritus, University Hospital of Münster, Münster, Germany
| | - M Augustin
- Institute and German Center for Health Services Research in Dermatology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - S Ständer
- Department of Dermatology, Competence Center Chronic Pruritus, University Hospital of Münster, Münster, Germany
| |
Collapse
|
34
|
Affiliation(s)
- J D Bernhard
- University of Massachusetts Medical School, Worcester, MA, U.S.A.
| |
Collapse
|
35
|
Ständer S, Zeidler C, Magnolo N, Raap U, Mettang T, Kremer AE, Weisshaar E, Augustin M. Klinisches Management bei Pruritus. J Dtsch Dermatol Ges 2015. [DOI: 10.1111/ddg.12522_suppl] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Sonja Ständer
- Kompetenzzentrum Chronischer Pruritus; Klinik für Hautkrankheiten; Universitätsklinikum Münster
| | - Claudia Zeidler
- Kompetenzzentrum Chronischer Pruritus; Klinik für Hautkrankheiten; Universitätsklinikum Münster
| | - Nina Magnolo
- Kompetenzzentrum Chronischer Pruritus; Klinik für Hautkrankheiten; Universitätsklinikum Münster
| | - Ulrike Raap
- Klinik für Dermatologie; Allergologie und Venerologie; Medizinische Hochschule Hannover
| | | | - Andreas E. Kremer
- Medizinische Klinik 1; Gastroenterologie; Pneumologie und Endokrinologie; Friedrich-Alexander- Universität Erlangen
| | - Elke Weisshaar
- Abteilung für Klinische Sozialmedizin; Berufs- und Umweltdermatologie; Universitätsklinikum Heidelberg
| | - Matthias Augustin
- Competenzzentrum Versorgungsforschung in der Dermatologie (CVderm); Institut für Versorgungsforschung in der Dermatologie und bei Pflegeberufen (IVDP), Universitätsklinikum Eppendorf, Hamburg
| |
Collapse
|
36
|
|
37
|
Abstract
Pruritus, also known as itch, is a very common, unpleasant sensation that elicits an urge to scratch. Its origin is not always in the skin, and neuropathic itch that is caused by neuronal or glial damage is common, but poorly understood by both dermatologists and neurologists. Although pruritus has not been considered as serious a symptom as pain, it is difficult to treat and--if chronic--can severely impair quality of life. Neuropathic itch is often associated with other clinical symptoms, most commonly neuropathic pain, and hypersensitization to stimuli is present in both pruritus and pain of neuropathic origin. The shared aetiology can aid in finding suitable treatment for itch in some cases, but more detailed knowledge of the mechanisms of itch, along with standardized, well-controlled trials, is needed. Pruritus research is an emerging but currently very active field, and our understanding of this sensation is rapidly increasing. Here, we review new discoveries regarding the role of the nervous system and the contribution of different pathways in pruritus, discuss the different aetiologies of neuropathic itch, and outline currently available and potential strategies for managing neuropathic pruritus.
Collapse
|
38
|
Prurit brachioradial révélant un astrocytome médullaire cervical et traité par patchs de capsaïcine à 8 %. Ann Dermatol Venereol 2014; 141:374-5. [DOI: 10.1016/j.annder.2014.01.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Revised: 12/29/2013] [Accepted: 01/10/2014] [Indexed: 11/21/2022]
|
39
|
Zeidler C, Ständer S. [Secondary generalized brachioradial pruritus. An uncommon but easy-to-use differential diagnostic approach to generalized pruritus]. Hautarzt 2014; 65:56-8. [PMID: 24445945 DOI: 10.1007/s00105-013-2679-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Brachioradial pruritus is a neuropathic form of chronic pruritus and mostly localized on the forearms. We report on a patient whose pruritus generalized 4 months after beginning on the forearms. The mechanism that leads to generalization is still unknown; multiplier factors may be involved. Systemic therapy with anticonvulsants and physical therapy measures produced improvement. This form of pruritus requires a focused, interdisciplinary diagnostic approach and therapy.
Collapse
Affiliation(s)
- C Zeidler
- Kompetenzzentrum Chronischer Pruritus (KCP), Klinik für Hautkrankheiten, Universitätsklinikum Münster, Von-Esmarch-Str. 58, 48149, Münster, Deutschland,
| | | |
Collapse
|
40
|
Mirzoyev S, Davis M. Brachioradial pruritus: Mayo Clinic experience over the past decade. Br J Dermatol 2013; 169:1007-15. [DOI: 10.1111/bjd.12483] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2013] [Indexed: 11/29/2022]
Affiliation(s)
- S.A. Mirzoyev
- Mayo Medical School; Mayo Clinic; 200 First Street SW Rochester MN 55905 U.S.A
| | - M.D.P. Davis
- Department of Dermatology; Mayo Clinic; 200 First Street SW Rochester MN 55905 U.S.A
| |
Collapse
|
41
|
Kwatra SG, Stander S, Bernhard JD, Weisshaar E, Yosipovitch G. Brachioradial pruritus: A trigger for generalization of itch. J Am Acad Dermatol 2013; 68:870-3. [DOI: 10.1016/j.jaad.2012.11.026] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Revised: 11/08/2012] [Accepted: 11/09/2012] [Indexed: 10/27/2022]
|
42
|
Affiliation(s)
- Astrid Stumpf
- Department of Psychosomatics and Psychotherapy; Competence Center of Chronic Pruritus; University Hospital Münster; Münster; Germany
| | - Sonja Ständer
- Department of Dermatology; Competence Center of Chronic Pruritus; University Hospital Münster; Münster; Germany
| |
Collapse
|
43
|
Masuda PY, Martelli ACC, Wachholz PA, Akumatsu HT, Martins ALGP, Silva NM. Brachioradial pruritus -- descriptive analysis of Brazilian case series. J Dtsch Dermatol Ges 2013; 11:530-5. [PMID: 23280069 DOI: 10.1111/ddg.12009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Accepted: 10/30/2012] [Indexed: 01/29/2023]
Abstract
BACKGROUND The epidemiology and clinical features of brachioradial pruritus are variably described in the literature. We sought to analyze these features in a large group of Brazilian patients. PATIENTS AND METHODS In a descriptive, observational study, we identified all patients with a final diagnosis of brachioradial pruritus seen over a one-year period and re-trospectively reviewed their records. The diagnosis was made after clinical-laboratory investigation had ruled out other causes of chronic pruritus. Demographic and clinical variables were collected along with pruritus characteristics, and analyzed using des-criptive statistics. RESULTS Forty-three patients were identified; their mean age was 55.9 years, with predominance of women (81.4%) and Caucasians (86%). In 52%, the pruritus worsened with heat and sun exposure; 58.1% had intermittent complaints; the ice-pack sign was present only in 20.9%. The arms involving dermatomes C5-C6-C7-C8 (62.8%) were the most affected sites, while psychoactive drugs were the most frequently prescribed therapy. CONCLUSIONS Although uncommon, brachioradial pruritus should not be neglected in dermatological diagnosis. This case series analysis indicated that Brazilian patients from a tropical climate show characteristics similar to those described in other series from more temperate regions.
Collapse
Affiliation(s)
- Paula Y Masuda
- Dermatology Service of Instituto Lauro de Souza Lima, Brazil
| | | | | | | | | | | |
Collapse
|
44
|
Weisshaar E, Kallen U, Weiß M. "The itching hand"- important differential diagnoses and treatment. J Dtsch Dermatol Ges 2012; 11:31-42. [PMID: 23176572 DOI: 10.1111/j.1610-0387.2012.08002.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Skin diseases affecting the hands receive particular individual attention and constitute a considerable emotional burden. Many dermatoses also present with itching of the hands. Itch is often underestimated when it occurs in a comparably limited body area such as the hands. The high occupational significance of the hands in many professions must, nevertheless, be stressed. One of the most frequent diagnoses in itching of the hands is eczema. In the differential diagnosis, less common diseases such as neurological and systemic diseases and adverse drug reactions must also be taken into consideration. Itching of the hands can also be accompanied by other sensations, such as burning, stinging and pain. A thorough history regarding sensations and dysesthesias already allows for a diagnostic classification of the disease in some cases. Itching of the hands requires a careful and thorough diagnostic approach. This forms the basis of a specific and successful therapy which may be adapted stepwise, depending on the underlying cause, and also may require, in addition to causal therapy, symptomatic antipruritic therapy. Therapy should follow the current guidelines for chronic pruritus and hand eczema. This article reviews over the differential diagnosis and therapy of "itching hands".
Collapse
Affiliation(s)
- Elke Weisshaar
- Department of Clinical Social Medicine, Occupational and Environmental Dermatology, University Hospital Heidelberg, Germany.
| | | | | |
Collapse
|
45
|
Beuscher L, Reeves G. Brachioradial Pruritus: Approach to the Patient With Enigmatic Forearm Pruritus. J Nurse Pract 2012. [DOI: 10.1016/j.nurpra.2012.09.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
46
|
Bibliography Current World Literature. CURRENT ORTHOPAEDIC PRACTICE 2012. [DOI: 10.1097/bco.0b013e318256e7f2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|