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Ladwa R, Fogarty G, Chen P, Grewal G, McCormack C, Mar V, Kerob D, Khosrotehrani K. Management of Skin Toxicities in Cancer Treatment: An Australian/New Zealand Perspective. Cancers (Basel) 2024; 16:2526. [PMID: 39061166 DOI: 10.3390/cancers16142526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2024] [Revised: 07/08/2024] [Accepted: 07/09/2024] [Indexed: 07/28/2024] Open
Abstract
Cancer systemic therapeutics and radiotherapy are often associated with dermatological toxicities that may reduce patients' quality of life and impact their course of cancer treatment. These toxicities cover a wide range of conditions that can be complex to manage with increasing severity. This review provides details on twelve common dermatological toxicities encountered during cancer treatment and offers measures for their prevention and management, particularly in the Australian/New Zealand context where skincare requirements may differ to other regions due to higher cumulative sun damage caused by high ambient ultraviolet (UV) light exposure. Given the frequency of these dermatological toxicities, a proactive phase is envisaged where patients can actively try to prevent skin toxicities.
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Affiliation(s)
- Rahul Ladwa
- Princess Alexandra Hospital, Ipswich Road, Woolloongabba, QLD 4102, Australia
- Faculty of Medicine, University of Queensland, Herston, QLD 4006, Australia
| | - Gerald Fogarty
- Icon Cancer Centre Revesby, Revesby, NSW 2212, Australia
| | - Peggy Chen
- Peggy Chen Skin Cancer and Mohs Surgery, New Plymouth 4310, New Zealand
- Te Whatu Ora Health New Zealand Taranaki, Westtown, New Plymouth 4310, New Zealand
| | - Gurpreet Grewal
- McGrath Foundation Breast Care Nurse, Alfred Health, Cancer Services, Melbourne, VIC 3127, Australia
| | - Chris McCormack
- Department Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC 3052, Australia
| | - Victoria Mar
- Victorian Melanoma Service, Alfred Health, Melbourne, VIC 3004, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3800, Australia
| | | | - Kiarash Khosrotehrani
- Dermatology Research Centre, Experimental Dermatology Group, Frazer Institute, The University of Queensland, Woolloongabba, QLD 4072, Australia
- Department of Dermatology, Princess Alexandra Hospital, Woolloongabba, QLD 4102, Australia
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2
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Butler DC, Berger T, Elmariah S, Kim B, Chisolm S, Kwatra SG, Mollanazar N, Yosipovitch G. Chronic Pruritus: A Review. JAMA 2024; 331:2114-2124. [PMID: 38809527 DOI: 10.1001/jama.2024.4899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/30/2024]
Abstract
Importance Chronic pruritus, defined as itch experienced for 6 weeks or longer, affects approximately 22% of people in their lifetime. Approximately 1% of physician visits are for the chief concern of chronic pruritus. Chronic pruritus is associated with adverse outcomes, including impaired sleep and reduced quality of life. Observations Chronic pruritus can be categorized by etiology into inflammatory, neuropathic, or a combination of inflammatory and neuropathic pruritus. Chronic pruritus is due to inflammation in approximately 60% of patients and may be caused by eczema, psoriasis, or seborrheic dermatitis. Chronic pruritus is due to a neuropathic or mixed etiology in approximately 25% of patients. Neuropathic causes of chronic pruritus include postherpetic neuralgia and notalgia paresthetica and are typically due to localized or generalized nerve dysregulation. Approximately 15% of people with chronic pruritus have other causes including systemic diseases with secondary itch, such as uremic pruritus and cholestatic pruritus, medication-induced pruritus such as pruritus due to immunotherapy, and infectious etiologies such as tinea corporis and scabies. When few primary changes are present, a thorough history, review of symptoms, and laboratory evaluation should be performed, particularly for people with chronic pruritus lasting less than 1 year. Clinicians should consider the following tests: complete blood cell count, complete metabolic panel, and thyroid function testing to evaluate for hematologic malignancy, liver disease, kidney disease, or thyroid disease. First-line treatment for inflammatory chronic pruritus includes topical anti-inflammatory therapies such as hydrocortisone (2.5%), triamcinolone (0.1%), or tacrolimus ointment. Approximately 10% of patients do not respond to topical therapies. In these patients, referral to dermatology and systemic oral or injectable treatments such as dupilumab or methotrexate may be considered. When no underlying systemic disease associated with pruritus is identified, patients are likely to have neuropathic chronic pruritus or mixed etiology such as chronic pruritus of unknown origin. In these patients, neuropathic topical treatments such as menthol, pramoxine, or lidocaine can be used either alone or in combination with immunomodulatory agents such as topical steroids. Other effective therapies for neuropathic pruritus include gabapentin, antidepressants such as sertraline or doxepin, or opioid receptor agonist/antagonists such as naltrexone or butorphanol. Conclusions and Relevance Chronic pruritus can adversely affect quality of life and can be categorized into inflammatory, neuropathic, or a combined etiology. First-line therapies are topical steroids for inflammatory causes, such as hydrocortisone (2.5%) or triamcinolone (0.1%); topical neuropathic agents for neuropathic causes, such as menthol or pramoxine; and combinations of these therapies for mixed etiologies of chronic pruritus.
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Affiliation(s)
| | - Timothy Berger
- Department of Dermatology, University of California, San Francisco
| | - Sarina Elmariah
- Department of Dermatology, University of California, San Francisco
| | - Brian Kim
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sarah Chisolm
- Department of Dermatology, Emory University, Grady Memorial Hospital, Atlanta, Georgia
- Regional Telehealth Service, Veterans Affairs Veterans Integrated Service Network 7 Southeast Network, Duluth, Georgia
| | - Shawn G Kwatra
- Department of Dermatology, Johns Hopkins University School of Medicine and Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Nicholas Mollanazar
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Gil Yosipovitch
- Miami Itch Center, Phillip Frost Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, University of Miami, Miami, Florida
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Davis MP. Novel therapies for nausea and vomiting in advanced illness and supportive cancer care. Palliat Care Soc Pract 2024; 18:26323524241257701. [PMID: 38855566 PMCID: PMC11159532 DOI: 10.1177/26323524241257701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 05/07/2024] [Indexed: 06/11/2024] Open
Abstract
Nausea and vomiting are common experiences and are often dreaded more than pain. This review discusses blonanserin, mirtazapine, and isopropyl alcohol as antiemetics. Blonanserin, an atypical antipsychotic with a high affinity for dopamine D2 and D3 receptors and serotonin receptor 5-HT2A, has less of a risk of extrapyramidal adverse effects. Transdermal blonanserin, available in Korea, Japan, and China in a small number of trials, has improved nausea in patients not responding to standard antiemetics. Mirtazapine is a noradrenergic and specific serotonergic antidepressant that has been used for multiple symptoms besides depression. There is little evidence that mirtazapine improves anorexia or nausea in advanced cancer but is as effective as olanzapine in reducing chemotherapy-induced nausea and vomiting. Isopropyl alcohol aromatherapy has been successfully used in the emergency department for nausea and vomiting with an onset to benefit more rapidly than standard antiemetics. Isopropyl alcohol prep pads can be used for home-going antiemetic therapy and as a bridge to treating acute nausea until standard antiemetics take effect.
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Affiliation(s)
- Mellar P. Davis
- Geisinger Commonwealth School of Medicine, 100 North Academy Avenue, Danville, PA 17822, USA
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Patterson AT. JAAD Game Changer: "Use of oral antidepressants in patients with chronic pruritus: A systematic review". J Am Acad Dermatol 2024; 90:345. [PMID: 37607611 DOI: 10.1016/j.jaad.2023.08.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 08/14/2023] [Indexed: 08/24/2023]
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Tóth KF, Ádám D, Arany J, Ramirez YA, Bíró T, Drake JI, O'Mahony A, Szöllősi AG, Póliska S, Kilić A, Soeberdt M, Abels C, Oláh A. Fluoxetine exerts anti-inflammatory effects on human epidermal keratinocytes and suppresses their endothelin release. Exp Dermatol 2024; 33:e14988. [PMID: 38284184 DOI: 10.1111/exd.14988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 11/08/2023] [Accepted: 11/22/2023] [Indexed: 01/30/2024]
Abstract
Fluoxetine is a safe antidepressant with remarkable anti-inflammatory actions; therefore, we aimed to investigate its effects on immortalized (HaCaT) as well as primary human epidermal keratinocytes in a polyinosinic-polycytidylic acid (p(I:C))-induced inflammatory model. We found that a non-cytotoxic concentration (MTT-assay, CyQUANT-assay) of fluoxetine significantly suppressed p(I:C)-induced expression and release of several pro-inflammatory cytokines (Q-PCR, cytokine array, ELISA), and it decreased the release of the itch mediator endothelins (ELISA). These effects were not mediated by the inhibition of the NF-κB or p38 MAPK pathways (western blot), or by the suppression of the p(I:C)-induced elevation of mitochondrial ROS production (MitoSOX Red labeling). Instead, unbiased activity profiling revealed that they were most likely mediated via the inhibition of the phosphoinositide 3-kinase (PI3K) pathway. Importantly, the PI3K-inhibitor GDC0941 fully mimicked the effects of fluoxetine (Q-PCR, ELISA). Although fluoxetine was able to occupy the binding site of GDC0941 (in silico molecular docking), and exerted direct inhibitory effect on PI3K (cell-free PI3K activity assay), it exhibited much lower potency and efficacy as compared to GDC0941. Finally, RNA-Seq analysis revealed that fluoxetine deeply influenced the transcriptional alterations induced by p(I:C)-treatment, and exerted an overall anti-inflammatory activity. Collectively, our findings demonstrate that fluoxetine exerts potent anti-inflammatory effects, and suppresses the release of the endogenous itch mediator endothelins in human keratinocytes, most likely via interfering with the PI3K pathway. Thus, clinical studies are encouraged to explore whether the currently reported beneficial effects translate in vivo following its topical administration in inflammatory and pruritic dermatoses.
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Affiliation(s)
- Kinga Fanni Tóth
- Department of Physiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- University of Debrecen, Doctoral School of Molecular Medicine, Debrecen, Hungary
| | - Dorottya Ádám
- Department of Physiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- University of Debrecen, Doctoral School of Molecular Medicine, Debrecen, Hungary
| | - József Arany
- Department of Physiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- University of Debrecen, Doctoral School of Molecular Medicine, Debrecen, Hungary
| | - Yesid A Ramirez
- Design and Applied Sciences, School of Applied Sciences and Sustainable Industry, Department of Pharmaceutical and Chemical Sciences, Faculty of Engineering, Universidad Icesi, Cali, Valle del Cauca, Colombia
- Cannaflos-Gesellschaft für medizinisches Cannabis mbH, Köln, Germany
| | - Tamás Bíró
- Department of Immunology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | | | - Alison O'Mahony
- Eurofins Discovery, St. Charles, Missouri, USA
- Recursion, Salt Lake City, Utah, USA
| | - Attila Gábor Szöllősi
- Department of Immunology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Szilárd Póliska
- Genomic Medicine and Bioinformatics Core Facility, Department of Biochemistry and Molecular Biology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Ana Kilić
- Dr. August Wolff GmbH & Co. KG Arzneimittel, Bielefeld, Germany
| | - Michael Soeberdt
- Dr. August Wolff GmbH & Co. KG Arzneimittel, Bielefeld, Germany
- Bionorica SE, Neumarkt, Germany
| | - Christoph Abels
- Dr. August Wolff GmbH & Co. KG Arzneimittel, Bielefeld, Germany
- Bionorica SE, Neumarkt, Germany
| | - Attila Oláh
- Department of Physiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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Kouwenhoven TA, van de Kerkhof PCM, Kamsteeg M. Gabapentin and oral antidepressants for chronic pruritus: a prospective cohort study evaluating efficacy and side effects in daily dermatological practice. J DERMATOL TREAT 2023; 34:2274291. [PMID: 37905412 DOI: 10.1080/09546634.2023.2274291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 10/10/2023] [Indexed: 11/02/2023]
Abstract
BACKGROUND Chronic pruritus is frequently seen in daily dermatological practice and is associated with marked impact on quality of life. Research on the use of gabapentin and oral antidepressants in daily dermatological practice is scarce. OBJECTIVE To evaluate the efficacy and safety of gabapentin and oral antidepressants in patients with chronic pruritus in daily clinical practice. METHODS A prospective observational single-center cohort study was conducted including adult patients with chronic pruritus and an indication for systemic treatment between June 2016 and May 2019. RESULTS Systemic treatment with gabapentin and/or antidepressants was initiated in 31 patients with severe chronic pruritus (median average pruritus NRS score 7.0), in which most cases no underlying origin was identified (83.9%). In patients treated with gabapentin 900-1800 mg/day (N = 25), median average pruritus NRS decreased to 5.5 (IQR 3.0) after 4 weeks and remained stable up to 24 weeks of treatment. Efficacy of antidepressants was variable, with the highest response after initiation of amitriptyline, nortriptyline, and mirtazapine. Side effects were frequently observed in both gabapentin and antidepressant treatments; however, were mostly mild and temporary. LIMITATIONS This was a single-site observational study, with limited sample size. CONCLUSION Treatment with gabapentin and antidepressants should be considered in patients with chronic pruritus unresponsive to conventional treatment.
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Affiliation(s)
- T A Kouwenhoven
- Department of Dermatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - P C M van de Kerkhof
- Department of Dermatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - M Kamsteeg
- Department of Dermatology, Radboud University Medical Center, Nijmegen, the Netherlands
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Abstract
This JAMA Network Insight reviews the underlying mechanisms and management of peripheral sensory itch conditions.
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Affiliation(s)
- Kelsey L Auyeung
- Kimberly and Eric J. Waldman Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Blair A Jenkins
- Department of Dermatology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Brian S Kim
- Kimberly and Eric J. Waldman Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York
- Mark Lebwohl Center for Neuroinflammation & Sensation, Icahn School of Medicine at Mount Sinai, New York, New York
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Radtke S, Grossberg AL, Wan J. Mental health comorbidity in youth with atopic dermatitis: A narrative review of possible mechanisms. Pediatr Dermatol 2023; 40:977-982. [PMID: 37665064 PMCID: PMC10863653 DOI: 10.1111/pde.15410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 07/22/2023] [Indexed: 09/05/2023]
Abstract
The presence of atopic dermatitis (AD) in youth has been linked to a variety of mental health concerns including disruptive behavior, symptoms of anxiety and depression, and diagnoses of attention deficit/hyperactivity disorder and autism spectrum disorder. However, the factors accounting for these relationships are not well understood. The current review summarizes possible mechanisms identified in previous research and highlights areas for future investigation. Among the primary mechanisms studied to date, child sleep is the only factor that has been characterized in relative detail, with findings generally supporting the mediating role of sleep problems in the relationship between AD and psychological symptoms. There is substantial evidence suggesting a negative impact of child AD on parent mental health and the impact of parent mental health on child psychological functioning, although the latter has not been assessed specifically in populations of children with AD. There is also preliminary support for other mechanisms, including pruritus and pain, atopic comorbidities, social functioning, and systemic antihistamine use, in the development of mental health concerns in pediatric AD. Furthermore, research suggests the presence of bidirectional relationships between AD and psychological functioning via inflammatory responses to stress and impaired treatment adherence. Overall, significant additional research is needed to better characterize the nature and magnitude of the relationships among these multiple mechanisms and various psychosocial outcomes. Nevertheless, the findings to date support routine screening of psychological health in patients with AD as well as screening for potential risk factors, which may also serve as targets of therapeutic intervention.
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Affiliation(s)
- Sarah Radtke
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Anna L. Grossberg
- Department of Dermatology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Joy Wan
- Department of Dermatology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Wang J, Mi X, Ban F, Zhao J. Anti-amphiphysin antibody-associated paraneoplastic brainstem encephalitis with pruritus and dysphagia as the first symptoms: A case report. Medicine (Baltimore) 2023; 102:e35325. [PMID: 37773812 PMCID: PMC10545241 DOI: 10.1097/md.0000000000035325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 08/31/2023] [Indexed: 10/01/2023] Open
Abstract
RATIONALE Anti-amphiphysin antibodies are uncommonly detected in paraneoplastic neurologic syndromes (PNS), especially in patients with small cell lung cancer. Here, we report the first case of anti-amphiphysin antibody-associated PNS with pruritus and dysphagia as the first complaints. PATIENT CONCERNS The patient was a 58-year-old man who sought medical advice with a chief complaint of dysphagia and the lung occupancy. We found that he had developed progressive pruritus several months ago. DIAGNOSES In the outer basal segment of the right lung lower lobe, PET-CT revealed small occupancies with hypermetabolism. Later, the pathology showed small cell lung cancer. And anti-amphiphysin antibodies were detected in serum. Above all, the patient's symptoms improved significantly after antitumor treatment. Even neither of the 2 cranial enhancement MRIs showed any meaningful imaging signs, the above evidence could confirm the diagnosis of PNS. INTERVENTIONS The chemotherapy regimen was etoposide 0.1g d1-3+cisplatin 40 mg d1-3 (q3w). Paroxetine 20 mg/day was given to relieve the itching. OUTCOMES After the treatment, the Watian water swallowing test dropped from grade 5 to grade 1, the intense itching also became tolerable. LESSONS Clinicians should consider diagnoses other than anxiety states or esophageal cancer in a patient with pruritus and dysphagia, such as PNS.
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Affiliation(s)
- Jin Wang
- Department of Neurology, The Fourth Hospital of Hebei Medical University, Jian Kang Road No.12, Shijiazhuang, China
| | - Xiaokun Mi
- Department of Neurology, The Fourth Hospital of Hebei Medical University, Jian Kang Road No.12, Shijiazhuang, China
| | - Feng Ban
- Department of Neurology, The Fourth Hospital of Hebei Medical University, Jian Kang Road No.12, Shijiazhuang, China
| | - Jingxia Zhao
- Department of Neurology, The Fourth Hospital of Hebei Medical University, Jian Kang Road No.12, Shijiazhuang, China
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Lalani E, Menon R, Mufti MA, Kumfa C, Raji M. Mirtazapine: A One-Stop Strategy for Treatment of Opioid Withdrawal Symptoms. Cureus 2023; 15:e43821. [PMID: 37736438 PMCID: PMC10509332 DOI: 10.7759/cureus.43821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2023] [Indexed: 09/23/2023] Open
Abstract
Public health efforts to reduce the opioid overdose epidemic and treat opioid use disorder (OUD) have met with challenges associated with current non-standardized approaches to managing opioid withdrawal symptoms, such as itching, jitteriness, anxiety, depression, craving, vomiting, diarrhea, insomnia, and anorexia. These symptoms pose substantial obstacles to the safe initiation of medications for OUD, maintenance of long-term sobriety, and prevention of relapse. In clinical practice, multiple medications (polypharmacy) are prescribed to manage these withdrawal symptoms, including ondansetron and promethazine for vomiting and nausea, loperamide and Lomotil for diarrhea, hydroxyzine and doxepin for pruritus, benzodiazepines, the Z-drugs, and melatonin for insomnia, and benzos, tricyclic antidepressants (TCAs), and various serotonergic agents for anxiety. This polypharmacy is associated with an increased risk of adverse drug-drug interactions and adverse drug events, increased medical costs, and increased odds of medication non-adherence and relapse. We propose an alternative single medication, mirtazapine, a noradrenergic and specific serotonergic receptor antagonist, that can be used for myriad symptoms of opioid withdrawal. Case series, clinical studies, and clinical trials have shown mirtazapine to be effective for treating nausea and vomiting resulting from multiple etiologies, including hyperemesis gravidarum and chemotherapy-induced emesis. Other evidence supports the salutary effects of mirtazapine on itching and craving. Research findings support mirtazapine's beneficial effects on diarrhea and anxiety, a consequence of its modulating effects on serotonergic receptors mediating mood and gastrointestinal symptoms. There is also evidence supporting its efficacy as a potent and non-addictive sleep aid, which presents itself as a solution for insomnia associated with opioid withdrawal. The current review presents evidence from extant literature supporting mirtazapine as a one-drug strategy to treat the variety of symptoms of opioid withdrawal. This one-drug strategy has much potential to decrease polypharmacy, adverse drug events, relapse, and healthcare cost and increase the likelihood of prolonged sobriety and better quality of life for people living with OUD.
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Affiliation(s)
- Elisha Lalani
- Department of Internal Medicine, Division of General Medicine, University of Texas Medical Branch, Galveston, USA
| | - Raakhi Menon
- Department of Internal Medicine, Division of General Medicine, University of Texas Medical Branch, Galveston, USA
| | - Mariam A Mufti
- Department of Internal Medicine, Division of Geriatrics & Palliative Medicine, University of Texas Medical Branch, Galveston, USA
| | - Cecil Kumfa
- Department of Internal Medicine, Division of Geriatrics & Palliative Medicine, University of Texas Medical Branch, Galveston, USA
| | - Mukaila Raji
- Department of Internal Medicine, Division of Geriatrics & Palliative Medicine, University of Texas Medical Branch, Galveston, USA
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Turk T, Liu C, Fujiwara E, Straube S, Hagtvedt R, Dennett L, Abba-Aji A, Dytoc M. Pharmacological Interventions for Primary Psychodermatologic Disorders: An Evidence Mapping and Appraisal of Randomized Controlled Trials. J Cutan Med Surg 2023; 27:140-149. [PMID: 36802832 PMCID: PMC10068402 DOI: 10.1177/12034754231155888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
BACKGROUND The lack of clinical guidelines for the treatment of primary psychodermatologic disorders (PPDs) hinders the delivery of optimal care to patients. The review aimed to identify, appraise, and summarize the currently available evidence about the safety and effectiveness of pharmacological management of PPDs through randomized controlled trials (RCTs). METHODS The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRIMSA) statement and the Global Evidence Mapping Initiative guidance were followed. Medline, Embase, PsycInfo, Cochrane and Scopus were searched, and two reviewers independently completed article review, data extraction, and quality assessment. RESULTS Among 2618 unique studies, full texts of 83 were reviewed and 21 RCTs were included. Five PDDs were identified: trichotillomania (n = 12), pathologic skin picking (n = 5), nail biting (n = 2), delusional parasitosis (n = 1), and dermatitis from compulsive hand washing (n = 1). Seven different classes of medications were investigated: SSRIs (i.e., fluoxetine, sertraline, and citalopram), tricyclic antidepressants (i.e., clomipramine and desipramine), antipsychotics (i.e., olanzapine and pimozide), anticonvulsant (i.e., lamotrigine), N-acetylcysteine, inositol, and milk thistle. RCT-derived evidence supports the use of antidepressants in trichotillomania (sertraline and clomipramine), pathologic skin picking (fluoxetine), pathologic nail biting and dermatitis from compulsive hand washing (clomipramine or desipramine); antipsychotics in trichotillomania (olanzapine) and delusional parasitosis (pimozide); N-acetyl cysteine in trichotillomania and skin picking. CONCLUSION Few pharmacotherapies for primary psychodermatologic disorders are assessed through controlled trials in the literature. This review serves as a roadmap for researchers and clinicians to reach informed decisions with current evidence, and to build on it to establish guidelines in the future.
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Affiliation(s)
- Tarek Turk
- 3158 Department of Psychiatry, University of Alberta, Edmonton, Canada.,Department of Dermatology and Venereology, Syrian Arab Red Crescent Hospital, Ministry of Health, Damascus, Syria
| | - Chaocheng Liu
- 8166 Department of Dermatology and Skin Science, University of British Columbia, Vancouver, Canada
| | - Esther Fujiwara
- 3158 Department of Psychiatry, University of Alberta, Edmonton, Canada
| | - Sebastian Straube
- 12357 Division of Preventive Medicine, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Reidar Hagtvedt
- 12357 ABA, Alberta School of Business, University of Alberta, Edmonton, Canada
| | - Liz Dennett
- 67111 Scott Health Sciences Library, University of Alberta, Edmonton, Canada
| | - Adam Abba-Aji
- 3158 Department of Psychiatry, University of Alberta, Edmonton, Canada
| | - Marlene Dytoc
- 3158 Division of Dermatology, Department of Medicine, University of Alberta, Edmonton, Canada
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12
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Park BC, Jung S, Chen ST, Dewan AK, Johnson DB. Challenging Dermatologic Considerations Associated with Immune Checkpoint Inhibitors. Am J Clin Dermatol 2022; 23:707-717. [PMID: 35708849 DOI: 10.1007/s40257-022-00706-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2022] [Indexed: 11/25/2022]
Abstract
Immune checkpoint inhibitors have emerged as a new paradigm in oncologic care for many malignancies. However, nonspecific immune activation has led to "collateral damage" in the form of immune-related adverse events, with skin being a commonly affected organ. Cutaneous immune-related adverse events include a wide spectrum of clinical presentations and challenging considerations, often necessitating dermatology referral to support diagnosis and management, particularly for atypical presentations or more severe, cutaneous immune-related adverse events that may require specialized dermatologic evaluations including biopsy and histopathology. Close collaborations between oncologists and dermatologists may optimize clinical decision making in the following challenging management settings: non-steroidal therapies for corticosteroid-refractory, cutaneous immune-related adverse events, immune checkpoint inhibitor rechallenge, balancing cutaneous immune-related adverse events and treatments, and immune checkpoint inhibitors in patients with pre-existing autoimmune disease, skin conditions, and organ transplants. These complex clinical decisions that often lack rigorous data should be made in close collaboration with dermatologists to minimize unnecessary morbidity and mortality. This article provides a review of approaches to challenging dermatologic considerations associated with immune checkpoint inhibitor therapies.
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Affiliation(s)
- Benjamin C Park
- School of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Seungyeon Jung
- School of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Steven T Chen
- Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Anna K Dewan
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Douglas B Johnson
- Department of Medicine, Vanderbilt University Medical Center, 2220 Pierce Avenue, 777 Preston Research Building, Nashville, TN, 3723, USA.
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Utility of a Single Itch-Related Question and the Skindex-10 Questionnaire for Assessing Pruritus and Predicting Health-Related Quality of Life in Hemodialysis Patients. Kidney Med 2022; 4:100476. [PMID: 35651592 PMCID: PMC9149192 DOI: 10.1016/j.xkme.2022.100476] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Rationale & Objective Chronic kidney disease-associated pruritus has been linked with poorer mental and physical health-related quality of life (HR-QOL) in patients receiving hemodialysis. We used the Skindex-10 questionnaire and a single itch-related question to evaluate their prediction of HR-QOL. Study Design Prospective, international cohort. Setting & Participants We analyzed data from 4,940 patients receiving hemodialysis from 17 countries enrolled in phase 5 (2013) of the Dialysis Outcomes and Practice Patterns Study. Predictors The responses to the 10 questions of Skindex-10 (0-6 scale) pertaining to itchiness in the past week were summed to create a summary score (range, 0-60). Concurrently, a single question from the Kidney Disease Quality of Life 36-item survey asked “during the past 4 weeks, to what extent were you bothered by itchy skin?” with 5 responses, ranging from “not at all” to “extremely" bothered. Outcomes Physical component summary (PCS) and mental component summary (MCS) scores of HR-QOL. Analytical Approach We used separate linear regression models to evaluate the predictive power, based on R2 values, for 3 models: 1 for each predictor and 1 with both predictors. Results The correlation between the single itch-related question and the Skindex-10 score was 0.72. A 10-point higher Skindex-10 score was associated with a 1.2-point lower PCS score (95% CI, −1.4 to −0.9) and a 1.5-point lower MCS score (95% CI, −1.7 to −1.3) . The R2 value for PCS was 0.065 when the single question was used and only 0.033 when Skindex-10 was used as the predictor; the R2 value for MCS was 0.056 for the single question versus 0.052 for Skindex-10. Limitations Measurement bias and translation issues in the questionnaires. Conclusions The single question about the extent to which the patients were bothered by itchy skin was highly correlated with the Skindex-10 score and at least as predictive of key HR-QOL measures. In daily clinical practice, using 1 simple question about the extent to which patients are bothered by itchy skin can be a feasible and efficient method for the routine assessment of pruritus.
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14
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Tang Y, Cheng S, Wang J, Jin Y, Yang H, Lin Q, Xu S, Hui L, Yin Q, Yang Y, Wu X. Acupuncture for the Treatment of Itch: Peripheral and Central Mechanisms. Front Neurosci 2022; 15:786892. [PMID: 35431769 PMCID: PMC9005788 DOI: 10.3389/fnins.2021.786892] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 12/13/2021] [Indexed: 11/21/2022] Open
Abstract
Despite the widespread clinical use of acupuncture in the treatment of pruritus caused by psoriasis, urticaria, uremic, and other diseases, insights into the mechanism of action of acupuncture are still emerging. For the above reasons, a beneficial effect of acupuncture on pruritus was not recommended or reported in recent clinical practice guidelines. Acupuncture is a kind of physical stimulation, which has the characteristics of multi-channel and multi-target effects. The biomechanical stimulation signal of acupuncture needling can be transformed into bioelectric and chemical signals; interfere with kinds of cells and nerve fibers in the skin and muscle; alter signaling pathways and transcriptional activity of cells, mediators, and receptors; and result in inhibition of peripheral and central transmission of pruritus. Available mechanistic data give insights into the biological regulation potency of acupuncture for pruritus and provide a basis for more in-depth and comprehensive mechanism research.
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15
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Lu PH, Tai YC, Yu MC, Lin IH, Kuo KL. Western and complementary alternative medicine treatment of uremic pruritus: A literature review. Tzu Chi Med J 2021; 33:350-358. [PMID: 34760630 PMCID: PMC8532575 DOI: 10.4103/tcmj.tcmj_151_20] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 08/10/2020] [Accepted: 09/18/2020] [Indexed: 12/28/2022] Open
Abstract
Uremic pruritus (UP), also called chronic kidney disease-associated pruritus (CKD-aP), is a bothersome symptom that causes sleep disturbance, anxiety, depression, and reduced quality of life. Pruritus often occurs in patients with end-stage renal disease. There is still no definite treatment for UP due to its unclear pathogenesis. We searched electronic databases (PubMed and Google Scholar) and gathered the latest clinical trials and pilot studies of Western and complementary alternative medicine (CAM) therapies for UP in English. These UP studies were separated into three main groups: systemic, topical, and others and CAM. Gabapentin, nalfurafine, acupuncture, and Chinese herbal bath therapy (CHBT) show antipruritic effects, with higher evidence grades in the meta-analysis. Emollients with additive compounds are more effective for reducing itch than emollients without additives. Supplements for deficient elements, such as zinc, omega-3, and omega-6, also show benefits for pruritus improvement. CAM therapies such as acupuncture, herbs, and herbal baths or creams all have good results for UP treatment. We summarize the treatments and suggest a treatment algorithm for UP according to severity. Some UP therapies are already supported by large-scale clinical evidence, and some new treatments can provide patients with new hope and treatment options. However, these new methods still need large population studies and further exploration.
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Affiliation(s)
- Ping-Hsun Lu
- Department of Chinese Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan.,School of Post-Baccalaureate Chinese Medicine, Tzu Chi University, Hualien, Taiwan
| | - Yu-Chih Tai
- Department of Chinese Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
| | - Min-Chien Yu
- Department of Chinese Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
| | - I-Hsin Lin
- School of Post-Baccalaureate Chinese Medicine, Tzu Chi University, Hualien, Taiwan
| | - Ko-Lin Kuo
- Division of Nephrology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
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16
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McGovern C, Quasim T, Puxty K, Shaw M, Ng W, Gilhooly C, Arkoulis N, Basler M, Macfarlane A, Paton L. Neuropathic agents in the management of pruritus in burn injuries: a systematic review and meta-analysis. Trauma Surg Acute Care Open 2021; 6:e000810. [PMID: 34722931 PMCID: PMC8547510 DOI: 10.1136/tsaco-2021-000810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 09/02/2021] [Indexed: 11/03/2022] Open
Abstract
Objectives Pruritus is a common and often distressing complication after a burn injury. The purpose of this review is to explore the efficacy of drugs classically used to treat neuropathic pain in the management of pruritus after burn injury. Methods A systematic literature search of medical databases was conducted to find studies investigating drugs listed in the National Institute for Health and Care Excellence (NICE) guideline (CG173, "neuropathic pain in adults") for the management of pruritus after burn injury in patients of any age. Controlled studies were stratified by the drug class studied and their risk of bias before conducting meta-analysis. A narrative review of case series or observational studies was presented. Severity of pruritus at any time point, with all quantitative and qualitative measures, was included. Results Fifteen studies were included in the final analysis, 10 investigated the use of gabapentinoids, 4 studied doxepin, and 1 local anesthetic agents. Meta-analysis of three randomized controlled trials (RCTs) demonstrated that the use of gabapentinoids was associated with an improvement in mean VAS (Visual Analog Scale) 0-10 scores of 2.96 (95% confidence interval (95% CI) 1.20 to 4.73, p<0.001) when compared with placebo or antihistamine. A meta-analysis of four RCTs investigating topical doxepin showed an improvement in mean VAS scores of 1.82 (95% CI 0.55 to 3.09, p<0.001). However, when excluding two studies found to be at high risk of bias, no such improvement was found (-0.32, 95% CI -1.64 to -0.99, p=0.83). Conclusion This study suggests that gabapentinoids are beneficial in the management of burn-related pruritus. There is a lack of evidence to suggest that doxepin is an effective treatment. Topical local anesthetic agents may be safe and beneficial, but studies are scarce. Level of evidence Systematic review, level II.
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Affiliation(s)
- Christopher McGovern
- Anaesthesia, Critical Care and Peri-operative Medicine, University of Glasgow, Glasgow, UK.,Anaesthesia & Critical Care, Glasgow Royal Infirmary, Glasgow, UK
| | - Tara Quasim
- Anaesthesia, Critical Care and Peri-operative Medicine, University of Glasgow, Glasgow, UK.,Anaesthesia & Critical Care, Glasgow Royal Infirmary, Glasgow, UK
| | - Kathryn Puxty
- Anaesthesia, Critical Care and Peri-operative Medicine, University of Glasgow, Glasgow, UK.,Anaesthesia & Critical Care, Glasgow Royal Infirmary, Glasgow, UK
| | - Martin Shaw
- Anaesthesia, Critical Care and Peri-operative Medicine, University of Glasgow, Glasgow, UK.,Department of Clinical Physics and Bioengineering, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Wijnand Ng
- Medical Student, University of Glasgow, Glasgow, UK
| | - Charlotte Gilhooly
- Anaesthesia, Critical Care and Peri-operative Medicine, University of Glasgow, Glasgow, UK.,Anaesthesia & Critical Care, Glasgow Royal Infirmary, Glasgow, UK
| | - Nikolaos Arkoulis
- Plastic and Burn Surgery, Glasgow Royal Infirmary, Glasgow, UK.,Honorary Clinical Senior Lecturer (Medicine), University of Glasgow, Glasgow, UK
| | - Michael Basler
- Anaesthesia and Pain Medicine, Glasgow Royal Infirmary, Glasgow, UK
| | - Alan Macfarlane
- Anaesthesia, Critical Care and Peri-operative Medicine, University of Glasgow, Glasgow, UK.,Anaesthesia and Pain Medicine, Glasgow Royal Infirmary, Glasgow, UK
| | - Lia Paton
- Anaesthesia & Critical Care, Glasgow Royal Infirmary, Glasgow, UK
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17
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Patel P, Patel K, Pandher K, Tareen RS. The Role of Psychiatric, Analgesic, and Antiepileptic Medications in Chronic Pruritus. Cureus 2021; 13:e17260. [PMID: 34522555 PMCID: PMC8425105 DOI: 10.7759/cureus.17260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2021] [Indexed: 11/30/2022] Open
Abstract
Chronic pruritus is a complex yet prevalent concern without a gold standard treatment. The mainstay therapy for chronic pruritus includes topical ointments such as corticosteroids, capsaicin, local anesthetics, antihistamines, and immunomodulators. There are many different subtypes of chronic pruritus, and each unique subtype may benefit from specialized treatments. This review article sheds light on the role of psychiatric, analgesic, and antiepileptic medications in chronic pruritus. We believe that further large-scale studies are needed to determine the true effectiveness of these medications in treating chronic pruritus.
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Affiliation(s)
- Parth Patel
- Dermatology, Lake Erie College of Osteopathic Medicine, San Diego, USA
| | - Keshav Patel
- Internal Medicine, University of Illinois Chicago, Kalamazoo, USA
| | - Karan Pandher
- Dermatology, Rosalind Franklin University Chicago Medical School, North Chicago, USA
| | - Ruqiya Shama Tareen
- Psychiatry, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, USA
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18
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Use of Sertraline in Hemodialysis Patients. MEDICINA-LITHUANIA 2021; 57:medicina57090949. [PMID: 34577872 PMCID: PMC8470022 DOI: 10.3390/medicina57090949] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 08/29/2021] [Accepted: 09/06/2021] [Indexed: 11/25/2022]
Abstract
Depression and anxiety are the most common psychiatric disorders in end-stage renal disease (ESRD) patients treated with hemodialysis (HD) and may correlate with lower quality of life and increased mortality. Depression treatment in HD patients is still a challenge both for nephrologists and psychiatrists. The possible treatment of depressive disorders can be pharmacological and non-pharmacological. In our article, we focus on the use of sertraline, the medication which seems to be relatively safe and efficient in the abovementioned population, taking under consideration several limitations regarding the use of other selective serotonin reuptake inhibitors (SSRIs). In our paper, we discuss different aspects of sertraline use, taking into consideration possible benefits and side effects of drug administration like impact on QTc (corrected QT interval) prolongation, intradialytic hypotension (IDH), chronic kidney disease-associated pruritus (CKD-aP), bleeding, sexual functions, inflammation, or fracture risk. Before administering the medication, one should consider benefits and possible side effects, which are particularly significant in the treatment of ESRD patients; this could help to optimize clinical outcomes. Sertraline seems to be safe in the HD population when provided in proper doses. However, we still need more studies in this field since the ones performed so far were usually based on small samples and lacked placebo control.
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19
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Gurnani P, Miloh T, Chandar J, Landau DA, Hajjar F, Yosipovitch G. Systemic causes of non-dermatologic chronic pruritus in the pediatric population and their management: An unexplored area. Pediatr Dermatol 2021; 38:1051-1060. [PMID: 34515372 DOI: 10.1111/pde.14596] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Chronic pruritus associated with systemic diseases in the pediatric population has been infrequently addressed in the literature. This review focuses on chronic pruritus presenting without cutaneous manifestations. Common systemic etiologies include diseases with hepatic, renal, and hematologic origins. This encompasses several congenital liver disorders, end-stage renal disease (ESRD), and lymphoproliferative disorders such as Hodgkin's lymphoma. In this paper, an expert panel describes the clinical characteristics, pathophysiology, and therapeutic treatment ladders for chronic pruritus associated with the aforementioned systemic etiologies. Novel therapies are also reviewed. Our aim is to shed light on this unexplored area of pediatric dermatology and instigate further research.
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Affiliation(s)
- Pooja Gurnani
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery & Miami Itch Center, University of Miami, Miller School of Medicine, Miami, FL, USA.,Florida International University, Herbert Wertheim College of Medicine, Miami, FL, USA
| | - Tamir Miloh
- Pediatric Transplant Hepatology, Miami Transplant Institute, Jackson Health System, Miami, FL, USA
| | - Jayanthi Chandar
- Pediatric Kidney Transplantation, Miami Transplant Institute, Jackson Health System, Miami, FL, USA
| | | | - Fouad Hajjar
- AdventHealth For Children Pediatric Oncology and Hematology, Orlando, FL, USA
| | - Gil Yosipovitch
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery & Miami Itch Center, University of Miami, Miller School of Medicine, Miami, FL, USA
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20
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Gundogan B, Dowlut N, Rajmohan S, Borrelli MR, Millip M, Iosifidis C, Udeaja YZ, Mathew G, Fowler A, Agha R. Assessing the compliance of systematic review articles published in leading dermatology journals with the PRISMA statement guidelines: A systematic review. JAAD Int 2021; 1:157-174. [PMID: 34409336 PMCID: PMC8361930 DOI: 10.1016/j.jdin.2020.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2020] [Indexed: 11/24/2022] Open
Abstract
Background Reporting quality of systematic reviews and meta-analyses is of critical importance in dermatology because of their key role in informing health care decisions. Objective To assess the compliance of systematic reviews and meta-analyses in leading dermatology journals with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement guidelines. Methods This review was carried out in accordance with PRISMA guidelines. Included studies were reviews published across 6 years in the top 4 highest-impact-factor dermatology journals of 2017. Records and full texts were screened independently. Data analysis was conducted with univariate multivariable linear regression. The primary outcome was to assess the compliance of systematic reviews and meta-analyses in leading dermatology journals with the PRISMA statement. Results A total of 166 studies were included and mean PRISMA compliance across all articles was 73%. Compliance significantly improved over time (β = .016; P = <.001). The worst reported checklist item was item 5 (reporting on protocol existence), with a compliance of 15% of articles. Conclusion PRISMA compliance within leading dermatology journals could be improved; however, it is steadily improving.
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Affiliation(s)
- Buket Gundogan
- University College London Hospital, London, United Kingdom
| | - Naeem Dowlut
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | | | - Mimi R Borrelli
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Mirabel Millip
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Christos Iosifidis
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Yagazie Z Udeaja
- Luton and Dunstable University Hospital NHS Foundation Trust, Luton, United Kingdom
| | - Ginimol Mathew
- University College London Medical School, Gower Street, London, United Kingdom
| | | | - Riaz Agha
- Bart's Health NHS Foundation Trust, London, United Kingdom
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21
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Abstract
Chronic pruritus (itch lasting ≥6 weeks) is a bothersome chief complaint that may present in a broad variety of diseases. Most itch-causing diagnoses fit into 1 of 5 categories (inflammatory, secondary to systemic disease, neuropathic, chronic pruritus of undetermined origin, and psychogenic itch) and this broad differential can be narrowed using key findings in the history and physical. In this article, we discuss which key findings are most pertinent for narrowing this differential and guiding further workup and treatment, as well as how to treat many itchy conditions.
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Affiliation(s)
- Zoe M Lipman
- Dr Phillip Frost Department of Dermatology and Miami Itch Center, University of Miami, University of Miami Hospital, 1600 Northwest 10th Avenue RMSB Building, 10th Street, 2067B Miami, FL, USA
| | - Giuseppe Ingrasci
- Dr Phillip Frost Department of Dermatology and Miami Itch Center, University of Miami, University of Miami Hospital, 1600 Northwest 10th Avenue RMSB Building, 10th Street, 2067B Miami, FL, USA
| | - Gil Yosipovitch
- Dr Phillip Frost Department of Dermatology and Miami Itch Center, University of Miami, University of Miami Hospital, 1600 Northwest 10th Avenue RMSB Building, 10th Street, 2067B Miami, FL, USA.
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22
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Drozdowski R, Gronbeck C, Feng H. Declining utilization of potentially inappropriate medications in older adults by dermatologists: A cross-sectional Medicare analysis. J Am Acad Dermatol 2021; 86:1422-1425. [PMID: 34144082 DOI: 10.1016/j.jaad.2021.06.839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 06/07/2021] [Accepted: 06/09/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Roman Drozdowski
- University of Connecticut School of Medicine, Farmington, Connecticut
| | | | - Hao Feng
- Department of Dermatology, University of Connecticut Health Center, Farmington, Connecticut.
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23
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Kim HS, Hashimoto T, Fischer K, Bernigaud C, Chosidow O, Yosipovitch G. Scabies itch: an update on neuroimmune interactions and novel targets. J Eur Acad Dermatol Venereol 2021; 35:1765-1776. [PMID: 33960033 DOI: 10.1111/jdv.17334] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 04/23/2021] [Indexed: 12/14/2022]
Abstract
Frequently described as 'the worst itch' one can ever experience scabies itch is the hallmark of Sarcoptes scabiei mite infestation. Notably, the itchiness often persists for weeks despite scabicides therapy. The mechanism of scabies itch is not yet fully understood, and effective treatment modalities are still missing which can severely affect the quality of life. The aim of this review is to provide an overview of the scope of itch in scabies and highlight candidate mechanisms underlying this itch. We herein discuss scabies itch, with a focus on the nature, candidate underlying mechanisms and treatment options. We also synthesize this information with current understanding of the mechanisms contributing to non-histaminergic itch in other conditions. Itch is a major problem in scabies and can lead to grave consequences. We provide the latest insights on host-mite interaction, secondary microbial infection and neural sensitization with special emphasis on keratinocytes and mast cells to better understand the mechanism of itch in scabies. Also, the most relevant current modalities remaining under investigation that possess promising perspectives for scabies itch (i.e. protease-activated receptor-2 (PAR-2) inhibitor, Mas-related G protein-coupled receptor X2 (MRGPRX2) antagonist) are discussed. Greater understanding of these diverse mechanisms may provide a rational basis for the development of improved and targeted approaches to control itch in individuals with scabies.
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Affiliation(s)
- H S Kim
- Dr Philip Frost Department of Dermatology and Cutaneous Surgery, Miami Itch Center, Miller School of Medicine, University of Miami, Miami, FL, USA.,Department of Dermatology, Incheon St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - T Hashimoto
- Department of Dermatology, National Defense Medical College, Saitama, Japan
| | - K Fischer
- QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | - C Bernigaud
- Faculté de Santé de Créteil et Service de Dermatologie, APHP, Hôpital Henri-Mondor, Université Paris-Est, Créteil, France.,Research Group Dynamic, EA7380, Faculté de Santé de Créteil, Ecole Nationale Vétérinaire d'Alfort, USC ANSES, Université Paris-Est Créteil, Créteil, France
| | - O Chosidow
- Faculté de Santé de Créteil et Service de Dermatologie, APHP, Hôpital Henri-Mondor, Université Paris-Est, Créteil, France.,Research Group Dynamic, EA7380, Faculté de Santé de Créteil, Ecole Nationale Vétérinaire d'Alfort, USC ANSES, Université Paris-Est Créteil, Créteil, France
| | - G Yosipovitch
- Dr Philip Frost Department of Dermatology and Cutaneous Surgery, Miami Itch Center, Miller School of Medicine, University of Miami, Miami, FL, USA
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24
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Gao CQ, Zhou JJ, Tan YY, Tong CJ. Effectiveness of montelukast for uremic pruritus in hemodialysis patients: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e23229. [PMID: 33181709 PMCID: PMC7668522 DOI: 10.1097/md.0000000000023229] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Uremic pruritus (UP) is a common and tormenting symptom in end-stage renal disease patients undergoing maintenance hemodialysis. An increasing number of studies have been published in recent years to support the effectiveness of montelukast for UP. We will conduct a comprehensive systematic review and meta-analysis to evaluate effectiveness of montelukast for UP in hemodialysis patients. METHODS The following electronic databases were searched: Pubmed, Embase, Web of Science, Cochrane Library, the China National Knowledge Infrastructure, Chinese Biomedical Literature Database, and China Science and Technology Journal Database. The range of publication time was from the inception of the database to December 2020. Two reviewers will independently conduct article selection, data collection, and assessment of risk of bias. Any disagreement will be resolved by discussion with the third reviewer. Meta-analysis will be performed by Review Manager 5.3. The Cochrane Collaboration tool will be used to assess the risk of bias. RESULTS This study will provide a systematic synthesis of current published data to explore the effectiveness of montelukast for UP in hemodialysis patients. CONCLUSIONS This systematic review and meta-analysis will provide clinical evidence for the effectiveness of montelukast for UP in hemodialysis patients and inform our understanding of the value of montelukast in improving pruritus symptoms. This study will help clinicians, patients, and policy makers to make better decisions regarding the appropriate role of montelukast as a part of patient management routines. STUDY REGISTRATION NUMBER INPLASY2020100043.
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25
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Koga K, Shiraishi Y, Yamagata R, Tozaki-Saitoh H, Shiratori-Hayashi M, Tsuda M. Intrinsic braking role of descending locus coeruleus noradrenergic neurons in acute and chronic itch in mice. Mol Brain 2020; 13:144. [PMID: 33109226 PMCID: PMC7590446 DOI: 10.1186/s13041-020-00688-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 10/19/2020] [Indexed: 11/24/2022] Open
Abstract
Itch is defined as an unpleasant sensation that provokes a desire to scratch. Our understanding of neuronal circuits for itch information transmission and processing in the spinal dorsal horn (SDH) has progressively advanced following the identification of SDH neuron subsets that are crucial for scratching behavior in models of itch. However, little is known about the control of acute and chronic itch by descending signals from the brain to the SDH. In this study, using genetic approaches that enable cell-type and circuit-specific functional manipulation, we reveal an intrinsic potential of locus coeruleus (LC)-noradrenergic (NAergic) neurons that project to the SDH to control acute and chronic itch. Activation and silencing of SDH-projecting LC-NAergic neurons reduced and enhanced scratching behavior, respectively, in models of histamine-dependent and -independent acute itch. Furthermore, in a model of chronic itch associated with contact dermatitis, repetitive scratching behavior was suppressed by the activation of the descending LC-NAergic pathway and by knocking out NA transporters specific to descending LC-NAergic neurons using a CRISPR-Cas9 system. Moreover, patch-clamp recording using spinal slices showed that noradrenaline facilitated inhibitory synaptic inputs onto gastrin-releasing peptide receptor-expressing SDH neurons, a neuronal subset known to be essential for itch transmission. Our findings suggest that descending LC-NAergic signaling intrinsically controls acute and chronic itch and provide potential therapeutic strategies for the treatment of acute and chronic itch.
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Affiliation(s)
- Keisuke Koga
- Department of Life Innovation, Graduate School of Pharmaceutical Sciences, Kyushu University, Fukuoka, 812-8582, Japan.,Department of Neurophysiology, Hyogo College of Medicine, Nishinomiya, Hyogo, 663-8501, Japan
| | - Yuto Shiraishi
- Department of Life Innovation, Graduate School of Pharmaceutical Sciences, Kyushu University, Fukuoka, 812-8582, Japan.,Department of Molecular and System Pharmacology, Graduate School of Pharmaceutical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Ryo Yamagata
- Department of Life Innovation, Graduate School of Pharmaceutical Sciences, Kyushu University, Fukuoka, 812-8582, Japan
| | - Hidetoshi Tozaki-Saitoh
- Department of Life Innovation, Graduate School of Pharmaceutical Sciences, Kyushu University, Fukuoka, 812-8582, Japan.,Department of Molecular and System Pharmacology, Graduate School of Pharmaceutical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Miho Shiratori-Hayashi
- Department of Life Innovation, Graduate School of Pharmaceutical Sciences, Kyushu University, Fukuoka, 812-8582, Japan.,Department of Molecular and System Pharmacology, Graduate School of Pharmaceutical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Makoto Tsuda
- Department of Life Innovation, Graduate School of Pharmaceutical Sciences, Kyushu University, Fukuoka, 812-8582, Japan. .,Department of Molecular and System Pharmacology, Graduate School of Pharmaceutical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
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26
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Practical Approach for the Diagnosis and Treatment of Chronic Pruritus. J Nurse Pract 2020. [DOI: 10.1016/j.nurpra.2020.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Shenoi SD, Soman S, Munoli R, Prabhu S. Update on Pharmacotherapy in Psychodermatological Disorders. Indian Dermatol Online J 2020; 11:307-318. [PMID: 32695685 PMCID: PMC7367593 DOI: 10.4103/idoj.idoj_330_19] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Revised: 09/28/2019] [Accepted: 09/28/2019] [Indexed: 12/15/2022] Open
Abstract
Psychodermatological (PD) conditions encountered in dermatologic practice include primary psychiatric conditions such as delusions of parasitosis or secondary psychiatric conditions such as anxiety and depression due to dermatologic disease. The psychotropics include antipsychotic agents, anti-anxiety agents, antidepressants, and miscellaneous drugs such as anti convulsants. Anti psychotics are further divided into first-generation and second-generation drugs. Currently, second-generation drugs e.g., risperidone are preferred over first-generation drugs e.g., pimozide in delusional infestation owing to the side effect profile of the latter. Anti-anxiety agents include benzodiazepines used in acute anxiety and buspirone in chronic anxiety disorders. They are frequently prescribed along with antidepressants. Although dependence and necessity of tapering is a problem with benzodiazepines, delayed onset of action is a feature of buspirone. The commonly used antidepressants in dermatology include selective serotonin reuptake inhibitors (citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline), selective serotonin norepinephrine reuptake inhibitors (venlafaxine, desvenlefaxine, and duloxetine), norepinephrine dopamine reuptake inhibitors (bupropion), tricyclic antidepressants (doxepin, amitriptyline, imipramine, and clomipramine), and tetracyclic antidepressants (mirtazapine). Miscellaneous drugs include anticonvulsants such as gabapentin and pregabalin, naltrexone, and N-acetyl cysteine. The principles of PD treatment are first establish the psychiatric diagnosis, followed by initiating drug treatment. The choice of drugs is dependent on multiple factors such as side-effect profile, drug interactions, and co-morbid conditions. Usually, drugs are started at a low dose and gradually increased. A literature search was done in Pubmed, Google Scholar, and Medline databases, and articles on treatment were analyzed.
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Affiliation(s)
- Shrutakirthi D Shenoi
- Department of Dermatology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Udupi, Karnataka, India
| | - Savitha Soman
- Department of Psychiatry, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Udupi, Karnataka, India
| | - Ravindra Munoli
- Department of Psychiatry, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Udupi, Karnataka, India
| | - Smitha Prabhu
- Department of Dermatology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Udupi, Karnataka, India
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Nair D, Finkelstein FO. Pruritus as a Patient-Reported Primary Trial End Point in Hemodialysis: Evaluation and Implications. Am J Kidney Dis 2020; 76:148-151. [PMID: 32334827 DOI: 10.1053/j.ajkd.2020.01.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 01/19/2020] [Indexed: 12/22/2022]
Affiliation(s)
- Devika Nair
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt Center for Kidney Disease, Nashville, TN
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Shahriari N, Lin TC, Litman HJ, Dube B, McLean RR, Shahriari M. Characterization of real-world patients with psoriasis and without a history of depression: The Corrona Psoriasis Registry. J Am Acad Dermatol 2020; 84:1444-1447. [PMID: 32603721 DOI: 10.1016/j.jaad.2020.06.994] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 06/18/2020] [Accepted: 06/24/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Neda Shahriari
- Department of Dermatology, University of Connecticut, Farmington, Connecticut
| | | | | | | | | | - Mona Shahriari
- Department of Dermatology, Yale University, New Haven, Connecticut; Central Connecticut Dermatology, Cromwell, Connecticut.
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Golpanian RS, Yosipovitch G. Current and emerging systemic treatments targeting the neural system for chronic pruritus. Expert Opin Pharmacother 2020; 21:1629-1636. [PMID: 32515664 DOI: 10.1080/14656566.2020.1775815] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
INTRODUCTION Pruritus is a debilitating symptom that significantly affects the quality of life of patients who suffer from it. Many current and emerging systemic treatments targeting the neural system have been successful in treating itch of various underlying etiologies. AREAS COVERED A complete search of the PUBMED and Google Scholar databases was completed and literature pertinent to current and emerging systemic anti-pruritic drugs which target the neural system was compiled. The purpose of this review is to give the reader with an overview of the current and emerging systemic therapeutic options which target the neural system for chronic pruritus. The authors then provide the reader with their expert perspectives on the future of these therapies. EXPERT OPINION Exciting new anti-pruritic therapies targeting the neural system which show promise include NK-1 inhibitors, opioid receptor modulators, and drugs targeting specific itch receptors such as Mrgpr, Nav1.7, and PAR2, as well as selective GABA modulators. Future studies should be conducted in order to fully understand these exciting therapeutic options.
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Affiliation(s)
- Rachel Shireen Golpanian
- Department of Dermatology and Cutaneous Surgery, and Itch Center, University of Miami Miller School of Medicine , Miami, FL, USA
| | - Gil Yosipovitch
- Department of Dermatology and Cutaneous Surgery, and Itch Center, University of Miami Miller School of Medicine , Miami, FL, USA
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Abstract
Introduction: Treatment for chronic pruritus ranges from use of topical formulations to newer biologic agents. Targeting treatment to the underlying etiology is key in reducing the burden of disease while avoiding systemic or adverse effects.Areas covered: This review details the effective medical treatments used in various etiologies of chronic itch with a focus on the potential adverse effects and safety data available for each.Expert opinion: New drug developments in the areas of neural signaling and immune targeting show great promise for the future of chronic itch treatment. These new therapies broaden the available treatment options but also pose new considerations for safety and adverse effects.
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Affiliation(s)
- Kayla Fourzali
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery and Miami Itch Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Gil Yosipovitch
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery and Miami Itch Center, University of Miami Miller School of Medicine, Miami, FL, USA
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Andrade A, Kuah CY, Martin‐Lopez JE, Chua S, Shpadaruk V, Sanclemente G, Franco JVA. Interventions for chronic pruritus of unknown origin. Cochrane Database Syst Rev 2020; 1:CD013128. [PMID: 31981369 PMCID: PMC6984650 DOI: 10.1002/14651858.cd013128.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Pruritus is a sensation that leads to the desire to scratch; its origin is unknown in 8% to 15% of affected patients. The prevalence of chronic pruritus of unknown origin (CPUO) in individuals with generalised pruritus ranges from 3.6% to 44.5%, with highest prevalence among the elderly. When the origin of pruritus is known, its management may be straightforward if an effective treatment for the causal disease is available. Treatment of CPUO is particularly difficult due to its unknown pathophysiology. OBJECTIVES To assess the effects of interventions for CPUO in adults and children. SEARCH METHODS We searched the following up to July 2019: Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, and trials registries. We checked the reference lists of included studies for additional references to relevant trials. SELECTION CRITERIA We sought to include randomised controlled trials and quasi-randomised controlled trials that assessed interventions for CPUO, as defined in category VI ('Other pruritus of undetermined origin, or chronic pruritus of unknown origin') of the International Forum for the Study of Itch (IFSI) classification, in children and adults. Eligible interventions were non-pharmacological or topical or systemic pharmacological interventions, and eligible comparators were another active treatment, placebo, sham procedures, or no treatment or equivalent (e.g. waiting list). DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Our primary outcomes were 'Patient- or parent-reported pruritus intensity' and 'Adverse events'. Our secondary outcomes were 'Health-related quality of life', 'Sleep disturbances', 'Depression', and 'Patient satisfaction'. We used GRADE to assess the certainty of evidence. MAIN RESULTS We found there was an absence of evidence for the main interventions of interest: emollient creams, cooling lotions, topical corticosteroids, topical antidepressants, systemic antihistamines, systemic antidepressants, systemic anticonvulsants, and phototherapy. We included one study with 257 randomised (253 analysed) participants, aged 18 to 65 years; 60.6% were female. This study investigated the safety and efficacy of three different doses of oral serlopitant (5 mg, 1 mg, and 0.25 mg, once daily for six weeks) compared to placebo for severe chronic pruritus; 25 US centres participated (clinical research centres and universities). All outcomes were measured at the end of treatment (six weeks from baseline), except adverse events, which were monitored throughout. A pharmaceutical company funded this study. Fifty-five per cent of participants suffered from CPUO, and approximately 45% presented a dermatological diagnosis (atopic dermatitis/eczema 37.3%, psoriasis 6.7%, acne 3.6%, among other diagnoses). We unsuccessfully attempted to retrieve outcome data from study authors for the subgroup of participants with CPUO. Participants had pruritus for six weeks or longer. Total study duration was 10 weeks. Participants who received serlopitant 5 mg may have a greater rate of relief of patient-reported pruritus intensity as measured by the visual analogue scale (VAS; a reduction in VAS score indicates improvement) compared to placebo (126 participants, risk ratio (RR) 2.06, 95% confidence interval (CI) 1.27 to 3.35; low-certainty evidence). We are uncertain of the effects of serlopitant 5 mg compared to placebo on the following outcomes due to very low-certainty evidence: adverse events (127 participants; RR 1.48, 95% CI 0.87 to 2.50); health-related quality of life (as measured by the Dermatology Life Quality Index (DLQI); a higher score indicates greater impairment; 127 participants; mean difference (MD) -4.20, 95% CI -11.68 to 3.28); and sleep disturbances (people with insomnia measured by the Pittsburgh Sleep Symptom Questionnaire-Insomnia (PSSQ-I), a dichotomous measure; 128 participants; RR 0.49, 95% CI 0.24 to 1.01). Participants who received serlopitant 1 mg may have a greater rate of relief of patient-reported pruritus intensity as measured by VAS compared to placebo; however, the 95% CI indicates that there may also be little to no difference between groups (126 participants; RR 1.50, 95% CI 0.89 to 2.54; low-certainty evidence). We are uncertain of the effects of serlopitant 1 mg compared to placebo on the following outcomes due to very low-certainty evidence: adverse events (128 participants; RR 1.45, 95% CI 0.86 to 2.47); health-related quality of life (DLQI; 128 participants; MD -6.90, 95% CI -14.38 to 0.58); and sleep disturbances (PSSQ-I; 128 participants; RR 0.38, 95% CI 0.17 to 0.84). Participants who received serlopitant 0.25 mg may have a greater rate of relief of patient-reported pruritus intensity as measured by VAS compared to placebo; however, the 95% CI indicates that there may also be little to no difference between groups (127 participants; RR 1.66, 95% CI 1.00 to 2.77; low-certainty evidence). We are uncertain of the effects of serlopitant 0.25 mg compared to placebo on the following outcomes due to very low-certainty evidence: adverse events (127 participants; RR 1.29, 95% CI 0.75 to 2.24); health-related quality of life (DLQI; 127 participants; MD -5.70, 95% CI -13.18 to 1.78); and sleep disturbances (PSSQ-I; 127 participants; RR 0.60, 95% CI 0.31 to 1.17). The most commonly reported adverse events were somnolence, diarrhoea, headache, and nasopharyngitis, among others. Our included study did not measure depression or patient satisfaction. We downgraded the certainty of evidence for all outcomes due to indirectness (only 55% of study participants had CPUO) and imprecision. We downgraded outcomes other than patient-reported pruritus intensity a further level due to concerns regarding risk of bias in selection of the reported result and some concerns with risk of bias due to missing outcome data (sleep disturbances only). We deemed risk of bias to be generally low. AUTHORS' CONCLUSIONS We found lack of evidence to address our review question: for most of our interventions of interest, we found no eligible studies. The neurokinin 1 receptor (NK1R) antagonist serlopitant was the only intervention that we could assess. One study provided low-certainty evidence suggesting that serlopitant may reduce pruritus intensity when compared with placebo. We are uncertain of the effects of serlopitant on other outcomes, as certainty of the evidence is very low. More studies with larger sample sizes, focused on patients with CPUO, are needed. Healthcare professionals, patients, and other stakeholders may have to rely on indirect evidence related to other forms of chronic pruritus when deciding between the main interventions currently used for this condition.
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Affiliation(s)
- Andrea Andrade
- Hospital Italiano de Buenos AiresDepartment of DermatologyTte. Peron 4230Buenos AiresArgentina1199
- Instituto Universitario Hospital ItalianoArgentine Cochrane CentrePotosi 4234Buenos AiresBuenos AiresArgentinaC1199ACL
| | - Chii Yang Kuah
- King's College Hospital NHS Foundation TrustDenmark HillLondonUKSE5 9RS
| | - Juliana Esther Martin‐Lopez
- Andalusian Public Foundation for Progress and HealthDepartment of Research for Health Technology Assessment ServiceSevilleSpain
| | - Shunjie Chua
- urong East St21 Blk288A #03‐358SingaporeSingapore601288
| | - Volha Shpadaruk
- University Hospitals of LeicesterDepartment of DermatologyLeicester Royal InfirmaryOPD3 Balmoral BuildingLeicesterUKLE1 5WW
| | - Gloria Sanclemente
- Universidad de AntioquiaGrupo de Investigación Dermatológica (GRID)Carrera 25 A #1 A Sur 45, Of 2026Torre Medica El TesoroMedellínColombia
| | - Juan VA Franco
- Instituto Universitario Hospital ItalianoArgentine Cochrane CentrePotosi 4234Buenos AiresBuenos AiresArgentinaC1199ACL
- Hospital Italiano de Buenos AiresFamily and Community Medicine ServiceTte. Gral. Juan Domingo Perón 4190Buenos AiresBuenos AiresArgentinaC1199ABB
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Pruritic Primary Nonessential Cutis Verticis Gyrata. ACTAS DERMO-SIFILIOGRAFICAS 2019. [DOI: 10.1016/j.adengl.2019.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Yosipovitch G, Rosen JD, Hashimoto T. Itch: From mechanism to (novel) therapeutic approaches. J Allergy Clin Immunol 2019; 142:1375-1390. [PMID: 30409247 DOI: 10.1016/j.jaci.2018.09.005] [Citation(s) in RCA: 183] [Impact Index Per Article: 36.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 08/27/2018] [Accepted: 09/07/2018] [Indexed: 12/13/2022]
Abstract
Itch is a common sensory experience that is prevalent in patients with inflammatory skin diseases, as well as in those with systemic and neuropathic conditions. In patients with these conditions, itch is often severe and significantly affects quality of life. Itch is encoded by 2 major neuronal pathways: histaminergic (in acute itch) and nonhistaminergic (in chronic itch). In the majority of cases, crosstalk existing between keratinocytes, the immune system, and nonhistaminergic sensory nerves is responsible for the pathophysiology of chronic itch. This review provides an overview of the current understanding of the molecular, neural, and immune mechanisms of itch: beginning in the skin, proceeding to the spinal cord, and eventually ascending to the brain, where itch is processed. A growing understanding of the mechanisms of chronic itch is expanding, as is our pipeline of more targeted topical and systemic therapies. Our therapeutic armamentarium for treating chronic itch has expanded in the last 5 years, with developments of topical and systemic treatments targeting the neural and immune systems.
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Affiliation(s)
- Gil Yosipovitch
- Department of Dermatology and Cutaneous Surgery and Miami Itch Center Miller School of Medicine University of Miami, Miami, Fla.
| | - Jordan Daniel Rosen
- Department of Dermatology and Cutaneous Surgery and Miami Itch Center Miller School of Medicine University of Miami, Miami, Fla
| | - Takashi Hashimoto
- Department of Dermatology and Cutaneous Surgery and Miami Itch Center Miller School of Medicine University of Miami, Miami, Fla
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Özkaya E, Babuna Kobaner G, Yılmaz Z, Kutlay A. Doxepin in difficult‐to‐treat chronic urticaria: A retrospective, cross‐sectional study from Turkey. Dermatol Ther 2019; 32:e12993. [DOI: 10.1111/dth.12993] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 05/02/2019] [Accepted: 06/04/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Esen Özkaya
- Department of Dermatology and Venereology, Istanbul Faculty of MedicineIstanbul University Istanbul Turkey
| | - Goncagül Babuna Kobaner
- Department of Dermatology and Venereology, Istanbul Faculty of MedicineIstanbul University Istanbul Turkey
| | - Zeynep Yılmaz
- Department of Dermatology and Venereology, Istanbul Faculty of MedicineIstanbul University Istanbul Turkey
| | - Armağan Kutlay
- Department of Dermatology and Venereology, Istanbul Faculty of MedicineIstanbul University Istanbul Turkey
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Schmid Y, Navarini A, Thomas ZRM, Pfleiderer B, Krähenbühl S, Mueller SM. Sex differences in the pharmacology of itch therapies-a narrative review. Curr Opin Pharmacol 2019; 46:122-142. [PMID: 31299512 DOI: 10.1016/j.coph.2019.05.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 05/17/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Chronic itch is the most common skin-related condition, associated with a high psychosocial and economic burden. In recent years, increasing evidence of sex differences in the perception, clinical presentation and treatment requirements of itch points towards potential benefits when using sex-adapted therapies. It is well-known that body composition, absorption, metabolism, elimination and adverse drug reactions (ADRs) differ between sexes, but only little is known about the impact of sex in the pharmacology of itch treatments, which could help to rationalise sex-adapted treatment strategies. AIM To evaluate and review sex effects in the pharmacokinetics and /-dynamics of drugs used to treat itch. METHODS In this narrative review we performed a PubMed and MEDLINE (Ovid) search using the terms (itch OR pruritus) AND (gender OR sex) AND (drug OR medication OR pharmacokinetics OR pharmacodynamics). Additional searches were performed for the topical and systemic drugs recommended by the European Guideline on Chronic Pruritus. RESULTS We found numerous reports with variable levels of evidence of sex effects with respect to the pharmacokinetics and/or pharmacodynamics of 14 drug classes used for the treatment of itch, including a total of 19 systemic and 3 topical drugs. Women seem to present higher plasma levels of several drugs used in itch treatment, including tri- and tetracyclic antidepressants (e.g. doxepin, amitriptyline, mirtazapine), serotonin reuptake inhibitors (e.g. paroxetine, sertraline, fluoxetine), immunosuppressive drugs (e.g. cyclosporine, mycophenolate mofetil), serotonin receptor antagonists (e.g. ondansetron) and betablockers (e.g. propranolol). Adverse drug reactions (ADRs) were generally more common in women. Being female was reported to be an independent risk factor for QTc-prolongation associated with antihistamines and tetracyclic antidepressants. Additionally, women seem to be more prone to sedative effects of antihistamines, and to suffer from a higher frequency as well as severity of side effects with systemic calcineurin inhibitors, opioid agonists, and opioid antagonists. Women were also sensitised more often to topically applied drugs. Of note, apart from only one experimental study with capsaicin, none of these reports were designed specifically to assess the effect of sex (and gender) in the treatment of itch. DISCUSSION/CONCLUSION Our review supports previous reports that sex is of importance in the pharmacokinetics and /-dynamics of several drugs used to treat itch although those drugs were mostly evaluated for non-itch indications. However, the results are limited by methodological limitations evident in most studies such as underrepresentation of women in clinical trials. This emphasises the need to study the impact of sex (and gender) in future itch trials to yield better outcomes and prevent ADRs in both sexes.
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Affiliation(s)
- Yasmin Schmid
- Clinical Pharmacology & Toxicology, University Hospital Basel, Switzerland
| | | | | | - Bettina Pfleiderer
- Department of Clinical Radiology, University Hospital Münster and Medical Faculty, University of Münster, Germany; Competence Center Chronic Pruritus (KCP), University of Muenster, Germany
| | - Stephan Krähenbühl
- Clinical Pharmacology & Toxicology, University Hospital Basel, Switzerland
| | - Simon M Mueller
- Department of Dermatology, University Hospital Basel, Switzerland.
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Morphological and functional properties distinguish the substance P and gastrin-releasing peptide subsets of excitatory interneuron in the spinal cord dorsal horn. Pain 2019; 160:442-462. [PMID: 30247267 PMCID: PMC6330098 DOI: 10.1097/j.pain.0000000000001406] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Supplemental Digital Content is Available in the Text. Superficial dorsal horn excitatory interneuron populations, as identified by neuropeptide expression, differ in morphological, electrophysiological, and pharmacological properties. This has implications for understanding pain processing. Excitatory interneurons account for the majority of neurons in the superficial dorsal horn, but despite their presumed contribution to pain and itch, there is still limited information about their organisation and function. We recently identified 2 populations of excitatory interneuron defined by expression of gastrin-releasing peptide (GRP) or substance P (SP). Here, we demonstrate that these cells show major differences in their morphological, electrophysiological, and pharmacological properties. Based on their somatodendritic morphology and firing patterns, we propose that the SP cells correspond to radial cells, which generally show delayed firing. By contrast, most GRP cells show transient or single-spike firing, and many are likely to correspond to the so-called transient central cells. Unlike the SP cells, few of the GRP cells had long propriospinal projections, suggesting that they are involved primarily in local processing. The 2 populations also differed in responses to neuromodulators, with most SP cells, but few GRP cells, responding to noradrenaline and 5-HT; the converse was true for responses to the μ-opioid agonist DAMGO. Although a recent study suggested that GRP cells are innervated by nociceptors and are strongly activated by noxious stimuli, we found that very few GRP cells receive direct synaptic input from TRPV1-expressing afferents, and that they seldom phosphorylate extracellular signal–regulated kinases in response to noxious stimuli. These findings indicate that the SP and GRP cells differentially process somatosensory information.
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Miyahara Y, Funahashi H, Naono-Nakayama R, Haruta-Tsukamoto A, Nishimori T, Ishida Y. Role of serotonin and noradrenaline in the acute itch processing in mice. Eur J Pharmacol 2019; 850:118-125. [PMID: 30763572 DOI: 10.1016/j.ejphar.2019.02.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Revised: 01/20/2019] [Accepted: 02/11/2019] [Indexed: 12/22/2022]
Abstract
The contribution of serotonin and noradrenaline to the modulation of pruriceptive processing was evaluated by administrating antidepressants or noradrenaline reuptake inhibitors. The pretreatment with milnacipran, a serotonin and noradrenaline reuptake inhibitor, and mirtazapine, a noradrenergic and specific serotonergic antidepressant, attenuated the induction of scratching behavior by chloroquine, a representative pruritogen, indicating the involvement of serotonin and/or noradrenaline in the modulation of pruriceptive processing. By contrast, the single administration of noradrenaline reuptake inhibitor such as atomoxetine and nisoxetine or serotonin reuptake inhibitor such as fluvoxamine and escitalopram had little effect on chloroquine-induced scratching, whereas the induction of scratching behavior by chloroquine was significantly ameliorated by co-administration of serotonin reuptake inhibitors and noradrenaline reuptake inhibitors. These results indicate that the simultaneous increases of serotonin and noradrenaline elicit the attenuating effect on pruriceptive processing induced by acute itch, and may also play a crucial role in the descending itch inhibitory system.
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Affiliation(s)
- Yu Miyahara
- Department of Psychiatry, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki city, Miyazaki 889-1692, Japan
| | - Hideki Funahashi
- Department of Psychiatry, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki city, Miyazaki 889-1692, Japan
| | - Rumi Naono-Nakayama
- Division of Anatomy and Cell Biology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, 1-15-1 Fukumuro, Miyagino-ku, Sendai 983-8536, Japan
| | - Ayaka Haruta-Tsukamoto
- Department of Psychiatry, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki city, Miyazaki 889-1692, Japan
| | - Toshikazu Nishimori
- Department of Psychiatry, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki city, Miyazaki 889-1692, Japan
| | - Yasushi Ishida
- Department of Psychiatry, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki city, Miyazaki 889-1692, Japan.
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Tomás-Velázquez A, Moreno-Artero E, Abengózar M, Palacios-Álvarez I. Pruritic Primary Nonessential Cutis Verticis Gyrata. ACTAS DERMO-SIFILIOGRAFICAS 2019; 110:702-704. [PMID: 30871719 DOI: 10.1016/j.ad.2018.03.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Revised: 03/19/2018] [Accepted: 03/24/2018] [Indexed: 11/26/2022] Open
Affiliation(s)
- A Tomás-Velázquez
- Departamento de Dermatología Médico-Quirúrgica y Venereología, Clínica Universidad de Navarra, Pamplona, Navarra, España.
| | - E Moreno-Artero
- Departamento de Dermatología Médico-Quirúrgica y Venereología, Clínica Universidad de Navarra, Pamplona, Navarra, España
| | - M Abengózar
- Departamento de Anatomía Patológica, Clínica Universidad de Navarra, Pamplona, Navarra, España
| | - I Palacios-Álvarez
- Departamento de Dermatología Médico-Quirúrgica y Venereología, Clínica Universidad de Navarra, Pamplona, Navarra, España
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Fowler E, Yosipovitch G. Chronic itch management: therapies beyond those targeting the immune system. Ann Allergy Asthma Immunol 2019; 123:158-165. [PMID: 30685562 DOI: 10.1016/j.anai.2019.01.016] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 01/16/2019] [Accepted: 01/17/2019] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Chronic itch can be a debilitating, unrelenting symptom. Over the years, we have advanced our knowledge about immune-mediated itch (eg, atopic dermatitis) and have developed several treatments targeting these immune pathways. Chronic itch that is noninflammatory in nature is more elusive. However, we have gained some understanding of the neural component mediating itch and have made progress in treating this challenging symptom. DATA SOURCES A comprehensive literature search was conducted, and data and literature were reviewed on the topics of chronic itch, its pathophysiology, and nonimmunological treatments for chronic itch that work on the nerves. STUDY SELECTIONS Basic science papers, review articles, case reports, and clinical trial data were considered. RESULTS A variety of topical and systemic therapies targeting the nerves have shown effectiveness in treating patients with chronic itch of different types. CONCLUSION Treating chronic itch may be challenging, but an arsenal of treatments are available and many are on the horizon as we expand our knowledge of mechanisms of itch and the neural receptors involved.
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Affiliation(s)
- Emilie Fowler
- Department of Dermatology and Cutaneous Surgery, and Miami Itch Center, University of Miami Miller School of Medicine, Florida
| | - Gil Yosipovitch
- Department of Dermatology and Cutaneous Surgery, and Miami Itch Center, University of Miami Miller School of Medicine, Florida.
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Dermatology today and tomorrow: from symptom control to targeted therapy. J Eur Acad Dermatol Venereol 2018; 33 Suppl 1:3-36. [DOI: 10.1111/jdv.15335] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 11/05/2018] [Indexed: 02/07/2023]
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Manway M, Blackburn S, Barr J, Hull E, Averitte R, Ahn Y. Effects of acupuncture on chronic idiopathic pruritus: an uncontrolled pilot study evaluating inflammatory changes with treatment. JOURNAL OF COMPLEMENTARY & INTEGRATIVE MEDICINE 2018; 16:/j/jcim.ahead-of-print/jcim-2018-0021/jcim-2018-0021.xml. [PMID: 30391935 DOI: 10.1515/jcim-2018-0021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Accepted: 10/04/2018] [Indexed: 11/15/2022]
Abstract
Background Conduct a pilot study addressing the efficacy of acupuncture in the treatment of chronic idiopathic pruritus to aid in the design of a larger clinical trial. Routine laboratory tests to assess systemic inflammation in addition to subjective patient surveys were performed provide documentation of efficacy of treatment. Methods Patients with chronic pruritus who did not respond to standard treatment were recruited to participate. After exclusion of systemic or known reversible causes, each patient received up to 10 treatments which were performed approximately one week apart. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were measured before and after a series of acupuncture treatments to evaluate levels of inflammation and pre- and post-treatment surveys were conducted to evaluate levels of perceived itch. Results Only one of the ten patients in this study possessed an elevation of ESR before treatment. This patient's ESR value returned to normal range after treatment and this participant reported subjective relief of her pruritus. Conclusions Future studies on the efficacy of acupuncture in the treatment of chronic idiopathic pruritus should focus on those patients with measurable levels of inflammation at the initiation of the study or utilize alternative and more comprehensive values to monitor disease response.
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Affiliation(s)
- Mitchell Manway
- Affiliated Dermatology & Affiliated Laboratories, Midwestern University Osteopathic Postdoctoral Training Institute, Scottsdale, AZ, USA
| | - Stephanie Blackburn
- Affiliated Dermatology & Affiliated Laboratories, Midwestern University Osteopathic Postdoctoral Training Institute, Scottsdale, AZ, USA
| | - Jason Barr
- Affiliated Dermatology & Affiliated Laboratories, Midwestern University Osteopathic Postdoctoral Training Institute, Scottsdale, AZ, USA
| | - Elizabeth Hull
- Biomedical Sciences Program, College of Graduate Studies, Midwestern University, 19555 N 59Avenue, Glendale, AZ 85308, USA
| | - Richard Averitte
- Affiliated Dermatology & Affiliated Laboratories, Midwestern University Osteopathic Postdoctoral Training Institute, Scottsdale, AZ, USA
| | - Yang Ahn
- Medical Acupuncture, Ahn Clinic, Scottsdale, AZ, USA
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Rosen JD, Fostini AC, Yosipovitch G. Diagnosis and Management of Neuropathic Itch. Dermatol Clin 2018; 36:213-224. [DOI: 10.1016/j.det.2018.02.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Pereira MP, Ständer S. Therapy for pruritus in the elderly: a review of treatment developments. Expert Opin Pharmacother 2018; 19:443-450. [DOI: 10.1080/14656566.2018.1444752] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Manuel P. Pereira
- 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
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