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Poddar S, Mondal H, Podder I. Aetiology, pathogenesis and management of neuropathic itch: A narrative review with recent updates. Indian J Dermatol Venereol Leprol 2024; 90:5-18. [PMID: 37317726 DOI: 10.25259/ijdvl_846_2022] [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: 09/24/2022] [Accepted: 02/17/2023] [Indexed: 06/16/2023]
Abstract
Neuropathic itch is a relatively common yet under-reported cause of systemic pruritus. It is a debilitating condition often associated with pain, which impairs the patient's quality of life. Although much literature exists about renal and hepatic pruritus, there is a dearth of information and awareness about neuropathic itch. The pathogenesis of neuropathic itch is complex and can result from an insult at any point along the itch pathway, ranging from the peripheral receptors and nerves until the brain. There are several causes of neuropathic itch, many of which do not produce any skin lesions and are thus, often missed. A detailed history and clinical examination are necessary for the diagnosis, while laboratory and radiologic investigations may be needed in select cases. Several therapeutic strategies currently exist involving both non-pharmacological and pharmacological measures, the latter including topical, systemic, and invasive options. Further research is ongoing to clarify its pathogenesis and to design newer targeted therapies with minimal adverse effects. This narrative review highlights the current understanding of this condition, focusing on its causes, pathogenesis, diagnosis, and management, along with newer investigational drugs.
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Affiliation(s)
- Shreya Poddar
- Department of Dermatology, Asansol District Hospital, Asansol, West Bengal, India
| | - Himel Mondal
- Department of Physiology, All India Institute of Medical Sciences (AIIMS), Deoghar, Jharkhand, India
| | - Indrashis Podder
- Department of Dermatology, College of Medicine & Sagore Dutta Hospital, Kolkata, West Bengal, India
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2
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Mineroff J, Uwakwe LN, Mojeski J, Jagdeo J. Using botulinum toxin A to treat postherpetic itch. Arch Dermatol Res 2023; 315:2971-2972. [PMID: 37747568 DOI: 10.1007/s00403-023-02726-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 08/16/2023] [Accepted: 09/06/2023] [Indexed: 09/26/2023]
Affiliation(s)
- Jessica Mineroff
- Department of Dermatology, State University of New York, Downstate Health Sciences University, Brooklyn, NY, USA
| | - Laura N Uwakwe
- Department of Dermatology, State University of New York, Downstate Health Sciences University, Brooklyn, NY, USA
- Dermatology Service, Veterans Affairs New York Harbor Healthcare System-Brooklyn Campus, Brooklyn, NY, USA
| | - Jacob Mojeski
- Department of Dermatology, State University of New York, Downstate Health Sciences University, Brooklyn, NY, USA
- Dermatology Service, Veterans Affairs New York Harbor Healthcare System-Brooklyn Campus, Brooklyn, NY, USA
| | - Jared Jagdeo
- Department of Dermatology, State University of New York, Downstate Health Sciences University, Brooklyn, NY, USA.
- Dermatology Service, Veterans Affairs New York Harbor Healthcare System-Brooklyn Campus, Brooklyn, NY, USA.
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3
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Cao X, Jiao B, Wen D, Duan G, Zhang M, Zhang C, Wu G, Zhang X. Evaluation of the correlation of dorsal root ganglia and spinal nerves with clinical symptoms in patients with postherpetic neuralgia using magnetic resonance neurography. PeerJ 2023; 11:e15998. [PMID: 37667753 PMCID: PMC10475274 DOI: 10.7717/peerj.15998] [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: 04/28/2023] [Accepted: 08/08/2023] [Indexed: 09/06/2023] Open
Abstract
Purpose To assess changes of dorsal root ganglia (DRG) and spinal nerves in patients with postherpetic neuralgia (PHN), and investigate the correlation between DRG morphology and clinical symptoms in PHN patients using magnetic resonance neurography (MRN). Methods In this case-control study, forty-nine lesioned DRG in 30 patients and 49 normal DRG in 30 well-matched (age, sex, height, weight) healthy controls were assessed. Clinical symptoms of patients (pain, allodynia, itching, and numbness) were assessed. MRN features (DRG volume (VDRG), the largest diameter (Dmax) of spinal nerves, signal intensity of DRG and spinal nerves (M-value)) were measured in all participants. Multilinear regression analysis was used to evaluate the relationship between the DRG morphology and clinical symptoms in patients. Results The volume and relative M-value of lesioned DRG in patients were significantly higher than those on the same side of healthy controls (p = 0.013, p < 0.001, respectively). The mean Dmax and relative M-value of spinal nerves on the lesioned side were significantly higher than those on the contralateral and same side of healthy controls (p < 0.0001, p = 0.0001, p = 0.0011, p = 0.0053, respectively). No difference was found between the mean VDRG of the lesioned and contralateral sides. Multiple linear regression analysis revealed that disease duration was independent risk factor for the maximum rate of VDRG differences (p = 0.013). Conclusions DRG and spinal nerves on the lesioned side are swollen during PHN. Disease duration is an independent risk factor for morphological differences in the lesioned DRG of PHN patients. This study provides important guidance for individualized treatments of PHN.
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Affiliation(s)
- Xueqin Cao
- Department of Anesthesiology, Hubei Key Laboratory of Geriatric Anesthesia and Perioperative Brain Health, and Wuhan Clinical Research Center for Geriatric Anesthesia, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Bo Jiao
- Department of Anesthesiology, Hubei Key Laboratory of Geriatric Anesthesia and Perioperative Brain Health, and Wuhan Clinical Research Center for Geriatric Anesthesia, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Donglin Wen
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Guangyou Duan
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Wuhan, Hubei, China
| | - Mi Zhang
- Department of Anesthesiology, Zhongnan Hospital, Wuhan University, Wuhan, Hubei, China
| | - Caixia Zhang
- Department of Anesthesiology, Hubei Key Laboratory of Geriatric Anesthesia and Perioperative Brain Health, and Wuhan Clinical Research Center for Geriatric Anesthesia, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Gang Wu
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xianwei Zhang
- Department of Anesthesiology, Hubei Key Laboratory of Geriatric Anesthesia and Perioperative Brain Health, and Wuhan Clinical Research Center for Geriatric Anesthesia, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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4
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Obara S, Oishi R, Nakano Y, Kurosawa S, Inoue S. Marked improvement in severe postherpetic itching following an epidural block: a case report. JA Clin Rep 2023; 9:24. [PMID: 37184726 DOI: 10.1186/s40981-023-00618-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 05/04/2023] [Accepted: 05/06/2023] [Indexed: 05/16/2023] Open
Affiliation(s)
- Shinju Obara
- Department of Anesthesiology, Fukushima Medical University, 1 Hikarigaoka, Fukushima, Fukushima, 960-1295, Japan.
- Center for Pain Management, Fukushima Medical University Hospital, 1 Hikarigaoka, Fukushima, Fukushima, 960-1295, Japan.
| | - Rieko Oishi
- Department of Anesthesiology, Fukushima Medical University, 1 Hikarigaoka, Fukushima, Fukushima, 960-1295, Japan
| | - Yuko Nakano
- Department of Anesthesiology, Fukushima Medical University, 1 Hikarigaoka, Fukushima, Fukushima, 960-1295, Japan
| | - Shin Kurosawa
- Department of Anesthesiology, Fukushima Medical University, 1 Hikarigaoka, Fukushima, Fukushima, 960-1295, Japan
| | - Satoki Inoue
- Department of Anesthesiology, Fukushima Medical University, 1 Hikarigaoka, Fukushima, Fukushima, 960-1295, Japan
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5
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Cronin SJF, Tejada MA, Song R, Laval K, Cikes D, Ji M, Brai A, Stadlmann J, Novatchikova M, Perlot T, Ali OH, Botta L, Decker T, Lazovic J, Hagelkruys A, Enquist L, Rao S, Koyuncu OO, Penninger JM. Pseudorabies virus hijacks DDX3X, initiating an addictive "mad itch" and immune suppression, to facilitate viral spread. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.05.09.539956. [PMID: 37214906 PMCID: PMC10197578 DOI: 10.1101/2023.05.09.539956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Infections with defined Herpesviruses, such as Pseudorabies virus (PRV) and Varicella zoster virus (VZV) can cause neuropathic itch, referred to as "mad itch" in multiple species. The underlying mechanisms involved in neuropathic "mad itch" are poorly understood. Here, we show that PRV infections hijack the RNA helicase DDX3X in sensory neurons to facilitate anterograde transport of the virus along axons. PRV induces re-localization of DDX3X from the cell body to the axons which ultimately leads to death of the infected sensory neurons. Inducible genetic ablation of Ddx3x in sensory neurons results in neuronal death and "mad itch" in mice. This neuropathic "mad itch" is propagated through activation of the opioid system making the animals "addicted to itch". Moreover, we show that PRV co-opts and diverts T cell development in the thymus via a sensory neuron-IL-6-hypothalamus-corticosterone stress pathway. Our data reveal how PRV, through regulation of DDX3X in sensory neurons, travels along axons and triggers neuropathic itch and immune deviations to initiate pathophysiological programs which facilitate its spread to enhance infectivity.
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Affiliation(s)
- Shane J F Cronin
- Institute of Molecular Biotechnology Austria (IMBA), Dr. Bohrgasse 3, A-1030 Vienna, Austria
| | - Miguel A Tejada
- Institute of Molecular Biotechnology Austria (IMBA), Dr. Bohrgasse 3, A-1030 Vienna, Austria
| | - Ren Song
- Department of Molecular Biology, Princeton University, Princeton, New Jersey, USA
| | - Kathlyn Laval
- Department of Molecular Biology, Princeton University, Princeton, New Jersey, USA
- Department of Translational Physiology, Infectiology and Public Health, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - Domagoj Cikes
- Institute of Molecular Biotechnology Austria (IMBA), Dr. Bohrgasse 3, A-1030 Vienna, Austria
| | - Ming Ji
- Institute of Materia Medica, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Annalaura Brai
- Department of Biotechnology, Chemistry and Pharmacy, University of Siena, I-53100 Siena, Italy
| | - Johannes Stadlmann
- Institute of Molecular Biotechnology Austria (IMBA), Dr. Bohrgasse 3, A-1030 Vienna, Austria
| | - Maria Novatchikova
- Institute of Molecular Biotechnology Austria (IMBA), Dr. Bohrgasse 3, A-1030 Vienna, Austria
| | - Thomas Perlot
- Institute of Molecular Biotechnology Austria (IMBA), Dr. Bohrgasse 3, A-1030 Vienna, Austria
| | - Omar Hasan Ali
- Department of Medical Genetics, Life Sciences Institute, University of British Columbia, Vancouver, Canada
- Institute of Immunobiology, Cantonal Hospital St. Gallen, Rorschacher Strasse 95, 9007 St. Gallen, Switzerland
- Department of Dermatology, University of Zurich, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
| | - Lorenzo Botta
- Department of Biotechnology, Chemistry and Pharmacy, University of Siena, I-53100 Siena, Italy
| | - Thomas Decker
- Max F. Perutz Laboratories, Department of Microbiology, Immunobiology and Genetics, University of Vienna, Vienna Biocenter, Vienna, Austria
| | - Jelena Lazovic
- Institute of Molecular Biotechnology Austria (IMBA), Dr. Bohrgasse 3, A-1030 Vienna, Austria
| | - Astrid Hagelkruys
- Institute of Molecular Biotechnology Austria (IMBA), Dr. Bohrgasse 3, A-1030 Vienna, Austria
| | - Lynn Enquist
- Department of Molecular Biology, Princeton University, Princeton, New Jersey, USA
| | - Shuan Rao
- Department of Thoracic Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Orkide O Koyuncu
- Department of Molecular Biology, Princeton University, Princeton, New Jersey, USA
- Department of Microbiology and Molecular Genetics, School of Medicine, University of California, Irvine, Irvine, CA 92697-4025, USA
| | - Josef M Penninger
- Institute of Molecular Biotechnology Austria (IMBA), Dr. Bohrgasse 3, A-1030 Vienna, Austria
- Department of Medical Genetics, Life Sciences Institute, University of British Columbia, Vancouver, Canada
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6
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Chen O, He Q, Han Q, Furutani K, Gu Y, Olexa M, Ji RR. Mechanisms and treatments of neuropathic itch in a mouse model of lymphoma. J Clin Invest 2023; 133:160807. [PMID: 36520531 PMCID: PMC9927942 DOI: 10.1172/jci160807] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022] Open
Abstract
Our understanding of neuropathic itch is limited due to a lack of relevant animal models. Patients with cutaneous T cell lymphoma (CTCL) experience severe itching. Here, we characterize a mouse model of chronic itch with remarkable lymphoma growth, immune cell accumulation, and persistent pruritus. Intradermal CTCL inoculation produced time-dependent changes in nerve innervations in lymphoma-bearing skin. In the early phase (20 days), CTCL caused hyperinnervations in the epidermis. However, chronic itch was associated with loss of epidermal nerve fibers in the late phases (40 and 60 days). CTCL was also characterized by marked nerve innervations in mouse lymphoma. Blockade of C-fibers reduced pruritus at early and late phases, whereas blockade of A-fibers only suppressed late-phase itch. Intrathecal (i.t.) gabapentin injection reduced late-phase, but not early-phase, pruritus. IL-31 was upregulated in mouse lymphoma, whereas its receptor Il31ra was persistently upregulated in Trpv1-expressing sensory neurons in mice with CTCL. Intratumoral anti-IL-31 treatment effectively suppressed CTCL-induced scratching and alloknesis (mechanical itch). Finally, i.t. administration of a TLR4 antagonist attenuated pruritus in early and late phases and in both sexes. Collectively, we have established a mouse model of neuropathic and cancer itch with relevance to human disease. Our findings also suggest distinct mechanisms underlying acute, chronic, and neuropathic itch.
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Affiliation(s)
- Ouyang Chen
- Center for Translational Pain Medicine, Department of Anesthesiology,,Department of Cell Biology, and
| | - Qianru He
- Center for Translational Pain Medicine, Department of Anesthesiology
| | - Qingjian Han
- Center for Translational Pain Medicine, Department of Anesthesiology
| | - Kenta Furutani
- Center for Translational Pain Medicine, Department of Anesthesiology
| | - Yun Gu
- Center for Translational Pain Medicine, Department of Anesthesiology
| | - Madelynne Olexa
- Center for Translational Pain Medicine, Department of Anesthesiology
| | - Ru-Rong Ji
- Center for Translational Pain Medicine, Department of Anesthesiology,,Department of Cell Biology, and,Department of Neurobiology, Duke University Medical Center, Durham, North Carolina, USA
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7
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Baka P, Birklein F. [Neuropathic pruritus-Evidence-based treatment recommendations]. DER NERVENARZT 2023; 94:136-141. [PMID: 35951052 PMCID: PMC9898430 DOI: 10.1007/s00115-022-01369-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 07/11/2022] [Indexed: 02/06/2023]
Abstract
Neuropathic pruritus is a previously neglected symptom of a wide range of neurological diseases. Peripheral nerve or root compression syndromes, space-occupying lesions of the central nervous system, chronic inflammatory neurological diseases and polyneuropathy can cause neuropathic pruritus. Even when the identification of the underlying neurological disease is successful, a direct causal treatment is not always possible, hence an effective symptomatic treatment remains the only therapeutic option. The purpose of this review article is to present the current literature on various therapeutic agents and options in the treatment of neuropathic pruritus.
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Affiliation(s)
- Panoraia Baka
- Klinik für Neurologie, Universitätsmedizin Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland.
| | - Frank Birklein
- Klinik für Neurologie, Universitätsmedizin Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland
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8
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A Guide to Preclinical Models of Zoster-Associated Pain and Postherpetic Neuralgia. Curr Top Microbiol Immunol 2022; 438:189-221. [PMID: 34524508 DOI: 10.1007/82_2021_240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Reactivation of latent varicella-zoster virus (VZV) causes herpes zoster (HZ), which is commonly accompanied by acute pain and pruritus over the time course of a zosteriform rash. Although the rash and associated pain are self-limiting, a considerable fraction of HZ cases will subsequently develop debilitating chronic pain states termed postherpetic neuralgia (PHN). How VZV causes acute pain and the mechanisms underlying the transition to PHN are far from clear. The human-specific nature of VZV has made in vivo modeling of pain following reactivation difficult to study because no single animal can reproduce reactivated VZV disease as observed in the clinic. Investigations of VZV pathogenesis following primary infection have benefited greatly from human tissues harbored in immune-deficient mice, but modeling of acute and chronic pain requires an intact nervous system with the capability of transmitting ascending and descending sensory signals. Several groups have found that subcutaneous VZV inoculation of the rat induces prolonged and measurable changes in nociceptive behavior, indicating sensitivity that partially mimics the development of mechanical allodynia and thermal hyperalgesia seen in HZ and PHN patients. Although it is not a model of reactivation, the rat is beginning to inform how VZV infection can evoke a pain response and induce long-lasting alterations to nociception. In this review, we will summarize the rat pain models from a practical perspective and discuss avenues that have opened for testing of novel treatments for both zoster-associated pain and chronic PHN conditions, which remain in critical need of effective therapies.
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9
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Park C, John H, Lee J, Hong S, Kim M, Park S, Kim JH. The relative frequency of pruritus in postherpetic neuralgia patients presenting to the pain clinic and associative factors. Medicine (Baltimore) 2022; 101:e30208. [PMID: 36107606 PMCID: PMC9439806 DOI: 10.1097/md.0000000000030208] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Postherpetic neuralgia (PHN) is the most common complication of herpes zoster, whereas postherpetic pruritus (PHP) a rare one. Although PHN has been extensively studied, few studies have investigated PHP. The purpose of this study was to investigate PHP incidence and associated factors in patients with PHN. This was a retrospective study of patients with PHN. A total of 645 patients were included. This study conducted in a single university hospital. Data included age, sex, height, weight, pain score, PHN site, medications, nerve blocks, and pulsed radiofrequency treatment. Data also included PHP onset and duration among those with PHP. We divided patients into 2 groups: the control group (group C), comprising those without PHP, and pruritus group (group P), comprising those with PHP. The correlation of PHP with other factors was analyzed. Of 207 patients, 58 were in group P whereas 149 in group C. The mean onset time and duration of PHP were 96.5 and 278.6 days, respectively. Pain scores were lower in group P than in group C after 3 and 4 months following vesicle formation. Patients with PHN in the trigeminal nerve had a higher incidence of PHP compared to those with PHN in others. Twenty-eight percent of patients with PHN developed PHP. At 3 and 4 months after vesicle formation, patients with PHP had greater pain improvement compared to those without. Patients with PHN in the trigeminal nerve also had a higher incidence of PHP compared to others.
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Affiliation(s)
- Cheolhwan Park
- Department of Anesthesiology and Pain Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Hyunji John
- Department of Anesthesiology and Pain Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Jaemoon Lee
- Department of Anesthesiology and Pain Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Seungwan Hong
- Department of Anesthesiology and Pain Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Minjung Kim
- Department of Anesthesiology and Pain Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Sangtae Park
- Department of Anesthesiology and Pain Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Jae Hun Kim
- Department of Anesthesiology and Pain Medicine, Konkuk University School of Medicine, Seoul, Korea
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10
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Weng HJ, Pham QTT, Chang CW, Tsai TF. Druggable Targets and Compounds with Both Antinociceptive and Antipruritic Effects. Pharmaceuticals (Basel) 2022; 15:ph15070892. [PMID: 35890193 PMCID: PMC9318852 DOI: 10.3390/ph15070892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 07/07/2022] [Accepted: 07/15/2022] [Indexed: 12/10/2022] Open
Abstract
Pain and itch are both important manifestations of various disorders, such as herpes zoster, atopic dermatitis, and psoriasis. Growing evidence suggests that both sensations have shared mediators, overlapping neural circuitry, and similarities in sensitization processes. In fact, pain and itch coexist in some disorders. Determining pharmaceutical agents and targets for treating pain and itch concurrently is of scientific and clinical relevance. Here we review the neurobiology of pain and itch and discuss the pharmaceutical targets as well as novel compounds effective for the concurrent treatment of these sensations.
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Affiliation(s)
- Hao-Jui Weng
- Department of Dermatology, Taipei Medical University-Shuang Ho Hospital, New Taipei City 23561, Taiwan;
- Department of Dermatology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan;
- International Ph.D. Program for Cell Therapy and Regeneration Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan;
| | - Quoc Thao Trang Pham
- International Ph.D. Program for Cell Therapy and Regeneration Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan;
- Department of Dermatology, Faculty of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City 70000, Vietnam
| | - Chia-Wei Chang
- Department of Dermatology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan;
| | - Tsen-Fang Tsai
- Department of Dermatology, National Taiwan University Hospital, Taipei 100225, Taiwan
- Correspondence:
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11
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Ingrasci G, Arbrouk M, Haitz K, Kirsner R, Yosipovitch G. A protracted, postherpetic neuralgic ulcer treated with risperidone and intranasal butorphanol. JAAD Case Rep 2021; 15:7-10. [PMID: 34381859 PMCID: PMC8340051 DOI: 10.1016/j.jdcr.2021.06.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Giuseppe Ingrasci
- Correspondence to: Giuseppe Ingrasci, BS, Department of Dermatology and Cutaneous Surgery, University of Miami, 1600 NW 10th Ave RMSB Building 2067B, Miami, FL 33131.
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12
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Raef HS, Elmariah SB. Vulvar Pruritus: A Review of Clinical Associations, Pathophysiology and Therapeutic Management. Front Med (Lausanne) 2021; 8:649402. [PMID: 33898486 PMCID: PMC8058221 DOI: 10.3389/fmed.2021.649402] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 03/12/2021] [Indexed: 01/08/2023] Open
Abstract
Vulvar pruritus is an unpleasant sensation and frequent symptom associated with many dermatologic conditions, including infectious, inflammatory and neoplastic dermatoses affecting the female genitalia. It can lead to serious impairment of quality of life, impacting sexual function, relationships, sleep and self-esteem. In this review, common conditions associated with vulvar itch are discussed including atopic and contact dermatitis, lichen sclerosus, psoriasis and infectious vulvovaginitis. We review the potential physiologic, environmental and infectious factors that contribute to the development of vulvar itch and emphasize the importance of addressing their complex interplay when managing this disruptive and challenging symptom.
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Affiliation(s)
- Haya S Raef
- Tufts University School of Medicine, Boston, MA, United States.,Massachusetts General Hospital, Boston, MA, United States
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13
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Patnaik S, Imms JB, Varadi G. The neuropathic itch: Don't scratch your head too hard! Clin Case Rep 2021; 9:914-916. [PMID: 33598271 PMCID: PMC7869385 DOI: 10.1002/ccr3.3688] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 12/04/2020] [Indexed: 11/30/2022] Open
Abstract
Postherpetic complications can sometimes result in significant debility. A multidisciplinary approach is crucial in deciding the appropriate treatment strategy in these patients.
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Affiliation(s)
- Soumya Patnaik
- Department of MedicineEinstein Medical CenterPhiladelphiaPAUSA
| | - John Brady Imms
- Department of MedicineEinstein Medical CenterPhiladelphiaPAUSA
| | - Gabor Varadi
- Division of HematooncologyEinstein Medical CenterPhiladelphiaPAUSA
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14
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Meixiong J, Dong X, Weng HJ. Neuropathic Itch. Cells 2020; 9:cells9102263. [PMID: 33050211 PMCID: PMC7601786 DOI: 10.3390/cells9102263] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 10/07/2020] [Accepted: 10/08/2020] [Indexed: 12/12/2022] Open
Abstract
Neurologic insults as varied as inflammation, stroke, and fibromyalgia elicit neuropathic pain and itch. Noxious sensation results when aberrantly increased afferent signaling reaches percept-forming cortical neurons and can occur due to increased sensory signaling, decreased inhibitory signaling, or a combination of both processes. To treat these symptoms, detailed knowledge of sensory transmission, from innervated end organ to cortex, is required. Molecular, genetic, and behavioral dissection of itch in animals and patients has improved understanding of the receptors, cells, and circuits involved. In this review, we will discuss neuropathic itch with a focus on the itch-specific circuit.
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Affiliation(s)
- James Meixiong
- Solomon H. Snyder Department of Neuroscience and Medical Scientist Training Program, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA;
| | - Xinzhong Dong
- Solomon H. Snyder Department of Neuroscience, Department of Dermatology, and Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA;
- Howard Hughes Medical Institute, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Hao-Jui Weng
- Department of Dermatology, Taipei Medical University-Shuang Ho Hospital, New Taipei City 23561, Taiwan
- Department of Dermatology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
- Correspondence:
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15
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Ständer S, Schmelz M. [Neuropathic pruritus]. Schmerz 2020; 34:525-535. [PMID: 33025226 DOI: 10.1007/s00482-020-00502-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 07/14/2020] [Accepted: 07/15/2020] [Indexed: 11/26/2022]
Abstract
In the past 10 years specific pathways for pruritus have been characterized on a cellular and molecular level but their exact role in the pathophysiology of neuropathic pruritus remains unclear. This also applies to the question which of the competing theories for pruritus, e.g. specificity, temporal/spatial pattern or intensity, would best apply. While experimental trials on mice have mostly confirmed the theory of specificity, the results on humans indicate a role of spatial and temporal patterns. The skin innervation is greatly reduced by the neuropathy and could provide a "spatial contrast pattern" and the axotomy could induce a de novo expression of gastrin-releasing peptide (GRP) in primarily afferent nociceptors and thus modulate spinal pruritus processing. In addition, the overlap of pruritus and pain in neuropathy patients complicates the direct translation from animal experiments and requires collaboration at the clinical level between pain medicine and dermatology.
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Affiliation(s)
- Sonja Ständer
- Kompetenzzentrum Chronischer Pruritus, Universitätsklinikum Münster, Münster, Deutschland
| | - Martin Schmelz
- Experimentelle Schmerzforschung, MCTN, Medizinische Fakultät Mannheim, Universität Heidelberg, Ludolf-Krehl-Str. 13-17, 68167, Mannheim, Deutschland.
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Shimada N, Niwa Y, Hotta K, Igarashi T, Takeuchi M. Pregabalin for postherpetic itch: a case report. JA Clin Rep 2020; 6:24. [PMID: 32206971 PMCID: PMC7090110 DOI: 10.1186/s40981-020-00330-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Accepted: 03/16/2020] [Indexed: 11/29/2022] Open
Abstract
Background Postherpetic itch has not commonly received attention as a complication of herpes zoster because pain predominates over itch in most patients with herpes zoster. Most cases of postherpetic itch are mild; however, cases of severe postherpetic itch reducing quality of life are rare. Case presentation A 52-year-old woman complained of severe itch in her left pinna and cheek 1 month after the first onset of herpes zoster at the same site. Owing to her scratching, she developed ulcers on her left pinna and cheek. Pregabalin was prescribed, and the itch subsided immediately, with the ulcers disappearing within 1 month. Discussion Severe itch was thought to be caused by neural injury from herpes zoster. Pregabalin may be a useful treatment option for neuropathic itch induced by herpes zoster.
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Affiliation(s)
- Nobuhiro Shimada
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan.
| | - Yasunori Niwa
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Kunihisa Hotta
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Takashi Igarashi
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Mamoru Takeuchi
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
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Lee SH, Ryu KH, Kim PO, Lee HW, Cho EA, Ahn JH, Youn I, Yang KS. Efficacy of extracorporeal shockwave therapy in the treatment of postherpetic neuralgia: A pilot study. Medicine (Baltimore) 2020; 99:e19516. [PMID: 32195953 PMCID: PMC7220462 DOI: 10.1097/md.0000000000019516] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Established conventional treatments for postherpetic neuralgia (PHN) and postherpetic itch (PHI) are difficult and often disappointing. In this study, the authors investigated the effect and mechanisms of extracorporeal shockwave therapy (ESWT) on pain and itch associated with PHN and PHI.Thirteen patients, 50 to 80 years of age, with symptoms associated with PHN or PHI (duration of persistent pain >3 months) and complaints of pain or itch rated >4 on a numerical rating scale (NRS), were included. ESWT was administered using a shockwave device (Piezo Shockwave, Richard Wolf GmbH, Knittlingen, Germany) to skin areas affected by pain or itch. An energy flux density of 0.09 to 0.16 mJ/mm at a frequency of 5 Hz and 2000 impulses was administered at 3-day intervals for 6 sessions. The NRS, 5D-Itch Scale, and Patients Global Impression of Change (PGIC) scale were used to evaluate the efficacy of ESWT.NRS scores of pain and itch and 5D-Itch Scale scores decreased significantly compared with before treatment and at the end of the treatment sessions (P < .0001, P = .001, P = .0002, respectively). There was a statistically significant difference between PGIC scores, which were checked every 2 sessions (P < .0001).ESWT is a noninvasive modality that significantly reduced PHN-associated pain and itch.
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Affiliation(s)
| | | | | | - Hyo-Won Lee
- Department of Anesthesiology and Pain Medicine
| | - Eun-Ah Cho
- Department of Anesthesiology and Pain Medicine
| | - Jin-Hee Ahn
- Department of Anesthesiology and Pain Medicine
| | - Inyoung Youn
- Department of Radiology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine
| | - Kyung Seung Yang
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's clinic, Seoul, Korea
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Abstract
Chronic pruritus may arise from different conditions, including dermatological, systemic, neurologic, psychiatric, and psychosomatic diseases, leading to a substantial decrease in the quality of life of affected patients. The neurobiological mechanisms involved in chronic pruritus are not yet fully understood. However, in recent years important achievements have been made in this regard. This article aims to provide an overview of the current understanding of these mechanisms. The complex network of neurons, keratinocytes, inflammatory cells, cytokines, and neurotrophic factors which play a role in the development and maintenance of chronic pruritus are highlighted, as well as the pruritogens involved in pruritic diseases in humans. Additionally, the importance of neuropathy and scratch-induced changes for the pathophysiology of chronic pruritus are discussed. The new findings on the neurobiological mechanisms underlying chronic pruritus have already led to the development of novel therapies, e. g., monoclonal antibodies against specific interleukins, which are important for pruritus transmission. A deeper understanding of the neurobiological mechanisms is necessary in order to develop specifically targeted therapeutic options and thus provide better care for affected patients.
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Affiliation(s)
- M P Pereira
- Kompetenzzentrum Chronischer Pruritus (KCP), Klinik für Hautkrankheiten, Universitätsklinikum Münster, Von-Esmarch-Str. 58, 48149, Münster, Deutschland.
| | - K Agelopoulos
- Kompetenzzentrum Chronischer Pruritus (KCP), Klinik für Hautkrankheiten, Universitätsklinikum Münster, Von-Esmarch-Str. 58, 48149, Münster, Deutschland
| | - A E Kremer
- Medizinische Klinik 1, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Deutschland
| | - M Schmelz
- Klinik für Anästhesiologie und Operative Intensivmedizin, Fakultät für Klinische Medizin Mannheim, Ruprecht-Karls-Universität Heidelberg, Mannheim, Deutschland
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Abstract
Neuropathic itch is a pathological condition that is due to damage within the nervous system. This type of itch can be severe and unrelenting, which has a very negative impact on quality of life. Neuropathic itch is more common than generally appreciated because most types of neuropathic pain have a neuropathic itch counterpart. Unfortunately, much like neuropathic pain, there is a lack of effective treatments for neuropathic itch. Here, we consider the neural basis of itch and then describe how injuries within these neural circuits can lead to neuropathic itch in both animal models and human disease states.
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Scalp Pruritus: Review of the Pathogenesis, Diagnosis, and Management. BIOMED RESEARCH INTERNATIONAL 2019; 2019:1268430. [PMID: 30766878 PMCID: PMC6350598 DOI: 10.1155/2019/1268430] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Accepted: 01/03/2019] [Indexed: 12/19/2022]
Abstract
Scalp pruritus is a frequent problem encountered in dermatological practice. This disorder is caused by various underlying diseases and is a diagnostic and therapeutic challenge. Scalp pruritus may be localized to the scalp or extended to other body areas. It is sometimes not only associated with skin diseases or specific skin changes, but also associated with lesions secondary to rubbing or scratching. Moreover, scalp pruritus may be difficult to diagnose and manage and may have a great impact on the quality of life of patients. It can be classified as dermatologic, neuropathic, systemic, and psychogenic scalp pruritus based on the potential underlying disease. A thorough evaluation of patients presenting with scalp pruritus is important. Taking history and performing physical examination and further investigations are essential for diagnosis. Therapeutic strategy comprises removal of the aggravating factors and appropriate treatment of the underlying condition. All treatments should be performed considering an individual approach. This review article focuses on the understanding of the pathophysiology and the diagnostic and therapeutic management of scalp pruritus.
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Investigation of the Correlation between Postherpetic Itch and Neuropathic Pain over Time. Pain Res Manag 2018; 2018:9305126. [PMID: 30631388 PMCID: PMC6304928 DOI: 10.1155/2018/9305126] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 11/15/2018] [Indexed: 11/17/2022]
Abstract
Postherpetic itch (PHI), or herpes zoster itch, is an intractable and poorly understood disease. We targeted 94 herpes zoster patients to investigate their pain and itch intensities at three separate stages of the condition (acute, subacute, and chronic). We used painDETECT questionnaire (PDQ) scores to investigate the correlation between PHI and neuropathic pain. Seventy-six patients were able to complete follow-up surveys. The prevalence of PHI was 47/76 (62%), 28/76 (37%), and 34/76 (45%) at the acute, subacute, and chronic stages, respectively. PHI manifestation times and patterns varied. We investigated the relationship of PHI with neuropathic pain using the visual analog scale (VAS), which is a measure of pain intensity, and the PDQ, which is a questionnaire used to evaluate the elements of neuropathic pain. The VAS and PDQ scores did not differ significantly between PHI-positive and PHI-negative patients. A large neuropathic component was not found for herpes zoster itch, suggesting that neuropathic pain treatments may not able to adequately control the itch. Accordingly, we suggest that a more PHI-focused therapy is required to address this condition.
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Vázquez-Herrera NE, Sharma D, Aleid NM, Tosti A. Scalp Itch: A Systematic Review. Skin Appendage Disord 2018; 4:187-199. [PMID: 30197900 PMCID: PMC6120392 DOI: 10.1159/000484354] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 10/18/2017] [Indexed: 12/19/2022] Open
Abstract
Scalp itch is a frequent complaint in the dermatological setting. It is common for the dermatologist to encounter patients with no evident cause of scalp pruritus, making it a distressing situation for both the clinician and the patient. The aim of this paper is to propose a systematic approach to scalp itch, which classifies scalp pruritus into two types: (1) with or (2) without dermatological lesions, and presence or absence of hair loss. Also, it is important to think first about the most common causes and then rule out other, less common etiologies. The acronym SCALLP and the five steps for scalp evaluation (listen, look, touch, magnify, and sample) are useful tools to keep in mind for an assertive approach in these patients.
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Affiliation(s)
| | - Divya Sharma
- Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Nouf Mohammed Aleid
- Department of Dermatology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Antonella Tosti
- Fredric Brandt Endowed Professor of Dermatology, University of Miami, Miami, FL, USA
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Steinhoff M, Schmelz M, Szabó IL, Oaklander AL. Clinical presentation, management, and pathophysiology of neuropathic itch. Lancet Neurol 2018; 17:709-720. [PMID: 30033061 DOI: 10.1016/s1474-4422(18)30217-5] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 05/15/2018] [Accepted: 06/01/2018] [Indexed: 12/19/2022]
Abstract
Unlike conventional itch, neuropathic itch develops in normal skin from excess peripheral firing or dampened central inhibition of itch pathway neurons. Neuropathic itch is a symptom of the same central and peripheral nervous system disorders that cause neuropathic pain, such as sensory polyneuropathy, radiculopathy, herpes zoster, stroke, or multiple sclerosis, and lesion location affects symptoms more than aetiology. The causes of neuropathic itch are heterogeneous, and thus diagnosis is based primarily on recognising characteristic, disease-specific clinical presentations. However, the diagnosis of neuropathic itch is challenging, different subforms exist (eg, focal vs widespread, peripheral vs central), and the mechanisms of neuropathic itch are poorly understood, resulting in reduced treatment availability. Currently available strategies include treating or preventing causal diseases, such as diabetes or herpes zoster, and topical or systemic medications that calm excess neuronal firing. Discovery of itch mediators such as gastrin releasing peptide, receptors (eg, neurokinin-1), and pathways (eg, Janus kinases) might encourage much needed new research into targeted treatments of neuropathic itch.
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Affiliation(s)
- Martin Steinhoff
- Department of Dermatology and Venereology, Hamad Medical Corporation, Doha, Qatar; HMC Translational Research Institute, Hamad Medical Corporation, Doha, Qatar; Weill Cornell Medicine-Qatar, Doha, Qatar; College of Medicine, Qatar University, Medical School, Doha, Qatar.
| | - Martin Schmelz
- Department of Experimental Pain Research, CBTM Mannheim, Heidelberg University, Mannheim, Germany
| | - Imre Lőrinc Szabó
- Department of Dermatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Anne Louise Oaklander
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Neuropathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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A Study and Review of Effects of Botulinum Toxins on Mast Cell Dependent and Independent Pruritus. Toxins (Basel) 2018; 10:toxins10040134. [PMID: 29570628 PMCID: PMC5923300 DOI: 10.3390/toxins10040134] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 03/21/2018] [Accepted: 03/21/2018] [Indexed: 12/03/2022] Open
Abstract
Pruriceptive itch originates following activation of peripheral sensory nerve terminals when pruritogens come in contact with the skin. The ability of botulinum neurotoxins (BoNTs) to attenuate transmitter release from afferent terminals provides a rationale for studying its effect on pruritus. This study investigated the effects of BoNT/A1 and BoNT/B1 on mast cell dependent (Compound 48/80:48/80) and independent (Chloroquine:CQ) scratching. C57Bl/6 male mice received intradermal injection of 1.5 U of BoNT/A1, BoNT/B1 or saline 2, 7, 14 and 21 days prior to ipsilateral 48/80 or CQ at the nape of the neck. Ipsilateral hind paw scratching was determined using an automated recording device. The effect of BoNTs on 48/80 mediated mast cell degranulation was analyzed in human and murine mast cells and the presence of SNAREs was determined using qPCR, immunostaining and Western blot. Pre-treatment with BoNT/A1 and BoNT/B1 reduced 48/80 and CQ induced scratching behavior starting on day 2 with reversal by day 21. Both serotypes inhibited 48/80 induced mast cell degranulation. qPCR and immunostaining detected SNAP-25 mRNA and protein, respectively, in mast cells, however, Western blots did not. This study demonstrates the long-lasting anti-pruritic effects of two BoNT serotypes, in a murine pruritus model using two different mechanistically driven pruritogens. These data also indicate that BoNTs may have a direct effect upon mast cell degranulation.
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Andersen HH, Arendt-Nielsen L, Yosipovitch G, Elberling J. A prospective case of postherpetic itch monitored by quantitative sensory testing for 1 year while undergoing 8% topical capsaicin treatments. ACTA ACUST UNITED AC 2017. [DOI: 10.1097/itx.0000000000000008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Shevchenko A, Valdes-Rodriguez R, Yosipovitch G. Causes, pathophysiology, and treatment of pruritus in the mature patient. Clin Dermatol 2017; 36:140-151. [PMID: 29566918 DOI: 10.1016/j.clindermatol.2017.10.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Chronic itch is a common and debilitating health condition in the elderly. There are several common causes of itch in the mature population, such as skin xerosis, immunosenescence, and neuropathic changes. In addition, skin diseases, such as seborrheic dermatitis and stasis dermatitis, systemic conditions (end-stage renal disease and diabetes), or psychogenic derailments, such as depression, anxiety, and dementia, can all serve as triggers of pruritus. Polypharmacy, a common occurrence among the elderly population, may also serve as a cause of itch that may or may not be accompanied by dermatitis. Such medications as μ opioids and calcium channel blockers have been found to have a connection with pruritus in the advanced aging population. Determining the exact trigger for pruritus in the elderly may be especially challenging, because itch can be idiopathic in many cases. The role of treatments should not only take into account elimination of various underlying cutaneous, systemic, or psychogenic conditions associated with itch but also focus on the skin changes that are characteristic of the aging process. Development of such treatment options can be guided by elucidation of the mechanisms underlying the pathophysiology of itch in the geriatric population.
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Affiliation(s)
- Alina Shevchenko
- Department of Dermatology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Rodrigo Valdes-Rodriguez
- Department of Dermatology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Gil Yosipovitch
- Department of Dermatology & Miami Itch Center at the University of Miami, Leonard M. Miller School of Medicine, Miami, FL, USA.
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Yamanaka D, Kawano T, Shigematsu-Locatelli M, Nishigaki A, Kitamura S, Aoyama B, Tateiwa H, Kitaoka N, Yokoyama M. Peripheral nerve block with a high concentration of tetracaine dissolved in bupivacaine for intractable post-herpetic itch: a case report. JA Clin Rep 2016; 2:43. [PMID: 29492438 PMCID: PMC5813738 DOI: 10.1186/s40981-016-0069-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 11/30/2016] [Indexed: 02/12/2023] Open
Abstract
Background Post-herpetic itch (PHI) is a neuropathic itch syndrome following herpes zoster. It has been reported that PHI is occasionally sufficiently severe to compromise patients’ quality of life and frequently refractory to treatment. Here, we present a case of severe chronic PHI successfully treated with supraorbital nerve block using a high concentration of tetracaine dissolved in bupivacaine. Case presentation An 82-year-old man presented with severe chronic itching in the ophthalmic branch of the left trigeminal nerve dermatome, following acute herpes zoster. The patient’s itching was unresponsive to usual medical treatments for PHI including antiepileptic drugs, topical capsaicin cream, and supraorbital nerve radiofrequency thermo-coagulation. Topical lidocaine cream could relieve the itching, but could not provide long-term relief of itching and thus failed to achieve a satisfactory result. After these conventional treatments, left supraorbital nerve block using 4% tetracaine dissolved with 0.5% bupivacaine was conducted. Afterwards, the patient experienced long-lasting resolution of the itching with improvement of sleep disturbance. A transient, mild edema of the eyelids occurred, but there were no other complications. Conclusions Peripheral nerve block using 4% tetracaine dissolved with 0.5% bupivacaine was beneficial in relieving PHI in the ophthalmic division of the trigeminal nerve.
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Affiliation(s)
- Daiki Yamanaka
- Department of Anesthesiology and Intensive Care Medicine, Kochi Medical School, Kohasu, Oko-cho, Nankoku, Kochi 783-8505 Japan
| | - Takashi Kawano
- Department of Anesthesiology and Intensive Care Medicine, Kochi Medical School, Kohasu, Oko-cho, Nankoku, Kochi 783-8505 Japan
| | - Marie Shigematsu-Locatelli
- Department of Anesthesiology and Intensive Care Medicine, Kochi Medical School, Kohasu, Oko-cho, Nankoku, Kochi 783-8505 Japan
| | - Atsushi Nishigaki
- Department of Anesthesiology and Intensive Care Medicine, Kochi Medical School, Kohasu, Oko-cho, Nankoku, Kochi 783-8505 Japan
| | - Sonoe Kitamura
- Department of Anesthesiology and Intensive Care Medicine, Kochi Medical School, Kohasu, Oko-cho, Nankoku, Kochi 783-8505 Japan
| | - Bun Aoyama
- Department of Anesthesiology and Intensive Care Medicine, Kochi Medical School, Kohasu, Oko-cho, Nankoku, Kochi 783-8505 Japan
| | - Hiroki Tateiwa
- Department of Anesthesiology and Intensive Care Medicine, Kochi Medical School, Kohasu, Oko-cho, Nankoku, Kochi 783-8505 Japan
| | - Noriko Kitaoka
- Department of Anesthesiology and Intensive Care Medicine, Kochi Medical School, Kohasu, Oko-cho, Nankoku, Kochi 783-8505 Japan
| | - Masataka Yokoyama
- Department of Anesthesiology and Intensive Care Medicine, Kochi Medical School, Kohasu, Oko-cho, Nankoku, Kochi 783-8505 Japan
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van Wijck AJM, Aerssens YR. Pain, Itch, Quality of Life, and Costs after Herpes Zoster. Pain Pract 2016; 17:738-746. [PMID: 27611885 DOI: 10.1111/papr.12518] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 07/02/2016] [Accepted: 08/01/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Herpes zoster (HZ) and postherpetic neuralgia are known to have a profound effect on the patient's quality of life, but the incidence and severity of itch and its relation with pain and quality of life in the long term are still relatively unknown. OBJECTIVE The aim of this study was to measure the presence and severity of pain and itch and impact on quality of life in patients over 50 years old with HZ. METHODS We enrolled 661 patients with HZ in this 12-month observational study. Patient data were collected via a web-based questionnaire. Outcomes were pain, itch, burden of illness, impact on patient's daily life, impact on quality of life, and healthcare costs. RESULTS At inclusion, 94% of patients reported any pain, 74.3% significant pain, and 26% severe pain. After 3 months, 18.8% of patients suffered from postherpetic neuralgia. At inclusion, 70.8% of patients had any itch, 39.2% significant itch, and 7.3% severe itch. The occurrence of pain increases costs and has a high impact on the quality of life, lowering EQ-5D scores by an average of 18%. In contrast, itch has little effect on the quality of life. CONCLUSIONS Pain and itch are highly prevalent months after HZ. Pain caused by HZ has a large impact on quality of life, burden of illness, impact on daily life, and health care costs for these patients. The impact of itch on quality of life is relatively small.
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Affiliation(s)
- Albert J M van Wijck
- Pain Clinic, Department of Anaesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Yannick R Aerssens
- Pain Clinic, Department of Anaesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands
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30
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Affiliation(s)
- Asit Mittal
- Department of Dermatology, Venereology and Leprology, Rabindra Nath Tagore (RNT) Medical College, Udaipur, Rajasthan, India
| | - Ankita Srivastava
- Department of Dermatology, Venereology and Leprology, Rabindra Nath Tagore (RNT) Medical College, Udaipur, Rajasthan, India
| | - Manisha Balai
- Department of Dermatology, Venereology and Leprology, Rabindra Nath Tagore (RNT) Medical College, Udaipur, Rajasthan, India
| | - Ashok Kumar Khare
- Department of Dermatology, Venereology and Leprology, Rabindra Nath Tagore (RNT) Medical College, Udaipur, Rajasthan, India
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DʼArcy Y. Soothing the stinging pain of shingles. Nursing 2015; 45:65-66. [PMID: 26460843 DOI: 10.1097/01.nurse.0000472573.39245.33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- Yvonne DʼArcy
- Yvonne D'Arcy is a pain management and palliative care nurse practitioner
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Abstract
The burden of chronic pruritus is increasingly recognized as significant worldwide. As wet-laboratory researchers investigate the pathophysiology of chronic pruritus, epidemiologists and health services researchers are quantifying the impact of pruritus by incidence, prevalence, and quality of life measures. Outcomes researchers are also investigating factors that may predict chronic pruritus incidence and severity. Such efforts will direct resources for research, public health intervention, and clinical care.
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Lee HJ, Kim GW, Kim WJ, Mun JH, Song M, Kim HS, Ko HC, Kim MB, Kim BS. Clinical characteristics of postherpetic pruritus: assessment using a questionnaire, von Frey filaments and Neurometer. Br J Dermatol 2015; 172:1672-1673. [DOI: 10.1111/bjd.13569] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- H.-J. Lee
- Department of Dermatology; School of Medicine; Pusan National University Hospital; Busan Korea
| | - G.-W. Kim
- Department of Dermatology; School of Medicine; Pusan National University Hospital; Busan Korea
| | - W.-J. Kim
- Department of Dermatology; School of Medicine; Pusan National University Hospital; Busan Korea
| | - J.-H. Mun
- Department of Dermatology; School of Medicine; Pusan National University Hospital; Busan Korea
| | - M. Song
- Department of Dermatology; School of Medicine; Pusan National University Hospital; Busan Korea
| | - H.-S. Kim
- Department of Dermatology; School of Medicine; Pusan National University Hospital; Busan Korea
| | - H.-C. Ko
- Department of Dermatology; School of Medicine; Pusan National University Hospital; Busan Korea
| | - M.-B. Kim
- Department of Dermatology; School of Medicine; Pusan National University Hospital; Busan Korea
- Biomedical Research Institute; Pusan National University Hospital; Busan Korea
| | - B.-S. Kim
- Department of Dermatology; School of Medicine; Pusan National University Hospital; Busan Korea
- Biomedical Research Institute; Pusan National University Hospital; Busan Korea
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Abstract
Pain and itch are generally regarded antagonistic as painful stimuli such as scratching suppresses itch. Moreover, inhibition of pain processing by opioids generates itch further supporting their opposing role. Separate specific pathways for itch and pain processing have been uncovered, and several molecular markers have been established in mice that identify neurons involved in the processing of histaminergic and non-histaminergic itch on primary afferent and spinal level. These results are in agreement with the specificity theory for itch and might suggest that pain and itch should be investigated separately on the level of neurons, mediators, and mechanisms. However, in addition to broadly overlapping mediators of itch and pain, there is also evidence for overlapping functions in primary afferents: nociceptive primary afferents can provoke itch when activated very locally in the epidermis, and sensitization of both nociceptors and pruriceptors has been found following local nerve growth factor application in volunteers. Thus, also mechanisms that underlie the development of chronic itch and pain including spontaneous activity and sensitization of primary afferents as well as spinal cord sensitization may well overlap to a great extent. Rather than separating itch and pain, research concepts should therefore address the common mechanisms. Such an approach appears most appropriate for clinical conditions of neuropathic itch and pain and also chronic inflammatory conditions. While itch researchers can benefit from the large body of information of the pain field, pain researchers will find behavioral readouts of spontaneous itch much simpler than those for spontaneous pain in animals and the skin as source of the pruritic activity much more accessible even in patients.
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Affiliation(s)
- Martin Schmelz
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine Mannheim, University of Heidelberg, Theodor-Kutzer Ufer 1-3, Mannheim, 68167, Germany,
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Receptors, cells and circuits involved in pruritus of systemic disorders. Biochim Biophys Acta Mol Basis Dis 2014; 1842:869-92. [DOI: 10.1016/j.bbadis.2014.02.007] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Revised: 02/16/2014] [Accepted: 02/18/2014] [Indexed: 12/12/2022]
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Abstract
Pruritus, also known as itch, is a very common, unpleasant sensation that elicits an urge to scratch. Its origin is not always in the skin, and neuropathic itch that is caused by neuronal or glial damage is common, but poorly understood by both dermatologists and neurologists. Although pruritus has not been considered as serious a symptom as pain, it is difficult to treat and--if chronic--can severely impair quality of life. Neuropathic itch is often associated with other clinical symptoms, most commonly neuropathic pain, and hypersensitization to stimuli is present in both pruritus and pain of neuropathic origin. The shared aetiology can aid in finding suitable treatment for itch in some cases, but more detailed knowledge of the mechanisms of itch, along with standardized, well-controlled trials, is needed. Pruritus research is an emerging but currently very active field, and our understanding of this sensation is rapidly increasing. Here, we review new discoveries regarding the role of the nervous system and the contribution of different pathways in pruritus, discuss the different aetiologies of neuropathic itch, and outline currently available and potential strategies for managing neuropathic pruritus.
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Dorfman D, George MC, Tamler R, Lushing J, Nmashie A, Simpson DM. Pruritus induced self injury behavior: an overlooked risk factor for amputation in diabetic neuropathy? Diabetes Res Clin Pract 2014; 103:e47-8. [PMID: 24447805 DOI: 10.1016/j.diabres.2013.12.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 12/28/2013] [Accepted: 12/19/2013] [Indexed: 11/23/2022]
Abstract
Pruritus is a risk factor for self-injury behavior (SIB) in sensory polyneuropathies. Although diabetes patients have elevated risk for pruritus, there are no reports of SIB in diabetic neuropathy. We present the case of a diabetes patient with neuropathy, whose pruritus induced SIB, resulted in partial amputation of a toe.
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Affiliation(s)
- David Dorfman
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.
| | - Mary Catherine George
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Ronald Tamler
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Julia Lushing
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Alexandra Nmashie
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - David M Simpson
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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Abstract
While considerable effort has been made to investigate the neural mechanisms of pain, much less effort has been devoted to itch, at least until recently. However, itch is now gaining increasing recognition as a widespread and costly medical and socioeconomic issue. This is accompanied by increasing interest in the underlying neural mechanisms of itch, which has become a vibrant and rapidly-advancing field of research. The goal of the present forefront review is to describe the recent progress that has been made in our understanding of itch mechanisms.
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Affiliation(s)
- Tasuku Akiyama
- University of California, Davis, Department of Neurobiology, Physiology & Behavior, 1 Shields Avenue, Davis, CA 95616, United States
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Solak Y, Biyik Z, Atalay H, Gaipov A, Guney F, Turk S, Covic A, Goldsmith D, Kanbay M. Pregabalin versus gabapentin in the treatment of neuropathic pruritus in maintenance haemodialysis patients: a prospective, crossover study. Nephrology (Carlton) 2013; 17:710-7. [PMID: 22909343 DOI: 10.1111/j.1440-1797.2012.01655.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM Pruritus is common in dialysis patients. Peripheral neuropathy is also prevalent in this patient population. However, the role of neuropathy in the genesis of uraemic itch has not been adequately studied to date. Therefore, we aimed to investigate the effects of gabapentin and pregabalin on uraemic pruritus along with neuropathic pain in patients receiving haemodialysis. METHODS This is a 14 week long randomized, prospective, cross-over trial. Haemodialysis patients with established neuropathy and/or neuropathic pain were included. Fifty patients were randomly assigned to gabapentin 300 mg after each haemodialysis session and pregabalin 75 mg daily. After 6 weeks of treatment, cross-over was performed and patients received the other drug for another 6 weeks. Short Form of McGill Pain Questionnaire and Visual Analogue Scale were used to evaluate pain and pruritus, respectively. At each week's visit, patients were interrogated in terms of adverse effects of study drugs. Baseline laboratory data and demographic characteristics were recorded from patient charts. RESULTS Forty (12 males, 28 females) out of 50 patients completed the study. Mean age was 58.2 ± 13.7. Overall, 29 out of 40 patients (72.5%) had pruritus symptoms at baseline evaluation. Fifteen patients (37.5%) were diabetic. Thirty-one out of 40 patients (77.5%) had electromyography (EMG)-proven peripheral neuropathy. Twenty three patients (57.5%) had both EMG-proven neuropathy and pruritus. Gabapentin and pregabalin improved both neuropathic pain and pruritus significantly. There was no difference between the study drugs in terms of efficacy against pain and pruritus. CONCLUSION Treatment of neuropathic pain with either pregabalin or gabapentin effectively ameliorates uraemic itch.
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Affiliation(s)
- Yalcin Solak
- Division of Nephrology, Department of Internal Medicine, Meram School of Medicine, Konya University, Meram, Konya, Turkey.
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Affiliation(s)
- Astrid Stumpf
- Department of Psychosomatics and Psychotherapy; Competence Center of Chronic Pruritus; University Hospital Münster; Münster; Germany
| | - Sonja Ständer
- Department of Dermatology; Competence Center of Chronic Pruritus; University Hospital Münster; Münster; Germany
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Pfab F, Schalock PC, Napadow V, Athanasiadis GI, Yosipovitch G, Ring J. Complementary integrative approach for treating pruritus. Dermatol Ther 2013; 26:149-56. [DOI: 10.1111/dth.12031] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
| | - P. C. Schalock
- Department of Dermatology; Massachusetts General Hospital; Harvard Medical School; Boston; Massachusetts; USA
| | | | - G. I. Athanasiadis
- Department of Dermatology and Allergy; Technische Universität München; Munich; Germany
| | - G. Yosipovitch
- Department of Dermatology, Neurobiology & Anatomy; Regenerative Medicine Wake Forest University Health Sciences; Winston-Salem; North Carolina; USA
| | - J. Ring
- Department of Dermatology and Allergy; Technische Universität München; Munich; Germany
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[Pain and pruritus : differences and similarities as revealed by the PainDetect questionnaire parameters]. Hautarzt 2012; 63:539-46. [PMID: 22751856 DOI: 10.1007/s00105-011-2322-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Chronic pruritus and chronic pain are frequent symptoms of a variety of underlying diseases. Painful sensations usually suppress acute itching. In chronic states, both may be present in parallel and be a part of one event. Patients with chronic pruritus should be asked for the presence of pain, which can be identified and characterized using specific and validated questionnaires. The early detection of (neuropathic) pain in patients with chronic pruritus can be done using the PainDetect questionnaire. In general, patients suffering from both itch and pain have a highly impaired quality of life, high degree of objective health burden, need a more intensive health care and a complex analgetic and antipruritic therapy.
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Spradley JM, Davoodi A, Gee LB, Carstens MI, Carstens E. Differences in peripheral endocannabinoid modulation of scratching behavior in facial vs. spinally-innervated skin. Neuropharmacology 2012; 63:743-9. [PMID: 22683515 DOI: 10.1016/j.neuropharm.2012.05.032] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2012] [Revised: 05/09/2012] [Accepted: 05/14/2012] [Indexed: 11/29/2022]
Abstract
Cannabinoids suppress nocifensive behaviors in rodents. We presently investigated peripheral endocannabinoid modulation of itch- and pain-related behaviors elicited from facial vs. spinally-innervated skin of rats. Intradermal (id) injection of the pruritogen serotonin (5-HT) elicited significantly more hindlimb scratch bouts, and longer cumulative time scratching, when injected in the rostral back compared to the cheek. Pretreatment of skin with inhibitors of degrading enzymes for the endocannabinoids anandamide (URB597) or 2-arachidonoylglycerol (JZL184) significantly reduced scratching elicited by 5-HT in the rostral back. These effects were prevented by co-treatment with antagonists of the CB₁ (AM251) or CB₂ receptor (AM630), implicating both receptor subtypes in endocannabinoid suppression of scratching in spinally-innervated skin. Conversely, pretreatment with either enzyme inhibitor, or with AM630 alone, increased the number of scratch bouts elicited by id 5-HT injection in the cheek. Moreover, pretreatment with JZL184 also significantly increased pain-related forelimb wipes directed to the cheek following id injection of the algogen, allyl isothiocyanate (AITC; mustard oil). Thus, peripheral endocannabinoids have opposite effects on itch-related scratching behaviors in trigeminally- vs. spinally-innervated skin. These results suggest that increasing peripheral endocannabinoid levels represents a promising therapeutic approach to treat itch arising from the lower body, but caution that such treatment may not relieve, and may even exacerbate, itch and pain arising from trigeminally-innervated skin of the face or scalp.
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Affiliation(s)
- Jessica Marie Spradley
- Department of Neurobiology, Physiology & Behavior, University of California, One Shields Avenue, Davis, CA 95616-8519, USA
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Abstract
Scalp pruritus is a common complaint that is considered a diagnostically and therapeutically challenging situation. Scalp skin has a unique neural structure that contains densely innervated hair follicles and dermal vasculature. In spite of the recent advances in our understanding of itch pathophysiology, scalp itching has not been studied as yet. In this review, we summarize the current knowledge on the neurobiology of scalp and hair follicles as well as itch mediators and provide a putative mechanism for scalp itch with special emphasis on neuroanatomy and pathophysiology.
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Affiliation(s)
- Ghada A Bin Saif
- Department of Dermatology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Curtis AR, Oaklander AL, Johnson A, Yosipovitch G. Trigeminal trophic syndrome from stroke: an under-recognized central neuropathic itch syndrome. Am J Clin Dermatol 2012; 13:125-8. [PMID: 22220970 DOI: 10.2165/11594060-000000000-00000] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Trigeminal trophic syndrome (TTS) is the historic name for neuropathic self-induced facial ulceration from abnormal sensory symptoms leading to uncontrolled scratching. Anatomic co-localization of sensory loss (numbness) plus neuropathic itch and pain permits painless scratching. If the itch is severe, some patients will scratch to the point of causing self-injury. Patients may be unaware or may conceal the fact that their lesions are self-induced and thus the diagnosis presents a clinical challenge. Many cases remain undiagnosed, leading to unnecessary and ineffective tests, procedures, and prescribing. We document a patient with a central cause of TTS - multiple cerebral vascular accidents - and summarize the presentation, pathogenesis, and treatment options.
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Affiliation(s)
- Ashley R Curtis
- Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, NC 27104, USA
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Abstract
Chronic itch can be caused by dysfunctions of itch-sensing neurons that produce sensory hallucinations of pruritogenic stimuli. The cellular and molecular mechanisms are still unknown. All neurological disease categories have been implicated, and neurological causes should be considered for patients with otherwise-unexplained itch. The same neurological illnesses that cause neuropathic pain can also or instead cause itch. These include shingles (particularly of the head or neck), small-fiber polyneuropathies, radiculopathies (eg, notalgia paresthetica and brachioradial pruritis), and diverse lesions of the trigeminal nerve, root, and central tracts. Central nervous system lesions affecting sensory pathways, including strokes, multiple sclerosis, and cavernous hemangiomas, can cause central itch. Neuropathic itch is a potent trigger of reflex and volitional scratching although this provides only fleeting relief. Rare patients whose lesion causes sensory loss as well as neuropathic itch can scratch deeply enough to cause painless self-injury. The most common location is on the face (trigeminal trophic syndrome). Treating neuropathic itch is difficult; antihistamines, corticosteroids, and most pain medications are largely ineffective. Current treatment recommendations include local or systemic administration of inhibitors of neuronal excitability (especially local anesthetics) and barriers to reduce scratching.
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Affiliation(s)
- Anne Louise Oaklander
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
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