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Rodriguez D, Kwatra SG, Dias-Barbosa C, Zeng F, Jabbar Lopez ZK, Piketty C, Puelles J. Patient Perspectives on Living With Severe Prurigo Nodularis. JAMA Dermatol 2023; 159:1205-1212. [PMID: 37728897 PMCID: PMC10512162 DOI: 10.1001/jamadermatol.2023.3251] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 07/07/2023] [Indexed: 09/22/2023]
Abstract
Importance Because of a paucity of qualitative research on prurigo nodularis (PN), the symptoms and impacts of PN that are most important to patients are poorly understood. Objective To explore patients' perspectives on their PN symptoms and to understand the impacts of the condition. Design, Setting, and Participants One-on-one qualitative telephone interviews were held with English-speaking US adults aged 18 years or older with a confirmed diagnosis of PN, severe pruritus, and moderate to severe sleep disturbance. Participants were recruited via patient associations, patient panels, and social media posts. Interviews took place between September 10, 2020, and March 16, 2021. Main Outcomes and Measures The main symptoms of PN and their impacts on quality of life were identified by content analysis of deidentified interview transcripts. Results A total of 21 adults with PN (mean [SD] age, 53.1 [11.8] years; 15 [71%] female; 2 African American or Black patients [10%], 1 Asian patient [5%], and 18 White patients [86%]; of these, 1 patient [ 5%] had Hispanic or Latino ethnicity) participated in the interviews. All participants reported itch, pain associated with PN, bleeding or scabbing, and dry skin. Other frequently reported symptoms included lumps or bumps (95%), having a crust on the skin (95%), burning (90%), stinging (90%), lesions or sores (86%), skin discoloration (86%), and raw skin (81%). Of the 17 participants who indicated what their worst symptoms were, 15 (88%) identified itching as the worst or 1 of the worst symptoms. The most frequently reported impacts of PN for quality of life were changes in sleep (100%), daily life (100%), feelings or mood (95%), relationships (95%), social life (81%), and work or school (71%). Overall, the worst impact of PN was its association with impaired feelings or mood. Conclusions and Relevance This qualitative study suggests the importance of itching, sleep disturbance, and other symptoms and impacts of PN. This information can be used to guide end point selection in clinical trials and to inform patient-centric decision-making in clinical practice.
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Affiliation(s)
| | - Shawn G. Kwatra
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Ständer S, Yosipovitch G, Lacour J, Legat F, Paul C, Reich A, Chaouche K, Ahmad F, Piketty C. Nemolizumab efficacy in prurigo nodularis: onset of action on itch and sleep disturbances. J Eur Acad Dermatol Venereol 2022; 36:1820-1825. [PMID: 35766128 PMCID: PMC9796585 DOI: 10.1111/jdv.18377] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 06/02/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND Patients with prurigo nodularis (PN) have multiple itchy nodules, impaired quality of life and sleep deprivation. Prurigo nodularis patients have a high burden of disease, primarily due to the intensity of the itch. It is reasonable to expect that rapid relief of itch - and associated improvement of sleep - are highly valued clinical outcomes for patients. Nemolizumab is an IL-31A-receptor inhibitor that modulates the neuroimmune response with reported positive efficacy and safety data in a phase 2 study of PN. OBJECTIVES To evaluate the onset of action of nemolizumab on itch and sleep disturbances. METHODS Post hoc analysis of a phase 2 trial of nemolizumab 0.5 mg/kg SC vs. placebo in patients (n = 70) with moderate-to-severe PN (≥20 nodules) and severe pruritus (NRS ≥ 7). Time to significant reduction was assessed for peak pruritus (PP) and sleep disturbance (SD) using numerical rating scales (NRS), also assessed was scratching time during sleep. RESULTS Nemolizumab significantly reduced itch vs. placebo within 48 h (PP NRS -19.5% vs. -5.8%, respectively, P = 0.014). Significant difference between nemolizumab and placebo in reducing itch by ≥4 on PP NRS was achieved at Day 3 (23.5% vs. 0%, P < 0.001). A significant difference in SD NRS was reported by Day 4 (-24.0% vs. -4.3% placebo, P = 0.012). In addition, there was a separation between groups in SD responders (decrease of ≥4 points) in favour of nemolizumab by Day 2 (8.8% vs. 0%, P = 0.037). Sleep continued improving through Week 4, when there was a -56.0% reduction in SD NRS vs. -22.9% placebo (P < 0.001). Actigraphy data showed improvement in scratch/sleep duration for nemolizumab vs. placebo, respectively, by Week 1 (-32.15 vs. +28.15 min/h, P = 0.001). CONCLUSION Nemolizumab has a rapid and robust onset of action in PN with itch reduction and improvement of sleep within 48 h.
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Affiliation(s)
- S. Ständer
- Department of Dermatology and Center for Chronic PruritusUniversity Hospital MünsterMünsterGermany
| | - G. Yosipovitch
- Itch Center, Dr Phillip Frost Department of Dermatology and Cutaneous SurgeryUniversity of Miami HospitalMiamiFLUSA
| | - J.‐P. Lacour
- Department of DermatologyMedical University of NiceNiceFrance
| | - F.J. Legat
- Department of Dermatology and VenereologyMedical University of GrazGrazAustria
| | - C. Paul
- Department of DermatologyMedical University of ToulouseToulouseFrance
| | - A. Reich
- Department of DermatologyUniversity of RzeszowRzeszowPoland
| | | | - F. Ahmad
- Galderma Laboratories LPFort WorthTexasUSA
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Luo N, Wang Q, Lei M, Li T, Hao P. Dupilumab for Chronic Prurigo in Different Backgrounds: A Case Series. CLINICAL, COSMETIC AND INVESTIGATIONAL DERMATOLOGY 2022; 15:1863-1867. [PMID: 36117770 PMCID: PMC9480179 DOI: 10.2147/ccid.s379231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 09/05/2022] [Indexed: 12/03/2022]
Abstract
Chronic prurigo (CPG) is a chronic inflammatory disease characterized by intense pruritus, and therapy is often challenging due to its unclear pathogenesis. Here, we report four patients with refractory CPG from different backgrounds who experienced failure of conventional therapy and were controlled with dupilumab, accompanied by a significant decrease in pruritus numerical rating scale, dermatology life quality index, and investigator global assessment, without adverse effects. Furthermore, dupilumab improved the condition of asthma in CPG patients along with an increase in asthma control test scores.
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Affiliation(s)
- Nana Luo
- Department of Dermatology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, People's Republic of China.,School of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, People's Republic of China
| | - Qiuyue Wang
- School of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, People's Republic of China
| | - Min Lei
- School of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, People's Republic of China
| | - Tianhao Li
- Department of Dermatology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, People's Republic of China
| | - Pingsheng Hao
- Department of Dermatology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, People's Republic of China
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Abstract
INTRODUCTION Prurigo nodularis (PN) or chronic prurigo of nodular type (CNPG) is a subtype of chronic prurigo with severe pruritus and neuroimmune underlying pathophysiology occurring in a plethora of dermatological, systemic, neurologic, and psychiatric conditions. AREAS COVERED We review the increasing repertoire of biologics in the treatment of CNPG focusing on those targeting interleukins 4, 13, 31, oncostatin M and IgE. Presented information is based on a database research on current clinical trials (clinicaltrials.gov, European Clinical Trials Database (EudraCT), US clinical trial registry ICH-GCP) and a PubMed search for latest publications conducted with the combinations of the terms 'chronic prurigo,' 'prurigo nodularis,' 'pathophysiology,' 'treatment,' 'therapy', and 'biologics.' EXPERT OPINION CNPG gets more and more attention as new therapeutic targets have been revealed in recent years, thus allowing the use of targeted approaches. The off-label advent of dupilumab offered advanced insight into the pathogenesis of CNPG and showed an impressive relief of pruritus in the vast majority of patients. New therapies including biologics (e.g. nemolizumab, tralokinumab, lebrikizumab), small molecules (e.g. neurokinin-1 receptor antagonists, janus kinase inhibitors) as well as mu-opioid receptor antagonists and nalbuphine, a μ-antagonist/κ-agonist, are in the pipeline and offer new hope for an improved future patient care.
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Affiliation(s)
- Svenja Müller
- Department of Dermatology and Allergy; Christine Kühne-Center for Allergy Research and Education (CK-CARE), University Hospital Bonn, Bonn, Germany
| | - Thomas Bieber
- Department of Dermatology and Allergy; Christine Kühne-Center for Allergy Research and Education (CK-CARE), University Hospital Bonn, Bonn, Germany
| | - Sonja Ständer
- Department of Dermatology and Center for Chronic Pruritus, University Hospital Münster, Münster, Germany
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Whang KA, Le TK, Khanna R, Williams KA, Roh YS, Sutaria N, Choi J, Gabriel S, Chavda R, Semenov Y, Kwatra SG. Health-related quality of life and economic burden of prurigo nodularis. J Am Acad Dermatol 2021; 86:573-580. [PMID: 34058278 DOI: 10.1016/j.jaad.2021.05.036] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 04/26/2021] [Accepted: 05/12/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Prurigo nodularis (PN) is an understudied, pruritic inflammatory skin disease. Little is known about the effect of PN on quality of life and its associated economic burden. OBJECTIVE To quantify the impact of PN on quality of life and its economic implications. METHODS A cohort study of PN patients (n = 36) was conducted using the Health Utilities Index Mark 3 questionnaire. Control data from US adults (n = 4187) were obtained from the 2002-2003 Joint Canada/United States Survey of Health. Quality-adjusted life year loss and economic costs were estimated by comparing the Health Utilities Index Mark 3 scores of the PN patients with those of the controls. RESULTS The PN patients had lower overall health performance compared to the controls, (mean ± SE, 0.52 ± 0.06 vs 0.86 ± 0.003, respectively, P < .001). In multivariable regression, PN was found to be associated with worse health performance (coefficient -0.34, 95% CI [-0.46 to -0.23]), most prominent in the pain subdomain (coefficient -0.24, 95% CI [-0.35 to -0.13]). This correlated to an average of 6.5 lifetime quality-adjusted life years lost per patient, translating to an individual lifetime economic burden of $323,292 and a societal burden of $38.8 billion. CONCLUSION These results demonstrate that PN is associated with significant quality-of-life impairment, similar to the level of other chronic systemic conditions. PN is also associated with a substantial individual economic burden, emphasizing the necessity of research on effective treatment options.
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Affiliation(s)
- Katherine A Whang
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Thomas K Le
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Raveena Khanna
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kyle A Williams
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Youkyung Sophie Roh
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nishadh Sutaria
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Justin Choi
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sylvie Gabriel
- Galderma Prescription Global Business Unit, Rue d'Entre-deux-Villes, La Tour-de-Peilz, Switzerland
| | - Rajeev Chavda
- Galderma Prescription Global Business Unit, Rue d'Entre-deux-Villes, La Tour-de-Peilz, Switzerland
| | - Yevgeniy Semenov
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts; Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts
| | - Shawn G Kwatra
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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Williams KA, Roh YS, Brown I, Sutaria N, Bakhshi P, Choi J, Gabriel S, Chavda R, Kwatra SG. Pathophysiology, diagnosis, and pharmacological treatment of prurigo nodularis. Expert Rev Clin Pharmacol 2020; 14:67-77. [PMID: 33191806 DOI: 10.1080/17512433.2021.1852080] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Introduction: Prurigo nodularis (PN) is a chronic inflammatory skin disease characterized by intensely pruritic, hyperkeratotic nodules distributed on the trunk and extensor surfaces of the extremities. PN has a profoundly negative impact on sleep and quality of life in patients with PN. There are currently no U.S. Food and Drug Administration-approved agents and patients are often recalcitrant to current therapies, highlighting the importance of further research into this severely debilitating condition. Areas covered: A PubMed search was conducted to find available literature on the pathophysiology and clinical management of PN. In this review article, we discuss the current understanding of the pathophysiology, recommended diagnostic approach, and treatment options available for PN. Expert opinion/commentary: PN is an extremely difficult condition to treat, because there is a lack of effective therapies available due to our limited understanding of its pathophysiology. Currently, available treatment options are often multimodal due to the intersection of neuroimmune etiologic factors in the pathogenesis of PN. Fortunately, as our knowledge of PN expands, novel treatments targeting specific molecular biomarkers of PN are emerging, providing hope to this long-suffering patient population.
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Affiliation(s)
- Kyle A Williams
- Department of Dermatology, Johns Hopkins University School of Medicine , Baltimore, USA
| | - Youkyung S Roh
- Department of Dermatology, Johns Hopkins University School of Medicine , Baltimore, USA
| | - Isabelle Brown
- Department of Dermatology, Johns Hopkins University School of Medicine , Baltimore, USA
| | - Nishadh Sutaria
- Department of Dermatology, Johns Hopkins University School of Medicine , Baltimore, USA
| | - Pegah Bakhshi
- Department of Dermatology, Johns Hopkins University School of Medicine , Baltimore, USA
| | - Justin Choi
- Department of Dermatology, Johns Hopkins University School of Medicine , Baltimore, USA
| | - Sylvie Gabriel
- 27 Galderma Presciption GBU , La Tour-dePeilz, Switzerland
| | - Rajeev Chavda
- 27 Galderma Presciption GBU , La Tour-dePeilz, Switzerland
| | - Shawn G Kwatra
- Department of Dermatology, Johns Hopkins University School of Medicine , Baltimore, USA
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Practical approaches for diagnosis and management of prurigo nodularis: United States expert panel consensus. J Am Acad Dermatol 2020; 84:747-760. [PMID: 32682025 DOI: 10.1016/j.jaad.2020.07.025] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 07/03/2020] [Accepted: 07/05/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Prurigo nodularis (PN) is a chronic disease characterized by intensely pruritic, raised, nodular lesions. Because there are currently no United States Food and Drug Administration-approved therapies specifically for PN, management is highly variable, and no consensus exists on treatment regimens. OBJECTIVE To provide practical guidance to help United States dermatologists diagnose and effectively treat patients with PN. METHODS We participated in a roundtable discussion to develop consensus recommendations on diagnosis and treatment of PN from a United States perspective. RESULTS The core findings in PN are the presence of firm, nodular lesions; pruritus lasting at least 6 weeks; and a history or signs, or both, of repeated scratching, picking, or rubbing. The diagnostic workup involves a complete review of systems, considering potential systemic diseases, and assessment of disease severity, including disease burden and pruritus intensity. Treatment should be selected based on a patient's clinical presentation, comorbidities, and response to prior treatments and should address both neural and immunologic components of pruritus. LIMITATIONS Data on PN are from anecdotal or small clinical trials, and all treatments are currently used off-label. CONCLUSION An effective treatment approach for patients with PN should be based on clinical judgment and tailored to the individual needs of the patient.
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Fernandez JM, Hurlbert MG, Shi VY. Response: Management challenges in prurigo nodularis. J DERMATOL TREAT 2020; 33:583-584. [PMID: 32068455 DOI: 10.1080/09546634.2020.1729953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
| | | | - Vivian Y Shi
- Department of Medicine, Division of Dermatology, University of Arizona, Tucson, AZ, USA
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