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Brooks SG, Yosipovitch G. Unmet needs in treating itch: reaching beyond eczema. J DERMATOL TREAT 2024; 35:2351487. [PMID: 38945542 DOI: 10.1080/09546634.2024.2351487] [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: 04/01/2024] [Accepted: 04/29/2024] [Indexed: 07/02/2024]
Abstract
PURPOSE Pruritus is an unpleasant sensation that creates the urge to scratch. In many chronic conditions, relentless pruritus and scratching perpetuates a vicious itch-scratch cycle. Uncontrolled itch can detrimentally affect quality of life and may lead to sleep disturbance, impaired concentration, financial burden, and psychological suffering. Recent strides have been made to develop guidelines and investigate new therapies to treat some of the most common severely pruritic conditions, however, a large group of diseases remains underrecognized and undertreated. The purpose of this article is to provide a comprehensive review of the challenges hindering the treatment of pruritus. METHODS An online search was performed using PubMed, Web of Science, Google Scholar, and ClinicalTrials.gov from 1994 to 2024. Included studies were summarized and assessed for quality and relevance in treating pruritus. RESULTS Several barriers to treating pruritus emerged, including variable presentation, objective measurement of itch, and identifying therapeutic targets. Itch associated with autoimmune conditions, connective tissue diseases, genodermatoses, cutaneous T-cell lymphoma, and pruritus of unknown origin were among the etiologies with the greatest unmet needs. CONCLUSION Treating pruritus poses many challenges and there are many itchy conditions that have no yet been addressed. There is an urgent need for large-scale controlled studies to investigate potential targets for these conditions and novel therapies.
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Affiliation(s)
- Sarah G Brooks
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, Miami Itch Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Gil Yosipovitch
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, Miami Itch Center, University of Miami Miller School of Medicine, Miami, FL, USA
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Müller S, Ständer S, Naatz M, Augustin M, Steinke S. Cost-effectiveness and Quality of Specialized and Routine Care in a German Cohort of Patients with Chronic Pruritus. Acta Derm Venereol 2023; 103:adv4868. [PMID: 37083094 PMCID: PMC10134063 DOI: 10.2340/actadv.v103.4868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 01/19/2023] [Indexed: 04/22/2023] Open
Abstract
Chronic pruritus is a prevalent interdisciplinary symptom with a strong influence on health-related quality of life. Patients need extensive diagnostics and long-term treatment. This retrospective and prospective cohort study compared routine and university-based specialized care in terms of cost-effectiveness and patient benefit. Direct medical and non-medical costs and patient-reported outcomes (PRO; pruritus intensity, quality of life, treatment needs and benefits) were assessed. Data analyses were conducted using descriptive methods and non-parametric statistical tests. A total of 300 adult patients (54.3% female) participated in the study. Six months after the treatment start in a specialized German pruritus care unit, the total costs were significantly reduced (mean total costs 686 € vs 433 € per patient per half year (total cohort); p < 0.001; mean out-of-pocket costs 198 € vs 124 € per half year (total cohort), p < 0.001). Pruritus intensity (numerical rating scale 5.3 vs 3.7, p < 0.001), quality of life (Dermatology Life Quality Index 8.9 vs 5.7, p < 0.001) and patient benefit (Patient Benefit Index Pruritus 1.2 vs 2.1, p < 0.001) improved significantly (total cohort). The results of this study show, that treatment of chronic pruritus patients in a specialized itch centre leads to an improvement in patient benefit and reduces the economic burden at the same time.
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Affiliation(s)
- Svenja Müller
- Department of Dermatology and Allergy; University Hospital Bonn, Bonn, Germany.
| | - Sonja Ständer
- Department of Dermatology and Center for Chronic Pruritus, University Hospital Münster, Germany
| | - Mandy Naatz
- German Center for Health Services Research in Dermatology (CVderm), University Medical Center Hamburg-Eppendorf (UKE), Germany
| | - Matthias Augustin
- German Center for Health Services Research in Dermatology (CVderm), University Medical Center Hamburg-Eppendorf (UKE), Germany
| | - Sabine Steinke
- Department of Dermatology and Center for Chronic Pruritus, University Hospital Münster, Germany; Bielefeld University, Medical School OWL, Germany
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Ahn YH, Kang HR. Pathophysiology, diagnosis, and management of chronic pruritus. ALLERGY ASTHMA & RESPIRATORY DISEASE 2021. [DOI: 10.4168/aard.2021.9.4.189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Yoon Hae Ahn
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Hye-Ryun Kang
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul, Korea
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Jockenhöfer F, Zaremba A, Wehrmann C, Benson S, Ständer S, Dissemond J. Pruritus in patients with chronic leg ulcers: A frequent and often neglected problem. Int Wound J 2019; 16:1464-1470. [DOI: 10.1111/iwj.13215] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 08/13/2019] [Accepted: 08/18/2019] [Indexed: 11/28/2022] Open
Affiliation(s)
- Finja Jockenhöfer
- Department of Dermatology, Venereology and AllergologyUniversity Hospital of Essen Germany
| | - Anne Zaremba
- Department of Dermatology, Venereology and AllergologyUniversity Hospital of Essen Germany
| | - Caren Wehrmann
- Department of Dermatology and VenereologyVivantes Hospital Neukölln Berlin Germany
| | - Sven Benson
- Institute for Medical Psychology and Behavioural ImmunobiologyUniversity Hospital of Essen Germany
| | - Sonja Ständer
- Competence Centre of chronic pruritus (CCP), Department of DermatologyUniversity Hospital of Münster Germany
| | - Joachim Dissemond
- Department of Dermatology, Venereology and AllergologyUniversity Hospital of Essen Germany
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Yosipovitch G, Rosen JD, Hashimoto T. Itch: From mechanism to (novel) therapeutic approaches. J Allergy Clin Immunol 2019; 142:1375-1390. [PMID: 30409247 DOI: 10.1016/j.jaci.2018.09.005] [Citation(s) in RCA: 194] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 08/27/2018] [Accepted: 09/07/2018] [Indexed: 12/13/2022]
Abstract
Itch is a common sensory experience that is prevalent in patients with inflammatory skin diseases, as well as in those with systemic and neuropathic conditions. In patients with these conditions, itch is often severe and significantly affects quality of life. Itch is encoded by 2 major neuronal pathways: histaminergic (in acute itch) and nonhistaminergic (in chronic itch). In the majority of cases, crosstalk existing between keratinocytes, the immune system, and nonhistaminergic sensory nerves is responsible for the pathophysiology of chronic itch. This review provides an overview of the current understanding of the molecular, neural, and immune mechanisms of itch: beginning in the skin, proceeding to the spinal cord, and eventually ascending to the brain, where itch is processed. A growing understanding of the mechanisms of chronic itch is expanding, as is our pipeline of more targeted topical and systemic therapies. Our therapeutic armamentarium for treating chronic itch has expanded in the last 5 years, with developments of topical and systemic treatments targeting the neural and immune systems.
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Affiliation(s)
- Gil Yosipovitch
- Department of Dermatology and Cutaneous Surgery and Miami Itch Center Miller School of Medicine University of Miami, Miami, Fla.
| | - Jordan Daniel Rosen
- Department of Dermatology and Cutaneous Surgery and Miami Itch Center Miller School of Medicine University of Miami, Miami, Fla
| | - Takashi Hashimoto
- Department of Dermatology and Cutaneous Surgery and Miami Itch Center Miller School of Medicine University of Miami, Miami, Fla
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Luk KM, Shaw FM, Zhang C, Culler SD, Chen SC. The Annual Direct and Indirect Health Care Costs for Patients with Chronic Pruritus and their Determining Factors. J Invest Dermatol 2019; 140:699-701.e5. [PMID: 31465742 DOI: 10.1016/j.jid.2019.07.711] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Revised: 07/12/2019] [Accepted: 07/16/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Kevin M Luk
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Fiona M Shaw
- Department of Internal Medicine, Division of Dermatology, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Chao Zhang
- Department of Biostatistics and Bioinformatics Shared Resource, Winship Cancer Institute, Atlanta, Georgia, USA
| | - Steven D Culler
- Department of Health Policy and Management, Rollins School of Public Health, Atlanta, Georgia, USA
| | - Suephy C Chen
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia, USA; Regional Telehealth Services, VISN 7, Atlanta, Georgia, USA.
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Metz M. Treatments for chronic pruritus outside of the box. Exp Dermatol 2019; 28:1476-1481. [DOI: 10.1111/exd.14007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 06/17/2019] [Accepted: 07/11/2019] [Indexed: 12/19/2022]
Affiliation(s)
- Martin Metz
- Department of Dermatology, Venereology and Allergology Charité ‐ Universitätsmedizin Berlin Berlin Germany
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Serlopitant reduced pruritus in patients with prurigo nodularis in a phase 2, randomized, placebo-controlled trial. J Am Acad Dermatol 2019; 80:1395-1402. [DOI: 10.1016/j.jaad.2019.01.052] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 01/17/2019] [Accepted: 01/21/2019] [Indexed: 01/30/2023]
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The Immunosuppressant Macrolide Tacrolimus Activates Cold-Sensing TRPM8 Channels. J Neurosci 2018; 39:949-969. [PMID: 30545944 DOI: 10.1523/jneurosci.1726-18.2018] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 11/02/2018] [Accepted: 11/18/2018] [Indexed: 12/30/2022] Open
Abstract
TRPM8 is a polymodal, nonselective cation channel activated by cold temperature and cooling agents that plays a critical role in the detection of environmental cold. We found that TRPM8 is a pharmacological target of tacrolimus (FK506), a macrolide immunosuppressant with several clinical uses, including the treatment of organ rejection following transplants, treatment of atopic dermatitis, and dry eye disease. Tacrolimus is an inhibitor of the phosphatase calcineurin, an action shared with cyclosporine. Tacrolimus activates TRPM8 channels in different species, including humans, and sensitizes their response to cold temperature by inducing a leftward shift in the voltage-dependent activation curve. The effects of tacrolimus on purified TRPM8 in lipid bilayers demonstrates conclusively that it has a direct gating effect. Moreover, the lack of effect of cyclosporine rules out the canonical signaling pathway involving the phosphatase calcineurin. Menthol (TRPM8-Y745H)- and icilin (TRPM8-N799A)-insensitive mutants were also activated by tacrolimus, suggesting a different binding site. In cultured mouse DRG neurons, tacrolimus evokes an increase in intracellular calcium almost exclusively in cold-sensitive neurons, and these responses were drastically blunted in Trpm8 KO mice or after the application of TRPM8 antagonists. Cutaneous and corneal cold thermoreceptor endings are also activated by tacrolimus, and tacrolimus solutions trigger blinking and cold-evoked behaviors. Together, our results identify TRPM8 channels in sensory neurons as molecular targets of the immunosuppressant tacrolimus. The actions of tacrolimus on TRPM8 resemble those of menthol but likely involve interactions with other channel residues.SIGNIFICANCE STATEMENT TRPM8 is a polymodal TRP channel involved in cold temperature sensing, thermoregulation, and cold pain. TRPM8 is also involved in the pathophysiology of dry eye disease, and TRPM8 activation has antiallodynic and antipruritic effects, making it a prime therapeutic target in several cutaneous and neural diseases. We report the direct agonist effect of tacrolimus, a potent natural immunosuppressant with multiple clinical applications, on TRPM8 activity. This interaction represents a novel neuroimmune interface. The identification of a clinically approved drug with agonist activity on TRPM8 channels could be used experimentally to probe the function of TRPM8 in humans. Our findings may explain some of the sensory and anti-inflammatory effects described for this drug in the skin and the eye surface.
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Yosipovitch G, Ständer S, Kerby MB, Larrick JW, Perlman AJ, Schnipper EF, Zhang X, Tang JY, Luger T, Steinhoff M. Serlopitant for the treatment of chronic pruritus: Results of a randomized, multicenter, placebo-controlled phase 2 clinical trial. J Am Acad Dermatol 2018; 78:882-891.e10. [DOI: 10.1016/j.jaad.2018.02.030] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Revised: 01/30/2018] [Accepted: 02/04/2018] [Indexed: 02/06/2023]
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Abstract
Chronic pruritus is a common condition that has a detrimental impact on quality of life. As the molecular pathogenesis of itch is elucidated, novel therapies that disrupt itch pathways are being investigated. Emerging treatments include drugs targeting the neural system, drugs targeting the immune system, antihistamines, bile acid transport inhibitors, and topical drugs that work through a variety of mechanisms such as phosphodiesterase-4 inhibition or targeting of nerve ion channels. Many of these therapies show promising results in the treatment of chronic itch of various etiologies, such as atopic dermatitis, psoriasis, uremic pruritus, and cholestatic pruritus.
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Affiliation(s)
- Matthew W McEwen
- Kaplan-Amonette Department of Dermatology, College of Medicine, University of Tennessee Health Science Center, 930 Madison Avenue, Suite 840, Memphis, TN 38163, USA
| | - Elizabeth M Fite
- Department of Dermatology, University of Tennessee Health Science Center, 930 Madison Avenue, Suite 840, Memphis, TN 38163, USA
| | - Gil Yosipovitch
- Department of Dermatology, Miami Itch Center, University of Miami, Miller School of Medicine, 1600 Northwest 10th Avenue, Rosenstiel Medical Science Building - Room 2023, Miami, FL 33136, USA
| | - Tejesh Patel
- Kaplan-Amonette Department of Dermatology, University of Tennessee Health Science Center, 930 Madison Avenue, Suite 840, Memphis, TN 38163, USA.
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Furue M, Kadono T, Tsuji G, Nakahara T. Topical E6005/RVT-501, a novel phosphodiesterase 4 inhibitor, for the treatment of atopic dermatitis. Expert Opin Investig Drugs 2017; 26:1403-1408. [PMID: 29068253 DOI: 10.1080/13543784.2017.1397626] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Local adverse effects of steroid use and the burning sensation of calcineurin inhibitors impair patients' adherence to treatment and decrease the treatment response in atopic dermatitis (AD). Steroid phobia appears to be a psychological problem in patients with AD. Topical non-steroidal remedies are in demand. Areas covered: This manuscript reviews the current literature on preclinical and clinical studies regarding topical E6005/RVT-501, a novel phosphodiesterase 4 inhibitor. We also discuss the mechanistic background of E6005/RVT-501 in the treatment of AD. Expert opinion: Topical E6005/RVT-501 improves skin eruption and pruritus of pediatric and adult AD patients without any serious side effects. It is useful for mild to moderate lesions of AD in pediatric and adult patients. Topical E6005/RVT-501 is non-steroidal agent but its potency is equal to that of mild rank topical steroid, therefore, it may fit the demand of patients with steroid phobia. Its steroid-sparing effects may also be investigated in future clinical trials and may minimize the dose and frequency of topical steroids.
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Affiliation(s)
- Masutaka Furue
- a Department of Dermatology , Kyushu University , Fukuoka , Japan.,b Division of Skin Surface Sensing, Department of Dermatology , Kyushu University , Fukuoka , Japan.,c Research and Clinical Center for Yusho and Dioxin , Kyushu University , Fukuoka , Japan
| | - Takafumi Kadono
- d Department of Dermatology , St Marianna University School of Medicine , Kawasaki , Japan
| | - Gaku Tsuji
- a Department of Dermatology , Kyushu University , Fukuoka , Japan
| | - Takeshi Nakahara
- c Research and Clinical Center for Yusho and Dioxin , Kyushu University , Fukuoka , Japan
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Nair VS, Chandrasekaran V, Jagadisan B, Biswal N. Chronic Pruritus in an 18-Month-Old Male Infant Due to Anicteric Cholestasis. J Trop Pediatr 2017; 63:321-323. [PMID: 28082665 DOI: 10.1093/tropej/fmw084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
An 18-month-old male infant was referred to us with pruritus from 6 months of age. He was being managed as atopic eczema with emollients and antihistamines without any response to treatment. On examination, he was found to have extensive scratch marks, mild hepatomegaly and no icterus. Blood investigations were suggestive of anicteric cholestatic liver disease. Liver biopsy was suggestive of progressive familial intrahepatic cholestasis type 3. He showed symptomatic improvement after starting ursodeoxycholic acid and fat-soluble vitamins and is under follow up.
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Affiliation(s)
- Vishnu S Nair
- Department of Paediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry 605006, India
| | - Venkatesh Chandrasekaran
- Department of Paediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry 605006, India
| | - Barath Jagadisan
- Department of Paediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry 605006, India
| | - Niranjan Biswal
- Department of Paediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry 605006, India
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Lee BH, Kim HK, Jang M, Kim HJ, Choi SH, Hwang SH, Kim HC, Rhim H, Cho IH, Nah SY. Effects of Gintonin-Enriched Fraction in an Atopic Dermatitis Animal Model: Involvement of Autotaxin Regulation. Biol Pharm Bull 2017; 40:1063-1070. [DOI: 10.1248/bpb.b17-00124] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Byung-Hwan Lee
- Ginsentology Research Laboratory and Department of Physiology, College of Veterinary Medicine, Konkuk University
| | - Ho-Kyoung Kim
- Mibyeong Research Center, Korea Institute of Oriental Medicine
| | - Minhee Jang
- Department of Convergence Medical Science, College of Korean Medicine, Kyung Hee University
| | - Hyeon-Joong Kim
- Ginsentology Research Laboratory and Department of Physiology, College of Veterinary Medicine, Konkuk University
| | - Sun-Hye Choi
- Ginsentology Research Laboratory and Department of Physiology, College of Veterinary Medicine, Konkuk University
| | - Sung-Hee Hwang
- Department of Pharmaceutical Engineering, College of Health Sciences, Sangji University
| | - Hyoung-Chun Kim
- Neuropsychopharmacology and Toxicology Program, College of Pharmacy, Kangwon National University
| | - Hyewhon Rhim
- Center for Neuroscience, Korea Institute of Science and Technology
| | - Ik-Hyun Cho
- Department of Convergence Medical Science, College of Korean Medicine, Kyung Hee University
| | - Seung-Yeol Nah
- Ginsentology Research Laboratory and Department of Physiology, College of Veterinary Medicine, Konkuk University
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Nocturnal Pruritus: The Battle for a Peaceful Night's Sleep. Int J Mol Sci 2016; 17:425. [PMID: 27011178 PMCID: PMC4813276 DOI: 10.3390/ijms17030425] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 03/16/2016] [Accepted: 03/16/2016] [Indexed: 12/26/2022] Open
Abstract
Chronic pruritus is a debilitating condition with numerous etiologies. Many patients suffer from nocturnal pruritus, which can decrease quality of life and affect mortality in hemodialysis patients. Nocturnal pruritus may occur in all sleep stages but is most prevalent in stages N1 and N2. Further research is needed to elucidate the pathophysiology of nocturnal itch, which will aid in the development of tailored management strategies.
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