Pathophysiology and Treatment of Pruritus in Elderly

Symptom severity reflected by NYHA grade is independently associated with pruritus in chronic heart failure patients

BACKGROUND

Pruritus is a symptom profoundly impairing patients' quality of life (QoL). It is a common symptom in chronic heart failure (CHF) patients of yet unknown nature. The aim of this study was to evaluate the risk factors of pruritus in CHF patients.

METHODS

For this monocentric, prospective cohort study, CHF patients were recruited and CHF symptoms, comorbidities and drug intake were assessed using a structured report. Additionally, a questionnaire evaluated pruritus symptoms. Detailed medical histories including laboratory test results were retrieved from patient files for all participants.

RESULTS

We evaluated data from 550 CHF patients. Of those, 25.3% reported pruritus to occur frequently (3-5 times per week), often (1-2 times per week) or daily. Patients of higher NYHA classes (NYHA III + IV) experienced significantly more pruritus (31.2%) than lower NYHA classes (NYHA I + II) (21.1%, p = 0.024). Patients with pruritus reported disproportionately often concomitant stasis dermatitis (p = 0.026) and chronic lung disease (p = 0.014). Other parameters reflecting cardiac, liver, kidney and thyroid function, as well as medical therapies showed no significant differences between patients with and without pruritus. In the multivariate logistic regression analysis, only NYHA class (p = 0.016, OR 1.55, 95% confidence interval (CI): [1.09; 2.20]) and elevated leukocyte count (p = 0.007, OR 1.11, CI [1.03; 1.21]) remained significantly associated with pruritus in CHF patients.

CONCLUSIONS

NYHA class is an independent predictor for pruritus in CHF patients. Besides NYHA class, leukocyte count was also associated with increased pruritus. Pruritus may impair QoL in CHF patients and should thus be included in the assessment of those patients. We suggest that providing best care for CHF patients can be achieved through an interdisciplinary approach of cardiologists and dermatologists and should include a pruritus assessment.

Unmet needs in treating itch: reaching beyond eczema

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.

Delta opioid receptor expression correlates to skin ageing and melanin expression in Asian women

While the evidence for the implication of opioid receptors (OPr) in ageing is growing, there is, to our knowledge, no study focusing directly on changes in vivo cutaneous OPr expression with increasing age. We thus investigated OPr expression in 30 healthy female Asian volunteers in Southern China whose ages range from the early 20s to the early 60s. Excisional biopsies were taken from the sun-exposed extensor area of the lower arm and the photo-protected area of the upper inner arm. The thickness of the epidermal layers, melanin content, as well as expression of mu-opioid receptors (MOPr) and delta-opioid receptors (DOPr) were compared between different age ranges and photo-exposure status. Significant increased epidermal hypertrophy on the extensor surface was observed. There was significant reduction of DOPr in the epidermis with increasing age, independent of photo-ageing. The increase of melanin was significantly correlated with epidermal DOPr expression, not with MOPr expression. DOPr expression could thus serve as a marker for real biological ageing unaffected by chronic photo-exposure. Additionally, DOPr expression was inversely correlated with the deposition of melanin. Based on these results, we hypothesise that regulation of DOPr expression could be used to improve aged skin, including hyperpigmentation.

Model of Chronic Itch in Aged Mice: Beneficial Effects of Drugs Affecting Descending Modulatory Systems

Pruritus in the elderly, particularly those cases without skin dryness or other identifiable causes, makes treatment challenging due to the lack of evidence regarding the therapeutic effects of antipruritics. This study proposes an age-related alloknesis mouse model for an evaluation system for such cases, and aimed to investigate the effectiveness and mechanisms of action of several drugs commonly used as antipruritics in Japan, utilizing this model. Mice 69-80 weeks old were used as aged mice, and the level of mechanical alloknesis was counted as the number of scratching behaviours in response to innocuous stimuli. Bepotastine, neurotropin, pregabalin, baricitinib, and abrocitinib were used as antipruritics, and yohimbine and methysergide as inhibitors of the descending inhibitory pathway. The findings suggest that mechanical alloknesis in aged mice is a suitable animal model for assessing pruritus in the elderly without xerosis, and pregabalin, neurotropin, baricitinib, and abrocitinib may be effective antipruritics in the elderly through activating both the noradrenergic and serotonergic descending inhibitory pathways. These findings may be useful for the selection of antipruritics for pruritus in the elderly without skin lesions or dryness.

Effects of Siegesbeckia herba extract against particulate matter 10 (PM10 ) in skin barrier-disrupted mouse models

OBJECTIVES

Skin barrier disruption is a significant problem of the older population in an aging society. It is characterized by increased transepidermal water loss and decreased skin water content, and particulate matter (PM) is a social issue that can contribute to the exacerbation of skin inflammation. Thus, addressing this problem is urgent.

METHODS

Skin barrier-disrupted mouse models were induced by two methods using acetone application or tape-stripping. This study investigated the antioxidative and anti-inflammatory properties of the Siegesbeckia herba extract (SHE) on PM-induced changes in skin barrier-disrupted mouse models. To examine changes in skin water content, inflammatory cytokines, and keratinocyte differentiation markers, mouse models were treated with vehicle 100 μL, PM10 100 μL (100 μg/mL), SHE 100 μL, or PM10 100 μL (100 μg/mL) plus SHE 100 μL.

RESULTS

SHE preserved skin hydration in the skin barrier-disrupted mouse models regardless of the presence of PM10 . SHE also inhibited the upregulation of inflammatory cytokines such as interleukin (IL)-1β, IL-4, IL-6, IL-8, and tumor necrosis factor-α and normalized the downregulation of keratinocyte differentiation markers against PM10 in skin barrier-disrupted mouse models.

CONCLUSIONS

This study elucidated the therapeutic effects of SHE against PM10 in skin barrier-disrupted mouse models.

Circadian rhythm of cutaneous pruritus

One of the most common and significant symptoms for skin disorders is pruritus. Additionally, it serves as a significant catalyst for the exacerbation or reoccurrence of skin diseases. Pruritus seriously affects patients' physical and mental health, and even the quality of life. It brings a heavy burden to the patients, the families, even the whole society. The pathogenesis and regulation mechanisms for pruritus are complicated and have not yet been elucidated. Previous clinical studies have shown that itch worsens at night in scabies, chronic pruritus, atopic dermatitis, and psoriasis, suggesting that skin pruritus may change with circadian rhythm. Cortisol, melatonin, core temperature, cytokines, and prostaglandins are the main regulatory factors of the circadian rhythm of pruritus. Recent studies have shown that some CLOCK genes, such as BMAL1, CLOCK, PER, and CRY, play an important role in the regulation of the circadian rhythm of pruritus by regulating the Janus tyrosine kinase (JAK)-signal transducer and activator of transcription (STAT) and nuclear factor kappa-B (NF-κB) signaling pathways. However, the mechanisms for circadian clock genes in regulation of circadian rhythm of pruritus have not been fully elucidated. Further studies on the mechanism of circadian clock genes in the regulation of circadian rhythm of pruritus will lay a foundation for elucidating the regulatory mechanisms for pruritus, and also provide new ideas for the control of pruritus and the alleviation of skin diseases.

Improvement in Cutaneous Conditions Can Benefit Some Health Conditions in the Elderly

As we are aging, a number of cutaneous and extracutaneous disorders will be developed. Although the pathogenesis of these aging-associated disorders is not clear yet, abnormalities in the skin are linked to some aging-associated disorders at least to some extent. Inflammatory dermatoses such as psoriasis and atopic dermatitis predispose to the development of cardiovascular diseases, obesity and type 2 diabetes. In addition, both chronologically aged skin and individuals with some aging-associated systemic conditions display altered epidermal function, such as reduced stratum corneum hydration levels, which can provoke cutaneous inflammation. Because aged skin exhibits higher expression levels of inflammatory cytokines, which play a pathogenic role in a variety of aging-associated health condition, the association of the skin with some aging-associated disorders is likely mediated by inflammation. This postulation is supported by the evidence that improvement in either epidermal function or inflammatory dermatoses can mitigate some aging-associated disorders such as mild cognitive impairment and insulin sensitivity. This perspective discusses the association of the skin with aging-associated disorders and highlights the potential of improvement in cutaneous conditions in the management of some health conditions in the elderly.

Considerations in geriatric dermatopathology

This review provides an overview of considerations in geriatric dermatopathology. The nuances of specimen collection and reporting in this population, including the importance of obtaining adequate tissue, providing detailed clinical information and ethical considerations surrounding specimen collection will be discussed. The histopathologic changes associated with aging and the morphologic features of common lesions related to photoaging are outlined followed by a discussion of common interpretation pitfalls, specifically entities at risk of overinterpretation and those related to hyper- and hypopigmentation. Finally, the recent literature is reviewed regarding special cases and what this implies for future research both in dermatology and dermatopathology.

Scabies: an update for community nurses

Community nurses may encounter scabies in homeless people, those living in prisons, people living at home or in people living in care homes. Scabies is more prevalent in older adults and there is evidence that this infection is becoming more prevalent and difficult to treat. The community nurse can help reduce such risks. This article aims to enable the community nurse to be aware of the clinical features of scabies and how it is treated.

[Modern extemporaneous formulations in the geriatric care management: current opportunities and future challenges. A review]

Age-associated disorders, including cognitive functions, that often occur in geriatric patients, necessitate the use of novel approaches to provide appropriate medical care, pharmacoprophylaxis and pharmacotherapy among them. At the same time, an important objective of the national healthcare system is not only stimulating of pharmaceutical companies and pharmacies to expand the range of medicines intended for elderly patients, but also increasing availability of medicinal products, including the integration of extemporaneous formulations into clinical practice. Presented review considers several features of the regulation of the use of extemporaneous formulations in the treatment of geriatric patients. Examples of prescriptions that are used in Russian medical practice and are of the greatest interest in the treatment of elderly patients are also presented.

Association of Exposure to Wildfire Air Pollution With Exacerbations of Atopic Dermatitis and Itch Among Older Adults

This cross-sectional study evaluates the association of exposure to wildfire air pollution with exacerbations of atopic dermatitis and itch among adults aged 65 years or older.

Evaluation of the efficacy and safety of artemether emulsion on localized senile pruritus: A randomized pilot study

BACKGROUND

Localized senile pruritus is a continued health problem for the elderly. This study aimed to evaluate the efficacy and safety of artemether emulsion on localized senile pruritus.

METHODS

Sixty patients diagnosed with senile pruritus were randomized into the artemether emulsion (1%) group or emulsion base group in a 1:1 ratio (the artemether group vs the control group). The patients used artemether emulsion or emulsion base for pruritus twice daily for 2 weeks. The pruritus visual analog scale (VAS) and the rate of adverse events were evaluated in week 0 and week 2.

RESULTS

The VAS scores in week 2 after treatment decreased significantly compared with those before treatment in both groups (P < .05). After treatment, patients receiving the artemether emulsion had significantly lower mean VAS scores compared to those who received the emulsion base (1.21 ± 1.64 vs 3.67 ± 2.97, P < .05). When the VAS scores were compared between the 2 groups before treatment, the effective rate of the artemether group was significantly higher than that of the control group (χ2 = 55, P < .05) in week 2 after treatment. Besides, no adverse events occurred in both groups.

CONCLUSIONS

Both artemether emulsion and emulsion base were effective in treating localized senile pruritus, and artemether emulsion was superior to emulsion base.

Adverse reactions of ALA-PDT for the treatment of cutaneous diseases: A retrospective study

BACKGROUND

5-Aminolaevulinic acid photodynamic therapy (ALA-PDT) is an effective therapy for cutaneous diseases, such as precancers, superficial non melanoma skin cancers and certain inflammatory or viral conditions. However, the absence of a complete picture of adverse reactions limits the promotion of ALA-PDT.

OBJECTIVE

To systemically investigate the detailed evidence of adverse reactions relating to ALA-PDT for skin diseases.

METHODS

A retrospective study performed at the Shanghai Skin Disease Hospital.

RESULTS

In the retrospective study, 439 patients were included. Incidences of adverse reactions, including in-treatment pain (98.8%), erythema (92.4%), edema (35.0%), exudation (23.0%), hyperpigmentation (27.3%) were clarified. Edema was more common in female patients (P<0.05). Patients with HPV-related skin diseases were more likely to suffer erythema, edema or exudation (P<0.05). Hyperpigmentation was more likely to occur in skin appendage disorders (P<0.05). Fever (2.4%) and hypopigmentation (1.9%) are two neglected adverse reactions analyzed in detail. Fever is more prevalent in female patients. Hypopigmentation occurred predominantly in elderly with skin cancer or precancerosis lesions.

CONCLUSION

The results outline detailed information about the adverse reactions, including systemic reactions following ALA-PDT, assisting dermatologists in predicting and managing adverse reactions for greater efficacy and higher patient satisfaction.

A prospective study of adverse reactions of ALA-PDT for acne vulgaris

BACKGROUND

Acne vulgaris is a chronic inflammatory skin disease around pilosebaceous unit. 5-Aminolaevulinic acid photodynamic therapy (ALA-PDT) is an effective therapy for severe acne vulgaris. However, the lack of detailed information of adverse reactions limits the promotion of ALA-PDT in clinic.

OBJECTIVE

To systemically investigate the adverse reactions relating to ALA-PDT for acne vulgaris.

METHODS

A prospective study was performed at the Shanghai Skin Disease Hospital.

RESULTS

In the prospective study, 35 patients with acne vulgaris completed the trial. The adverse reactions were first divided into acute-phase adverse reactions, including erythema (94.3%), post-treatment pain (91.4%), burning skin (91.4%), dry skin (91.4%), itching (85.7%), pustule (82.9%), edema (20%) and blister (11.4%), or recovery-phase adverse reactions, which included crust (65.6%), exudation (48.6%) and hyperpigmentation (42.7%). Younger patients were more likely to have pustules (P<0.05). Male patients were represented itching more often than female patients (P<0.05). The efficacy of ALA-PDT for severe acne was positively related to the severity of acute-phase adverse reactions. The duration of pain was shortest. Crusting and hyperpigmentation lasted considerably longer.

CONCLUSION

In the present study, we recorded the relative incidence of various adverse reactions following ALA-PDT for acne vulgaris. The severity of adverse reactions tended to decrease with increased patient age, except for itching and hyperpigmentation. Light-to-moderate adverse reactions might be the inflammatory reactions of ALA-PDT, predicting a good efficacy. A form for evaluation of adverse reactions based on the present study could assist dermatologists in predicting and managing adverse reactions for greater efficacy and higher patient satisfaction.

New insight into chronic pruritus' characteristics and association with the demographic characteristics and sleep of community-dwelling older adults in Taiwan

This study aimed to understand the characteristics of chronic pruritus (CP), its correlations with sleep quality and demographic characteristics, and its impacts on sleep of older adults. This study used convenience sampling to recruit adults aged 65 or older and living at home. The prevalence rate of CP in older adults was 25.8%. Most subjects with CP reported mild pruritus on 1-2 anatomical parts, especially the lower extremities. Overall, the five domains of CP were correlated with the seven components of sleep quality (r > .14; p > .05) except for sleep disturbance. The global itchy scores were significantly different between different sexes, educational attainments, and marital statuses (p<.05-.001). CP, sex, and the number of comorbid diseases significantly contributed to global sleep quality (β = .26, -.19, .15, respectively; .000 ≤ p ≤ .011). This study provides new insight into the correlations of CP with marital status and educational attainment.

Granzyme B in Epithelial Barrier Dysfunction and Related Skin Diseases

The predominant function of the skin is to serve as a barrier - to protect against external insults and to prevent water loss. Junctional and structural proteins in the stratum corneum, the outermost layer of the epidermis, are critical to the integrity of the epidermal barrier as it balances ongoing outward migration, differentiation, and desquamation of keratinocytes in the epidermis. As such, epidermal barrier function is highly susceptible to upsurges of proteolytic activity in the stratum corneum and epidermis. Granzyme B is a serine protease scarce in healthy tissues but present at high levels in tissues encumbered by chronic inflammation. Discovered in the 1980s, Granzyme B is currently recognized for its intracellular roles in immune cell-mediated targeted apoptosis as well as extracellular roles in inflammation, chronic injuries, tissue remodeling, and processing of cytokines, matrix proteins, and autoantigens. Increasing evidence has emerged in recent years supporting a role for Granzyme B in promoting barrier dysfunction in the epidermis by direct cleavage of barrier proteins and eliciting immunoreactivity. Likewise, Granzyme B contributes to impaired epithelial function of the airways, retina, gut and vessels. In the present review, the role of Granzyme B in cutaneous epithelial dysfunction is discussed in the context of specific conditions with an overview of underlying mechanisms as well as utility of current experimental and therapeutic inhibitors.

Differential Diagnosis and Treatment of Itching in Children and Adolescents

Itching is prevalent in children with skin disorders and associated with effects on their mood, quality of life, and social functioning. Surprisingly, there are no data on childhood prevalence of pruritus in the general population. The aim of this article is to explore the epidemiology, clinical manifestation, and treatment for itch (pruritus) in the pediatric population (from infancy to adolescence), and to be helpful to primary care physicians who assess and diagnose pediatric patients with itching. In this study, we searched for specific keywords using PubMed and MEDLINE (Ovid) and, then, refined the retrieved searches for each cause and treatment. As a result of reviewing the literature, atopic dermatitis was shown to be the most common cause of itching, especially during infancy and through preschool. Not only skin disorders but also systemic diseases, drugs, and postburn states can predispose an individual to itching in childhood. There are traditional and newly developed treatment modalities for itching in pediatric patients. However, because the pharmacokinetics and pharmacodynamics of childhood are different from those of adults, the medications for itching have to be applied carefully for these age groups. There are many areas to be elucidated regarding the prevalence and objective assessment of pruritus in pediatric patients. Moreover, the safety profiles of medications in the pediatric population need to be better understood. Further studies to investigate itching in childhood are warranted.