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Sensitive Skin and Noneczematous Dermatoses
Published in Golara Honari, Rosa M. Andersen, Howard Maibach, Sensitive Skin Syndrome, 2017
Ian McDonald, Helen Rea, Martin Steinhoff
Many cutaneous dysthesias are associated with predominant symptoms of burning, stinging, and itch/pruritus. They typically exist within well defined areas in the absence of primary cutaneous signs. Although the exact pathomechanism in all dysthesias is not entirely clear, some are thought to result from specific nerve root pathology. They include scalp dysthesias buring scalp syndrome, anogenital dysthesa burning scrotum/vulva syndrome, brachioradial pruritus, meralgia parasthetica, notalgia parasthetica, and trigeminal tropic syndrome. Management of dysthesias begins by aiming to identify underlying causes (nerve root impingement). Treatment strategies depend on the subtype involved and include topical corticosteroids, capsaicin, some antidepressants (amitriptyline, venlafaxine), gabapentin, carbamazepine, and lamotrigine among others.
Current and emerging systemic treatments targeting the neural system for chronic pruritus
Published in Expert Opinion on Pharmacotherapy, 2020
Rachel Shireen Golpanian, Gil Yosipovitch
Inhibition of the NK-1 receptor has resulted in decreased itch perception. Aprepitant is an NK-1 inhibitor which demonstrated significant reductions in pruritus in patients with Sezary syndrome [80], brachioradial pruritus [81], cutaneous T-cell lymphoma [82], and pruritus related to biological cancer treatments [83]. Furthermore, this drug was also shown to treat chronic refractory pruritus in a cohort of 20 patients; interestingly, patients with atopic diathesis or prurigo nodularis experienced greater reductions of pruritus than those without dermatologic disease [84]. In contrast, in a phase II clinical trial seeking to determine the effect of aprepitant on itch intensity in 58 patients with prurigo nodularis, no significant differences were found between patients who received the drug versus placebo [85]. The major restriction when using aprepitant is drug interaction with other medications (i.e. corticosteroids, cyclophosphamide, alpha-blockers, diltiazem, amiodarone, and several anti-cancer drugs among many others), which may limit its use [86].
Notalgia paresthetica: treatment review and algorithmic approach
Published in Journal of Dermatological Treatment, 2020
Ahmed Ansari, David Weinstein, Naveed Sami
Acupuncture has also shown beneficial results in treating neurogenic pruritus based on a study involving one patient with NP, two patients with brachioradial pruritus, and thirteen patients with pruritus of unknown etiology. Deep intramuscular stimulation acupuncture to paravertebral muscles in the affected dermatomal segments was performed using 1–3 inch 32 G needles (duration of stimulation varied from several seconds to 1–2 min). Patients received one to two sessions per week until their pruritus decreased or resolved. Twelve patients had complete resolution of their pruritus and four patients had partial resolution with a median of four treatments (range 2–6). At 7-month follow-up, six patients relapsed and required further acupuncture. The author hypothesized that acupuncture decreases the neural irritation that can occur as the spinal nerves traverse the paraspinal muscles by stopping muscle spasm. Acupuncture was safe and well tolerated by all of the patients (42).
Novel drugs for the treatment of chronic pruritus
Published in Expert Opinion on Investigational Drugs, 2018
Manuel P. Pereira, Sonja Ständer
CP shows partial improvement or is refractory but does not show complete resolution to currently used therapies, such as non-sedating antihistamines, topical corticosteroids, or emollients. Often a multimodal approach, i.e., the combination of topical and systemic drugs, is necessary to achieve a clinically meaningful improvement of CP. Guidelines [5,6] recommend various agents according to the clinical presentation (CP on inflamed skin, CP on normal appearing skin and CP accompanied by chronic scratch lesions) and underlying etiology [2]. Regarding topical therapy options, in addition to steroids, calcineurin inhibitors such as pimecrolimus and tacrolimus may be employed for inflammatory dermatoses, while crisaborole was recently approved for the treatment of atopic dermatitis in the USA [7]. For localized neuropathic conditions (e.g. brachioradial pruritus, notalgia paresthetica or zoster neuralgia), capsaicin administered as a cream or an 8% high-dose patch is indicated [8,9]. As for systemic agents, immunosuppressive drugs such as cyclosporine or methotrexate (e.g. for inflammatory dermatoses), gabapentinoids such as gabapentin or pregabalin (e.g. for CP of neuropathic, nephrogenic, or cholestatic origin), antidepressants such as paroxetine or mirtazapine (e.g., for paraneoplastic pruritus) and mu-opioid receptor antagonists such as naloxone or naltrexone (e.g., for CP of unknown origin) are recommended by current guidelines [5,6]. Importantly, drugs acting at central nervous system level may be necessary to break the itch-scratch cycle once neuronal sensitization mechanisms have developed.