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Biazus Soares G, Hashimoto T, Yosipovitch G. Atopic Dermatitis Itch: Scratching for an Explanation. J Invest Dermatol 2024; 144:978-988. [PMID: 38363270 DOI: 10.1016/j.jid.2023.10.048] [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: 08/26/2023] [Revised: 10/20/2023] [Accepted: 10/31/2023] [Indexed: 02/17/2024]
Abstract
Chronic pruritus is a cardinal symptom of atopic dermatitis (AD). The mechanisms underlying atopic itch involve intricate crosstalk among skin, immune components, and neural components. In this review, we explore these mechanisms, focusing on key players and interactions that induce and exacerbate itch. We discuss the similarities and differences between pruritus and pain in patients with AD as well as the relationship between pruritus and factors such as sweat and the skin microbiome. Furthermore, we explore novel targets that could provide significant itch relief in these patients as well as exciting future research directions to better understand atopic pruritus in darker skin types.
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Affiliation(s)
- Georgia Biazus Soares
- Miami Itch Center, Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Takashi Hashimoto
- Department of Dermatology, National Defense Medical College, Tokorozawa, Japan
| | - Gil Yosipovitch
- Miami Itch Center, Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA.
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Kambala A, Rajeh A, Joel MZ, Ma E, Cornman H, Zhang J, Kwatra SG. HLA DRB5∗01:01 is associated with pruritus in individuals with Fitzpatrick skin type IV-VI. J Am Acad Dermatol 2024; 90:855-857. [PMID: 38104778 DOI: 10.1016/j.jaad.2023.11.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 10/16/2023] [Accepted: 11/27/2023] [Indexed: 12/19/2023]
Affiliation(s)
- Anusha Kambala
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ahmad Rajeh
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Marina Z Joel
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Emily Ma
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Hannah Cornman
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jeni Zhang
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Shawn G Kwatra
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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Marani M, Madan V, Le TK, Deng J, Lee KK, Ma EZ, Kwatra SG. Dysregulation of the Skin-Liver Axis in Prurigo Nodularis: An Integrated Genomic, Transcriptomic, and Population-Based Analysis. Genes (Basel) 2024; 15:146. [PMID: 38397136 PMCID: PMC10887737 DOI: 10.3390/genes15020146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 01/06/2024] [Accepted: 01/18/2024] [Indexed: 02/25/2024] Open
Abstract
Pruritus has long been linked to hepatic dysfunction; however, there are limited data characterizing the association between liver disease and prurigo nodularis (PN), a chronic inflammatory skin disease featuring severe pruritis. We thus conducted a cross-sectional analysis of hepatic comorbidities in PN patients using TriNetX, a large global health research network. This analysis revealed that PN patients had a higher risk (p < 0.001) of developing liver cirrhosis, acute and subacute hepatic failure, inflammatory liver disease, chronic hepatitis, nonalcoholic steatohepatitis, portal hypertension, fatty liver, chronic passive congestion of the liver, and hepatocellular carcinoma compared with healthy controls. The cumulative incidence of liver disease was about three times higher in PN patients compared with healthy controls. These findings provided the basis for translational studies to investigate a genetic mechanism for this association. Cutaneous transcriptomic analysis performed on PN patients revealed the dysregulation of genes related to hepatic failure in lesional PN compared with both nonlesional PN and control skin. Similarly, gene set variation analysis (GSVA) revealed a significantly increased (p < 0.05) activation of liver metabolism, chronic hepatic failure, acute hepatic failure, cholestatic liver disease, polycystic liver disease, and hepatocellular carcinoma pathways in lesional PN compared with control skin. A subsequent genome-wide association study (GWAS) identified shared single-nucleotide polymorphisms (SNPs) in the genes AR, EDIL3, MACROD2, PCSK5, RUNX1T1, TENM4, and ZEB2 between PN and liver disease from the FinnGen cohort. Significant dysregulation of the skin-liver axis in PN patients may explain the increased incidence and severity of hepatic comorbidities and help identify future therapeutic targets for PN.
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Affiliation(s)
| | | | | | | | | | | | - Shawn G. Kwatra
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
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Mahmoud O, Choragudi S, Nwaopara A, Yosipovitch G. Prevalence of Chronic Pruritus in Elderly Black and White Inpatients: A Comparative Population Study. J Clin Med 2023; 12:5025. [PMID: 37568427 PMCID: PMC10420273 DOI: 10.3390/jcm12155025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 07/20/2023] [Accepted: 07/26/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND Black and geriatric patients were reported in small scale studies to have more intense chronic pruritus (CP). Studies comparing itch across geriatric racial groups are lacking. OBJECTIVES To compare the prevalence of CP in Black and White inpatients ≥ 65 years old as well as the top primary diagnoses of these populations. METHODS We used data from the National Inpatient Sample from 2016-2019 to analyze CP prevalence and ICD10-CM to identify diseases. The top five primary diagnoses were calculated for a subpopulation with CP. Sample characteristics were described, and the data was pooled and analyzed using IBM SPSS® Complex Sample modules. RESULTS Among hospitalized Black inpatients ≥ 65 years old, the prevalence of CP was 0.26% while in the White cohort it was 0.22%. The top five primary diagnoses in the Black population with itch were sepsis (4.2%); hypertensive heart and chronic kidney disease (CKD) with heart failure (HF) and stage 1-4 CKD, or unspecified CKD (4.1%); acute kidney failure (4.0%); hypertensive heart and CKD with HF with stage 5 CKD, or end-stage renal disease (2.1%); and hypertensive heart disease with HF (1.7%). The top five primary diagnoses in the White population were sepsis (4.25%); acute kidney failure (3.0%); hypertensive heart and CKD with HF and stage 1-4 CKD, or unspecified CKD (2.5%); cellulitis of left lower limb (1.9%); and unilateral primary osteoarthritis, right knee (1.9%). CONCLUSIONS Geriatric hospitalized Black patients demonstrated a higher prevalence of chronic itch compared with the White cohort, which may be related to the higher prevalence of chronic kidney disease in different stages of severity in this population.
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Affiliation(s)
| | | | | | - Gil Yosipovitch
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, Miami Itch Center, Miller School of Medicine, University of Miami, Miami, FL 33146, USA; (O.M.); (S.C.); (A.N.)
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Weisshaar E, Bentz P, Apfelbacher C, Haufe E, Heinrich L, Heratizadeh A, Abraham S, Harder I, Kleinheinz A, Wollenberg A, Schäkel K, Wiemers F, Ertner J, Augustin M, Wildberger J, Von Kiedrowski R, Worm M, Zink A, Effendy I, Asmussen A, Pawlak M, Sticherling M, Hilgers M, Handrick C, Quist S, Schwarz B, Bell M, Staubach-Renz P, Hong-Weldemann SH, Homey B, Brücher JJ, Weidinger S, Werfel T, Schmitt J. Itching in Atopic Dermatitis: Patient- and Physician-reported Outcomes in the German Atopic Dermatitis Registry TREATgermany. Acta Derm Venereol 2023; 103:adv00854. [PMID: 36688701 PMCID: PMC10391776 DOI: 10.2340/actadv.v103.4426] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 01/04/2023] [Indexed: 01/24/2023] Open
Abstract
TREATgermany is an investigator-initiated prospective disease registry. It investigates physician- and patient-reported disease severity (Eczema Area and Severity Index (EASI), objective Scoring Atopic Dermatitis (oSCORAD), Investigator Global Assessment, Patient-Oriented Eczema Measure (POEM), Patient Global Assessment (PGA)), patient-reported symptoms (itch, sleep loss, depressive symptoms), therapy courses and dermatological quality of life (DLQI) in moderate-to-severe atopic dermatitis with SCORAD > 20. 1,134 atopic dermatitis patients (mean age 41.0 ± 14.7 years, 42.5% females) were enrolled by 40 German recruiting sites (dermatological clinics and practices) between June 2016 and April 2021. The current analysis focuses on itch scores obtained with a numerical rating scale (NRS)) documented for the previous 3 days prior to baseline visit. The results show that 97.2% (1,090 of 1,121) patients experienced itch. Itch severity correlated moderately with severity of atopic dermatitis oSCORAD (rho = 0.44 (0.39-0.48)) and EASI score (rho = 0.41 (0.36-0.46)). A strong correlation was found with self-reported disease severity as PGA (rho = 0.68 (0.65-0.71)), POEM sum score (rho = 0.66 (0.63-0.69)) and dermatological quality of life impairment DLQI (rho = 0.61 (0.57-0.65)). Itch as a subjective complaint is more closely correlated with patient-reported outcomes than with objective assessments by the physician.
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Affiliation(s)
- Elke Weisshaar
- Occupational Dermatology, Department of Dermatology, University of Heidelberg.
| | - Philipp Bentz
- Occupational Dermatology, Department of Dermatology, University of Heidelberg
| | - Christian Apfelbacher
- Institute of Social Medicine and Health Systems Research, Otto von Guericke University Magdeburg, Magdeburg, Germany; Institute for Epidemiology and Preventive Medicine/Medical Sociology, University of Regensburg, Regensburg, Germany
| | - Eva Haufe
- Center of Evidence-based Healthcare, University Hospital and Medical Faculty Carl Gustav Carus, TU Dresden
| | - Luise Heinrich
- 4. Center of Evidence-based Healthcare, University Hospital and Medical Faculty Carl Gustav Carus, TU Dresden
| | - Annice Heratizadeh
- Division of Immunodermatology and Allergy Research, Department of Dermatology and Allergy, Hannover Medical School, Hannover
| | - Susanne Abraham
- Department of Dermatology, University Allergy Center, Medical Faculty Carl Gustav Carus, TU Dresden, Germany
| | - Inken Harder
- Center for Inflammatory Skin Diseases, Department of Dermatology and Allergy, University Hospital Schleswig-Holstein, Campus Kiel
| | | | | | - Knut Schäkel
- Department of Dermatology, University of Heidelberg
| | | | | | - Matthias Augustin
- Institute for Health Services Research in Dermatology, University Medical Center Hamburg Eppendorf
| | | | - Ralph Von Kiedrowski
- Focus Practice for chronic inflammatory dermatoses, skin cancer and allergology and also Study Center CMS3 (Company for Medical Study and Service), Selters/Westerwald
| | - Margitta Worm
- Department of Dermatology, Allergy and Venereology, Charité Berlin
| | | | - Isaak Effendy
- Department of Dermatology, OWL University Hospital of Bielefeld University, Campus Clinic Bielefeld
| | - Andrea Asmussen
- Practice Dr. med. Andrea Asmussen, Dermatology at Lesum, Bremen.
| | - Mario Pawlak
- Practice Dr. med. Anika Hünermund and Mario Pawlak, Heiligenstadt
| | - Michael Sticherling
- 21. Department of Dermatology, German Center for Immunotherapy, University of Erlangen
| | - Melanie Hilgers
- Clinics for Dermatology and Allergy, University Hospital Aachen
| | | | - Sven Quist
- Dermatology Clinic, Helix Medical Excellence Center, Mainz
| | | | | | | | | | - Bernhard Homey
- Department of Dermatology and Allergology, University Hospital Duesseldorf
| | | | - Stephan Weidinger
- Center for Inflammatory Skin Diseases, Department of Dermatology and Allergy, University Hospital Schleswig-Holstein, Campus Kiel
| | - Thomas Werfel
- Division of Immunodermatology and Allergy Research, Department of Dermatology and Allergy, Hannover Medical School, Hannover
| | - Jochen Schmitt
- Center of Evidence-based Healthcare, University Hospital and Medical Faculty Carl Gustav Carus, TU Dresden
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Kherlopian A, Fischer G. Identifying predictors of systemic immunosuppressive treatment of vulvovaginal lichen planus: A retrospective cohort study of 122 women. Australas J Dermatol 2022; 63:335-343. [PMID: 35500127 DOI: 10.1111/ajd.13851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/09/2022] [Accepted: 04/04/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Between 20% and 40% of women with vulvovaginal lichen planus (VLP) fail to respond to first-line ultra-potent topical corticosteroid treatment and require systemic immunosuppression to control disease. No data exist regarding risk factors for patients with severe VLP requiring systemic immunosuppression. We aimed to identify clinical features that predict women with VLP who are at risk of severe, recalcitrant disease requiring eventual escalation to systemic treatment. METHODS A chart review was performed on a cohort of 122 adult women with VLP followed prospectively for 15 years by the same clinician in a private dermatology practice in Australia between 1 January 2004 and 1 October 2021. Uni- and multivariable binary logistical regression analyses were performed to identify clinical features distinguishing women eventually requiring systemic treatment of VLP against those whose VLP was controlled with topical corticosteroids alone. RESULTS The mean age at diagnosis of VLP was 61 years, with 35 women (28.7%) requiring systemic treatment of VLP. A multivariable regression model utilising 'Age at Diagnosis' (adjusted OR = 0.97, 95% CI 0.94-0.99), 'Non-Caucasian Ethnicity' (adjusted OR = 10.3, 95% CI 2.27-73.9) and 'Vulvar Pruritus' (adjusted OR = 2.69, 95% CI 1.11-6.86) demonstrated moderate predictive capacity, with specificity and sensitivity for predicting whether a patient will require systemic treatment for VLP of 95.3% and 40.5%, respectively. CONCLUSIONS Our findings may indicate women with VLP who are younger, of non-Caucasian ethnicity, and presenting with vulval pruritus are the highest risk of severe disease requiring systemic immunosuppressive treatment and may benefit most from earlier initiation of systemic treatment.
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Affiliation(s)
- Ashod Kherlopian
- Department of Dermatology, Dermatology Research Office, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Gayle Fischer
- Department of Dermatology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
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Lehloenya RJ, Phillips EJ, Pasieka HB, Peter J. Recognizing Drug Hypersensitivity in Pigmented Skin. Immunol Allergy Clin North Am 2022; 42:219-238. [PMID: 35469616 PMCID: PMC9952815 DOI: 10.1016/j.iac.2022.01.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The imagery of pigmented skin is underrepresented in teaching materials such as textbooks, journals, and online references, and this has resulted in poorer diagnostic and management outcomes of skin pathology, including delayed cutaneous drug hypersensitivity reactions. In this review, we use clinical images to highlight factors that impact clinical presentations and sequelae of drug hypersensitivity reactions in pigmented skin compared with nonpigmented skin. We describe clinical features in some anatomic sites that aid diagnosis or are associated with more severe sequelae. Finally, we discuss strategies that may aid the diagnosis and management of these reactions in pigmented skin.
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Affiliation(s)
- Rannakoe J Lehloenya
- Division of Dermatology, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Dermatology ward G23, New Groote Schuur Hospital, Observatory, Cape Town 7925, South Africa; Combined Drug Allergy Clinic, Groote Schuur Hospital, Dermatology ward G23, New Groote Schuur Hospital, Observatory, Cape Town 7925, South Africa.
| | - Elizabeth J Phillips
- Center for Drug Safety & Immunology, Vanderbilt University Medical Center, Nashville, TN; Institute for Immunology & Infectious Diseases, Murdoch University, Murdoch, Western Australia, Australia
| | - Helena B Pasieka
- Department of Dermatology, Uniformed Serviced University, Bethesda, MD, USA; Department of Medicine, Uniformed Serviced University, Bethesda, MD, USA; Department of Dermatology, MedStar Washington Hospital Center/Georgetown University Hospital, Washington, DC, USA; The Burn Center, MedStar Washington Hospital Center, Washington, DC, USA
| | - Jonny Peter
- Combined Drug Allergy Clinic, Groote Schuur Hospital, Dermatology ward G23, New Groote Schuur Hospital, Observatory, Cape Town 7925, South Africa; Division of Allergy and Clinical Immunology, Department of Medicine, Groote Schuur Hospital, University of Cape Town Lung institute, George Street, Mowbray, 7925, Cape Town, South Africa; Allergy and Immunology Unit, University of Cape Town Lung Institute, Old Main Building, Groote Schuur Hospital, Anzio Road, 7925, Cape Town, South Africa
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Racial differences in dysregulation of the renin-angiotensin-aldosterone system in patients with prurigo nodularis. J Dermatol Sci 2022; 105:130-136. [DOI: 10.1016/j.jdermsci.2022.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/16/2022] [Accepted: 02/02/2022] [Indexed: 11/23/2022]
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Roh YS, Choi J, Sutaria N, Kwatra SG. Itch: Epidemiology, clinical presentation, and diagnostic workup. J Am Acad Dermatol 2022; 86:1-14. [PMID: 34428534 PMCID: PMC8678917 DOI: 10.1016/j.jaad.2021.07.076] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 07/24/2021] [Accepted: 07/28/2021] [Indexed: 01/03/2023]
Abstract
Itch, or pruritus, is the uncomfortable sensation underlying the desire to scratch. Itch is a very common complaint in the general population that can result from dermatologic, systemic (eg, renal, hepatobiliary, endocrine), paraneoplastic, neuropathic, and psychogenic etiologies. Chronic itch is associated with significant sleep disturbances and profoundly reduces overall quality of life. Certain populations, including elderly and African Americans, are at increased risk of experiencing heightened burden of itch. Because of the variable clinical presentation and wide-ranging etiologies, itch presents a challenge for clinicians. The initial evaluation should include a complete blood count, with differential, hepatic, renal, and thyroid function testing along with diabetes screening. Further testing should be guided by history and physical examination findings. There should be a heightened concern for underlying malignancy in individuals older than 60 years of age who have a history of liver disease and diffuse itch less than 12 months of duration. For individuals with chronic pruritus of unknown origin, increased blood eosinophils may serve as a biomarker of T helper cell type 2 polarization and response to immunomodulator therapies. In this first part of a 2-part continuing medical education series, we describe the broader epidemiology and specific conditions associated with itch and the clinical presentation and diagnostic workup for patients with itch.
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Affiliation(s)
- Youkyung S. Roh
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Justin Choi
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nishadh Sutaria
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - 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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