Itching at night: A review on reducing nocturnal pruritus in children

Efficacy and safety of nemolizumab in paediatric patients aged 6-12 years with atopic dermatitis with moderate-to-severe pruritus: results from a phase III, randomized, double-blind, placebo-controlled, multicentre study

BACKGROUND

Atopic dermatitis (AD) is a chronic, inflammatory skin condition affecting up to one-quarter of children. Uncontrolled pruritus associated with childhood AD, and the accompanying scratching, negatively impacts quality of life (QoL), sleep and development. The humanized monoclonal antibody nemolizumab, used concomitantly with topical agents, was shown to reduce pruritus and improve QoL in patients with AD aged ≥ 13 years. However, data relating to its efficacy and safety in younger children (aged < 13 years) have been lacking.

OBJECTIVES

To evaluate the efficacy and safety of nemolizumab, administered concomitantly with topical agents, in Japanese paediatric patients (aged 6-12 years) with AD and inadequately controlled moderate-to-severe pruritus.

METHODS

This was a randomized, placebo-controlled, double-blind, parallel-group, multicentre, 16-week, phase III study. Patients aged ≥ 6 and < 13 years, with confirmed AD, and an inadequate pruritic response despite treatment with topical agents and oral antihistamines were randomly assigned (1 : 1) to receive nemolizumab 30 mg or placebo every 4 weeks (Q4W). The primary efficacy endpoint was the change in the weekly mean 5-level itch score from baseline to week 16; secondary efficacy endpoints were related to pruritus, indicators for AD and QoL. Safety was assessed via adverse events (AEs) and laboratory test results.

RESULTS

In total, 89 patients were enrolled, received either nemolizumab 30 mg (n = 45) or placebo (n = 44) Q4W, and completed the study. The mean patient age was 9.1 (SD 1.9) years, and mean duration of AD was 8.5 (2.7) years. The change in 5-level itch score from baseline to week 16 showed a statistically significant difference in the nemolizumab treatment group (-1.3) compared with placebo (-0.5; least-squares mean difference -0.8, 95% confidence interval -1.1 to -0.5; P < 0.0001). Improvements with nemolizumab were observed from the second day of administration. Secondary endpoints were in favour of nemolizumab. No AEs resulted in discontinuation, and the overall safety profile in patients aged 6-12 years was comparable with that in older patients (aged ≥ 13 years) with AD.

CONCLUSIONS

Nemolizumab is a potential new treatment option for paediatric patients with AD whose pruritus has not been sufficiently improved with topical treatments and antihistamines.

Self-stigma Among Children Living with Atopic Dermatitis in Hong Kong: a Qualitative Study

BACKGROUND

Stigma has been recently identified as a crucial factor associated with the psychosocial burden of those who have chronic skin diseases. The self-stigma experiences of children living with atopic dermatitis (AD) have yet to be fully investigated, and questions of how these children respond to public stigma and how AD symptoms further affect their self-stigma experiences remain unresolved. The current qualitative study aimed to (1) describe the main manifestations of self-stigma in children living with AD; (2) investigate factors that might influence their self-stigma experiences; and (3) explore the potential mechanisms underlying the impacts of AD on their psychosocial well-being from the self-stigma perspective.

METHODS

We performed a secondary analysis of the qualitative literal transcription data which were collected earlier by using the participatory, drawing-based qualitative interviews with 17 children aged 8-12 who were diagnosed with severe or moderate AD.

RESULTS

The qualitative findings indicated that the visible and invisible symptoms of AD and its management exerted unique influences on self-stigma in children living with AD, which manifested in cognitive, affective, and behavioral aspects and ultimately affected their psychosocial well-being.

CONCLUSIONS

Findings of this study allowed us to advocate for eliminating public stigma of people with skin diseases and propose recommendations for helping children living with AD relieve their self-stigma.

The Association between Melatonin Levels and Sleep Quality in Patients with Pruritus: A Potential Biomarker on a Candidate Future Treatment

Background:

Melatonin is a hormone that regulates the sleep–wake cycle and has immunomodulatory and anti-inflammatory roles.

Aims:

The aim of this study is to assess melatonin levels and investigate the association with pruritus severity, sleep quality, and depressive symptoms in dermatoses with nocturnal pruritus.

Methods:

The study was a prospective study with 82 participants, including 41 patients and 41 healthy volunteers. The visual analog scale (VAS), Pittsburg Sleep Quality Index (PSQI), and Beck Depression Inventory (BDI) were recorded for each patient. To assess the melatonin levels, urinary 6-sulfatoxymelatonin levels in the first urine in the morning were measured.

Results:

Melatonin concentrations were significantly lower (P = 0.007), while the BDI (P = 0.001) and PSQI (P = 0.001) scores were significantly higher in the patients with pruritus than in the healthy control subjects. There was an inverse correlation between melatonin levels and PSQI scores (r = −0.355, P = 0.023), and a positive correlation was detected between BDI scores and PSQI scores (r = 0.631, P = 0.001) in the pruritus group.

Conclusion:

Melatonin levels were found to decrease in relation to sleep quality in nocturnal pruritus patients. Low melatonin levels in these patients may be associated with sleep disorders and pruritus.

Patient Journey in Atopic Dermatitis: The Real-World Scenario

Introduction

The diagnosis and management of atopic dermatitis (AD) is extensively addressed in detailed clinical guidelines. However, the high heterogeneity regarding presentation and progression and the increasingly broad therapeutic landscape suggest a complex real-world scenario, leading to multiple trajectories of AD patients.

Methods

Using a Delphi methodology for assessing the degree of consensus, we explored the views of a panel of dermatologists regarding the patients’ trajectory through the diagnosis (block 1), treatment (block 2), and long-term management (block 3) of AD. Based on a systematic search of the literature, a scientific committee prepared a questionnaire of relevant items that were rated on a 10-point scale (from “totally agree” to “totally disagree”) by a panel of dermatologists attending patients with AD in the hospital setting. Consensus was established based on predefined rules.

Results

The final questionnaire included 58 items and was answered by 17 dermatologists. Overall, consensus was reached on 22 items (37.9%), each of which was a consensus for agreement. The consensus rates in blocks 1, 2, and 3 were 22.7%, 19.0%, and 86%, respectively.

Conclusions

Our analysis revealed a remarkable lack of consensus on various aspects of the routine diagnosis and treatment of AD. These findings suggest the presence of unmet needs or limited implementation of guidelines for the management of AD and encourage further research to explore the causes of this low consensus on the management of AD in the real-world setting.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13555-021-00592-y.

Postnatal maturation of spinal dynorphin circuits and their role in somatosensation

Inhibitory interneurons in the adult spinal dorsal horn (DH) can be neurochemically classified into subpopulations that regulate distinct somatosensory modalities. Although inhibitory networks in the rodent DH undergo dramatic remodeling over the first weeks of life, little is known about the maturation of identified classes of GABAergic interneurons, or whether their role in somatosensation shifts during development. We investigated age-dependent changes in the connectivity and function of prodynorphin (DYN)-lineage neurons in the mouse DH that suppress mechanosensation and itch during adulthood. In vitro patch clamp recordings revealed a developmental increase in primary afferent drive to DYN interneurons and a transition from exclusive C-fiber monosynaptic input to mixed A-fiber and C-fiber innervation. Although most adult DYN interneurons exhibited tonic firing as expected from their inhibitory phenotype, neonatal and adolescent DYN cells were predominantly classified as phasic or single-spiking. Importantly, we also found that most of the inhibitory presynaptic terminals contacting lamina I spinoparabrachial projection neurons (PNs) originate from DYN neurons. Furthermore, inhibitory synaptic input from DYN interneurons onto PNs was weaker during the neonatal period, likely reflecting a lower number of GABAergic terminals and a reduced probability of GABA release compared to adults. Finally, spinal DYN interneurons attenuated mechanical sensitivity throughout development, but this population dampened acute nonhistaminergic itch only during adulthood. Collectively, these findings suggest that the spinal "gates" controlling sensory transmission to the brain may emerge in a modality-selective manner during early life due to the postnatal tuning of inhibitory synaptic circuits within the DH.

Real-world comorbidities of atopic dermatitis in the pediatric ambulatory population in the United States

BACKGROUND

Increasing evidence has suggested the systemic nature of atopic dermatitis (AD), a common inflammatory skin condition in children. However, comprehensive analyses of real-world comorbidities in pediatric AD are limited.

OBJECTIVE

To characterize comorbidity burden in patients with AD aged <18 years old.

METHODS

The MarketScan commercial claims database was queried from January 1, 2017, to December 31, 2017. Age- and sex-matched analyses were used to compare patients with AD with general population controls.

RESULTS

A total of 86,969 pediatric patients with AD and 116,564 matched controls were identified. Increased anxiety (odds ratio [OR], 1.20) and attention-deficit hyperactivity disorder (OR, 1.11) were noted in patients with AD. In addition to dermatologic/allergic diseases, AD was also associated with infections, including methicillin-resistant Staphylococcus aureus (OR, 3.76), and autoimmune conditions, including vitiligo (OR, 2.98) and alopecia areata (OR, 4.32). Pediatric patients with AD had higher likelihoods of lymphoid/hematologic malignancies (OR, 1.94), ocular disorders (OR, 1.37-2.02), metabolic syndrome (OR, 1.61), and obesity (OR, 1.81). For all the ORs mentioned above, P was <.001.

LIMITATIONS

Retrospective analysis of health care claims data.

CONCLUSIONS

AD in pediatric patients was associated with a wide range of psychologic and systemic comorbidities. Increased awareness can help minimize its negative effects on the quality of life and prevent long-term health consequences in young patients with AD.

Sleep disturbance in adults with chronic pruritic dermatoses is associated with increased C-reactive protein levels

BACKGROUND

Pruritus is a common symptom that can significantly reduce quality of life through sleep disruption.

OBJECTIVE

To examine features of disturbed sleep in patients with chronic pruritic dermatoses and test the hypothesis that systemic inflammation may serve as a biomarker for impaired sleep in these patients.

METHODS

Cross-sectional analysis of the National Health and Nutrition Examination Survey investigating systemic inflammation using C-reactive protein (CRP) levels. Logistic regression was used to compare patients with and without sleep disturbances, adjusting for demographics (model 1) and medical comorbidities (model 2).

RESULTS

Chronic pruritic dermatoses were associated with multiple sleep disturbances, including nighttime awakenings (model 1: odds ratio [OR], 1.646; 95% confidence interval [CI], 1.031-2.627; model 2: OR, 1.329; 95% CI, 0.888-1.989) and early morning awakening (model 1: OR, 1.669, 95% CI, 1.118-2.493; model 2: OR, 1.582; 95% CI, 1.008-2.481). Mean CRP levels were 52.8% higher among patients with pruritic dermatoses reporting trouble sleeping compared with those who did not (0.663 vs 0.434 mg/dL; P = .034). Trouble sleeping was also positively correlated with CRP levels (β = 0.142, P = .025).

LIMITATIONS

Potential recall bias among participants.

CONCLUSIONS

In addition to confirming sleep disturbances with pruritic dermatoses, we found these disturbances are more likely to present with elevated CRP levels. Clinicians should consider the potential risk for sleep-related and cardiac comorbidities in patients diagnosed with itchy skin conditions.

Emerging Research in Chronic Pruritus: From Bedside to Bench and Back Again

This Medicines special issue highlights emerging research spanning from epidemiology to diagnostic workup, pathogenesis, and therapeutics for patients suffering from chronic pruritus. The special issue contains 13 articles reporting relevant epidemiologic and experimental data on chronic pruritus.

Clinical Validity of the PROMIS Pediatric Sleep Measures across Populations of Children with Chronic Illnesses and Neurodevelopment Disorders

OBJECTIVE

To examine the clinical validity of the Patient Reported Outcome Measurement Information System (PROMIS) Pediatric Sleep Disturbance (SD) and Sleep-Related Impairment (SRI) short forms.

METHODS

Youth (8-17 years) from clinical populations with known SDs (sleep clinic n = 126, autism n = 276, asthma n = 82, asthma + eczema n = 68) and the general population (n = 902) completed the PROMIS Pediatric SD and SRI 8-item short forms, along with established measures of sleep (Children's Report of Sleep Patterns, Sleep Habits Survey), PROMIS Pediatric Fatigue, and parent-reported clinical indicators (does child have sleep problem, use melatonin, use prescription sleep medication).

RESULTS

Confirmatory factor analyses demonstrated factorial invariance for all clinical groups. Significant differences between the general population and clinical groups were found for SD and SRI (medium to large effect sizes). Convergent validity was demonstrated through separate hierarchical regression models that showed significant associations between parent-reported clinical indicators and SD and SRI, above and beyond clinical group, as well as moderate to strong correlations between the PROMIS sleep measures and both established measures of sleep and fatigue.

CONCLUSIONS

The PROMIS Pediatric SD and SRI short forms provide clinicians and researchers a brief, accurate, and valid way to measure patient-reported sleep outcomes in pediatric populations.