Dupilumab for the Treatment of Prurigo Nodularis

Prurigo nodularis (PN) is a chronic inflammatory skin condition characterized by the presence of pruritic nodules. Dupilumab was approved by the US Food and Drug Administration in September 2022 and Health Canada in July 2023 for the treatment of PN. Dupilumab is a human monoclonal immunoglobulin G4 antibody that binds the interleukin (IL)-4 receptor alpha subunit, blocking intercellular signalling of IL-4 and IL-13. Inhibition of these cytokines downregulates the inflammatory response and improves disease severity and pruritus. Two randomized controlled trials have shown dupilumab to be effective in reducing pruritus and lesion count in patients with PN. The approval of dupilumab for PN represents the first approved therapy for PN and may indicate a paradigm shift in the way this condition is treated.

Vulvovaginal Issues in Mature Women

Mature women often present with symptomatic vulvovaginal atrophy and vulvar dermatoses, causing noncoital pain, dyspareunia, and sexual changes. Diagnosis of these conditions can be challenging, and long-term management is required to decrease morbidity and enhance quality of life. Vaginal estrogen therapies remain safe and effective for treating symptomatic vulvovaginal atrophy. A vulvar biopsy is easy to perform and generally well tolerated when indicated for the diagnosis of lichen simplex chronicus, lichen sclerosus, and lichen planus. Therapy with moderate- to high-potency corticosteroids is effective for these frequently debilitating conditions.

[Vulval dermatitis: localized condition--serious problem]

An overview of the literature of the dermatitis of the vulva is presented. The etiology, epidemiology, clinical manifestations, diagnosis, pathological diagnosis, treatment, and prevention of contact, allergic-contact, atopic, and seborrheic dermatitis of the vulva are described in details. Lichen simplex chronicus is additionally described as complication of chronic itching dermatitis.

Topical tacrolimus for the treatment of lichen simplex chronicus

Owing to severe itching and scratching, the natural course of lichen simplex chronicus (LSC) is clinically characterized by typical lichenoid lesions. Topical corticosteroids are often used to treat LSC but after withdrawal a relapse will sometimes occur. Therefore, LSC can be difficult to treat over time. We report a 13-year-old boy suffering from LSC on two symmetrical circumscribed areas on the temple, whose lesions healed completely with tacrolimus 0.1% ointment within approximately 9 months. During active treatment no adverse drug reaction was observed. The patient is completely free of symptoms 3 years after cessation of treatment. We conclude that topical tacrolimus can be used as an effective, long-lasting therapeutic modality in treating LSC, especially in sensitive skin areas such as the face.

Pimecrolimus Cream 1% for Treatment of Vulvar Lichen Simplex Chronicus: An Open-Label, Preliminary Trial

BACKGROUND

To evaluate efficacy and safety of pimecrolimus cream 1% twice daily for treatment of vulvar lichen simplex chronicus (LSC).

METHODS

Patients in this 12-week, open-label study had biopsy-proven vulvar LSC. Inclusion criteria were patient-reported Visual Analog Scale for Pruritus Relief > or = 3 (VAS-PR, 0 cm = no itching to 10 cm = severe itching) and Investigator's Global Assessment > or = 2 (IGA, 0 = no disease to 3 = severe disease). Safety was evaluated by adverse event reports and pimecrolimus blood level measurements.

RESULTS

Twelve women aged 25-53 years were enrolled. The median pruritus score (VAS-PR) decreased from 6 (min. 4.9, max. 9.0) at baseline to 0 cm at week 4 (max. 4.2), week 8 (max. 3.1) and week 12 (max. 2.1). Seven patients reported complete resolution of pruritus by week 4. Median IGA decreased from 2.5 (min. 2, max. 3) at baseline to 0 (min. 0, max. 2) at week 12. Erythema, excoriation, and lichenification improved for all patients. Pimecrolimus blood concentration for all samples was below the limit of quantification, 0.3 ng/ml. No adverse events were reported.

CONCLUSIONS

In this exploratory study, signs and symptoms of vulvar LSC improved for all women and pimecrolimus cream showed a favorable safety profile. Larger prospective studies are needed to further evaluate pimecrolimus for treatment of vulvar LSC.

Homoeopathy for the treatment of lichen simplex chronicus: a case series

Twenty-seven patients with chronic lichen simplex involving various parts of the body were treated. Hydrocotyle was prescribed to 21 patients in different potencies (6c, 30c, 200c, 1 M, 10 M), Thuja to three patients (1 M, 10 M), Graphites (6c), Kali bich (30c) and Sulphur (200c) to one patient each during 1 year study period. Only two patients showed complete improvement with Thuja and one with Graphites. In other cases, the response was limited to partial relief of [corrected] itching.

Treatment of the localized neurodermatitis by plum-blossom needle tapping and with the modified yangxue dingfeng tang--a clinical observation of 47 cases

OBJECTIVE

To observe the therapeutic effects of plum-blossom needle tapping combined with the modified yangxue dingfeng tang (a decoction for nourishing the blood and expelling wind) for the localized neurodermatitis.

METHODS

141 cases of the localized neurodermatitis were randomly divided into 3 groups. Forty-seven patients in the treatment group received local tapping and oral medication of the modified yangxue dingfeng tang which consisted of sheng di huang ([Chinese characters: see text] Radix Rehmanniae), dang gui ([Chinese characters: see text] Radix Angelicae Sinensis), chi shao ([Chinese characters: see text] Radix Paeoniae Rubra), tian dong ([Chinese characters: see text] Radix Asparagi), mai dong ([Chinese characters: see text] Radix Ophiopogonis), jiang can ([Chinese characters: see text] Bombyx Batryticatus), mu dan pi ([Chinese characters: see text] Cortex Moutan), chuan xiong ([Chinese characters: see text] Rhizoma Chuanxiong), he shou wu ([Chinese characters: see text] Radix Polygoni Multiflori), and quan xie ([Chinese characters: see text] Scorpio). Forty-seven patients in the control group I were simply given the modified yangxue dingfeng tang; and 47 patients in the control group II were treated with oral benadryl and Vitamin C plus local external application of 10% urea ointment. The treatment course for all the 3 groups lasted 30 days.

RESULTS

The short-term and long-term effects for the treatment group were much better than those of the 2 control groups (P < 0.05).

CONCLUSION

The plum-blossom needle tapping plus the modified yangxue dingfeng tang exhibits a better and stable effect for the localized neurodermatitis.

[Topical corticosteroids versus topical inhibitors of calcineurin]

Topical corticosteroids (TCC) have significantly shaped dermatological therapy for five decades. A few months ago the TCC were joined by competition, the topical inhibitors of calcineurin (TIC), wrongly termed topical immunomodulators. The present paper reviews the pharmacological effects and clinical efficacy of TIC, compares the risks, benefits and costs of those two groups of topical drugs and develops a position on the use of TIC. While TIC have ushered in a new era of topical anti-inflammatory therapy, the age of TCC is far from over.

Botulinum toxin type A injection in the treatment of lichen simplex: an open pilot study

Recalcitrant pruritus is a hallmark of lichen simplex, a localized variant of atopic dermatitis. Acetylcholine has been demonstrated to mediate pruritus in atopic dermatitis. This open pilot study was done to determine the therapeutic effect of blocking acetylcholine release with botulinum toxin A in highly pruritic lichen simplex. Botulinum toxin A (Dysport) was injected intradermally into 5 circumscribed lichenoid lesions in 3 patients suffering from recalcitrant pruritus. No corticosteroids or any other specific topical therapy was administered. Pruritus subsided within 3 to 7 days in all 3 patients. Within 2 to 4 weeks all lesions cleared completely. No recurrences were noted over a 4-month follow-up. In one patient lichen simplex developed on the contralateral shin, which responded equally to a subsequent injection. We concluded that lichen simplex-associated pruritus can be overcome by intradermal botulinum toxin A injection. Acetylcholine appears to be a dominant pruritic mediator in this condition.

The effect of topically applied aspirin on localized circumscribed neurodermatitis

BACKGROUND

Lichen simplex chronicus is a troublesome intractable itchy dermatosis, which may persist despite intensive topical treatments. Recently it has been demonstrated that topical aspirin solution with dichloromethane has a significant antipruritic effect in an experimentally induced itch.

OBJECTIVE

The aim of this double-blind, crossover placebo trial was to evaluate the efficacy of this solution in the treatment of lichen simplex chronicus.

METHODS

Twenty-nine patients with lichen simplex chronicus of at least 3 months' duration that did not respond to topical corticosteroids were randomized in a double-blind fashion to receive aspirin/dichloromethane solution in treatment period 1 for 2 weeks followed by placebo in treatment period 2 or placebo followed by aspirin in period 2 with a crossover design after a 2-week washout. The patients rated the pruritus intensity before and during therapy with a visual analog scale; a blinded investigator performed photographic assessment.

RESULTS

A significant therapeutic response was achieved in 11 (46%) of the patients who completed the study compared with 3 patients (12%) receiving placebo. Overall, aspirin-treated patients experienced an average decrease in the visual analog scale of 2.18 +/- 2.86 versus 0.69 +/- 2.31 of those receiving placebo. The difference between the 2 treatments for week 2 was significant (P =.03).

CONCLUSION

The study suggests that topical aspirin/dichloromethane might be a practical treatment for lichen simplex chronicus.

Unilateral, circumscribed, chronic dermatitis of the papillary-areolar complex: case report and review of the literature

Lichen simplex chronicus is a well-described, common pruritic disorder resulting from repeated rubbing and scratching. Typically, only one site is involved. When this site involves the papillary-areolar complex of one breast, the condition is termed unilateral, circumscribed, chronic dermatitis of the papillary-areolar complex. A patient with this uncommon condition is herein reported, and the literature, including a discussion of the differential diagnosis, is reviewed. An aggressive approach to the work-up of such a patient is recommended, to ensure accurate diagnosis and initiation of appropriate therapy.

Transmittance properties of flurandrenolide tape for psoriasis: helpful adjunct to phototherapy

BACKGROUND

Flurandrenolide tape is a valuable agent in the treatment of lichen simplex chronicus and in psoriasis. The corticosteroid is helpful for reducing the symptoms and induration of the lichen simplex chronicus lesion, and occlusion of the lesion with the tape reduces the patient's opportunity to rub and scratch the affected area.

OBJECTIVES

The purpose of this study was to determine to what extent flurandrenolide tape may block ultraviolet (UV) light and interfere with phototherapy of psoriasis.

METHODS

Flurandrenolide tape was applied to quartz spectroscopy cuvettes, and the absorption spectrum was determined using a Beckman DU-600 spectrophotometer. The effect of the tape on UV light transmission was also determined using our UVA-UVB office phototherapy unit.

RESULTS

Flurandrenolide tape has considerable UV absorption in the UVC range with less absorption in the UVB and UVA range. The transmittance is greater (less absorption) with longer wavelengths. There was greater UV absorption in the UVB range than in the UVA range.

CONCLUSION

Although flurandrenolide tape may be left in place during PUVA therapy, adjustment of UV dose or removal of the tape is probably needed during UVB phototherapy.

Vulvar dermatoses: lichen sclerosus, lichen planus, and vulval dermatitis/lichen simplex chronicus

In our vulvar specialty clinic at Oxford Radcliffe Hospital (Oxford, UK), dermatoses are frequently seen. A recent survey of new patients showed that lichen sclerosus was the most commonly diagnosed vulvar dermatosis; approximately one third of the women had this disorder. Vulvar dermatitis was observed in 20% to 25% of new patients, but lichen planus was rare. Differences were observed in treatment outcomes for patients with vulvar dermatoses, such as lichen sclerosus and lichen planus, versus those with dermatologic disorders affecting the vulva, such as psoriasis and eczema.

Lichen amyloidosus: a consequence of scratching

BACKGROUND

Lichen amyloidosus (LA) is generally said to be a pruritic type of amyloidosis of unknown cause. Histopathologically, it is characterized by epidermal changes of lichen simplex chronicus and by deposits of amyloid in the papillary dermis that are derived from keratin peptides of necrotic keratinocytes. Chronic scratching is responsible for the development of lichen simplex chronicus and may lead to necrosis of individual keratinocytes.

OBJECTIVE

Our purpose was to evaluate whether chronic scratching may also be responsible for the formation of amyloid in LA.

METHODS

We studied patients with LA in regard to histopathologic findings, onset of pruritus, associated diseases, and response to treatment.

RESULTS

In most cases, pruritus had preceded the skin lesions. Eight of nine patients suffered from diseases other than LA that may be associated with pruritus. Histopathologically, amyloid was confined to areas that also showed signs of lichen simplex chronicus. Systemic treatment with sedating antihistamines and intense local treatment with corticosteroids were found to be effective.

CONCLUSION

LA is considered to be a variant of lichen simplex chronicus in which scratching leads to necrosis of keratinocytes and eventually to the formation of amyloid in the papillary dermis. Because chronic scratching seems to be the cause and not the result of the deposits of amyloid, treatment should be directed at the amelioration of pruritus.

Pruritus circumscriptus sine materia: a sequel of postzosteric neuralgia. Evaluation by quantitative psychophysical examination and laser-evoked potentials

A case of circumscribed pruritus existing since 1 year on clinically uninvolved skin is reported, in which careful history revealed a 5-year previous episode of herpes zoster in the same dermatome. Impairment of cutaneous sensitivity was evaluated by use of a quantitative psychophysical examination and laser-evoked cortical potentials (LEP).

The antipruritic effect of 5% doxepin cream in patients with eczematous dermatitis. Doxepin Study Group

BACKGROUND AND DESIGN

Eczematous dermatitis is commonly characterized by intense pruritus. Current treatment modalities for this condition, regardless of its cause, are primarily directed at blunting the cutaneous inflammatory response and thereby providing relief of pruritus. To expand on our previous findings in atopic dermatitis, the present multicenter double-blind trial was conducted to evaluate the safety and antipruritic efficacy of 5% doxepin hydrochloride cream in patients with lichen simplex chronicus (n = 136), nummular eczema (n = 87), or contact dermatitis (n = 86). A total of 309 patients with moderate to severe pruritus were randomly assigned to apply either doxepin cream (n = 154) or vehicle cream (n = 155) to eczematous areas four times per day for a period of 7 days. Efficacy was assessed using a pruritus severity rating scale, a Physician's Global Evaluation for pruritus relief, and a Visual Analogue Scale for pruritus relief.

RESULTS

Twenty-four hours after initiation of treatment, and continuing throughout the remainder of the study, patients treated with doxepin cream experienced significantly greater pruritus relief than did vehicle-treated patients as determined by all efficacy parameters (P < .002). Sixty percent of doxepin-treated patients experienced pruritus relief within 24 hours. The response rate increased to 84% by conclusion of the study. As judged by significant changes (P < or = .05) occurring in at least one assessment of efficacy, doxepin cream provided pruritus relief in all forms of eczematous dermatitis that were examined. The study medication was well tolerated. The two most common adverse effects, stinging at the site of application and drowsiness, were usually transient and mild to moderate in severity.

CONCLUSION

Topical application of doxepin provides significant antipruritic activity with a favorable safety profile, suggesting a role for doxepin cream in the symptomatic treatment of pruritus associated with eczematous dermatitis.

[Thalidomide treatment of prurigo nodularis]

Twenty-two patients suffering from prurigo nodularis were treated with thalidomide 50-300 mg daily for an average of 12 months (two weeks to five years), following a special arrangement between the Danish Government and the producer Grünenthal GMBH, by which the Government took full economical responsibility for any claims related to the treatment. All patients received prior to treatment a detailed written information about all potential side-effects from the treatment, and had by their signature acknowledged, that they wished to be treated. All but two of the patients had an immediate pronounced effect on their main symptom, the tormenting itching. The same patients had a significant decrease in size and numbers of skin lesions after one to two months of treatment. However, the therapy had to be discontinued in thirteen patients (59%) due to side-effects. The most important side-effect, neuropathy, was the reason for discontinuation of thalidomide in five patients (22%). In spite of the high frequency of side-effects, we consider that this treatment modality should still be offered to the patients with the most severe symptoms due to the pronounced effect on this otherwise therapy resistant disease.

A review of two controlled multicenter trials comparing 0.05% halobetasol propionate ointment to its vehicle in the treatment of chronic eczematous dermatoses

The efficacy and safety of 0.05% halobetasol propionate ointment were evaluated in patients with chronic atopic or other eczematous dermatoses in two vehicle-controlled, double-blind studies: a paired-comparison study in 124 patients (study A) and a parallel-group study in 100 patients (study B). In study A, patients applied both treatments twice daily for 2 weeks and were evaluated by investigators on days 0, 7, and 14 with 0 to 3 severity scales and by self-assessment with two 5-step end-of-treatment rating scales. In study B, patients applied treatments twice daily for 2 weeks, and investigators made evaluations on days 0, 3, 7, and 14 with 0 to 6 scales and also made a 5-step end-of-treatment physician's global assessment. In study A, both severity scores and patient ratings favored halobetasol propionate significantly on days 7 (p less than or equal to 0.0013) and 14 (p less than 0.0001); in study B, severity scores on days 3 (p less than or equal to 0.045, pruritus, erythema, and overall lesion severity), 7, and 14 (p less than 0.001, all comparisons) also favored halobetasol propionate significantly, and global assessments showed complete resolution or marked improvement for 83% of patients using halobetasol propionate versus 28% of those using vehicle (p less than 0.0001). No instances of systemic effects or skin atrophy were reported in either study. We conclude that 0.05% halobetasol propionate ointment is highly effective and well tolerated in the treatment of the conditions studied, with the rapid action and high degree of clearing associated with superpotent corticosteroid formulations.

Double-blind bilateral paired comparison of 0.05% halobetasol propionate cream and its vehicle in patients with chronic atopic dermatitis and other eczematous dermatoses

Six investigators evaluated 0.05% halobetasol propionate cream and its vehicle in 111 patients with chronic atopic dermatitis and several other eczematous dermatoses. Patients applied treatment twice daily to bilateral lesions for 14 days. Investigators graded pruritus, erythema, scaling, papulation, and lichenification using 4-point severity scales on days 0, 7, and 14. On day 14 patients provided an assessment of efficacy for both treatments. Statistically significant differences favoring halobetasol propionate over the vehicle were seen for all signs and symptoms (p less than 0.001). Substantial improvements were achieved by the active treatment by day 7 (p less than 0.001). Patients assessments of efficacy were significantly higher for halobetasol cream than for vehicle (p less than 0.001). No instances of systemic effects or skin atrophy were reported and adverse experiences were limited to burning or stinging and other minor, nonspecific complaints distributed uniformly between active treatment and vehicle. These results demonstrate that 0.05% halobetasol propionate cream is highly effective in the treatment of atopic dermatitis and other eczematous dermatoses.

A double-blind, multicenter, parallel-group trial with 0.05% halobetasol propionate ointment versus 0.1% diflucortolone valerate ointment in patients with severe, chronic atopic dermatitis or lichen simplex chronicus

In a double-blind, parallel-group, multicenter, comparative trial in 120 evaluable patients with chronic, localized atopic dermatitis or lichen simplex chronicus, the success rate (described as "healed" and "marked improvement") was 91.5% in patients treated with halobetasol propionate ointment and 83.6% in those in the diflucortolone valerate treatment group. Of patients treated with halobetasol propionate ointment, 40.7% reported healing within 17 days, whereas of those in the diflucortolone valerate treatment group, 32.8% reported healing within that time. Early onset of therapeutic effect, that is, within 3 days of the start of treatment, was reported in a higher percentage of patients treated with halobetasol propionate ointment than in those treated with diflucortolone valerate ointment (70% versus 59%). Adverse effects at the site of application were less frequently reported in patients belonging to the halobetasol propionate treatment group than in those treated with diflucortolone valerate ointment (3% versus 8%).

A double-blind, multicenter trial of 0.05% halobetasol propionate ointment and 0.05% clobetasol 17-propionate ointment in the treatment of patients with chronic, localized atopic dermatitis or lichen simplex chronicus

In a double-blind, parallel-group, multicenter comparative trial in 127 evaluable patients with chronic, localized atopic dermatitis or lichen simplex chronicus, healing was reported in a higher percentage of patients treated with halobetasol propionate ointment than in those in the clobetasol propionate treatment group (65.1% versus 54.7%). The success rates (described as "healed" and "marked improvement") were practically identical in the two treatment groups (93.7% versus 92.2%). Early onset of therapeutic effect, that is, within 3 days of the start of treatment, was similar in the two treatment groups (24% versus 28%). Both preparations were well tolerated. Adverse effects were reported in 5% and 2% of the patients treated with halobetasol propionate and clobetasol propionate ointments, respectively.

[The use of the electrophoresis of water-insoluble preparations of fencarol and parmidine from dimexide solutions]

Hepatic mitochondrial respiration was recorded by polarography in various metabolic states using relevant substrates and inhibitors in rat male experiments in vivo and in vitro. The above measurements were made following electrophoresis of parmidine and phencarol in 50% dimexide solution. Parmidine from dimexide solution proved indifferent to mitochondrial energy apparatus, while phencarol could inhibit NADH-dehydrogenase link of the respiratory chain and arrest dimexide inhibition of succinate oxidase system. The findings provided a basis for therapeutic procedures which were tested in 105 patients. The immediate response of coronary and neurodermatitis patients appeared satisfactory.

[Clinical experiences of interval treatment with dermatologic agents containing urea]

Topical vehicles containing urea are increasingly used in dermatology because of their favorable pharmacological properties, which are due to the following capacities of urea: (1) its beneficial influence on the structure and physiology of the skin, and (2) its therapeutic effect in combination with other topically active agents in various skin diseases, such as psoriasis, ichthyosis, and chronic eczema. Our own experiences presented here are in accordance with these statements.