The antihistamine era for chronic itch is ending, said Gil Yosipovitch, MD, during his presentation at the 2019 Fall Clinical Dermatology Conference. Dr Yosipovitch is a professor of dermatology at the University of Miami and director of the Miami Itch Clinic in Miami, FL.
Pruritis is mediated by the neural system, he said. Nerves transmit the sensation similar to chronic pain.
Dr Yosipovitch reviewed data on crisaborole (Eucrisa), which showed the topical therapy improved itch after 2 days of use. “Now we have real world experience,” said Dr Yosipovitch, with crisaborole for hand eczema, dyshidrotic eczema, psoriasiform atopic eczema, and for the flexures of arms/thighs. He noted that crisaborole caused burning sensation when applied to the face.
Dupilumab (Dupixent) works for pruritus among patients with atopic dermatitis, as well as for other itchy dermatoses, noted Dr Yosipovitch. He also reviewed the role of IL-17, IL-31, and Janus kinase inhibitors for treating itch. One study, said Dr Yosipovitch, found ligelizumab improved chronic urticaria.
Other therapies Dr Yosipovitch reviewed in his presentation included ketamine 5% to 10%, which has a robust antipruritic effect that lasts from 30 minutes to 7 hours. However, this cannot be applied to the entire body, noted Dr Yosipovitch, due to risk of toxicity.
According to Dr Yosipovitch, substance P and neurokinin (NK)-1 are involved in both pain and itch in the periphery, spinal cord, and brain. Serlopitant, an NK-1 receptor antagonist, was found to reduce itch among patients with no specific cause for pruritis, stated Dr Yosipovitch, as well as been reported to reduce psoriatic itch and treat prurigo nodularis.
Dr Yosipovitch also discussed the use of aprepitant for chronic refractory itch, noting that the drug is expensive and did not show improvement compared with placebo for patients with prurigo nodularis in a double-blind study. He also discussed options for neuropathic itch, such as using mechanical barriers, topical therapies, and gabapentinoids. Another option Dr Yosipovitch reviewed was low-dose mirtazapine, which is a non-addictive antidepressant that has been reported to improve atopic dermatitis-associated itch, along with neuropathic, psychogenic, and idiopathic pruritis.
For systemic itch, there are not a lot of options, said Dr Yosipovitch. One option are k-receptor opioids, such as nalfurafine, butorphanol (Stadol), and CR845. Butorphanol, indicated for migraines, is a non-addictive kappa opioid administered as an inhaler but is still considered a controlled substance, noted Dr Yosipovitch. He said he prescribed it for patients with intractable chronic itch who failed other therapies.
This is a new era and there will be new drugs for our patients with pruritus, concluded Dr Yosipovitch. Dermatologists should expect multiple therapies in the pipeline to address the complexity of chronic itch, he added.
Yosipovitch G. What you have been itching to know about pruritis therapies. Presented at: 2019 Fall Clinical Dermatology Conference; October 17, 2019; Las Vegas, NV.