Diagnosis and Management of Neuropathic Itch.

Neuropathic pruritus is a challenging condition that can be caused by injury or dysfunction in any part of the nervous system. A vast array of clinical pictures exist, including both localized and generalized pruritus, and their principal entities are described in this article. Diagnosis is often difficult and depends on patient history, imaging, and neurophysiologic studies. Other causes of chronic itch should be excluded. The management of neuropathic itch is demanding and the majority of interventions are not curative. The best treatment options include anticonvulsants, topical anesthetics, and capsaicin.

Multidisciplinary Management of Spondyloarthritis-Related Immune-Mediated Inflammatory Disease.

INTRODUCTION: Immune-mediated inflammatory diseases (IMIDs) are chronic autoimmune conditions that share common pathophysiologic mechanisms. The optimal management of patients with IMIDs remains challenging because the coexistence of different conditions requires the intervention of several specialists. The aim of this study was to develop a series of statements defining overarching principles that guide the implementation of a multidisciplinary approach for the management of spondyloarthritis (SpA)-related IMIDs including SpA, psoriasis, psoriatic arthritis, Crohn's disease, ulcerative colitis and uveitis. METHODS: A Delphi consensus-based approach was used to identify a core set of statements. The process included development of initial questions by a steering committee, an exhaustive search of the literature using complementary approaches to identify potential statements and two Delphi voting rounds for finalization of the statements. RESULTS: Consensus was achieved on the related nature of IMIDs, the existence of a high prevalence of multiple IMIDs in a single patient and the fact that a multidisciplinary approach can result in a more extensive evaluation and comprehensive approach to treatment. The goals of a multidisciplinary team should be to increase diagnosis of concomitant IMIDs, improve the decision-making process, and increase patient satisfaction and adherence. Early referral and diagnosis, early recognition of concomitant IMIDs and optimizing treatment to improve patient quality of life are some of the advantages of using multidisciplinary teams. To be effective, a multidisciplinary team should be equipped with the appropriate tools for diagnosis and follow-up, and at a minimum the multidisciplinary team should include a dermatologist, gastroenterologist and rheumatologist; providing psychologic support via a psychologist and involving an ophthalmologist, general practitioners and nurses in multidisciplinary care is also important. CONCLUSION: The present Delphi consensus identified a set of overarching principles that may be useful for implementation of a multidisciplinary approach for the management of SpA-related IMIDs. FUNDING: Aristea and Hippocrates.

Psoriasis and the metabolic syndrome.

Chronic plaque psoriasis is an immune-mediated inflammatory skin disease that is strongly associated with the clinical features of the metabolic syndrome (MetS), including abdominal obesity, hypertension, atherogenic dyslipidemia, type 2 diabetes, insulin resistance, and nonalcoholic fatty liver disease. The strength of these associations has been repeatedly confirmed by several observational studies. In particular, the prevalence of MetS in patients with psoriasis ranges from 20% to 50%, with a risk of having MetS is at least double in psoriatic patients compared with nonpsoriatic control individuals. MetS is also more common in patients with severe psoriasis than in those with mild skin disease. Emerging evidence now suggests that psoriasis and MetS share multiple metabolic risk factors, genetic background, and pathogenic pathways. The association between psoriasis and MetS has important clinical implications. Systemic conventional treatments should be used with caution in psoriatic patients with MetS, because they could adversely affect the coexisting metabolic disorders, especially in the case of their chronic use. Biologics appear to have a different safety profile compared with conventional treatments, and so they are usually tolerated. Collectively, dermatologists should pay close attention to the early recognition of coexisting metabolic disorders and give appropriate pharmacologic and nonpharmacologic (hypocaloric diet and regular exercise) recommendations to their patients.

Experimental elicitation of itch: Evoking and evaluation techniques.

Itch is a very common symptom of many skin diseases. Chronic itch may be very troublesome and may strongly impact on work ability, sleep and on the quality of life. Many studies have been conducted to define peripheral and central itch pathways, and to test the anti-pruritic effect of drugs, in which pruritus was experimentally evoked by chemical mediators and by physical stimuli. However, no objective methods to reproduce and to evaluate itch has been standardized. In this review we summarize the experimental techniques used to induce pruritus and to quantify it both in animal models and in humans.

Prurigo nodularis: an update on etiopathogenesis and therapy.

Prurigo nodularis (PN) is a chronic, highly pruritic condition characterized by the presence of hyperkeratotic, excoriated, pruritic papules and nodules, with a tendency to symmetrical distribution. No reliable data exist about incidence and prevalence of PN in the general population, but it seems to be more frequent and more intense in females. PN may be associated with many dermatological and non-dermatological comorbidities, including psychiatric disease. Recent findings suggest a neuropathic origin of PN, with alterations in the dermal and epidermal small diameter nerve fibers. PN may have a tremendous impact on the quality of life, and few effective treatment options are available. Few randomized controlled trials (RCT) on the therapy of PN are available, demonstrating the efficacy of phototherapy alone or with psoralen, and of topical calcipotriol and topical steroids in occlusive medications. Thalidomide may be effective, but no RCT are available and its use is impractical due to the unfavorable safety profile. Gabapentin, pregabalin and the neurokinin receptor 1 antagonist, aprepitant, seem also to be effective in the therapy of PN, but RCTs are still lacking.