Intralesional triamcinolone acetonide in notalgia paresthetica: Treatment outcomes in five patients.

Numerous treatment modalities have been tried with diverse results for pruritus due to notalgia paresthetica (NP). Corticosteroids suppress ectopic neural discharges from injured nerve fibers and also have short-lived suppressive effect on transmission in normal C-fibers. Herein, we evaluated the efficacy of intralesional triamcinolone acetonide in the treatment of NP. The medical reports of five patients who had been diagnosed with NP and treated with intralesional triamcinolone acetonide injections were retrospectively evaluated. Triamcinolone acetonide solution was injected intradermally (10 mg/mL; 0.1 mL/cm2 ) every 3 weeks for a maximum of four treatments. The severity of itch was scored by the patients on a combined numerical and visual analogue scale. After treatment, reduction in itch severity scores varied between 33% and 100%.

Historical background of itch.

Itch as a disease, and especially as a symptom, was the object of medical and scientific curiosity for centuries. The reluctance of historians to focus on the history of itch relates to its nature as a subjective symptom. After all, how can historians have known what itch really felt like in previous centuries? Since the establishment of dermatology as an independent discipline of medicine in the middle of the nineteenth century, itch has become a subject of investigation in its own right. This chapter summarises research we conducted on the medical history of itch in ancient medicine and up through the twentieth century.

Systemic kappa opioid receptor agonists in the treatment of chronic pruritus: a literature review.

Chronic pruritus is frequently refractory to currently available treatments. Studies suggest that pruritus may arise from an imbalance of the mu- and kappa-opioid receptor system activity in either the skin or the central nervous system. Stimulation of kappa-opioid receptors by their agonists inhibits pruritus in both animals and humans. The antipruritic effect of kappa-opioid receptors agonists can currently be assumed to be related to their binding to kappa-opioid receptors on keratinocytes and cutaneous and/or central itch neurones. To date, several case reports and 2 controlled trials have demonstrated a beneficial effect of systemic kappa-opioid receptor agonists in the treatment of uraemic pruritus, prurigo nodularis, paraneoplastic and cholestatic pruritus. Nalfurafine hydrochloride (Remitch(®)), a selective kappa-opioid receptor agonist, is approved for the treatment of chronic pruritus in Japan. The aim of this review is to provide an overview of the promising role of kappa- opioid receptors and their agonist in the pathophysiology and treatment of pruritus.

Antipruritic treatment with systemic µ-opioid receptor antagonists: a review.

During the past two decades, systemic µ-opioid receptor antagonists (MORA) have been used in the treatment of various forms of chronic pruritus. In a number of case reports, case series, and controlled trials, treatment with MORA has demonstrated considerable antipruritic effects. In double-blind controlled studies, significant antipruritic relief has been achieved by MORA in cholestatic pruritus, chronic urticaria, and atopic dermatitis. In case reports and case series, antipruritic efficacy of MORA has been reported in prurigo nodularis, mycosis fungoides, postburn pruritus, aquagenic pruritus, hydroxyethyl starch-induced pruritus, and pruritus of unknown origin. However, most of the evidence remains anecdotal, the design of these trials varies, and comparison of results is difficult. In this review we aim to present an overview of these reports and to assess the evidence for the antipruritic action of the drugs naloxone, nalmefene, and naltrexone, which are currently in use for the treatment of chronic pruritus of different origins. We will also evaluate recommendations for the use of MORA in daily medical practice.

Topical imiquimod or fluorouracil therapy for basal and squamous cell carcinoma: a systematic review.

OBJECTIVES: To conduct a systematic review to determine clearance rates and adverse effects of topical imiquimod or fluorouracil therapy in the treatment of nonmelanoma skin cancers such as basal (BCC) and squamous cell carcinoma (SCC), and to develop recommendations for the use of topical imiquimod or fluorouracil to treat BCC and SCC. DATA SOURCES: MEDLINE, CANCERLIT, and Cochrane databases. STUDY SELECTION: Prospective, retrospective, and case studies in English containing a minimum of 4 subjects and a 6-month follow-up or posttreatment histologic evaluation. DATA EXTRACTION: We calculated the rate of clearance and adverse effects for BCC subtypes and invasive and in situ SCC treated with topical imiquimod or fluorouracil. DATA SYNTHESIS: Clearance rates varied by drug regimen, and most of the studies lacked long-term follow-up. Imiquimod use produced the following clearance rates: 43% to 100% for superficial BCC, 42% to 100% for nodular BCC, 56% to 63% for infiltrative BCC, 73% to 88% for SCC in situ, and 71% for invasive SCC. Fluorouracil use produced the following clearance rates: 90% for superficial BCC and 27% to 85% for SCC in situ. Up to 100% and 97% of patients applying imiquimod and fluorouracil, respectively, experienced at least 1 adverse event. Adverse event intensity ranged from mild to severe; erythema, pruritus, and pain were common. CONCLUSIONS: Evidence supports the use of topical imiquimod as monotherapy for superficial BCC and topical fluorouracil as monotherapy for superficial BCC and SCC in situ. Based on the available evidence, the strength of any recommendations for the use of these 2 agents in the primary treatment of these tumors is weak. We recommend that their use be limited to patients with small tumors in low-risk locations who will not or cannot undergo treatment with better-established therapies for which long-term clearance rates have been determined. Long-term clinical follow-up is essential for patients treated with topical imiquimod or fluorouracil. Limitations of therapy include high rates of adverse effects, lower clearance rates than other treatment modalities, dependence on patient adherence to treatment, and higher costs than other therapies.

Fate of manuscripts declined by the Journal of the American Academy of Dermatology.

BACKGROUND: Submissions to the Journal of the American Academy of Dermatology (JAAD) undergo a rigorous peer-review process. However, little is known regarding the fate of manuscripts declined by the JAAD. OBJECTIVE: We sought to: (1) determine the proportion of manuscripts declined by the JAAD that are subsequently published elsewhere; (2) identify the journals in which they were published; and (3) study whether the authors of declined manuscripts adopted in their final publications the changes suggested by the JAAD reviewers. METHODS: We reviewed the outcomes of the 489 submissions declined by the JAAD during two 4-month periods: from March 1, 2004, to June 30, 2004, and from March 1, 2005, to June 30, 2005. RESULTS: Of the 981 manuscripts submitted to JAAD during the two 4-month periods studied, 489 manuscripts (50%) were declined. Among the declined manuscripts, 201 (41%) had been subsequently published in other medical journals as of March 1, 2007. Among the 55 journals that published manuscripts declined by JAAD, 23 (42%) were nondermatology journals. The median impact factor for these 55 journals was 1.638, compared with the JAAD's impact factor of 2.402. Among the declined manuscripts, Case Reports comprised the largest proportion (n = 149, 31%), followed by Original Research Reports (n = 90, 18%). Overall, 46 (51%) rejected Original Research Reports were subsequently published, compared with 145 (36%) rejected submissions in other categories that were later published (P < .01). Among the 101 subsequently published manuscripts for which full texts were available, 82% of the authors incorporated at least one change suggested by the JAAD reviewers. The manuscripts that adopted JAAD-reviewer suggestions were published in journals with higher impact factors than those that did not incorporate any JAAD-reviewer suggestions (P = .0305). LIMITATIONS: It is possible that the average lag time of 28 months in this study is not sufficient for some rejected manuscripts to reach subsequent publication. CONCLUSIONS: Approximately half of the manuscripts rejected by the JAAD were subsequently published in other journals within 28 months, among which, roughly 40% went to nondermatology journals. The median impact factor of the journals that published JAAD-rejected manuscripts was lower than that of the JAAD. Rejected Original Research Reports have a significantly higher probability of being subsequently published than other category submissions. This may be a result of relative quality of Original Research Reports versus submissions for other sections of the journal (eg, Case Reports). Manuscripts that adopted JAAD-reviewer suggestions were subsequently published in journals with higher impact factors than those that did not incorporate JAAD-reviewer suggestions. This indicates that peer-reviewer comments can be useful and important for improving the quality of scientific publications.

Clinical classification of itch: a position paper of the International Forum for the Study of Itch.

Chronic itch is a common and distressing symptom that arises from a variety of skin conditions and systemic diseases. Despite this, there is no clinically based classification of pruritic diseases to assist in the diagnosis and cost-effective medical care of patients with pruritus. The proposed classification focuses on clinical signs and distinguishes between diseases with and without primary or secondary skin lesions. Three groups of conditions are proposed: pruritus on diseased (inflamed) skin (group I), pruritus on non-diseased (non-inflamed) skin (group II), and pruritus presenting with severe chronic secondary scratch lesions, such as prurigo nodularis (group III). The next part classifies the underlying diseases according to different categories: dermatological diseases, systemic diseases including diseases of pregnancy and drug-induced pruritus, neurological and psychiatric diseases. In some patients more than one cause may account for pruritus (category "mixed") while in others no underlying disease can be identified (category "others"). This is the first version of a clinical classification worked out by the members of the International Forum for the Study of Itch. It is intended to serve as a diagnostic route for better evaluation of patients with chronic pruritus and aims to improve patients' care.

Noxious heat and scratching decrease histamine-induced itch and skin blood flow.

The aim of this study was to assess the effect of thermal stimuli or distal scratching on skin blood flow and histamine-induced itch in healthy volunteers. Twenty-one healthy volunteers participated in the study. Baseline measurements of skin blood flow were obtained on the flexor aspect of the forearm. These measurements were compared with skin blood flow after various stimuli: heating the skin, cooling the skin, noxious cold 2 degrees C, noxious heat 49 degrees C, and scratching via a brush with controlled pressure. Afterwards histamine iontophoresis was performed and skin blood flow and itch intensity were measured immediately after the above-mentioned stimuli. Scratching reduced mean histamine-induced skin blood flow and itch intensity. Noxious heat pain increased basal skin blood flow but reduced histamine-induced maximal skin blood flow and itch intensity. Cold pain and cooling reduced itch intensity, but neither affected histamine-induced skin blood flow. Sub-noxious warming the skin did not affect the skin blood flow or itch intensity. These findings suggest that heat pain and scratching may inhibit itch through a neurogenic mechanism that also affects skin blood flow.

Itch and pruritus: what are they, and how should itches be classified?

Itch and pruritus are two terms for the same thing. In this essay I will argue that casting about for a distinction between them creates only confusion. Once that matter is settled, it is still necessary to come up with a clinical classification for itches of different types. No system yet proposed, including the one that will be suggested here, is perfect.

Willan's itch and other causes of pruritus in the elderly.

Itch in the elderly presents a diagnostic and therapeutic challenge. A thorough history, review of systems, and physical examination are critical to determining its cause. Examination of the skin may be misleading. There are frequently only secondary lesions, eczematous changes, lichenification, and excoriation, which may be misdiagnosed as a primary dermatitis. Xerosis may be the cause, but it is sometimes merely coincidental. If primary lesions are present, a skin biopsy can enable a diagnosis to be made. Systemic causes of itch, such as cholestasis, uremia, hyperthyroidism, medications, or lymphoma, must be considered. If the cause remains elusive, idiopathic itching of the elderly or so-called "senile pruritus" may be considered. However, we propose to discard the term "senile pruritus", which can be offensive and frightening. We propose to replace it with "Willan's itch". Robert Willan (1757-1812) is honored as one of the founders of modern dermatology thanks to his book, On Cutaneous Diseases, and its morphological approach to skin disease. He was probably the first to give a good clinical description of itching in the elderly. The diagnosis of Willan's itch should be reserved for generalized pruritus in the absence of xerosis or other recognizable cause. The pathophysiology of this form of pruritus is poorly understood, but it is likely that age-related changes of the skin, cutaneous nerves, and other parts of the nervous system play a role. Anecdotal and limited data suggest that gabapentin, cutaneous field stimulation, serotonin antagonists, and ultraviolet B phototherapy may attenuate itch in some of these patients.