Treating Chronic Pruritus: Are We at the Threshold of a Breakthrough?

Chronic pruritis, characterized by persistent itchiness lasting more than six weeks, affects up to 15% of the population, significantly impairing quality of life. Despite its prevalence and impact, there is an absence of FDA-approved medications specifically for the treatment of chronic pruritus, highlighting a significant unmet need in dermatology. Advancements in dermatologic medications, however, including the development of biologics and Janus kinase (JAK) inhibitors, signal potential breakthroughs in pruritus management through a radically different mechanism of action that focuses on their effect on the nervous system. Currently, the most commonly utilized treatments for pruritis are sedating antihistamines, which have been largely ineffective for non-histamine-induced itch, underscoring the necessity for novel approaches. This editorial reviews key studies and clinical trials with a particular focus on cases of prurigo nodularis, where itch serves as the primary pathology rather than just a symptom. The effectiveness of dupilumab in phase III trials for treating prurigo nodularis, independent of its effects on dermatitis or atopic background, alongside the success of JAK inhibitors in managing chronic idiopathic pruritus, indicates a shift towards therapies that directly and specifically target itch nerve pathways instead of indirectly via immune system modulation or sedation. These developments suggest that significant progress may be on the horizon for treating chronic itch, providing hope for those suffering from pruritis, the number one cause of misery in dermatology.

Commercial Diagnostics and Emerging Precision Medicine Technologies in Psoriasis and Atopic Dermatitis.

While psoriasis and atopic dermatitis (AD) are two common dermatological conditions, their diagnosis and therapeutic decision-making pathways are often complex. As a result, there has been increased focus on the development of precision medicine approaches for psoriasis and AD. Two companies at the forefront of dermatology precision medicine research are Mindera Health and Castle Biosciences. Here, we review the technologies developed by these two companies using a dermal diagnostic patch and superficial skin scrapings, respectively, their research published to date, and their future research goals. Research from both companies shows promise in predicting the response of inflammatory skin disease to biologics using minimally invasive techniques. However, challenges to adoption include insurance coverage and patient trust in the technologies. While there are several differences between Mindera Health and Castle Biosciences, they have a shared goal of utilizing minimally invasive technologies to sample skin and predict response to biologic treatments using a panel of optimized biomarkers.

Risk of Cutaneous T Cell Lymphoma with Psoriasis Biologic Therapies.

BACKGROUND: The risk of developing cutaneous T cell lymphoma (CTCL) in patients using psoriasis biologics has not been well characterized. The goals of this review were to investigate the incidence of CTCL in patients with psoriasis receiving biologic therapy in clinical trials and psoriasis registries, and to review cases of CTCL and biologic use reported in scientific publications. METHODS: The US National Library of Medicine clinical trials database (clinicaltrials.gov) was queried to identify phase 3 and 4 clinical trials of the 12 biologic agents currently FDA approved for psoriatic disease. The incidence of CTCL in these trials was examined and summarized. To examine the incidence of CTCL in psoriasis registries, a Medline search was conducted. Finally, we performed a systematic review of CTCL cases reported in the literature. RESULTS: Only two cases of CTCL were reported in 35,801 subjects with psoriasis receiving a biologic agent in the active arm of 108 psoriasis phase 3 clinical trials. One of these CTCL cases was determined by the investigator to be CTCL misdiagnosed as psoriasis prior to randomization. No cases of CTCL were reported in 5440 subjects with psoriasis in 34 phase 4 clinical trials. Only one case of CTCL was identified in 34,111 registry subjects. In the literature, tumor necrosis factor (TNF) inhibitors had the highest number of reported cases of CTCL (34 cases), followed by interleukin (IL)-17 inhibitors (7 cases), and IL-12/23 inhibitors (6 cases). No cases of CTCL were found to be reported with IL-23 inhibitors. CONCLUSION: Our findings indicate that the development of CTCL is rare in the setting of psoriasis biologic use. Of the limited number of cases of CTCL found, most were in the setting of TNF inhibitor use and no cases of CTCL were reported in the setting of IL-23 inhibitor use.

Adapting the Goeckerman Regimen for Psoriasis Treatment in Kenya: A Case Study of Successful Management in a Resource-Limited Setting.

Introduction:  Goeckerman therapy, which combines ultraviolet B (UVB) light with crude coal tar (CCT), remains highly effective for moderate-to-severe psoriasis. While it is rarely still used in the USA as effective biotherapeutics have become more readily available, it offers an alternative therapy in developing countries with limited access to newer medications. Moi Teaching & Referral Hospital (MTRH) in Eldoret, Kenya, in collaboration with UCSF, developed a modified Goeckerman regimen suitable for local healthcare needs, condensing the treatment into an intensive two-week program. Case Report:  A 55-year-old female with erythrodermic psoriasis traveled 350 kilometers to MTRH. After the diagnosis was confirmed, she underwent a nine-day inpatient treatment with narrow-band UVB phototherapy and topical medications under occlusion as a modified Goeckerman regimen. Response to Treatment:  Significant improvement was observed within three days, with full recovery in ten days. Follow-up one month later showed no active lesions, and her psoriasis remained controlled for four months with topical treatments. Conclusion:  The modified Goeckerman regimen at MTRH, in collaboration with UCSF, effectively treated severe psoriasis in a challenging healthcare context. This case highlights the potential for adapting established treatments to improve patient outcomes in developing countries with limited access to systemic therapies.

Advancing Psoriasis Care through Artificial Intelligence: A Comprehensive Review.

Purpose of Review: Machine learning (ML), a subset of artificial intelligence (AI), has been vital in advancing tasks such as image classification and speech recognition. Its integration into clinical medicine, particularly dermatology, offers a significant leap in healthcare delivery. Recent Findings: This review examines the impact of ML on psoriasis-a condition heavily reliant on visual assessments for diagnosis and treatment. The review highlights five areas where ML is reshaping psoriasis care: diagnosis of psoriasis through clinical and dermoscopic images, skin severity quantification, psoriasis biomarker identification, precision medicine enhancement, and AI-driven education strategies. These advancements promise to improve patient outcomes, especially in regions lacking specialist care. However, the success of AI in dermatology hinges on dermatologists' oversight to ensure that ML's potential is fully realized in patient care, preserving the essential human element in medicine. Summary: This collaboration between AI and human expertise could define the future of dermatological treatments, making personalized care more accessible and precise.

Psoriasis and Sleep Disturbance: A US Population-Based Study Using the NHANES Database.

INTRODUCTION: Psoriasis, a chronic inflammatory skin condition, affects approximately 3.0% of the US population, with patients often experiencing significant sleep disturbances. These disturbances include a higher prevalence of conditions such as obstructive sleep apnea, restless leg syndrome, and insomnia. Given the additional risks for cardiovascular disease, metabolic disorders, and depression linked to both poor sleep and psoriasis, addressing sleep issues in this patient group is critical. METHODS: The study utilized National Health and Nutrition Examination Survey (NHANES) data, focusing on individuals aged ≥ 20 years who provided information on psoriasis status and sleep. Multistage stratified survey methodology was applied, with multivariable logistic regression models used to examine the association between psoriasis and sleep issues, adjusting for factors such as age, gender, and health history. RESULTS: Psoriasis diagnosis was significantly associated with trouble sleeping (adjusted odds ratio [aOR] 1.88; 95% confidence interval [CI] 1.44-2.45). There was no significant association between psoriasis and sleep quantity. Older age, female gender, and a history of sleep disorders were predictors of trouble sleeping among psoriasis patients. CONCLUSIONS: Psoriasis is significantly associated with sleep disturbances, independent of sleep duration. This underscores the need for clinical screening focusing on sleep quality rather than quantity in psoriasis patients to effectively identify and treat sleep-related comorbidities. Further research using objective sleep measures is warranted to guide clinical management and improve patient quality of life.