Start from Scratch: Approaches to Itch

Itch is a common and often frustrating symptom that presents to the dermatology clinic. Adam Friedman, MD provides updates on emerging management strategies while Joe Gorelick, MSN, FNP-C shares tips for documenting itch--and its improvement. Plus, Gilly Munavalli, MD gives the skinny on GLP-1s and their effects on the face, and Brad Glick, DO discusses intralesional injections for nails.

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Transcript

Transcript provided as a courtesy only. It has not been edited for accuracy.

Welcome to the Dermalorian Podcast from the Dermatology Education Foundation. Pruritis or itch is a frustrating symptom associated with dermatologic, systemic, paraneoplastic, neuropathic, and psychogenic causes. For patients, itch can interfere with sleep, work, or study, and generally have a detrimental impact on quality of life.

For those treating skin disease, symptoms of itch can also be frustrating, from trying to uncover the cause of pruritus of unknown origin, to quelling itch associated with common cutaneous diseases.

According to dermatologist Dr. Adam Friedman, newly approved directed therapies for certain cutaneous diseases are showing a substantial impact on itch, and improved understanding of neurogenic itch is yielding new approaches for affected individuals. He provides an update on new and emerging strategies to target itch. He also addresses the importance of assessing the patient's experience and treatment goals.

Dr. Adam Friedman:

When it comes to the treatment of itch, whether it be topical or systemic, I think you have to consider the patient their complaint. So there are patients who have regional itch, and there are many examples of that from notalgia paresthetica, the dreaded brachioradial pruritus, or even scrotal itch or pruritus anii, where a topical can be your first line because it's easy to apply to a small body surface area.

But when you think about generalized itch, and I think that's really the generalized pruritus with no rash, it'd be very difficult to give someone just a topical. It's easy to say, it's another to do, because think about trying to apply something once or twice a day head to toe. That is just not going to pan out. So I think you need to take the whole picture into account, of where the itch is and is it amenable for a topical treatment?

When we think about the topicals that would be appropriate, to me, I think some of the greatest innovation is going to be when we first start with anti-inflammatories will be topical JAK inhibitors. We actually have some really great clinical trial data showing that, in the right setting, topical ruxolitinib can work on itch within a matter of 15 minutes.

I think the same is true in my experience with PD4 inhibitors, though some of them, some of the older forms come with a little bit of burning more likely related to the chemical structure. But I think these non-steroidal alternatives that have the potency of a topical steroid will actually work better on itch. When it comes to more mixed picture, maybe more neuropathic, we do have some stuff up our sleeve. I think things like strontium, which is found in several over-the-counter products, hypochlorous acid. And near and dear to my heart, our cannabinoids, and have to be careful how I say that if anyone from my work is listening. But I think cannabinoids can really manipulate signal transduction, can also be anti-inflammatory. And there's plenty of evidence that topical cannabinoids, when delivered the right way and formulated the right way, can have an impressive impact on itch.

And when in doubt, last line, you can use topical ketamine formulations. Got to give credit to Dr. Yosipovich who really coined the Yosipovich cocktail of lidocaine and metriptyline and ketamine. One clinical pearl though, is if patients are applying to broad surface area, they can get systemic absorption of ketamine. And I actually had a patient who was on this who was actually a drug counselor, and he comes in the next time after I gave it to him, he goes, "Funny story, I got high at my AA meeting." So, that was fun for no one.

So I think it's important to use it regional, local, small body surface areas, but when in doubt that triple combo can absolutely work.

When it comes to systemic agents, you need to decide, is this neuropathic, is it inflammatory, or is it in between? A lot of cases going to be in between. The in-between ones I think respond very nicely to some of the advanced biologics such as dupilumab, nemolizumab, and I'm very curious to see how some of the other IL-13 biologics will play out and we're starting to see some data emerge.

But when you're more in the kind of neuropathic piece, I think drugs like gabapentinoids, like pregabalin and gabapentin. And for the elderly, I really have been leaning more on mirtazapine because I think it has less sedation less you aim for that sedation with a lower dose, totally counterintuitive. The lower you go the more soporific. So you can actually go at a higher dose where someone older, if you're worried about being drowsy in the middle of the night and falling and cracking their head open, that actually limits that soporific effect.

And then other SSRIs can be useful as well. But my simple and very direct advice, combination is king or queen. Don't rely on just one eye often, when if someone's miserable, they might get intramuscular kenalog, a potent topical anti-inflammatory or a nerve targeting therapy. They may get a biologic. They may also get gabapentin. Do not rely on one thing and then pivot to the other, layer cake your options to get someone clear.

Host:

In an interesting recent development, a study published online in Journal of Dermatology early this month, suggests that discontinuation of washcloth use could significantly reduce pruritus scores for some patients. The retrospective observational study involved 79 subjects with a variety of dermatologic diagnoses. The mean NRS scores for individuals who stopped using washcloths when bathing dropped from 4.89 to 1.9 with no therapeutic escalation. There was no significant change in NRS score among those who continued to use washcloths.

There are more itch insights ahead, but first, in this episode's Dermalorian Derm Decoder, cosmetic dermatologist Dr. Gilly Munavalli talks about so-called Ozempic face and its aesthetic implications. Use of GLP-1 medications continues to increase across the US, and the first oral agent has just come to market.

Dr. Gilly Munavalli:

The GLP-1 inhibitors are wonderful drugs and they've changed lives, no doubt. Having, being a healthier person as a result of losing some unwanted body fat has effects over your whole body, metabolically. So I think they're good things. Because medically though they can cause a problem .for whatever reason, they seem to impact the superficial facial fat pads more than the deep ones.

And those that can be responsible for some of the lines as we talked about with toxins, but they're more static lines so you get on your cheek, under your eyes. So things that form after you lose facial volume. In addition, you can get sort of a hollow gaunt appearance from these drugs if you've been using them for long enough. It doesn't take long, even less than a year can cause that.

It's a problem for people that have a lot of weight to lose. We recommend, and the skin doesn't always compensate for that by shrinking appropriately, because usually they're older patients and the skin just doesn't snap back as well. It's been damaged by the sun, the passage of time. And so, we would suggest judicious use of fillers to help, dermal fillers in certain areas. Potentially, some of the technologies that do well with skin laxity can be used along the way, not just after you've reached your end point. So to keep the skin contracted or try to contract it as you're losing weight. And those can be things like microfocused ultrasound, radiofrequency microneedling, those are two big ones that come to mind.

Host:

Let's get back to our discussion of itch, which is strongly associated with atopic dermatitis. Dermatology nurse practitioner and DEF President Joe Gorelick discusses the importance of documenting symptoms like itch in the patient chart to track the patient response to treatment and to support therapeutic need. There are validated measures for symptoms like itch, that can be used in the chart notes.

Joe Gorelick:

EASI is a clinical trial tool with a maximum 72 point score. The score read is a little bit more practical, and it's a patient... It's an evaluation to determine how bad the patient's disease is.

These are clinical trial assessments. There may be one or two things when you look at the individual points that they measure that you want to incorporate into your notes. What you want to pull out of these things are meaningful end points that you can start with and say, okay, I saw this patient, their erythema was a four out of four, their lichenification was a three out of four. So if you don't see that patient next time, somebody else sees them, they have an objective measurement, they can kind of tell what happened a little bit, versus, "Eh, the patient's got moderate eczema and a little bit of erythema."

So, quantifying those things makes a really a big improvement. There are practical tools that can be built into your EMR that patients can fill out while they're in the waiting room or they're waiting to see you. Like the POEM, easy to do.

And then the investigator global assessment. So for PAs and MPs, I love the IGA. I don't love the PGA because the PGA and the IGA are exactly the same, but IGA means the investigator global assessment, versus a physician global assessment. And that's what we do every single time we walk in the room. Investigator global assessment, we look at the patient, we make a determination based on how their disease looks, whether they're absolutely clear, which is a zero or they're on the other end of the spectrum and they're severe, which would be a four out of four.

So investigator global assessment is something that you should put every single chart note that you make for patients. So if you're seeing a new patient with atopic dermatitis, and most of the EMRs have this built in, and sometimes the medical assistants can get this stuff going with your help, but make sure it's in the assessment portion. This patient has an investigator global assessment of moderate or severe disease. They're a three out of four or a four out of four. Their body surface area, as measured either by your hand or the rule of nine, is whatever it is, put it in there at baseline.

And then get an NRS score. Super easy, look at the patient, ask them, "Hey, on a scale of zero to 10, what's the absolute worst itch that you're experiencing?" And they'll tell you, write that number down in the chart so you have a baseline that can be measurable. At the end of the day, at some point in time, your reimbursement may be tied to improvements in NRS scores, reductions in body surface area, and other objective measurements. So it's a really good practice to get into those.

With atopic dermatitis, of course you want to measure itch, but there's other questions that you can ask to determine how well the patient, or how out of control the patient's disease is. And one of the best measures of that is sleep. One of the things we learned with patients with atopic dermatitis is that when they're initiated on biologic agents, the first thing they said, that they would tell us when they would come, and JAK inhibitors, is that they had their first restful night of sleep forever, because they weren't itching all night and they couldn't believe it. They laid down in bed, they watched the TV or their iPad or whatever they were doing, and then when they turn it off, the itch would come to the forefront and they would be miserable.

But once you initiate the right therapy for these patients, they do all that business and they turn it off and they're laying there like, oh my God, I'm not itching. And guess who is happier than everyone? The parents of the kids and the spouse that's been itching their other spouse. So, itch is real. Sleep impact is really important to measure. There's lots of ways to capture it, but quantify it when you ask the questions, put it in your chart at baseline, then you can really have an objective measurement, whether you're seeing them back next time or somebody else is seeing them.

So in your notes, make sure you got the right body, every part of the body that's involved. Calculate the BSA, make an investigator global assessment, because you are the investigator, you are their care provider. And call it three out of four, four out four, whatever it is, and get these patients down to zero or ones. That's what we should be shooting for. Ask a numerical rating score for itch. Scale of zero to 10, what's the absolute worst itch you have over the past 24 hours.

And then, you can ask them on a scale of zero to 10, right now, how bad is your itch? Those two things are very neat to have in the chart, and when you see them again, ask them the same questions. They usually won't remember what they told you, and you can get a statistically validated improvement of four points oftentimes. Put in the chart, things they've tried and failed. If you want to do POEM, it's a really easy thing to do. Document sleep issues or sleep improvements. Specific quality of life impairments. We probably don't do EASI in our clinics, but usually if you're looking for an EASI score that qualifies patients for a biologic or a systemic, small molecule like the JAK, it's got to be 16 or more.

,And then psoriasis. These patients itch they itch. Itch is a thing with psoriasis. It's not unique to atopic dermatitis. Go ahead and do an NRS. Why not? It's a quick question that you can ask the patient, and throw that stuff into your chart note in the assessment portion.

Host:

Now it's time for our Dermalorian clinical clip. If you're looking to hone your skill for intralesional nail injections, Dermatologist Dr. Brad Glick has some practical tips.

Dr. Brad Glick:

Nail disease too is somewhat complex and what I've learned over the last 30 plus years of practice is that most of our dermatology colleagues have a little bit of discomfort with treating nail diseases in general, although I think we're doing better. I talked a lot about just the anatomy and physiology, the functional nail unit. And I answer your question about intralesional tips and tricks, because if you don't understand the anatomy and physiology, the functional units, particularly the understanding of the behavior of the germinal matrix and the sterile matrix, and how the nail matrix and the nail plate and the nail bed interact, when you may have some challenges in the appropriate approach to intramatrix injections.

And for the most part, 95% of the time what we're injecting in an intramatrix fashion is going to be intramatrix steroids. So what's my approach? Well, you know what, I've kind of changed my approach a little bit, but typically what I have done, most expert nail disease would tell us that you're injecting somewhere about a quarter of an inch, maybe two or three millimeters proximal to the distal aspect, the proximal nail fold or just behind the cuticle, right in the center. It's a singular approach. It's one injection you're typically injecting right into that matrix at about a 45, I will now say to a 90 degree angle.

I talked about a recent publication just in this last year that talks in about an absolute perpendicular approach, just about a quarter of an inch proximal to the cuticle, and injecting just a small quantity anywhere from 0.1 to as much as 0.3, 0.4, or 0.5 CCs depending on the size of an individual's matrix, right into the matrix as well.

So some of the other tips are, there are other approaches to injecting that matrix, and we see it clinically as the lunula, but you have to realize that there's a lot going on proximal to the lunula, that proximal matrix. And so there are some that advocate either a singular injection at the lateral aspect, proximal to the lateral nail fold, proximally just at the lateral nail fold, proximal nail fold interface. It could be potentially a singular injection. I don't favor that, as I talked about in my talk, because I believe you best do two injections laterally. And so I don't like that because I think it's more painful.

Some advocate that as a singular injection, but I do think it's hard to completely blanch the entire matrix. And so, I prefer the singular injection that is immediately proximal to the cuticle, or the distal aspect of the proximal nail fold. Again, about a quarter of an inch or just a few millimeters.

Host:

Thanks for joining us for this episode of the Dermalorian Podcast. I hope you feel we've nailed it.

The Dermalorian Podcast is produced for the DEF by Physician Resources. We'll catch you next time.