Myriad therapies provide clinicians with options for chronic pruritus

A broad range of therapeutic approaches may be used for patients with chronic pruritus, according to a review.

“The management of [chronic pruritus] remains challenging despite a plethora of modalities, which can be classified as topical therapy, phototherapy and systemic therapy,” Radomir Reszke, MD, of the department of dermatology, venereology and allergology at Wroclaw Medical University, Poland, and colleagues wrote.

A complex pathogenesis is one reason treatment of chronic itch can be difficult. A range of contributing factors is another. “This review covers the most relevant current modalities remaining under investigation that possess promising perspectives of approval in the near future,” the researchers wrote.

Looking at opioid receptor agonists and antagonists, nalbuphine has been successful in trials, while Japan has made nalfurafine the only drug registered for the treatment of both uremic and chronic pruritus, according to the findings.

Neurokinin1 receptor antagonists have shown the capacity to induce “vasodilatation, degranulation of mast cells, nerve growth factor expression in keratinocytes and [stimulate] neurogenic inflammation,” the researchers wrote. Aprepitant and serlopitant are the leading drugs for this approach.

Looking at biologic therapies, a growing body of evidence has begun to link cytokines with pruritus. This, the researchers suggested, validates the use of targeted biologic treatment for a number of chronic inflammatory dermatoses.

Dupilumab, lebrikizumab and tralokinumab top the list of interleukin (IL)4 and IL13 treatments that may be used in chronic pruritus.

In the IL-17 category, secukinumab has shown efficacy, while ixekizumab has demonstrated a “rapid onset of action,” according to the researchers.

Regarding IL-23 therapies, ustekinumab and guselkumab have undergone clinical trials in pruritus. In addition, risankizumab yielded improvements in patient assessment of itch in studies.

Nemolizumab and vixarelimab are “promising” IL-31 inhibitors, while ligelizumab has shown strong tolerability outcomes as an immunoglobulin E approach to pruritus.

There is a long list of Janus kinase inhibitors that have shown efficacy and safety in psoriasis, atopic dermatitis, alopecia areata and vitiligo, according to the researchers. These include ruxolitinib, baricitinib, tofacitinib, abrocitinib, upadacitinib and delgocitinib.

Looking deeper into the therapeutic armamentarium, the researchers wrote that phosphodiesterase4 inhibitors, tropomyosinreceptor kinase A inhibitors, ileal bile acid transporter inhibitors, histamine H₄ receptor antagonists and aryl hydrocarbon receptor agonists all may be considered for patients experiencing some form of chronic pruritus.

“Regardless of the cause, patients with [chronic pruritus] will benefit from the continuously increasing armamentarium of novel therapies,” the researchers wrote. “To a large extent, the expected progress is based on the flourishing data on [chronic pruritus] pathophysiology, but, in the era of evidence-based medicine, another crucial factor (conscientious planning and execution of clinical trials) has to be taken into account.”