Optimal Itch Management

Transcription

1 Optimal Itch Management Forum F126: Practice Gaps in Dermatology Jason S. Reichenberg, MD Associate Professor Dermatology

2 DISCLOSURE OF RELATIONSHIPS WITH INDUSTRY Jason Reichenberg Optimal Itch Management DISCLOSURES I do not have any relevant relationships with industry.

3 Disclosures ctd I DO intend to discuss either non-fda approved or investigational use of a product(s) or device(s) Most of the medications used to treat itch are used off-label. All treatments are FDAapproved for other uses

4 Disclosures ctd

5 Itching to get started? After this talk, the audience members should be able to: 1. Perform the initial workup of a patient complaining of itch 2. Avoid common errors in managing itch patients 3. Prescribe medication to treat a patient s underlying cause of itch 4. Begin a discussion about psychological factors driving itch.

6 The Pioneers Timothy Berger Gil Yosipovitch

7 Itch Desperate Helplessness Lack of Sleep Lack of Sympathy (less than in pain syndromes) Lack of Efficacy of treatment Measure itch 0-10: 6 distracts from activities 8 awakens from sleep, 10 is the worst imaginable

8 I. Dermatological Classification of Pruritus: Yosipovitch, Acta Derm Vener 2007 "diseases of the skin" II. Systemic "diseases of organs, metabolic states, or drugs III. Neurological "diseases or disorders of the central or peripheral nervous system" IV. Psychogenic/ Somatoform V. Mixed pruritus with co-morbidity of "psychiatric and psychosomatic diseases" Overlapping and coexistence of several diseases VI. Other Undetermined origin

9 Workup of Pruritus Neurologic Systemic HPI/ROS Dermatologic Skin exam, biopsy Psychogenic Labs/imaging

10 Pruritus workup Get a good HPI Ask for some more detailed descriptors Where is the pruritus located? On the Head? In the Nose?

11 Pruritus workup Get a good HPI medication (changes) traumatic Injuries what makes it worse?

12 Pruritus workup Brachioradial pruritus- may have cervical pain, sun exacerbates but worse at end of summer (fall) rather than the beginning Can generalize Anticonvulsants > antidepressants help

13 Pruritus workup Pull out your Review of Systems forms! Age-appropriate cancer screening B symptoms Ask about every organ

14 Pruritus workup Systemic cause treat the systemic problem

15 Pruritus treatment chronic renal failure treat xerosis first Then (bb>nb) ultraviolet B phototherapy 300 mg of Neurontin x1 after each dialysis treatment cholestasis naltrexone 12.5 to 50 mg/day, slowly increase dose

16 Pruritus treatment Hematological and lymphoproliferative diseases Hodgkin's disease treat better with paroxetine> fluoxetine

17 Pruritus treatment Pregnancy Intrahepatic cholestasis of pregnancy (check LFTs, serum bile acids) Drug-induced pruritus (no rash) Opioids, ACE-inhibitors, amiodarone, hydrochlorothiazide, estrogens, simvastatin, allopurinol

18 Pruritus workup Look at the patient during your interviewdo they itch? What do you think is going on? Did they bring a bag of bugs?

19 Pruritus workup Full skin exam Look at the mucosa

20 In all: Pruritus workup CBC w differential, CMP, TSH (R20.9: Skin sensation disturbance) HIV, Hep B/C (R53.81: Other malaise and fatigue) May be reasonable: Peripheral smear, Iron studies (R53.81: Other malaise and fatigue) drug screen (R41.82: Other alteration of consciousness) As indicated: B12/ Folate, SPEP/UPEP, 5-HIAA RAST testing, ANA, indirect serum florescence colonoscopy, Stool O&P, UA p prostatic massage Sinus X Ray, MRI of brain, CXR

21 Itch- from the skin skin exam and biopsy to diagnose, then treat the skin problem Skin problems can be invisible Xerosis/ Ichthyosis Urticaria (H1 blockers) Invisible Drug Rashes: calcium channel blockers, hydrochlorothiazide Cutaneous T-cell-lymphoma, leukemic infiltrates of the skin

22 Itch- from the skin skin exam and biopsy to diagnose, then treat the skin problem Itchy old man skin Moisturization and compliance! hydrocortisone 2.5% with 0.25% menthol, disp 1 pound Sarna with pramoxine Phototherapy sertraline give 50 mg tablet, start 1/2 qd x1wk, then go to 1 tab qd should help in 3-5 weeks, sexual side effects, h/a, abd pain, anxiety (for a week) Mycophenolate mofetil 500 q2-3 days

23 Topical treatment of localized pruritus without a known cause Menthol/ Camphor/ Capsacin Newer Agents: tacrolimus ointment, pimecrolimus cream Doxepin cream Calcipotriol ointment

24 Systemic treatment of generalized pruritus without a known cause Antihistamines: Diphenhydramine 25 mg po qid, increase as tolerated to avoid sedation Hydroxyzine 25 mg po qid, increase as tolerated to avoid sedation Anti-depressants TCIs: Doxepin 10 mg po qhs, increase slowly up to 100 mg qhs SSRIs: Sertraline 25 mg po qd, increase to 100 mg qd Fluvoxamine 50 mg qhs, increase to 100 qhs NaSSA Mirtazapine: mg/day

25 Risk of dementia from anticholinergic medications In patients >65, recent students suggest an increased risk of dementia when using anticholinergic medications for long periods of time Gray SL et al, Cumulative use of strong anticholinergics a nd incident dementia: a prospective cohort study. JAMA Intern Med Mar;175(3):401 7.

26 Systemic treatment of generalized pruritus without a known cause Phototherapy: PUVA, narrow-band UVB Opiate antagonists: Naltrexone, Naloxone Anti-convulsants: gabapentin, pregabalin Immunosuppressants: Mycophenolate Mofetil (as low as 500 mg q2 or q3 days), MTX, AZTH

27 Distinguish LSC/PN from OCD/Picking Why are you picking? it itches Itch is the driver vs I need to get that hair out The obsession/compulsion is the driver

28 Itch- supratentorial Do all other evaluations, but there is still something you just can t put your finger on Delusional? Manic? PHQ-15 (not just a diagnostic tool, but a way to broach the subject) Modified MINI screen Call their other doctors!

29 Key Points: Pruritus Systemic causes of itch are determined through focused questioning and labwork Patients with systemic itch improve through treatment of their underlying disease Dermatologic causes of itch are determined through physical exam and biopsy Patients with dermatologic itch improve through treatment of their skin disease For patients with an unknown cause of picking, determine if it is itch or a primary psychiatric problem that is driving their problem, and treat appropriately

30 Itching to know more? Craig-Müller S, Reichenberg J. The other itch that rashes: A clinical and therapeutic approach to Pruritus and Skin Picking Disorders. Current Allergy and Asthma Reports. Jun;15(6):532 The Itch Issue, Sem Cut Med and Surgery, June 2011 Anything by Gil Yosipovitch (text: Living with Itch) jreichenberg@ascension.org