In this episode of Topical Conversations, Daniel Butler, MD, associate professor of dermatology at the University of Arizona College of Medicine, discusses his recent publication that reshapes the understanding of chronic pruritus.

Historical neglect and new understanding

The impact of chronic pruritus has been underappreciated by the medical community. As a ubiquitous symptom that everyone experiences at times, the health care system has struggled to adapt to its more severe, chronic forms, leaving many patients without effective treatments for prolonged periods. Dr Butler reexamines the mechanisms of itch, significantly impacting the perception of chronic pruritus by recognizing the role of both the immune system and the nervous system.

Moving beyond a singular entity

Historically, pruritus was viewed as a singular entity—find the right cause, and the symptom can be treated. However, Dr Butler explains that chronic pruritus may be more like a Venn diagram of contributing systems, including barrier dysfunction, immune dysfunction, and neuropathic or nerve dysfunction. This new understanding allows for a more comprehensive approach to treatment. Instead of seeking a singular cause, dermatologists can now consider how to combine treatments to address the various contributing factors.  

Advances in personalized treatments

Dr Butler explains that some treatments can target multiple systems simultaneously, like biologics that block IL-4 and IL-13 also profoundly impacting neuropathic itch, or tacrolimus, a classic topical treatment, not only controlling the immune response but also affecting neuropathic pathways, making it highly effective for pruritus. The scaffolding and schematic for understanding chronic pruritus are evolving, and by highlighting the unique pathophysiologic mechanisms involved, each with its own treatment targets, this evolution provides dermatologists with a diverse arsenal of treatments, ranging from topical to systemic, and from neuropathic to immune-based therapies.

A more effective way to manage patients

Dr Butler emphasizes that the most crucial takeaway from his publication is the recognition of chronic pruritus as its own distinct entity. Nearly 1% of all doctor's visits are for chronic pruritus, affecting a wide range of specialties, including primary care, gastroenterology, allergy, and even surgery. By rethinking chronic pruritus not as a singular or secondary disease, but as a complex mix of dysfunctional etiologies and considering various treatment tools that address different aspects of this condition, dermatologists can become more effective in managing these patients with more nuanced and effective strategies.