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• W2773562245 abstract "To the Editor: Localized chronic pruritus is a common condition that significantly affects health-related quality of life. A variety of diseases result in localized chronic itch, which can be broadly classified as dermatologic, neuropathic, or psychogenic in nature. For patients with chronic pruritus that is refractory to conventional therapy, the burden of disease is substantial. Current management is directed at the underlying cause, with the majority of cases of localized chronic itch being nonhistaminergic in etiology. Treatment typically begins with nonpharmacologic therapies, adding topical glucocorticoids, topical anesthetics, coolants, topical calcineurin inhibitors, and intralesional corticosteroids in a stepwise approach. Botulinum toxin type A (BoNT/A) is a neurotoxic protein approved by the US Food and Drug Administration for the treatment of glabellar and periorbital wrinkles, severe primary axillary hyperhidrosis, and numerous neurologic indications.1Wanitphakdeedecha R. Ungaksornpairote C. Kaewkes A. Rojanavanich V. Phothong W. Manuskiatti W. The comparison between intradermal injection of abobotulinumtoxinA and normal saline for face-lifting: a split-face randomized controlled trial.J Cosmet Dermatol. 2016; 15: 452-457Crossref PubMed Scopus (15) Google Scholar BoNT/A has shown potential in the medical literature as an antipruritic agent for patients with localized, chronic pruritus that is refractory to conventional therapies. BoNT/A is believed to reduce pruritic symptoms by dulling the transmission of C fiber itch signals; it may also have an effect on small fiber neuropathies by altering transmission of neural input from the peripheral nervous system.2Gazerani P. Pedersen N.S. Drewes A.M. Arendt-Nielsen L. Botulinum toxin type A reduces histamine-induced itch and vasomotor responses in human skin.Br J Dermatol. 2009; 161: 737-745Crossref PubMed Scopus (51) Google Scholar We conducted a review of the current literature using the PubMed database to evaluate the use of intradermal BoNT/A in treating various types of localized chronic itch. Our search included English language articles containing the words “botulinum” and “itch” published before November 2016. We found 25 studies containing these key words dating from 1996 to 2016. Eleven articles that focused on the use of intradermal BoNT/A for the treatment of chronic refractory pruritus were included (Table I) . The Preferred Reporting Items for Systematic Reviews and Meta-Analysis flow chart is shown in Fig 1. The grade of recommendation for each study was determined using the Oxford Centre for Evidence-based Medicine Levels of Evidence (Table I).Table ISummary of studies examining the effect of botulinum toxin type A in chronic pruritusGrade of recommendation∗Determined based on the Oxford Centre for Evidence-based Medicine levels of evidence.Study designDiagnosisNRegimenDegree of pruritus reductionReferenceCPOSLichen simplex4100 U/mL BoNT/A spaced 2 cm apartOne treatment led to complete relief of symptoms lasting 4 monthsHeckmann et al, J Am Acad Dermatol. 2002;46:617-619.CPOSPartial-thickness to full-thickness burns925 U/mL BoNT/A (spacing unknown)One treatment led to a reduction in symptoms to <3/10 lasting an average of 6.3 monthsAkhtar and Brooks, Burns. 2012;38:1119-1123.CPOSInverse psoriasis1520 U/mL BoNT/A spaced 2.8 cm apartOne treatment led to a reduction in the mean visual analog score to 2.1/10 lasting 3 monthsZanchi et al, J Eur Acad Dermatol Venereol. 2008;22:432-436.CPOSNotalgia paresthetica540 U/mL BoNT/A spaced 2 cm apartIn 3 patients: 1 treatment led to “symptomatic improvement” lasting 1 month; in 2 patients: 1 treatment led to “worsening of pruritus”Pérez-Pérez et al, Actas Dermosifiliogr. 2014;105:74-77.CPOSNotalgia paresthetica, meralgia paresthetica, and neuropathic itch60.27-0.47 U/mL BoTN/A (spacing unknown)One treatment led to a 28% reduction in the mean visual analog score lasting ≥6 weeksWallengren and Bartosik, Br J Dermatol. 2010;163:424-426.CPOSNotalgia paresthetica21.3 U/mL BoNT/A spaced 2 cm apartFirst patient: 1 treatment led to complete relief of symptoms lasting ≥18 months; second patient: 2 treatments spaced 18 months apart led to complete relief of symptoms lasting an unknown durationWeinfeld, Arch Dermatol. 2007;143:980-982.DCRBrachioradial pruritus133.3 U/mL BoNT/A spaced 1.5 cm apartOne treatment led to complete relief of symptoms lasting 6 monthsKavanagh and Tidman, Br J Dermatol. 2012;166:1147.DCRIntractable pruritus after facial surgery115 U BoNT/A (unknown dilution or spacing)One treatment led to a “significant reduction” of symptoms lasting 2 monthsSalardini et al, Clin Neuropharmacol. 2008;31:303-306.DCRAxillary granular parakeratosis150 U BoNT/A (unknown dilution or spacing)One treatment led to a complete relief of symptoms lasting 4 monthsRai et al, Clin Exp Dermatol. 2012;37:928-930.DCRInverse Psoriasis1100 U BoNT/A (unknown dilution or spacing)One treatment led to a complete relief of symptoms lasting ≥1 monthSaber et al, Arch Dermatol. 2011;147:629-630.DCRHailey–Hailey disease1200 U BoNT/A (unknown dilution or spacing)One treatment led to a complete relief of symptoms lasting 3 monthsHo and Jagdeo, J Drugs Dermatol. 2015;14:68-70.CR, Case report; POS, prospective observational study.∗ Determined based on the Oxford Centre for Evidence-based Medicine levels of evidence. Open table in a new tab CR, Case report; POS, prospective observational study. Overall, these studies suggest the potential for BoNT/A to relieve symptoms in patients with localized chronic itch caused by brachioradial pruritus, lichen simplex, partial- to full-thickness burns, inverse psoriasis, and Hailey–Hailey disease that are refractory to conventional therapy. Of note, the use of BoNT/A in treating pruritus caused by notalgia and meralgia paresthetica seems to have less consistent results, with some patients reporting significant improvements, others reporting no effect, and some reporting worsening of pruritus. With the limited number of studies, there is still insufficient evidence to make a conclusion about the effectiveness of BoNT/A in the treatment of localized chronic pruritus. Other limitations include the lack of randomized controlled trials, the small sample size in each study, the wide variety of outcome measures, and the role of placebo effect. Given these limitations, it is too early to recommend the regular use of BoNT/A in the treatment of chronic localized pruritus; however, it remains an option for the clinician in cases of recalcitrant localized pruritus. Of note, there are 3 ongoing, large-scale trials evaluating the efficacy of BoNT/A in relieving localized chronic itch caused by notalgia paresthetica, hypertrophic scars, and histamine prick–induced itch.3Innovaderm Research IncTreatment of notalgia paresthetica with xeomin. ClinicalTrials.gov.2012https://clinicaltrials.gov/ct2/show/NCT01098019?term=notalgia+paresthetica+with+xeomin&rank=1Date accessed: November 14, 2016Google Scholar, 4Kaohsiung Veterans General HospitalThe use of botulinum toxin in the treatment of itching from hypertrophic scar—a randomised controlled trial. ClinicalTrials.gov.2015https://clinicaltrials.gov/ct2/show/NCT02168634?term=botulinum+hypertrophic+scar+itching&rank=1Date accessed: November 14, 2016Google Scholar, 5Aalborg UniversityTo study the peripheral effect of botulinum toxin-A (botox-A) on experimentally induced cutaneous pain in healthy subjects. ClinicalTrials.gov.2008https://clinicaltrials.gov/ct2/show/NCT00435682?term=botulinum+experimentally+induced+cutaneous+pain&rank=1Date accessed: November 14, 2016Google Scholar" @default.
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• W2773562245 date "2018-01-01" @default.
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• W2773562245 title "Botulinum toxin type A for the treatment of localized recalcitrant chronic pruritus" @default.
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