With numerous therapeutic options available for chronic pruritus in atopic dermatitis, there is a need for structured, rational approaches to finding a treatment that will provide an individual patient with relief from itching.
In an article published in the book series Advances in Experimental Medicine and Biology, Kalyani S. Marathe, M.D, and William S. Farmer, B.S, both of George Washington University in Washington, D.C., describe a “therapeutic ladder” approach designed to help clinicians and patients select treatments appropriately.
“Initially, practitioners should advise patients to employ non-pharmaceutical treatments such as emollients with wet wraps, elimination of triggers, changing scratching habits, and psychological interventions. If these methods of treatment are not successful or if the disease presentation is severe, pharmacological therapies should be employed,” the authors wrote.
The first rung of the therapeutic ladder, according to the authors, is treatment with topical glucocorticoids and topical calcineurin inhibitors.
The second rung on the ladder includes more topical agents, including coal tar, menthol, capsaicin and doxepin.
Once topical options have been exhausted, the authors said, the third rung would include systemic agents such as sedating or non-sedating antihistamines, oral glucocorticoids, or cyclosporine A.
If those primary systemic agents fail, the fourth and final rung in the therapeutic ladder for pruritus in AD includes neuromodulating or immunomodulating agents, such as immunosuppressants, SSRI/SNRIs, TCAs, and opioid receptor modulators.
Phototherapy has a place at each rung in the ladder as described by Farmer and Marathe, who say the treatment can provide “dramatic improvement” at each stage of treatment, including first line.
While this laddered approach seems simple in theory, determining the appropriate rung to select might be challenging in practice, particularly since pruritus can be so subjective.
To help guide clinical decisions, the authors recommend using the Eppendorf Itch Questionnaire at each office visit. It rates the severity of the symptoms and assesses the temporal nature of the pruritus, location of the itch and palliation.