Immunological eruptions of ageing: reframing chronic pruritic rashes in older adults

Abel, Mary Kathryn; Jelousi, Sami; Berger, Timothy G.; Murase, Jenny E.; Butler, David F.

doi:10.1111/bjd.20414

Cited by 3 publications

(4 citation statements)

References 5 publications

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“…This may occur in immunologic eruption of aging, a specific presentation of chronic pruritus of unknown origin in which older adults present with subtle or absent skin changes and workup for systemic causes is negative but they respond to immunologic treatments. Skin biopsies in these patients can show subtle inflammation and may suggest an immunologic cause of chronic pruritus …”

Section: Discussionmentioning

confidence: 99%

“…Skin biopsies in these patients can show subtle inflammation and may suggest an immunologic cause of chronic pruritus. 33,34 Systemic diseases, such as malignancies and liver or kidney dysfunction, are typically associated with generalized pruritus in the absence of a primary skin eruption. Evaluation for systemic causes of pruritus, if needed, may consist of complete blood cell count, comprehensive metabolic panel, and thyroid function testing.…”

Section: Diagnostic Evaluationmentioning

confidence: 99%

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Chronic Pruritus

Butler,

Berger,

Elmariah

et al. 2024

JAMA

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ImportanceChronic pruritus, defined as itch experienced for 6 weeks or longer, affects approximately 22% of people in their lifetime. Approximately 1% of physician visits are for the chief concern of chronic pruritus. Chronic pruritus is associated with adverse outcomes, including impaired sleep and reduced quality of life.ObservationsChronic pruritus can be categorized by etiology into inflammatory, neuropathic, or a combination of inflammatory and neuropathic pruritus. Chronic pruritus is due to inflammation in approximately 60% of patients and may be caused by eczema, psoriasis, or seborrheic dermatitis. Chronic pruritus is due to a neuropathic or mixed etiology in approximately 25% of patients. Neuropathic causes of chronic pruritus include postherpetic neuralgia and notalgia paresthetica and are typically due to localized or generalized nerve dysregulation. Approximately 15% of people with chronic pruritus have other causes including systemic diseases with secondary itch, such as uremic pruritus and cholestatic pruritus, medication-induced pruritus such as pruritus due to immunotherapy, and infectious etiologies such as tinea corporis and scabies. When few primary changes are present, a thorough history, review of symptoms, and laboratory evaluation should be performed, particularly for people with chronic pruritus lasting less than 1 year. Clinicians should consider the following tests: complete blood cell count, complete metabolic panel, and thyroid function testing to evaluate for hematologic malignancy, liver disease, kidney disease, or thyroid disease. First-line treatment for inflammatory chronic pruritus includes topical anti-inflammatory therapies such as hydrocortisone (2.5%), triamcinolone (0.1%), or tacrolimus ointment. Approximately 10% of patients do not respond to topical therapies. In these patients, referral to dermatology and systemic oral or injectable treatments such as dupilumab or methotrexate may be considered. When no underlying systemic disease associated with pruritus is identified, patients are likely to have neuropathic chronic pruritus or mixed etiology such as chronic pruritus of unknown origin. In these patients, neuropathic topical treatments such as menthol, pramoxine, or lidocaine can be used either alone or in combination with immunomodulatory agents such as topical steroids. Other effective therapies for neuropathic pruritus include gabapentin, antidepressants such as sertraline or doxepin, or opioid receptor agonist/antagonists such as naltrexone or butorphanol.Conclusions and RelevanceChronic pruritus can adversely affect quality of life and can be categorized into inflammatory, neuropathic, or a combined etiology. First-line therapies are topical steroids for inflammatory causes, such as hydrocortisone (2.5%) or triamcinolone (0.1%); topical neuropathic agents for neuropathic causes, such as menthol or pramoxine; and combinations of these therapies for mixed etiologies of chronic pruritus.

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Section: Discussionmentioning

confidence: 99%

Section: Diagnostic Evaluationmentioning

confidence: 99%

Chronic Pruritus

Butler,

Berger,

Elmariah

et al. 2024

JAMA

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“…Ultimately, 30% of the cohort was diagnosed as having some form of dermatitis (atopic/nummular/allergic with suspected missed allergen/irritant). Most patients (52.2%) were diagnosed with immunologic eruptions of aging (IEA), a diagnosis of exclusion hypothesized to be related to age associated changes of the immune system [2] . Although these 2 diagnostic groups did share overlapping features, they were differentiated based on atopic diathesis and distribution of lesions.…”

mentioning

confidence: 99%

“…Nomenclature before and after diagnosis was variable. It is likely that this population has systemic immunodysregulation in the Th2 pathway from intrinsic immune system aging, which has been postulated to be an underlying etiology of pruritus among older adults, but unfortunately lacks a serum biomarker or specific skin test for elucidation [2] . IEA therefore represents a subset of patients with chronic pruritus of unknown origin.…”

mentioning

confidence: 99%

Pruritic eruptions in older adults: characterization of a patch test negative cohort

Sreekantaswamy

Tully

Botto

et al. 2023

Itch

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Workup for chronic itch in older adults varies significantly across practices. Patch testing remains an important piece of the workup for chronic pruritic rashes in this population, however, there remains a subset of these patients who test negative. This descriptive study sought to better characterize shared clinical and histopathologic features of patch negative older adults to improve understanding of contributing etiologies for itch in this group.

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