Oral cyclosporine effective drug in decreasing episodes and intensity of cholinergic itch

Written By : Dr Manoj Kumar Nayak |Medically Reviewed By : Dr. Kamal Kant Kohli Published On 2022-09-20T20:00:41+05:30 | Updated On 21 Sept 2022 1:18 PM IST

Cyclosporine effective in cholinergic itch- IDOJ

Cholinergic itch is a part of the symptom complex which includes cholinergic erythema and cholinergic urticaria. It is characterized by sudden onset of severe itching, burning, or pricking sensations without any visible cutaneous changes. It primarily affects whole body in response to increased core body temperature, sunlight exposure, exercise/physical activities, warm atmosphere/clothing, emotional stress, and hot and spicy food intake.

There is a paucity of data on management of cholinergic itch even though it can severely compromise the quality of life. Recently an article describing efficacy of cyclosporine in cholinergic itch was published in the Indian Dermatology Online Journal.

Cholinergic itch can be transient, mild, and self‑resolving but in some patients it can interfere with the daily activities due to episodes of intense pruritus which can even force a patient to avoid the triggers (e.g., exercise, warm clothing, field works). It is usually relieved by cooling the skin or in some cases taking the clothes off, which can be considerably embarrassing.

Various mechanisms have been proposed which can explain the development of cholinergic itch and cholinergic urticaria symptom complex:

Acetylcholine can act as endogenous algesiogenic in human skin especially in cholinergic urticaria and aquagenic pruritus.
Histamine also acts as an itch mediator, and its release can be stimulated by sweat‑induced acetylcholine.
Xerosis induces sweat duct obstruction in winters, resulting in inflammatory substances contained in sweat being refluxed into the dermis. Sweat materials contain numerous pruritogenic substances such as a renin‑like substance, immunoglobulin E, secretory immunoglobulin A, and cytokines including interleukin 1/8/ß which can induce local inflammatory reactions.
Imbalance in cutaneous expression of several neuropeptides like substance P, vasoactive intestinal peptide, and neuropeptide Y is believed to be involved in the itch production in several skin diseases.

Twenty consenting patients of severe cholinergic itch refractory to both sedating and non‑sedating antihistamine therapy were included in the study. Itch severity before and after the treatment was assessed by unidimensional numerical rating scale (NRS). These patients were started on oral cyclosporine (5mg/kg) for 2 weeks, and the dose was reduced by 50 mg every 15^th day until a dose of 50mg/day was reached. Baseline blood pressure, baseline blood urea, serum creatinine, lipid profile, and liver enzymes were recorded and re‑evaluated every 15th day. Patients with hypertension, deranged lipid, liver, and renal biochemical profile were excluded from the study. Paired t test was applied for NRS before and after the treatment.

Results

Of the 20 patients, 19 were males and 1 was female. Mean age of the patients was 15.95 years. Mean age of the onset of disease was 19.5 years. Mean duration of the disease was 13.3 months. Cholinergic itch occurred more during winters (65%). Eight (40%) patients had a history of atopic diathesis. Mean NRS before

initiating treatment was 7.8 which decreased to 0.3 at the end of the second week. Eighteen patients (90%) reported the absence of any episode of cholinergic itch at the end of the first week of initiating cyclosporine therapy. The other two patients continued to develop cholinergic itch during the first 2 weeks with a significant decline in NRS score (initial mean NRS = 8.5 to NRS = 3). No episode of cholinergic itch occurred in any of the included patients after 2 weeks of starting cyclosporine therapy, even when the dose was tapered to as low as 50 mg/day over the period of 14 weeks. No post‑treatment follow‑up was performed.

Antihistamine drugs are considered as first‑line treatment in cholinergic urticaria though not always effective. Cyclosporine is known to produce anti‑inflammatory and neuromodulatory actions. Apart from anti‑inflammatory action, it may also have anti‑pruritic activity produced through neuromodulation by suppressing "pruritogenic cytokines" and by directly acting on cutaneous nerve endings, which leads to decreased levels of neuropeptide substance P, nerve growth factor, and neurotrophin‑3. It also decreases itch via interleukin‑31RA inhibition and decreased TRPV1 and NKR1 gene expression.

To conclude oral cyclosporine appears to be a very effective drug in decreasing the number of episodes and intensity of cholinergic itch within a very short duration of time (5–7 days). It can be considered as a short‑duration alternative therapeutic option in patients of refractory severe cholinergic itch.

References-

Sehgal S, Arora V, Gupta L, Khare AK, Vyas K, Mittal A. Cyclosporine in cholinergic itch. Indian Dermatol Online J 2022;13:234-6.

Cyclosporineanhistaminecholinergic itchIDOJ

Source : Indian Dermatology Online Journal

Dr Manoj Kumar Nayak

MBBS

Dr Manoj Kumar Nayak has completed his M.B.B.S. from the prestigious institute Bangalore medical college and research institute, Bengaluru. He completed his M.D. Dermatology from AIIMS Rishikesh. He is actively involved in the field of dermatology with special interests in vitiligo, immunobullous disorders, psoriasis and procedural dermatology. His continued interest in academics and recent developments serves as an inspiration to work with medical dialogues.He can be contacted at editorial@medicaldialogues.in.

Dr. Kamal Kant Kohli

Dr Kamal Kant Kohli-MBBS, DTCD- a chest specialist with more than 30 years of practice and a flair for writing clinical articles, Dr Kamal Kant Kohli joined Medical Dialogues as a Chief Editor of Medical News. Besides writing articles, as an editor, he proofreads and verifies all the medical content published on Medical Dialogues including those coming from journals, studies,medical conferences,guidelines etc. Email: drkohli@medicaldialogues.in. Contact no. 011-43720751