Advances in the Management of Prurigo Nodularis - Episode 16
Experts in dermatology discuss unmet needs in prurigo nodularis (PN) and the importance of addressing those needs for disease management.
Raj Chovatiya, MD, PhD: I'm excited that there's so much interest and so much happening as far as the space goes. That leads me to the last couple of thoughts maybe we can all share. I've learned a lot talking to you both. Maybe you can boil down what you really think are the key unmet needs in PN [prurigo nodularis]. I know that we've gone over some of these throughout, but maybe you can share from the physician’s perspective and from the patients. What do you think really needs to be the next thing that we figure out? Sarina, I'll start with you.
Sarina B. Elmariah, MD, PhD: I think we've highlighted this a couple of times, which is the idea of how to control the itch and to do so effectively and rapidly. To allow other aspects of PN to come in line. I think that’s still, quite frankly, to me a huge unmet need with this disorder. I also think as Shawn has highlighted a couple of times, the hyperpigmentation, the potential scarring, and the nodule itself, even chronically, the other aspects of the disease still weighs heavily on patients, particularly, patients with skin of color. I think that's also another point at which we really need to focus and emphasize in our management and how we're going to conquer this disorder.
Raj Chovatiya, MD, PhD: How about you, Shawn?
Shawn Kwatra, MD: To me, what's unique about prurigo nodularis compared to atopic dermatitis and psoriasis is the fibroblast. It's fiber proliferation. It's these nodules that can be so tough and firm. I think some of the biggest questions that the patients are having is how do we get this nodule to have a resolution? What is the natural history long-term? I think we need more natural history studies to zone in on, ‘Your nodule can be expected to resolve in X amount of time.’ Is it going to leave postinflammatory hyperpigmentation? Is that going to be chronic? All those features, I think, are very important.
I think that we need more mechanistic studies because patients also ask me all the time, ‘Why?’ Why is it happening? I think for a disease like atopic dermatitis and psoriasis the why involves a lot more genetics. I think in a disease that penetrates in middle age, it's a lot more of other things too. It's the environment. It's also the social determinants of health. It's a lot of other factors. I think wrapping our minds around why that does happen. Why does it disproportionally affect patients with a skin of color? What are the factors that make folks more likely to suffer from this disease? We need to do more research on that. I think that will be able to shed greater light also as to what patients can expect in terms of the natural history of the disease.
Raj Chovatiya, MD, PhD: I love it. That's a lot of food for thought. I might throw in something that you were mentioning before. It's something I've thought about a lot for atopic dermatitis. PN is a new exception as far as an inflammatory disease goes. What is going on with the heterogeneity of our patients, right? Why do we have these subsets where some people respond, and some don't? Even in targeted therapies, some people don't respond as well as others. What's going on there? Are we going to get to a point where we can figure out the right monotherapy for people? Or is it going to always be a combination-type approach, where we're going to have to have something that's targeted but also something that's more nerve-acting vs immune-acting as well? I know it's an area in which you among others are going to help us understand what's happening in the future. I think that's really, exciting.
I think from a patient’s perspective, patient education here is huge. Patients know so little about the condition because we know so little about the condition. They oftentimes are not knowing where to go when we can't tell them that it's either in their head or something is going on. They can't Google search the solution effectively. For anybody with deep pockets out there, there's a lot of health care provider education and disease state that has to happen for us. I think it's going to be equally important for patients. The ones that are out there who feel that they haven't been heard or feel like they don't know what they're going through can really feel that there is a name for what's happening to them. They can see their dermatologist in order to try to get control of their symptoms.
Transcript edited for clarity