Sleep disturbances in older adults with pruritic eruptions: Implications across inconsistent literature and a commentary on “Association of sleep disturbances with geriatric age in atopic dermatitis patients”

Abstract

To the Editor: We read the letter by Manjunath and Silverberg1Manjunath J. Silverberg J.I. Association of sleep disturbances with geriatric age in atopic dermatitis patients.J Am Acad Dermatol. 2021 Jul 29; https://doi.org/10.1016/j.jaad.2021.07.039Abstract Full Text Full Text PDF Scopus (1) Google Scholar on sleep disturbances in geriatric patients with atopic dermatitis with great interest. The authors’ conclusions highlight the uniquely impairing morbidity of chronic itch in geriatric patients. Acknowledging the substantial quality-of-life burden in older adults is critical to understanding and managing disease in this population. However, we believe that such effects are not exclusive to atopic dermatitis. Several pruritic dermatoses, including but not limited to chronic idiopathic pruritus, idiopathic papular dermatitis, and subacute prurigo, affect the elderly population and, similarly, can impair the quality of life.2Xu A.Z. Tripathi S.V. Kau A.L. Schaffer A. Kim B.S. Immune dysregulation underlies a subset of patients with chronic idiopathic pruritus.J Am Acad Dermatol. 2016; 74: 1017-1020Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar, 3Ollech A. Hodak E. David M. Trattner A. Didkovsky E. Pavlovsky L. Idiopathic papular dermatitis in the spectrum of chronic papular eruptions (subacute prurigo): reappraisal and diagnostic algorithm.Dermatology. 2019; 235: 205-212Crossref PubMed Scopus (3) Google Scholar, 4Gambichler T. Hyun J. Sommer A. Stücker M. Altmeyer P. Kreuter A. A randomised controlled trial on photo(chemo)therapy of subacute prurigo.Clin Exp Dermatol. 2006; 31: 348-353Crossref PubMed Scopus (25) Google Scholar Unfortunately, chronic pruritus in older adults is a poorly characterized clinical entity, with significant inconsistencies and terminological heterogeneity in the extant literature. Because pruritus in this population is imprecisely defined, currently, there is a state of ambiguity in the literature. As a result, this ubiquitous population of patients lacks a cohesive diagnosis, understanding of their suffering, and consensus in the dermatologic community. This diminishes the perceived prevalence, creates confusion among patients and providers, and limits the ability to research these conditions. Upon searching the extant literature, several conditions were identified and are outlined in Table I. These conditions share the key similarities of proclivity for older adults, chronicity of symptoms, and presentation with pruritus as the primary concern. However, these conditions lack consistent nomenclature, morphology, histopathology, workup, and treatment.Table IVariations in nomenclature across studiesName of conditionClinical descriptionProposed workupHistological findingsTreatments effectiveTreatments ineffectiveCIPPruritus in the absence of a distinct rash.A thorough workup was performed to establish the diagnosis of CIP by the exclusion of other cutaneous and systemic causes of pruritus, including psychiatric and neurologic conditions, renal failure, biliary dysfunction, thyroid abnormalities, HIV/AIDS, hepatitis B, and hepatitis C.Superficial perivascular lymphocytic infiltrate with or without abundant eosinophils.Not reported.Topical emollients, steroids, oral antihistamines, doxepin, zolpidem.Idiopathic papular dermatitisFlesh-colored or erythematous papules on the trunk and extremities.Histology, DIF, IgE levels, patch tests.Scabies scraping + microscopy, drug discontinuation/change, routine blood tests, routine imaging (ultrasound, X-ray, endoscopy, computed tomography).Spongiform dermatitis with superficial and deep perivascular lymphohistiocytic infiltrates.Conventional therapy: antihistamines, topical steroids, systemic steroids, phototherapy.Not reported.Subacute prurigoExcoriated papules, mostly in a symmetrical distribution on the extensor surfaces of the extremities, neck, lower trunk, and buttocks.Complete blood cell count, liver and kidney parameters, antinuclear antibodies, hemoglobin A1c, and screening for hepatitis and HIV. Chest X-ray and abdominal ultrasound to exclude liver disorders and internal malignancies.Not reported.PUVA.Not reported.Subacute prurigoFlesh-colored to erythematous nonfollicular papules with superimposed excoriations or lichenification.Extensive history, skin biopsy, immunofluorescence studies, and patch testing.Mixed superficial and deep perivascular infiltrate with scattered interstitial eosinophils ± spongiosis.Not reported.Topical corticosteroids, oral antihistamines, anxiolytic agents, systemic steroids, and UV-B/PUVA.Idiopathic pruritusNot reported.Total and differential blood count, serum biochemistry, thyroid-stimulating hormone, erythrocyte sedimentation rate, total protein, albumin, protein electrophoresis, hepatitis serology, urine analysis, and chest roentgenogram.Not reported.Narrowband UV-B.Not specified.CIP, Chronic idiopathic pruritus; DIF, direct immunofluorescence; IgE, immunoglobulin E; PUVA, psoralen plus ultraviolet A. Open table in a new tab CIP, Chronic idiopathic pruritus; DIF, direct immunofluorescence; IgE, immunoglobulin E; PUVA, psoralen plus ultraviolet A. Although our understanding of these patients remains incomplete, known physiologic changes in the aging immune system provide a plausible mechanism for immunologic overactivity. There is unquestionably more to understand about this subset of patients; however, we can use our understanding of related diseases, such as atopic dermatitis, to understand the patient experience with these similar and poorly characterized entities. Highlighting the relatedness of these conditions and their impact can offer valuable insights and help the researchers in the field better understand these patients. Manjunath and Silverberg1Manjunath J. Silverberg J.I. Association of sleep disturbances with geriatric age in atopic dermatitis patients.J Am Acad Dermatol. 2021 Jul 29; https://doi.org/10.1016/j.jaad.2021.07.039Abstract Full Text Full Text PDF Scopus (1) Google Scholar introduced a critical piece of patient experience. The researchers in this field would be wise to use these data to move toward a cohesive and inclusive discussion on pruritic eruptions in older adults. Acknowledging the relatedness of many currently separate entities with underlying pathophysiologic similarities in this population can lead to impactful collaborations and studies to move toward an improved understanding of these nuanced concepts and their clinical impact on this vulnerable population. None disclosed.