PS11 Successful treatment of chronic pruritus and secondary ulceration with aprepitant

Abstract A 55-year-old woman was referred to the dermatology clinic with unexplained ulceration on her dorsal hands leading to recurrent skin infection. On review, she described a 2-year history of intractable pruritus and paraesthesia of her hands leading to compulsive skin picking. She described similar sensations across her upper torso and feet. Her history was notable for borderline personality disorder, carpal tunnel syndrome, type II diabetes mellitus, hypertension and obesity. On examination there were multiple atrophic scars, small lichenified nodules and excoriations scattered across her dorsal hands and upper back. A pruritus screen was completed. No underlying systemic cause for pruritus was identified. Initial treatment focused on neuropathic itch and nodular prurigo. Potent and ultrapotent topical steroids were trialled, including under occlusion, alongside menthol-containing aqueous cream. Pregabalin was commenced in the community for neuropathic pain. However, at subsequent clinic visits there was progressive ulceration, with numerous shallow well-circumscribed ulcers scattered across her limbs. Multiple skin biopsies demonstrated nonspecific ulceration, with no evidence of an inflammatory dermatosis. An initial 1-week trial of aprepitant 80 mg once daily provided rapid improvement in the pruritus and paraesthesia. This was not maintained following the initial treatment and approval was obtained for long-term use of aprepitant 80 mg on alternate days alongside careful wound care management. Over several months, resolution of the ulcerated areas was achieved alongside sustained improvement in symptoms and quality of life. Aprepitant was withdrawn following successful wound healing; however, there was rapid recurrence of symptoms and areas of ulceration leading to reintroduction of treatment with some early signs of possible improvement. Aprepitant is a neurokinin-1 receptor antagonist that is primarily used for chemotherapy and postsurgical-induced nausea and vomiting. There is a growing evidence base for off-licence use of aprepitant to relieve chronic intractable pruritus in patients where conventional therapies have failed. Significant impact on quality of life has been demonstrated with aprepitant in a wide variety of underlying causes of pruritus including chronic kidney disease, solid organ tumours, lymphoma and mycosis fungoides, and neuropathic disease such as brachioradial pruritus. Here we demonstrate the benefit of aprepitant in compulsive skin picking secondary to pruritus.