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PN: More Than an Itch
Hear fellow providers share insights about PN and treatment with DUPIXENT
A Chance for Real Change
Dr Sarina Elmariah, Dermatologist
Dr Tim Berger, Dermatologist
DR ELMARIAH: I'm really excited to have the opportunity to talk with you about a condition in dermatology that I feel is so profoundly instructional and educational. A disease that is so impactful for patients: prurigo nodularis.
DR BERGER: And now is well recognized. So, it was a disease waiting for a treatment.
INDICATION
DUPIXENT is indicated for the treatment of adult patients with prurigo nodularis (PN).
IMPORTANT SAFETY INFORMATION
CONTRAINDICATION: DUPIXENT is contraindicated in patients with known hypersensitivity to dupilumab or any of its excipients.
DR ELMARIAH: Throughout my lifetime as a dermatologist managing PN, I have realized that it is one of the hardest conditions to deal with. Patients struggle often for a very, very long time.
DR BERGER: Well, I think the under-appreciation of the amount of suffering the patients undergo, the intensity of the itch, the social stigmatization that the lesions create. All these things make it particularly challenging for the patient to deal with.
DR ELMARIAH: That itch is so relentless, it impacts all aspects of the patient's day, all aspects of their night. And they really can't imagine being without it.
DR BERGER: I think one of the ways that it reflects in the patient presentation is the amount of desperation the patients express in their voice.
DR ELMARIAH: The first thing I do is try to set the foundation where the patient knows that I'm listening, that I care.
DR BERGER: I think how the disease has impacted the patient is something that no one ever asks. They've told doctors they itch, but they haven't told them how much. And once that discussion begins, they feel that they have an ally as a dermatologist.
DR ELMARIAH: I welcomed DUPIXENT into my practice. Here was a drug that could address the multiple aspects of the pathophysiology, the underlying pathophysiology of PN. A disease that previously had been so poorly understood.
DR BERGER: And I think it led patients out of this space where they weren't understood to a space where they had something that people could treat.
DR ELMARIAH: Having a monoclonal antibody that can simultaneously target IL-4 and its ability to tame T-cell differentiation and type 2 inflammation as well as influence IL-13 signaling that is important in the inflammatory components—and also the cutaneous sensitization and neural components of the disease—is pretty profound. And in particular for a disorder like PN.
DR BERGER: I think that the concept of Th2 inflammation has been very powerful in science in general, but that this disease is manifesting itself as the immune system and the nervous system of the skin leading to this dysregulation. So I think that over time we've sort of turned the boat a little bit from a disease of desperation to one of hope. And DUPIXENT has helped us with that.
DR ELMARIAH: It built an awareness about this disease that had a huge impact on the field. For my patients themselves, I think having someone come in and improving in their itch for the first time in months, years, sometimes even decades. It's such an intense experience. They're beginning to see the improvement, you know, in their nodules or even that many of their nodules have already resolved, and very often, you know, it's followed by, it's followed by a hug.
DR BERGER: Yeah, I think it's been a gratifying journey for all of us to see patients improve. Patients who were very desperate in the beginning and to sort of have a few patients come back in the clinic every time that at the beginning were challenges and now are your friends and are willing to talk to other patients about the experiences. It's just very gratifying.
DR ELMARIAH: One of the things I love about DUPIXENT is its demonstrated safety profile. The most common adverse reactions with an incidence of greater than or equal to 2% are nasopharyngitis, conjunctivitis, herpes infection, dizziness, myalgia, and diarrhea.
DR BERGER: In a complex disease like this, the safety becomes paramount.
DR ELMARIAH: I remember one patient who came in, very complex medical history. Our very first visit, she was just in tears. I remember just even talking about DUPIXENT as an option was something that again brought her to tears. And she came back and she said she finally had hope. Her skin was feeling better.
DR BERGER: This patient had been in treatment for 150 days with topical steroids, topical tar, phototherapy, and basically was not responding. We put the patient on DUPIXENT, and the lesions began to heal. And for the first time in more than a decade, that intensity of itch—it's so gratifying when they get better. Grateful is a common response to patients with PN who go on DUPIXENT.
DR ELMARIAH: Yeah, it's true.
DR BERGER: So Sarina, it's been a great pleasure working with you here today, and I'm so delighted we've had this opportunity to talk about prurigo nodularis.
DR ELMARIAH: Thanks, Tim. It's been great to speak with you not only about PN, but how DUPIXENT's been changing the field.
Resetting Expectations in Prurigo Nodularis
Douglas DiRuggiero, DMSc, PA-C
Victor Czerkasij, DNP, FNP-C
DOUGLAS: Let's talk about prurigo nodularis.
VICTOR: There was a time that I would've been very discouraged because it would've taken me a long time to try to work out what this condition is, explain it to the patient.
DOUGLAS: It's so exciting right now to be in dermatology because now you walk in like, “Yeah, I can. I've got something to offer them.”
INDICATION
DUPIXENT is indicated for the treatment of adult patients with prurigo nodularis (PN).
IMPORTANT SAFETY INFORMATION
CONTRAINDICATION: DUPIXENT is contraindicated in patients with known hypersensitivity to dupilumab or any of its excipients.
VICTOR: So, Doug, when it comes to our patients who have prurigo nodularis, it's been a condition that, for many years, has been quite difficult for us to work with.
DOUGLAS: These patients complain tremendously about itch, and the fight to try to not itch when they're in certain social situations. A gentleman the other day, he says, “You just don't know how tough it is to fight the itch when I'm sitting there talking to someone.”
VICTOR: There was a lady that I walked into the room to see. She was a new patient and she was weeping. I looked at her arms that were excoriated, bleeding from the condition. She had scars.
DOUGLAS: On the outskirts of our town for a couple years, they had a large billboard that had a picture of this gentleman with all these excoriations all over his face. And it was for a drug rehab center that they were advertising. And she says, “People look at me and they say, 'Do you have the same problem as that person on the billboard?'” And so I think these people are so relieved when I say “I want you to know that your body is doing something that's causing this and we've got things that can help.”
VICTOR: I tell patients, for example, explaining autoimmune, we have a very complex immune system, and when it's firing on all cylinders, there's a balance, right? But it's imbalance that occurs. So you're overproducing these proteins or cytokines or interleukins and they're so specific we even have name numbers for them. So it's 4 and 13.
DOUGLAS: But also other players come in like interleukin-31 and others that can drive this whole cascade.
VICTOR: We have too much of that, it also engenders an itch factor in the skin. You scratch it and now you make more. “Oh,” they're like, “Wow. So it's a vicious cycle.” To have something now that is not an immunosuppressant, not a steroid, like DUPIXENT.
DOUGLAS: And it's so nice to be able to tell them that there is a demonstrated safety profile. The most common adverse reactions, with an incidence of greater than or equal to 2%, are nasopharyngitis, conjunctivitis, herpes infection, dizziness, myalgia, and diarrhea.
VICTOR: My first DUPIXENT patient for prurigo nodularis when it was approved, she just cried all the time. And I began her on that medication. It was significant for her that she was able to achieve a place where there was a lack of itch.
DOUGLAS: I had a mother who had several young kids. And when I put her on DUPIXENT and she began to see this decrease in the nodules and began to see the improvement in itch. So it makes what we do very satisfying to have those patients who come in that are prescribed DUPIXENT and they tell you that their itch is better, whether it's day or night, and that the lesions that they had so many of they're seeing begin to resolve.
VICTOR: There's a bonding experience when you're there with them and then all of a sudden you've got that improvement.
DOUGLAS: I had a similar experience too. A gentleman that I had who is a used car salesman. All of his employees, they have kind of a dress code. They're supposed to wear khakis and a golf shirt, but he's had to get the exception because he feels like his arms were so covered in these nodules and these excoriations that to wear something long sleeve. When he started the DUPIXENT the reduction in the number of nodules that he experienced, it makes what we do a lot of fun.
VICTOR: I really want them, since they've lived for many years with discouragement, to celebrate the improvements.
DOUGLAS: Victor, this has been very enjoyable. Even though we've known each other for years, it's just nice to be able to really sit down and talk about the difference that DUPIXENT's making in our patients with prurigo nodularis.
VICTOR: Thank you, Doug. I appreciate that your experiences with prurigo nodularis patients is similar to mine. And I'm just looking forward to spending more time talking about these topics with you in the future.
PN, prurigo nodularis.
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