Antihistamines-refractory chronic pruritus in psoriatic patients undergoing biologics: aprepitant vs antihistamine double dosage, a real-world data

Background: Psoriasis-related pruritus (PRP) in patients under systemic treatment is challenging. The risk to switch anti-psoriatic drugs and to lose response to previous therapy is high, thus dermatologists prefer to add an anti-pruritic agent. Objectives: To evaluate the effect of anti-histamines and aprepitant in treating PPR of psoriatic patients undergoing systemic anti-psoriatic therapies. Methods: A pilot observational open-label study was performed on responsive psoriatic patients with PPR under treatment. Initial therapy included oral rupatadine (10 mg/day for 30 days). In case of the Epworth Sleepiness Scale (ESS) was above 14, patients were switched to aprepitant (80 mg/day for 7 days), otherwise, rupatadine dosage was increased (20 mg/day for 7 days). Clinical evaluation was performed at the baseline (T0) and after 7 days (T7). Results: We enrolled 40 patients with PPR, 20 in each group. Age, gender, Psoriatic arthritis (PsA) and the itch–VAS, were matched. At T7, aprepitant displayed higher improvements than rupatadine (itch–VAS = 4 [3–5] vs 8.5 [8–9], p <.01, DLQI = 14 [13–16] vs. 18 [16–21], p <.01 and ESS = 5 [4–7] vs 15 [14–16], p <.01). Doubling the rupatadine dosage from 10 mg to 20 mg/day only slightly improve itch (itch–VAS = 9 [8–10] vs 9 [8–9], p =.03), conversely no modifications in the quality of life (DLQI = 18 [17–20] vs 18 [17–21], p =.73) and increased sleepiness (ESS = 10 [9–11] vs 15 [14–16], p <.01). Conclusions: Aprepitant may be a valid alternative in PPR patients with ESS >14 under antihistamines.