Advances in Itch: Brian S. Kim, MD, Shares Insights and Treatment Tips

“The ability to bring science to the clinic—to our patients—is getting better and faster and much more gratifying as time goes on. I think the next 10 years will be amazing for dermatology,” Brian S. Kim, MD, MTR, FAAD, told Dermatology Times in an exclusive interview.

Brian S. Kim, MD

Kim, vice chair of research in dermatology at the Icahn School of Medicine at Mount Sinai and Director of the Mark Lebwohl Center for Neuroinflammation and Sensation, received the Marion B. Sulzberger Award at the 2024 American Academy of Dermatology Annual Meeting in San Diego, California.

Kim spoke with Dermatology Times about the latest research in understanding the etiology of itch, the implications for treatment, and what the future might hold.

“We know that there are molecules on your sensory nervous system that trigger itch. We know that there are neuropeptides within your sensory nervous system that trigger itch, we know about a lot of factors, inflammatory and otherwise, that now are lock and key with these molecules,” he explained. “We have already done it. A lot of therapies are already doing it. The future is bright, because we now know a number of targets and we can go after them systematically.”

Kim noted the research and understanding is already being used in the clinic to help guide treatment decisions. “We're already doing it. I mean, we know that when we have agents like dupilumab that have long term effect on itch. The Jak inhibitors have a very rapid effect on itch—very, very rapid—so you can shut down triggers very quickly,” he told Dermtaology Times. I think you'll see with newer agents that are emerging, like with nemolizumab, you'll have now a monoclonal antibody, not a Jak inhibitor, and a rapid effect on itch. There's difelikefalin that is being developed for notalgia paresthetica, rapid improvement in itch, and neuropathic itch.”

“So what we're doing is aligning all of these molecules with diseases of high probability of success, and then directing them out to those diseases—in development, but now also post-development,” Kim said. “We know, for instance, probably a lot of these agents are going to work for many conditions beyond atopic dermatitis, and prurigo nodularis as well. And I know we're hearing a lot about that at this conference.”

How does Kim choose a treatment strategy? “Well, the first thing you want to do is make sure that you are treating the patient appropriately,” he said. “So the idea is if they have very generalized itch, you probably want to use more of a systemic treatment. If they have more localized itch, ideally, you would use more of topical routes of delivery and such. And that's the general idea.”

“You want to start with safety as your primary concern, but you also don't want to disregard efficacy,” Kim added. “You don't want to be so avoidant of [certain agents due to] safety concerns, and then you don't treat the itch at all. I think that has to come from in a very informed conversation with the patient, for them to understand what the risk/benefits are.”

“For a subjective disease, sometimes we minimize it. And that's a big problem with that. We think, ‘Oh, there's not a rash. There's not a lot going on. I don't think we really need to treat this aggressively.’ But the patient might want to treat it very aggressively. That's been my experience in the clinic.”

“Those are all the considerations. You have to take into account safety, efficacy, and all that, but there's a different lens you have to consider: It as a patient experience that you're really getting; it's not a provider experience. It's not objective,” Kim explained.

“I don't say when patients come in at the first visit ‘Let's do this—the big gun out of the gate,’” Kim said. “’The idea is we're going to start here, this is easier: safety-wise, ease of use, maybe even price point. We'll start there; we'll get this going. We'll see how you respond. We'll learn a little bit about your itch along the way. But here are other options that I want you to consider. I'll give you the kind of the highs and lows of that you can go home and Google it and think about it.’”

“Contemplation in medicine is very important. There's some patients that say out of the gate, ‘I'm never going to do that. I don't want to. I don't want to go on that therapy.’ And that's fine. That's totally fine,” he said. “But after a month, 2, 3, 6 months, 9 months—their feelings about that might change, often change. Living with itch becomes less bearable and their risk tolerance may change.

“I also feel it's my job as a physician to take certain risks with them, hand in hand. To say I'm not going to ever do that—I don't think works in medicine, right?”

“A lot of my patients come in having seen many other physicians and providers. They want relief. I have to be willing to go there, but they also need to be very informed if we're going to do that,” he told Dermatology Times.

Watch the video to hear more from Dr Kim.