Rédacteurs : Johan Nguyen, Henri Truong
Sommaire
itch
Prurit : évaluation de l'acupuncture
1. Systematic Reviews and Meta-Analysis
| ☆☆☆ | Evidence for effectiveness and a specific effect of acupuncture |
| ☆☆ | Evidence for effectiveness of acupuncture |
| ☆ | Limited evidence for effectiveness of acupuncture |
| Ø | No evidence or insufficient evidence |
1.1. Generic Acupuncture
1.1.1. Ranpariya 2024 (Prurigo Nodularis)
Ranpariya M, Zaino ML, McCampbell LE, Patel T, Feldman SR. Non-Systemic Medication for the Treatment of Prurigo Nodularis: A Systematic Review. J Cutan Med Surg. 2024 Mar-Apr;28(2):173-177. https://doi.org/10.1177/12034754241227634
| Background | Prurigo nodularis (PN) is a skin disease characterized by firm, itchy, erythematous lesions. Treatment consists of systemic and non-systemic modes of therapy. Non-systemic forms of treatment are first-line and include topical corticosteroids, topical steroid-sparing agents, and phototherapy. |
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| Objective | The objective was to review the efficacy of non-systemic treatment used to treat PN. |
| Methods | A systematic search was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and registered with PROSPERO (CRD42023412012). The search consisted of keywords and Medical Subject Heading (MeSH) terms and translated to Ovid MEDLINE, Embase, and Scopus. Google Scholar was also searched for the first 200 articles. Article quality of evidence was scored using GRADE criteria. |
| Results | The search yielded 1151 results; 37 met criteria for inclusion. There were 14 studies on phototherapy, and 11 studies on topical corticosteroids, most of which were also combined with topical antihistamines, antipruritics, and/or phototherapy. There were 2 studies each on topical antipruritics used in isolation, vitamin D analogues, and intralesional triamcinolone acetonide. There was 1 study each on topical pimecrolimus, tacrolimus, 2% dinitrochlorobenzene, cryotherapy, acupuncture, and the Paul Gerson Unna boot. Most were case reports and case series, although 2 randomized controlled trials on phototherapy and topical pimecrolimus were included.Corticosteroids had varying levels of positive response in patients and appeared more effective when used in combination or under occlusive dressing. Phototherapy is likely effective, but the risk of relapse is high. Cryotherapy may also be a lesion-directed agent to circumvent challenges to adherence and avoidance of systemic medication. |
1.1.2. Chan 2016 ~
Chan IH, Murrell DF. Itch Management: Physical Approaches (UV Phototherapy, Acupuncture). Curr Probl Dermatol. 2016;:54-63. [187874].
| Background | Physical therapies refer to non-medical treatment strategies, including surgery, cryotherapy, UV phototherapy, and acupuncture. Most physical approaches are inappropriate in the context of itch. UV phototherapy and acupuncture may be effective in the management of itch. |
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| Methods | A literature search was performed using MEDLINE and EMBASE. Bibliographies were reviewed for relevant articles. |
| Results | Narrowband UVB (311-313 nm) and UVA1 (340-400 nm) are equally effective in managing atopic dermatitis and associated itch. The efficacy of broadband UVB in reducing uraemic itch has been demonstrated in a series of randomised controlled trials, but more recent studies have failed to reproduce these results. Non-randomised, uncontrolled studies and case series suggest that UV is effective in managing itch associated with cholestasis, chronic urticaria, prurigo, cutaneous T-cell lymphoma, aquagenic itch, and scleroderma. UV phototherapy is well tolerated, and no significant relationship between UVB therapy and skin cancer has been found. Experimentally, acupuncture has been shown to reduce allergen-related itch, although this finding has been limited by the small number of studies, inconsistency in agreement on acupuncture sites and study design, small sample sizes, and limited follow-up. |
| Conclusions | UV phototherapy is an effective treatment for itch associated with atopic dermatitis. UVB may be effective in managing itch associated with end-stage kidney disease, cholestasis, chronic urticaria, prurigo, cutaneous T-cell lymphoma, aquagenic itch, and scleroderma. Phototherapy should be combined with standard first-line therapies. Insufficient evidence exists to justify acupuncture as a physical therapy for itch. Further well-designed studies are required to establish the effectiveness of physical therapies in managing itch. |
1.1.3. Yu 2015 ☆
Yu C, Zhang P, Lv ZT, Li JJ, Li HP, Wu CH, Gao F, Yuan XC, Zhang J, He W, Jing XH, Li M. Efficacy of Acupuncture in Itch: A Systematic Review and Meta-Analysis of Clinical Randomized Controlled Trials. Evid Based Complement Alternat Med. 2015;2015:208690. [001]
| Background | Itch (pruritus) is a sensitive state that provokes the desire to scratch. It is not only a common symptom of skin diseases but it also occurs in some systemic diseases. Clinical studies on the efficacy of the acupuncture therapy in alleviating itch are increasing, while systematic reviews assessing the efficacy of acupuncture therapy are still lacking. |
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| Objective | This systematic review aims to assess the effectiveness of acupuncture therapy for itch. Materials and Methods. A comprehensive literature search of eight databases was performed up to June 2014, and randomized controlled trials which compared acupuncture therapy and placebo acupuncture or no treatment group were identified. Accordingly, a meta-analysis was conducted. |
| Results | This review included three articles of randomized controlled trials (RCTs) from a total of 2530 articles. The results of Meta-analysis showed that acupuncture therapy was effective to alleviate itch compared with placebo acupuncture and no treatment group. |
| Conclusion | Based on the findings of this systematic review, we cautiously suggest that acupuncture therapy could improve the clinical efficacy of itch. However, this conclusion needs more studies on various ethnic samples to confirm our final conclusion. |
1.2. Special Clinical Forms
1.2.1. Uremic Pruritus
1.2.1.1. Lu 2024
Lu PH, Chuo HE, Chiu LY, Lai CC, Wang JY, Lu PH. Comparative efficacy of acupuncture point stimulation treatments for dialysis patients with uremic pruritus: a systematic review and network meta-analysis. Front Neurol. 2024 Mar 22;15:1342788. https://doi.org/10.3389/fneur.2024.1342788
| Backgound | Uremic pruritus (UP) is a common complication of chronic kidney disease that causes sleep disturbances and increases all-cause mortality. Currently, the first-line medications for UP exhibit inadequate pruritus control with adverse effects. Various acupuncture point stimulation treatments (APSTs) have been shown to be effective as adjuvant therapies in UP, and a network meta-analysis can offer relative efficacy estimates for treatments for which head-to-head studies have not been performed. |
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| Methods | We conducted a random-effects network meta-analysis on a consistency model to compare the different APSTs for UP. The primary outcomes were the mean visual analog scale (VAS) score and effectiveness rate (ER). |
| Results | The network meta-analysis retrieved 27 randomized controlled trials involving 1969 patients. Compared with conventional treatment alone, combination treatment with acupuncture (mean difference, -2.63; 95% confidence interval, -3.71 to -1.55) was the most effective intervention in decreasing VAS scores, followed by acupoint injection and massage (mean difference, -2.04; 95% confidence interval, -3.96 to -0.12). In terms of the ER, conventional treatment with acupuncture and hemoperfusion (risk ratio, 14.87; 95% confidence interval, 2.18 to 101.53) was superior to other therapeutic combinations. Considering the VAS score and ER, combination treatment with acupoint injection and massage showed benefits in treating UP. |
| Conclusion | Our network meta-analysis provided relative efficacy data for choosing the optimal adjuvant treatment for UP. Combined treatment with acupuncture was more effective than conventional treatment only and was the most promising intervention for treating UP. |
1.2.1.2. Hsieh 2023
Hsieh ML, Huang HS, Chao YF, Liu HL. [Systematic Review and Meta-Analysis of Non-Invasive Acupoint Therapy as an Approach to Urinary Itching Control in Dialysis Patients]. Hu Li Za Zhi. 2023 Aug;70(4):69-80. https://doi.org/10.6224/JN.202408_71(4).09
| Backgound | |
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| Purpose | Relevant domestic and international research on the effectiveness and methods of non-invasive acupoint therapy in improving uremic pruritus in dialysis patients was reviewed. Discussing related knowledge can facilitate the evidence-based use of non-invasive acupoint therapy in clinical practice by clinical medical personnel. |
| Methods | Based on the PRISMA (preferred reporting items for systematic reviews and meta-analyses) systematic literature review and integrated analysis method, a keyword search of related articles published before September 2023 was conducted in the following databases: PubMed, Cochrane Library, Embase, Web of Science, Airiti Library, Taiwan Master and Doctoral Dissertation System, Chinese Journal Full-text Database and Wanfang Data Knowledge Service Platform. In 2019, the second version of the Risk of Bias Tool for Randomized Controlled Trials was used to evaluate research quality, after which RevMan 5.4 and Stata 14.0 suite software were used for meta-analysis. |
| Results | Nine of the 112 articles selected, including 10 sets of data and 597 participants, were included in the meta-analysis. The results indicate non-invasive acupoint therapy significantly reduces the degree of uremic pruritus (synthetic effect size = -1.30, 95% confidence interval [-1.67, -0.93], p < .00001). Because the heterogeneity test I² = 76%, showed a high degree of heterogeneity, a subgroup analysis was performed, showing that acupoint massage combined with traditional Chinese medicine fumigation and washing, a general simple itching assessment scale, and the Chinese region achieved better effect sizes. |
| Conclusions / implications for practice | Non-invasive acupoint therapy is easy to implement, inexpensive, non-invasive, and associated with few side effects. The authors hope these findings may increase the awareness and understanding of patients with dialysis regarding the practical operation techniques of itching acupoints. According to the results of this systematic review and meta-analysis, massage of the lung and endocrine acupoints at ST-6, SP-10, and LI-11 as well as the relevant points on the ear may be most effective in achieving urinary itching relief. Also, acupoint massage combined with traditional Chinese medicine fumigation, ST-6 far-infrared irradiation, or LI11 transcutaneous acupoint electrical stimulation can further relieve uremic pruritus in this patient population. Based on the results, acupoint massage combined with traditional Chinese medicine fumigation and washing is a complementary method of treatment for uremic pruritus that may be recommended to patients in the future. |
1.2.1.3. Lu 2022
Lu PH, Chung CH, Chuo HE, Lin IH, Lu PH. Efficacy of acupoint stimulation as a treatment for uremic pruritus: A systematic review and meta-analysis. Front Med (Lausanne). 2022 Dec 1;9:1036072. https://doi.org/10.3389/fmed.2022.1036072
| Background | Uremic pruritus causes sleep disturbances, poor quality of life, and increased morbidity in patients with chronic kidney disease. Acupuncture has been shown to improve uremic pruritus. There is limited evidence of the efficacy of traditional Chinese therapies. We conducted a systematic review and meta-analysis to evaluate the efficacy of acupoint stimulation therapy in patients with uremic pruritus. |
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| Methods | A systematic search of seven databases (up to Sep 2022) was conducted for randomized controlled trials that evaluated the clinical efficacy of acupuncture, acupressure, auricular acupressure, acupoint injection, acupoint thermal therapy, acupoint sticking therapy, or transcutaneous electrical acupoint stimulation in the treatment of patients with uremic pruritus. Two reviewers selected eligible articles for inclusion in the meta-analysis and evaluated the risk of bias via Cochrane Collaboration. The results of pruritus assessments and uremic pruritus-related laboratory parameters were analyzed. |
| Results | Forty trials published between 2002 and 2022, including a total of 2,735 participants, were identified for inclusion in the meta-analysis. The effective rates for acupuncture, auricular acupressure, and the combination of acupoint injection and acupoint massage were significantly greater in patients with uremic pruritus compared to the control group. The levels of serum BUN, PTH, and histamine levels were significantly lower vs. control group. |
| Conclusions | Acupuncture, auricular acupressure, and the combination of acupoint injection and acupoint massage seem to be effective in improving uremic pruritus in patients with chronic kidney disease. However, further investigation of these potential treatments is now warranted in larger patient populations and over a longer time frame. |
1.2.1.4. Zhang 2022 ★★
Zhang L, Li Y, Xiao X, Shi Y, Xu D, Li N, Deng Y. Acupuncture for uremic pruritus: A systematic review and meta-analysis. J Pain Symptom Manage. 2022 Aug 30:S0885-3924(22)00871-5. https://doi.org/10.1016/j.jpainsymman.2022.08.017
| Background | Uremic pruritus (UP) is a chronic disease that can seriously affect the quality of life of dialysis patients. Acupuncture is a non-medication therapy that has been used to treat pruritus disorders. This systematic review aimed to evaluate the efficacy and safety of acupuncture for the treatment of UP. |
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| Methods | A total of 9 Chinese and English databases were searched from their inception to December 31, 2021, and 214 studies were retrieved. These articles were selected according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. The quality of included studies was judged as low to moderate using the Cochrane's risk of bias (RoB) tool V.5.1.0. |
| Results | Finally, 7 randomized controlled trials (n=504) were included in the meta-analysis performed using RevMan V.5.3. Results included effective rate (The effective rate is the percentage of the total number of patients who are clinically cured, reporting treatment to be markedly effective, and reporting treatment to be effective), recurrence rates, and adverse events. Compared with conventional treatment, acupuncture was more effective in treating UP (risk ratio [RR] = 1.28, 95% confidence interval [CI]=1.09 to 1.50, P=0.003). The results were consistent after sensitivity analysis (RR=1.38, 95% CI=1.21 to 1.57, P<0.00001). In subgroup analysis, the efficacy rates of acupuncture and medications (oral and topical) were comparable (RR=1.20, 95% CI= 0.98 to 1.47, P=0.07). Acupuncture combined with hemodialysis was more effective than hemodialysis alone in relieving pruritus (RR = 1.42, 95% CI=1.18 to 1.72, P=0.0002). Adverse events were reported in only three studies, including one case of hyperphosphatemia in the medications group (RR=0.29, 95% CI=0.01 to 7.06, P=0.45). None of the studies reported recurrence rates. |
| Conclusion | In conclusion, acupuncture is a safe treatment modality for patients with UP receiving hemodialysis that can effectively improve UP symptoms, and acupuncture in combination with hemodialysis has more efficacy than hemodialysis alone in improving the UP symptoms. |
1.2.1.5. Yeam 2021
Yeam CT, Yo TE, Tan YLC, Liew A, Seng JJB. Complementary and alternative medicine therapies for uremic pruritus - A systematic review of randomized controlled trials. Complement Ther Med. 2021. [220841]. https://doi.org/10.1016/j.ctim.2020.102609
| Introduction | Uremic pruritus (UP) is one of the most bothersome symptoms among chronic kidney disease (CKD) patients. The pathophysiology of UP remains elusive, resulting in limited treatment options. The inability of standard medical treatments to provide effective relief has piqued interest in complementary and alternative medicine (CAM). |
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| Methodology | A systematic review of randomized controlled trials (RCTs) summarizing the efficacy and safety profile of CAM used for UP in CKD patients was performed. CAM interventions were classified using categories proposed by the National Center for Complementary and Integrative Health. The efficacy of each CAM was determined from changes in UP severity and all reported adverse effects were extracted. |
| Results | Of 5242 articles screened, 34 RCTs were included, with 15 (44.1 %) studies having a sample size greater than 50. The studies considered 21 treatments including omega-3 fatty acid supplementation (n=5), acupuncture (n=5), topical capsaicin (n=4) and acupressure (n=3). Acupuncture, acupressure and topical capsaicin were shown to be effective in improving uremic pruritus. Interventions which include oral omega-3 fatty acid and zinc supplementation demonstrated mixed efficacy. Other therapies such as evening primrose oil, turmeric, vitamin B3, vitamin D and thermal therapy were not effective for treatment of UP. Common adverse effects reported with topical capsaicin included mild burning sensations (50.0-88.2 %) or erythema (6.7-22.7%) while that of acupuncture included soreness (7.5 %), bleeding (6.0-7.5%) and hematoma (1.9 %). |
| Conclusions | Acupuncture, acupressure and topical capsaicin have the largest body of evidence for efficacy in the treatment of UP. Larger and higher quality RCTs are required to examine the efficacy and safety of promising CAM. |
1.2.1.6. Badiee 2018 ☆
Badiee Aval S, Ravanshad Y, Azarfar A, Mehrad-Majd H, Torabi S, Ravanshad S. A Systematic Review and Meta-analysis of Using Acupuncture and Acupressure for Uremic Pruritus. Iran J Kidney Dis. 2018;12(2):78-83. [99957].
| Introduction | Uremic pruritus is characterized by an uncomfortable and unlimited sensation which leads to scratch, which strongly reduces the quality of life. Pruritus is a common symptom in patients with end-stage renal disease. Various clinical trial studies have examined the effects of acupuncture and acupressure on treatment of uremic pruritus. This systematic review meta-analysis aimed to evaluate the effectiveness based on published studies. |
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| Materials and methods | An electronic literature search was conducted to identify appropriate trial studies. The results for continuous outcomes were presented as weighted mean difference, with 95% confidence intervals. |
| Results | A total of 5 articles, including 6 trials, were enrolled in this systematic review. Only 3 of the six trial studies used a visual analogue scale score for assessing pruritus and acupressure for intervention regime, which were considered for meta-analysis. The combined results showed that acupuncture or acupressure was effective in treatment of uremic pruritus (pooled mean difference, -1.994; 95% confidence interval, -2.544 to -1.445). |
| Conclusions | This study confirms that using acupuncture and acupressure is effective in treatment of uremic pruritus. However, further vigorous studies are needed to verify these findings |
1.2.1.7. Malekmakan 2018 Ø
Malekmakan L, Tadayon T, Pakfetrat M, Mansourian A, Zareei N. Treatments of uremic pruritus: A systematic review. Dermatol Ther. 2018;31(5):e12683. [196645].
| Background | Till now many treatments attempted to relieve uremic pruritus (UP) though none of them are definite treatment. |
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| Methods | In this study, we gathered all studies conducted on UP treatment since 2000-2016. We conducted a systematic review by searching the electronic databases (PubMed, Scopus, and Google scholar). Patients were with chronic kidney disease who complained of UP. Clinical trials and pilot studies in English and Persian which were done on patients with ESRD who complained of itching between 2000 till 2016 were gathered. |
| Results | A total of 166 articles were collected. After excluding articles 41 articles were remaining. Then UP treatments classified into two main groups: Medical (chemical and herbal medicine) and non-medical. Most studies measured UP by VAS scoring system in which patients described the severity. This scoring system is individual dependent. |
| Conclusions | There are lots of studies on UP treatment though there are lots of controversies in studies. Finding a definite cure for this unpleasant symptom can improve patients' quality of life. Conducting further studies for each treatment on larger population is essential to improve quality of life among the end stage renal disease patients. |
| Acupuncture | Chou Che-yi et al. mentioned that acupuncture reduced pruritus more than control group (Che-yi et al., 2005). |
1.2.1.8. Kim 2010
Kim KH, Lee MS, Choi SM, Ernst E. Acupuncture for treating uremic pruritus in patients with end-stage renal disease: a systematic review. J Pain Symptom Manage. 2010: 40(1):117-25. [165753].
| Objectifs | Uremic pruritus (UP) is a common and bothersome symptom in end-stage renal disease (ESRD) that does not always respond to conventional care. Acupuncture is frequently used for the treatment of a wide range of conditions, but its effects on UP in ESRD patients are unclear. The objective of this review was to evaluate the effectiveness of acupuncture for UP in patients with ESRD. |
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| Méthode | We searched 16 electronic databases from their inception to November 2009. All prospective clinical studies of needle acupuncture for UP in hemodialysis patients with ESRD were included regardless of their design. Risk of bias of the included studies was assessed using the Cochrane criteria. |
| Résultats | Three randomized controlled trials and three uncontrolled observational studies were included. All of the included trials reported beneficial effects of acupuncture. However, most of the studies showed high risk of bias, which leaves their reports unconvincing. |
| Conclusions | The current evidence is insufficient to show that acupuncture is an effective treatment for UP inpatients with ESRD because of suboptimal quality and lack of methodological rigor of included studies. Future trials should overcome the limitations of the currently available evidence. |
2. Clinical Practice Guidelines
| ⊕ positive recommendation (regardless of the level of evidence reported) Ø negative recommendation (or lack of evidence) |
2.1. European Dermatology Forum (EDF) and the European Academy of Dermatology and Venereology (EADV) 2019 ⊕
Weisshaar E, Szepietowski JC, Dalgard FJ, Garcovich S, Gieler U, Giménez-Arnau AM, Lambert J, Leslie T, Mettang T, Misery L, Şavk E, Streit M, Tschachler E, Wallengren J, Ständer S. European S2k Guideline on Chronic Pruritus Acta Derm Venereol. 2019;99(5):469-506. [212182]. doi
| 6.4.13. Physical treatment modalities. Physical treatments such as transcutaneous electrical(field)stimulation and acupuncture. Expert recommendation: We cannot make a recommendation with respect to physical treatment for the treatment of Chronic Pruritus. Therapeutic options in chronic kidney disease-associated pruritus : acupuncture. |
2.2. British Association of Dermatologists 2018 ⊕
Millington GWM, Collins A, Lovell CR, Leslie TA, Yong ASW, Morgan JD, Ajithkumar T, Andrews MJ, Rushbook SM, Coelho RR, Catten SJ, Lee KYC, Skellett AM, Affleck AG, Exton LS, Mohd Mustapa MF, Levell NJ. British Association of Dermatologists' guidelines for the investigation and management of generalized pruritus in adults without an underlying dermatosis, 2018. Br J Dermatol. 2018;178(1):34-60. [197400].
| Patients with GPUO should consider acupuncture in combination with Chinese herbal remedies (Strength of recommendation D), Patients with GPUO should consider acupuncture as a second-line therapy (Strength of recommendation D). Patients with uraemic pruritus may consider auricular acupressure, topical Sericin, topical turmeric, oral omega-3 supplements or aromatherapy (Strength of recommendation D). |
