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“Why am I so itchy?” If you have itchy skin without rash, including issues like eczema, psoriasis, or chronic hives, you might have neuropathic itch.
Though itch is caused primarily by inflammation, neuropathic itch is actually caused by dysfunction of your nervous system!
Put simply, this type of itch has no primary skin rash, so you won’t see inflamed dry patches or welts. You’ll only feel itchy.
It is often localized to certain areas of the body. For example, you could have an itchy scalp, back, or arms. The itchy skin can sometimes be mild, but is unfortunately usually quite intense, leading to scratching, which can damage the skin.
And because there’s no treatment for neuropathic itch, despite it being very common, you might start to feel like there’s no hope. Yes, what’s causing this is not yet well understood, but it sounds like experts are digging into this.
Joining me to discuss neuropathic itch is returning guest Dr. Shawn Kwatra. He is the Chair of Dermatology at the University of Maryland School of Medicine. He specializes in medical dermatology areas of clinical expertise, including atopic dermatitis, psoriasis, chronic itch of unknown origin and dermatology for ethnic skin. Dr. Kwatra also runs a basic science laboratory and clinical trials unit and is funded by the National Institutes of Health and multiple foundations.
He currently serves as the National Secretary/Treasurer of the Skin of Color Society. He is a member of the National Eczema Association’s Scientific and Medical Advisory Council.
Dr. Kwatra has been an author or co-author on over 200 publications and author of the book Living with Itch.
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In This Episode:
- What is neuropathic itch (aka. itchy skin without rash)?
- How could your brain cause itchy skin without rash?
- Itch intensity of different examples of neuropathic itch
- Treatment options for neuropathic itch
- Which inflammatory cytokines are involved?
- Could Low Dose Naltrexone help itchy skin without rash?
- Alternative therapies for neuropathic itch
Quotes
“[Neuropathic itch is] initiated or caused by dysfunction of the nervous system…so it actually is caused by the nerves. And the core symptoms here are that you have normal skin, or skin only with some secondary skin changes or signs of scratching, excoriation, and it oftentimes favors a localized distribution. And so the scalp is actually a very common site where folks itch.”
“Unfortunately, a lot of the medications we use to treat this condition are very sedating. They're drugs that are focusing on the transmission of itch in the central nervous system and spinal cord like gabapentin or anticonvulsants. So those are the type of drugs that we're giving for this condition.”
Links
Find Dr. Shawn Kwatra online here and here | Twitter
Get Dr. Kwatra's book Living with Itch: A Patient's Guide
357: Got Itchy Skin Without Rash? The Surprising Neuropathic Itch Trigger No One Talks About w/ Dr. Shawn Kwatra {FULL TRANSCRIPT}
Jennifer Fugo (00:05.949)
Dr. Kwatra, welcome back. I'm so excited to have you here, and we're gonna talk about our favorite topic, again on itch, but we're gonna go in a completely different direction today.
Shawn Kwatra (00:17.814)
I'm so excited to be here. Thanks for having me, Jen.
Jennifer Fugo (00:20.789)
You're welcome. So you are the person who shared with me this concept of neuropathic itch. And to be honest with you, I was like, okay, maybe some connection to the brain, I'm not sure. And then you were like, look, layman's terms are it's itchy skin without rash. And I was like, oh, now I get it. Now I get it.
So since itch is like your thing, you're like the king of understanding itch and doing itch research. And because itchy skin without rash can drastically impact somebody's quality of life and so many facets of their just daily experience. You have this paper that you published, and obviously you're doing a lot of work in this area to understand, like what exactly is neuropathic itch and how is it associated with the nervous system?
Shawn Kwatra (01:13.106)
Absolutely. So neuropathic itch, you know, it's a mouthful, you're like, what is that? But it's so incredibly common. It's when you're itchy, there's not necessarily a primary rash. And what it's caused by is, instead of inflammation, which we've talked a lot about inflammation, oh, histamine, all these different things, cytokines, IL-4, all these different cytokines. Actually, this is the type of itch where you don't think about as much inflammation. It's an itch that's initiated or caused by dysfunction of the nervous system, the nerves. So it actually is caused by the nerves. And the core symptoms here are that you have normal skin, or skin only with some secondary skin changes or signs of scratching, excoriation, and it oftentimes favors a localized distribution.
So areas that can be affected, such as the scalp. And so the itchy scalp is actually a very common site. And if you look at the scalp, many derms will look there. And what you'll see is that many times there's no rash. You're looking for scalp psoriasis, which can be scaly. You're looking for things like seborrheic dermatitis, which can also have some redness and scale and dandruff and all of that stuff. You're looking for areas of eczema or hair loss or other things to guide you, but there's really nothing. And that happens more common than you'll actually know. Actually, it's becoming understood that that's actually one of the most common complaints that we're seeing from patients is scalp pruritus. And it's thought to be a localized form of this neuropathic itch, and there's actually been some studies done showing that there can be damage to the cervical nerves. So actually degeneration of cervical discs. There have been studies also showing that there could be nerve impingement as well.
Shawn Kwatra (04:13.07)
So when you have itchy scalp, actually one thing you should think about is cervical spinal disease. And so there's actually a nice study published in JAMA Dermatology looking at these patients, and what was found was that a lot of folks actually had issues with the cervical spine. So in the neck, patients had chronic neck pain or neck fusion surgeries. There were also instances of degenerative disc disease that was present in a lot of patients, and I see that a lot in patients. So it's actually damage to the nerves that are transmitting itch. And what people don't realize is you can have damage to the nerve and have pain, but you can also have damage to the nerves and have itch as a symptom. And they oftentimes coexist too.
So it can be in the scalp, if you have damage to some of those cervical nerves. It can actually also be in other places like the back. So it's really common to actually have itching on unilateral areas of the back, maybe over one shoulder blade or the other one. And I'm sure many folks who are listening may have that, have this condition called notalgia paresthetica. And it's characterized by this itch, really without a primary rash. There may be some pigmentation from scratching at it a lot, but it can be really debilitating, very bothersome to patients as well.
So that's another area. There's also another form of itching on the arms called brachioradial pruritus. So cervical damage can happen and cause the scalp pruritus, it can also happen a little bit lower and be related to the brachioradial parietis. And then notalgia paraesthetica, which we discussed is on the back, can be some damage to the thoracic vertebrae also.
Shawn Kwatra (06:09.806)
And what's interesting is you don't have to have any history of trauma. You don't have to have any history of surgeries. This happens just to people randomly. Happened to my wife. She was like, I came home from work and she said, hey, can you scratch my back? And I'm like, no, I'm setting boundaries. Work and private life, I'm not dealing with your itch. But I had to scratch it because it was so debilitating. And actually there have been some studies showing that if you strengthen the muscles and you do muscle exercises, it can help relieve the itching because these actual nerves can be impinged upon. So there's actually some things you can do. And so other things that we treat with, we'll try topical steroids, but they have a little bit less efficacy in most cases because there's less true inflammation. But we would use a neuromodulating agent. So things like gabapentin, also antidepressants off label, so oftentimes those are used as well. So antidepressants are oftentimes used in these patients. And agents like capsaicin too.
Jennifer Fugo (07:09.421)
Well, can I just jump in because I will say, and I think most listeners, if they follow me on Instagram will know that I've had a really serious history with back issues and disc issues. And so I will be honest with you, I didn't know that this was where we were headed and this is absolutely fascinating and underscores that deep interconnection between two, I mean, I guess they are and they're not two separate systems. It's a nerve transmission, but it's impacting the skin and you're, like you said, it could be this, the way your brain is interpreting, right? Or is it your brain, the way your brain is interpreting the signals as pain versus itch?
Shawn Kwatra (07:58.954)
It's a great question. So actually, if you think about the itch signal in the skin, you can appreciate the itch signal through what we call unmyelinated C fibers and A delta fibers. So some of them have a thin level of myelin that lets the nerve message travel faster. They go from the skin to what we call the dorsal ganglion. Just think about it as like a docking station right there where the spinal cord is. You go through there, go to the spinal cord up to the brain.
So if you're having neuropathic itch, you can actually have an issue anywhere. There have been cases of folks who've had a stroke and then they either start or stop itching. There are specific brain areas that are over-activated in certain itch syndromes. There's also folks who have things like trigeminal neuralgia and other syndromes where they have itch that's directly related to even a central nervous system defect. Spinal cord is another area, so dorsal root ganglion, the spinal cord is what we're talking about.
But the pain and itch pathways, they share so many similarities, right? We know that there are some systems that are unique to itch, but we also know that there's actually some shared transmission pathways, because drugs like gabapentin work for pain and they work for itch as well, because they're able to modulate in the spinal cord some of the calcium release and signaling pathways as well. So that's why there actually are some, a lot of similarities, and actually a lot of researchers who study itch got into the field because they studied pain. And then that was a good model to have them understand. So more research now is going on, looking at these different areas and receptors in your spinal cord and dorsal ganglion and trying to see where are the itch-specific pathways and the pain-specific pathways, where are the overlaps and where are the unique areas. And so we're making some progress helping to find where those unique areas are.
Jennifer Fugo (09:55.273)
This is fascinating. So wait, okay. So I just, first of all, I'm having a lot of mental explosions over here of like how fascinating this is. So, okay, if somebody is listening to this and going “Why am I so itchy?” I have itchy skin without rash, I have an itch say like, and are we talking like just a little itchy skin, or like you're scraping your itchy scalp or you're raking your back because it's just like won't stop and you can't get it to stop. Is it that type of itch are we talking about?
Shawn Kwatra (10:27.958)
So you can have it both ways. It's rare that it's mild, but it can be mild. Usually it's very tough to treat, and folks are scratching so much that it's really destroying a lot of their quality of life. And I'll tell you what, there are no approved therapies. So it's very hard. I struggle, and I do everything we can possibly think about outside the box, and we've actually made a lot of contributions to new therapeutics for this condition, but there's no approved therapies. So these patients are suffering, and there's really a poor understanding of the disease biology. In contrast, all of the immune-related disorders, eczema, psoriasis, all of those, with new therapeutics, I can get every patient clear. Pretty much every patient, I can figure out a way to get them clear between biologics and JAK inhibitors and you know, different compounds, we can get them clear. This patient population is so hard to treat. And I think one of the reasons it's been so hard to treat is because there hasn't even been a consensus, an expert consensus, on the terminology.
So actually one of the things I'm most proud about is that I had the opportunity to help lead a United States expert panel consensus that should be coming out soon about nomenclature and diagnosis of this condition, and that it's actually defined as having lesions or distress of the nervous system, normal-appearing skin. It's associated with dysesthesia, so pain, stinging, burning, tingling, a lot of these things. And noting the different subtypes of the disease so we can encourage clinical trials.
Unfortunately, a lot of the medications we use to treat this condition are very sedating. They're drugs that are focusing on the transmission of itch in the central nervous system and spinal cord like gabapentin or anticonvulsants. So those are the type of drugs that we're giving for this condition. We're actually giving opioids. So there's a kappa opioid. So there's mu and kappa opioids. A mu-opioid is morphine, and morphine causes itch. So the opposite of that is a kappa opioid. And so the kappa opioid actually is associated with reduction of itch. And so there's actually some drugs that are looking at a kappa opioid agonist. And so these drugs, actually, if you look at the clinical trials, there can be central nervous system side effects, dizziness, sedation, a lot of those different things. That's where we're at, that we're going to have to prescribe agents like that. So we're really grasping. There's another drug, butorphanol inhaler that sometimes we have to give to these patients. I don't like giving this drug because it's off label. It's approved for a form of neuropathic pain, but it's actually an inhaler that increases your kappa opioid tone, but I mean, it causes folks to get very sedated, they can get very nauseous. I've had very significant side effects, but we've had to even go there with something that we can't treat very easily because there's no approved agents. It's so sad, I'm telling you, this is so sad that we have such poor therapeutics, and even the therapeutics in development, they're causing a lot of sedation, dizziness, all of these issues. It's like, we need to find solutions. So what we're working on is actually, if you have a localized itch, we're trying to have a localized solution. So folks who have itchy scalp pruritus, what we're doing is we're innovating and we're trying to do occipital nerve blocks with long-acting anesthetics.
Shawn Kwatra (13:53.614)
And if they have this notalgia paraesthetica trying to do similar things, actually other folks are looking at other types of localized techniques. One of my colleagues in Germany, Dr. Ständer, actually had a study about a capsaicin patch you can put on that helps with the itch locally. So other folks are looking at localized solutions for localized problems. It can sometimes become generalized, but many times it's localized.
Jennifer Fugo (14:17.437)
Do you think it's worthwhile in these patients, and somebody who's dealing with itchy skin without rash, maybe they've gone to their doctor. And I don't know, you know, with like, prurigo nodularis, like a lot of times people are blown off for a long time and not taken seriously. So I do wonder if maybe that's a factor here of somebody saying, oh, that's just in your head, I don't see anything wrong. But would it be possible for someone to maybe go see, I don't even know who, like a neurologist or, I'm not sure.
Shawn Kwatra (14:52.598)
The sad part is that these patients oftentimes get lost. So even though it is technically a neuropathy, oftentimes they'll see the neurologist and kind of they won't, it's not something that's necessarily well-versed in their training as well. And then for dermatologists, mostly we're versed in actually treating things we can see to some extent. So what's really sad here is these itch patients who have sometimes the most devastating forms of itch and it's destroying and ravaging their quality of life are lost between doctors. It is so sad and that's why we're doing these kind of expert consensus articles with other leaders. There's very few people in the United States, but you know that was something that we wanted to do to help bring leadership to this space to raise awareness. We're trying to make the pathway for trials easier, so that's why we're putting this criteria forward because we're trying to encourage folks to do new therapeutics.
One issue is that there's so many different subtypes like itchy scalp pruritus, notalgia paresthetica, brachioradial pruritus. It's hard to do trials for all of these. So we're trying to encourage just neuropathic itch trials encompassing different subtypes. And the next trial I'm looking to help start is a scalp pruritus trial. So I've been trying to identify the right agent to do a clinical trial on this because this is very ripe for development. Folks don't have a rash, they have maybe some cervical nerve damage that is causing this itch without inflammation.
And so there's actually a lot of different drugs that have been developed that can be repurposed. So there's so many drugs that have gone in for pain or depression or other indications that may actually work in this condition. So that's something that we're trying to do is encourage more academic industry collaborations. It's so crucial that we have important channels of communication and collaboration because there's probably drugs out there that will help, but we're not able to connect the dots. So for example, I had a patient who had brachioradial pruritus. They were suffering very deeply and terribly. Nothing we did worked, everything off-label. So then what we did is we worked with the interventional anesthesiologist, and we were able to get this patient systemic ketamine infusions. And it reduced this person's itch, it will be published in JAMA Dermatology, from a 10 to a one within an hour. They had weeks of relief. They got another one and they had another time, more and more relief.
We're trying to understand the pathways. Is it central sensitization? So that's one topic is that in the spinal cord, you can actually have sensitization. And so you just have this intense state of itch as well. So you can modulate that. There's different ways to change it. We know because we're seeing similar processes, right? For depression, you can do ketamine infusions, right? Even things in the future, like, you know, we've heard some stories about the mushrooms, other things like all this, really at the edge of discovery, but that's where we are for neuropathic itch. Because otherwise, these folks are just getting off-label anticonvulsants, antidepressants, really nonspecific drugs, opioids, even kappa opioids, which are associated with a lot of dizziness and sedation and likely have other activity, cannabinoids we give sometimes, so medical marijuana, things like that.
Jennifer Fugo (18:11.965)
And can I ask how they are, is itchy skin without rash tied to some of the cytokines? I know you said this is sort of different. It's not necessarily inflammation, but then we've talked about, like you've touched on, IL-31, and in your paper you did briefly mention some like neuroinflammation with IL-33, IL-31. Is this, is there any tie between?
Shawn Kwatra (18:35.526)
Yeah, so research is still going on about the cytokine component, but what we think is that there's a dominant role for the end of neuroinflammation. So neuroinflammation is a process where you have neuropeptides that are released from these nerves. Maybe there's damage to a nerve and you have neuropeptides that are released. So the thought is even in something like prurigo nodularis, you have maybe some damage to the nerve, there's neuropeptides release, and it then causes those neuropeptides, cause the immune cells to release cytokines. And you get this actually micro itch-scratch cycle going on where you have neuropeptides from the nerves causing the immune cells to release cytokines. And so you're trying to break that cycle.
And what we know is in a condition like prurigo nodularis, you can target the immune end, IL-31, IL-4 and 13, and you can stop it there. But for the neuropathic pruritus, what we think is that actually we have to target that neuropeptide component, neurogenic inflammation component. We're not sure the right way, but there are some neurotransmitters like substance P, calcitonin gene-related peptide, glutamate, nerve growth factor, other neuropeptides. And like I talked about, the kappa opioids, we think may help, but the question is, is it worth the side effects? So we're trying to find safer therapies that can actually help target this patient population. We don't want to have to use drugs like butorphanol and anticonvulsants and all of that. So really, the race is on.
The hard part is there aren't great mouse models. Actually, most companies now are shifting to human models, because the mouse models don't actually reflect these unique disease states. So we're looking at humans more, but it's just very difficult, because you don't have a rash, so then how do you phenotype it? So what we're looking at is we're also looking at the blood, we're looking at different ways to manifest differences and actually in these neuropathic itch patients, we're also finding there's systemic inflammation in many ways too, in their blood. Even though they don't have it on the skin, they may have different elements of it in the blood. So it's really a new frontier. Other conditions like multiple sclerosis and other conditions like neuropathic disorders, we look a lot at depression and pain. There's a lot of overlaps here with these different conditions. So it needs to have a light shined on it.
Jennifer Fugo (20:54.261)
Yeah, I definitely wanted to ask you, because you mentioned in the paper about naltrexone being one of the possible treatment options. I've noticed that there's been this increasing use of low-dose naltrexone and we've actually had a couple of people, a couple of doctors actually come on the show and talk about it for its use with psoriasis and atopic dermatitis and other things. Do you feel like LDN, or at least in your experience, do you think it could be helpful for someone with itchy skin without rash?
Shawn Kwatra (21:27.978)
I think it could, my experience has been sometimes it’s not potent enough. So we talked about how there's dysfunction of the opioid system. And so in chronic itchy skin, neuropathic itch also, but also things like eczema, psoriasis, what we're oftentimes finding is there's more of this mu opioid. So think about morphine and all that. So naltrexone is the converse of morphine, right? It blocks this mu opioid receptor. So there haven't been hugely done studies like with very large sample size studying controlled effect, but I've tried it in several patients and it's a little bit hit or miss, like who responds and who doesn't. I would say you wanna try to target what the underlying dysfunction is. So in psoriasis, for example, we have a lot of very targeted biologics, IL-23 inhibitors, IL-17, other inhibitors like that, that are very targeted, and actually disease, you know, targeting where the pathogenic issue is in the disease. Same thing with eczema.
I think in a condition like neuropathic pruritus, it's definitely worth trying. It just has been a situation where it sometimes isn't potent enough, which is why sometimes people are going to this kappa opioid agonist. But what we're hoping is that with academic-industry collaborations, we're able to unlock new therapeutics. You know, a thing like ketamine that we did, that patient also failed kappa opioids and all these other drugs, and they still, you know, had nothing else work. So we had to go to that extent, but there should be therapeutics that we can target. We're very much so looking into interventional itch therapeutics. I don’t even know if that's a thing, we're making a thing. Interventional itch therapeutics. So there's actually more data and studies coming out about CT guided, like say, for example, radio nerve frequency ablation of the nerves coming out of the occipital scalp. Same thing going on sometimes in the spinal cord where you're able to actually, using a missile-targeted approach, stop really where that itch is emanating from. So that's what I think is gonna happen in neuropathic parietis is we're really gonna focus on that.
I also had a friend, she had a notalgia paraesthetica on the back and she actually got this trans-electrical nerve stimulator, and they're just patches that you put on your back. She put it on her back and it like kind of reversed her itch. And so what we're finding is things like acupuncture, reorienting like neural messages, this capsaicin patch, which capsaicin actually works because it makes you burn, because it actually releases all the neuropeptides, all the substance P, all gets released, and then it desensitizes your nerves. So that's the new area of therapeutics. We've also been doing things like Botox injections for itch, because what does Botox do, right? It actually is a toxin that's able to kind of get your nerves not functioning, so you can stop getting wrinkles, but you can also stop getting itch from that. So there haven't been great studies, but we've used it sometimes and it's helped folks.
Anesthetic injections, all sorts of things like that. So I think, especially if you have an itch just only on the upper part of your back, it's a tough sell to say, hey, take this medicine, it’s going to have a lot of side effects. It's better to try to have very guided solutions, but that is tough because it involves dermatologists interacting with pain docs and other folks, I mean, nobody's going to let me inject things in their spinal cord. But we have a good rationale for it, right. So that's where we are.
Jennifer Fugo (24:49.445)
And it sounds like too, you mentioned about maybe strengthening the back and possibly, if you know you've been sedentary, or like for myself where I do have known back issues where I've had disc issues. If someone had a history like that, perhaps that could warrant maybe doing some physical therapy and some targeted exercises to help strengthen, because I found physical therapy to be so helpful in strengthening the areas around the spine so that it did decrease the nerve impingements, as you discussed. Mine went down the legs, unfortunately, so it wasn’t an itch, but I could understand when you’re living with chronic pain.
And maybe this is a good question to ask you. I've heard from clients and I even myself, I mean, itch can be so debilitating. You can almost feel like you're going crazy, and pain can make you especially, when it's severe and it's unending, unrelenting no matter what position you're in, can make you just so depressed and feel like you don't want to be here to be entirely honest. Do you feel like that, maybe I don't know what exactly I'm asking, but I feel like a lot of times people don't feel heard when they are dealing with really severe sensations like this. And it sounds like you're saying they do share some sort of similar nerves. So for somebody who's dealing with this, do you have any final words or thoughts? Obviously you've dealt with atopic dermatitis yourself and you're working with all of these patients. Is there any wisdom or thought that you have for somebody who's really, like really struggling right now?
Shawn Kwatra (26:39.858)
Absolutely. And you know, I think among a lot of the itch patients, the neuropathic itch patients are arguably struggling the most because of the lack of therapeutics. So what I would say to them is, you know, this is the untapped frontier in itch, and we're undergoing a revolution in new therapies. We're learning more about the diseases in humans. And I think that that's really what has helped us become in a better position to study this condition. I would tell folks, have hope because we are actually emerging on this revolution where there's gonna be new trials, safer therapeutics, and also I think many other outside-the-box therapies. It's really that type of a time. I know we've been trying everything. So when I see a patient like this, I'm very honest with them and I say, hey, there's no approved therapies. There's things that are, have sometimes been done. So like anesthetics, right? You can use anesthetics over the counter, things that contain pramoxine, which are anesthetics or cooling agents that are over the counter. You can use capsaicin creams, coolants, menthol, camphor, we talk about antidepressants, we talk about even compounded medicines. You can put ketamine in a cream. So we put it with amitriptyline and lidocaine and ketamine in the cream. And we put that on for like, we can put it in a solution for the scalp, you can put it on the body for neuropathic on your back. Ice packs help a lot. We do gabapentin, anticonvulsants, antidepressants that we use, tricyclic antidepressants and these kappa opioids, dronabinol, physical therapy like you mentioned, Botox, CT guided nerve roots, trans-electrical nerve stimulation, and it goes on and on. We just did ketamine infusions, we just published on that, we're trying to do nerve ablation. So this is a rapidly changing area that we're innovating in. And so there's a lot of innovation that's happening. So I think it's a good time.
Jennifer Fugo (28:39.385)
Yeah. And it sounds like if you go to one doctor who might not be familiar with this, there are other doctors out there who are. So it shouldn't be you just give up after one person. You should keep looking. And is there any type of maybe specialty or something like, are there any other of you out there? How do we find more of you?
Shawn Kwatra (29:01.17)
Yeah, you know, we're trying to recruit more people because traditionally, itch has been not a very attractive area for the docs because it can be very complicated. It's not efficient, so it takes a lot of time, but you know, we're trying to encourage more folks to get interested in it. We're trying to encourage other specialties. So I can't tell you how much we're trying to encourage neurologists and other docs who have this great understanding of different systems. So stay tuned, we're trying to really get and mobilize a lot of docs and get a lot of interest going. And really forums like this are gonna help us stimulate those conversations. I know we're very interested in expanding our group and our center and just really studying this very much so in depth and hopefully lots of other people will also be joining the space to study it.
Jennifer Fugo (29:51.177)
Well, thank you so much for joining us yet again. You always have so much, you have such a unique perspective. And I think because you've also experienced skin conditions, like you do understand it from a patient perspective, which sometimes is different, you know, when you've never really had even a rash, you're just like, well, I understand what it looks like clinically, I can empathize. But you literally have been in this boat of being itchy, you've had itch issues and other skin issues that allow you to really be there with your patients, which is something that I deeply appreciate, as well as your level of empathy and your excited curiosity for finding answers for people because quality of life is so huge and it unfortunately, as we've talked about many times, itch specifically can be one that can really wreck everything. Full stop. Full stop. So thank you so much for joining us again. I really appreciate it. I'm sure we're gonna have more to talk about. So stay tuned everyone.
Shawn Kwatra (31:00.758)
Thank you so much for having me. I really appreciate it.
