We have read with great interest the letter to the editor of this journal commenting on our review of skin manifestations in chronic kidney disease (CKD), and wish to add the following comments.1

Erythropoietin acts by lowering histamine levels and increasing hemoglobin levels. Since the etiology of uremic pruritus is multifactorial and these 2 factors make only a small contribution to the condition, it is to be expected that this treatment does not improve pruritus in all patients.2 At best, erythropoietin would be an adjuvant treatment in a subgroup of patients in whom these factors are present.

We are conscious that kidney transplantation is a solution not accessible to all patients with CKD and that optimal control of the patient's disease with dialysis and by monitoring hemoglobin and calcium-phosphorus levels is essential in the management of uremic pruritus. From the dermatologist's standpoint, a practical approach would be to use moisturizers (the first-line treatment in the management of uremic pruritus), especially those containing paraffin, glycerol, and adjuvant additives, (endocannabinoids and gamma-linolenic acid), in addition to anti-pruriginous lotions based on pramoxine and capsaicin and carefully calibrated systemic treatment with gabapentin.1,3,4

On the subject of half and half nails, we note that they have classically been linked to CKD and are found in between 15% and 50% of patients in this setting. However, we agree with Tercedor et al. that half and half nails are not only found in CKD, but have also been observed in association with other etiologies, including Crohn disease, Behçet disease, chemotherapy, and isoniazid-induced pellagra and that idiopathic forms have been reported in up to 3% of healthy controls.5–9