Use of a wrist activity monitor for the measurement of nocturnal scratching in patients with atopic dermatitis

Nocturnal Scratching and Quality of Sleep in Children with Atopic Dermatitis

Itching due to atopic dermatitis causes sleep disorders in children, but its pathology is unknown. The aim of this study is to investigate nocturnal scratching as an indirect index of itching during sleep and its relationship with depth of sleep in children with atopic dermatitis. Nocturnal scratching was measured in a total of 20 children with atopic dermatitis, using a smartwatch installed with the application Itch Tracker. Depth of sleep was analysed using polysomnography. The severity of atopic dermatitis was scored using Eczema Area and Severity Index (EASI) and Patient-Oriented Eczema Measure (POEM). The number and time of nocturnal scratching measured by Itch Tracker had a significantly positive correlation with EASI scores, whereas POEM scores were not correlated with EASI scores. Mean sleep efficiency was 90.0% and scratching episodes (n = 67) started mainly during the awake stage or light sleep stages. In the scratching episodes that started during sleep stages (n = 34), the sleep stage changed to a lighter one or to the awake stage in 35.5% of episodes. Itch Tracker is applicable to measure nocturnal scratching in children. Nocturnal scratching can deteriorate quality of sleep by changing the sleep stage to a lighter one or to the awake stage.

Electromagnetic Sensing Techniques for Monitoring Atopic Dermatitis-Current Practices and Possible Advancements: A Review

Atopic dermatitis (AD) is one of the most common skin disorders, affecting nearly one-fifth of children and adolescents worldwide, and currently, the only method of monitoring the condition is through an in-person visual examination by a clinician. This method of assessment poses an inherent risk of subjectivity and can be restrictive to patients who do not have access to or cannot visit hospitals. Advances in digital sensing technologies can serve as a foundation for the development of a new generation of e-health devices that provide accurate and empirical evaluation of the condition to patients worldwide. The goal of this review is to study the past, present, and future of AD monitoring. First, current medical practices such as biopsy, tape stripping and blood serum are discussed with their merits and demerits. Then, alternative digital methods of medical evaluation are highlighted with the focus on non-invasive monitoring using biomarkers of AD-TEWL, skin permittivity, elasticity, and pruritus. Finally, possible future technologies are showcased such as radio frequency reflectometry and optical spectroscopy along with a short discussion to provoke research into improving the current techniques and employing the new ones to develop an AD monitoring device, which could eventually facilitate medical diagnosis.

Defining digital measurement of scratching during sleep, or “Nocturnal Scratch”: A review of the literature (Preprint)

BACKGROUND

Digital sensing solutions represent a convenient, objective, relatively inexpensive method that could be leveraged for assessing symptoms of various health conditions. Recent progress in the capabilities of digital sensing products has targeted the measurement of scratching during sleep, traditionally referred to as nocturnal scratching, in patients with atopic dermatitis or other skin conditions. Many solutions measuring nocturnal scratch have been developed; however, a lack of efforts toward standardization of the measure's definition and contextualization of scratching during sleep hampers the ability to compare different technologies for this purpose.

OBJECTIVE

We aimed to address this gap and bring forth unified measurement definitions for nocturnal scratch.

METHODS

We performed a narrative literature review of definitions of scratching in patients with skin inflammation and a targeted literature review of sleep in the context of the period during which such scratching occurred. Both searches were limited to English language studies in humans. The extracted data were synthesized into themes based on study characteristics: scratch as a behavior, other characterization of the scratching movement, and measurement parameters for both scratch and sleep. We then developed ontologies for the digital measurement of sleep scratching.

RESULTS

In all, 29 studies defined inflammation-related scratching between 1996 and 2021. When cross-referenced with the results of search terms describing the sleep period, only 2 of these scratch-related papers also described sleep-related variables. From these search results, we developed an evidence-based and patient-centric definition of nocturnal scratch: an action of rhythmic and repetitive skin contact movement performed during a delimited time period of intended and actual sleep that is not restricted to any specific time of the day or night. Based on the measurement properties identified in the searches, we developed ontologies of relevant concepts that can be used as a starting point to develop standardized outcome measures of scratching during sleep in patients with inflammatory skin conditions.

CONCLUSIONS

This work is intended to serve as a foundation for the future development of unified and well-described digital health technologies measuring nocturnal scratching and should enable better communication and sharing of results between various stakeholders taking part in research in atopic dermatitis and other inflammatory skin conditions.

Which objective itch-assessment tools are applicable to patients with advanced cognitive impairments? A scoping review

BACKGROUND

Itching is an irritating and uncomfortable sensation that has a profound effect on patients' physical and mental health. It is a major under-recognised problem in older patients who cannot express their pain due to advanced cognitive impairment. Therefore, objective itch-assessment tools that do not rely on patients' reports of itching may be of value for this patient group.

OBJECTIVE

To summarise the characteristics of validated objective itch-assessment tools for patients with advanced cognitive impairment.

METHODS

This scoping review was conducted according to the PRISMA extension for scoping reviews checklist. The PubMed, CINAHL and Cochrane Library databases were searched, via database-specific search strategies, for articles published in English between January 1, 1990 and March 11, 2020. Based on the eligibility criteria, two authors independently screened the articles for inclusion. Thereafter, the lead author performed data extraction and analysis.

RESULTS

Three validated scratch-monitoring using accelerometers and a sound sensor and one validated scratch-mark assessment have been reported. The Actiwatch Plus, ActiTrac^® , body-conducted sound sensor and Scoring Atopic Dermatitis index for scratching (SCORAD-scratch) had positive criterion validity outcomes. The Actiwatch Plus, ActiTrac^® and body-conducted sound sensor were significantly correlated with scratch behaviour (r = 0.91, p < 0.001; r = 0.71, p = 0.042; r = 0.99, and p-value not shown, respectively). The SCORAD-scratch was significantly correlated with subjective itch-assessment scores (r = 0.78-0.80, p = <0.0001-0.010).

CONCLUSIONS

This scoping review summarises the characteristics of validated objective itch-assessment tools to investigate which of these are applicable to older patients with advanced cognitive impairments. Although there are limitations and further verification is required, the ActiTrac^® , Actiwatch Plus and body-conducted sound sensor may be useful for measuring scratch movements and itching.

IMPLICATIONS FOR PRACTICE

Nurses and patients' families may better understand the characteristics and validity of each objective itch-assessment tool and select the optimal tool for patients with advanced cognitive impairment who cannot express their discomfort caused due to itching.

Use of technology for the objective evaluation of scratching behavior: A systematic review

Introduction

Pruritus is a common symptom across various dermatologic conditions, with a negative impact on quality of life. Devices to quantify itch objectively primarily use scratch as a proxy. This review compares and evaluates the performance of technologies aimed at objectively measuring scratch behavior.

Methods

Articles identified from literature searches performed in October 2020 were reviewed and those that did not report a primary statistical performance measure (eg, sensitivity, specificity) were excluded. The articles were independently reviewed by 2 authors.

Results

The literature search resulted in 6231 articles, of which 24 met eligibility criteria. Studies were categorized by technology, with actigraphy being the most studied (n = 21). Wrist actigraphy's performance is poorer in pruritic patients and inherently limited in finger-dominant scratch detection. It has moderate correlations with objective measures (Eczema and Area Severity Index/Investigator's Global Assessment: r_s(ρ) = 0.70-0.76), but correlations with subjective measures are poor (r² = 0.06, r_s(ρ) = 0.18-0.40 for itch measured using a visual analog scale). This may be due to varied subjective perception of itch or actigraphy's underestimation of scratch.

Conclusion

Actigraphy's large variability in performance and limited understanding of its specificity for scratch merits larger studies looking at validation of data analysis algorithms and device performance, particularly within target patient populations.

Dissecting the precise nature of itch-evoked scratching

Itch is a discrete and irritating sensation tightly coupled to a drive to scratch. Acute scratching developed evolutionarily as an adaptive defense against skin irritants, pathogens, or parasites. In contrast, the itch-scratch cycle in chronic itch is harmful, inducing escalating itch and skin damage. Clinically and preclinically, scratching incidence is currently evaluated as a unidimensional motor parameter and believed to reflect itch severity. We propose that scratching, when appreciated as a complex, multidimensional motor behavior, will yield greater insight into the nature of itch and the organization of neural circuits driving repetitive motor patterns. We outline the limitations of standard measurements of scratching in rodent models and present new approaches to observe and quantify itch-evoked scratching. We argue that accurate quantitative measurements of scratching are critical for dissecting the molecular, cellular, and circuit mechanisms underlying itch and for preclinical development of therapeutic interventions for acute and chronic itch disorders.

A skin-conformable wireless sensor to objectively quantify symptoms of pruritus

Itch is a common clinical symptom and major driver of disease-related morbidity across a wide range of medical conditions. A substantial unmet need is for objective, accurate measurements of itch. In this article, we present a noninvasive technology to objectively quantify scratching behavior via a soft, flexible, and wireless sensor that captures the acousto-mechanic signatures of scratching from the dorsum of the hand. A machine learning algorithm validated on data collected from healthy subjects (n = 10) indicates excellent performance relative to smartwatch-based approaches. Clinical validation in a cohort of predominately pediatric patients (n = 11) with moderate to severe atopic dermatitis included 46 sleep-nights totaling 378.4 hours. The data indicate an accuracy of 99.0% (84.3% sensitivity, 99.3% specificity) against visual observation. This work suggests broad capabilities relevant to applications ranging from assessing the efficacy of drugs for conditions that cause itch to monitoring disease severity and treatment response.

Association between chronic pruritus, depression, and insomnia: A cross-sectional study

Background

Skin diseases that cause chronic pruritus can have negative effects on a patient's quality of life.

Objective

We evaluated the associations between chronic pruritus and psychological conditions including insomnia and depression.

Methods

This study included responses from 91 participants with chronic pruritus (response rate: 74.6%). A survey including questionnaires regarding data on demographic characteristics, intensity of pruritus using the visual analog scale (VAS) and the 4-item itch questionnaire, and the degrees of insomnia and depression measured by the Insomnia Severity Index and Beck Depression Inventory, respectively.

Results

Patients with symptoms of insomnia or depression had significantly more intense pruritus than patients without psychological symptoms (insomnia, VAS median [interquartile range]: 7.0 [5.0-8.25] vs. 5.0 [3.0-7.5]; depression, VAS median [interquartile range]: 7.5 [5.0-8.25] vs. 5.0 [3.0-7.0]). Multivariable analyses revealed that patients with moderate to severe pruritus were more likely to have depression than those with mild pruritus (odds ratio: 10.95; 95% confidence interval: 2.24-53.06). There were no differences in the severity of insomnia and depression among skin diseases.

Limitations

This study had a cross-sectional design and limited generalizability.

Conclusion

Chronic pruritus is significantly associated with insomnia and depression, regardless of the etiology.

Development of digital measures for nighttime scratch and sleep using wrist-worn wearable devices

Patients with atopic dermatitis experience increased nocturnal pruritus which leads to scratching and sleep disturbances that significantly contribute to poor quality of life. Objective measurements of nighttime scratching and sleep quantity can help assess the efficacy of an intervention. Wearable sensors can provide novel, objective measures of nighttime scratching and sleep; however, many current approaches were not designed for passive, unsupervised monitoring during daily life. In this work, we present the development and analytical validation of a method that sequentially processes epochs of sample-level accelerometer data from a wrist-worn device to provide continuous digital measures of nighttime scratching and sleep quantity. This approach uses heuristic and machine learning algorithms in a hierarchical paradigm by first determining when the patient intends to sleep, then detecting sleep–wake states along with scratching episodes, and lastly deriving objective measures of both sleep and scratch. Leveraging reference data collected in a sleep laboratory (NCT ID: NCT03490877), results show that sensor-derived measures of total sleep opportunity (TSO; time when patient intends to sleep) and total sleep time (TST) correlate well with reference polysomnography data (TSO: r = 0.72, p < 0.001; TST: r = 0.76, p < 0.001; N = 32). Log transformed sensor derived measures of total scratching duration achieve strong agreement with reference annotated video recordings (r = 0.82, p < 0.001; N = 25). These results support the use of wearable sensors for objective, continuous measurement of nighttime scratching and sleep during daily life.

Efficacy of pregabalin for the treatment of chronic pruritus of unknown origin, assessed based on electric current perception threshold

Chronic pruritus of unknown origin (CPUO) is defined as itching lasting more than 6 weeks in the absence of discernible skin lesions. Pregabalin is used to treat patients with CPUO. In this study, we aimed to investigate differences in the perception threshold of itch sensation between patients with CPUO and healthy individuals and to evaluate the efficacy of pregabalin for CPUO. At baseline, week 2, and week 4 after treatment initiation, the visual analogue scale (VAS) score was measured to assess pruritus severity, and electric current perception threshold (CPT) was measured at 250 and 5 Hz using a NEUROMETER CPT/C stimulator. Twenty healthy individuals and 41 patients with CPUO were enrolled in this study. The patients with CPUO were categorised as those who responded to antihistamines (Antihistamine group), were not improved by antihistamines (Pregabalin group), and were not improved by antihistamines and pregabalin (Refractory group). The baseline CPT values were not significantly different between patients with CPUO and healthy control. Pruritus was improved in 7 of 10 patients in the Pregabalin group after treatment with pregabalin, showing decreased CPT at 5 Hz. The sensitive C-fibres presented a high threshold to detect itch sensation, and this sensitivity decreased in response to treatment with pregabalin.

An overview of drug discovery efforts for eczema: why is this itch so difficult to scratch?

Introduction: Atopic dermatitis (AD) is a type of allergic/inflammatory dermatitis characterized by itch and an impairment in quality of life.Areas covered: Herein, the authors review drug discovery efforts for AD, highlighting the clinical efficacy of novel drugs, with a particular focus on the relief of pruritus. Topical agents include emollients, topical antihistamines, corticosteroids, calcineurin inhibitors and herbs. Recently, topical phosphodiesterase E4 (PDE4) inhibitors like crisaborole have become available and are efficacious for mild to moderate AD with few side effects. For more severe AD, monoclonal antibodies like dupilumab are considered as efficacious subcutaneous treatment options. In severe and recalcitrant AD, systemic treatment can ameliorate AD symptoms.Expert opinion: Many topical and systemic medications have demonstrated therapeutic benefits for AD. Indeed, randomized trials have shown that topical PDE4 inhibitors and subcutaneous dupilumab are safe and efficacious. Objective tools to evaluate itch and gauge treatment efficacy is important, but current methodology relies primarily on clinical scores. AD is a systemic atopic disease with a lot of complicated psychosocial issues. Suboptimal efficacy is often due to poor compliance and unrealistic expectation of curative treatment, rendering treatment difficult despite the existence of effective medications.

Emerging Methods to Objectively Assess Pruritus in Atopic Dermatitis

INTRODUCTION

Atopic dermatitis (AD) is an inflammatory skin disease with a chronic, relapsing course. Clinical features of AD vary by age, duration, and severity but can include papules, vesicles, erythema, exudate, xerosis, scaling, and lichenification. However, the most defining and universal symptom of AD is pruritus. Pruritus or itch, defined as an unpleasant urge to scratch, is problematic for many reasons, particularly its negative impact on quality of life. Despite the profoundly negative impact of pruritus on patients with AD, clinicians and researchers lack standardized and validated methods to objectively measure pruritus. The purpose of this review is to discuss emerging methods to assess pruritus in AD by describing objective patient-centered tools developed or enhanced over the last decade that can be utilized by clinicians and researchers alike.

METHODS

This review is based on a literature search in Medline, Embase, and Web of Science databases. The search was performed in February 2019. The keywords were used "pruritus," "itch," "atopic dermatitis," "eczema," "measurements," "tools," "instruments," "accelerometer," "wrist actigraphy," "smartwatch," "transducer," "vibration," "brain mapping," "magnetic resonance imaging," and "positron emission tomography." Only articles written in English were included, and no restrictions were set on study type. To focus on emerging methods, prioritization was given to results from the last decade (2009-2019).

RESULTS

The search yielded 49 results in PubMed, 134 results in Embase, and 85 results in Web of Science. Each result was independently reviewed in a standardized manner by two of the authors (M.S., K.L.), and disagreements between reviewers were resolved by consensus. Relevant findings were categorized into the following sections: video surveillance, acoustic surveillance, wrist actigraphy, smart devices, vibration transducers, and neurological imaging. Examples are provided along with descriptions of how each technology works, instances of use in research or clinical practice, and as applicable, reports of validation studies and correlation with other methods.

CONCLUSION

The variety of new and improved methods to evaluate pruritus in AD is welcomed by clinicians, researchers, and patients alike. Future directions include next-generation smart devices as well as exploring new territories, such as identifying biomarkers that correlate to itch and machine-learning programs to identify itch processing in the brain. As these efforts continue, it will be essential to remain patient-centered by developing techniques that minimize discomfort, respect privacy, and provide accurate data that can be used to better manage itch in AD.

Actigraphy-measured nocturnal wrist movements and assessment of sleep quality in patients with bullous pemphigoid: a pilot case-control study

BACKGROUND

Bullous pemphigoid (BP) is a distressing autoimmune bullous disease strongly associated with severe pruritus; however, data concerning pruritus in BP are still scarce. No clinical research evaluating the effect of BP on sleep quality has been conducted.

AIM

To evaluate the intensity of pruritus measured by nocturnal wrist movements (NWMs) and the sleep quality in patients with BP using actigraphy in comparison with nonpruritic healthy controls (HCs) with subsequent correlations with an itch visual analogue scale (VAS) as a subjective measure, disease severity [Bullous Pemphigoid Disease Area Index (BPDAI), urticaria/erythema, erosions/blisters] and serum total IgE level.

METHODS

In total, 31 patients with newly diagnosed BP (mean ± SD age 75.4 ± 12.3 years) and 40 nonpruritic HCs (age 73.5 ± 11.7 years) were recruited. All participants wore a sleep monitor (ActiSleep+) on the dominant wrist.

RESULTS

For patients with BP, median VAS score was 5.5 and median BPDAI was 43 (urticaria/erythema BPDAI was 16, erosions/blisters BPDAI was 29). Scratching, defined as bouts of NWMs, was significantly (P < 0.001) more intensive in patients with BP than in controls. Characteristic of BP was that scratching bouts corresponded with the slowest wrist movements. There were no correlations with VAS, BPDAI or total IgE level. Compared with HCs, patients with BP presented significant (P < 0.001) sleep disturbances, as determined by sleep efficiency, waking after sleep onset and average duration of awakening, and these were strongly correlated with urticaria/erythema BPDAI.

CONCLUSION

Nocturnal wrist movements measured by actigraphy are more intensive in patients with BP than in nonpruritic HCs, and characteristically slow movements. Actigraphy method showed very low sleep quality in patients with BP, thus severity of BP has a negative impact on sleep.

Activity During Sleep Measured by a Sheet-Shaped Body Vibrometer and the Severity of Atopic Dermatitis in Adults: A Comparison With Wrist Actigraphy

STUDY OBJECTIVES

To use a sheet-shaped body vibrometer (SBV) for measuring sleep in adult patients with atopic dermatitis (AD) of various severities and to compare the results with those measured by wrist actigraphy (WA).

METHODS

Simultaneous measurements of activity during sleep by WA and the SBV were performed in 20 outpatients with AD for 5 to 10 days. The mean activity count per minute (ACT) and sleep efficiency (SE) were obtained using each device. The severity of AD was evaluated by the severity scoring of AD (SCORAD), serum thymus and activation-regulated chemokine (TARC) level, serum total immunoglobulin E level, and peripheral eosinophil count.

RESULTS

The ACT measured by WA was correlated with SCORAD (Spearman correlation coefficient [r_s] = .64, P = .002) and TARC (r_s = .60, P = .005). The ACT obtained by the SBV was significantly correlated with TARC (r_s = .58, P = .008) and ACT obtained by WA (r_s = .63, P = .003). SE obtained by WA resulted in lower values compared with SE obtained by the SBV (69.7 ± 9.4% versus 82.9 ± 9.3%, P < .001), although SE obtained by WA was highly correlated with SE obtained by the SBV (r_s = .82, P < .001). Bland-Altman plots revealed that SE measured by WA always had lower values in all the patients.

CONCLUSIONS

Activity during sleep, presumably composed of scratching and other motions, is more vigorous in patients with severe adult AD. This was successfully demonstrated by the SBV and WA assessment. However, we consider that ACT measured by WA is more suited for the scratch evaluation and SE measured by the SBV is preferable for the sleep evaluation.

Use of Accelerometer Activity Monitors to Detect Changes in Pruritic Behaviors: Interim Clinical Data on 6 Dogs

Veterinarians and pet owners have limited ability to assess pruritic behaviors in dogs. This pilot study assessed the capacity of the Vetrax® triaxial accelerometer to measure these behaviors in six dogs with pruritus likely due to environmental allergens. Dogs wore the activity monitor for two weeks while consuming their usual pet food (baseline), then for eight weeks while consuming a veterinary-exclusive pet food for dogs with suspected non-food-related skin conditions (Hill's Prescription Diet® Derm DefenseTM Canine dry food). Veterinarians and owners completed questionnaires during baseline, phase 1 (days 1-28) and phase 2 (days 29-56) without knowledge of the activity data. Continuous 3-axis accelerometer data was processed using proprietary behavior recognition algorithms and analyzed using general linear mixed models with false discovery rate-adjusted p values. Veterinarian-assessed overall clinical signs of pruritus were significantly predicted by scratching (β 0.176, p = 0.008), head shaking (β 0.197, p < 0.001) and sleep quality (β -0.154, p < 0.001), while owner-assessed quality of life was significantly predicted by scratching (β -0.103, p = 0.013) and head shaking (β -0.146, p < 0.001). Among dogs exhibiting pruritus signs eating the veterinary-exclusive food, the Vetrax® sensor provided an objective assessment of clinically relevant pruritic behaviors that agreed with owner and veterinarian reports.

Detection of Nocturnal Scratching Movements in Patients with Atopic Dermatitis Using Accelerometers and Recurrent Neural Networks

Atopic dermatitis is a chronic inflammatory skin condition affecting both children and adults and is associated with pruritus. A method for objectively quantifying nocturnal scratching events could aid in the development of therapies for atopic dermatitis and other pruritic disorders. High-resolution wrist actigraphy (three-dimensional accelerometer sensors sampled at 20 Hz) is a noninvasive method to record movement. This paper presents an algorithm to detect nocturnal scratching events based on actigraphy data. The twofold process consists of segmenting the data into "no motion," "single handed motion," and "both handed motion" followed by discriminating motion segments into scratching and other motion using a bidirectional recurrent neural network classifier. The performance was compared against manually scored infrared video data collected from 24 subjects (6 healthy controls and 18 atopic dermatitis patients) demonstrating an score of 0.68 and a rank correlation of 0.945. The algorithm clearly outperformed a published reference method based on wrist actigraphy ( score of 0.09 and a rank correlation of 0.466). The results suggest that scratching movements can be discriminated from other nocturnal movements accurately.

Nocturnal Pruritus: The Battle for a Peaceful Night's Sleep

Chronic pruritus is a debilitating condition with numerous etiologies. Many patients suffer from nocturnal pruritus, which can decrease quality of life and affect mortality in hemodialysis patients. Nocturnal pruritus may occur in all sleep stages but is most prevalent in stages N1 and N2. Further research is needed to elucidate the pathophysiology of nocturnal itch, which will aid in the development of tailored management strategies.

Assessment of pruritus in patients with psoriasis and atopic dermatitis: subjective and objective tools

Pruritus is a major symptom of skin disease. The quest to identify a valid and reliable method to assess this important symptom has led to the development of a myriad of measurement tools. Some clinical trials using subjective measurements of itch intensity have reported itch intensity levels in psoriasis that are close to severity levels found in atopic dermatitis. Although it is possible that we have previously underestimated the severity of pruritus in psoriasis, these unexpected findings prompted us to review and evaluate these subjective methodologies. We provide an overview of the current tools available to measure itch severity, including subjective rating scales and questionnaires and objective measures of scratch activity through videotape observation and wrist actigraphy. We discuss the advantages and limitations of these methods and encourage consideration of a novel objective method of evaluation.

Atopic dermatitis, melatonin, and sleep disturbance

BACKGROUND AND OBJECTIVES

Sleep disturbance is common in patients with atopic dermatitis (AD). However, studies have largely been questionnaire-based, and the pathophysiology remains unclear. The aims of this study were to determine objective characteristics of sleep disturbance in children with AD and explore contributing factors and clinical predictors.

METHODS

Sleep parameters were measured by actigraphy and polysomnography in 72 patients with AD and 32 controls ages 1 to 18 years. Urinary 6-sulfatoxymelatonin levels, serum cytokines, and total and allergen-specific immunoglobulin E (IgE) levels were also measured.

RESULTS

The patients with AD had significantly reduced sleep efficiency, longer sleep onset latency, more sleep fragmentation, and less nonrapid eye movement sleep. Results from actigraphy correlated well with those from polysomnography. The AD disease severity was associated with sleep disturbance (r = 0.55-0.7), and a Scoring Atopic Dermatitis index of ≥48.7 predicted poor sleep efficiency with a sensitivity of 83.3% and a specificity of 75% (area under the curve = 0.81, P = .001). Lower nocturnal melatonin secretion was significantly associated with sleep disturbance in the patients with AD. Other correlates of sleep disturbance included pruritus, scratching movements, higher total serum IgE levels, and allergic sensitization to dust mite and staphylococcal enterotoxins.

CONCLUSIONS

Poor sleep efficiency is common in children with AD and can be predicted by the Scoring Atopic Dermatitis index. Melatonin and IgE might play a role in the sleep disturbance. Further studies are required to explore the mechanisms and clinical implications, and actigraphy could serve as a useful evaluating tool.

Measure of atopic dermatitis disease severity using actigraphy

BACKGROUND

Analyzing adherence to treatment and outcomes in atopic dermatitis is limited by methods to assess continual disease severity. Atopic dermatitis significantly impacts sleep quality, and monitoring sleep through actigraphy may capture disease burden.

PURPOSE

To assess if actigraphy monitors provide continuous measures of atopic dermatitis disease severity and to preliminarily evaluate the impact of a short-course, high-potency topical corticosteroid regimen on sleep quality.

METHODS

Ten patients with mild to moderate atopic dermatitis applied topical fluocinonide 0.1% cream twice daily for 5 days. Sleep data were captured over 14 days using wrist actigraphy monitors. Investigator Global Assessment (IGA) and secondary measures of disease severity were recorded. Changes in quantity of in-bed time sleep were estimated with random effects models.

RESULTS

The mean daily in-bed time, total sleep time, and wake after sleep onset (WASO) were 543.7 minutes (SEM 9.4), 466.0 minutes (SEM 7.7), and 75.0 minutes (SEM 3.4), respectively. WASO, a marker of disrupted sleep, correlated with baseline (ρ  =  .75) and end of treatment IGA (ρ  =  .70). Most patients did not have marked changes in sleep. IGA scores declined by a median change of 1 point at days 7 (p  =  .02) and 14 (p  =  .008).

CONCLUSIONS

Using actigraphy, atopic dermatitis disease severity positively correlated with sleep disturbances. Actigraphy monitors were well tolerated by this cohort of atopic dermatitis subjects.

Novel acoustic evaluation system for scratching behavior in itching dermatitis: rapid and accurate analysis for nocturnal scratching of atopic dermatitis patients

Quantitative analysis of itching in patients with itching dermatitis including atopic dermatitis (AD) is indispensable for the evaluation of disease activity and response to therapy. However, the objective evaluation system for itching is limited. We have developed a new objective and quantitative scratching behavior detection system using a wristwatch-type sound detector. The scratch sound detected on the wrist is recorded on a personal computer through a filtering, squaring and smoothing process by specific hardware. Subsequently, the data is automatically processed and judged for the scratching movement using specific software based on the periodicity and energy of the signal. Twenty-four measurements for healthy volunteers and those with AD by this system were evaluated by comparison with a simultaneously recorded video analysis system. The ratio of scratching time in sleeping time evaluated by these two systems was almost identical. The healthy subjects scratched their skin approximately 2 min during 6 h of sleeping time, while the mean scratching time of AD subjects was 24 min in their sleeping time. In contrast to the time-consuming video analysis system, this system takes only several minutes for evaluation of an overnight record. This scratch sound detection system is expected to serve as a new objective evaluation tool for itching dermatitis, namely, AD, and development of anti-itch therapies for dermatitis.

The role of ondansetron in the management of cholestatic or uremic pruritus--a systematic review

CONTEXT

Pruritus associated with hepatic or renal failure can be a troublesome symptom, refractory to treatment and associated with significant physical and emotional distress and a reduction in quality of life for patients already burdened with chronic disease. Serotonin has been implicated as a possible pathological mediator, and, therefore, 5HT(3) antagonists have been suggested as a possible therapeutic intervention.

OBJECTIVES

This review of the literature systematically explores the role of ondansetron in the management of cholestatic or uremic pruritus.

METHODS

Electronic databases were systematically searched for randomized controlled trials examining the role of ondansetron in cholestatic or uremic pruritus between 1966 and 2008.

RESULTS

Five randomized controlled trials were included in this systematic review: three for cholestatic pruritus and two for uremic pruritus. All trials examined ondansetron vs. placebo, with differing treatment protocols. Overall, three studies showed no benefit to ondansetron over placebo; however, two studies in cholestatic pruritus showed small reductions in pruritus with questionable clinical significance.

CONCLUSION

Ondansetron was demonstrated to have negligible effect on cholestatic or uremic pruritus on the basis of a limited number of studies.

Wrist actigraphy for scratch detection in the presence of confounding activities

Scratching is a symptom of many dermatological disorders, especially atopic dermatitis. For the development of anti-itch medications, there is a need for objective measures of scratching. Wrist actigraphy (monitoring wrist and hand movements with micro-accelerometers) is a promising method for assessing scratching; however, currently available technology has a limited capacity to discriminate scratching from other similar movements. In this study, we investigated methods to improve the specificity of actigraphy for scratch detection on movement data collected from subjects using the PAM-RL actigraph. A k-means cluster analysis was used to differentiate scratching from walking and restless sleep, which are potential confounds for nighttime scratching. Features used in the analysis include variance, peak frequency, autocorrelation value at one lag, and number of counts above 0.01 g's. The k-means cluster analysis exhibited a high sensitivity (0.90 ± 0.10) and specificity for walking (0.98 ± 0.05) and restless sleep (0.88 ± 0.06), respectively, demonstrating the separability of these activities. This work indicates that the features described here can be used to develop a classifier that discriminates scratch from other activities. The described method of scratch detection shows promise as an objective method for assessing scratching movements in clinical trials and longitudinal studies of scratch.

Automatic sleep/wake scoring from body motion in bed: validation of a newly developed sensor placed under a mattress

The purpose of this study was to formulate a "sleep/wake" scoring algorithm for processing activity measurements obtained using a newly developed nonwear actigraphy (NWA) device, and to test its validity. The NWA device has a highly sensitive pressure sensor and is placed under a mattress. It can continuously record the activity of a person lying on the mattress and identify an "in-bed/out-of-bed" state from the vibrations of the mattress. We formulated the sleep/wake scoring algorithm by using data obtained simultaneously by wrist actigraphy (Act) and the NWA device in 33 healthy participants. Agreement rate, sensitivity, and specificity with Act were 95.7%, 97.6%, and 75.8% (33 healthy people); the corresponding values were 85.9%, 89.1%, and 79.8% for 12 nursing home residents and 93.7%, 97.2%, and 60.8% for 60 nights for 6 healthy persons who slept 10 nights on their futons. Agreement rate, sensitivity, and specificity with polysomnography were in almost perfect agreement with Act (12 nights; 6 healthy persons who slept 2 nights). All our validation results indicate that the NWA device, placed under a mattress or a futon, can produce almost identical sleep/wake scores to Act. It is expected that the NWA device, a nonwear device for scoring sleep/wake and in-bed/out-of-bed, enables convenient long-term sleep-related evaluation in various fields, including hospital settings, home-care settings, and care facility settings such as nursing homes.

Are subjective accounts of itch to be relied on? The lack of relation between visual analogue itch scores and actigraphic measures of scratch

There is a widespread belief that subjective accounts of disease are key components of measures of disease severity and quality of life. In the present study we have set out to test this hypothesis using visual analogue scales (VAS) for itch, as a subjective measure, and actigraphy as an objective measure. One-hundred and seventeen itchy children and adults (and 25 controls) were studied for clusters of nights (total number 1,654) and actigraphy scores and VAS itch taken daily. Fifty-six percent of the night-to-night variation in actigraphy scores occurred between different individuals, while 44% was intra-subject. Neither age nor sex (children's or adults') predicted actigraphy scores, and the only significant predictor of actigraphy score was disease type (p = 0.001, r² = 0.51). In a multivariate model VAS itch score was not a significant determinant of actigraphy scores for either children or adults (p = 0.26). In order to see if there was a relation between VAS itch and actigraphy within the same patients (rather than between patients), 20 eczema patients wore the actigraph and scored VAS itch nightly for 42 nights. Little relationship was found between the actigraphy score and the VAS itch. Empirical autocorrelation analysis of VAS itch and actigraphy score reveal a clear autocorrelation for subjective VAS scores that was not found for the objective actigraphy score. Our data suggest a dissociation between scratch and perceived or recalled itch. One explanation is that VAS itch scores suffer from considerable anchoring, and context bias, and that their use in measures of disease severity is problematic.

Eczema and sleep and its relationship to daytime functioning in children

Chronic childhood eczema has significant morbidity characterised by physical discomfort, emotional distress, reduced child and family quality-of-life and, of particular note, disturbed sleep characterised by frequent and prolonged arousals. Sleep disturbance affects up to 60% of children with eczema, increasing to 83% during exacerbation. Even when in clinical remission, children with eczema demonstrate more sleep disturbance than healthy children. Notably, disturbed sleep in otherwise healthy children is associated with behavioural and neurocognitive deficits. Preliminary evidence suggests that disturbed sleep in children with eczema is also associated with behavioural deficits while the impact on neuropsychological functioning remains unexplored. In conclusion, a disease which affects up to 20% of children in some countries and may produce long-term behavioural and neurocognitive deficits merits further evaluation using standardised tests of sleep, behaviour and neurocognition.

Comparison of the efficacy of levocetirizine 5 mg and desloratadine 5 mg in chronic idiopathic urticaria patients

BACKGROUND

Nonsedating H(1)-antihistamines are recommended for the treatment of urticaria by the recent EAACI/GA(2)LEN/EDF guidelines. The aim of this study was to compare the efficacy, after 4 weeks of treatment, with levocetirizine 5 mg and desloratadine 5 mg, both once daily in the morning, in symptomatic chronic idiopathic urticaria (CIU) patients.

METHODS

This multi-center, randomized, double-blind study involved 886 patients (438 on levocetirizine and 448 on desloratadine). The primary objective was to compare their efficacy on the mean pruritus severity score after 1 week of treatment. Mean pruritus severity score over 4 weeks and pruritus duration score, number and size of wheals, mean CIU composite score (sum of the scores for pruritus severity and numbers of wheals), quality of life, and the patient's and investigator's global satisfaction with treatment, were secondary efficacy measures.

RESULTS

Levocetirizine led to a significantly greater decrease in pruritus severity than desloratadine over the first treatment week; mean pruritus severity scores of 1.02 and 1.18 for levocetirizine and desloratadine, respectively (P < 0.001). The result was similar for the entire 4-week treatment period (P = 0.004). In addition, levocetirizine decreased pruritus duration and the mean CIU composite scores to a significantly greater extent than desloratadine during the first week (P = 0.002 and 0.005, respectively) and over the entire study (P = 0.009 and P < 0.05, respectively). Similarly, levocetirizine increased the patients' global satisfaction after one and 4 weeks (P = 0.012 and 0.021, respectively), compared with desloratadine. Safety and tolerability were similar in both groups.

CONCLUSIONS

Levocetirizine 5 mg was significantly more efficacious than desloratadine 5 mg in the treatment of CIU symptoms.

Disease severity, scratching, and sleep quality in patients with atopic dermatitis

BACKGROUND

The relationship between sleep quality and disease severity in patients with atopic dermatitis has not been clearly defined.

METHODS

Sleep efficiency and scratching were measured over 2 nights by polysomnography, actigraphy, and self-report in 20 adults with atopic dermatitis. Tumor necrosis factor, interleukin (IL)-6, and IL-10 were assayed from a subset of 9 participants.

RESULTS

Sleep measured by actigraphy and polysomnography were strongly associated with each other. Decreased sleep efficiency was associated with increasing disease severity, scratching, and IL-6. Self-reported sleep quality and quality of life were not significantly correlated with either objective sleep measure.

LIMITATIONS

Results in this pilot study await confirmation in a larger investigation.

CONCLUSION

Objective measures but not self-report documented that increasing severity of atopic dermatitis results in more scratching and declining sleep quality. Our data also suggest an important relationship between sleep and IL-6.

Objective measurement of pruritus in dogs: a preliminary study using activity monitors

Pruritus is an important clinical sign and quality-of-life measure in canine dermatology, but can be difficult to assess objectively. Several studies in humans have used activity monitors to measure nocturnal scratching in patients with atopic dermatitis. The results correlate with observation of scratching, scoring in atopic dermatitis indices and levels of inflammatory chemokines. The aim of this study was to examine whether an activity monitor could be used to detect elevated interexercise (i.e. 'resting') activity in atopic dogs compared to healthy dogs. Five healthy dogs and six dogs with atopic dermatitis were fitted with a collar-mounted activity monitor (Actiwatch) that recorded the piezo-electric voltage generated over 15-s epochs for 7 days. Data from defined periods of exercise, playing, etc., were disregarded. Within each group, median (+/- interquartile range) epoch activity was similar during the day (atopic 21.0 [9.8-24.8]; healthy 5.1 [4.6-6.0]) and evening (atopic 19.1 [10.9-25.2]; healthy 5.8 [5.3-11.7]), and significantly lower overnight (atopic 5.8 [4.1-15.7]; healthy 2.5 [1.6-4.4]) (Mann-Whitney test; P < 0.05). The mean epoch activity, however, was significantly higher in atopic dogs compared to healthy dogs for all three time periods (P < 0.05). This study provides preliminary evidence that activity monitors could objectively assess canine pruritus in the normal home environment.

Lesson from performing SCORADs in children with atopic dermatitis: Subjective symptoms do not correlate well with disease extent or intensity

BACKGROUND

Atopic dermatitis (AD) is a distressing disease associated with pruritus and sleep disturbance. It is not known how well these symptoms correlate with the extent and intensity of eczematous involvement. We evaluated whether: (i) the level of sleep loss correlates with pruritus and (ii) the level of pruritus correlates with the extent or severity of AD in children according to the SCORing Atopic Dermatitis (SCORAD) index.

METHOD

Patients with AD younger than 18 years old were recruited from the pediatric dermatology clinic of a university teaching hospital, and AD severity was evaluated by the SCORAD index.

RESULTS

One hundred and eighty-two Chinese children with AD (107 boys and 75 girls) [mean (SD) age of 9.6 (4.2) years] were recruited. Their mean (SD) overall SCORAD was 30.1 (19.2). Sleep loss was strongly correlated with pruritus (r = 0.57, P < 0.001). However, the two subjective symptoms were only weakly correlated with the objective signs (extent and intensity) of AD. The correlations between pruritus and extent and intensity were 0.42 (P < 0.001) and 0.38 (P < 0.001), respectively, and the correlations between sleep loss and extent and intensity were 0.38 (P < 0.001) and 0.34 (P < 0.001), respectively.

CONCLUSION

We speculate that the lack of a better correlation was either because pruritus and sleep loss as reported by parents were imprecise, or that mechanisms other than disease extent or severity are responsible for the pathogenesis of these subjective symptoms.

Nocturnal wrist movements are correlated with objective clinical scores and plasma chemokine levels in children with atopic dermatitis

BACKGROUND

Atopic dermatitis (AD) is a distressing disease associated with pruritus and sleep disturbance. Scratching due to pruritus is an important mechanism in the exacerbation of AD but is difficult to document in the home environment.

OBJECTIVES

To evaluate whether nocturnal wrist activities, defined as average acceleration in the early hours of sleep, were correlated with components of the SCORing Atopic Dermatitis (SCORAD) index and various AD-associated chemokine markers.

METHODS

Patients with AD aged under 18 years were recruited and the severity of eczema was assessed with the SCORAD index. Concentrations of plasma AD-associated chemokines [cutaneous T-cell attracting cytokine (CTACK); macrophage-derived chemokine (MDC); thymus and activation regulated chemokine (TARC)], interleukin (IL)-18, serum total IgE, and eosinophil counts were measured in these patients. Healthy children with noninflammatory and nonitchy skin conditions as well as healthy children of staff volunteers were recruited as controls. All children were instructed to wear the DigiTrac monitor on their dominant wrist before sleeping. The monitor was programmed to record limb motion between 22.00 and 08.00 h the following morning.

RESULTS

Twenty-four Chinese children with AD (mean +/- SD age 12.6 +/- 3.7 years) and 15 normal children (mean +/- SD age 11.9 +/- 3.4 years) were recruited. The median (interquartile range) SCORAD was 54.8 (32.8-70.2). Plasma concentrations in pg mL(-1) of CTACK, MDC, TARC and IL-18 in the patients were 105 (92-172), 1648 (973-4214), 258 (100-850) and 415 (304-539), respectively. When compared with controls, most wrist activities occurred at frequencies between 1 and 3 Hz. These activities were most consistent over the first 3 h of sleeping and correlated significantly with disease severity, extent, intensity, and AD-associated chemokine markers CTACK, MDC and TARC. However, there was no significant correlation between wrist activities and the subjective symptom of pruritus or sleep loss.

CONCLUSIONS

This is the first study to demonstrate that wrist activities, nonintrusively measured by the DigiTrac monitor at home, are closely correlated with the objective clinical scores and levels of peripheral blood chemokine markers for AD but not with the reported symptoms of pruritus or sleep loss. We propose that wrist activities between 1 and 3 Hz for the first 3 h are a good indicator of AD severity in children and should substitute for the pruritus and sleep-loss components of the SCORAD.

Itching for progress

The study of itch remains a neglected field, with a number of barriers limiting satisfactory therapy in the majority of instances. We review recent advances, focusing on the identification of the neural pathways, distinct from pain, that signal itch; methods to measure itch as scratch in humans; and the identification of a role for H4 receptors in mediating itch (in the mouse).

The future: critical knowledge about anti-itch therapy

Itch is an extremely frequent and enervating symptom of many diseases. Current anti-itch therapy, which is based almost exclusively on an "immunocentric" viewpoint, is often unsatisfactory. Recent studies show that this symptom is in fact the result of a complex interplay among skin, nervous system, endocrine system, and immune system. This explains the frequent failure of therapeutic strategies focused only on a single factor and suggests the usefulness of a polypharmacologic symptomatic treatment, designed on a case-by-case basis as a result of a multidisciplinary approach. We discuss the perspectives of anti-itch therapy in light of the new pathogenetic and pharmacologic acquisitions.

Measurement of itch using actigraphy in pediatric and adult populations

We have studied nocturnal movements using wrist-worn accelerometers in 33 adults with a range of pruritic dermatoses, 30 adult control subjects, 25 children with atopic dermatitis, and 17 pediatric control subjects. In all, 26 adults and 20 children were studied on more than one occasion, up to a maximum of 6 occasions. Participants were examined and a range of subjective measures about the extent of skin disease, itch, and quality of sleep were recorded. We show clear differences between patients and control subjects for both age groups studied, with activity medians approximately twice as high in the patients as in the control subjects ( P < .001). Studies on the same person show a considerable night-to-night variation that is unlikely to relate to measurement error, but instead, we believe, reflect genuine differences in nocturnal activity (and perhaps disease severity). Movement through the night did not seem to follow any obvious pattern. The relation between subjective measures, Severity sCORing of Atopic Dermatitis (SCORAD) index scores, and objective recorded activity was imperfect, with much unaccounted for variation. In particular, in adults, but not in children, we found a negative correlation (-0.44, P < .02) between objective movement activity and self-reported quality of sleep. Our results support the use of objective measures of scratch in the assessment of disease activity, and suggest that the relation between subjective and objective measures of disease severity may not be straightforward.

The development of an objective method for measuring scratch in children with atopic dermatitis suitable for clinical use

Itch is a major symptom of skin disease and remains poorly studied. We have used limb-worn digital accelerometers, and infrared video of patients as a gold standard, on children with atopic dermatitis and control subjects in their own homes at night. Video analysis shows that nocturnal scratching and restlessness are more complex than we first thought, with many movements that potentially damage the skin not conforming to stereotypical scratch movements. Children with atopic dermatitis spent a mean of 46 minutes less time motionless or sleeping at night than control subjects (468 +/- 3 [SEM] vs 422 +/- 37 [SEM], P<.001). Children with atopic dermatitis showed 2 to 3 times as much scratching or restlessness activity as control subjects, with little overlap between groups (P<.01). Scratching and restlessness were highly correlated with each other (0.94, P<.01). Accelerometer scores were highly correlated with video results (rho>0.02, P<.01, for scratching, restlessness, and sleeping time). Individual limb scores were highly correlated with each other (rho approximately 0.87-0.98), suggesting that little information would be lost if only 1 limb was measured. There was little relation between parental assessment of scratch and objective measured scratch. Accelerometers provide a useful and practical way of assessing scratching at night in the patient's own home and could be used as an objective measure of disease activity both in clinical trials and in everyday clinical practice.

Measurement of electrical current perception threshold of sensory nerves for pruritus in atopic dermatitis patients and normal individuals with various degrees of mild damage to the stratum corneum

BACKGROUND

Patients with atopic dermatitis (AD) are well known to be sensitive to irritation from the environment due to the impaired function of the stratum corneum (SC). Electrical current perception threshold (CPT) evaluation quantifies the sensory threshold to transcutaneous electrical stimulation of the sensory nerves.

OBJECTIVE

To study the CPT in a noninvasive fashion using Neurometer CPT/C, together with measurements of various functions of the SC.

METHODS

We measured the CPT on the flexor forearm and cheek of AD patients and normal individuals. Subsequently, we evaluated the CPT and skin sensitivity to a 30% aqueous solution of lactic acid after the infliction of various mildly disruptive measures on the SC on the flexor forearm of healthy individuals by the following three methods: (1) removal of the superficial sebum with acetone/ether, (2) scarification with a needle and (3) tape stripping of the SC. Finally, we examined the effect of topical applications of emollients such as petrolatum or a moisturizing cream to the scratched skin.

RESULTS

AD patients showed a lower barrier function and lower CPT than normal individuals. In subsequent studies conducted in normal individuals, the CPT was found to be inversely correlated with transepidermal water loss (TEWL) levels after tape stripping. However, most of all, the partial superficial scarification with a needle decreased the CPT and increased the lactic acid stinging response. Prolonged removal of lipids from the SC with acetone/ether for 30 min that increased the TEWL levels for only 1 day decreased the high-frequency conductance value for 2 days and the CPT only on the 2nd day after treatment. Topical applications of emollients were effective to prevent the increased sensitivity caused by scratching.

CONCLUSIONS

AD patients showed functional abnormalities of the SC and tended to have more sensitive skin on the cheek and flexor forearm than healthy controls. Even focal SC damage caused by superficial cracking may lead to further disruption of the already damaged SC in AD patients, by eliciting scratching and facilitating the permeation of various environmental allergens and also the induction of hypersensitive skin.

Actigraphy assessment of sleep disturbance in patients with atopic dermatitis: an objective life quality measure

BACKGROUND

Patients with atopic dermatitis (AD) frequently report compromised quality of life because of disturbed sleep and daytime fatigue secondary to their skin disease, but few studies provide objective measurement of sleep change in this population.

OBJECTIVE

The purpose of this investigation was to contrast subjective and objective measures of sleep quality in patients with AD.

METHODS

Fourteen adult patients with AD and 14 adult control subjects with no skin disease wore actigraphs for 1 week and completed questionnaires about sleep, itch, and quality of life.

RESULTS

As measured by self-report and actigraphy, the AD group slept more poorly and reported more daytime fatigue than the control group. Actigraphy alone was correlated with itch and quality of life and was able to discriminate movement during sleep, number of awakenings, minutes asleep, and minutes awake.

CONCLUSIONS

Results from this study demonstrate that sleep is significantly compromised in patients with AD. Patients' perception of their sleep provides less detail and accuracy than actigraphy. The actigraph is an objective, unobtrusive measure of sleep at home in patients with skin disease and can provide an important outcome measure in clinical trials.

Itch

Itch is a common skin sensation, with substantial effects on behaviour. Neurophysiological research has permitted accurate definition of neural pathways of itch, and has confirmed the distinctiveness of itch pathways in comparison with pain. A clinical classification of itch, based on such improved understanding, describes the difference between peripheral (pruritoceptive) and central (neurogenic or neuropathic) itch. New specific and sensitive investigational methods in people and animals enable us to better understand this bothersome symptom, and have important clinical implications. We describe the clinical classification of itch, new findings on neuropathophysiology of itch, methods for assessment, and improved treatments.