Assessment of itch: more to be learned and improvements to be made

Peristomal Skin Itch: An Integrative Review

Survey data from the United Stated, the United Kingdom, and the Netherlands indicate peristomal itch is prevalant among ostomy patients. Pruritus has a significant negative impact on health-related quality of life, resulting in discomfort and interrupted sleep. In ostomy patients, peristomal skin scratching also may interfere with adherence of the ostomy pouching system. This article reviews the classification and pathophysiology of itch in the peristomal skin, along with options for its management.

Pruritus in psoriasis and atopic dermatitis: current treatments and new perspectives

Psoriasis and atopic dermatitis (AD) are two common chronic inflammatory skin diseases. Although showing different etiology and clinical manifestations, patients with either disease suffer from low health-related quality of life due to pruritus (dermal itch). Recent studies have revealed that more than 85% of psoriasis patients suffer from pruritus, and it is also the dominating symptom of AD. However, as this is a non-life treating symptom, it was partly neglected for years. In this review, we focus on current findings as well as the impact and potential treatments of pruritus in these two skin diseases. We first distinguish the type of itch based on involved mediators and modulators. This clear delineation between the types of pruritus based on involved receptors and pathways allows for precise treatment. In addition, insights into recent clinical trials aimed to alleviate pruritus by targeting these receptors are presented. We also report about novel advances in combinatorial treatments, dedicated to the type of pruritus linked to a causal disease. Altogether, we suggest that only a focused treatment tailored to the primary disease and the underlying molecular signals will provide fast and sustained relief of pruritus associated with psoriasis or AD.

Advances in Understanding the Initial Steps of Pruritoceptive Itch: How the Itch Hits the Switch

Pruritoceptive (dermal) itch was long considered an accompanying symptom of diseases, a side effect of drug applications, or a temporary sensation induced by invading pruritogens, as produced by the stinging nettle. Due to extensive research in recent years, it was possible to provide detailed insights into the mechanism of itch mediation and modulation. Hence, it became apparent that pruritus is a complex symptom or disease in itself, which requires particular attention to improve patients’ health. Here, we summarize recent findings in pruritoceptive itch, including how this sensation is triggered and modulated by diverse endogenous and exogenous pruritogens and their receptors. A differentiation between mediating pruritogen and modulating pruritogen seems to be of great advantage to understand and decipher the molecular mechanism of itch perception. Only a comprehensive view on itch sensation will provide a solid basis for targeting this long-neglected adverse sensation accompanying numerous diseases and many drug side effects. Finally, we identify critical aspects of itch perception that require future investigation.

Itching and its related factors in subtypes of eczema: a cross-sectional multicenter study in tertiary hospitals of China

Itching is a leading symptom of eczema or dermatitis and has a great impact on patients' lives. Previous studies on itching have focused mostly on atopic dermatitis (AD). A cross-sectional multicenter study was conducted among outpatients with eczema from 39 tertiary hospitals in mainland China from July 1 to September 30, 2014. This work elaborates on itching in different types of eczema. Itching was very common (97%, 8499/8758) in outpatients with eczema. The severity of the itch increased with age and disease duration (P < 0.001). The top three subtypes of dermatitis with severe itching were atopic dermatitis (30.4%), widespread eczema (30.1%), and asteatotic eczema (27.9%). Widespread eczema refers to the involvement of more than three body parts, without clinical features of other specific types of eczema. The proportion of outpatients without itching was highest in hand eczema (6.8%). Positive correlations were observed between the severity of itching and the proportions of different diseases based on trend tests, including atopic dermatitis (P < 0.001), widespread eczema (P < 0.001), asteatotic eczema (P < 0.001), and autosensitization dermatitis (P < 0.001). Eczema outpatients with older age, longer disease duration, and, especially, a history of allergic diseases might be more prone to itching.

The relationship between pruritus and clinical variables in patients with psoriasis

Background

Pruritus is the most commonly occurring subjective symptom of dermatological disease. Published data on both prevalence and intensity of pruritus in psoriasis is limited.

Objective

In this study we aimed to investigate the prevalence of pruritus and its relation with psoriasis area severity index, body mass index and presence of systemic disease in patients with psoriasis.

Methods

We analyzed data of psoriatic patients diagnosed in our psoriasis outpatient clinic between March 2013 and June 2014 collected retrospectively from PSR-TR registration system.

Results

In total, 880 patients were analyzed. Pruritus was more prominent in female patients. This difference was statistically significant. No significant associations were found between age of patients, clinical type of disease and pruritus. The itching was more common in patients with higher body mass index. Presence of pruritus was correlated significantly with severity of psoriasis. Five hundred and sixty of 880 patients had no systemic disease. The presence of pruritus was not related with presence of systemic disease. Existence of systemic disease with psoriasis has minimal effect on pruritus.

Study Limitations

We did not evaluate intensity of pruritus.

Conclusions

Pruritus is not mentioned within the classical symptoms of psoriasis. Pruritus in psoriasis is a very unpleasant symptom with great potential to impair patient's quality of life and may exacerbate psoriasis as a Koebner phenomenon.

Eye rubbing type and prevalence including contact lens 'removal-relief' rubbing

BACKGROUND

Eye rubbing is commonly associated with keratoconus and may contribute to disease onset and progression. Verbal counselling to avoid rubbing may not be successful and adverse consequences of rubbing, which occurs on contact lens removal may be more serious. This study examines the prevalence of 'removal-relief' rubbing and its potential consequences.

METHODS

Rubbing histories were recorded for contact lens wearing normal and keratoconic patients as well as for normal non-contact lens wearers. Analogue scaled responses were used to identify and compare abnormal rubbing habits.

RESULTS

Contact lens wearing patients (both with and without keratoconus) reported significantly more rubbing before contact lens insertion (p < 0.05) compared to non-contact lens wearers. Eye rubbing after contact lens removal ('removal-relief' rubbing) was found to be significantly more prevalent among contact lens-wearing keratoconic patients compared to contact lens-wearing non-keratoconic patients (p < 0.001 in both cases).

CONCLUSIONS

Rubbing-related trauma occurring before contact lens insertion may predispose the cornea to wound healing activities and greater levels of adverse response to contact lens wear. Such adverse responses could predispose the cornea to greater trauma, which occurs in response to rubbing on removal of contact lenses. Strong counselling to avoid eye rubbing is often not an adequate form of management for a significant number of patients with keratoconus. Evidence of relapses indicates the need for better methods of counselling and for them to be repeated regularly. Apart from keratoconus, any other keratectasia, corneal disease or wound healing (including post-surgical) may increase susceptibility to corneal rubbing trauma. Such cases also appear to warrant counselling on avoidance of rubbing.

Increased ZAP70 Is Involved in Dry Skin Pruritus in Aged Mice

Dry skin pruritus is common in the elderly. Recent reports show that T-cell signal path is involved in dry skin pruritus. Zeta-chain-associated protein kinase 70 (ZAP70), as a T-cell receptor, may induce interleukin 2 (IL-2) secretion and promote nerve growth factor (NGF) secretion in skin. This study aimed to detect the alteration of ZAP70 in a mice model with dry skin pruritus. The C57BL mice with 5 months and 22 months were used as experimental animal. Following a 5-day period of treatment of back with a mixture of acetone-diethyl-ether-water (AEW), mice exhibited a significant increase in spontaneous scratching behavior directed to the treated back compared to control animals in which back was similarly treated with water only (W). After AEW process, spontaneous scratching in 22-month AEW mice was increased compared to 5-month AEW mice. Western blot and real-time quantitative PCR data analysis showed that ZAP70 expression was significantly increased in 22-month AEW mice compared with 5-month AEW mice. ELISA data showed that secretions of IL-2 and NGF in 22-month AEW mice were higher than 5-month AEW mice. Our results indicate that increased ZAP70 is involved in dry skin in elderly pruritus. Increased secretion of IL-2 and NGF may induce dry skin itch.

Understanding the pathophysiology of itch

Itch is the most common symptom described by our patients. Treating this symptom can be challenging. A revolution is ongoing in understanding the pathophysiology of itch and will allow this challenge to be met. The present authors review and update the current understanding of the pathophysiology of itch.

Correlating an 11-point verbal numeric rating scale to a 4-point verbal rating scale in the measurement of pruritus

Pruritus, the subjective sensation of itch, can be a difficult symptom to assess and treat. Evaluating levels of patient discomfort across populations has proven to be challenging because of a lack of a standardized measurement tool to quantify levels of itch. The most widely used tool is the 4-point verbal rating scale (VRS-4), but others use an 11-point verbal numeric rating scale (VNRS-11). Therefore, the purpose of our study was to correlate a VNRS-11 to a VRS-4 for the assessment of pruritus. Fifty parturients were enrolled in this correlational study. Each subject's level of pruritus was measured at five specific intervals after administration of intrathecal opioids. The scales were administered one minute apart in random order. Data analysis demonstrated a strong correlation between these two scales, (r=.910 to .853) indicating that each verbal descriptor on the VRS-4 could readily be substituted with a quantifiable range on the VNRS-11.

Itch in psoriasis: epidemiology, clinical aspects and treatment options

BACKGROUND

Pruritus is an important symptom in psoriasis vulgaris, may be severe and seriously affect the quality of life of patients, but published data on its frequency and characteristics are limited.

OBJECTIVE

The study objective was to characterize the prevalence of itch in psoriatic patients and the effect of treatment modalities by using a comprehensive itch questionnaire of own design.

METHODS

A structured itch questionnaire was given to 90 patients with moderate to severe chronic-plaque psoriasis selected consecutively from the patients visiting the Department of Dermatology of the University of Florence. The questionnaire concerned the areas involved psoriasis and pruritus, the pruritus characteristics, the worsening and relieving factors and treatment modalities. Itch intensity was reflected by a 10 point visual analog scale (VAS) and the degree of symptoms discriminated between mild (1-3), moderate (4-7) and severe (8-10).

RESULTS

Almost 85% of psoriatic patients suffered from itching; the frequency of pruritus was daily and mean intensity by VAS scale was moderate. Presence and intensity of pruritus and body mass index (BMI) were correlated. 40% of patients with pruritus were overweight (BMI > 25 < 30) and 10% obese (BMI > 30). Almost all patients appeared unsatisfied with the available treatment modalities for pruritus in psoriasis. Emollients, topical steroids and calcipotriol cream could relieve pruritus but their effect was temporary. Among the antipsoriatic therapies, phototherapy with narrow band ultraviolet B (nb-UVB) was the most effective treatment in reducing pruritus. Biological therapies, mainly etanercept and efalizumab, proved useful in its control.

CONCLUSIONS

The questionnaire was a useful tool to characterize itch, and the results might help us to better understand pruritus in psoriasis. The results confirmed the need for a global study of psoriasis with regard to both the cutaneous manifestations and the itch symptom.

Clinical implications of aging skin: cutaneous disorders in the elderly

Aging skin undergoes progressive degenerative change. Structural and physiologic changes that occur as a natural consequence of intrinsic aging combined with the effects of a lifetime of ongoing cumulative extrinsic damage and environment insult (e.g. overexposure to solar radiation) can produce a marked susceptibility to dermatologic disorders in the elderly. As skin ages, the vasculature progressively atrophies. The supporting dermis also deteriorates, with collagen and elastin fibers becoming sparse and increasingly disordered. These changes leave the elderly increasingly susceptible to both vascular disorders such as stasis dermatitis and skin injuries such as pressure ulcers and skin tears, with a steadily decreasing ability to effect skin repair. A parallel erosion of normal immune function produces higher levels of autoimmune skin disorders such as bullous pemphigoid, benign mucous membrane pemphigoid, paraneoplastic pemphigoid, and pemphigus vulgaris. Lichen sclerosus, an autoimmune disorder often occurring in the genital area in older women, is not common but is an important development because of the potential for substantial discomfort as well as serious complications. The prevalence of polypharmacy in this population increases the risk for autoimmune drug reactions, and diagnosis should be undertaken with an awareness that polypharmacy in this population creates a greatly increased susceptibility to drug eruptions that can mimic other cutaneous disorders. Immunologic senescence in the elderly also sets the stage for potential reactivation of the Varicella zoster virus, in which initial dermatologic involvement expands into the major sensory ganglia. Known as shingles, this disorder can be excruciatingly painful with the potential to cause blindness if the optic nerve becomes involved. Dermatoses such as xerosis, pruritus, and eczema are also widespread in the elderly, create substantial suffering in those afflicted, and often prove recalcitrant to treatment. Individual susceptibility to specific types of contact dermatitis changes over the lifetime, and seborrheic dermatitis is substantially more prevalent in the elderly. It is not uncommon for older patients to have multiple impairments, with the potential for cognitive dysfunction as well as impaired vision, hearing, or mobility. In addition, they may not have adequate housing or nutrition, or the financial resources necessary for adequate compliance. Physicians must take into consideration the patient's physical ability to comply with the recommended therapy as well as socioeconomic factors that may impact on compliance. Simple topical regimens are preferable wherever possible in order to maximize compliance and, therefore, efficacy. Extra effort may be necessary to ensure that instructions are accurately followed and that ongoing compliance with the regimen prescribed is actually achieved. Management of dermatologic disorders in the elderly is often less than optimal, due to the fact that the special needs and limitations of this population are not adequately considered. Treatments should consider the intrinsic differences between younger and older patients that may impact on diagnosis and therapy choice. The aged patient is often afflicted with numerous co-morbidities that can influence the choice of therapy. Skin integrity in the elderly is compromised, and safety concerns are increased with the long-term use of any medication prescribed. In addition, the prevalence of polypharmacy in the aged population substantially increases the risk of cutaneous drug reactions, which can profoundly complicate accurate diagnosis of dermatologic disorders. The aged population also needs to be more closely monitored because of increased fragility of the skin and the physical limitations that may hinder compliance with prescribed regimens.