12-Item Pruritus Severity Scale: Development and Validation of New Itch Severity Questionnaire

The Dermatology Life Quality Index (DLQI) used as the benchmark in validation of 101 quality-of-life instruments: A systematic review

BACKGROUND

The validation of psychometric measures requires use of other established and standardized validated measures. The Dermatology Life Quality Index (DLQI) is the most widely used tool to measure the burden of skin diseases and assess effectiveness of interventions based on patients' perspective.

OBJECTIVES

The objective of this study was to systematically analyse peer-reviewed publications describing use of the DLQI in validation of other patient-reported outcome (PRO) and quality-of-life (QoL) measures.

METHODS

Seven databases were searched for papers published between January 1994 and December 2022 for articles containing data using DLQI in the validation of other PRO/QoL measures. The methodology followed PRISMA guidelines. The protocol was prospectively registered on PROSPERO.

RESULTS

Of 1717 screened publications, 122 articles including 30,727 patients from 34 different countries with 41 diseases met the inclusion criteria. The DLQI was used in validation of 101 measures: 80 dermatology-specific QoL measures, mostly disease-specific, and 21 generic measures. Of these studies, 47 were cross-cultural adaptations, 116 single arm, 100 were cross-sectional, 18 longitudinal and six randomized placebo controlled. DLQI was used for 14 known group, and correlation for 10 construct, 101 convergent, 10 concurrent, 10 divergent/discriminant and three criterion validity tests using Mann-Whitney (2), Spearman's (80), Pearson's correlation (26) and Student's t-test (1). The DLQI was used in responsiveness analysis in 13 studies.

CONCLUSIONS

This review identified widespread use of the DLQI in validation of other dermatology PRO/QoL measures and confirmed the central role that the DLQI plays as a benchmark in instrument development and validation across dermatology and beyond. The use of the DLQI by so many developers of other instruments has provided a common standard for comparability.

Construction and Validation of a Novel "Pruritus Impact Scale" (PIS) for Assessment of Chronic Pruritus

Background

Currently available pruritus assessment tools may not always fulfill the needs of the Indian population and populations who share similar sociocultural backgrounds. To overcome this limitation, a new assessment tool "Pruritus Impact Scale (PIS)" was constructed and validated.

Aims and Objectives

The primary objective is to construct and validate the novel PIS. The secondary objective is to evaluate the responsiveness of PIS to changes in symptoms.

Patients and Methods

This study design was cross-sectional for the primary objective and longitudinal for the secondary objective. The study recruited 435 patients of chronic pruritus of different etiologies for the construction of the PIS scale. Patients were asked to fill out four different pruritus measuring tools i.e., Numerical Rating Scale (NRS), Dermatology Life Quality Index (DLQI), 12-item Pruritus Severity Score (PSS), and newly constructed PIS. The PIS was derived from existing standard assessment tools with certain modifications to keep a balance of psychometric properties of the scale and the sociocultural needs of the population. The validity and reliability of the scale was assessed. For detecting the response of PIS to change in pruritus intensity, 276 patients were followed and were instructed to refill all four scales at 6 weeks from the baseline. The responsiveness was judged by comparing the mean score of all scales at baseline with the mean score at 6 weeks. In addition, the changes in the scores among all 4 scales were correlated and compared.

Results

PIS showed strong internal consistency (Cronbach α = 0.882) and positively correlated with other validated pruritic tools such as NRS (ρ = 0.938, P < 0.0001), DLQI (ρ = 0.914, P < 0.01) and 12- PSS (ρ = 0.913, P < 0.001) at baseline. PIS showed satisfactory reproducibility at 3-hour intervals (Cronbach α = 0.994). Responsiveness to change in pruritus as measured by PIS at 6 weeks reassessment was correlated well with the changes in NRS (ρ = 0.689, P value < 0.0001), DLQI (ρ = 0.586, P value < 0.0001) and 12-PSS (ρ = 0.928, P value <0.0001).

Limitations

A noteworthy limitation of the present study is the lack of comparison of different items (within a construct) comprised in different tools used for comparison.

Conclusions

The newly constructed PIS is a valid tool in the studied population.

Quality of Life and Clinical Outcomes of Endosonography-Guided Biliary Drainage in Patients with Malignant Biliary Obstruction: A Single-Center, Prospective Analysis

Introduction: Endosonography-guided biliary drainage (EUS-BD) serves as a rescue treatment modality for patients with malignant biliary obstruction when endoscopic retrograde cholangiopancreatography (ERCP) fails. Objectives: This study explores the effects of EUS-BD on liver function and quality of life (QoL). Patients and Methods: Patients with malignant biliary obstruction and failed ERCP were enrolled to undergo EUS-BD. QoL, including pruritus severity, was evaluated using EQ-5D-5L and PSS-10 questionnaires before and after EUS-BD. Serum bilirubin and liver function tests were measured on the procedure day, two days, and at least 14 days post-procedure. Results: During a 20-month study period, 1755 ERCPs were performed, with 595 for malignant cases. Of these, 49 underwent EUS-BD following failed ERCP, and 37 (54% women, age range 34-87 years) completed the 14-day follow-up. Pancreatic cancer was the most common (49%) condition, and the median hospital stay was 4 days. Serum bilirubin, alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, and gamma-glutamyl transferase significantly decreased 2 and 14 days after EUS-BD (all p < 0.001). Pruritus significantly improved, with an average reduction of 5.19 points on the PSS-10 scale two weeks post-procedure (p < 0.001). EUS-BD led to improvements in anxiety and depression according to the EQ-5D-5L (p = 0.013). Conversely, deteriorations were observed in the Mobility, Self-Care, and Usual Activities domains over time (all p < 0.05). Successful EUS-BD enabled the resumption of chemotherapy in 11 (30%) patients. The median post-procedure survival was 112 (range 27-1030) days. Conclusions: EUS-BD improves liver parameters and some aspects of life quality in patients with malignant biliary obstruction, thereby increasing their eligibility for optimal palliative care.

Comparative study of the efficacy of azathioprine, dapsone, and NB-UVB phototherapy as steroid-sparing modalities in generalised lichen planus

Background Generalised lichen planus (GLP) is a chronic disease with an overall prevalence of 1% requiring longer treatment. Limited studies are available on GLP and its treatment in the literature, unlike oral lichen planus. Objective To determine the best steroid-sparing treatment modality for GLP by comparing the efficacy, response, safety, side effects, and remission with azathioprine, dapsone, and narrowband UV-B (NB-UVB) along with their impact on itching severity and life quality. Methodology Open-label, prospective, comparative, interventional study on generalised lichen planus patients treated with systemic steroids along with one of three steroid-sparing modalities. Totally 90 patients were studied including 30 patients each who received azathioprine (Group A), dapsone (Group B), and narrow band UVB (NB-UVB) (Group C), respectively, for 16 weeks. Itch severity index (ISI) and Dermatology life quality Index (DLQI) were assessed at baseline and week 24. All patients received oral prednisolone until there was no more active disease. Response was assessed in terms of occurrence of new lesions, flattening of lesions, post-inflammatory hyperpigmentation (PIH), and grading of lesions two weeks once for 6 months followed by six months of follow-up after treatment completion. Results Females outnumbered males in all 3 groups. Mean patient ages (34, 38, and 34) and the presence of one or more co-morbidities (50%, 42.3%, 37.5%) in Groups A, B, and C, respectively, were comparable. ISI and DLQI improvement at 24 weeks were greatest with NB-UVB, followed by azathioprine and dapsone in that order; the differences in improvement between groups showed high statistical significance. At week 24, occurrence of new lesions (0%, 0%, 3.8%), flattening (100% - all groups), PIH (100% - all groups), grade 3 lesions i.e. poor response, resolution of 20-50% of lesions (7.1%, 11.5%, 0%), grade 2 lesions i.e. partial response, resolution of 50-90% of lesions (35.7%, 76.9%, 8.3%) and grade 1 lesions i.e. complete response, resolution of >90% lesions (57.1%, 11.5%, 91.3%) were noted in Groups A, B and C, respectively; the differences in the extent of resolution of lesions between the groups were highly significant statistically. Remission was seen in 100%, 76.9%, and 87.5% in Groups A, B, and C, respectively, after six months. Limitations The sample size was small. Only 3 treatment options were compared in this study but many more options have been used for lichen planus. Long term follow-up is required. Conclusions NB-UVB with oral steroids showed a better response in terms of improvement in DLQI, ISI, disease control, and side effects than azathioprine and dapsone. Azathioprine showed a faster response and more prolonged remission. Dapsone showed poor response with multiple side effects.

Chronic Pruritus Alleviation in the Elderly Through Drug-Free Autophagy Activation by Magnetized Saline Water: A Case Series

Chronic pruritus is a common and distressing condition in the elderly population, frequently associated with various underlying systemic diseases and age-related skin changes. Conventional treatments, such as emollients and moisturizers, may not invariably provide adequate relief. Magnetized saline water has previously been shown to activate autophagy, a cellular process involved in maintaining skin barrier function, reducing inflammaging, and modulating neuropathic pain. This case series investigated the efficacy of a topical serum containing magnetized saline water in managing chronic pruritus with diverse etiologies in elderly patients. Five patients aged 69-80 years, presenting with chronic pruritus lasting two to six months, were instructed to apply the serum daily to the most affected areas for a minimum of 14 consecutive days. Pruritus severity was assessed using the 12-Item Pruritus Severity Scale (12-PSS) at baseline and post-intervention. The underlying causes of pruritus included end-stage renal disease, type 2 diabetes mellitus with peripheral neuropathy, advanced liver fibrosis, and xerosis cutis. All five patients reported a substantial improvement in pruritus severity following the application of the magnetized saline water serum, with post-intervention 12-PSS scores decreasing by 3-5 points. The serum was well-tolerated, and no adverse effects were reported. These findings suggest that topical formulations containing magnetized saline water may be a promising alternative or adjunctive therapy for managing chronic pruritus in the elderly population. However, clinical trials are needed to confirm these findings, elucidate the precise mechanisms of action, and establish optimal treatment protocols.

Pruritus, Fatigue, Osteoporosis and Dyslipoproteinemia in Pbc Patients: A Clinician’s Perspective

In this review article, we summarize the most common clinical manifestations of Primary biliary cholangitis (PBC): pruritus, fatigue, osteoporosis, and dyslipoproteinemia and discuss their impact of the patients’ quality of life. More than half of PBC patients suffer from pruritus or fatigue at the time of diagnosis. We discuss the pathophysiological aspects of the PBC clinical manifestations and treatment options. The pathophysiology of pruritus and fatigue is not adequately elucidated, but IL-31 is associated with the severity of pruritus and could be used to objectify the subjective reporting by questionnaires. Although PBC patients suffer from atherogenic dyslipidemia, they do not seem to have a higher cardiovascular risk; however, this observation needs to be clarified by further clinical studies. The second-line of PBC treatment affects pruritus severity: Obeticholic acid (OCA) worsens pruritus while fibrates improve it. Itching can be alleviated by both non-pharmacological and pharmacological approach, however the are multiple barriers to pharmacological treatment. There is no adequate treatment for fatigue today. Treatment of osteoporosis and dyslipidemia is similar for non-PBC patients; stage of liver disease should be considered in treatment. Further research to clarify the pathophysiology and to eventually discover an effective treatment to improve survival and quality of life (especially pruritus and fatigue) in PBC patients is needed.

The relationship between fatigue, pruritus, and thirst distress with quality of life among patients receiving hemodialysis: a mediator model to test concept of treatment adherence

Hemodialysis is a conservative treatment for end-stage renal disease. It has various complications which negatively affect quality of life (QOL). This study aimed to examine the relationship between fatigue, pruritus, and thirst distress (TD) with QOL of patients receiving hemodialysis, while also considering the mediating role of treatment adherence (TA). This cross-sectional study was carried out in 2023 on 411 patients receiving hemodialysis. Participants were consecutively recruited from several dialysis centers in Iran. Data were collected using a demographic information form, the Fatigue Assessment Scale, the Thirst Distress Scale, the Pruritus Severity Scale, the 12-Item Short Form Health Survey, and the modified version of the Greek Simplified Medication Adherence Questionnaire for Hemodialysis Patients. Covariance-based structural equation modeling was used for data analysis. The structural model and hypothesis testing results showed that all hypotheses were supported in this study. QOL had a significant inverse association with fatigue, pruritus, and TD and a significant positive association with TA. TA partially mediated the association of QOL with fatigue, pruritus, and TD, denoting that it helped counteract the negative association of these complications on QOL. This model explained 68.5% of the total variance of QOL. Fatigue, pruritus, and TD have a negative association with QOL among patients receiving hemodialysis, while TA reduces these negative associations. Therefore, TA is greatly important to manage the associations of these complications and improve patient outcomes. Healthcare providers need to assign high priority to TA improvement among these patients to reduce their fatigue, pruritus, and TD and improve their QOL. Further studies are necessary to determine the most effective strategies for improving TA and reducing the burden of complications in this patient population.

Prophylatic use of IV nalmefene to prevent epidural opioid-induced pruritus: A multicenter, randomized clinical trial

STUDY OBJECTIVE

The incidence of pruritus from neuraxial opioids is about 60%. Pruritus causes discomfort and decreases the quality of recovery. This randomized double-blinded clinical trial was aimed to evaluate the prophylactic effects of a single dose IV nalmefene on the incidence and severity of epidural opioid-induced pruritus within 24 h after surgeries.

DESIGN

A two-center, randomized, double blinded, controlled clinical trial.

SETTING

The study was conducted from March 2022 to February 2023 at two tertiary care hospitals in China.

PATIENTS

Patients aged between 18 and 80 years-old who underwent elective surgeries and received epidural analgesia intra- and post-operatively were screened for study enrollment. A total of 306 patients were enrolled, 302 patients underwent randomization and 296 patients were included in the final analysis.

INTERVENTIONS

The nalmefene group was prophylactically given 0.5 μg/kg nalmefene intravenously while the control group was given the same volume of saline.

MEASUREMENTS

The primary endpoint was the incidence of pruritus within 24 h after surgeries. The secondary endpoints included time of the first patient-reported pruritus, severity of pruritus after surgeries, severity of acute pain scores after surgeries and other anesthesia/analgesia related side effects.

MAIN RESULTS

Pruritus occurred in 51 of the 147 (34.69%) patients in the control group and 35 of the 149 (23.49%) patients in the nalmefene group (odds ratio, 0.58; 95% CI, 0.35 to 0.96; P = 0.034) within 24 h postoperatively. Nalmefene group demonstrated delayed onset of pruritus, reduced severity of pruritus and decreased vomiting within 24 h after surgery. There were no significant differences in postoperative analgesia and the incidence of other anesthesia/analgesia associated side effects.

CONCLUSIONS

A single dose of 0.5 μg/kg nalmefene intravenously significantly reduced the incidence and severity of epidural-opioid induced pruritus within 24 h after surgery without affecting the efficacy of epidural analgesia.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (www.chictr.org.cn) and the registration number is ChiCTR2100050463. Registered on August 27th, 2021.

Evaluation of sleep quality and pruritus severity in psoriatic patients and their impact on quality of life: a cross section correlational study

Psoriasis is a chronic inflammatory condition associated with genetic and immunological susceptibility. The objective of the study was to evaluate pruritus and sleep quality in correlation (r) to psoriasis severity and to detect their impact on quality of life. Two hundred (200) patients with psoriasis were included. Psoriasis severity was determined using the psoriasis area severity index (PASI), the quality of life (QoL) was assessed by the psoriasis disability index (PDI) questionnaire, and the sleep quality was evaluated by the Pittsburgh sleep quality index (PSQI). Finally, the severity of itching was evaluated using a 12-item pruritus severity scale (PSS). Poor sleep quality was found in 16.0% of patients in this study. Poor sleep was detected among 50.0% of cases with severe psoriasis. PASI scores correlated significantly with sleep quality, duration and sleep disturbances (p < 0.001). The global PSQI and PASI were also significantly correlated (p = 0.004). In conclusion patients complaining of psoriasis exacerbated by pruritus and sleep problems demonstrated lower quality of life in all domains. Sleep disturbances and depressive symptoms impairing quality of life should be taken into consideration when screening patients suffering from psoriasis.

Early clinical observation of supra-hemodiafiltration with endogenous reinfusion in the treatment of uremic pruritus

BACKGROUND

To evaluate the clinical efficacy of supra-hemodiafiltration with endogenous reinfusion (Supra-HFR) for pruritus in uremic maintenance hemodialysis (HD) patients and explore the possible mechanism.

METHODS

This study prospectively included 60 patients with uremia who underwent maintenance hemodialysis and developed pruritus. Patients were randomly divided into a study group (30 cases) and a control group (30 cases). Patients in the study group underwent dialysis once a week with Supra-HFR and twice a week with HD. The group received HD dialysis 3 times a week. Visual analog scales (VAS) scores, 5-D itch scale scores, and 12-Item Pruritus Severity Scale (12-PSS) were used to evaluate the itching degree of patients. Quality of life was assessed using KDTA and SF-36 scores. Blood levels of hypersensitive C-reactive protein, calcium ion (Ca2+), phosphorus ion (P3+ ), free parathyroid hormone (iPTH), and β2-microglobulin (β2-MG) were compared between the two groups before treatment and at follow-up 24 weeks after treatment.

RESULTS

Before treatment, there was no significant difference in VAS, 5-D itch scale, and 12-PSS score between the study group and the control group (all p > 0.05). After 24 weeks of treatment, the VAS score of the study group (2.82 ± 0.91) was significantly lower than that of the control group (7.47 ± 1.32, p < 0.001), the 5-D itch scale score of the study group (9.47 ± 2.34) was significantly lower than that of the control group (18.53 ± 4.02, p < 0.001), the 12-PSS score of the study group (11.20 ± 1.81) was significantly lower than that of the control group (16.47 ± 2.09, p < 0.001). KDTA of the study group (64.17 ± 8.07 vs. 47.83 ± 13.46, p < 0.001) and SF-36 scores (65.37 ± 6.28 vs. 55.90 ± 14.28, p = 0.002) were significantly higher than that in the control group. The levels of hs-CRP, P3+ , iPTH, and β2-MG in the study group after treatment were lower than those before treatment, and lower than those in the control group after treatment (all p < 0.05).

CONCLUSIONS

The Supra-HFR can effectively reduce the itching symptoms of uremia patients and improve their quality of life.

Association of pruritus with sleep in patients with psoriasis and chronic spontaneous urticaria: A cross-sectional study

Background

Pruritus is a frequent complaint associated with various inflammatory dermatoses. Sleep is often disturbed because of pruritus but the impact of severity and diurnal pattern of pruritus has not been studied so far.

Objectives

To estimate the prevalence of nocturnal itch (NI) and its association with itch severity, sleep disturbance and quality of life (QoL) compared with non-NI in chronic plaque psoriasis (CPP) and chronic spontaneous urticaria (CSU).

Methods

We performed a cross-sectional study in patients aged ≥18 years with CPP or CSU for at least 6 weeks. A comprehensive in-house questionnaire designed for study formed the basis for categorizing patients into NI and non-NI. Validated instruments like visual analog scale, pruritus grading system, General Sleep Disturbance Scale, and Dermatology life quality index were used to assess itch severity, sleep, and QoL.

Results

A total of 255 patients (CPP: 131; CSU: 124) were included in this study. Prevalence of NI was 43.5% (95% confidence interval: 34.9%-52.4%) in CPP and 29% (95% confidence interval: 21.2%-37.9%) in CSU. NI was strongly associated with higher pruritus grading system scores in CSU and CPP (regression coefficient = 1.5, P =0.004 and regression coefficient = 1.3, P =0.004, respectively), with impaired sleep (OR = 2.97, P = 0.025) in CPP and with itch-affected sleep in CSU. Itch severity was associated with impaired sleep; however, the association was modified by the presence of NI in CSU patients.

Conclusion

Nocturnal itch is prevalent in chronic dermatoses and significant for sleep deficit and impaired QoL. Early screening and management of sleep disturbance among patients presenting with nocturnal itch should be routinely undertaken.

Serum Mediators in Patients with Both Type 2 Diabetes Mellitus and Pruritus

Chronic pruritus is an unpleasant sensory perception that negatively affects quality of life and is common among patients with type 2 diabetes mellitus. Current antipruritic therapies are insufficiently effective. Thus, the mediation of diabetic pruritus by histamine-independent pathways is likely. The aim of this study was to identify possible mediators responsible for diabetic pruritus. A total of 87 patients with type 2 diabetes mellitus were analysed, of whom 59 had pruritus and 28 did not. The 2 groups were assessed for baseline demographics, serum biochemistry parameters, cytokines, and chemokines. This study also investigated the associations of these factors with the severity of itching. Neither haemoglobin A1c nor serum creatinine levels were correlated with severity of itching. Significantly higher levels of interleukin-4 (p = 0.004), interleukin-13 (p = 0.006), granulocyte-macrophage colony-stimulating factor (p < 0.001) and C-X-C motif chemokine ligand 10 (p = 0.028) were observed in the patients with pruritus than in those without pruritus. Moreover, the levels of these mediators were positively correlated with the severity of itching. Thus, novel antipruritic drugs can be developed to target these molecules. This is the first study to compare inflammatory mediators comprehensively in patients with diabetes mellitus with pruritus vs those without pruritus.

Efficacy of acupoint stimulation as a treatment for uremic pruritus: A systematic review and meta-analysis

BACKGROUND

Uremic pruritus causes sleep disturbances, poor quality of life, and increased morbidity in patients with chronic kidney disease. Acupuncture has been shown to improve uremic pruritus. There is limited evidence of the efficacy of traditional Chinese therapies. We conducted a systematic review and meta-analysis to evaluate the efficacy of acupoint stimulation therapy in patients with uremic pruritus.

METHODS

A systematic search of seven databases (up to Sep 2022) was conducted for randomized controlled trials that evaluated the clinical efficacy of acupuncture, acupressure, auricular acupressure, acupoint injection, acupoint thermal therapy, acupoint sticking therapy, or transcutaneous electrical acupoint stimulation in the treatment of patients with uremic pruritus. Two reviewers selected eligible articles for inclusion in the meta-analysis and evaluated the risk of bias via Cochrane Collaboration. The results of pruritus assessments and uremic pruritus-related laboratory parameters were analyzed.

RESULTS

Forty trials published between 2002 and 2022, including a total of 2,735 participants, were identified for inclusion in the meta-analysis. The effective rates for acupuncture, auricular acupressure, and the combination of acupoint injection and acupoint massage were significantly greater in patients with uremic pruritus compared to the control group. The levels of serum BUN, PTH, and histamine levels were significantly lower vs. control group.

CONCLUSIONS

Acupuncture, auricular acupressure, and the combination of acupoint injection and acupoint massage seem to be effective in improving uremic pruritus in patients with chronic kidney disease. However, further investigation of these potential treatments is now warranted in larger patient populations and over a longer time frame.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022354585, identifier: PROSPERO CRD42022354585.

Cholestatic pruritus: a knowledge update

This review is focused on updating knowledge about cholestatic pruritus. It summarizes clinical-epidemiological characteristics, pathophysiology, diagnostic approach, and evidence-based therapeutic recommendations regarding this form of pruritus. Pruritus is a frequent symptom that accompanies several liver diseases, particularly cholestatic ones. The symptom may be mild and tolerable, but it can also dramatically reduce the quality of life. Although the exact pathophysiology of this form of pruritus remains unclear, current evidence supports a mixed origin. It is extremely important for dermatologists to have knowledge about cholestatic pruritus since they are usually the first physicians to be sought by the patient when they experience the symptom. In the absence of specific dermatological alterations, cholestasis must always be considered as a possible cause of pruritus. In addition to allowing an adequate diagnosis, a better pathophysiological understanding of hepatic pruritus provides the identification of new therapeutic targets and, consequently, optimization of the approach in patients with this condition.

Chronic itch induced by thalamic deep brain stimulation: a case for a central itch centre

Background

Central itch syndrome has been previously described in conditions such as stroke. The neurophysiology of central itch syndrome has been investigated in non-human primates but remains incompletely understood.

Methods

We report an observational study of a rare case of severe central itch following thalamic deep brain stimulation and postulate the location of the central itch centre in humans.

Results

The patient was a 47-year-old female, with congenital spinal malformations, multiple previous corrective spinal surgeries and a 30-year history of refractory neuropathic pain in her back and inferior limbs. Following multidisciplinary pain assessment and recommendation, she was referred for spinal cord stimulation, but the procedure failed technically due to scarring related to her multiple previous spinal surgeries. She was therefore referred to our centre and underwent bilateral deep brain stimulation (DBS) of the ventral posterolateral nucleus of the thalamus for management of her chronic pain. Four weeks after switching on the stimulation, the patient reported significant improvement in her pain but developed a full body progressive itch which was then complicated with a rash. Common causes of skin eczema were ruled out by multiple formal dermatological evaluation. A trial of unilateral “off stimulation” was performed showing improvement of the itchy rash. Standard and normalized brain atlases were used to localize the active stimulating contact within the thalamus at a location we postulate as the central itch centre.

Conclusions

Precise stereotactic imaging points to the lateral portion of the ventral posterolateral and posteroinferior nuclei of the thalamus as critical in the neurophysiology of itch in humans.

Effects of Uremic Clearance Granules in Uremic Pruritus: A Meta-Analysis

Uremic pruritus is common among patients with advanced or end-stage renal disease, with an incidence of >40% among patients on dialysis. Uremic clearance granules (UCGs) are effective in managing uremic pruritus and delay the progression of chronic kidney disease. We conducted a systematic review and a meta-analysis to evaluate the efficacy of UCG in patients with uremic pruritus. Several electronic databases were searched systematically from their inceptions until 19 July 2021. Randomized control trials evaluating the efficacy of UCG in patients with uremic pruritus were selected. Eleven trials including 894 participants were published between 2011 and 2021. Patients administered UCGs had a significantly decreased visual analog scale score (mean difference [MD], -2.02; 95% confidence interval [CI], -2.17 to -1.88), serum levels of hsCRP (MD, -2.07 mg/dL; 95% CI, -2.89 to -1.25; p < 0.00001), TNF-α (MD, -15.23 mg/L; 95% CI, -20.00 to -10.47; p < 0.00001]), β2-MG (MD, -10.18 mg/L; 95% CI, -15.43 to -4.93; p < 0.00001), and IL-6 (MD, -6.13 mg/L; 95% CI, -7.42 to -4.84; p < 0.00001). In addition, UCGs significantly reduced serum levels of creatinine, BUN, PTH, iPTH, phosphorus, and the overall effectiveness rate. UCGs could be an attractive complementary therapy for patients with uremic pruritus.

Safety and immunogenicity of a plant-derived rotavirus-like particle vaccine in adults, toddlers and infants

BACKGROUND

This study is the first clinical trial for a parenteral non-replicating rotavirus vaccine developed using virus-like particle (VLP) technology.

METHODS

This open-labeled, randomized, placebo-controlled trial was conducted in two parts: Part A (a first-in-human study in Australian adults) and Part B (ascending dose and descending age in South African adults, toddlers and infants). In Part A, two cohorts of 10 adults were assigned to receive a single intramuscular injection of 1 of 2 escalating dose levels of the rotavirus VLP (Ro-VLP) vaccine (7 μg or 21 μg) or placebo. In Part B, one cohort of 10 adults was assigned to receive a single injection of the Ro-VLP vaccine (21 μg) or placebo, two cohorts of 10 toddlers were assigned to receive 2 injections of 1 of 2 escalating dose levels of the Ro-VLP vaccine (7 μg or 21 μg) or placebo 28 days apart, and three cohorts of 20 infants were assigned to receive 3 injections of 1 of 3 escalating dose levels of the Ro-VLP vaccine (2.5 μg, 7 μg or 21 μg) or placebo or 2 doses of oral Rotarix 28 days apart. Safety, reactogenicity and immunogenicity were assessed.

RESULTS

There were no safety or tolerability concerns after administration of the Ro-VLP vaccine. The Ro-VLP vaccine induced an anti-G1P[8] IgG response in infants 4 weeks after the second and third doses. Neutralizing antibody responses against homologous G1P[8] rotavirus were higher in all Ro-VLP infant groups than in the placebo group 4 weeks after the third dose. No heterotypic immunity was elicited by the Ro-VLP vaccine.

CONCLUSIONS

The Ro-VLP vaccine was well tolerated and induced a homotypic immune response in infants, suggesting that this technology platform is a favorable approach for a parenteral non-replicating rotavirus vaccine.

CLINICAL TRIAL REGISTRATION

NCT03507738.

Differential Diagnosis and Treatment of Itching in Children and Adolescents

Itching is prevalent in children with skin disorders and associated with effects on their mood, quality of life, and social functioning. Surprisingly, there are no data on childhood prevalence of pruritus in the general population. The aim of this article is to explore the epidemiology, clinical manifestation, and treatment for itch (pruritus) in the pediatric population (from infancy to adolescence), and to be helpful to primary care physicians who assess and diagnose pediatric patients with itching. In this study, we searched for specific keywords using PubMed and MEDLINE (Ovid) and, then, refined the retrieved searches for each cause and treatment. As a result of reviewing the literature, atopic dermatitis was shown to be the most common cause of itching, especially during infancy and through preschool. Not only skin disorders but also systemic diseases, drugs, and postburn states can predispose an individual to itching in childhood. There are traditional and newly developed treatment modalities for itching in pediatric patients. However, because the pharmacokinetics and pharmacodynamics of childhood are different from those of adults, the medications for itching have to be applied carefully for these age groups. There are many areas to be elucidated regarding the prevalence and objective assessment of pruritus in pediatric patients. Moreover, the safety profiles of medications in the pediatric population need to be better understood. Further studies to investigate itching in childhood are warranted.

Measurement properties of patient-reported outcome measures for pruritus: An updated systematic review

This systematic review aims to provide an update on measurement properties of patient-reported outcome measures for pruritus. A Medline literature search was conducted to update the systematic review published by Schoch et al. in 2017 and to identify new validation studies published between October 2015 and July 2019. The methodological quality of validation studies was assessed based on the COnsensus-based Standards for the selection of health status Measurement INstruments (COSMIN) checklist and the measurement properties of patient-reported outcome measures were evaluated. Nineteen new studies were included and added to the 22 studies identified in the previously published review. Evidence from all 41 studies evaluating 38 different measures was summarized. Outcome measures were mapped to one of three constructs where possible: pruritus intensity, pruritus severity, pruritus-specific health-related quality of life. COSMIN rating revealed mixed results with deficiencies in methodological quality of many studies across all constructs. The most appropriate pruritus severity measure was the "Itch Severity Scale". "Itchy Quality of Life" and the disease-specific "Uremic Pruritus in Dialysis Scale" achieved most promising results considering the construct pruritus-specific health-related quality of life. For pruritus intensity, nine measures performed similarly well.

The pruritus severity scale-a novel tool to assess itch in burns patients

BACKGROUND

Pruritus assessment is difficult due to the varying subjective nature of the experience. There have been several validated tools described to quantify the severity of itch, however these tools fail to provide a comprehensive assessment or are too cumbersome and therefore lack usability. Our novel burn assessment tool, "The Pruritus Severity Scale" (PSS) allows for accurate quantification of itch components. The aim of this study was to assess its use in the burns population.

METHODS

A prospective observational study was conducted on all patients over five years of age with a burn injury over a six month period. Patients underwent subjective evaluation of their itch as determined by two validated scores, the Visual Analogue Scale (VAS) and the Itch Man scale (IMS) and in addition to the PSS. The pruritus severity scale was correlated with the previously validated scoring methods using bi-variate correlations.

RESULTS

Twenty-two patients were included in the study. The most common cause of injury was due to flame burn. The mean total body surface area was 6.5% (range: 1-26%). Both the IMS and the VAS positively correlated well with the PSS. The Spearman Coefficient for the PSS vs IMS was 0.81, R² = 0.65 (P<0.05). The Spearman Coefficient for the PSS vs VAS was 0.87 (R² = 0.76 (P<0.01)). There is a positive linear relationship between our novel scoring methods and the currently validated methods, indicating its validity as a burn assessment too.

CONCLUSION

The Pruritus Severity Scale was shown to be an accurate, objective tool that was able to effectively record the patient's experience of itch. We believe that this novel score is quick, easy to use and allows for more comprehensive assessment than other short assessment tools.

Development and preliminary validation of the patient-reported Chronic Itch Burden Scale assessing health-related quality of life in chronic pruritus

BACKGROUND

Chronic pruritus (CP) significantly affects patients' health-related quality of life (HRQoL). Very few self-reported HRQoL questionnaires exploring CP have been developed according to international guidelines, thus limiting their use in preauthorization trials.

OBJECTIVES

To develop a self-reported HRQoL questionnaire in patients with CP owing to psoriasis, atopic dermatitis, seborrhoeic dermatitis of the scalp or idiopathic dermatitis, and to explore the preliminary psychometric properties of the questionnaire.

METHODS

The study was performed in France. A conceptual framework was developed based on a structured literature review and expert insight, and was improved using three focus groups involving 19 participants. A 50-item questionnaire was created and tested with 21 participants using cognitive debriefings; 11 items were removed. A cross-sectional study including 251 participants was performed to explore the preliminary psychometric properties of the 39-item questionnaire. Dimensionality was explored using principal component analysis. Cronbach's alpha and correlation coefficients (interitem, item-total score and item-dimension score) were measured. The number of items was reduced through expert consensus.

RESULTS

In the 39-item version, three main dimensions were identified (Cronbach's alpha = 0·94) and all correlation coefficients were > 0·34. Upon review, 13 items were deleted owing to poor quality and six items were deleted by the team, generating a 20-item version. The questionnaire's factorial structure was best reflected with a two-dimension solution, i.e. (i) social and emotional repercussions and (ii) relation to others, fear of judgement.

CONCLUSIONS

The Chronic Itch Burden Scale patient-reported questionnaire explores broad aspects of HRQoL that are relevant for patients with various skin diseases. Its good cross-sectional validity makes it useful for trials and practitioners.

Clinical characteristics of itch in cutaneous lupus erythematosus: A prospective, multicenter, multinational, cross-sectional study

OBJECTIVE

Pruritus is an important symptom frequently accompanying various inflammatory skin conditions and some recent data indicated that it may be associated with autoimmune connective tissue diseases. The aim of this study was to assess the frequency and clinical presentation of itch in CLE.

METHODS

A multinational, prospective, cross-sectional study was performed to assess the prevalence, intensity and clinical characteristic of pruritus in various subtypes of CLE. A total of 153 patients with active CLE lesions were included. Their age ranged between 17 and 82 years (mean 49.8 ± 15.4 years), and 115 patients (75.2%) were women. The disease activity and damage were assessed according to the Cutaneous Lupus Erythematosus Disease Area and Severity Index (CLASI). Pruritus severity was assessed with Numeric Rating Scale (NRS) and the 12-Item Pruritus Severity Scale. Dermatology Life Quality Index and EQ-5D questionnaire were used to measure quality of life.

RESULTS

Pruritus was present in 116 (76.8%) of patients of whom half had NRS scoring equal or above 4 points indicating moderate or severe pruritus. Most commonly itch was localized on the scalp, face (excluding ears and nose) and arms (40.5%, 36.2%, 31.9%, respectively). Sensations connected with pruritus were most frequently described as burning, tingling and like ants crawling feeling, but 31.9% patients described it as "pure itch". More than half of patients reported that pruritus was present every day, and it was most frequent during the evenings. The pruritus scoring and the CLASI activity score were significantly correlated (r = 0.42, p = 0.0001), while no correlation was found with the CLASI damage score (p = 0.16). Both the maximum and average itch intensity were correlated with systemic lupus erythematosus (SLE) activity measured with the Systemic Lupus Erythematosus Disease Activity Index.

CONCLUSIONS

Pruritus is a common, but frequently overlooked symptom of CLE. Its intensity correlates with the activity of CLE, but not with the skin damage. In more than a half of patients it occurs on a daily basis. The correlation between the intensity of pruritus and the activity of the skin lesions and the systemic involvement indicate that pruritus could be an individual indicator of both SLE and CLE activity.

Beneficial effects of an alkaline topical treatment in patients with mild atopic dermatitis

BACKGROUND

Atopic dermatitis (AD) is the most common cause of eczema. The skin condition affects millions of people worldwide. Severe cases of AD demand systemic treatment, but most AD cases rely on local therapy with topical corticosteroids, emollients, and moisturizing agents to alleviate eczema. Commonly, derma-cosmetics with a pH around 5.5 are used to treat eczematous lesions (EL). However, evidence is currently amassing that the use of mildly alkaline topical creams is beneficial for AD-related eczema treatment because of its effect on the inflammation in the skin.

AIMS

To test an alkaline two-phase care concept for the treatment of eczema.

PATIENTS/METHODS

An open-label study of 25 patients with eczema associated with mild AD. Patients were treated with Alkaline Build Up Caring Cream INTENSIVE and Alkaline Build Up Caring Cream PLUS+ (both Siriderma^® ) for eight weeks. Dermatological, biochemical, and questionnaire-based examinations were conducted prior to the trial and after its completion.

RESULTS

Topical administration of slightly alkaline creams led to small and statistically insignificant increases of skin pH. Clinical examination at the end of the observation period revealed a significant decrease of total eczematous-affected skin area, a significant decrease in average severity scores of EL, and significant improvements in patient-reported outcome parameters. Blood tests did not reveal any significant changes, except for small but significant increases in IL-8 and monocytes.

CONCLUSION

Mildly alkaline topical creams seem to provide soothing effects on eczema-related skin inflammation and thus might contribute to treatment of local symptoms of eczema in patients with mild AD.

The 12-Item Pruritus Severity Scale - Determining the Severity Bands

Introduction: Assessment of pruritus still remains a challenge due to its subjective character. Various itch questionnaires are widely used to evaluate the severity of pruritus. The aim of the current study was to define the cut off values for the 12-Item Pruritus Severity Scale (12-PSS). Methods: A total of 240 patients (86 males and 154 females) in the age between 19 and 87 years (mean 52.9 ± 20.7 years) suffering from pruritic dermatological conditions were asked to assess their maximal pruritus with the 12-PSS, the Verbal Rating Scale (VRS) and the Numerical Rating Scale (NRS). All subjects also completed the Dermatology Life Quality Index (DLQI). VRS, NRS, and DLQI scorings were used as anchor measures to define cut-offs of 12-PSS. Results: According to VRS, 43 (17.9%) patients suffered from mild, 96 (40%) from moderate, 65 (27.1%) from severe and 36 (15%) from very severe pruritus. Mean 12-PSS scoring for each VRS category was 7.6 ± 3.9, 10.4 ± 3.9, 13.0 ± 3.8, and 13.9 ± 3.8 points, respectively (p < 0.001). Each VRS category significantly differed from the others regarding the mean 12-PSS scoring, except the mean scoring of severe and very severe pruritus (p = 0.72). Thus, three pruritus severity categories of 12-PSS were defined with following score ranges: mild pruritus-3-6 points of 12-PSS, moderate pruritus-7-11 points of 12-PSS and severe pruritus-12-22 points of 12-PSS based on calculation of weighted κ coefficient against VRS, NRS, and DLQI as anchor measures. Conclusions: The 12-PSS is able to differentiate between patients suffering from mild, moderate, and severe pruritus.

A Pilot Randomized, Clinical Trial of the Anti-pruritus Effect of Melatonin in Patients with Chronic Liver Disease

Pruritus is one of the disturbing complications induced by chronic liver disease (CLD), bearing a negative impact on patient quality of life and potentially resulting in early liver transplants. Given the main role of the autotaxin enzyme in pruritus induced by CLD and the suppressive effects of melatonin on the expression of the autotaxin gene, this study was designed to evaluate the antipruritic effect of melatonin in patients with CLD. A double-blind, cross-over, randomized, placebo-controlled pilot trial was conducted on patients with CLD -induced pruritis. Patients were randomly assigned to two groups where they received melatonin 10-mg at night or placebo for 2 weeks. After a 2-week washout period, patients were then crossed over to the other group. The Visual Analog Scale (VAS) and the 12-Item Pruritus Severity Score (12-PSS) were used to assess patient response to therapy as the co-primary outcomes, while liver function tests were assayed too. Forty patients completed the study. The VAS score showed alleviation of 3.21 ± 2.24 (in pruritus) with melatonin (p-value <0.05). The study goal (a reduction of at least 20% in VAS) was achieved in 33 (82%) of study participants. In patients who received melatonin, the 12-PSS and Body Surface Area (BSA) affected by pruritus decreased on average 46.57% and 51.71%, respectively, with mood, sleep pattern and daily activity levels also demonstrating significant improvement (p-value < 0.05). Melatonin was found to be effective for managing pruritus in patients with CLD.

Effect of treating chronic hepatitis C with direct-acting antivirals on extrahepatic cutaneous manifestations

BACKGROUND

Hepatitis C virus (HCV) is a disease with a significant global impact, affecting approximately 2%-2.5% of the world's population. New direct-acting antivirals (DAAs) have been introduced over the past few years with great success in viral eradication. The association of chronic HCV infection with a wide spectrum of cutaneous manifestations has been widely reported in the literature.

AIM

To assess the effect of treating HCV with DAAs on the extrahepatic cutaneous manifestations of HCV.

METHODS

This prospective observational study included 1039 HCV positive Egyptian patients who were eligible to receive DAAs. A total of 30 patients were diagnosed with extrahepatic cutaneous manifestations and fulfilled the inclusion criteria of the study. Of these patients, 6 had classic lichen planus, 8 were diagnosed with psoriasis vulgaris and 16 had pruritus. All patients received DAAs from October 2018 to July 2019 in the form of a three-month course of sofosbuvir/daclatasvir combination. Patients with lichen planus or psoriasis were dermoscopically evaluated before treatment and 6 mo after treatment, while patients with hepatic pruritus were assessed using the 12-Item Pruritus Severity Scale over the same period.

RESULTS

All patients with psoriasis showed significant improvement in all psoriatic plaques, and all patients with hepatic pruritus scored 0 on the 12-Item Pruritus Severity Scale indicating total improvement of pruritus. In addition, four of six patients with lichen planus showed complete improvement.

CONCLUSION

Treatment of HCV with DAAs was significantly effective in improving virus-related extrahepatic cutaneous manifestations.

The application of medical scale in the treatment of plantar warts: analysis and prospect

Plantar warts are common cutaneous diseases on the sole caused by the human papillomavirus, with a high annual incidence rate of 14%. It often causes pain, which impairs quality of life of patients. Numerous therapeutic options for plantar warts exist with variable success. However, all of them, including first-line treatment, have different adverse reactions or high recurrence rates. There is no one effective method for all patients. The choice of treatment method puzzles doctors. With the help of medical scales, we can analyze the patients' condition, so as to guide the choice of treatment methods, which is of great significance for the individualized treatment of patients with plantar warts. This review takes cryotherapy, intralesional injection of bleomycin and photodynamic therapy as examples to discuss the application of medical scales in the treatment of plantar warts, summarizes the scales that can be used to evaluate the status of plantar wart, adverse reactions, prognosis and patient's financial situation, and discusses their clinical and scientific value. We hope to use scales to consider the severity of plantar warts and economic level, help different patients to choose different treatment options, and make suggestions on the evaluation of the adverse reactions and treatment effect.

Predictors of itch and pain in the 12 months following burn injury: results from the Burns Registry of Australia and New Zealand (BRANZ) Long-Term Outcomes Project

Background

Itch and pain are common complaints of patients with burn injuries. This study aimed to describe the prevalence and predictors of itch and moderate to severe pain in the first 12 months following a burn injury, and determine the association between itch, moderate to severe pain, work-related outcomes, and health-related quality of life following a burn injury.

Methods

Burn patients aged 18 years and older were recruited from five Australian specialist burn units. Patients completed the 36-item Short Form Health Survey Version 2 (SF-36 V2), the Sickness Impact Profile (SIP) work scale, and a specially developed questionnaire relating to itch at 1, 6, and 12 months post-injury. Moderate to severe pain was defined as a score less than 40 on the bodily pain domain of the SF-36 V2. Multivariate mixed-effects regression models were used to identify patient and burn injury predictors of itch and moderate to severe pain.

Results

Three hundred and twenty-eight patients were included. The prevalence of itch decreased from 50% at 1 month to 27% at 12 months. Similarly, the prevalence of moderate to severe pain decreased from 23% at 1 month to 13% at 12 months. Compared to patients aged 18-34, the adjusted odds of experiencing any itch were 59% (95% CI: 0.20, 0.82) and 55% (95% CI: 0.22, 0.91) lower for patients aged between 35 and 49 and ≥ 50 years, respectively. Compared to patients aged 18-34, the adjusted odds of experiencing moderate to severe pain were 3.12 (95% CI: 1.35, 7.20) and 3.42 (95% CI: 1.47, 7.93) times higher for patients aged 35-49 and ≥ 50 years, respectively.

Conclusions

Less than 15% of patients reported moderate or severe pain at 12 months, while approximately one-quarter of the patients reported itch at the same period. The presence of moderate to severe pain was associated with a greater negative impact on health-related quality of life and work outcomes compared to itch. Further research is needed to improve our ability to identify patients at higher risk of persistent itch and pain who would benefit from targeted review and intervention studies.

Impacts of low-energy extracorporeal shockwave therapy on pain, pruritus, and health-related quality of life in patients with burn: A randomized placebo-controlled study

BACKGROUND

The management of post-burn pain and pruritus remain a potent challenge because of their bad effects on health-related quality of life (HRQOL). The main purpose of this study was to evaluate the impacts of low-energy extracorporeal shockwave therapy (low-energy ESWT) in the management of pain, pruritus, and HRQOL in patients with burn.

METHODS

Forty-five adult patients with burn, their age ranged from 18 to 55 years, were included in the study, they randomly assigned into 22 patients in the study group (low-energy ESWT) and 23 patients in the placebo group. The study group received low-energy ESWT (0.05-0.20mJ/mm², a frequency of 4Hz with total shocks from 1000 to 2000 shocks) once per week for 4 successive weeks, while the placebo group received ESWT without energy. Both groups received traditional physical therapy program of selective different exercises (respiratory, range of motion, endurance, strengthening, balance, mobilization, stretching, and gait training) 3days per week for 4 weeks. Numerical Rating Scale (NRS) for pain and for pruritus, Pressure Pain Threshold (PPT), 12-Item Pruritus Severity Scale (12-PSS), and Burn Specific Health Scale-Brief (BSHS-B) were measured before and after treatment procedures in both groups.

RESULTS

NRS were decreased significantly in the study group than in the placebo group (P<0.05). PPT, 12-PSS, and BSHS-B scores were improved more significantly in the study group than in the placebo group (P<0.05) while body image and burn associated issues were improved at the same level in both groups (P>0.05).

CONCLUSION

The findings suggest that low-energy ESWT with traditional regular physical therapy may relive post-burn pain and pruritus, and improve HRQOL, particularly in adult patients with burn.