Servando E. Marron1,4, Lucia Tomas-Aragones2,4, Santiago Boira2 and Ricardo Campos-Rodenas3,4

1Department of Dermatology, Alcañiz Hospital, Alcañiz, 2Departments of Psychology and Sociology, University of Zaragoza, 3Department of Psychiatry, “Lozano Blesa” Universitary Hospital of Zaragoza, and 4Aragon Health Sciences Institute, Zaragoza, Spain

A better understanding of the psychosocial impact of chronic itching could lead to improved intervention strategies. The aim of this study is to examine the prevalence and characteristics of chronic itching in dermatological patients. The Itch Severity Scale (ISS) was completed by a sample of 201 patients from a Dermatology Outpatient Clinic in Spain and 61.69% (n = 124) of participants recorded a positive score (mean = 8.89, standard deviation = 4.06). The results indicate that chronic itching has significant psychosocial repercussions. The Dermatology Life Quality Index (DLQI) showed that the negative impact on quality of life was significantly greater for the group that experienced chronic itching (p < 0.001). Scores on the Hospital Anxiety and Depression Scale (HADS) revealed that the group with chronic itching had more symptoms associated with anxiety (p = 0.001). No statistically significant differences between the groups with regards to repercussions on the family dynamic were found. Key words: quality of life; psychosocial impact; family repercussions; chronic itching; skin conditions.

Accepted Oct 29, 2015; Epub ahead of print Nov 2, 2015

Acta Derm Venereol 2015; XX: XX–XX.

Lucía Tomas-Aragones, Department of Psychology, University of Zaragoza, Calle Pedro Cerbuna 12, ES-50009 Zaragoza, Spain. E-mail: ltomas@unizar.es

Itching is a common symptom among the general population. At some point in their lives most people experience some level of discomfort associated with itching. In a population study of healthy adolescents aged 18–19 years, Halvorsen et al. (1) noted the presence of itching in 8.8% of participants and identified statistically significant differences between men (6%) and women (11%).

Chronic itching is also a common symptom in the adult population, reaching percentages of between 13.5% and 16.8% (2, 3). In a study of a group of patients with chronic itching, underlying dermatosis was identified in 41.8% of cases (4). However, epidemiological data on itching is limited.

Weisshaar & Dalgard (5) discussed the difficulties involved in the measurement of the severity of itching. The severity of itching depends on a number of factors, such as age, ethnicity, the inherent characteristics of the health services and the study population. Moreover, the fact that pruritus is a subjective experience must also be taken into account. More research is needed in order to increase the body of knowledge on the perception, characteristics and distribution of itching among dermatology patients. A further complication in the study of itching is the fact that its evaluation may be influenced by sociocultural factors (6) or even a particular moment in the life of the patient (7–9). The results of studies that analyse the prevalence of the problem among both the general population and dermatology patients must therefore be considered in the light of these possible limitations (4, 6, 10).

The International Forum for the Study of Itch (IFSI) (11) defines chronic itching as a disorder that is present for 6 months or more. Some studies have analysed itching and cutaneous conditions (4, 12). Weisshaar et al. (13) found that 57% of patients in their study experienced itching due to dermatosis. Other authors have linked itching with specific cutaneous conditions, such as atopic eczema (14) and psoriasis, in which the incidence of itching is as high as 80% (15). A recent study in a Madrid tertiary hospital, based on a cohort of 861 dermatology patients who attended the accident and emergency service, found that in 38.1% of cases severe itching was the reason given for the need for immediate attention (16).

Another issue is the effect that chronic itching has on the quality of life (QoL) and emotional wellbeing of the individual. With regards to QoL, it seems clear that itching has negative consequences (13, 17). A number of studies have examined the possible relationship between chronic itching and anxiety, depression and other psychopathological problems (10, 18–20). Verhoeven et al. (21) undertook a review of the bio-psychosocial mechanisms of itching, analysing personality traits, stressors and cognitive, behavioural and social mediating factors in patients who experienced chronic itching.

The present paper aims to examine the impact of itching on family relationships and the family dynamic. The specific objectives of this work are: (i) to determine the prevalence and characteristics of itching in a sample of Spanish dermatology patients; (ii) to assess the impact of itching on the QoL of the participants; (iii) to evaluate the emotional wellbeing of the patients; (iv) to explore the consequences of itching on family interaction.

MATERIALS AND METHODS (for complete details see Appendix S11)

Participants

The study population comprised 201 consecutive patients who met the inclusion criteria for participation, presenting between 12 December 2011 and 10 February 2012, at the Dermatology Outpatient Clinic of the Public Health Service Hospital, Alcañiz, Spain.

Study design and hypotheses

The analysis was descriptive, observational and transversal. We advanced 3 hypotheses: (i) patients with chronic itching would show more symptoms of anxiety-depression than patients who did not experience pruritus; (ii) the QoL of the study population (patients with a dermatological condition and chronic itching) would be worse than that of the control group (patients with a dermatological condition but no itching); (iii) patients with chronic itching experience deterioration in their family relationships, in comparison with patients who do not experience pruritus.

Assessment instruments

The Hospital Anxiety and Depression Scale (HADS) (22); Itch Severity Scale (ISS) (26); Dermatology Life Quality Index (DLQI) (28); and Family APGAR (Adaptability, Partnership, Growth, Affection, and Resolve) (31) (N.B.: not to be confused with Apgar score in newborns.)

RESULTS

Clinical characteristics

Of the participants, 61.69% (n = 124) had a positive score on the ISS scale (Group X1) and 38.31% (n = 77) experienced no itching (control group X2). The mean age was 44.55 years (range 18–77 years) (X1 = 45.41; X2 = 43.16 years). The main sociodemographic characteristics and the distribution of the skin diseases are shown in Table SI1.

No statistically significant differences were identified with regards to the sociodemographic variables of the 2 groups, they were therefore comparable. In the “itch” group (X1), statistically significant differences were identified with regards to the distribution of skin diseases. The percentage of itch in each of skin diseases is as follows: eczema (100%), hand eczema (100%), psoriasis (82.69%), atopic eczema (81.82%), infectious skin (78.57%), non-melanoma skin cancer (58.33%), alopecia (56.25%), benign skin tumours (42.46%), naevus (73.62%) and acne (28.57%). Fig. 1 shows the frequency distribution of the total ISS scores.

Fig. 1. Distribution of frequency of the Itch Severity Scale (ISS) (range 1–17).

Table I gives the results for each of the items of the Itch Severity Scale (ISS) for the “itch” group (X1). With the exception of item ISS4-Intensity (p = 0.042), there were no statistically significant differences between men and women. In item ISS4, the mean intensity perceived by men (0.65) was higher than that perceived by women ( 0.51).

Finally, Fig. 2 indicates the body areas affected (in percentages) by itching for both men and women (the head, neck, torso, arms, legs).

Fig. 2. Distribution of the affected body areas (%) according to the Itch Severity Scale (ISS) in men and woman.

Psychological data

The main results of the HADS can be seen in Table II. There were statistically significant differences for the Emotional Wellbeing scale (p = 0.001) and the Anxiety subscale (p = 0.001), but this was not the case with the Depression subscale.

Quality of life and Family APGAR

The results of the Dermatology Life Quality Index (DLQI) showed statistically significant differences be­tween the study group (X1) and the control group (X2). The differences were observed both in the items on the scale and in the total score (X1=4.48; X2 = 0.56) (p < 0.001). The mean values obtained from the Family APGAR revealed no statistically significant differences between the groups (X1 = 8.38; X2 = 8.80) or between any of the items on the scale. The results are shown in Table III.

DISCUSSION

The skin plays a vital role in the human socialization process; it responds to emotional stimuli and its appearance has a fundamental influence on an individual’s body image and self-esteem (33).

It is often the case that cutaneous disorders are provoked, maintained or aggravated as a consequence of factors related to psychological processes (34–36). Given that itching is a common symptom in dermatology patients, the study of its psychosocial repercussions is of significant importance. Research on the issues involved could lead to improvement in treatment and to a better understanding of how the patient feels and copes (37–40).

This work has examined the characteristics of pruritus in a sample of Spanish dermatology patients in an attempt to estimate the prevalence of the condition. Furthermore, this study explored the impact of itching on QoL, anxiety and/or depression and its effect on family functioning. Previous studies have considered the relationship between itching and QoL (29, 30) and anxiety/depression (24, 25), but we have been unable to find any references to studies that deal with the effect of chronic itching on family life and affectivity.

In the study group (X1, “itch”), 57.26% were women; this figure is similar to previous studies (2–4) and slightly higher than the original ISS validation study (26). The mean age was 44.55 years, which is lower than that in the study by Mazeh et al. (18) with psychiatric patients, in which the mean age was 48 years. The educational level was lower than the sample used by Mazeh et al. (18) and Majeski et al. (26), in which the proportion of participants with university studies was 47% and 54%, respectively. This may be explained by the fact that our sample was drawn from a hospital located in a primarily rural environment. In our study, the number of participants who were married was higher than in a number of other works, for example, Mazeh et al. (18), although broadly similar to the figure reported by Majeski et al. (26).

Of the sample, 61.69% experienced itching, a result that was similar to the findings of Weisshaar et al. (13) and Gupta et al. (41), higher than figures published by Verhoeven et al. (12) in a primary care study, and lower than that of Szepietowski et al. (15) for a sample of patients with psoriasis.

The mean ISS results (8.89, standard deviation (SD) 4.06), were in line with those of other studies, although lower than those published by Zachariae et al. (17) (mean 9.7; SD 3.9). The explanation for this may reside in the sample composition; the aforementioned work included 5 pathologies (psoriasis, atopic dermatitis, chronic urticaria, genital itch, uraemic pruritus) that commonly involve intense and persistent itching. The mean ISS results obtained by Majeski et al. (26) (7.4 ± 3.6) were lower than ours. As Weisshaar & Dalgard (5) and Dalgard et al. (6) commented, the comparison of results in this field must be approached with caution as they may be conditioned by the sociodemographic characteristics of the participants and the community in which the study is undertaken.

Four of the scores for the 7 main components of the ISS were similar to results obtained by Zachariae et al. (17); in our study the scores for the 2 components (mood and effect on sexuality) were lower, and the last (affected area) were higher.

The most common body locations for pruritus in men were the head (29.9%) and the legs (28.7%), and for women the torso (27.6%) and head (25%). These results are lower than those of Szepietowsky et al. (15): head (35%); torso (49.7%); arms 50%); and legs (48.7%). Ferm et al. (19) evaluated itching in patients with systematic illnesses, psychiatric disorders and patients experiencing pruritus of unknown origin, and reported that 16.7% of psychiatric patients and 10.01% of non-psychiatric patients indicated that the head was the main area of itching.

Our first hypothesis (that patients with chronic itching would show more symptoms of anxiety-depression than those who did not experience pruritus) was proven with regards to Anxiety (p < 0.001) and the overall score for Emotional Wellbeing (p = 0.001), but not for Depression. In a sample of patients with chronic urticaria, Staubach et al. (42), found that 30% revealed symptoms of anxiety and 17% had symptoms of depression (measured using the HADS). The same authors further noted a significant increase in emotional distress. Pujol et al. (43) also used HADS with a sample of 64 patients with psoriasis and obtained differing scores for anxiety (mean 7.85; SD 4.54) and depression (mean 4.72; SD 4.12).

The second hypothesis (that the QoL of the study population would be worse than that of the control group) was proved. There was a statistically significant relationship between itching and quality of life (DLQI) (X1 = 4.48; X2 = 0.56). Susel et al. (44) reported a mean of 3.6 ± 3.4, in patients with uraemic pruritus, whilst Sanchez-Perez et al. (45) obtained mean DLQI scores of 7.8 ± 5.3 in a sample of 172 Spanish psoriasis patients. In the latter study, given that the sample only comprised patients with psoriasis (mainly moderate to severe) it is logical that the scores were rather higher than those for our population.

The final hypothesis (that patients with chronic itching experience a deterioration in their family relationships, in comparison with patients who do not have pruritus) was not proved. This could in part be due to the instrument used to measure family dysfunction, the Family APGAR. Psychosomatic patients have difficulties in being disloyal to their family; this includes describing their families as unloving or admitting they have problems. On the contrary, there is often the need to protect the family cohesion and tend to describe their family as ideal (46). The Family APGAR is thus not the most suitable test to use in this context and qualitative methods, such as the genogram, should be considered.

However, the impact of chronic illness on the family dynamic and QoL is an emerging issue of medical research interest that has been explored by a few recent studies (46–49).

The main limitation of our study was the difficulty involved in evaluating family life through a self-administered questionnaire.

There was further complication that the surveys were completed in the hospital waiting room, often in the presence of a family member, which may have influenced the responses. Future research should ensure greater privacy and consider the use of qualitative methods to complement the self-administered scales.

Although this work failed to verify the impact of itching on family function, it clearly establishes that the condition has significant psychosocial repercussions on QoL, levels of anxiety and the emotional wellbeing of the patients.

1http://www.medicaljournals.se/acta/content/?doi=10.2340/00015555-2263

REFERENCES