Laurent Misery1,5, Joanna Wallengren2, Elke Weisshaar3, Anna Zalewska4 and French Psychodermatology Group5
1Department of Dermatology, University of Western Brittany, Brest, France, 2Department of Dermatology, University of Lund, Sweden, 3Department of Social Medicine, Allergy and Occupational Dermatology, University of Heidelberg, Germany, 4Department of Dermatology, Medical University of Lodz, Poland, and 5French Society of Dermatology, Paris, France. E-mail: firstname.lastname@example.org
Accepted March 27, 2008.
The demonstration of the role of the brain in the pathogenesis of pruritus confirms that a psychological component could be present in every case of pruritus (1) and that a specific psychogenic pruritus is possible (2). Unfortunately, this diagnosis is too often mislabelled as idiopathic pruritus. In order to try to avoid these misdiagnoses, following consensus meetings the French Psycho Dermatology Group (FPDG) has proposed a definition and 10 diagnostic criteria (3). The FPDG proposed to prefer the words “functional itch disorder” (FID) rather than “psychogenic pruritus” and to define FID as “an itch disorder, where itch is at the centre of the symptomatology, and where psychological factors play an evident role in the triggering intensity, aggravation or persistence of the pruritus”. The 10 diagnostic criteria can be divided into 3 compulsory criteria and 7 optional ones (Table I). For a diagnosis of functional itch disorder, all of the 3 compulsory criteria and at least 3/7 of the optional ones must be met.
Table I. The diagnostic criteria of functional itch disorder (or psychogenic pruritus)
• localized or generalized pruritus sine materia (without primary skin lesion)
• chronic pruritus (> 6 weeks)
• no somatic cause
Optional criteria (3/7 required):
• a chronological relationship of the occurrence of pruritus with one or several life events that could have psychological repercussions
• variations in intensity associated with stress
• nocturnal variations
• predominance during rest or inaction
• associated psychological disorder
• pruritus that could be improved by psychotropic drugs
• pruritus that could be improved by psychotherapies.
With the aim of validating these criteria, the FPDG asked 3 non-French investigators, who are well-known to treat lot of patients with pruritus and who did not participate in FPDG consensus meetings, to use FPDG criteria in cases with a previous diagnosis of psychogenic pruritus. This diagnosis was made by the investigators using their usual diagnostic approach. Questionnaires were completed by investigators, who were selected in Germany, Poland and Sweden.
RESULTS AND DISCUSSION
Thirty-one patients were included in the study: 23 women and 12 men. The mean age was 64.2 years, range 19–85 years. Seventeen patients were from the Swedish centre, 10 from the German centre and 8 from the Polish centre. All patients presented with chronic pruritus (more than 6 weeks). This pruritus was sine materia, i.e. not associated with primary skin lesion, in all cases and was generalized or localized. There was no identified cause in all cases. A chronological relationship of the occurrence of pruritus with one or several life events that could have psychological repercussions was found in 16 cases (46%), variations in intensity associated with stress in 16 cases (46%), nocturnal variations in 24 cases (69%), predominance during rest or inaction in 20 cases (57%). A psychological disorder was associated in 26 cases (74%). Pruritus was improved by psychotropic drugs in 21 cases (60%) and by psychotherapy in 5 cases (14%). In all cases, 3 compulsory criteria were present. Twenty-seven patients out of 35 presented with 3 optional criteria or more out of 7 (3 criteria: 7; 4 criteria: 13; 5 criteria: 4; 6 criteria: 3).
Compulsory criteria appeared well-defined because they were present in all patients. In 8/35 patients (23%), only 1 or 2 optional criteria were found. We propose to classify the diagnosis of FID as doubtful in these cases. In 77%, FPDG criteria allow to confirm this diagnosis. Among optional criteria, nocturnal variations and predominance during rest or inaction appear as very good clinical criteria because they were reported by 69% and 57%, respectively, of patients. An associated psychological disorder was noted by investigators in 73%. Variations according to stress and a chronological relationship of the occurrence of pruritus with one or several life events that could have psychological repercussions were present in only 46%: it could be more difficult spontaneously to spot such a chronology for patients. The effects of treatments do not appear to be discriminant criteria, but they were not used in most cases (especially psychotherapies). They are useful to confirm diagnosis later and to convert a doubtful diagnosis of FID into a definite one.
Hence, FPDG criteria and their repartition between compulsory and optional criteria seem to be adequate and discriminant and their use pertinent and helpful. Further studies are needed to validate these criteria with doctors who are not experts in pruritus, unlike the investigators in this study, or to test these criteria on other causes of pruritus. Definition of similar criteria in other somatoform disorders could be very useful (4).
1. van Os-Medendorp H, Eland-de Kok PCM, Grypdonck M, Bruijnzeel-Koomen CA, Ros WJG. Prevalence and predictors of psychosocial morbidity in patients with chronic pruritic skin. J Eur Acad Dermatol Venereol 2006; 20: 810–817.
2. Paus R, Schmelz M, Biro T, Steinhoff M. Frontiers in pruritus research: scratching the brain for more effective itch therapy. J Clin Invest 2006; 116: 1174–1185.
3. Misery L, Alexandre S, Dutray S, Chastaing M, Consoli SG, Audra H, et al. Functional itch disorder or psychogenic pruritus: suggested diagnosis criteria from the French psychodermatology group. Acta Derm Venereol 2007; 87: 341–344.
4. Misery L. Functional itch disorder or psychogenic pruritus. Expert Rev Dermatol 2008; 3: 49–53.