Relationship between anger and pruritus perception in patients with chronic idiopathic urticaria and psoriasis

Background  There is evidence that chronic idiopathic urticaria (CIU) and psoriasis are associated with personality based difficulties in emotional regulation particularly with regard to the feeling of anger. This deficit in emotional awareness could lead to the phenomenon that emotions are rather experienced in bodily symptoms such as pruritus.
Aim  We investigated whether there is a relationship between pruritus as major symptoms in CIU and psoriasis and the experience of negative emotions.
Setting  Forty-one CIU patients and 44 psoriasis patients treated at Bonn University Hospital and 49 healthy controls were included.
Method  Patients and controls were compared on questionnaires measuring alexithymia (TAS-20), emotional distress (SCL-90-R) and anger (STAXI). In skin-disordered patients, separate stepwise regressions with pruritus severity as dependent variable and questionnaires, skin status, duration, sex and age as independent variables were calculated.
Results  CIU and psoriasis patients showed higher alexithymia, emotional distress, depression, anxiety and state anger compared with controls. State anger was the only significant predictor of pruritus severity in CIU explaining 19% of variance. Depression was the only significant predictor of pruritus severity in psoriasis explaining 12% of variance.
Conclusions  Our findings suggest a relationship between pruritus severity and anger in CIU. Furthermore, our results indicate a relationship between pruritus severity and depression in psoriasis.     

Streptococcal throat infections and exacerbation of chronic plaque psoriasis: a prospective study

BACKGROUND: Guttate psoriasis has a well-known association with streptococcal throat infections but the effects of these infections in patients with chronic psoriasis remains to be evaluated in a prospective study. OBJECTIVES: To determine whether streptococcal throat infections are more common in and can cause exacerbation in patients with chronic psoriasis. METHODS: Two hundred and eight patients with chronic plaque psoriasis and 116 unrelated age-matched household controls were followed for 1 year. At recruitment all patients were examined, their disease severity scored and throat swabs taken. Patients and corresponding controls were then re-examined and tested for streptococcal colonization whenever they reported sore throat or exacerbation of their psoriasis during the study period. RESULTS: The psoriasis patients reported sore throat significantly more often than controls (61 of 208 vs. three of 116, P < 0.0001), and beta-haemolytic streptococci of Lancefield groups A, C and G (M protein-positive streptococci) were more often cultured from the patients than the controls (19 of 208 vs. one of 116, P = 0.003). A significant exacerbation of psoriasis (P = 0.004) was observed only if streptococci were isolated and the patients were assessed 4 days or later after the onset of sore throat. No difference was observed between groups A, C or G streptococci in this respect. CONCLUSIONS: This study confirms anecdotal and retrospective reports that streptococcal throat infections can cause exacerbation of chronic plaque psoriasis. It is concluded that psoriasis patients should be encouraged to report sore throat to their physician and that early treatment of streptococcal throat infections might be beneficial in psoriasis. A controlled trial for assessing potential benefits of tonsillectomy in patients with severe psoriasis should also be considered.     

Itch Severity Scale: a self-report instrument for the measurement of pruritus severity

Background Assessing pruritus severity is difficult because of its subjective nature. A questionnaire that takes into account how the symptom is perceived by the patient may provide a more accurate representation of the pruritus. However, recently developed questionnaires do not specifically quantify severity of the symptom. Objectives To develop a self‐report questionnaire to measure pruritus severity and to provide initial evidence of its validity and reliability. Methods We modified a previously developed interview for the characterization and evaluation of pruritus, which was completed along with the RAND‐36 Health Status Inventory and Dermatology Life Quality Index by patients with psoriasis‐associated pruritus. Exploratory factor analysis, studies of internal consistency, and correlation analyses with health‐related quality of life scores were used to help determine which components of the modified pruritus interview to include in the new questionnaire, the Itch Severity Scale (ISS). The ISS was then assessed for construct validity, internal consistency reliability and test–retest reliability. Results Seven of the initial 11 components of the modified pruritus interview were included in the ISS. ISS scores correlated moderately with physical (r = −0·483) and mental (r = −0·492) health composite scores of the RAND‐36 and strongly with Dermatology Life Quality Index scores (r = 0·628), evidence of construct validity. It had an internal consistency reliability of 0·80 and a test–retest reliability of 0·95. Conclusions Based on this preliminary evidence of validity and reliability, this new seven‐item ISS may be useful in comparing pruritus severity among different disease populations or in assessing pruritus treatment effectiveness.     

Vitiligo in a patient receiving infliximab for chronic plaque psoriasis

Infliximab is a tumor necrosis factor‐alpha (TNF‐a) inhibitor widely used in the treatment of moderate to severe chronic plaque psoriasis. Here, we report a case of vitiligo following infliximab administration in a patient with chronic plaque psoriasis. The case serves as a reminder of vitiligo induced by TNF‐a‐antagonist therapy.     

Comparison of calcipotriol and coal tar in conjunction with sun exposure in chronic plaque psoriasis: a pilot study

This study was a left-right comparison of the efficacy of 0.005% calcipotriol ointment and 5% coal tar ointment in conjunction with sun exposure in 10 patients with stable plaque psoriasis. After four weeks of therapy, the calcipotriol treated site showed a significantly faster fall in PASI compared to the coal tar treated site. At eight weeks, this difference was not significant with both sides showing comparable improvement in lesions, as shown by PASI values. There were no significant side effects from either therapy. We conclude that both calcipotriol and coal tar ointments have comparable efficacy in treating stable plaque psoriasis when used simultaneously with sun exposure, although the initial response to calcipotriol is faster.     

Treatment of severe,recalcitrant, chronic plaque psoriasis with fumaric acid esters: a prospective study

Background Fumaric acid esters (FAE) are used in Germany as a first‐line systemic treatment for chronic plaque psoriasis, with proven efficacy and low toxicity. Their use in the U.K. is variable, and they remain unlicensed. Consequently, efficacy and safety data from U.K. patients is limited and their place in the psoriasis treatment armamentarium is unclear. Objectives To examine the efficacy and safety of FAE in a prospective cohort of U.K. patients with severe, treatment‐recalcitrant, chronic plaque psoriasis. Methods A single‐centre, open, nonrandomized, prospective study was performed in a regional referral centre for patients with severe psoriasis. Outcomes were measured by the Psoriasis Area and Severity Index (PASI), Dermatology Life Quality Index (DLQI), blood investigations and adverse events monitoring. Results Eighty patients were recruited. Fifty‐nine per cent were taking a concomitant oral antipsoriatic agent; 20% achieved a PASI‐50, 8% a PASI‐75 and 4% a PASI‐90 on intention‐to‐treat analysis at 3 months with an overall, statistically significant, reduction in PASI from 13·9 ± 9·0 to 11·3 ± 9·2 (P < 0·0001). At 3 months, lymphopenia was seen in 33% of the cohort with significantly lower counts in patients responsive to FAE (P = 0·008). In addition, by 3 months, 36% of concomitant antipsoriatic medication had been stopped and 25% of doses had been reduced without loss of disease control. Side‐effects (most commonly diarrhoea, abdominal pain and flushing) were reported by 74% of patients resulting in cessation of FAE in 36%. Conclusions FAE is a useful alternative treatment option in patients with severe, treatment‐resistant, chronic plaque psoriasis and can allow dose reduction, and subsequent cessation, of other, potentially more toxic agents.     

表现为持续性瘙痒性斑块的成人Still病一例

患者,女,58岁。全身持续性瘙痒性斑块伴发热20天。血清铁蛋白增高,血常规白细胞、中性粒细胞升高,肝功能异常,脾大。皮损组织病理示：棘层中上部见角化不良细胞,真皮浅层血管周围见淋巴细胞和嗜酸粒细胞浸润。诊断：成人Still病。予糖皮质激素及甲氨蝶呤治疗,病情好转。     

改良PUVA疗法治疗慢性斑块性银屑病疗效分析

目的：探索用改良PUVA疗法治疗慢性斑块性银屑病的疗效和安全性。方法：67例寻常型银屑病患者口服8-MOP0．6mg/kg后照射UVA和UVB，每周3次，共治疗8周，用PASI积分评价疗效，并记录不良反应。结果：治疗开始2-4周后出现疗效，随着治疗时间的延长，PASI总积分逐渐下降，有效率逐渐提高，在治疗结束时痊愈率达到96．5％，有效率达100％。27例患者(40．3％)出现不良反应，绝大多数为轻度，没有因不良反应停止治疗的病例。结论：改良PUVA疗法治疗慢性斑块性银屑病具有良好疗效和安全性。     

Sequential study on the treatment of moderate-to-severe chronic plaque psoriasis with mycophenolate mofetil and cyclosporin

BACKGROUND: There are numerous studies that individually evaluate the efficacy/effectiveness and toxicity of drugs in the systemic treatment of psoriasis. On the contrary, we can hardly find studies that compare each other. OBJECTIVE: To evaluate and compare the effectiveness and toxicity of mycophenolate mofetil and cyclosporin in chronic plaque psoriasis through a prospective, sequential, cross-over, non-randomized, two-phase, open-label study. PATIENTS/METHODS: Eight patients (five women and three men; mean age 57, range 35-78) with moderate-to-severe chronic plaque psoriasis were included in the study. They were treated with oral mycophenolate mofetil (30 mg/kg/day) over a period of 16 weeks. Following a variable washout period and after a new outbreak of the disease, oral cyclosporin was introduced at a dose of 4 mg/kg/day. During both treatment regimens, follow-up visits were performed at 3, 8 and 16 weeks. RESULTS: In both groups, the PASI started to decrease once treatment was begun. Cyclosporin was faster and statistically a lot more effective than mycophenolate mofetil, reaching a higher number of complete remissions and better percentages of PASI improvement from baseline (45.7%, 60.2% and 60.5% at 3, 8 and 16 weeks respectively for mycophenolate mofetil, and 89.7%, 95.3% and 95.3% respectively at the same intervals for cyclosporin). Cyclosporin was also more predictable in its action as the percentage of improvement along the follow-up visits had a much wider range for mycophenolate mofetil. Overall, the tolerability of both drugs was good. None of the patients had to discontinue treatment because of an adverse event. Two patients treated with cyclosporin showed increased plasma levels of creatinine. CONCLUSIONS: Cyclosporin is more effective, fast, and predictable in its effect than mycophenolate mofetil to control moderate-to-severe chronic plaque psoriasis. Both drugs are well tolerated in short courses of treatment.     

A systematic review of antistreptococcal interventions for guttate and chronic plaque psoriasis

BACKGROUND: Guttate psoriasis is closely associated with preceding or concurrent streptococcal infection. Some authorities have claimed that chronic plaque psoriasis may also be made worse by infection. In view of this many dermatologists have recommended using antibiotics for psoriasis, particularly guttate type. Some dermatologists have also recommended tonsillectomy for psoriasis in patients with recurrent streptococcal pharyngitis. OBJECTIVES: This review aims to assess the evidence for the effectiveness of antistreptococcal interventions, including antibiotics and tonsillectomy in the management of acute guttate and chronic plaque psoriasis. METHODS: Studies were identified by searching the Cochrane Clinical Trials Register (Cochrane Library, Issue 3, 1999), Medline (1966-September 1999), Embase (1988-September 1999), the Salford Database of Psoriasis Trials (to November 1999) and the European Dermato-Epidemiology Network (EDEN) Psoriasis Trials Database (to November 1999) for terms (STREPTOCOCC* or ANTIBIOTIC* or TONSIL*) and PSORIASIS using the Cochrane Skin Group search strategy. RESULTS: Only one trial met the selection criteria. This compared the use of two oral antibiotic schedules in 20 psoriasis patients, predominantly of guttate type, who had evidence of beta-haemolytic streptococcal colonization. Either rifampicin or placebo was added to the end of a standard course of phenoxymethylpenicillin or erythromycin. No patient in either arm of the study improved during the observation period. No randomized trials of tonsillectomy for psoriasis were identified. CONCLUSIONS: Although both antibiotics and tonsillectomy have frequently been advocated both for patients with guttate psoriasis and for selected patients with chronic plaque psoriasis, there is to date no good evidence that either intervention is beneficial.     

The 5‐D itch scale: a new measure of pruritus

Background Itching is a subjective and multidimensional experience which is difficult to quantify. Most methodologies to assess itching suffer from being unidimensional, for example only measuring intensity without impact on quality of life, or only measuring scratching activity. None has actually been demonstrated to be able to detect change over time, which is essential to using them as an outcome measure of response to an intervention. The 5‐D itch scale was developed as a brief but multidimensional questionnaire designed to be useful as an outcome measure in clinical trials. The five dimensions are degree, duration, direction, disability and distribution. Objectives To study the 5‐D with respect to validity, reliability and response to change. Methods The 5‐D was administered to 234 individuals with chronic pruritus due to liver disease (n = 63), kidney disease (n = 36), dermatological disorders (n = 56), HIV/AIDS (n = 28) and burn injuries (n = 51). The 5‐D was administered at baseline and after a 6‐week follow‐up period. A subset of 50 untreated patients was retested after 3 days to assess test–retest reliability. Results The 5‐D score correlated strongly with a visual analogue score: r = 0·727 at baseline (P < 0·0001), r = 0·868 at the 3‐day repeat (P < 0·0001), and r = 0·892 at the 6‐week follow‐up (P < 0·0001). There was no change in mean 5‐D score between day 1 and day 3 in untreated individuals (intraclass correlation coefficient = 0·96, P < 0·0001). The 5‐D did, however, detect significant changes in pruritus over the 6‐week follow‐up period (P < 0·0001). Subanalysis of the different patient groups revealed similar response patterns and scores, with the exception of lower total scores for the burn victims due to lower scores on the distribution domain because they itched only at the site of their burn. Conclusions The 5‐D, therefore, is a reliable, multidimensional measure of itching that has been validated in patients with chronic pruritus to able to detect changes over time. The 5‐D should be useful as an outcome measure in clinical trials.     

Matrix stimulation in chronic pruritus: A randomized controlled study

Chronic pruritus is one of the main symptoms in dermatology. We investigated a new intervention for chronic pruritus by neurostimulation through matrix electrodes. In this randomized controlled trial, 29 patients with chronic pruritus caused by a variety of dermatological diseases were allocated to an experimental group (EG; n = 14, 4-Hz neurostimulation of the itching area through matrix electrodes) or the control group (CG; n = 15, placement of matrix electrodes without neurostimulation). Outcome measures were the itching sensation as measured by a Numerical Rating Scale immediately after the intervention and the intermediate effect measured by the average itching sensation on the day before the intervention compared with the average itching sensation on day 1, 2 and 3 after the intervention. Regarding the short-term effect on itching, the anova showed a significant interaction effect for the 5-min stimulation with a larger reduction in the EG with a large effect size of d = 1.10. The average reduction in itching intensity was 78.2% for the EG compared with 34.3% for the CG. For the intermediate effect, no significant interaction was found (F = 1.721, P = 0.199). Comparing the itching sensation at day 0 with day 3, the interaction effect showed a statistical trend toward a greater reduction in the EG (F = 3.178, P = 0.086; statistical trend, d = 0.69). This study proved that neurostimulation through matrix electrodes is effective in the short-term reduction of itching in patients with chronic pruritus caused by dermatological diseases. Additional studies are needed with larger patient pools and covering longer study periods.     

Focus groups in Swedish psoriatic patients with pruritus

Pruritus is a common complaint among patients of psoriasis vulgaris of the chronic plaque type. Despite a high prevalence of pruritus in psoriasis, limited information is available on this subject. The aim was to assess patients' perspective of pruritus in psoriasis vulgaris of plaque type, by using focus groups. A total of 20 patients with chronic plaque psoriasis participated in focus group discussions and were divided into five groups, on different occasions. Themes for the discussion were introduced and moderated by the investigators. The focus groups created a proper atmosphere for discussion on different aspects of pruritus in psoriasis. The patients regarded themselves able to discriminate between pruritus and pain. Pruritus was most common on the lower back and legs. Stress, cold weather and skin dryness were seen as the most common worsening factors for pruritus. Sunbathing and application of emollients with or without steroids and calcipotriol cream were suggested as factors that relieved pruritus. Quality of life was affected in some patients, for instance they were reluctant to participate in social activities. Patients' perspectives on pruritus in psoriasis were important for a better understanding of this sensation. The information collected from the focus group discussions might be useful for further study in this area.