With Aaron Secrest, MD, PhD
To better understand how itch affects psoriasis patients, Dr. Secrest and colleagues conducted a study with five focus groups and 10 semi-structured interviews asking pointed questions about itch. The study enrolled 25 people diagnosed with at least moderate plaque psoriasis and 11 family members.
“Every dermatologist knows that psoriasis is itchy. But it is hard in a 5- to 10-minute visit to really understand what that actually means in the day-to-day life of the patient in front of you,” said Aaron Secrest, MD, PhD, senior author of “The Disruptiveness of Itchiness from Psoriasis: A Qualitative Study of the Impact of a Single Symptom on Quality of Life – JCAD | The Journal of Clinical and Aesthetic Dermatology” (jcadonline.com) published in the Journal of Clinical and Aesthetic Dermatology.
“At the end of these hour-long focus groups, I was almost in tears sometimes with how awful psoriasis is,” Dr. Secrest said. “I did not appreciate the impact of itch.”
Negative impacts of itch
For example, Dr. Secrest said he did not realize how embarrassed patients felt about needing to scratch.
“It is hard when you are at school or at work and are scratching yourself all the time. You get this feeling of isolation. You have to go to the bathroom or your own office so that you can relieve that itch without the embarrassment of people looking at you or judging you,” he said.
Dr. Secrest also was surprised by how much a loved one’s itchiness impacted families—especially significant others.
“Not only did it disturb the sleep of the person with psoriasis, but their loved one was often awakened in the night by scratching in the bed,” he said. “Itch creates kind of an unspoken tension in these relationships.”
Many of the patients interviewed admitted that the itch impacted intimacy with their partners.
“Even though a lot of the partners interviewed were extremely supportive, sympathetic, and compassionate, the patients themselves said things like, ‘I do not feel cute or sexy when I have a rash and I’m scratching,’” he noted. “There were all these nuanced things that would never come up in a clinic visit, but we as dermatologists need to understand that they are impacting our patients’ daily lives. If we understand that, we can be more empathetic about trying to aggressively treat the itch for our patients.”
Dr. Secrest has changed the way he talks with psoriasis patients about itch.
“Instead of asking them how itchy or how bothersome it is, I assume that it is really itchy and bothersome, and I approach it as something like, ‘This really must stink for you. How often are you being bothered by this in your day?’” he explained.
In some cases, Dr. Secrest uses humor or shock value. For instance, rather than asking if a psoriasis patient drinks alcohol, he asks how much alcohol they drink. “Like a case of beer a day?” he said. “If I throw out something ridiculous, they are much more likely to be honest with me and correct me with the right number.”
Getting good sleep is a big deal, and these patients often do not experience a restful sleep because of the itch.
Dr. Secrest pointedly asks his patients if the itchiness keeps them up all night. Typically, patients respond that they might wake up about one to two times each night.
“That’s important information,” Dr. Secrest said, noting he was also shocked to learn just how far people will go to relieve the itching.
“Several people said that they would take hot, scalding showers because the temporary severe pain would relieve the itching for a few hours, so they could fall asleep,” he said. “We know that scalding hot showers are terrible because they irritate and dry out the skin and make the problem worse.”
Today, Dr. Secrest gives patients the Skindex-16 to fill out in the waiting room.
“In about a minute, the patient can answer 16 questions in the waiting room that I would never be able to ask in the short time frame of a clinic visit,” he said. “It gives me so much information. And plenty of data exists showing that a patient will be much more likely to be honest with a survey on a tablet than with a doctor in a room.”
Dr. Secrest said the patients most likely to fall under the radar with itch are psoriasis patients who are not severe enough to go on biologics. That’s because biologics have done such a great job of treating nearly all aspects of psoriasis, he noted.
“Those are the patients who are probably struggling the most because we give them things like creams and ointments that they may or may not want to do twice a day every day,” he said. “We need to find out more about why they are not doing the things that we are recommending and why they are not getting the relief that we would expect them to be getting.”
By Lisette Hilton
Disclosures: None
REFERENCE
Taliercio VL, Snyder AM, Webber LB, et al. The disruptiveness of itchiness from psoriasis: a qualitative study of the impact of a single symptom on quality of life. J Clin Aesthet Dermatol. 2021;14(6):42-48.