Scratching provides high pleasure for patients with chronic spontaneous urticaria
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Key takeaways:
- Average scratch pleasurability was 2.97 ± 2.63 on a scale of –5 to 5.
- These scores were similar to scores reported by patients with lichen simplex chronicus, psoriasis and atopic dermatitis.
- The lack of scratch marks and secondary excoriations indicate that the mechanics behind this itching may be superficial.
Patients with chronic spontaneous urticaria experience more pleasure from scratching itches compared with patients with other skin conditions, according to a study published in The Journal of Allergy and Clinical Immunology: In Practice.
Though pruritus is the most troublesome symptom for these patients, little information is available about how they itch, the researchers wrote.
“We rarely see scratch marks in chronic urticaria,” Gil Yosipovitch, MD, director of the Miami Itch Center in the Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, and Peter Smith, MBBS, PhD, professor of clinical medicine at Griffith University, Southport, Australia, told Healio in a joint statement.
“However, in many chronic itch conditions, we see scratch marks, and patient self-reporting of how good it feels to scratch. We were curious to know whether chronic urticaria is similar to other chronic itch conditions,” they continued. “Pain and light touch travel via similar fibers, but scratching may contribute to secondary traumatic dermatitis.”
The researchers included survey results from 25 (24.8%) males (median age, 47; range, 12-77 years) and 76 (75.2%) females (median age, 39.5; range, 14-81 years), with a mean average total itch duration of 6.79 ± 9.46 years.
Also, 51 had generalized itch and 49 had localized itch. Itch locations included the abdomen (n = 98; 96%), lower extremities (n = 97; 95%), upper extremities (n = 96; 94%), back (n = 95; 93%), chest (n = 88; 86%), buttocks (n = 78; 76%), scalp (n = 72; 71%) and genitals (n = 44; 43%).
The researchers also found a 24-hour itch severity mean of 4.22 ± 2.99 and a 24-hour worst itch severity mean of 9.62 ± 0.86, both on a scale of 0 (least severe) to 10 (most severe). Mean average scratch pleasurability was 2.97 ± 2.63 on a scale of –5 (least pleasurable) to 5 (most pleasurable), although one patient had an unknown result and was excluded.
Further, the researchers said, patients with lichen simplex chronicus (3.4 ± 2.3), psoriasis (2.7 ± 2.8) and atopic dermatitis (2.5 ± 2.4) reported similarly high scratch pleasurability scores.
The researchers were surprised by these results since patients with chronic spontaneous urticaria had little clinical evidence of scratch marks or secondary excoriations, leading the researchers to hypothesize that these patients did not scratch their itching often enough to produce these marks and, therefore, it was not pleasurable for them.
However, six patients said that they had scratched themselves to the point of bleeding. The researchers also said they found surprising and ingenious methods for scratching.
“We found that scratching is extremely pleasurable in chronic urticaria, way beyond our expectations,” Yosipovitch and Smith said. “Some patients would use cutlery to scratch with. One would rub their back against a tree.”
Patients in the cohort also said that they used brushes, sticks, branches and scissors to scratch themselves. Hot showers, ice packs and alcoholic beverages also provided relief from itching. Treatment with omalizumab, meanwhile, led to less pleasure in scratching. The reasons behind the lack of signs of scratching are unclear, the researchers said, noting that histamine predominantly mediates the underlying mechanism of urticarial pruritus. Antihistamine treatments greatly mitigate itch, the researchers continued, possibly explaining why patients with effective treatment do not experience excoriations.
Also, the researchers explained that the mechanisms behind itch can be superficial or deep, with deeper itch leading to more excoriations and scarring. Perhaps, they continued, the pathogenesis behind itch in chronic spontaneous urticaria is superficial.
Doctors can discuss methods for addressing itch with their patients and help better care for the skin to avoid the scratching, the researchers said.
“We previously have shown that use of drugs such as kappa opioids like butorphanol affect brain areas involved in scratching and may attenuate scratching pleasurability,” Yosipovitch and Smith said.
“We hope to find in the future ways to mimic the scratching pleasurability and inhibition of itch but without damaging the skin, which induces the vicious cycle of itch and scratch,” they said.
The researchers are now looking at genes present in patients with pruritic skin conditions. Future studies, they continued should evaluate how treatment can address the pleasurability of scratching during chronic spontaneous urticaria as well as the temporal association between disease severity and itch in different body areas.