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Advances in dermatology and venereology Acta Dermato-Venereologica
Chronic Pruritus in Primary Sjögren’ s Syndrome: Characteristics and Effect on Quality of Life
Rodrigo VALDES-RODRIGUEZ 1, Brandon ROWE 1, Helen G. LEE 1, Thais MOLDOVAN 2, Yiong-Huak CHAN 3, Marissa BLUM 2 and Gil YOSIPOVITCH 1 *
1
Department of Dermatology and Itch Center, 2 Department of Rheumatology, Temple University School of Medicine, 3322 North Broad Street, Medical Office Building, Suite 212, Philadelphia, PA 19140, USA, and 3 Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore. * E-mail: yosipog @ gmail. com Accepted Aug 22, 2016; Epub ahead of print Aug 26, 2016
Sjögren’ s syndrome( SS) is an autoimmune disorder characterized by inflammatory destruction of the salivary and lacrimal glands( 1). SS can occur in the setting of comorbid rheumatologic disorders, which is considered secondary SS( s-SS), while primary SS( p-SS) occurs in the absence of such disorders( 1). The prevalence of p-SS widely varies depending on the diagnostic criteria utilized and has been reported to range from 0.22 to 2.7 %( 1). Previous studies have reported that pruritus and xerosis are among the most common cutaneous manifestations in p-SS( 2, 3). We aim to assess the characteristics of pruritus and its effect on quality of life( QoL) in patients with p-SS as no study to date has examined this.
PATIENTS AND METHODS
All patients with established diagnosis of p-SS using the American College of Rheumatology Classification Criteria( 4), were recruited from the Department of Rheumatology outpatient clinics, who were seen from February 2014 to March 2016. Of 21 patients with p-SS screened, 19 agreed to participate. All consented patients underwent both rheumatologic and dermatologic evaluations.
Participants suffering from chronic itch were asked to complete the Questionnaire for the Assessment of Pruritus, designed to capture the various dimensions and clinical characteristics of pruritus, as well as the ItchyQoL( 5, 6). The design of the questionnaire has been detailed previously( 6). The ItchyQoL evaluates how itch affects the subject’ s QoL by analyzing 3 domains: symptoms, functional limitations, and emotions relating to itch. Xerosis was objectively assessed utilizing the overall dry skin score( ODS), a standardized tool( 7).
From the chart, laboratory parameters, such as anti-nuclear antibody( ANA), rheumatoid factor( RF), anti-SSA, anti-SSB, complete blood count, and comprehensive metabolic panel, were obtained from patient medical records. Medications and comorbid conditions were also documented.
All analyses were performed using software( SPSS 16.0, IBM Corp, Armonk, NY). Descriptive statistics for quantitative variables were presented as mean ± SD and as percentages for qualitative variables. Spearman correlation coefficients were presented to assess relationships between quantitative and ordinal qualitative outcomes. Correlations between lab values and chronic pruritus were determined using the Mann Whitney U test. Statistical significance was set at p < 0.05.
RESULTS
The patients mean age was 55 years( range 30 – 74) with 18( 94 %) females and one( 6 %) male( Table SI 1).
1 https:// www. medicaljournals. se / acta / content / abstract / 10.2340 / 00015555-2524
Ten subjects( 53 %) reported suffering from chronic itch with a mean duration of 74.4 months( range 12 – 240). The mean ± SD itch intensity reported using the visual analogue scale( VAS) was 7.7 ± 1.7. The most common locations were: shins( 90 %), back( 80 %) and forearms( 70 %). Six out of 10 subjects considered scratching to be pleasurable with a mean score of 2.6 ± 3.2 on the Likert scale.
Itch intensity was worst during the evening and least severe in the morning. Itch was rated as most intense during the summer rather than the winter. The most common aggravating factors were dry skin( 70 %) and hot water( 50 %). The onset of itch ranged from 11 years prior to diagnosis of p-SS to 3 years after the diagnosis. Eight subjects with chronic itch reported sleep disturbance due to itch.
Xerosis was present in 9( 90 %) of the pruritic subjects as opposed to 4( 44 %) in those without itch. When the severity of xerosis( grade 0 to 4) was compared between patients with itch( mean 1.1) versus no itch( mean 0.6), no statistical significance was seen( p = 0.1).
The mean ± SD QoL score of p-SS patients with pruritus was 57.3 ± 18, which had a significant correlation coefficient of 0.71( p = 0.02) associated with severity of itch. The emotional domain of the total ItchyQoL score was the most noteworthy, with the largest reports being“ aggravated by temperature or seasonal changes”( mean ± SD score of 3.9 ± 1.2) and“ need to scratch”( 3.7 ± 0.8).
There was no significant difference in disease duration of p-SS between pruritic vs non-pruritic patients. Similarly, no differences were detected when analyzing liver enzymes( ALT, AST, ALP), creatinine, hemoglobin and serologic markers( ANA, SSA, SSB), between the 2 groups. Only RF was significantly elevated in patients without itch( p = 0.02)( Table I). None of the serologic markers were associated with xerosis( RF, ANA, SSA, and SSB)( data not shown).
Pruritic comorbidities among the patients with chronic itch included diabetes mellitus, steatohepatitis, and psoriasis( Table I).
DISCUSSION
Interestingly, itch may be the presenting symptom in patients with SS( 3). One previous study on p-SS revealed an itch prevalence of 42 %( 2). We found a similar prevalence with 53 % of our subjects reporting to suffer
This is an open access article under the CC BY-NC license. www. medicaljournals. se / acta Journal Compilation © 2017 Acta Dermato-Venereologica. doi: 10.2340 / 00015555-2524 Acta Derm Venereol 2017; 97: 385 – 386