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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