Understanding the Itch
Why the itch of psoriasis is getting more attention
Rita Bowen-Gilmore is surprised when she reads articles or comments claiming that psoriasis does not itch. "To me, the itch is much worse than the amount of coverage" on her skin, she said.
Bowen-Gilmore was responding to a question that the National Psoriasis Foundation posed on its Facebook page, asking people with psoriasis to discuss how itch affects their well-being and how they cope with it. And she is far from alone in saying that itch is a major problem for her, and that until fairly recently, its impact on those with psoriasis has been overlooked.
Itch is present in between 70 and 90 percent of psoriasis patients, yet it is only in the last decade that it has been recognized as a common symptom of the disease, said Dr. Gil Yosipovitch, a professor of dermatology and neurobiology at Wake Forest University Health Sciences in Winston-Salem, N.C.
Previously, there was a lack of awareness of the effect of itch on patients' quality of life. Doctors instead focused on improving the appearance of psoriasis, but patients want immediate relief from the itch, Yosipovitch said, and they need treatment.
More than an annoyance
The word "psoriasis" originates from the Greek word "psora," meaning "to itch." Yosipovitch said many people with psoriasis experience generalized itch, especially during the night, that significantly affects their sleep and quality of life. And the resulting scratching can aggravate psoriasis.
Physicians were once taught that psoriatic patients couldn't have both itch and pain, but scientists now understand that a lot of interactions occur between the two sensations. Itch and pain signals are transmitted along different pathways in the spinal cord. While each has a unique presentation, there is a lot of overlap, and doctors now recognize that a patient can have itch and pain together. Yosipovitch was so concerned about how itch affects patients that he founded the International Society for the Study of Itch to advance itch-related research. "We saw a lot of suffering and said, ‘We need to address this.'"
Psoriatic itch has several characteristics that make it unique to other inflammatory itchy skin disorders. For example, scalp itch in psoriasis is more intense and bothersome—and itch in the lower extremities is more frequently reported than in atopic dermatitis, he said. Psoriasis patients also complain about itch on the groin and buttocks.
Such problems can cause patients stress and embarrassment, and also can affect their relationships. Dr. John Koo, professor and vice chairman of dermatology at the University of California, San Francisco, who is board certified in psychiatry, emphasizes that the emotional stress challenges clinicians; it plays an important role in the onset, worsening the relapse of psoriasis. In addition, the visibility of psoriasis is hard on a person psychologically and socially.
"Stress is considered a component that activates or aggravates psoriasis," Yosipovitch said. "Stress also aggravates itch. The idea that stress is a significant component suggests that if we can control the psoriasis, it will alleviate itch, and a lot of treatments that work on influencing components also reduce itch."
Stopping itch before it starts
The goal in treating psoriatic itch is to inhibit the itch-scratch cycle and alleviate the patient's itch, even before the clearance of visible lesions. Biologic drugs approved for the treatment of psoriasis, such as Enbrel (etanercept), Humira (adalimumab), Remicade (infliximab) and Stelara (ustekinumab), can be effective and work faster than topical treatments because they have a central effect in the brain that reduces itch activation and improves mood. The result can be that a patient will say, "I feel like a new person," even though skin lesions are still active and visible, Yosipovitch said. Health care providers must tailor treatment to each individual's response and according to the intensity of itch and the area of the body involved, he said. Patients can become resistant to medications after repeated use and, for many patients, the best treatment strategy for itch may involve combining two or more therapies. This can include proven methods that can help a patient's mental state and reduce stress, Koo said.
"These stress busters may involve relaxation exercises, yoga, cognitive behavioral therapy and mindfulness meditation," he said.
Distraction also can help, posters on the National Psoriasis Foundation Facebook page testify. Several say that activities such as drawing, painting or dancing help take their minds off the itch. Joey Babauta offers another idea.
"A coping method for me is to stop what I'm doing, close my eyes and breathe in through the nose out through the mouth," Babauta wrote. "After a couple of seconds, the sensation to itch has stopped."