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Research

Original Investigation

Factors Mediating the Impact of Chronic Pruritus


on Quality of Life
Christopher W. Carr, MD; Emir Veledar, PhD; Suephy C. Chen, MD, MS

IMPORTANCE Chronic pruritus is a common problem with a deleterious effect on quality of


life. The factors mediating the relationship between chronic pruritus and quality of life are
poorly understood.

OBJECTIVE To determine the factors that mediate the impact of chronic pruritus on quality
of life.

DESIGN, SETTING, AND PARTICIPANTS Cross-sectional study based on a nationwide telephone


survey of US military veterans sampled from the Veterans Hospital Patient Database.
Participants were veterans who agreed to participate and were found to have chronic
pruritus.

MAIN OUTCOMES AND MEASURES Statistical significance of predictor variables (characteristics


of patients and their chronic pruritus) in multivariate analysis using ItchyQoL scores as
response variables.

RESULTS Of 6000 veterans telephoned, 1075 consented to participate; 405 of these had
chronic pruritus. Factors that mediated the impact of chronic pruritus on quality of life were
demographic characteristics (age [P = .007], race [P = .05], marital status [P = .04]),
personality (extroversion [P = .03], neuroticism [P = .01]), pruritus characteristics (severity
[P < .001], duration [P = .01], frequency [P < .001], location [P = .005]), and possible etiology
(cutaneous vs systemic [P = .03]). Notable factors not found significant include sex (P = .98)
and socioeconomic variables (education level [P > .99], employment status [P = .53], income
[P = .62]).
Author Affiliations: Department of
Dermatology, Emory University,
CONCLUSIONS AND RELEVANCE The multitude of factors that significantly influence the Atlanta, Georgia (Carr, Veledar, Chen);
impact of chronic pruritus on quality of life demonstrates the complex nature of this Atlanta Veterans Administration
relationship. A better appreciation of these factors will improve the clinical evaluation and Medical Center, Atlanta, Georgia
(Chen).
treatment of chronic pruritus.
Corresponding Author: Suephy C.
Chen, MD, MS, Department of
JAMA Dermatol. 2014;150(6):613-620. doi:10.1001/jamadermatol.2013.7696 Dermatology, Emory University, 1525
Published online March 26, 2014. Clifton Rd, First Floor, Atlanta, GA
30305 (schen2@emory.edu).

T
he scourge of chronic pruritus—pruritus lasting 6 or more Whereas the impact of chronic pruritus on QoL has been
weeks1—should not be underestimated. Recent stud- established, a second-order question—what factors mediate this
ies have documented the extent of the problem, find- impact—remains lightly studied. A negative correlation be-
ing point prevalences ranging from 13% to 17%2-4 and lifetime tween pruritus severity and QoL has been documented,2,10-12
prevalences of 22% to 26%.2,4 Prior research on chronic pru- and the importance of several other factors has been ad-
ritus has also found a substantial effect on quality of life dressed with small studies. Desai et al13 found that pruritus eti-
(QoL). In several studies, Yosipovitch and colleagues 5-7 ology and sex influenced the impact of pruritus on QoL: urti-
found pruritus to significantly influence QoL proxies includ- caria engendered greater impact on functional aspects of QoL,
ing mood, concentration, eating habits, sexual function, and and women were more negatively affected by chronic pruri-
sleep. Wolkenstein et al 8 found that chronic pruritus tus than men. Stander et al14 also found a greater impact of
impaired QoL more than other skin problems. Kini et al9 chronic pruritus on women. Kini et al9 found that unmarried
found no significant difference between the impact of persons were more adversely affected by chronic pruritus than
chronic pain and chronic itch on QoL. their married counterparts. A study of patients with psoriasis

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Research Original Investigation Impact of Chronic Pruritus on Quality of Life

found no relationship between age, sex, disease duration, sleep veterans were sampled at random. Interviewers at the Uni-
quality, and the impact of pruritus on QoL.12 Although these versity Center for Social and Urban Research at the University
studies explored the relevance of some variables, the role of of Pittsburgh attempted to call these 6000 veterans at least 3
many patient and pruritus characteristics in determining the times each. Exclusionary criteria were inability to speak En-
impact of pruritus on QoL remains a mystery. To address this glish or inability to answer questions due to disability. Ulti-
knowledge void, we undertook a cross-sectional study of a large mately, 1075 veterans agreed to participate; all participants pro-
sample of US military veterans. We hypothesized that a mul- vided verbal informed consent. At the time of the telephone
titude of factors would significantly affect how chronic pru- call, 405 of the veterans had chronic pruritus. The entire sur-
ritus influences QoL. vey was administered to these 405 veterans; the remaining 670
veterans answered fewer questions because the itch-related
questions were not applicable. Because our focus is the im-
pact of chronic pruritus on QoL, our analysis uses only the re-
Methods plies from the 405 veterans with chronic pruritus.
The Emory University institutional review board approved this
cross-sectional study. This study consisted of 2 phases: (1) cre- Statistical Analysis
ating a panel of comprehensive surveys to capture informa- Survey responses were translated into both categorical and con-
tion on patients and their pruritus and (2) administering the tinuous variables.
survey to a sample of patients from the Veterans Hospital Pa-
tient Database. Categorical Variables
Many survey questions featured multiple discrete answer
Survey Design choices (more than 12 choices in some cases); we trans-
We designed a panel of surveys to capture patient demo- formed these questions into categorical variables. To reduce
graphic, medical history, therapeutic, and personality data. the number of categories, answers were combined in a logi-
Questions from published surveys were assimilated, as fol- cal fashion. For example, hand, forearm, and upper arm were
lows: separate answer choices for a question asking the anatomic lo-
1. ItchyQoL – ItchyQoL is a validated, pruritus-specific instru- cation of pruritus. For analysis, these 3 answers were com-
ment that measures the degree to which pruritus affects bined to form a single upper extremity category. Answers to
QoL.13 This impact is quantified into 3 subscores (symp- some survey questions that were initially continuous (eg, in-
tom, function, emotion) and an overall score. A higher score come, body mass index [BMI, calculated as weight in kilo-
corresponds to a more adverse impact on QoL. We used the grams divided by height in meters squared], frequency of itch,
frequency version of this instrument. duration of pruritic condition) were translated into categori-
2. Questionnaire for the Assessment of Pruritus – This ques- cal variables when the responses did not show a normal dis-
tionnaire characterizes a patient’s pruritus.6 tribution. The categorical variables used in our analysis are
3. NEO 5-factor inventory – Developed by psychologists at the listed in Table 1.
National Institutes of Health, this survey is predicated on To derive the “possible etiology” variable, patients were
the 5-factor personality model, which divides personality asked a series of questions regarding whether they had any of
into 5 domains: openness, conscientiousness, extrover- a number of cutaneous and systemic diseases that can cause
sion, agreeableness, and neuroticism. Survey answers are pruritus. On the basis of their answers to these questions,
used to score patients on these 5 domains; a higher score patients were then grouped into the cutaneous only, sys-
corresponds to a higher degree of that personality trait.15 temic only, cutaneous and systemic, and idiopathic catego-
4. 12-Item Short Form Health Survey – This validated ques- ries. However, we cannot say for certain that a particular
tionnaire measures generic health-related QoL. We do not disease affirmed by a patient is definitively causing the
report results of this questionnaire here. patient’s pruritus, hence the modifier “possible” prepended
Questions regarding risk factors for pruritus were devel- to “etiology.”
oped through a literature review. Economic and family im-
pact questionnaires were developed by the adaptation of ex- Continuous Variables
isting validated measures. Phase 1 of the study involved testing Continuous variables are pruritus severity, personality do-
the panel of surveys with veterans for content and face valid- main scores, and age. Patients scored pruritus severity on a
ity, clarity, reliability, and feasibility. Cognitive interviewing and scale of 1 to 10. The NEO 5-factor inventory consists of 60 items.
psychometric analyses were performed. The results of this test- The interviewer read each item to a patient (eg, “I really enjoy
ing have been reported elsewhere.16 The final comprehen- talking to people”), who then responded on a scale of 1 (strongly
sive survey consisted of more than 300 questions. disagree) to 5 (strongly agree). Personality scores were calcu-
lated using the NEO inventory’s prescribed addition and sub-
Study Population and Sample traction of various responses. These personality scores are in-
Patients for phase 2 of this study were drawn from the Veter- terval variables. The means and standard deviations of the 5
ans Hospital Patient Database. The database was stratified using personality domains depend on the population to which the
the US Census Bureau’s 6 geographic areas to ensure diverse inventory is applied, so no inferences can be gleaned from the
geographic representation. From this stratified database, 6000 absolute level of these statistics.

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Table 1. Summary Statistics for Categorical Variables Table 1. Summary Statistics for Categorical Variables (continued)

Variable Frequency, No. (%)a Variable Frequency, No. (%)a


Patient characteristics Itch frequency
Sex >10 × per day 83 (21)
Male 374 (93) 5-10 × per day 90 (22)
Female 30 (7) 2-4 × per day 146 (36)
Race 2-7 × per week 63 (16)
White 298 (74) ≤4 × per month 21 (5)
African American 76 (19) Time of day when itch is worst
Other 30 (7) No particular time 143 (35)
Marital status Multiple different times 84 (21)
Married 230 (57) All day 40 (10)
Not married 174 (43) Morning 17 (4)
Region of residence Afternoon 15 (4)
South 129 (32) Evening before 8 PM 37 (9)
West 113 (28) Evening after 8 PM 69 (17)
Midwest 98 (24)
Abbreviation: BMI, body mass index (calculated as weight in kilograms divided
Northeast 63 (16) by height in meters squared).
Puerto Rico 1 (0) a
Percentages may not total 100% because of rounding.
Education level
College degree or more 174 (43) ItchyQoL Scores
Some college 109 (27) The frequency version of the ItchyQoL instrument consists of
High school or less 121 (30) 22 items. These items are divided into 3 constructs: sympto-
Employment status matic impact (6 items), functional limitations (7 items), and
Retired 185 (46) emotional impact (9 items). The interviewer read each item to
Employed 116 (29) a patient (eg, “my itchy skin often makes it difficult to con-
Unemployed 68 (17) centrate”), who then responded on a scale of 1 (never) to 5 (al-
Disabled 35 (9) ways). Subscores for each construct are summations of the nu-
Income, $ merical responses. The ItchyQoL total score for a patient is the
≤25 000 142 (37) sum of the symptom, function, and emotion subscores. Some
>25 000 and <50 000 139 (36) veterans responded to ItchyQoL items with “I don’t know.” For
≥50 000 105 (27) a given subscore, if a patient responded “I don’t know” to 1 or
BMI 2 items, these responses were replaced with the mean numeri-
<25 74 (18) cal response of that subscore’s other items. In total, 42 items
≥25 and <30 166 (41) were answered “I don’t know,” necessitating adjustment to 40
≥30 and <35 92 (23) subscores (3% of the total subscores). One of the 405 patients
≥35 72 (18) answered 3 emotion items with “I don’t know;” his data point
Possible etiology was removed entirely for the analyses involving the ItchyQoL
Cutaneous and systemic 300 (74) total score and emotion subscore.
Systemic only 61 (15)
Cutaneous only 32 (8) Analysis
As a first step, we undertook univariate analysis to screen
Idiopathic 11 (3)
for relationships between the total ItchyQoL score and other
Pruritus characteristics
variables. Relationships between continuous variables and
Itch location
the total ItchyQoL score were determined using analysis of
Multiple locations 262 (65)
variance and t testing. Relationships between categorical
Lower extremities 40 (10)
variables and ItchyQoL scores were determined using χ 2
Upper extremities 31 (8)
testing. A priori, we had decided to use all variables from
Torso 29 (7)
the univariate analysis with P values ≤.20 as predictor vari-
Groin and buttocks 23 (6)
ables in multivariate analysis. All of the aforementioned
Head and neck 19 (5)
variables met this threshold.
Itch duration, y
As the second step, we undertook multivariate analysis
≤2 106 (26)
using a generalized linear model with ItchyQoL scores (total and
>2 and ≤8 103 (26)
subscores) as the response variables for a total of 4 different
>8 and ≤20 108 (27)
models. By convention, we deemed P ≤ .05 to be significant.
>20 86 (21)
While undertaking the survey, occasionally a veteran re-
(continued) plied “I don’t know” or declined to answer a survey question.

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Research Original Investigation Impact of Chronic Pruritus on Quality of Life

We have outlined how we treated such responses to ItchyQoL


items. When veterans responded “I don’t know” or declined Results
to answer other questions, predictor variables derived from
those questions could not be calculated and/or categorized. Table 1 and Table 2 summarize the frequencies of the categori-
Ergo, such a patient was excluded from univariate and multi- cal variables and the means and standard deviations of the con-
variate analyses involving that variable. Fortunately, the “I tinuous variables, respectively. Because the means of the per-
don’t know” and declined responses were infrequent, with sonality scores are not informative (as explained in the Methods
most involving the question on income. The sample size for section), these variables are omitted from Table 2. Our pru-
multivariate analysis only decreased from 404 to 384 indi- ritic veteran population consisted primarily of white men; the
viduals. All analyses were performed with SAS software, ver- mean age was 60.7 years. The majority were married, had at
sion 9.3 (SAS Institute). least some college education, and had both cutaneous and sys-
temic conditions that could engender pruritus. Most veter-
Table 2. Summary Statistics for Continuous Variables
ans reported pruritus affecting multiple locations and lasting
Variable Mean (SD) more than 2 years. Region of residence, income, and employ-
Age, y 60.7 (13.0) ment status were fairly evenly distributed.
Itch severitya 5.2 (2.3) The multivariate model exhibited statistical significance
ItchyQoL scores (P < .001) and good explanatory power (R2 = 52%). Table 3 sum-
Symptom subscore 16.3 (5.0) marizes the results of the multivariate analysis, with the con-
Function subscore 16.4 (6.3) tinuous and categorical variables at the top and bottom of the
Emotion subscore 21.1 (9.4) table, respectively.
Totalb 53.7 (18.7)
a
On a scale of 1 to 10.
Pruritus Characteristics
b Itch severity significantly (P < .001) directly correlates with the
Total score differs from sum of subscores because of rounding.
total ItchyQoL score and its 3 constitutive constructs. Itch fre-

Table 3. Multivariate Results

ItchyQoL Response Variable


Total Symptom Function Emotion
Variable Coefficient P Value Coefficient P Value Coefficient P Value Coefficient P Value
Continuous variables
Itch severity 2.45 <.001 0.67 <.001 0.77 <.001 1.01 <.001
Age −0.20 .007 −0.07 .003 −0.05 .048 −0.08 .04
Personality domains
Neuroticism 0.30 .01 0.07 .047 … .79 0.22 <.001
Extroversion −0.28 .03 … .27 −0.13 .005 … .12
Agreeableness … .46 … .55 … .52 … .19
Conscientiousness … .97 … .16 … .29 … .86
Openness … .44 … .66 … .40 … .52
Categorical variables
Patient characteristics
Possible etiology … .03 … .23 … .009 … .14
Marital status … .04 … .04 … .19 … .06
Race … .05 … .08 … .02 … .23
BMI … .34 … .37 … .31 … .51
Education level … >.99 … .23 … .50 … .96
Employment status … .53 … .39 … .70 … .60
Sex … .98 … .67 … .39 … .71
Income … .62 … .30 … .92 … .60
Region of residence … .90 … .69 … .84 … .57
Pruritus characteristics
Itch frequency … <.001 … .53 … .003 … <.001
Itch location … .005 … .15 … <.001 … .04
Itch duration … .01 … .03 … .04 … .04
Time of day when itch … .08 … .13 … .40 … .12
is worst

Abbreviation: BMI, body mass index (calculated as weight in kilograms divided by height in meters squared).

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Impact of Chronic Pruritus on Quality of Life Original Investigation Research

quency, duration, and anatomic location are all significantly fully captured by the itch severity measure. One could rea-
related to the impact of pruritus on QoL. Pairwise compari- sonably expect that itch frequency is a prominent determi-
son generally supports that a higher itch frequency signifi- nant of itch severity and as such would not be independently
cantly (P < .01) correlates with a greater impact on QoL. Like- significant. However, our results suggest otherwise.
wise, pairwise comparison shows that pruritus of longer Several patterns for the influence of chronic disease du-
duration exerts a greater impact on QoL. Time of day when itch ration on QoL have been hypothesized: no effect, adaptation,
is worst is not significantly related to ItchyQoL scores. and chronic exasperation.18 Studies of congestive heart fail-
ure, chronic prostatitis, and diabetes mellitus have shown that
Patient Characteristics disease duration has no effect on QoL.19-21 Chronic pruritus does
Marital status, age, race, and possible etiology are all signifi- not behave in the same fashion, as our analysis provides evi-
cantly related to the impact of pruritus on QoL. Marriage is as- dence for chronic exasperation: increasing duration signifi-
sociated with a lower ItchyQoL total score and symptom sub- cantly correlates with greater negative QoL impact. The sig-
score. Age exhibits significant, negative correlation with the nificance of all 3 ItchyQoL subscores indicates that symptoms,
total ItchyQoL score and all 3 subscores. With respect to pos- functional status, and emotional health deteriorate as chronic
sible etiology, the ordinal ranking of the categories from great- pruritus persists.
est to least impact on QoL is as follows: (1) cutaneous and sys- The impact of chronic pain on QoL depends in part on
temic reason to itch, (2) systemic reason, (3) cutaneous reason, its anatomic location. 22 We included itch location in our
(4) neither. However, pairwise comparisons of these catego- analyses to investigate for a similar relationship, and loca-
ries revealed no significant differences. Race is significant, with tion did prove significant. Interestingly, pruritus afflicting
nonwhites experiencing a significantly greater impact on QoL the upper extremities has the most adverse impact on QoL,
than whites. Pairwise comparisons failed to find a significant although pairwise comparison revealed no significant dif-
difference between the race categories. ferences vs other anatomic locations. In the multivariate
Multivariate analysis revealed a significant negative analyses that used the 3 ItchyQoL subscores as dependent
coefficient for patients’ extroversion score with respect to variables, anatomic loc ation has the lowest P value
ItchyQoL total and function scores. Conversely, analysis found (P < .001) when modeled with the function subscore. This
a significant positive coefficient for patients’ neuroticism score finding suggests that the higher degree of impact experi-
with respect to ItchyQoL total, symptom, and emotion scores. enced by patients with upper extremity pruritus may be due
Three personality domains failed to show significance: open- to functional impairment.
ness, conscientiousness, and agreeableness.
Sex, region of residence, education level, employment Patient Characteristics
status, income, and BMI did not exhibit significant associa- Studies of the impact of age on QoL in chronic disease have pro-
tion with ItchyQoL scores. duced dissimilar results. Some researchers found increasing age
to diminish the negative impact on QoL20; some found no re-
lationship between age and QoL19,23; others found that increas-
ing age correlates with declining QoL.21 In our analysis, age has
Discussion a significant, negative coefficient when modeled against the
Medical research has established that chronic disease substan- total ItchyQoL score and the 3 subscores. The negative coeffi-
tially affects QoL.17 Similarly, dermatologic investigation has cient indicates that older age correlates with less adverse im-
found a deleterious effect of chronic pruritus on QoL.8,9 For pact on the QoL, and the pansignificance of all 3 ItchyQoL
some chronic diseases (eg, diabetes mellitus, congestive heart constructs demonstrates that the mitigating influence of age
failure, end-stage renal disease), investigation has revealed the pervades the spectrum of morbidity. The statistical signifi-
factors that mediate the impact of the disease on patients’ QoL. cance of age lies in contrast to the findings of a study of QoL in
For chronic pruritus, the identity of these factors is largely un- pruritic patients with psoriasis.12
known. To remedy this knowledge void, we collected exten- Research on the relationship between race and QoL in
sive demographic, medical, and QoL data from a large, di- chronic disease has yielded heterogeneous results. Some re-
verse sample of pruritic patients. Multivariate analysis revealed search has found no correlation between race and QoL
that an array of variables influences the impact of chronic pru- measures.20,24 End-stage renal disease has been shown to more
ritus on QoL. Important insights can be gleaned from the negatively affect the QoL of whites25 and nonwhites.26 King-
results. ton et al27 found that greater functional impairment of non-
whites with chronic disease was attributable to socioeco-
Pruritus Characteristics nomic status and not race. Our analysis has found a significant
Not surprisingly, itch severity was found to significantly in- association of race with the impact of chronic pruritus on QoL,
fluence the ItchyQoL total score and all 3 subscores. The cor- even after we controlled for socioeconomic variables. The total
relation is positive, with greater pruritus severity yielding a ItchyQoL scores for both the African American and other race
greater impact on QoL. At the same time, itch frequency sig- categories are approximately equal and 9% higher than the
nificantly correlates with total ItchyQoL. Taken in isolation, score for whites, although no comparisonwise error rate was
the significance of itch frequency is not surprising. However, significant. With respect to ItchyQoL subscores, race was sig-
it is interesting that the impact of itch frequency on QoL is not nificant (P = .02) only when modeled with the function sub-

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Research Original Investigation Impact of Chronic Pruritus on Quality of Life

score, suggesting that race’s influence on QoL is mediated Variables Not Significant
through functional impairment. A number of variables did not exhibit significance: sex, re-
Marital status significantly influences the impact of pru- gion of residence, education level, employment status, in-
ritus on QoL, with chronic pruritus having less effect on come, BMI, and time of day when itch is worst. Several inter-
married persons. The mean ItchyQoL score for an unmar- esting observations can be made. First, socioeconomic
ried person is 7% worse. Interestingly, the ItchyQoL symp- status—as represented by education level, employment sta-
tom subscore was the only significant construct, intimating tus, and income—does not mediate the impact of chronic pru-
that marriage ameliorates the impact of pruritus more ritus on QoL. Second, pruritus that is worst after 8 PM (ie, pru-
through symptom relief than through the function and ritus that affects sleep) does not produce a more negative
emotion constructs. The beneficial impact of marriage on impact on QoL. Not only is the worst-itch–time variable not sig-
QoL is consistent with prior QoL research21,28 and the afore- nificant, but the after–8 PM category exhibited the second low-
mentioned finding of Kini et al.9 We hypothesize that the est impact on QoL of the 7 time groups (although pairwise com-
social support available in marriage is responsible for this parisons revealed no significant differences). This finding
finding. challenges the widely held belief that pruritus (at least gener-
The presence of a disease that can cause pruritus (ie, the alized pruritus) is worst at night.38-40 Third, sex was not found
possible etiology variable) exhibits significant correlation with significant. This discovery lies in contrast to previous studies
the impact of pruritus on QoL. This finding suggests that the that found chronic pruritus to more severely affect the QoL of
impact of pruritus on QoL is determined not just by the char- female patients.13,14 Women constitute only 7% of our sample,
acteristics of the pruritus itself; the etiology matters. How- but the difference between the estimates for men and women
ever, we could not through a telephone survey determine with was miniscule (P = .98). There is no evidence to suggest that
sufficient certainty whether the medical condition(s) af- sex would become significant with a multiplicative increase
firmed by the patient are actually causing the patient’s pruri- in the sample size.
tus. As such, although the data support a relationship be-
tween possible etiology and QoL, the evidence is not as Limitations
conclusive as for other variables. Our sample features racial, socioeconomic, and regional
diversity but is constituted entirely of US military veterans.
Personality As such, generalization of results to nonveteran populations
To capture the influence of personality on QoL, we incorpo- merits caution. Furthermore, caution must also be exer-
rated personality domains into our analysis. Extroversion cised when extrapolating our findings to younger popula-
and neuroticism proved statistically significant. This finding tions because only 8% of our sample was 40 years or
is consistent with the psychology literature, which has younger. Conclusions drawn from our sample may not be
shown that extroversion and neuroticism are important fac- applicable to other populations.
tors in determining well-being. 29,30 Psychologists define Theoretically, one could argue that the problem of cau-
neuroticism with the modifiers anxious, self-pitying, tense, sality complicates the interpretation of the personality
touchy, unstable, and worrying.31 An association of neuroti- results. Our analysis presumes that personality affects a
cism with lower QoL has been shown in patients with patient’s response to chronic pruritus, but the possibility
inflammatory bowel disease,32 Parkinson disease,33 chronic exists that chronic pruritus may influence personality. This
headache, 34 cancer, 35 breast cancer specifically, 36 and chicken-and-egg issue (ie, how personality and events influ-
chronic disease in older patients.37 In our analysis, neuroti- ence each other) has been studied extensively in the psy-
cism featured a positive coefficient with respect to total chology literature, where it is generally accepted that adult
ItchyQoL; both the symptom and emotion constructs were personality is stable.41,42 As such, the presence of chronic
significant. Ergo, we conclude that chronic pruritus has a pruritus would not be expected to alter a person’s neuroti-
more detrimental QoL impact in more neurotic patients, cism and extroversion quotients, and the use of personality
manifesting as an exacerbation of symptoms and decline in factors as independent variables would not be complicated
emotional well-being. by bidirectional causality.
To define extroversion, psychologists use the adjectives
active, assertive, energetic, enthusiastic, outgoing, and
talkative.31 Unlike neuroticism, evidence for the influence
of extroversion on QoL in chronic disease is scant. Among
Conclusions
patients with Parkinson disease, Dubayova et al 33 found This study represents the next epidemiologic step in
extroversion to predict less impact on QoL in men only. chronic pruritus research: understanding the factors that
Similarly, our analysis found a significant negative associa- mediate the impact of chronic pruritus on QoL. Using data
tion of extroversion with total ItchyQoL and the function collected from a large, geographically diverse sample of the
construct. These findings indicate that a greater degree of US veteran population, we found that multiple patient and
extroversion reduces the impact of pruritus on QoL, specifi- pruritus characteristics significantly influence this relation-
cally on functional capacity. Note that this stands in con- ship: demographic characteristics (age, race, marital status),
trast to neuroticism, in which a greater degree of neuroti- personality (extroversion, neuroticism), pruritus para-
cism increases the symptomatic and emotional impact. meters (severity, duration, frequency, anatomic location),

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Impact of Chronic Pruritus on Quality of Life Original Investigation Research

and etiology (cutaneous, systemic). The significance of chronic pruritus and QoL. We hope that better appreciation
some of these variables (marital status, neuroticism, ana- of these factors will improve the clinical evaluation and
tomic location) mirrors what has been found in other treatment of chronic pruritus. Future directions of research
chronic diseases. Notable factors not found significant include investigating why race influences the impact of
include sex and socioeconomic variables (education level, chronic pruritus on QoL and exploring whether support
employment status, income). The multitude of significant groups or personality-specific interventions may help miti-
factors demonstrates the complex relationship between gate the QoL impact of chronic pruritus.

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pruritus among patients with extensive psoriasis. Br 19. Juenger J, Schellberg D, Kraemer S, et al. Health
Published Online: March 26, 2014. J Dermatol. 2000;143(5):969-973.
doi:10.1001/jamadermatol.2013.7696. related quality of life in patients with congestive
6. Yosipovitch G, Zucker I, Boner G, Gafter U, heart failure: comparison with other chronic
Author Contributions: Drs Chen and Veledar had Shapira Y, David M. A questionnaire for the diseases and relation to functional variables. Heart.
full access to all of the data in the study and take assessment of pruritus: validation in uremic 2002;87(3):235-241.
responsibility for the integrity of the data and the patients. Acta Derm Venereol. 2001;81(2):108-111.
accuracy of the data analysis. 20. McNaughton Collins M, Pontari MA, O’Leary
Study concept and design: Chen. 7. Yosipovitch G, Goon AT, Wee J, Chan YH, Zucker MP, et al; Chronic Prostatitis Collaborative Research
Acquisition of data: Chen. I, Goh CL. Itch characteristics in Chinese patients Network. Quality of life is impaired in men with
Analysis and interpretation of data: All authors. with atopic dermatitis using a new questionnaire chronic prostatitis: the Chronic Prostatitis
Drafting of the manuscript: Carr. for the assessment of pruritus. Int J Dermatol. Collaborative Research Network. J Gen Intern Med.
Critical revision of the manuscript for important 2002;41(4):212-216. 2001;16(10):656-662.
intellectual content: All authors. 8. Wolkenstein P, Grob JJ, Bastuji-Garin S, 21. Jacobson AM, de Groot M, Samson JA. The
Statistical analysis: Veledar. Ruszczynski S, Roujeau JC, Revuz J. French people evaluation of two measures of quality of life in
Obtained funding: Chen. and skin diseases: results of a survey using a patients with type I and type II diabetes. Diabetes
Administrative, technical, and material support: Carr. representative sample. Arch Dermatol. 2003;139 Care. 1994;17(4):267-274.
Study supervision: Chen. (12):1614-1619. 22. Lamé IE, Peters ML, Vlaeyen JW, Kleef MV,
Conflict of Interest Disclosures: Dr Chen has 9. Kini SP, DeLong LK, Veledar E, McKenzie-Brown Patijn J. Quality of life in chronic pain is more
received royalties from Eli Lilly (2007) and Pierre AM, Schaufele M, Chen SC. The impact of pruritus associated with beliefs about pain, than with pain
Fabre (2011) for licensing of the ItchyQoL on quality of life: the skin equivalent of pain. Arch intensity. Eur J Pain. 2005;9(1):15-24.
instrument and has been an outcomes research Dermatol. 2011;147(10):1153-1156. 23. Ketelaars CA, Schlösser MA, Mostert R, Huyer
consultant for Biogen and Astellas and a principal 10. Holm EA, Wulf HC, Stegmann H, Jemec GB. Life Abu-Saad H, Halfens RJ, Wouters EF. Determinants
investigator for studies sponsored by quality assessment among patients with atopic of health-related quality of life in patients with
Hoffman-LaRoche and Galderma. No other eczema. Br J Dermatol. 2006;154(4):719-725. chronic obstructive pulmonary disease. Thorax.
disclosures are reported. 1996;51(1):39-43.
11. Weisshaar E, Diepgen TL, Bruckner T, et al. Itch
Funding/Support: The Veterans Health intensity evaluated in the German Atopic Dermatitis 24. Glasgow RE, Ruggiero L, Eakin EG, Dryfoos J,
Administration (VHA) provided (1) financial support Intervention Study (GADIS): correlations with Chobanian L. Quality of life and associated
and (2) access to the Veterans Hospital Patient quality of life, coping behaviour and SCORAD characteristics in a large national sample of adults
Database for sampling purposes. severity in 823 children. Acta Derm Venereol. 2008; with diabetes. Diabetes Care. 1997;20(4):562-567.
Role of the Sponsors: The VHA had no role in the 88(3):234-239. 25. Kutner NG, Devins GM. A comparison of the
design and conduct of the study; collection, 12. Zachariae R, Zachariae CO, Lei U, Pedersen AF. quality of life reported by elderly whites and elderly
management, analysis, and interpretation of the Affective and sensory dimensions of pruritus blacks on dialysis. Geriatr Nephrol Urol. 1998;8(2):
data; preparation, review, or approval of the severity: associations with psychological symptoms 77-83.
manuscript; and decision to submit the manuscript and quality of life in psoriasis patients. Acta Derm
for publication. 26. Evans RW, Manninen DL, Garrison LP Jr, et al.
Venereol. 2008;88(2):121-127. The quality of life of patients with end-stage renal
Additional Contributions: We thank the VHA for 13. Desai NS, Poindexter GB, Monthrope YM, disease. N Engl J Med. 1985;312(9):553-559.
its support of this research. Bendeck SE, Swerlick RA, Chen SC. A pilot 27. Kington RS, Smith JP. Socioeconomic status
quality-of-life instrument for pruritus. J Am Acad and racial and ethnic differences in functional status
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NOTABLE NOTES

Dermatologic Food for Thought: A Word Search Challenge


Walter H. C. Burgdorf, MD; Leonard J. Hoenig, MD

Word search puzzles are fun to solve and have been around since 1968. We These words may be listed horizontally, vertically, or diagonally in a total
thought readers might enjoy the challenge of a dermatology-related word of 8 different possible directions. Some words may intersect. Answers
search,andsowehavepreparedonebasedonthethemeoffoodeponyms. are provided below.
To solve the puzzle, you must first identify, from the list below, 12 food There is no time limit to do the puzzle. However, if you can solve this
or beverage terms used in dermatology. To do this, you need to fill in the word search challenge in less than 10 minutes, then you are truly a der-
blanks with the appropriate food words. Each blank has only 1 word for matology word search champion! Good luck!
an answer except for number 1 (3 words) and number 7 (2 words). Please
Author Affiliations: Retired (Burgdorf); private practice (Hoenig).
note that the answer to number 3 is a homonym of a food name.
Once you have figured out the missing food or drink words, you must Corresponding Author: Leonard J. Hoenig, MD, 601 N Flamingo Rd, No. 201,
then find them in the word search grid below in which they are hidden. Pembroke Pines, FL 33028 (gooddocljh@gmail.com).

A T A S T R A W B E R R Y H D
H W V T H A Y F P J Q Q P Z Q

Y Y S S T S E O Y U T A F U O
X W W E Y O P L A B O B R T G

S X O E S P A G H E T T I K M
M N S P X P N O U Y O E I K P

P H Z N Y C E U A D Y U C K C 12. CHICKEN C U O Z T R A E S C A W T T Y

S I V I L C N Z A S C A H S B 11. HONEY H L Y R R E H C Y O L E G S X
10. SPAGHETTI
M M P W F K E Q O A U W T Y N
I B O X Z V A I L U G P Q P D
9. STRAWBERRY
Y V S T A A M R F L E A Y R E
C E B D Q A K F A N C O R N J
8. ORANGE
G O A R Z X A E I W K Z S R K
K R S Z W K I E A X Z R A O G
7. PORT-WINE
J N R O C N A F K A Q D B E C
E R Y A E L F R M A A T S V Y
6. MULBERRY
D P Q P G U L I A V Z X O B I
N Y T U W A O Q E K F W P M M
5. CAULIFLOWER
X S G E L O Y C H E R R Y L H
B S H A C S A Z N C L I V I S
4. SAUSAGE
Y T T A W C S E A R T Z O U C 3. CORN C K C U Y D A U E C Y N Z H P

P K I E O Y U O N P X P S M N 2. CHERRY M K I T T E H G A P S E O X S

G T R B O B A L P O Y E W W X 1. CAFÉ-AU-LAIT O U F A T U Y O E S T S S Y Y

Q Z P Q Q J P F Y A H T W V H
ANSWERS D H Y R R E B A W R T S A T A

FOOD WORDS CLUES


1. _____ SPOTS A finding in neurofibromatosis type 1 (3 words)
2. _____ ANGIOMA Also called Campbell De Morgan spots
3. _____ A heloma or clavus
4. _____ DIGIT Dactylitis
5. _____ EAR Common among wrestlers
6. _____ MOLAR Stigma of congenital syphilis
7. _____ STAIN Nevus flammeus (2 words)
8. PEAU D’ _____ Seen in inflammatory breast cancer
9. _____ MARK A type of hemangioma
10. _____ AND MEATBALLS Microscopic appearance of Malassezia
11. _____ COLORED CRUSTS Seen in impetigo
12. PLUCKED _____ SKIN Seen in pseudoxanthoma elasticum

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