STUDY

ONLINE FIRST
The Impact of Pruritus on Quality of Life
The Skin Equivalent of Pain
Seema P. Kini, MD, MSCR; Laura K. DeLong, MD, MPH; Emir Veledar, PhD;
Anne Marie McKenzie-Brown, MD; Michael Schaufele, MD; Suephy C. Chen, MD, MS

Objective: To compare the impact of chronic pruritus
and chronic pain on quality of life (QoL) using directly
elicited health utility scores.
Design: Cross-sectional study.
Setting: Convenience sample of patients attending
the Emory Dermatology Clinic, Emory Spine Center,
and Emory Center for Pain Management, Atlanta,
Georgia.
Participants: Adult men and women (aged ⱖ18 years)
experiencing chronic pain or pruritus for 6 weeks or more.
Main Outcome Measures: The mean utility score of
patients with chronic pruritus was compared with that
of patients with chronic pain. A regression analysis was
performed to determine the impact of the primary pre-
dictor variable—symptom type—on the primary out-
come variable—mean utility score (a metric represent-
ing the impact on QoL).
Results: The study included 73 patients with chronic
pruritus and 138 patients with chronic pain. The mean
(SD) utility among patients with pruritus was 0.87 (0.27)
compared with 0.77 (0.31) for patients with pain (P⬍.01).
After symptom severity, duration, and demographic fac-
tors were controlled for, only symptom severity (0.03
[P⬍ .05]) and single marital status (−0.12 [P =.02]), but
not symptom type (P=.43), remained significant predic-
tors of the mean symptom utility score.
Conclusions: Chronic pruritus has a substantial im-
pact on QoL, one that may be comparable to that of pain.
The severity of symptoms and the use of support net-
works are the main factors that determine the degree to
which patients are affected by their symptoms. Address-
ing support networks in addition to developing new thera-
pies may improve the QoL of itchy patients.
Arch Dermatol. 2011;147(10):1153-1156.
Published online June 16, 2011.
doi:10.1001/archdermatol.2011.178

Author Affiliations:
Departments of Dermatology
(Drs Kini, DeLong, Veledar,
and Chen), Anesthesiology
and Pain Medicine
(Dr McKenzie-Brown), and
Rehabilitation Medicine
(Dr Schaufele), Emory
University School of Medicine,
and Department of Health
Services Research &
Development, Division of
Dermatology, Veterans Affairs
Medical Center (Dr Chen),
Atlanta, Georgia.
S
EVERAL STUDIES HAVE AT -
tempted to demonstrate that
chronic pruritus has a signifi-
cant effect on health-related
quality of life (QoL).1-3 Be-
cause chronic pruritus is often not ame-
nable to treatments for acute pruritus, it
can result in a debilitating course, includ-
ing the development of symptoms of de-
pression, global distress, and impairment
of sleep.3 Although few large-scale epide-
miological studies have been performed to
determine the prevalence of chronic pru-
ritus, there is evidence to suggest that it
is a common problem: a cross-sectional
study of skin disease in France found that
pruritic cutaneous conditions may affect
20% to 30% of the French population.4
Author Interview available
at www.archdermatol.com
Despite the reported widespread and
debilitating effect of chronic pruritus, re-
search relating to this symptom has not
been as well established as in other chronic
conditions such as pain. Chronic pain and
pruritus share many similarities: both are
complex, subjective symptoms that have
been demonstrated to have a compelling
effect on health-related QoL, including the
development of symptoms of depression
See Practice Gaps
at end of article
and the impairment of activities of daily
living.5-7 However, unlike chronic pruri-
tus, pain syndromes have been well stud-
ied in health services and outcomes re-
search, resulting in a better understanding
of this complex condition and the devel-
opment of novel treatments. Given the
similarities between these 2 symptoms, we
believe that chronic pruritus has a sub-
stantial QoL impact, comparable to that
of pain. The purpose of this study was to
determine the extent of the QoL impact
of these 2 conditions by measuring health
utility scores—a metric that represents a

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 cruited via flyers placed in their respective clinic offices or were
Table 1. Study Characteristics informed of the study by their treating physician. We ex-
cluded patients who demonstrated an inability to speak or read
Pruritus Pain English or any other disability that would prevent them from
Cohort Cohort completing both the questionnaire and the FTF TTO. In-
Variable (n=73) (n=138) P Value a formed consent was obtained from all patients before they were
Demographic b included in the study. We included patients only once in the
Male b 31 (42) 52 (38) study, regardless of the number of times that they attended the
White b 54 (74) 112 (80) pain or the dermatology clinic during the duration of the study.
Married b 54 (74) 91 (66)
Age, mean (SD), y 55 (17) 55 (16) STUDY VARIABLES
Symptom severity, No. (%)
Mild 18 (24) 22 (16) The main outcome variable in this study was the symptom util-
Moderate 34 (47) 65 (47) ity score. For the purposes of statistical analysis, we grouped
Severe 21 (28) 50 (36) ⬍.001 the primary predictor variables so that each variable had 3 or
Utility score, mean (SD) 0.87 (0.27) 0.77 (0.30) ⬍.001
fewer potential degrees of freedom. Sociodemographic vari-
Mild 0.93 (0.19) 0.87 (0.23)
ables were limited to age, sex, race (white, nonwhite), marital
Moderate 0.91 (0.19) 0.83 (0.27)
Severe 0.71 (0.41) 0.66 (0.34)
status (married, single), education (ⱕhigh school, college, gradu-
ate school), and household income (⬍$50 000, $50 000-
a All P values other than those listed are ⱖ.05. 100 000, ⬎$100 000). Clinical variables included symptom du-
b Compared with the ␹2 test; all other variables werecompared with the ration (⬍1, 1-5, 5-10, or ⬎10 years) and symptom severity. The
t test, and all demographic values other than age are expressed as number patients rated their symptom severity over the past 6 weeks “at
(percentage). its worst,” “at its best,” “at present,” and “on average” using a
visual analog scale ranging from 0 to 10; the results were grouped
into mild (1-3), moderate (4-6), and severe (7-10). We used
subjective level of satisfaction with a certain health the daily average assessment of severity in the statistical analy-
state—in patients with chronic pruritus and pain. ses in this study.

METHODS
STATISTICAL ANALYSES

We used the independent sample t test and the ␹2 test in uni-

The institutional review board of Emory University, Atlanta, Geor-
gia, approved this cross-sectional study. The survey materials
included paper-based questionnaires regarding demographics,
clinical parameters, and symptom severity. In addition to these
paper-based surveys, each consenting patient completed a face-
to-face time trade-off (FTF TTO) interview to assess the QoL
impact of their symptom (pain or pruritus) by generating a util-
ity score for their respective health state. The FTF TTO method
is a standard method with which to elicit health utility scores.8
Utility scores are numeric values that are expressed on a con-
tinuous scale anchored at death (utility score, 0) to perfect health
(utility score, 1). Health utility scores closer to 0 indicate a greater
burden of disease than that of a health state closer to 1. Previ-
ously reported mean health utility scores for other dermatologi-
cal conditions include 0.640 for bullous diseases, 0.867 for my-
cosis fungoides, and 0.938 for acne vulgaris.9
In the FTF TTO interview, we used a computerized utility
instrument to provide patients with a hypothetical decision: liv-
ing the rest of their life in their current health state or living
for a shorter period in perfect health. In other words, patients
could exchange a portion of their future survival time in order
to live in perfect health during a shortened life span. The length
of time in perfect health was varied until the patient was in-
different about the decision. The FTF TTO–derived utility score
is the ratio of the time remaining after the trade to the life ex-
pectancy of the individual. For example, a patient with a life
expectancy of 75 years who was willing to give up 3 years to
live without pruritus would have a utility score of 72/75, or 0.960,
for the health state of chronic pruritus. Simply put, this pa-
tient would be willing to forfeit 4% of his or her life expec-
tancy to live without pruritus. The eAppendix (available at http:
//www.archdermatol.com) details the elicitation method.
From June 2007 to April 2008, we recruited adult patients
(aged ⱖ18 years) with chronic pain or pruritus (symptom du-
ration ⬎6 weeks) from the Emory Spine Center and the Cen-
ter for Pain Management or from the Emory Dermatology Clinic,
respectively, Atlanta, Georgia. Potential patients were re-
variate analyses to determine the impact of continuous and cat-
egorical variables, respectively, on the mean utility score. We
developed a generalized linear model to assess the effect of symp-
tom type (pain or pruritus) on the primary outcome variable,
ie, the mean utility score, after controlling for symptom sever-
ity, symptom duration, age, sex, race, marital status, and edu-
cational and income levels. We assessed variance inflation fac-
tors for each covariate of interest for multicollinearity.
All tests were 2-sided. P⬍.05 was required for statistical sig-
nificance. We performed all analyses with SAS software (Ver-
sion 9.1; SAS Institute, Cary, North Carolina).
POWER ANALYSIS
Rather than power for an equivalence study, we assumed a mini-
mum effect size that would be meaningful between the 2 sets
of utility scores. Power was calculated with the goal of detect-
ing a difference of at least 0.10 in the mean utility score (deemed
as a clinically significant difference10) between the pain and the
pruritus groups. We assumed a 2-sided t test, with a common
SD of 0.30, an ␣ value of .05, and 80% power to estimate the
need for 125 individuals per group. To power our regression
analysis, we used the rule of thumb of 10 patients per inde-
pendent variable. With the 9 anticipated variables, we would
need 90 patients.
RESULTS
DEMOGRAPHICS AND CHARACTERISTICS
OF PAIN AND PRURITUS COHORTS
A total of 138 patients with chronic pain and 73 pa-
tients with chronic pruritus were recruited. The demo-
graphic characteristics of the participants and the distri-
bution of the severity of symptoms among the 2 groups

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 are shown in Table 1. Continuous variables are re-
ported as mean (SD), and categorical variables are re-
ported as proportions. There were no differences in the
demographic characteristics between the 2 groups. Both
the pain and the pruritus groups had a mean age of 55
years, were mostly female (62% vs 58%, respectively),
and were predominantly white (80% vs 74%). In both
the pain and the pruritus groups, the median duration
of symptoms was 6 months to 1 year, and almost half of
the patients characterized the severity of their symp-
toms as moderate. A greater percentage (36% vs 28%
[P⬍ .001]) of the patients in the pain group, however,
characterized their symptom as severe. The mean utility
score among patients with pruritus was 0.87 (0.27) com-
pared with 0.77 (0.31) for patients with pain (P ⬍.01).
MULTIVARIATE REGRESSION:
PRIMARY OUTCOME VARIABLES
AND UTILITY SCORES FOR PAIN
AND PRURITUS COHORTS
We report the parameter estimates of the regression model
in Table 2. Single marital status (−0.12 [P = .02]) and
symptom severity (0.03 [P ⬍.05]) remained significant
predictors of the symptom utility score after other sub-
ject characteristics were controlled for. Race trended to-
ward significance (P=.07). Neither symptom (pain or pru-
ritus) type nor symptom duration was a significant
predictor of the symptom utility score.
COMMENT
This study of patients with chronic pruritus and pain has
several important findings. First, our data suggest that
chronic pruritus carries a considerable burden of dis-
ease, as measured by health utility scores. In this study,
the mean health utility score of patients with chronic pru-
ritus was 0.87, indicating that the average patient was will-
ing to forfeit 13% of his or her life expectancy to live with-
out pruritus. Previously reported health utility scores for
other dermatological conditions in a similar utility range
include bullous diseases (0.640) and mycosis fungoides
(0.867).9
Second, our results from this small study indicate that
chronic pruritus may have a QoL impact comparable to
that of chronic pain. In our univariate analysis, patients
with chronic pruritus had a significantly greater mean
utility score (0.87) for their symptom than patients with
chronic pain (0.77). However, on multivariate analysis,
symptom type was not a significant predictor (P=.43).
Although it may appear as though patients with chronic
pain carry a considerably greater burden of disease than
those with chronic pruritus, we believe that this differ-
ence exists because a greater proportion of patients char-
acterized their symptom as severe in the pain cohort com-
pared with the pruritus cohort (P ⬍ .01). Also, on
multivariate analysis, after demographic and clinical vari-
ables were controlled for, symptom type (pain or pruri-
tus) was not a significant predictor of the primary out-
come variable: the mean health utility score. This finding
suggests that chronic pruritus has a substantial burden
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Table 2. Multivariate Linear Regression
Independent Variable Coefficient P Value
Symptom type
Pain, 0; itch, 1 0.05 .43
Severity group
Mild, 1-3; moderate, 4-6; severe, 7-10 −0.03 .05
Duration, y
⬍1, 1-5, 5-10, ⬎10 0.02 .64
Sex 0.06 .27
Age −0.001 .56
Race
White, nonwhite −0.10 .07
Marital status
Married, single −0.12 .02
Education
ⱕHigh school, college, graduate school −0.01 .90
Income, $
ⱕ50 000, 50 000-100 000, ⬎100 000 0.01 .80
of disease, a burden that may be comparable to that of
chronic pain. Indeed, the primary determinants of the
mean health utility score, and thus the degree of QoL im-
pact, on multivariate modeling were symptom severity
(−0.03 [P⬍.05]) and marital status (−0.12 [P=.02]). Spe-
cifically, greater pruritus severity and single marital sta-
tus were associated with a lower mean health utility score
(ie, worse QoL).
It may seem peculiar that marital status had a stron-
ger measure of effect than symptom severity. However,
epidemiological research indicates that social relation-
ships (with marital status as a proxy measure) may be
protective of morbidity by aiding in economic well-
being, healthier lifestyles, lower stress, and social sup-
port.11-13 Furthermore, in a large cross-sectional study of
individuals with chronic pain and pruritus, Dalgard et
al14 found that those individuals who were most af-
fected by their chronic pain or pruritus tended to be
younger and female and reported more depressive symp-
toms and significantly poorer well-being. Together, these
findings underscore the importance of the psychosocial
and affective dimensions in affecting patient symptoms.
The role of support groups to connect patients who are
experiencing similar symptoms, as well as the use of pru-
ritus-specific QoL instruments to track improvements in
patient-defined end points, may have a profound effect
on reducing the burden of disease.
In this study, the median duration of symptoms for
both the pain and the pruritus cohorts was 6 months to
1 year. While symptom severity and marital status were
found to contribute significantly to the overall mean util-
ity score, symptom duration (0.06 [P=.27]) was not a
significant predictor of the mean utility score in the mul-
tivariate regression model. The reason that symptom du-
ration did not contribute significantly to the overall mean
utility score may be attributable to an adaptation phe-
nomenon whereby patients experiencing chronic ill-
nesses or disabilities are motivated to find ways to ac-
commodate their symptom. Consequently, an actual
patient’s overall rating of his or her own QoL is often much
higher than that of a healthy individual hypothetically
picturing life with the disease state of interest.15,16
WWW.ARCHDERMATOL.COM
 Our study has several limitations. As with all survey-
based studies, this study was subject to response, recall,
and selection biases. Because patients in both the pain
and the pruritus cohorts were recruited from Emory Uni-
versity, a tertiary referral center, the study population may
have included highly motivated patients with more se-
vere disease than those usually found at a nonacademic
center. Similarly, patients who are severely affected may
have been more likely to participate. Both of these bi-
ases, however, would result in an overestimation of the
burden of disease (ie, a lower mean utility score) and for
the purposes of comparison would affect both the pain
and the pruritus cohorts similarly. Finally, this study did
not assess the potential contribution of other comorbidi-
ties such as mood states (eg, depression, anxiety) that
have been previously reported to contribute to the over-
all poorer well-being experienced by patients with chronic
itch and pain.3,14
Despite these limitations, the aim of this study was to
provide greater insight into the burden of chronic pru-
ritus and to compare the QoL impact of this symptom
with that of chronic pain. Although itch is thought to be
mediated by a neuronal pathway that is distinct from the
pain-processing pathway, the sensations of itch and pain
continue to be conceptualized as closely related.17,18 Our
study provides a model to compare common debilitat-
ing symptoms that are best self-reported and have very
few objective findings. Symptoms other than pain and
pruritus include nausea, heartburn, neuralgias, and dys-
esthesias. The FTF TTO health utility scores show that
patients are giving up time, something of understand-
able value and a unit of measure that can be compared
across other health conditions.
Overall, our data support previously published re-
sults indicating that patients with chronic pruritus
carry a significant burden of disease.4,14,19 This study
provides preliminary data that future studies may build
on by incorporating larger and more general popula-
tions of patients and by assessing the contribution of
mood states (eg, depression, anxiety) to the impact of
pruritus on QoL. Such other studies are needed to cor-
roborate our findings. Our results also highlight the
value of developing new therapies to improve the QoL
of itchy patients and of providing support networks for
these patients to discuss their conditions and to com-
miserate with each other.
Accepted for Publication: April 20, 2011.
Published Online: June 16, 2011. doi:10.1001
/archdermatol.2011.178
Correspondence: Suephy C. Chen, MD, MS, Dermatol-
ogy Clinical and Outcomes Research Unit, Department
of Dermatology, Emory University School of Medicine,
Emory Clinic, Bldg A, 1365 Clifton Rd NE, Ste 1100, At-
lanta, GA 30322 (schen2@emory.edu).
Author Contributions: All authors had full access to all
the data in the study and take responsibility for the in-
tegrity of the data and the accuracy of the data analysis.
Study concept and design: DeLong, McKenzie-Brown,
Schaufele, and Chen. Acquisition of data: Kini, DeLong,
McKenzie-Brown, and Schaufele. Analysis and interpre-
tation of data: Kini, DeLong, Veledar, and Chen. Draft-
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ing of the manuscript: Kini and Chen. Critical revision of
the manuscript for important intellectual content: Kini,
DeLong, Veledar, McKenzie-Brown, Schaufele, and Chen.
Statistical analysis: Kini, Veledar, and Chen. Administra-
tive, technical, and material support: Kini, DeLong,
McKenzie-Brown, Schaufele, and Chen. Study supervi-
sion: Chen.
Financial Disclosure: None reported.
Online-Only Material: The eAppendix is available at http:
//www.archdermatol.com. Visit www.archdermatol
.com to listen to an author podcast about this article.
Additional Contributions: Alice Huang, BA, Livia Van,
MD, Shinko Lin, MD, Mary Jayne McIlwain, MD, Ricardo
Berrios, MD, and Tunisia Finch, MD, graciously as-
sisted with this study.
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