Scratching under the surface: The Temple Itch Center experience
By Warren R. Heymann, MDSept. 22, 2016
Nothing raises more questions than the development of a database. Nothing needs a database more than the study of chronic pruritus. Mollanazar et al reviewed their data from the Temple Itch Center in Philadelphia, encompassing 920 visits by 597 patients, in the first year of the center’s existence.
The main thrust of the article was validating the use of a numeric rating scale (NRS) quantifying itch intensity from 0 to 10 (where 10 is the worst imaginable itch), integrated into an electronic medical record (EMR). This easily allowed a determination of how patients perceived their pruritus,. and enabled measuring changes in the NRS following therapy. The authors conclude by advocating the use of a NRS in an EMR to easily monitor patient progress (1). (I thought this was a good idea, especially as dermatologists need to increasingly document outcomes for their patients. We use the Modernizing Medicine EMR — after reading this article I looked at our program and noted that there is a “visual analog scale of itch intensity” ranging from 0 to 10. I never knew that was there! I’ll have to start using it.)
When mining data, there are usually confirmatory findings and surprises that merit further analysis.:
The fact that patients older than 65 years fared worse than younger patients correlates with my experience.
Atopic dermatitis, neuropathic pruritus (including brachioradial pruritus and nostalgia paresthetica), and “pruritus of unspecified origin (PUO)” were the most common causes of chronic pruritus; that made sense.
Mirtazapine was the most commonly prescribed treatment; I have increasingly been using the second most commonly used drug — gabapentin.
The greatest change in NRS was for treating neuropathic pruritus and the least was for PUO, confirming how hard it is to treat the latter.
African-Americans experienced the greatest itch intensity, and those of Asian descent, the least.
The last finding about racial differences in pruritus caught me off guard. I have had the privilege of working in an ethnically diverse community my entire career, attending to virtually every race, color, creed, or gender. Everybody itches. I never considered racial predilections for pruritus (with the exception of certain conditions such as primary cutaneous amyloidosis in Asians or primary biliary cirrhosis in African-Americans) (2). There is a paucity of research exploring race and pruritus. Although differences may be theoretically due to altered barrier function, mast cell physiology, and itch receptor polymorphisms, much more research is warranted to help unravel racial variances in pruritus (3).
*My strongest emotion upon reading this paper, however, is that I miss Gil Yosipovitch. He came to Philadelphia a few years ago, quickly and amazingly establishing an outstanding Department of Dermatology at Temple, pardon the expression, from scratch. He established the Temple Itch Center that rapidly became the epicenter for patients with recalcitrant pruritus in the Delaware Valley (and beyond). His creativity, compassion, and dedication to his pruritic patients now reside in Miami. I am as likely to understand the pathophysiology of transient receptor potential vanilloid receptors as I am to comprehend how such a stellar center can be formed and disbanded within a three-year span. What I know, is that my review of this paper is, by definition, biased — biased by my personal respect, admiration, and friendship for a true gentleman and scholar. I wish him, his lovely wife Galit, and their family years ahead of personal and professional success in the Sunshine State.
1. Mollanazar NK, et al. Retrospective analysis of data from an itch center: Integrating validated tool in the electronic health record. J Am Acad Dermatol 2016; 75: 842-4.
2. Tey HL, Yosipovitch G. Itch in ethnic populations. Acta Derm Venereol 2010; 90: 227-34.
3. Hajdarbegovic E, Thio HB. Itch pathophysiology may differ among ethnic groups. Int J Dermatol 2012; 51: 771-6.
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