Itch and pain are major components of psoriatic disease and require management

Itch and pain are important symptoms of psoriatic disease impacting patients’ quality-of-life. During the IFPA 2024, Prof. Adam Reich (Medical College of Rzeszów University, Poland) reviewed itch in psoriasis, and Dr Anushka Irani (University of Oxford, UK) presented the link between pain and psoriatic disease.

“Historically, psoriasis was considered not to present with itch and this can even be found in textbooks,” said Prof. Reich [1]. However, recent data have shown that “more than 80% of patients who suffer from psoriasis also suffer from itch.”

The question of whether psoriatic itch intensity is related to disease severity was addressed in a cross-sectional study involving participants with large-plaque psoriasis, nummular psoriasis, guttate psoriasis, scalp psoriasis, inverse psoriasis, erythrodermic psoriasis, palmoplantar psoriasis vulgaris, palmoplantar pustular psoriasis, and generalised pustular psoriasis [2]. Itch intensity and psoriasis severity are significantly correlated in subtypes such as palmoplantar psoriasis, scalp psoriasis, and generalised pustular psoriasis.

Itch has a very detrimental effect on people living with psoriasis. Patients consider pruritus as the most bothersome symptom of psoriasis, and itch intensity is significantly associated with increased suicidal ideation [3,4]. Furthermore, improvement in itch is significantly associated with quality-of-life measures even after statistical adjustment for psoriasis objective severity measures [5].

“There is no single therapy licensed for itch,” said Prof. Reich [1]. “I do believe all biologics are highly effective in decreasing itch. Definitively, histamine is not a major player in the pathogenesis of psoriasis, but I don’t want to say that antihistamines are completely ineffective.”

Managing pain in psoriatic disease

Reducing pain is an important treatment goal for psoriasis, with up to 60% of patients considering it key and 70% of patients considering a reduction in burning as a treatment goal [6]. “As rheumatologists, we have traditionally assumed that the pain comes from inflammation in the joints and potentially from structural changes,” said Dr Irani [1]. “While there is some truth in that, it is not always the only cause of the pain.” An analysis of the large DANBIO cohort of patients with inflammatory arthritis showed that pain visual analogue scale scores were higher than 30 out of 100 in patients who were treated with biologics or disease-modifying antirheumatic drugs confirming that pain might be due to other causes [7].

Diagnosis of chronic pain can be based on widespread pain of a long duration that is unresponsive to treatment [8]. Other indirect indicators of chronic pain include heightened fatigue, unrefreshing sleep, poor memory and concentration, as well as hypersensitivity to visual, auditory, and tactile stimuli. Pain can also be measured with several tools including the Widespread Pain Index in case of fibromyalgia, the Pain Questionnaire, the DN4 questionnaire, and the Central Sensitisation Inventory (CSI) [9].

No specific guidelines are available for pain management in psoriatic disease. However, the EULAR recommendations for pain management in osteoarthritis and inflammatory arthritis can be used [10]. “The emphasis is thinking about the patients holistically and not only worrying about what’s happening in the joints but zooming out and thinking about the biopsychosocial elements as well and trying to tailor treatment utilising not only pharmacological elements but also other treatment options” [1].

1. 
   
   1. Reich AD, Irani A. Understanding pain and itch in psoriatic disease. IFPA Conference 2024, 27–29 June, Stockholm, Sweden.
   2. Jaworecka K, et al. J Eur Acad Dermatol Venereol. 2023;37(4):787-795.
   3. Pariser D, et al. J Dermatolog Treat. 2016;27(1):19-26.
   4. Lesner K, et al. Acta Derm Venereol. 2017;97(10):1182-1188.
   5. Zhu B, et al. Br J Dermatol. 2014;171(5):1215-9.
   6. Pithadia DJ, et al. J Dermatolog Treat. 2019;30(5):435-440.
   7. Rifbjerg-Madsen S, et al. PLoS One. 2017;12(7):e0180014.
   8. Kang Y, et al. BMJ. 2023:381:e076036.
   9. Neblett R, et al. J Pain. 2013;14(5):438-45.
   10. Geenen R, et al. Ann Rheum Dis. 2018;77(6):797-807.

Copyright ©2024 Medicom Medical Publishers



Posted on 17 July 202417 July 2024