PSORIASIS and COMORBIDITIES – CARDIOVASCULAR DISEASE

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WHAT IS COMORBIDITY?

Comorbidity is a concurrence of multiple diseases or disorders in association with a given disease, in this case, psoriasis.

 INCREASED RISK

 The patient with psoriasis has an increased risk of developing one or more of a number of other diseases/conditions that share many immunological features with psoriasis.

 CHART 1: Comorbidities Associated with Psoriasis 1,2,3

Metabolic Syndrome – Cardiovascular Disease

  • Arterial hypertension/ Atherosclerosis
  • Myocardial infarction (MI)
  • Dyslipidemia (Raised cholesterol)

The immunological abnormalities that lead to the development of psoriasis suggest that these patients may be at increased risk for other diseases associated with an inflammatory state. Research is yet to establish whether other diseases occur as a direct result of the systemic inflammation associated with psoriasis, as a consequence of genetically determined selection, or whether it is possible that the link between psoriasis and Cardiovascular disease and myocardial infarction (MI)  may be mediated by other factors beyond inflammation, such as psychological stress, sedentary lifestyle, or possibly poor compliance with management of cardiovascular risk factors.. 4.5

There is increasing evidence to suggest that the immune response, including activated T cells, antigen presenting cells, cytokines, and markers of systemic inflammation such as C-reactive protein, are important to the development of atherosclerosis (hardening and narrowing of the arteries) and ultimately, MI. 2 Research has shown that patients with psoriasis have a higher incidence of MI compared with control patients, with patients who have severe psoriasis as having the highest rate. The risk of MI associated with psoriasis is greatest in younger patients (under the age of 40) with severe psoriasis. This reduces with age but still remains an increased risk even after treatment for traditional cardiovascular risk factors that are associated with aging. 5

Psoriasis is also associated with hypertension (increased blood pressure). In one study researchers examined the association among hypertension, antihypertensive medication use, and risk of incident psoriasis using prospective data from a large cohort of US women. A total of 121,701 participants, of which 2477 participants were diagnosed with psoriasis, were followed for 11 years with 2 yearly questionnaires. Researchers found that a prior history of hypertension was associated with an increased risk of psoriasis among women with hypertension for 6 years or more. Specifically, hypertensive women without medication use and with current medication use were more likely to develop psoriasis compared with women who did not have hypertension. Among the individual antihypertensive drugs, only ?-blockers were associated with an increased risk of psoriasis after regular use for 6 years or more. 6

medical-monitoring-1306439_FreeImages

In a United Kingdom study using a large (7.5 million patients from 415 practices) electronic medical records database (The Health Improvement Network (THIN), a random sample of patients with psoriasis between the ages of 25 and 64 years were identified. The identification parameters were a diagnosis of hypertension; confirmed psoriasis diagnosis and classified psoriasis severity. The severity classification was identified according to the National Psoriasis Foundation classification system 1) mild (limited disease with ?2% BSA affected), moderate (scattered disease with 3%-10% BSA affected), or 2) severe (extensive disease with >10% BSA affected). Blood pressure was compared to the UK National Institute of Health and Care Excellence clinical guidelines, with uncontrolled hypertension being defined as systolic blood pressure of 140 mm Hg or higher or diastolic blood pressure of 90 mm Hg or higher. 

All patients with psoriasis who met the inclusion criteria were included in the study, yielding 680, 469, and 173 patients with mild, moderate, and severe psoriasis, respectively. The researchers found a significant positive relationship between psoriasis severity and uncontrolled hypertension independent of potential risk factors for poor blood pressure control. The likelihood of uncontrolled hypertension in patients with vs without psoriasis was greatest among those with moderate and severe skin disease, representing nearly half of the psoriasis patients seen by GPs in the United Kingdom. The findings have important clinical implications, highlighting a need for more effective management of blood pressure in patients with psoriasis, especially those with more extensive skin involvement (i.e. ?3% BSA affected).7 

The precise mechanisms that underlie psoriasis and hypertension are unknown. One theory proposed is that adipose (fat) tissue in psoriasis patients serves as a major source of angiotensinogen, which is subsequently converted to angiotensin II. Angiotensin II not only promotes salt retention by kidneys; it also stimulates T-cell proliferation. Angiotensin II also appears to promote inflammation and the development of atherosclerosis. Other theories suggest that increased visceral adipose tissue in psoriasis patients may contribute to hypertension development. Increased visceral adipose tissue may be associated with accumulation of perivascular fat, which can serve as a reservoir for activated effector T cells that promote dysfunction in both hypertension and psoriasis. Or that endothelin-1 may play an important role in the development of hypertension among psoriasis patients. Endothelin-1 is a protein that constricts blood vessels and increase blood pressure, and it is produced by several different cell types including keratinocytes. While the level of endothelin-1 is usually regulated through various mechanisms, their expression appears to be altered in psoriasis patients. 8 The connection between obesity and psoriasis, when taken in light of the above theories, is further strengthened. It is always advisable for those with moderate to severe psoriasis who are overweight to try to lose weight through sensible eating – reducing fast and fatty foods and increasing the intake of vegetables, especially green vegetables.

The development of atherosclerosis and its increased prevalence may be partially explained by the presence of atherosclerotic risk factors, e.g., diabetes, hypertension, obesity, and hyperlipidemia (increased levels of lipids in the blood, including cholesterol and triglycerides) as well as by the chronic inflammatory processes that are commonly observed in psoriasis. 9 

Researchers have found that psoriasis patients have impaired endothelial function and greater thickness of the innermost two layers of the wall of the carotid artery which leads to increased arterial stiffness. 9

Atherosclerosis, the underlying process resulting in cardiovascular events, is caused by the build up of atheromatous plaques in the inner layer of the arteries. Atheromatous plaques are an accumulation of degenerative material in the inner layer of an artery wall. The material consists of mostly macrophage cells, or debris, containing lipids, calcium and a variable amount of fibrous connective tissue. The interaction between metabolic abnormalities such as diabetes, high cholesterol etc. and the systemic proinflammatory mechanisms operating involved in psoriasis and psoriatic arthritis may explain the accelerated atherosclerotic process in these patients. Patients with psoriatic disease display abnormalities in the innate and adaptive immune system that result in high serum levels of proinflammatory cytokines that may upregulate cell-mediated immunity, promote inflammatory cell migration through the vascular endothelium (tissue that lines the interior surface of blood vessels), resulting in endothelial dysfunction and thus causing plaque formation and build up. 10

Recent studies clearly demonstrated that inflammation impairs reverse cholesterol transfer (High-density lipoprotein (HDL) cholesterol efflux) in vivo, providing evidence that inflammation impairs HDL function. HDL is a complex lipoprotein particle with a broad variety of functions, exerting atheroprotective activity via effects on the endothelium and by potent anti-inflammatory capabilities. Functional impairment of HDL may contribute to the increased cardiovascular mortality experienced by psoriatic patients. HDL from psoriasis patients and healthy controls was assessed for changed HDL composition. Researchers found that there was a significant reduction in apoA-I levels of HDL from psoriatic patients, whereas levels of apoA-II and proteins involved in acute-phase response, immune response, and endopeptidase /protease inhibition were increased. Psoriatic HDL also contained reduced phospholipid and cholesterol. The researchers found that the compositional alterations impaired the ability of psoriatic HDL to promote cholesterol efflux from macrophages. Importantly, HDL cholesterol efflux capability was more impaired as the psoriasis area and severity increased. 11

Efflux is a mechanism responsible for moving compounds, like cholesterol out of the cells.  The efflux process is extremely important because cholesterol overloading, such as occurs in the cells of the arterial walls, leads to the development of atherosclerotic plaque.12

Chronic systemic inflammation associated with psoriasis and psoriatic arthritis induces endothelial dysfunction, altered glucose metabolism, and insulin resistance that plays a significant role in the development of obesity, diabetes mellitus, dyslipidemia (high cholesterol), and cardiovascular disease such as atherosclerosis and myocardial infarction.

Those with moderate to severe psoriasis should ensure that they visit their General Practitioner to have their blood pressure and cholesterol checked and to have an ECG regularly to ensure the health of their heart.

 

REFERENCES

  • Arzu K?l?ç, Seray Cakmak; PSORIASIS AND COMORBIDITIES; EMJ Dermatol. 2013;1:78-85.
  • Howa Yeung et al.;Psoriasis Severity and the Prevalence of Major Medical Comorbidity – A Population-Based Study; JAMA Dermatol. 2013;149(10):1173-1179. doi:10.1001/jamadermatol.2013.5015
  • Aurangabadkar SJ. Comorbidities in psoriasis. Indian J Dermatol Venereol Leprol 2013;79, Suppl S1:10-7
  • Elgendy A, Alshawadfy E, Altaweel A, Elsaidi A (2016) Cardiovascular and Metabolic Comorbidities of Psoriasis. Dermatol Case Rep 1: 106.
  • Gelfand JM, Neimann AL, Shin DB, Wang X, Margolis DJ, et al. (2006) Risk of myocardial infarction in patients with psoriasis. JAMA 296: 1735-1741.
  • Wu S, Han J, Li W, Qureshi AA. Hypertension, Antihypertensive Medication Use, and Risk of Psoriasis.JAMA Dermatol. 2014;150(9):957-963. doi:10.1001/jamadermatol.2013.9957
  • Takeshita J, Wang S, Shin DB, et al. Effect of Psoriasis Severity on Hypertension Control: A Population-Based Study in the United Kingdom.JAMA dermatology. 2015;151(2):161-169. doi:10.1001/jamadermatol.2014.2094.
  • Wang Armstrong A. et al; Psoriasis and Hypertension Severity: Results from a Case-Control Study; PLoS ONE 6(3):e18227 · March 2011
  • Kalkan G , Karada? A.s.:The Association Between Psoriasis and Cardiovascular Diseases: Eur J Gen Med 2013; 10 (Suppl 1):10-16
  • Eder L. and Gladman D.D.; Atherosclerosis in psoriatic disease: latest evidence and clinical implications; Ther Adv Musculoskel Dis 2015, Vol. 7(5) 187–195 DOI: 10.1177/ 1759720X15591801
  • Holzer M. et al.; Psoriasis alters HDL composition and cholesterol efflux capacity; Journal of Lipid Research Volume 53, 2012
  • Phillips M.C.; Molecular Mechanisms of Cellular Cholesterol Efflux; J Biol Chem. 2014 Aug 29; 289(35): 24020–24029.

PSORIASIS and COMORBIDITIES – PSORIATIC ARTHRITIS

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WHAT IS COMORBIDITY?

 Comorbidity is a concurrence of multiple diseases or disorders in association with a given disease, in this case, psoriasis.

 INCREASED RISK

 The patient with psoriasis has an increased risk of developing one or more of a number of other diseases/conditions that share many immunological features with psoriasis.

Psoriatic Arthritis

Spondyloarthropathies

CHART 1: Comorbidities Associated with Psoriasis 1,2,3

Psoriatic arthritis (PsA) is an inflammatory arthropathy, which is associated with psoriasis in approximately 25% of patients. It is characterized by stiffness, pain, swelling, and tenderness of the joints as well as the surrounding ligaments and tendons. It affects men and women equally and typically presents at the age of 30 to 50 years. Skin lesions usually precedes the onset of PsA by an average of 10 years in the majority of patients but 14– 21% of patients with PsA develop symptoms of arthritis prior to the development of skin lesions.4

human_hand_bones-en The Foot

                  The Hand                                                                                             The Foot

The presentation of PsA is variable and can range from a mild, non-destructive arthritis to a severe, debilitating, erosive arthropathy.

There are various classifications for PsA:-

• Monoarthritis of the large joints – inflammation and arthritis in one joint.

PsN 1 Finger

          Swelling evident in the joint between the Intermediate and Proximal Phalanges in the index finger

  • Distal interphalangeal arthritis – affecting the joint between the Distal and Proximal phalanges.
  • Spondyloarthritis – affecting the spine and, in some people, the joints of the arms and legs.

Symmetrical deforming polyarthropathy – similar to that of rheumatoid arthritis

PsN all Distal Joints

Deformity of the Distal interphalangeal joints with varying degrees of severity seen across all of the fingers from severe to mild.

If PsA is left untreated, a percentage of patients may develop chronic inflammation with progressive deforming joint damage which leads to severe physical limitations and disability. So it is very important for a patient with psoriasis who is experiencing joint swelling or pain to be reviewed by a Rheumatologist as soon as possible. However, as there is no specific test for PsA, the diagnosis of PsA is based on clinical judgement. The main aspect is the absence of rheumatoid factor (91-94%), this key finding together with the specific presentation of joint pain and inflammation plus the presence of psoriasis skin lesions all combine to lead the Practitioner and the Rheumatologist to diagnose PsA. X-rays may aid diagnosis and can show the extent and location of joint damage. Other types of scans such as MRI or CT scans can also be used to look at the joints in more detail.

In many patients articular patterns change or overlap in time. Enthesitis, inflammation at the sites where tendons or ligaments insert into the bone, may occur at any site, but more commonly at the insertion sites of the plantar fascia (the fibrous band of tissue (fascia) connecting the heel bone to the base of the toe bones), the Achilles tendons, and ligamentous attachments to the ribs, spine, and pelvis. PsA is unusual in that it can affect joints on only one finger or toe, several joint on one side or on affect joints on both sides of the body. PsA symptoms often resemble those of rheumatoid arthritis. Both diseases cause the joints to become inflammed, painful, swollen and warm to the touch.4

The most common symptoms are:-

  • Swollen fingers and/or toes.  PsA can cause a painful, sausage-like swelling of the fingers and/or toes. Swelling and deformities in the hands and feet before having significant joint symptoms may occur.

  • Foot pain. Psoriatic arthritis can also cause pain at the points where tendons and ligaments attach to the bones — especially at the back of the heel or in the sole of the foot.
  • Lower back pain.Some sufferers develop a condition called spondylitis as a result of PsA which causes inflammation of the joints between the vertebrae of the spine and in the joints between your spine and pelvis (sacroiliitis).

Skin lesions in patients with PsA and psoriasis may vary from a mild to a severe presentation and the skin activity is commonly not indicative of the severity of the arthritis symptoms. It is important to note that skin lesions and symptoms normally precede arthritic signs and symptoms in 80% of psoriatic arthritis patients. Whilst simultaneous onset of arthritic and psoriatic symptoms will occur in approximately 13% of patients, only 3% of patients will have joint involvement preceding the development of skin lesions.5

People with PsA often experience pain, stiff joints and muscle weakness and often this is due to lack of use so a regime of light exercise is very important to improve overall health and to keep the joints as flexible as possible. It may be of benefit for people with PsA to consult with an exercise physiologist / remedial therapist who can give advice as the most suitable exercises that are patient specific, including how to get started safely, so that the potential to aggravate the joints are kept to a minimum.

Some of the types of exercise that should be discussed with your physiologist / therapist are:-

  • Aerobic exercises – walking, swimming or gentle water aerobics
  • Muscle-strengthening exercises – light weights
  • Muscle-stretching exercises
  • Hydrotherapy – supervised structured exercises of specific extremities and joints in warm water.

Use of Assistive Devices

An assistive device is a tool or implement that makes a particular function or action easier or possible to perform, e.g.:-

Clothing Aids

  • Velcro on clothes and shoes or elastic shoelaces.
  • Button and zipper hooks.
  • Leg-Up Leg Lifter allows users with limited mobility to avoid having to bend down or hold onto clothing to lift their leg.
  • Long handled shoe horns.

Grooming Aides

  • Fit Combs, brushes and toothbrushes with easier-to-hold handles for ease of use.
  • Or use Long handled brushes and combs that have anti-slip handles.
  • Use a toothpaste dispenser that automatically dispenses a set amount of toothpaste onto a brush.

Bathing and Showering Aides

  • Use a long handled hair washer that can be used to apply shampoo and massage the user’s scalp while reducing strain on the hands, shoulders, or arms.
  • Long handled foot wash brush to assist people with limited access to their feet.
  • Long handled sponge or cloth body washers.
  • Long handled lotion or ointment applicators.

Cooking and Cleaning Aides

  • Finger loop utensils.
  • Oven knob turner.
  • Cut resistance gloves and Finger protector (slicing) guard.
  • Easy glide plastic bag opener.
  • Jar “pop” openers.
  • Tin pull top openers.

Walking Aides

  • Walkers, canes, knee and ankle braces.

Remember there are many websites available where you can purchase any number of assistive devices.

It is important not to lock oneself away and use immobility as an excuse not to socialize. Use group exercise classes to not only improve one’s fitness and mobility but also use the opportunity to talk to other class member’s, or join a support group ….. just the act of talking and sharing can be enough to ensure that you do not become depressed.

 

 

REFERENCES

  • Arzu K?l?ç, Seray Cakmak; PSORIASIS AND COMORBIDITIES; EMJ Dermatol. 2013;1:78-85.
  • Howa Yeung et al.;Psoriasis Severity and the Prevalence of Major Medical Comorbidity – A Population-Based Study; JAMA Dermatol. 2013;149(10):1173-1179. doi:10.1001/jamadermatol.2013.5015
  • Aurangabadkar SJ. Comorbidities in psoriasis. Indian J Dermatol Venereol Leprol 2013;79, Suppl S1:10-7
  • Lloyd P. et al.; Psoriatic Arthritis: An Update; Hindawi Publishing Corporation Arthritis Volume 2012, Article ID 176298, 6 pages doi:10.1155/2012/176298
  • Gottlieb A.B. et al.; Clinical characteristics of psoriatic arthritis and psoriasis in dermatologists’ offices; Journal of Dermatological Treatment. 2006; 17: 279–287

 

 

PSORIASIS and DIET – Part 2

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In Part 1 we reviewed the research into diet and the various ways in which ones diet can impact on one’s health and the development of diseases such as psoriasis and arthritis.

Part 2 will concentrate on certain foods that can have a positive impact on one’s health and assist in the repair/healing processes.

It is known that throughout life, environmental conditions and dietary compounds influence gene expression. Only recently it has been observed that exposure to specific phytochemicals can affect gene expression via reversible epigenetic mechanisms and gets recorded in our “epigenome” through life. Epigenetics refers to heritable phenotypical differences or changes in gene expression that are not attributable to changes in DNA sequence, but rather depend on variations in DNA methylation, chromatin structure or microRNA profiles. As such, our dietary epigenetic imprint superposed on our genome may rewire gene expression patterns in the body and the host immune system, and protect against inflammatory disorders, cancer and ageing. 1

It has also been found that the metabolism of nutrients may vary person to person and ultimately result in different health status depending on the genotype of an individual. Nutrigenomic trends towards individualizing/personalizing foods (both to avoid and to consume) and nutritional supplementation, that leads to individual strategies to not only maintain good health but, more importantly, to assist in repair processes.

Phytochemicals/ phytonutrients/ phytonutriceuticals are organic compounds derived from plants that have health protective effects. Besides the common nutrients such as carbohydrates, amino acids and protein, there are certain non- nutrient phytochemicals in vegetables that have biological activity against chronic diseases. They are low in fat and like all plant products, contain no cholesterol. Most phytochemicals are found in relatively small quantities in vegetable crops. However, when consumed in sufficient quantities, phytochemicals contribute significantly towards protecting living cells against chronic diseases. 2

Cruciferous vegetables are vegetables of the family Brassicaceae (also called Cruciferae) which includes vegetable, such as kale, red and white cabbage, broccoli, brussels sprouts, cauliflower, turnip, Chinese cabbage and pak choi. This group of vegetables contains well-known antioxidants, such as vitamins C, E, carotenoids and antioxidant enzymes such as catalase, superoxide dismutase (SOD) and peroxidase, which are found in fresh vegetables. these vegetables are also rich in beneficial plant’s metabolites, which include sulfur containing glucosinolates, anthocyanins, flavonoids, terpenes, S-methylcysteine sulfoxide, coumarins and other minor compounds.4,5 Studies have also identified many compounds that have been isolated from Brassica vegetables and the pharmacological studies in vitro or in vivo have shown that they have a large spectrum of biological activities, including antiinflammatory, antibacterial, antifungal, antitumor, antimutagenic, neuroprotective and antioxidative properties. 4,5

The health potential of Brassica vegetables are partially attributed to their intricate fusion of phytochemicals and their antioxidant activity. Recently, considerable research has been aimed at the detection of plant derived natural antioxidants which can be utilized for human consumption for prevention of non-transmissible chronic diseases and promotion of health. Phytochemicals from Brassica vegetables may act on different and complementary levels. They prevent oxidative stress, induce detoxification enzymes and stimulate the immune system. Reactive oxygen species (ROS) in the body can cause lipid and protein oxidation, DNA damage, base modification and modulation of gene expression. 4,5

Antioxidants counteract, or neutralize, the harmful effects of free radicals. These antioxidants act as scavengers for these tree radicals and reactive oxygen species, thereby preventing them from disrupting the chemical stability of the cells. A variety of external factors such as inflammation, cigarette smoke, air pollutants, radiation (X-rays and ultra-violet rays) can promote free radical formation in our body. Consequently, individuals exposed to these sources of oxidants would require a greater supply of dietary antioxidants. 2 Skin is a major target of oxidative stress due to reactive oxygen species (ROS). Antioxidants attenuate the damaging effects of ROS and can impair and/or reverse many of the events that contribute to excessive growth and reproduction of skin cells. Increased ROS production in patients of psoriasis and decreased concentration of antioxidants leads to oxidative stress, which indicates lipid peroxidation. This may lead to cell damage by continuous chain reactions damaging the cell membranes and tissues. 3 Imbalance between ROS and antioxidants causes oxidative stress. Oxidative stress may be caused by antioxidant deficiency in the diets or increased production of free radicals caused by stress, smoking, environmental contaminations. Antioxidants and other bioactive compounds detoxify ROS and prevent damage to cellular macromolecules and organelles through multi-mechanisms. In human body, several mechanisms are known to defend from free radicals (for example antioxidant enzymes), however in some cases there is a need more substances to overcome their impact. Consumption of vegetables including Brassica species has been strongly associated with the reduced risk of chronic diseases, such as cardiovascular disease, diabetes, and age-related functional decline. 4,5 Antioxidants are also effective in reducing free radical damage of collagen and elastin, the fibers that support the skin structure.6

Carotenoids are yellow, red and orange pigments present in many fruits and vegetables. In the diet they act as powerful antioxidants and are believed to protect the body against free radical attack. Several studies on the bioavailability of B -carotene from vegetables in the human diet have shown that in broccoli it ranges from 22- 24%, in carrots 19-34%, and in leafy vegetables it ranges from 3-6%. Flavonols include quercetin, kaempferol, fisetin, and myricetin. Quercetin is the most important flavonoid in vegetables. It has been detected in onion. Kaempferol, myricetin, and fisetin have also been detected in onion as well as lettuce, and endive.

Anthocyanins give vegetable leaves and fruits their purple and or/red colour, such as in purple cabbage, purple broccoli, purple sweet potato, rhubarb, purple radish and onion. Anthocyanins have also been shown to protect mammalian cell lipoproteins from damage by free radicals. 2

Constant inflammation plays an essential role in many human illnesses and isothiocyanates (ITCs) slow down the activity of many inflammation mechanisms, restrain cyclooxygenase 2, and permanently inactivate the macrophage migration inhibitory factor. Studies have attributed ITCs with  anti-inflammatory abilities . They have been shown to reduce carrageenan-induced rat paw oedema, lessen ear oedema formation and induce leukocyte clearance in inflamed mouse skin and in studies using Human skin organ culture, has been shown to  reduce the expression and secretion of proinflammatory cytokines in human monocytes, macrophage-like cells and inflamed skin.7

As with anything diet should be balanced and any changes should be discussed with your Practitioner.

Also read our blog “PSORIASIS and DIET – Part 1, PSORIASIS and COMORBIDITIES, PSORIASIS and ALCOHOL and PSORIASIS and WATER INTAKE “.

REFERENCES

  • Vanden Berghe W. and Haegeman G.; Epigenetic Remedies by Dietary Phytochemicals Against Inflammatory Skin Disorders: Myth or Reality?; Curr Drug Metab.2010 Jun 1;11(5):436-50.
  • Pradeep Kumar Singh and K. Mallikarjuna Rao (2012): “Phytochemicals in Vegetables and their Health Benefits”, Asian Journal of Agriculture and Rural Development, Vol. 2, No. 2, pp. 177-183
  • Priya R. et al.; Oxidative stress in psoriasis.; Biomedical Research 2013; 25 (1): 132-134
  • Kapusta-Duch J. et al.; The beneficial effects of Brassica vegetables on human health; Rocz Panstw Zakl Hig 2012, 63, Nr 4, 389 – 395
  • Priya Sharma, Sonia Kapoor; Biopharmaceutical aspects of Brassica vegetables; Journal of Pharmacognosy and Phytochemistry 2015; 4(1): 140-147
  • Basavaraj, K H, C Seemanthini, and R Rashmi. “DIET IN DERMATOLOGY: PRESENT PERSPECTIVES.”Indian Journal of Dermatology 3 (2010): 205–210. PMC. Web. 16 Feb. 2016.
  • Yehuda H. et al.; Isothiocyanates inhibit psoriasis-related proinflammatory factors in human skin; Inflamm. Res. (2012) 61:735–742 DOI 10.1007/s00011-012-0465-3

Itch (Pruritus) & Eczema

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Scratching is the natural response to itch (Pruritus) and, by definition, inseparable from it. The act of scratching not only diminishes itch, but it has been found to be rewarding and addictive. The itch-scratch cycle is a complex phenomenon involving sensory, motor and emotional components. The urge to scratch can be remarkably intense because the reward provided by scratching brings such intense relief and may also be associated feelings of pleasure and enjoyment. Recent studies have shown that rating scratching as a pleasurable experience is correlated with the intensity of the underlying itch, both in patients with chronic itch and healthy individuals.1 Various functional brain imaging studies have discovered that the itch-scratch cycle in humans can be tracked to specific regions of the brain, including areas related to reward, pain sensation, and addiction.1,2

The Itch-Scratch-Rash cycle is commonly used to describe this ongoing, never ceasing, always constant itch that makes eczema very different from many other skin condition. Eczema has often been called the “Itch that Rashes” rather than the “Rash that Itches”.3 

Itch_1

The itchier a patient feels, the more scratching of the skin that occurs and which ultimately lead to skin damage and the appearance of a red rash. Often, in chronic presentations it becomes a completely unconscious habit and patients are often not even aware that they are scratching. When a patient scratches, the skin becomes inflamed, this inflammation then causes the skin to itch even more, thus making it even harder for the patient to resist the urge to scratch. This vicious circle can become so severe that it causes sleeplessness, irritability, anxiety and stress. In extreme cases it can lead to significant excoriations (open, bloody and deep scratch wounds) on the skin or even severe lichenification (thickening of the skin) and pain. 

The Practitioner and Patient need to recognize and address various aspects of itch, including:

(1) Identification and elimination of trigger factors;

(2) Maintaining the skin barrier through emollients – Oil based and Water Based;

(3) Targeting inflammation through topical medications and systemic (oral) medications

(4) Addressing psychological and behavioural components; and

(5) Education – understanding the condition.

The sensation of pruritus can be triggered by endogenous (internal) and exogenous (external) stimuli, which activate specific peripheral nerve endings in the epidermis and dermis layers of the skin.3

Trigger Factors3

Allergies                                   House dust mites, food allergens, air-born contact dermatitis (pollen, etc.), animals (e.g. cat                                                        dander), jewellery, certain cosmetic ingredients.

Infections                                 Staphylococcus aureus, viral infections (herpes, molluscum), yeasts (eg, Trichophyton,                                                                malassezia).

Exogenous                               Soaps, solvents, wool, sweat, chemicals, toxins, cigarette smoke, smog.

Physical stimuli                       Temperature: humidity, cold dry air, clothes rubbing on the skin.

Emotional                                Anxiety/Stress /Anger/ Depression.

How to rate your Itch4

Based on the Eppendorf  Itch Questionnaire.

Rate each of the following from 0 to 4

The following describes your Itch………

 01234
  Painful     
  Pulsating     
  Throbbing     
  Prickling     
  Hurting     
  Tickling     
  Stinging     
  Worse when Cold     
  Less when Cold     
  Worse when Hot     
  Less when Hot     
  Dull     
  Sharp     
  Burning     
  Feels like ants     
  Comes in waves     
  Unbearable     
  Annoying     
  Physical urge to scratch     
  Numbing     
  Relentless     
  Cruel     
  Tormenting     
  Tiring     
  Numbing     
  Severe     
  Uncontrollable     
  I only can think of the Itch     

When do you feel the need to Itch?

 01234
  In the Morning     
  In the Evening     
  At night     
  At rest     
  Worse in Bed     
  After a hot shower     
  After exercise     
  After being outside     
  After being in the Sun     
  After gardening     
  After Dusting, Sweeping/Vacuuming/ Changing beds     
  After eating certain foods

  Specify

     

How would you describe the need to Scratch?

 01234
  I find it enjoyable     
  It is a physical urge     
  It is compulsive     
  I forget when I do it     
  I always want to scratch     
  I find it satisfying     
  I find it pleasurable     
  It hurts but I cannot stop     
  Other –     

What action do you take when you feel the urge to scratch?

 01234
  I rub     
  I scratch with my nails     
  I scratch with my fingertips     
  I scratch with my knuckles     
  I use a pencil/pen/ruler/stick     
  I rub     
  I pinch     
  I use a cold pack     
  I use a heat pack     
  I take a cold shower     
  I take a warm shower     
  I take a hot shower     
  I put the air conditioner on     
  I turn down the ducted heating     
  I dig my fingernails in     
  I bite my lip     
  I scratch until I bleed     
  I apply pressure     
  Other –     

Which areas of the body do you scratch the most?

                              Front                                                           Back

What distracts you from the urge to scratch?

 01234
  Company distracts me     
  Watching Television     
  Reading a Book     
  Using a Computer/IPhone/IPad     
  Listening to music     
  Applying heat pack     
  Applying ice pack     
  Exercising     
  Doing something with my hands   (hobby)     
  Other –     

When you understand your itch, when you itch, what you do when you scratch and what distract you from scratching, you may be able to plan your approach to your itch more methodically and with more control. You may decide that you need to start a meditation or behavioural therapy class to help you control the need to scratch. You may find that you will learn the best times to apply your creams so that you circumvent the urge to scratch e.g. applying creams before gardening or mowing the lawn or doing housework etc.

What can a Patient do to avoid or control the urge to itch?

Scratching is difficult to resist because it gives the mental impression of easing the itch – but this is only for the short-term. Eventually the sensation to itch comes back – even worse that before you scratched. 

Basic tips to control the urge to itch:- 

  • Keep nails short to avoid tearing the skin when scratching. 
  • Keep cool. Over-heating can trigger the itch. Try to keep your body temperature as constant as you can, wear light layers of cotton clothes.
  • Avoid overheated rooms, keep ducted heating to a minimum, and at night keep the bedrooms cold.
  • Avoid heavy blankets and doonas – use cotton blankets if possible. 
  • Gently rub with the back of the fingers, place pressure or gently pinch the area instead of scratching. 
  • Use a cold compress 

Parents of children often ask “How can I stop my child from scratching?” And as scratching is an instinctive reaction to itching which can become a compulsive/unconscious habit, that question is not an easy one to answer. Parents can help by keeping their child’s nails short and, especially at night, by covering their hands with cotton mittens. 

With older children, it is important that you explain to them how scratching will actually make them feel worse, not better. And that their skin will become redder, more cracked and feel itchier and sorer. 

Become aware of any habits of scratching that your or your child may be developing and take especial note as whether it is at a particular time of day, or during a particular activity, such as playing sport or just watching television. If you or the parents of a child become aware of these types of habits then it is important to try to break the habit.

Nonpharmacological Treatments for the Management of Atopic Dermatitis Itch

 Cognitive-behavioural methods3,5,6

Cognitive-behavioural methods alter dysfunctional habits by interrupting and altering dysfunctional thought patterns (cognitions) or actions (behaviours) that damage the skin or interfere with dermatologic therapy. e.g. Itch-coping Training Programme or Habit Reversal Training, cognitive-behavioural methods for the reduction of itch and scratching behaviour, including self-monitoring, guidance in skin care and coping skills to manage itch- and scratch-triggering factors, stress-management methods with relaxation techniques and habit reversal. The habit reversal technique teaches patients to recognize the habit of scratching, identify situations that provoke scratching, and train them to develop a competing response practice, for example, a child who unconsciously scratches can be taught to recognize the early signs of the sensation of itch and instead of scratching be taught to clench his/her fists or place his/her hands underneath his/her legs as soon as they feel the sensation of itch.

Biofeedback5,7

Biofeedback can enhance the patient’s awareness of tension and help them to relax; improving skin disorders that flare with stress or that have an autonomic nervous system aspect. Biofeedback is a mind-body therapy that uses electronic instruments to assist patients to gain awareness and control over psychophysiological processes. The patient is connected to a machine that measures muscle activity, skin temperature, electrodermal activity, respiration, heart rate, heart rate variability, blood pressure, brain electrical activity, and brain blood flow and visually gives the patient feedback as they go through various “game” like tasks. Chronic itch, which may be somatic, emotional and cognitive, may be treated with therapies that can modulate the autonomic nervous system stress response. Behavioural biofeedback techniques that reduce stress and anxiety have been used to treat chronic pain and itch and could potentially alter the sympathetic over-activity noted in patients with AD.

Hypnosis / Meditation8

With proper training, an individual can intensify this trance state in himself or herself and use this heightened focus to induce mind-body interactions that help alleviate suffering or promote healing. The state of altered consciousness known as a “trance state” may be induced using guided imagery, relaxation, deep breathing, meditation techniques, self-hypnosis or by a trained medical practitioner. Researchers have used relaxation, stress management, direct suggestion for non-scratching behaviour, direct suggestion for skin comfort and coolness, ego strengthening, posthypnotic suggestions, and instruction in self-hypnosis. Their results were statistically significant for reduction in itch, scratching, sleep disturbance, and tension. Reported topical corticosteroid use decreased by 40% at 4 weeks, 50% at 8 weeks, and 60% at 16 weeks. For milder cases of atopic dermatitis, hypnosis along with moisturization can suffice as a primary alternative treatment. For more extensive or resistant atopic dermatitis, hypnosis can be a useful complementary therapy that reduces the amounts required of other conventional treatments.

Read also our Blogs for Psoriasis …. The same techniques can be used for Eczema

Simple Mental/Mind Relaxation Techniques Part 1 – For Psoriasis Patients

Simple Mental/Mind Relaxation Techniques Part 2 – For Psoriasis Patients

Itch_4 Itch_5 Itch_6

References

 

  • Papoiu A. D. P. et al.; Brain’s Reward Circuits Mediate Itch Relief. A Functional MRI Study of Active Scratching; PLOS ONE, www.plosone.org 1 December 2013, Volume 8, Issue 12, e82389
  • Mochizuki H. et al.; Chapter 23Brain Processing of Itch and Scratching; http://www.ncbi.nlm.nih.gov/books/NBK200933/?report=printable
  • Hong J. et al.; Management of Itch in Atopic Dermatitis; Seminars in Cutaneous Medicine and Surgery; Elsivier; doi:10.1016/j.sder.2011.05.002; Pg 71-88
  • Darsow U. et al.; New Aspects of Itch Pathophysiology: Component Analysis of Atopic Itch Using the ‘Eppendorf Itch Questionnaire’; Int Arch Allergy Immunol 2001;124:326–331
  • Shenefelt PD.; Psychological interventions in the management of common skin conditions; Psychology Research and Behavior Management 2010:3 51–63
  • Evers Et al.; Effectiveness of a Multidisciplinary Itch-coping Training Programme in Adults with Atopic Dermatitis; Acta Derm Venereol 2009; 89: 57–63
  • Tran BW. Et al.; Effect of Itch, Scratching and Mental Stress on Autonomic Nervous System Function in Atopic Dermatitis; Acta Derm Venereol 2010; 90: 354–361
  • Shenefelt PD. ;Hypnosis in Dermatology; Arch Dermatol / VOL 136, MAR 2000