Effectiveness of a multidisciplinary itch clinic in the management of chronic pruritus.

Sir,

Pruritus is the most frequent symptom dermatologists encounter and it has a significant negative impact on patients’ quality-of-life.[1] Chronic pruritus, defined as having itch for a duration longer than 6 weeks, is often difficult to manage. Advances in the understanding of the pathogenesis of pruritus have provided new perspectives for better management,[2] in particular, there is growing sentiment that specialized itch clinics can improve management.[23] A multidisciplinary itch clinic, was established at the National Skin Centre, Singapore, with the aim of providing better management for this difficult-to-treat condition through a holistic biomedical and psychosocial approach. The clinic comprises the concurrent services of a dermatologist, nurse educator, psychologist, psychiatrist and medical social worker. The role of the dermatologist in the itch clinic is focused on identifying the underlying cause/s of itch, with emphasis on establishing the contributory roles of the various pathogenetic factors. The nurse educator's main roles are to improve patient's understanding of their diseases and to educate them on the proper use of topical medications. Suitable patients are seen by the psychologist, who can provide psychoeducation, habit-reversal and stimulus control training, stress management and relaxation training, cognitive-behavioral therapy and acceptance and commitment therapy. Patients with psychiatric conditions will be co-managed between the dermatologist and psychiatrist. Patients with financial and social issues and those who require counseling will be referred to the medical social worker. At the end of the clinic, the team will meet to discuss about each patient's issues with the aim of formulating a unified holistic management plan.

A study was performed, to evaluate the effectiveness of managing patients with chronic pruritus in such a multidisciplinary clinic. Consecutive patients with chronic pruritus who were referred to the clinic were recruited during a 4 months period from 01 March to 31 July 2011. Patients with chronic pruritus who were unable to attend the itch clinic (as it runs on a specific time-slot each week) were recruited as controls. They were managed in the general dermatology clinics. All patients completed a comprehensive questionnaire during their first consultation and 3 months subsequently. The questionnaire was based on the validated impact of chronic skin disease on daily life questionnaire, which is a multidimensional health status inventory for chronic skin diseases.[4] The dermatology-specific part was modified to assess itch specifically and it included a 100 mm visual analog scale to assess itch intensity over the previous 4 weeks. The generic part of the inventory includes evaluation on the dimensions of psychological functioning (positive and negative mood symptoms), illness cognitions (helplessness and acceptance) and perception of social stigmatization.[5]

About 38 patients attended the itch clinic during the 4 months period, with 29 patients returning for follow-up after 3 months [Table 1]. Ten control patients were recruited, eight of which returned for follow-up. Results showed that patients managed at the itch clinic showed greater absolute improvement in itch intensity scores and all the psychosocial parameters tested compared with the controls [Table 2]. However, these differences were not statistically significant and this may be due to the small number of patients evaluated and the short interval of assessment. Nevertheless, the greater absolute improvement in scores of all the parameters suggests that management in the multidisciplinary specialized clinic confers a greater benefit compared to management in the general dermatology clinics and such an approach is promising towards the management of chronic pruritus.

Table 1

Clinical characteristics of patients seen at the itch clinic and the controls

Table 2

Pre and post-treatment itch scores and clinical parameters of psychological functioning