Pay attention to pain caused by itch in atopic dermatitis

Dr. Silverberg

Pain is a distinct and important symptom of atopic dermatitis experienced by almost two thirds of patients, reports a study published in The Journal of Allergy and Clinical Immunology: In Practice.¹

It is a symptom that can have a detrimental effect on quality of life with a third of patients saying they experienced pain from atopic dermatitis at least once a week and one twenty experienced it daily.

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The researchers looked at data collected from 602 adults who had self-assessed the severity of their atopic dermatitis and provided information on the severity and frequency of their symptoms and how their condition affected their quality of life for the internet-based Atopic Dermatitis in America survey.

The survey results showed that the majority of U.S. adults with atopic dermatitis report pain from their condition, but that in a subset of adults pain was both frequent and intense, says Jonathan Silverberg, M.D., Ph.D., MPH, from the department of dermatology at Northwestern University Feinberg School of Medicine in Chicago.

“Atopic dermatitis pain intensity was significantly higher among those who reported more frequent pain. Frequency and intensity of atopic dermatitis pain were both associated with more severe atopic dermatitis and itch,” he adds.

Almost two thirds (61%) of patents reported experiencing some pain from atopic dermatitis, with a third (33%) saying that they experienced pain at least once per week and 5% daily.

Those with pain were asked to assess its severity on a ten-point score with ten representing the worst possible pain, and 22% rated pain as ≥7. Almost half of patients (48%) reported that pain occurred only after frequent scratching, 42% said that their pain was intermittent and 11% said that it was constant.

Scratching was more likely to be implicated as the cause of pain in patients with mild atopic dermatitis, while those with more severe disease were more likely to experience more constant pain and pain related to inflamed skin.

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Pain was most commonly associated with open areas caused by scratching (27%) and with fissures in the skin (27%), followed by inflamed red skin (25%). Only a minority of patients (10%) reported that their pain was mostly burning from creams or ointments.

Higher pain intensity, but not frequency, was associated with more lesions on the face and lower level of education, and pain, particularly more frequent and/or severe pain, was associated with significantly worse quality of life.

Dr. Silverberg notes that pain was a commonly reported and burdensome symptom in atopic dermatitis and appeared to be a symptom distinct from itch.

A subset of atopic dermatitis patients reported having only mild itch but moderate or severe pain, or mild pain and moderate or severe itch, and approximately one-half of adults who experienced atopic dermatitis pain reported that it was not merely related to scratching, he explains.

“Atopic dermatitis pain appears to be multifactorial, with subsets of atopic dermatitis pain attributed to scratching, fissures, inflamed red skin per se and only a minority from poor tolerability of topical medications. In particular, pain attributed with inflamed red skin was most commonly reported in those with severe atopic dermatitis and atopic dermatitis lesions on the face,” says Dr. Silverberg. “Finally, atopic dermatitis pain was associated with worse quality of life even after controlling for severity of atopic dermatitis and itch.”

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The mechanisms of pain in atopic dermatitis are unknown, but Dr. Silverberg suggests that they are likely to be multifactorial and differ by pain characteristics.

“A subset of atopic dermatitis pain appears to be secondary to mechanical trauma of the skin from open sores secondary to excoriations. However, pain attributed to inflamed, red skin might be mediated by cutaneous inflammation or aberrant nerve signalling,” he says. “It is important to note that only a small minority of adults with atopic dermatitis reported that their pain was primarily caused by burning from topical medications.”

He adds, “Future studies are needed to determine the precise mechanisms and optimal treatment approaches for pain in atopic dermatitis.”

References:

1. Silverberg JI, Gelfand JM, Margolis DJ, et al. Pain Is a Common and Burdensome Symptom of Atopic Dermatitis in United States Adults. J Allergy Clin Immunol Pract. 2019;