Elke Weisshaar, Marion Büttner, Robert Ofenloch and Uwe Matterne
Department of Clinical Social Medicine, Occupational and Environmental Dermatology, University Hospital Heidelberg, Thibautstr. 3, DE-69115 Heidelberg, Germany. E-mail: elke.weisshaar@med.uni-heidelberg.de
Accepted May 25, 2011.
Pruritus is the most frequent symptom in dermatology, but it is also commonly found in other diseases, such as internal, neurological and psychosomatic/psychiatric diseases, and has a substantial impact on quality of life (1, 2). A population-based study reported a point-prevalence of 13.5% and a lifetime prevalence of 22% for chronic pruritus (duration > 6 weeks) (3). Patients presenting their symptom to a general practitioner (GP) mostly receive symptomatic therapies, such as topical corticosteroids and systemic antihistamines. Few specialists have sufficient expertise with chronic pruritus, and thus many patients have no access to more advanced therapeutic options. The University Hospital Heidelberg started an itch clinic in November 2006.
To date, little is known about whether patients with chronic pruritus benefit from specialized itch clinics. In a first step towards gathering more data on this subject, we therefore conducted a patient survey with chronic pruritus patients attending this itch clinic.
MATERIALS AND METHODS
Any physician may refer their patients to the itch clinic; the cost is covered by statutory health insurance. The itch clinic is led by a specialist trained in this field. Patients attending the clinic for the first time are asked to complete a special itch questionnaire (4). Medical assessment/diagnostics (i.e. clinical examination, laboratory screening, and other tests) and therapy (causative therapy and symptomatic treatment) are performed according to the European Dermatology Forum (EDF) guidelines (5). Patients are also invited to attend an educational multidisciplinary training programme for patients with chronic itch (6).
A total of 208 patients who had attended the itch clinic between May 2006 and June 2009 (first visit at least 6 months previously) were contacted again in August 2009 and sent a postal questionnaire. One reminder was sent 8 weeks later in case of non-response. The questionnaire contained questions about referral, waiting period, patient satisfaction and clinical aspects (occurrence and intensity of chronic pruritus). Patient satisfaction was assessed with a 9-item questionnaire. Responses could be given on a 5-point Likert-scale, with the endpoints “do not agree at all” to “totally agree”. The database also contains sociodemographic data (age, gender, education, occupational status, ethnic origin) assessed at the first visit to the clinic. Descriptive statistical analyses were conducted using SPSS 19.
RESULTS
A total of 126 patients (45.7% female, 54.3% male) returned the questionnaire, giving a response rate of 61%. Drop-out analysis revealed that there were no significant differences with regard to sex (χ2 = 1.930, p = 0.210), age (t = –0.230, p = 0.820) and itch duration (t = –0.003, p = 0.998) between responders and non-responders.
Based on underlying aetiology, as suggested by the International Forum for the Study of Itch (IFSI) (2) 34.4% had an underlying dermatological origin, 17.2% systemic, 7.8% neurological, 11.7% psychosomatic, 21.1 mixed, and in 7.8% the origin was undetermined. The mean age was 61 years (± 15.6 years), and 88% of subjects originated from Germany. Half of the respondents held elementary, 14% ordinary secondary and 25% advanced secondary school certificates. One-third of respondents were working, while the remainder was either retired or still undergoing tertiary education.
Thirty-six percent of the sample reported that they were referred to the itch clinic by the department of dermatology of the University Hospital Heidelberg. Sizable proportions were also referred by dermatologists in private practise (29%), by GPs (13%), or by other specialists in private practise (6.5%). Sixteen percent presented because they had heard about the clinic from family, friends, media or others. Seventy-nine percent stated that they had waited for their appointment for 4 weeks or less. Only 2% waited for more than 8 weeks.
Chronic pruritus within the previous 12 months was reported by 76% of the sample, while 67% reported present chronic pruritus (compared with 100% when they had presented to the itch clinic). Table I shows the mean scores on the 9-item patient satisfaction questionnaire.
Table I. Means and standard deviations (SD) of the 9-item patient satisfaction questionnairea
| Mean ± SD | |
| Satisfaction with time allocation | 4.04 ± 0.96 |
| Satisfaction with medical care | 3.91 ± 1.11 |
| Satisfaction with general procedure | 3.74 ± 1.02 |
| Itch clinic has generally helped me | 3.06 ± 1.28 |
| Advice received is incorporated into daily life | 3.50 ± 1.02 |
| Feel that symptom is taken seriously | 2.98 ± 1.34 |
| Itch clinic taught me to take better care of my health | 2.89 ± 1.03 |
| Itch clinic helped me to cope better with pruritus | 2.89 ± 1.11 |
| Itch clinic has helped me to come to terms with my illness | 2.50 ± 1.29 |
aRange 1 (do not agree at all) to 5 (totally agree).
DISCUSSION
In Germany, there are only a few university hospitals that offer a specialized itch clinic for patients with chronic pruritus, among them Münster (7) and Heidelberg. Many patients consult a number of specialists, without any therapeutic success, before presenting to one of these clinics.
The present survey provides a first indication that a specialized itch clinic is beneficial to patients with chronic pruritus. Analyses of the 9-item patient satisfaction questionnaire showed that patients favourably rate the services of the pruritus clinic in Heidelberg, and that they are generally satisfied, as expressed by the individual indicators of the scale. While this is encouraging, the fact remains that three-quarters of the sample still had chronic pruritus during the last 12 months and approximately two-thirds had chronic pruritus at the time of the survey. The number of specific anti-pruritic therapeutics is, however, still limited, and they can sometimes be offered only as off-label therapies by specialized physicians. It must be acknowledged that therapy of chronic pruritus is still a challenge, and therapeutic options may only partially benefit many patients (1, 4, 8). In addition, two-thirds of these patients were still being treated when they were contacted again. Therapy needs to be performed according to the underlying aetiology and, in case of ineffectiveness or undetermined origin, a step-wise procedure is necessary. This includes topical and systemic treatment, ultraviolet-phototherapy and the use of off-label medications. Off-label medication can be offered only in university hospitals, has to be approved by the health insurance provider, and often will have to be paid by the patients themselves. Physicians working in specialized itch clinics have usually acquired expert knowledge on chronic pruritus and update this knowledge regularly. This may prove beneficial to the patient afflicted with the bothersome symptom.
Future studies should assess patients’ satisfaction with specialized itch clinics by administering more standardized instruments, such as the pruritus-specific Patient-Benefit-Index (PBI) (8), as well as by specific quality-of-life instruments (e.g. ItchyQoL (9)) both before and some time after clinic attendance, in order more formally to assess such clinics’ benefits from the patients’ perspective. When the itch clinic started in 2006 neither the specific PBI nor the ItchyQoL was yet available. Future studies should assess patient satisfaction with instruments such as quality of life instruments before and after clinic attendance, to assess more formally the benefits of itch clinics from the patients’ perspective. Future studies could also attempt to compare subjective and objective improvements in patients treated in specialized clinics and in those simply presenting the symptom to a GP.
REFERENCES
