Assessing skin pain in psoriasis patients

Skin pain, experienced by more than 40 percent of people with psoriasis, is the most subjective of symptoms. To describe their pain, individuals use words such as aching, burning, throbbing, piercing, stinging, nagging, cramping, and the list goes on. 

By contrast, according to a review article in the September 2018 Journal of Dermatological Treatment, doctors and biomedical researchers tend to measure skin pain as mild, moderate or severe. And some pose the question even more simply as a matter of “yes or no.” As a result, the patient experience gets lost in translation. 

Co-author Deeti Pithadia, a fourth-year medical student at the Augusta University Medical College of Georgia, cited the need for a reliable way of measuring skin pain that melds the subjective with the objective. “Ensuring that patients and physicians are on the same linguistic page is a tremendous challenge,” she says, especially when trying to capture highly individualized sensations like pain and itch. 

At every step in their analysis, researchers kept returning to the need for improved assessment, both in the doctor’s office and in the research setting. 

In their view, the most promising assessment tool to emerge is the Pain Quality Assessment Scale. The PQAS aims to capture the severity of 20 specific qualities of skin pain, Pithadia says. However, its reliability has yet to be tested. 

She suggests one possible way for dermatologists to gain a deeper understanding of skin pain. “Treat the pain not just as a symptom but as a chief complaint in itself,” she says. “And ask people not just about the severity of their pain but about its location, character, duration and effects on day-to-day life.” She also recommends that dermatologists ask what aggravates skin pain and what brings relief. 

The authors noted that, in general, the more psoriasis symptoms per square inch of the body, the more severe the pain. Psoriasis plaques on the scalp, extremities and genitals can be especially painful. 

Although skin pain related to psoriasis is less common than itching and scaling, it may compromise your quality of life just as much, if not more, by disrupting mood, sleep, physical activity, personal relationships and work productivity.

Of all the major symptoms of psoriasis, skin pain – even mild pain – has the strongest association with mental health disorders, which can go hand-in-hand with the disease. 

While often seen together, skin pain and psychological distress are two separate yet related issues. The physical symptoms of psoriasis, paired with the social and emotional impact, can exacerbate skin pain. Researchers emphasize the need to independently manage the physical and psychiatric aspects of psoriasis.

“Chronic pain can produce anxiety and depression. In turn, these psychiatric comorbidities may perpetuate pain by lowering the threshold at which patients perceive it,” explains Jashin Wu, M.D., the article’s senior author and NPF medical board member.

As for short-term episodes of skin pain, treating skin plaques and their inflammatory underpinnings may not be enough. That’s because the healing process is not immediate, according to the study. To get through a short bout of skin pain, acetaminophen, nonsteroidal anti-inflammatory drugs, and mild opiates are all effective, along with treating the depression and anxiety that aggravate the perception of pain. 

Long-term or chronic skin pain is another story. Synthetic derivatives of vitamin D have been shown to be effective for some living with psoriasis. Light therapy also can help, and so can biologic drugs that target inflammation. Capsaicin, a natural painkiller derived from hot peppers, may work over time. However, when first applied, it actually creates more pain, making it problematic for clinical use. 

Pithadia and her co-authors will continue exploring assessment tools for psoriasis-related skin pain – a necessary step in the development of new treatments or optimizing existing treatments that target the source of inflammation. 

Researchers hope to solve the mismatch between patients’ lived experiences and the way these are assessed at the doctor’s office. That will require dermatologists to learn and interpret patients’ language in useful, measurable ways.

It’s time to take action

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