Special Interest Group (Def-SIG)

Paraneoplastic Itch: An Expert Position Statement from the Special Interest Group (SIG) of the International Forum on the Study of Itch (IFSI)

In clinical practice, the term “paraneoplastic itch” is used to describe itch in patients with cancer. Patients with hematological or solid tumor malignancies can be affected. In general, paraneoplastic itch is considered a rare disorder. However, paraneoplastic itch in hematological malignancies such as polycythemia vera and lymphoma are relatively frequent while other forms of paraneoplastic itch are in fact extremely rare. The true frequency of this symptom is unclear, epidemiological data in this field are limited. Itch in malignant disease may additionally impair patients’ quality of life. A population-based cohort study showed that chronic itch without concomitant skin changes is a risk factor for having undiagnosed hematologic and bile duct malignancies. Paraneoplastic itch is rather resistant to treatment. In 2012, an interdisciplinary interest group of physicians and researchers was founded, aiming to generate a clear definition of paraneoplastic itch. In this paper we briefly review the current knowledge and aim to define what can be summarized under the term “paraneoplastic itch”.
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SIG Sensitive skin

Sensitive skin is a frequent complaint in the general population, patients, and among subjects with itch. The International Forum for the Study of Itch (IFSI) decided to initiate a special interest group (SIG) on sensitive skin. Using the Delphi method, sensitive skin was defined as "A syndrome defined by the occurrence of unpleasant sensations (stinging, burning, pain, pruritus, and tingling sensations) in response to stimuli that normally should not provoke such sensations. These unpleasant sensations cannot be explained by lesions attributable to any skin disease. The skin can appear normal or be accompanied by erythema. Sensitive skin can affect all body locations, especially the face". This paper summarizes the background, unresolved aspects of sensitive skin and the process of developing this definition.

Pruritus Assessment in Clinical Trials: Consensus Recommendations from the International Forum for the Study of Itch (IFSI) Special Interest Group Scoring Itch in Clinical Trials

Chronic pruritus is a common symptom and there is an urgent need to test new anti-pruritic substances in high-quality clinical trials. However, no widely accepted standardized and validated method for objectively measuring pruritus is yet available. A special interest group of the International Forum for the Study of Itch has been established to assess scoring methods and questionnaires for use in clinical trials. This paper presents our current recommendations. The set of measures we recommend includes pruritus intensity scales, instruments for assessment of scratch lesions, chronic pruritus course, quality of life and patient benefits. Please click here to open the pdf version of this paper.

Verbalizing Extremes of the Visual Analogue Scale for Pruritus: A Consensus Statement

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European Guideline on Chronic Pruritus
In cooperation with the European Dermatology Forum (EDF) and the European Academy of Dermatology and Venereology (EADV)

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Questionnaires to Assess Chronic Itch: A Consensus Paper of the Special Interest Group of the International Forum on the Study of Itch

Chronic itch affects millions of patients worldwide and has a significant impact on quality of life. The assessment of itch and its associated effects is a significant component of clinical practice in itch management. Despite itch being a common complaint, there are few studies describing the use of structured questionnaires for evaluation and measurement of itch and its sensory and affective dimensions. The International Society of the Study of Itch (IFSI) has recently provided invaluable data on the use of visual analogue scales as an assessment tool for itch. However, it is clear that additional tools are needed to better assess the different dimensions of chronic itch and better tailor management. With this goal in mind, a Special Interest Group was initiated by members of IFSI to determine which of the various psychometric properties of itch questionnaires offer the greatest utility in the evaluation of chronic itch. This first consensus paper addresses what domains and structure of itch questionnaires need to be implemented to better assess chronic itch and guide therapy. Please click here to open the pdf version of this paper.

Visual Analogue Scale: Evaluation of the Instrument for the Assess­ment of Pruritus

The aim of this study was to evaluate the visual analogue scale (VAS) as a method of pruritus assessment. A total of 310 subjects with pruritic dermatoses (148 Caucasian subjects and 162 Asian subjects) were recruited. The patients assessed pruritus intensity using the horizontal and vertical VAS, numeric rating scale (NRS) and verbal rating scale (VRS). All scales showed very good repro - ducibility (intraclass coefficient (ICC) > 0.8). No significant differences were found between the horizontal and vertical VAS (5.3 ± 2.9 vs. 5.3 ± 3.0 points, p = 0.34). Using NRS, patients rated their pruritus significantly higher than with VAS (5.7 ± 2.6 points, p < 0.01). VRS showed the highest correlation with NRS (R = 0.82, p < 0.001), followed by horizontal (R = 0.75, p < 0.001) and vertical VAS (R = 0.74, p < 0.001). Based on detailed analysis following VAS categories were proposed: 0 = no pruritus, > 0–< 4 points = mild pruritus, ≥ 4 –< 7 points = moderate pruritus, ≥ 7–< 9 points = severe pruritus, and ≥ 9 points = very severe pruritus. In conclusion, the VAS is a valuable method of pruritus measurement. Please click here to open the pdf version of this paper.

Assessment of Pruritus Intensity: Prospective Study on Validity and Reliability of the Visual Analogue Scale, Numerical Rating Scale and Verbal Rating Scale in 471 Patients with Chronic Pruritus

The most commonly used tool for self-report of pruritus intensity is the visual analogue scale (VAS). Similar tools are the numerical rating scale (NRS) and verbal rating scale (VRS). In the present study (initiated by the International Forum for the Study of Itch) assessing reliability of these tools, 471 randomly selected patients with chronic itch (200 males, 271 females, mean age 58.44 years) recorded their pruritus intensity on VAS (100-mm line), NRS (0–10) and VRS (four-point) scales. Re-test reliability was analysed in a subgroup of 250 patients after one hour. Statistical analysis showed a high reliability and concurrent validity (r>0.8; p<0.01) for all tools. Mean values of all scales showed a high correlation. In conclusion, high reliability and concurrent validity was found for VAS, NRS and VRS. On re-test, higher correlation and less missing values were observed. A training session before starting a clinical trial is recommended. Please click here to open the pdf version of this paper.

Definition of terms and classifications concerning chronic pruritus

The dramatic growth in membership of the International Forum for the Study of Itch (IFSI) is a reflection of developments in pruritus research and patient care. As the knowledge base expands, it becomes more and more important for clinicians and researchers to have a forum to discuss highly specific issues in depth. One issue is the precise definitions of terms describing various forms of pruritus. Language is dynamic and underlies adaptation and changes corresponding to the development of new techniques and lifestyle. Most of the terms currently used for different types of pruritus were created decades ago. In 2007, the IFSI published a clinical classification of pruritus (Ständer S, Weisshaar E, Mettang T, Szepietowski JC, Carstens E, Ikoma A, Bergasa N, Gieler U, Misery L, Wallengren J, Darsow U, Streit M, Metze D, Luger TA, Greaves MW, Schmelz M, Yosipovitch G, Bernhard J. Clinical classification of itch: A position paper of the International Forum for the Study of Itch. Acta Dermatol Venerol 2007, 87: 291-294) Please click here to open the pdf version of this paper. For further publicationson IFSI, we refer to the website of Acta Dermato-Venereologica, http://adv.medicaljournals.se/.
The discussion around the definition of a first version of the IFSI-clinical classification already showed that an in-depth discussion and formation of a Special Interest Group (SIG) is necessary. This SIG aims to keep in continuous discussion about terms and definitions. Results will be published on the homepage of IFSI as well in to be determined Journals after consensus has been achieved among the members.
If you are interested in receiving the summary of the actual Def-SIG consensus or to contribute certain comments, please send an email to sonja.staender@uni-muenster.de.

Consensus among participants already achieved for:

  1. Acute pruritus: up to 6 weeks
                Chronic pruritus: lasting for 6 weeks and longer
  2. Somatoform pruritus: pruritus of psychosomatic / psychiatric origin
  3. Pruritus sine materia: should no longer be used
                Alternative: Pruritus of unknown origin, pruritus on non-inflamed / normal skin
  4. Pruritus of unknown origin (PUO):
    - can be used interchangeably with “Itch of undetermined pruritus (IUO)”
    - should be used in patients were a) no diagnostic is performed and history does not suggest an origin of pruritus; b) in patients with unknown origin of pruritus after diagnostics
  5. Senile pruritus: should no longer be used
                Alternative: pruritus of advanced age, pruritus in the elderly

IFSI - Special Interest Group: Scoring Itch in Clinical Trials
(SIG-Scoring Itch)
New in 2009

Chronic pruritus is a multidimensional and subjective symptom. Patients report next to individual pruritus intensity, quality, localization, duration, course, and scratching behaviour also interindividual variations in impact on quality of life, reduction of sleep time and psychosomatic conse-quences. Most of these factors temporally influence the itch severity, es-pecially the itch intensity. To date, the most commonly used tool for self-report of itch intensity is the visual analogue scale (VAS). VAS is a graphic method to obtain an objective representation of the subjective symptom itch. Currently, several new interesting tools for the objective measurement of itch are under development or already validated. For example, the Ep-pendorf Itch Questionnaire (EIQ), questionnaire for coping with itch (“JKF”), pruritus-specific quality-of-life questionnaire (ItchyQoL) and Pa-tient Benefit Index for pruritus patients (PBI-P) are already available. The world wide growing number of clinical trials evaluating antipruritic potency of new developed substances demands the development of further new robust assessment tools to monitor the improvement of several pruritus parameters such as e.g. dynamic pruritus score (measuring quantitative itch reduction), improvement of sleep time or regression of pruritus related-anxiety and depression. This SIG aims to give recommendations for the use of measurement tools such as VAS in clinical trials and application of additional and new tools.

This SIG is open to every IFSI member and interested experts. To contribute to our discussion, you can fill in the questionnaire. Please send it back via mail (Prof. Dr. S. Ständer, Department of Dermatology, Uni-versity of Münster, Von-Esmarch-Str. 58, 48149 Münster, Germany) or email (sonja.staender@uni-muenster.de).

The launch meeting of the new SIG and discussion of the questionnaire re-sults will take place during the next IFSI meeting in Tokyo: October 26th, 08.00 – 09.00 am.

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