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, according to investigators.
Itch is historically underrecognized as a symptom of MS, but physicians should know that it is common and may negatively impact quality of life, reported lead author Giuseppe Ingrasci, MD, a dermatology research fellow at the University of Miami, Miller School of Medicine, and colleagues.
While previous publications suggest that pruritus occurs in just 2%-6% of patients with MS, principal author Gil Yosipovitch, MD, professor, Stiefel Chair of Medical Dermatology, and director of the Miami Itch Center in the Dr. Phillip Frost department of dermatology and cutaneous surgery at the University of Miami Miller School of Medicine, encountered itch in enough patients with MS that he presented his observations to a group of neurologists.
Most of them dismissed him, he recalled in an interview: “The neurologists said, ‘Very interesting, but we don’t really see it.’ ”
One of those neurologists, however, decided to take a closer look.
Andrew Brown, MD, assistant professor of clinical neurology and chief of the general neurology division at the University of Miami, Miller School of Medicine, began asking his patients with MS if they were experiencing itch and soon found that it was “a very common problem,” according to Dr. Yosipovitch.
Dr. Yosipovitch, who was the first to report pruritus in patients with psoriasis, launched the present investigation with Dr. Brown to determine if itch is also a blind spot in the world of MS. Their results, and their uphill battle to publication, suggest that it very well could be.
After being rejected from six neurology journals, with one editor suggesting that itch is “not relevant at all to neurology,” their findings were published in the Journal of the European Academy of Dermatology & Venereology.
A common problem that may indicate more severe disease
At the Multiple Sclerosis Center of Excellence in Miami, 27 out of 79 outpatients with MS (35%) reported pruritus, with an average severity of 5.42 out of 10. Among those with itch, the extremities were affected in about half of the patients, while the face, scalp, and trunk were affected in about one-third of the patients. Many described paroxysmal itch that was aggravated by heat, and about half experienced itch on a weekly basis.
Further investigation showed that itch was associated with more severe MS. Compared with patients not experiencing itch, those with itch were significantly more likely to report fatigue (77% vs. 44%), anxiety or depression (48% vs. 16%), and cognitive impairment (62% vs. 26%).
MRI findings backed up these clinical results. Compared with patients not experiencing itch, patients with itch had significantly more T2 hyperintensities in the posterior cervical cord (74.1% vs. 46.0%) and anterior pons/ventromedial medulla (62% vs. 26%). These hyperintensities in the medulla were also associated with an 11-fold increased rate of itch on the face or scalp (odds ratio, 11.3; 95% confidence interval, 1.6-78.6, P = 0.025).
“Health care providers should be aware of episodes of localized, neuropathic itch in MS patients, as they appear to be more prevalent than previously thought and may impair these patients’ quality of life,” the investigators concluded.
Challenges with symptom characterization, management
“This is an important study for both patients and clinicians,” said Justin Abbatemarco, MD, of Cleveland Clinic’s Mellen Center for Multiple Sclerosis, in a written comment. “As the authors mention, many of our patients experience transient symptoms, including many different types of sensory disturbance (that is, pins & needles, burning, electrical shocks, and itching). These symptoms can be really distressing for patients and their caregivers.”
While Dr. Abbatemarco has encountered severe itching in “several patients” with MS, he maintained that it is “relatively uncommon” and noted that MS symptomatology is an inherently cloudy subject.
“I think it is difficult to be definite in any opinion on this topic,” Dr. Abbatemarco said. “How patients experience these symptoms is very subjective and can be difficult to describe/characterize.”
Dr. Abbatemarco emphasized that transient symptoms “do not usually represent MS relapse/flare or new inflammatory disease activity. Instead, we believe these symptoms are related to old areas of injury or demyelination.”
Symptom management can be challenging, he added. He recommended setting realistic expectations, and in the case of pruritus, asking dermatologists to rule out other causes of itch, and to offer “unique treatment approaches.”
Cool the itch?
Noting how heat appears to aggravate itch in patients with MS, Dr. Yosipovitch suggested that one of those unique – and simple – treatment approaches may be cooling itchy areas. Alternatively, clinicians may consider oral agents, like gabapentin to dampen neural transmission, or compounded formulations applied to the skin to reduce neural sensitivity, such as topical ketamine. Finally, Dr. Yosipovitch speculated that newer antibody agents for MS could potentially reduce itch.
All these treatment suggestions are purely hypothetical, he said, and require further investigation before they can be recommended with confidence.
The investigators disclosed relationships with Galderma, Pfizer, Novartis, and others. Dr. Abbatemarco disclosed no conflicts of interest.
Correction, 9/19/22: An earlier version of this article misidentified the photo of Dr. Justin Abbatemarco.
, according to investigators.
Itch is historically underrecognized as a symptom of MS, but physicians should know that it is common and may negatively impact quality of life, reported lead author Giuseppe Ingrasci, MD, a dermatology research fellow at the University of Miami, Miller School of Medicine, and colleagues.
While previous publications suggest that pruritus occurs in just 2%-6% of patients with MS, principal author Gil Yosipovitch, MD, professor, Stiefel Chair of Medical Dermatology, and director of the Miami Itch Center in the Dr. Phillip Frost department of dermatology and cutaneous surgery at the University of Miami Miller School of Medicine, encountered itch in enough patients with MS that he presented his observations to a group of neurologists.
Most of them dismissed him, he recalled in an interview: “The neurologists said, ‘Very interesting, but we don’t really see it.’ ”
One of those neurologists, however, decided to take a closer look.
Andrew Brown, MD, assistant professor of clinical neurology and chief of the general neurology division at the University of Miami, Miller School of Medicine, began asking his patients with MS if they were experiencing itch and soon found that it was “a very common problem,” according to Dr. Yosipovitch.
Dr. Yosipovitch, who was the first to report pruritus in patients with psoriasis, launched the present investigation with Dr. Brown to determine if itch is also a blind spot in the world of MS. Their results, and their uphill battle to publication, suggest that it very well could be.
After being rejected from six neurology journals, with one editor suggesting that itch is “not relevant at all to neurology,” their findings were published in the Journal of the European Academy of Dermatology & Venereology.
A common problem that may indicate more severe disease
At the Multiple Sclerosis Center of Excellence in Miami, 27 out of 79 outpatients with MS (35%) reported pruritus, with an average severity of 5.42 out of 10. Among those with itch, the extremities were affected in about half of the patients, while the face, scalp, and trunk were affected in about one-third of the patients. Many described paroxysmal itch that was aggravated by heat, and about half experienced itch on a weekly basis.
Further investigation showed that itch was associated with more severe MS. Compared with patients not experiencing itch, those with itch were significantly more likely to report fatigue (77% vs. 44%), anxiety or depression (48% vs. 16%), and cognitive impairment (62% vs. 26%).
MRI findings backed up these clinical results. Compared with patients not experiencing itch, patients with itch had significantly more T2 hyperintensities in the posterior cervical cord (74.1% vs. 46.0%) and anterior pons/ventromedial medulla (62% vs. 26%). These hyperintensities in the medulla were also associated with an 11-fold increased rate of itch on the face or scalp (odds ratio, 11.3; 95% confidence interval, 1.6-78.6, P = 0.025).
“Health care providers should be aware of episodes of localized, neuropathic itch in MS patients, as they appear to be more prevalent than previously thought and may impair these patients’ quality of life,” the investigators concluded.
Challenges with symptom characterization, management
“This is an important study for both patients and clinicians,” said Justin Abbatemarco, MD, of Cleveland Clinic’s Mellen Center for Multiple Sclerosis, in a written comment. “As the authors mention, many of our patients experience transient symptoms, including many different types of sensory disturbance (that is, pins & needles, burning, electrical shocks, and itching). These symptoms can be really distressing for patients and their caregivers.”
While Dr. Abbatemarco has encountered severe itching in “several patients” with MS, he maintained that it is “relatively uncommon” and noted that MS symptomatology is an inherently cloudy subject.
“I think it is difficult to be definite in any opinion on this topic,” Dr. Abbatemarco said. “How patients experience these symptoms is very subjective and can be difficult to describe/characterize.”
Dr. Abbatemarco emphasized that transient symptoms “do not usually represent MS relapse/flare or new inflammatory disease activity. Instead, we believe these symptoms are related to old areas of injury or demyelination.”
Symptom management can be challenging, he added. He recommended setting realistic expectations, and in the case of pruritus, asking dermatologists to rule out other causes of itch, and to offer “unique treatment approaches.”
Cool the itch?
Noting how heat appears to aggravate itch in patients with MS, Dr. Yosipovitch suggested that one of those unique – and simple – treatment approaches may be cooling itchy areas. Alternatively, clinicians may consider oral agents, like gabapentin to dampen neural transmission, or compounded formulations applied to the skin to reduce neural sensitivity, such as topical ketamine. Finally, Dr. Yosipovitch speculated that newer antibody agents for MS could potentially reduce itch.
All these treatment suggestions are purely hypothetical, he said, and require further investigation before they can be recommended with confidence.
The investigators disclosed relationships with Galderma, Pfizer, Novartis, and others. Dr. Abbatemarco disclosed no conflicts of interest.
Correction, 9/19/22: An earlier version of this article misidentified the photo of Dr. Justin Abbatemarco.
, according to investigators.
Itch is historically underrecognized as a symptom of MS, but physicians should know that it is common and may negatively impact quality of life, reported lead author Giuseppe Ingrasci, MD, a dermatology research fellow at the University of Miami, Miller School of Medicine, and colleagues.
While previous publications suggest that pruritus occurs in just 2%-6% of patients with MS, principal author Gil Yosipovitch, MD, professor, Stiefel Chair of Medical Dermatology, and director of the Miami Itch Center in the Dr. Phillip Frost department of dermatology and cutaneous surgery at the University of Miami Miller School of Medicine, encountered itch in enough patients with MS that he presented his observations to a group of neurologists.
Most of them dismissed him, he recalled in an interview: “The neurologists said, ‘Very interesting, but we don’t really see it.’ ”
One of those neurologists, however, decided to take a closer look.
Andrew Brown, MD, assistant professor of clinical neurology and chief of the general neurology division at the University of Miami, Miller School of Medicine, began asking his patients with MS if they were experiencing itch and soon found that it was “a very common problem,” according to Dr. Yosipovitch.
Dr. Yosipovitch, who was the first to report pruritus in patients with psoriasis, launched the present investigation with Dr. Brown to determine if itch is also a blind spot in the world of MS. Their results, and their uphill battle to publication, suggest that it very well could be.
After being rejected from six neurology journals, with one editor suggesting that itch is “not relevant at all to neurology,” their findings were published in the Journal of the European Academy of Dermatology & Venereology.
A common problem that may indicate more severe disease
At the Multiple Sclerosis Center of Excellence in Miami, 27 out of 79 outpatients with MS (35%) reported pruritus, with an average severity of 5.42 out of 10. Among those with itch, the extremities were affected in about half of the patients, while the face, scalp, and trunk were affected in about one-third of the patients. Many described paroxysmal itch that was aggravated by heat, and about half experienced itch on a weekly basis.
Further investigation showed that itch was associated with more severe MS. Compared with patients not experiencing itch, those with itch were significantly more likely to report fatigue (77% vs. 44%), anxiety or depression (48% vs. 16%), and cognitive impairment (62% vs. 26%).
MRI findings backed up these clinical results. Compared with patients not experiencing itch, patients with itch had significantly more T2 hyperintensities in the posterior cervical cord (74.1% vs. 46.0%) and anterior pons/ventromedial medulla (62% vs. 26%). These hyperintensities in the medulla were also associated with an 11-fold increased rate of itch on the face or scalp (odds ratio, 11.3; 95% confidence interval, 1.6-78.6, P = 0.025).
“Health care providers should be aware of episodes of localized, neuropathic itch in MS patients, as they appear to be more prevalent than previously thought and may impair these patients’ quality of life,” the investigators concluded.
Challenges with symptom characterization, management
“This is an important study for both patients and clinicians,” said Justin Abbatemarco, MD, of Cleveland Clinic’s Mellen Center for Multiple Sclerosis, in a written comment. “As the authors mention, many of our patients experience transient symptoms, including many different types of sensory disturbance (that is, pins & needles, burning, electrical shocks, and itching). These symptoms can be really distressing for patients and their caregivers.”
While Dr. Abbatemarco has encountered severe itching in “several patients” with MS, he maintained that it is “relatively uncommon” and noted that MS symptomatology is an inherently cloudy subject.
“I think it is difficult to be definite in any opinion on this topic,” Dr. Abbatemarco said. “How patients experience these symptoms is very subjective and can be difficult to describe/characterize.”
Dr. Abbatemarco emphasized that transient symptoms “do not usually represent MS relapse/flare or new inflammatory disease activity. Instead, we believe these symptoms are related to old areas of injury or demyelination.”
Symptom management can be challenging, he added. He recommended setting realistic expectations, and in the case of pruritus, asking dermatologists to rule out other causes of itch, and to offer “unique treatment approaches.”
Cool the itch?
Noting how heat appears to aggravate itch in patients with MS, Dr. Yosipovitch suggested that one of those unique – and simple – treatment approaches may be cooling itchy areas. Alternatively, clinicians may consider oral agents, like gabapentin to dampen neural transmission, or compounded formulations applied to the skin to reduce neural sensitivity, such as topical ketamine. Finally, Dr. Yosipovitch speculated that newer antibody agents for MS could potentially reduce itch.
All these treatment suggestions are purely hypothetical, he said, and require further investigation before they can be recommended with confidence.
The investigators disclosed relationships with Galderma, Pfizer, Novartis, and others. Dr. Abbatemarco disclosed no conflicts of interest.
Correction, 9/19/22: An earlier version of this article misidentified the photo of Dr. Justin Abbatemarco.
FROM THE JOURNAL OF THE EUROPEAN ACADEMY OF DERMATOLOGY & VENEREOLOGY