Research

Original Investigation

Factors Mediating the Impact of Chronic Pruritus

on Quality of Life
Christopher W. Carr, MD; Emir Veledar, PhD; Suephy C. Chen, MD, MS

IMPORTANCE Chronic pruritus is a common problem with a deleterious effect on quality of

life. The factors mediating the relationship between chronic pruritus and quality of life are
poorly understood.

OBJECTIVE To determine the factors that mediate the impact of chronic pruritus on quality
of life.

DESIGN, SETTING, AND PARTICIPANTS Cross-sectional study based on a nationwide telephone

survey of US military veterans sampled from the Veterans Hospital Patient Database.
Participants were veterans who agreed to participate and were found to have chronic
pruritus.

MAIN OUTCOMES AND MEASURES Statistical significance of predictor variables (characteristics

of patients and their chronic pruritus) in multivariate analysis using ItchyQoL scores as
response variables.

RESULTS Of 6000 veterans telephoned, 1075 consented to participate; 405 of these had
chronic pruritus. Factors that mediated the impact of chronic pruritus on quality of life were
demographic characteristics (age [P = .007], race [P = .05], marital status [P = .04]),
personality (extroversion [P = .03], neuroticism [P = .01]), pruritus characteristics (severity
[P < .001], duration [P = .01], frequency [P < .001], location [P = .005]), and possible etiology
(cutaneous vs systemic [P = .03]). Notable factors not found significant include sex (P = .98)
and socioeconomic variables (education level [P > .99], employment status [P = .53], income
[P = .62]).
Author Affiliations: Department of
Dermatology, Emory University,
CONCLUSIONS AND RELEVANCE The multitude of factors that significantly influence the Atlanta, Georgia (Carr, Veledar, Chen);
impact of chronic pruritus on quality of life demonstrates the complex nature of this Atlanta Veterans Administration
relationship. A better appreciation of these factors will improve the clinical evaluation and Medical Center, Atlanta, Georgia
(Chen).
treatment of chronic pruritus.
Corresponding Author: Suephy C.
Chen, MD, MS, Department of
JAMA Dermatol. 2014;150(6):613-620. doi:10.1001/jamadermatol.2013.7696 Dermatology, Emory University, 1525
Published online March 26, 2014. Clifton Rd, First Floor, Atlanta, GA
30305 (schen2@emory.edu).

T
he scourge of chronic pruritus—pruritus lasting 6 or more
weeks1—should not be underestimated. Recent stud-
ies have documented the extent of the problem, find-
ing point prevalences ranging from 13% to 17%2-4 and lifetime
prevalences of 22% to 26%.2,4 Prior research on chronic pru-
ritus has also found a substantial effect on quality of life
(QoL). In several studies, Yosipovitch and colleagues 5-7
found pruritus to significantly influence QoL proxies includ-
ing mood, concentration, eating habits, sexual function, and
sleep. Wolkenstein et al 8 found that chronic pruritus
impaired QoL more than other skin problems. Kini et al9
found no significant difference between the impact of
chronic pain and chronic itch on QoL.
Whereas the impact of chronic pruritus on QoL has been
established, a second-order question—what factors mediate this
impact—remains lightly studied. A negative correlation be-
tween pruritus severity and QoL has been documented,2,10-12
and the importance of several other factors has been ad-
dressed with small studies. Desai et al13 found that pruritus eti-
ology and sex influenced the impact of pruritus on QoL: urti-
caria engendered greater impact on functional aspects of QoL,
and women were more negatively affected by chronic pruri-
tus than men. Stander et al14 also found a greater impact of
chronic pruritus on women. Kini et al9 found that unmarried
persons were more adversely affected by chronic pruritus than
their married counterparts. A study of patients with psoriasis

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 Research Original Investigation
found no relationship between age, sex, disease duration, sleep
quality, and the impact of pruritus on QoL.12 Although these
studies explored the relevance of some variables, the role of
many patient and pruritus characteristics in determining the
impact of pruritus on QoL remains a mystery. To address this
knowledge void, we undertook a cross-sectional study of a large
sample of US military veterans. We hypothesized that a mul-
titude of factors would significantly affect how chronic pru-
ritus influences QoL.
Methods
The Emory University institutional review board approved this
cross-sectional study. This study consisted of 2 phases: (1) cre-
ating a panel of comprehensive surveys to capture informa-
tion on patients and their pruritus and (2) administering the
survey to a sample of patients from the Veterans Hospital Pa-
tient Database.
Survey Design
We designed a panel of surveys to capture patient demo-
graphic, medical history, therapeutic, and personality data.
Questions from published surveys were assimilated, as fol-
lows:
1. ItchyQoL – ItchyQoL is a validated, pruritus-specific instru-
ment that measures the degree to which pruritus affects
QoL.13 This impact is quantified into 3 subscores (symp-
tom, function, emotion) and an overall score. A higher score
corresponds to a more adverse impact on QoL. We used the
frequency version of this instrument.
2. Questionnaire for the Assessment of Pruritus – This ques-
tionnaire characterizes a patient’s pruritus.6
3. NEO 5-factor inventory – Developed by psychologists at the
National Institutes of Health, this survey is predicated on
the 5-factor personality model, which divides personality
into 5 domains: openness, conscientiousness, extrover-
sion, agreeableness, and neuroticism. Survey answers are
used to score patients on these 5 domains; a higher score
corresponds to a higher degree of that personality trait.15
4. 12-Item Short Form Health Survey – This validated ques-
tionnaire measures generic health-related QoL. We do not
report results of this questionnaire here.
Questions regarding risk factors for pruritus were devel-
oped through a literature review. Economic and family im-
pact questionnaires were developed by the adaptation of ex-
isting validated measures. Phase 1 of the study involved testing
the panel of surveys with veterans for content and face valid-
ity, clarity, reliability, and feasibility. Cognitive interviewing and
psychometric analyses were performed. The results of this test-
ing have been reported elsewhere.16 The final comprehen-
sive survey consisted of more than 300 questions.
Study Population and Sample
Patients for phase 2 of this study were drawn from the Veter-
ans Hospital Patient Database. The database was stratified using
the US Census Bureau’s 6 geographic areas to ensure diverse
geographic representation. From this stratified database, 6000
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Impact of Chronic Pruritus on Quality of Life
veterans were sampled at random. Interviewers at the Uni-
versity Center for Social and Urban Research at the University
of Pittsburgh attempted to call these 6000 veterans at least 3
times each. Exclusionary criteria were inability to speak En-
glish or inability to answer questions due to disability. Ulti-
mately, 1075 veterans agreed to participate; all participants pro-
vided verbal informed consent. At the time of the telephone
call, 405 of the veterans had chronic pruritus. The entire sur-
vey was administered to these 405 veterans; the remaining 670
veterans answered fewer questions because the itch-related
questions were not applicable. Because our focus is the im-
pact of chronic pruritus on QoL, our analysis uses only the re-
plies from the 405 veterans with chronic pruritus.
Statistical Analysis
Survey responses were translated into both categorical and con-
tinuous variables.
Categorical Variables
Many survey questions featured multiple discrete answer
choices (more than 12 choices in some cases); we trans-
formed these questions into categorical variables. To reduce
the number of categories, answers were combined in a logi-
cal fashion. For example, hand, forearm, and upper arm were
separate answer choices for a question asking the anatomic lo-
cation of pruritus. For analysis, these 3 answers were com-
bined to form a single upper extremity category. Answers to
some survey questions that were initially continuous (eg, in-
come, body mass index [BMI, calculated as weight in kilo-
grams divided by height in meters squared], frequency of itch,
duration of pruritic condition) were translated into categori-
cal variables when the responses did not show a normal dis-
tribution. The categorical variables used in our analysis are
listed in Table 1.
To derive the “possible etiology” variable, patients were
asked a series of questions regarding whether they had any of
a number of cutaneous and systemic diseases that can cause
pruritus. On the basis of their answers to these questions,
patients were then grouped into the cutaneous only, sys-
temic only, cutaneous and systemic, and idiopathic catego-
ries. However, we cannot say for certain that a particular
disease affirmed by a patient is definitively causing the
patient’s pruritus, hence the modifier “possible” prepended
to “etiology.”
Continuous Variables
Continuous variables are pruritus severity, personality do-
main scores, and age. Patients scored pruritus severity on a
scale of 1 to 10. The NEO 5-factor inventory consists of 60 items.
The interviewer read each item to a patient (eg, “I really enjoy
talking to people”), who then responded on a scale of 1 (strongly
disagree) to 5 (strongly agree). Personality scores were calcu-
lated using the NEO inventory’s prescribed addition and sub-
traction of various responses. These personality scores are in-
terval variables. The means and standard deviations of the 5
personality domains depend on the population to which the
inventory is applied, so no inferences can be gleaned from the
absolute level of these statistics.
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 Impact of Chronic Pruritus on Quality of Life Original Investigation Research

Table 1. Summary Statistics for Categorical Variables Table 1. Summary Statistics for Categorical Variables (continued)

Variable Frequency, No. (%)a Variable Frequency, No. (%)a

Patient characteristics Itch frequency
Sex >10 × per day 83 (21)
Male 374 (93) 5-10 × per day 90 (22)
Female 30 (7) 2-4 × per day 146 (36)
Race 2-7 × per week 63 (16)
White 298 (74) ≤4 × per month 21 (5)
African American 76 (19) Time of day when itch is worst
Other 30 (7) No particular time 143 (35)
Marital status Multiple different times 84 (21)
Married 230 (57) All day 40 (10)
Not married 174 (43) Morning 17 (4)
Region of residence Afternoon 15 (4)
South 129 (32) Evening before 8 PM 37 (9)
West 113 (28) Evening after 8 PM 69 (17)
Midwest 98 (24)
Abbreviation: BMI, body mass index (calculated as weight in kilograms divided
Northeast 63 (16) by height in meters squared).
Puerto Rico 1 (0) a
Percentages may not total 100% because of rounding.
Education level
College degree or more 174 (43) ItchyQoL Scores
Some college 109 (27) The frequency version of the ItchyQoL instrument consists of
High school or less 121 (30) 22 items. These items are divided into 3 constructs: sympto-
Employment status matic impact (6 items), functional limitations (7 items), and
Retired 185 (46) emotional impact (9 items). The interviewer read each item to
Employed 116 (29) a patient (eg, “my itchy skin often makes it difficult to con-
Unemployed 68 (17) centrate”), who then responded on a scale of 1 (never) to 5 (al-
Disabled 35 (9) ways). Subscores for each construct are summations of the nu-
Income, $ merical responses. The ItchyQoL total score for a patient is the
≤25 000 142 (37) sum of the symptom, function, and emotion subscores. Some
>25 000 and <50 000 139 (36) veterans responded to ItchyQoL items with “I don’t know.” For
≥50 000 105 (27) a given subscore, if a patient responded “I don’t know” to 1 or
BMI 2 items, these responses were replaced with the mean numeri-
<25 74 (18) cal response of that subscore’s other items. In total, 42 items
≥25 and <30 166 (41) were answered “I don’t know,” necessitating adjustment to 40
≥30 and <35 92 (23) subscores (3% of the total subscores). One of the 405 patients
≥35 72 (18) answered 3 emotion items with “I don’t know;” his data point
Possible etiology was removed entirely for the analyses involving the ItchyQoL
Cutaneous and systemic 300 (74) total score and emotion subscore.
Systemic only 61 (15)
Cutaneous only 32 (8) Analysis
As a first step, we undertook univariate analysis to screen
Idiopathic 11 (3)
for relationships between the total ItchyQoL score and other
Pruritus characteristics
variables. Relationships between continuous variables and
Itch location
the total ItchyQoL score were determined using analysis of
Multiple locations 262 (65)
variance and t testing. Relationships between categorical
Lower extremities 40 (10)
variables and ItchyQoL scores were determined using χ 2
Upper extremities 31 (8)
testing. A priori, we had decided to use all variables from
Torso 29 (7)
the univariate analysis with P values ≤.20 as predictor vari-
Groin and buttocks 23 (6)
ables in multivariate analysis. All of the aforementioned
Head and neck 19 (5)
variables met this threshold.
Itch duration, y
As the second step, we undertook multivariate analysis
≤2 106 (26)
using a generalized linear model with ItchyQoL scores (total and
>2 and ≤8 103 (26)
subscores) as the response variables for a total of 4 different
>8 and ≤20 108 (27)
models. By convention, we deemed P ≤ .05 to be significant.
>20 86 (21)
While undertaking the survey, occasionally a veteran re-
(continued) plied “I don’t know” or declined to answer a survey question.

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 Research Original Investigation Impact of Chronic Pruritus on Quality of Life

We have outlined how we treated such responses to ItchyQoL

items. When veterans responded “I don’t know” or declined Results
to answer other questions, predictor variables derived from
those questions could not be calculated and/or categorized. Table 1 and Table 2 summarize the frequencies of the categori-
Ergo, such a patient was excluded from univariate and multi- cal variables and the means and standard deviations of the con-
variate analyses involving that variable. Fortunately, the “I tinuous variables, respectively. Because the means of the per-
don’t know” and declined responses were infrequent, with sonality scores are not informative (as explained in the Methods
most involving the question on income. The sample size for section), these variables are omitted from Table 2. Our pru-
multivariate analysis only decreased from 404 to 384 indi- ritic veteran population consisted primarily of white men; the
viduals. All analyses were performed with SAS software, ver- mean age was 60.7 years. The majority were married, had at
sion 9.3 (SAS Institute). least some college education, and had both cutaneous and sys-
temic conditions that could engender pruritus. Most veter-
Table 2. Summary Statistics for Continuous Variables
ans reported pruritus affecting multiple locations and lasting
Variable Mean (SD) more than 2 years. Region of residence, income, and employ-
Age, y 60.7 (13.0) ment status were fairly evenly distributed.
Itch severitya 5.2 (2.3) The multivariate model exhibited statistical significance
ItchyQoL scores (P < .001) and good explanatory power (R2 = 52%). Table 3 sum-
Symptom subscore 16.3 (5.0) marizes the results of the multivariate analysis, with the con-
Function subscore 16.4 (6.3) tinuous and categorical variables at the top and bottom of the
Emotion subscore 21.1 (9.4) table, respectively.
Totalb 53.7 (18.7)
a
On a scale of 1 to 10.
Pruritus Characteristics
b Itch severity significantly (P < .001) directly correlates with the
Total score differs from sum of subscores because of rounding.
total ItchyQoL score and its 3 constitutive constructs. Itch fre-

Table 3. Multivariate Results

ItchyQoL Response Variable

Total Symptom Function Emotion
Variable Coefficient P Value Coefficient P Value Coefficient P Value Coefficient P Value
Continuous variables
Itch severity 2.45 <.001 0.67 <.001 0.77 <.001 1.01 <.001
Age −0.20 .007 −0.07 .003 −0.05 .048 −0.08 .04
Personality domains
Neuroticism 0.30 .01 0.07 .047 … .79 0.22 <.001
Extroversion −0.28 .03 … .27 −0.13 .005 … .12
Agreeableness … .46 … .55 … .52 … .19
Conscientiousness … .97 … .16 … .29 … .86
Openness … .44 … .66 … .40 … .52
Categorical variables
Patient characteristics
Possible etiology … .03 … .23 … .009 … .14
Marital status … .04 … .04 … .19 … .06
Race … .05 … .08 … .02 … .23
BMI … .34 … .37 … .31 … .51
Education level … >.99 … .23 … .50 … .96
Employment status … .53 … .39 … .70 … .60
Sex … .98 … .67 … .39 … .71
Income … .62 … .30 … .92 … .60
Region of residence … .90 … .69 … .84 … .57
Pruritus characteristics
Itch frequency … <.001 … .53 … .003 … <.001
Itch location … .005 … .15 … <.001 … .04
Itch duration … .01 … .03 … .04 … .04
Time of day when itch … .08 … .13 … .40 … .12
is worst

Abbreviation: BMI, body mass index (calculated as weight in kilograms divided by height in meters squared).

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 Impact of Chronic Pruritus on Quality of Life
quency, duration, and anatomic location are all significantly
related to the impact of pruritus on QoL. Pairwise compari-
son generally supports that a higher itch frequency signifi-
cantly (P < .01) correlates with a greater impact on QoL. Like-
wise, pairwise comparison shows that pruritus of longer
duration exerts a greater impact on QoL. Time of day when itch
is worst is not significantly related to ItchyQoL scores.
Patient Characteristics
Marital status, age, race, and possible etiology are all signifi-
cantly related to the impact of pruritus on QoL. Marriage is as-
sociated with a lower ItchyQoL total score and symptom sub-
score. Age exhibits significant, negative correlation with the
total ItchyQoL score and all 3 subscores. With respect to pos-
sible etiology, the ordinal ranking of the categories from great-
est to least impact on QoL is as follows: (1) cutaneous and sys-
temic reason to itch, (2) systemic reason, (3) cutaneous reason,
(4) neither. However, pairwise comparisons of these catego-
ries revealed no significant differences. Race is significant, with
nonwhites experiencing a significantly greater impact on QoL
than whites. Pairwise comparisons failed to find a significant
difference between the race categories.
Multivariate analysis revealed a significant negative
coefficient for patients’ extroversion score with respect to
ItchyQoL total and function scores. Conversely, analysis found
a significant positive coefficient for patients’ neuroticism score
with respect to ItchyQoL total, symptom, and emotion scores.
Three personality domains failed to show significance: open-
ness, conscientiousness, and agreeableness.
Sex, region of residence, education level, employment
status, income, and BMI did not exhibit significant associa-
tion with ItchyQoL scores.
Discussion
Medical research has established that chronic disease substan-
tially affects QoL.17 Similarly, dermatologic investigation has
found a deleterious effect of chronic pruritus on QoL.8,9 For
some chronic diseases (eg, diabetes mellitus, congestive heart
failure, end-stage renal disease), investigation has revealed the
factors that mediate the impact of the disease on patients’ QoL.
For chronic pruritus, the identity of these factors is largely un-
known. To remedy this knowledge void, we collected exten-
sive demographic, medical, and QoL data from a large, di-
verse sample of pruritic patients. Multivariate analysis revealed
that an array of variables influences the impact of chronic pru-
ritus on QoL. Important insights can be gleaned from the
results.
Pruritus Characteristics
Not surprisingly, itch severity was found to significantly in-
fluence the ItchyQoL total score and all 3 subscores. The cor-
relation is positive, with greater pruritus severity yielding a
greater impact on QoL. At the same time, itch frequency sig-
nificantly correlates with total ItchyQoL. Taken in isolation,
the significance of itch frequency is not surprising. However,
it is interesting that the impact of itch frequency on QoL is not
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Original Investigation Research
fully captured by the itch severity measure. One could rea-
sonably expect that itch frequency is a prominent determi-
nant of itch severity and as such would not be independently
significant. However, our results suggest otherwise.
Several patterns for the influence of chronic disease du-
ration on QoL have been hypothesized: no effect, adaptation,
and chronic exasperation.18 Studies of congestive heart fail-
ure, chronic prostatitis, and diabetes mellitus have shown that
disease duration has no effect on QoL.19-21 Chronic pruritus does
not behave in the same fashion, as our analysis provides evi-
dence for chronic exasperation: increasing duration signifi-
cantly correlates with greater negative QoL impact. The sig-
nificance of all 3 ItchyQoL subscores indicates that symptoms,
functional status, and emotional health deteriorate as chronic
pruritus persists.
The impact of chronic pain on QoL depends in part on
its anatomic location. 22 We included itch location in our
analyses to investigate for a similar relationship, and loca-
tion did prove significant. Interestingly, pruritus afflicting
the upper extremities has the most adverse impact on QoL,
although pairwise comparison revealed no significant dif-
ferences vs other anatomic locations. In the multivariate
analyses that used the 3 ItchyQoL subscores as dependent
variables, anatomic loc ation has the lowest P value
(P < .001) when modeled with the function subscore. This
finding suggests that the higher degree of impact experi-
enced by patients with upper extremity pruritus may be due
to functional impairment.
Patient Characteristics
Studies of the impact of age on QoL in chronic disease have pro-
duced dissimilar results. Some researchers found increasing age
to diminish the negative impact on QoL20; some found no re-
lationship between age and QoL19,23; others found that increas-
ing age correlates with declining QoL.21 In our analysis, age has
a significant, negative coefficient when modeled against the
total ItchyQoL score and the 3 subscores. The negative coeffi-
cient indicates that older age correlates with less adverse im-
pact on the QoL, and the pansignificance of all 3 ItchyQoL
constructs demonstrates that the mitigating influence of age
pervades the spectrum of morbidity. The statistical signifi-
cance of age lies in contrast to the findings of a study of QoL in
pruritic patients with psoriasis.12
Research on the relationship between race and QoL in
chronic disease has yielded heterogeneous results. Some re-
search has found no correlation between race and QoL
measures.20,24 End-stage renal disease has been shown to more
negatively affect the QoL of whites25 and nonwhites.26 King-
ton et al27 found that greater functional impairment of non-
whites with chronic disease was attributable to socioeco-
nomic status and not race. Our analysis has found a significant
association of race with the impact of chronic pruritus on QoL,
even after we controlled for socioeconomic variables. The total
ItchyQoL scores for both the African American and other race
categories are approximately equal and 9% higher than the
score for whites, although no comparisonwise error rate was
significant. With respect to ItchyQoL subscores, race was sig-
nificant (P = .02) only when modeled with the function sub-
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 Research Original Investigation
score, suggesting that race’s influence on QoL is mediated
through functional impairment.
Marital status significantly influences the impact of pru-
ritus on QoL, with chronic pruritus having less effect on
married persons. The mean ItchyQoL score for an unmar-
ried person is 7% worse. Interestingly, the ItchyQoL symp-
tom subscore was the only significant construct, intimating
that marriage ameliorates the impact of pruritus more
through symptom relief than through the function and
emotion constructs. The beneficial impact of marriage on
QoL is consistent with prior QoL research21,28 and the afore-
mentioned finding of Kini et al.9 We hypothesize that the
social support available in marriage is responsible for this
finding.
The presence of a disease that can cause pruritus (ie, the
possible etiology variable) exhibits significant correlation with
the impact of pruritus on QoL. This finding suggests that the
impact of pruritus on QoL is determined not just by the char-
acteristics of the pruritus itself; the etiology matters. How-
ever, we could not through a telephone survey determine with
sufficient certainty whether the medical condition(s) af-
firmed by the patient are actually causing the patient’s pruri-
tus. As such, although the data support a relationship be-
tween possible etiology and QoL, the evidence is not as
conclusive as for other variables.
Personality
To capture the influence of personality on QoL, we incorpo-
rated personality domains into our analysis. Extroversion
and neuroticism proved statistically significant. This finding
is consistent with the psychology literature, which has
shown that extroversion and neuroticism are important fac-
tors in determining well-being. 29,30 Psychologists define
neuroticism with the modifiers anxious, self-pitying, tense,
touchy, unstable, and worrying.31 An association of neuroti-
cism with lower QoL has been shown in patients with
inflammatory bowel disease,32 Parkinson disease,33 chronic
headache, 34 cancer, 35 breast cancer specifically, 36 and
chronic disease in older patients.37 In our analysis, neuroti-
cism featured a positive coefficient with respect to total
ItchyQoL; both the symptom and emotion constructs were
significant. Ergo, we conclude that chronic pruritus has a
more detrimental QoL impact in more neurotic patients,
manifesting as an exacerbation of symptoms and decline in
emotional well-being.
To define extroversion, psychologists use the adjectives
active, assertive, energetic, enthusiastic, outgoing, and
talkative.31 Unlike neuroticism, evidence for the influence
of extroversion on QoL in chronic disease is scant. Among
patients with Parkinson disease, Dubayova et al 33 found
extroversion to predict less impact on QoL in men only.
Similarly, our analysis found a significant negative associa-
tion of extroversion with total ItchyQoL and the function
construct. These findings indicate that a greater degree of
extroversion reduces the impact of pruritus on QoL, specifi-
cally on functional capacity. Note that this stands in con-
trast to neuroticism, in which a greater degree of neuroti-
cism increases the symptomatic and emotional impact.
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Impact of Chronic Pruritus on Quality of Life
Variables Not Significant
A number of variables did not exhibit significance: sex, re-
gion of residence, education level, employment status, in-
come, BMI, and time of day when itch is worst. Several inter-
esting observations can be made. First, socioeconomic
status—as represented by education level, employment sta-
tus, and income—does not mediate the impact of chronic pru-
ritus on QoL. Second, pruritus that is worst after 8 PM (ie, pru-
ritus that affects sleep) does not produce a more negative
impact on QoL. Not only is the worst-itch–time variable not sig-
nificant, but the after–8 PM category exhibited the second low-
est impact on QoL of the 7 time groups (although pairwise com-
parisons revealed no significant differences). This finding
challenges the widely held belief that pruritus (at least gener-
alized pruritus) is worst at night.38-40 Third, sex was not found
significant. This discovery lies in contrast to previous studies
that found chronic pruritus to more severely affect the QoL of
female patients.13,14 Women constitute only 7% of our sample,
but the difference between the estimates for men and women
was miniscule (P = .98). There is no evidence to suggest that
sex would become significant with a multiplicative increase
in the sample size.
Limitations
Our sample features racial, socioeconomic, and regional
diversity but is constituted entirely of US military veterans.
As such, generalization of results to nonveteran populations
merits caution. Furthermore, caution must also be exer-
cised when extrapolating our findings to younger popula-
tions because only 8% of our sample was 40 years or
younger. Conclusions drawn from our sample may not be
applicable to other populations.
Theoretically, one could argue that the problem of cau-
sality complicates the interpretation of the personality
results. Our analysis presumes that personality affects a
patient’s response to chronic pruritus, but the possibility
exists that chronic pruritus may influence personality. This
chicken-and-egg issue (ie, how personality and events influ-
ence each other) has been studied extensively in the psy-
chology literature, where it is generally accepted that adult
personality is stable.41,42 As such, the presence of chronic
pruritus would not be expected to alter a person’s neuroti-
cism and extroversion quotients, and the use of personality
factors as independent variables would not be complicated
by bidirectional causality.
Conclusions
This study represents the next epidemiologic step in
chronic pruritus research: understanding the factors that
mediate the impact of chronic pruritus on QoL. Using data
collected from a large, geographically diverse sample of the
US veteran population, we found that multiple patient and
pruritus characteristics significantly influence this relation-
ship: demographic characteristics (age, race, marital status),
personality (extroversion, neuroticism), pruritus para-
meters (severity, duration, frequency, anatomic location),
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 Impact of Chronic Pruritus on Quality of Life Original Investigation Research

and etiology (cutaneous, systemic). The significance of
some of these variables (marital status, neuroticism, ana-
tomic location) mirrors what has been found in other
chronic diseases. Notable factors not found significant
include sex and socioeconomic variables (education level,
employment status, income). The multitude of significant
factors demonstrates the complex relationship between
chronic pruritus and QoL. We hope that better appreciation
of these factors will improve the clinical evaluation and
treatment of chronic pruritus. Future directions of research
include investigating why race influences the impact of
chronic pruritus on QoL and exploring whether support
groups or personality-specific interventions may help miti-
gate the QoL impact of chronic pruritus.

ARTICLE INFORMATION
Accepted for Publication: August 22, 2013.
Published Online: March 26, 2014.
doi:10.1001/jamadermatol.2013.7696.
Author Contributions: Drs Chen and Veledar had
full access to all of the data in the study and take
responsibility for the integrity of the data and the
accuracy of the data analysis.
Study concept and design: Chen.
Acquisition of data: Chen.
Analysis and interpretation of data: All authors.
Drafting of the manuscript: Carr.
Critical revision of the manuscript for important
intellectual content: All authors.
Statistical analysis: Veledar.
Obtained funding: Chen.
Administrative, technical, and material support: Carr.
Study supervision: Chen.
Conflict of Interest Disclosures: Dr Chen has
received royalties from Eli Lilly (2007) and Pierre
Fabre (2011) for licensing of the ItchyQoL
instrument and has been an outcomes research
consultant for Biogen and Astellas and a principal
investigator for studies sponsored by
Hoffman-LaRoche and Galderma. No other
disclosures are reported.
Funding/Support: The Veterans Health
Administration (VHA) provided (1) financial support
and (2) access to the Veterans Hospital Patient
Database for sampling purposes.
Role of the Sponsors: The VHA had no role in the
design and conduct of the study; collection,
management, analysis, and interpretation of the
data; preparation, review, or approval of the
manuscript; and decision to submit the manuscript
for publication.
Additional Contributions: We thank the VHA for
its support of this research.
REFERENCES
1. Ständer S, Weisshaar E, Mettang T, et al. Clinical
classification of itch: a position paper of the
International Forum for the Study of Itch. Acta
Derm Venereol. 2007;87(4):291-294.
2. Matterne U, Apfelbacher CJ, Loerbroks A, et al.
Prevalence, correlates and characteristics of
chronic pruritus: a population-based cross-sectional
study. Acta Derm Venereol. 2011;91(6):674-679.
3. Ständer S, Schäfer I, Phan NQ, et al. Prevalence
of chronic pruritus in Germany: results of a
cross-sectional study in a sample working
population of 11,730. Dermatology. 2010;221(3):
229-235.
4. Matterne U, Apfelbacher CJ, Vogelgsang L,
Loerbroks A, Weisshaar E. Incidence and
determinants of chronic pruritus:
a population-based cohort study. Acta Derm
Venereol. 2013;93(5):532-537.
5. Yosipovitch G, Goon A, Wee J, Chan YH, Goh CL.
The prevalence and clinical characteristics of
pruritus among patients with extensive psoriasis. Br
J Dermatol. 2000;143(5):969-973.
6. Yosipovitch G, Zucker I, Boner G, Gafter U,
Shapira Y, David M. A questionnaire for the
assessment of pruritus: validation in uremic
patients. Acta Derm Venereol. 2001;81(2):108-111.
7. Yosipovitch G, Goon AT, Wee J, Chan YH, Zucker
I, Goh CL. Itch characteristics in Chinese patients
with atopic dermatitis using a new questionnaire
for the assessment of pruritus. Int J Dermatol.
2002;41(4):212-216.
8. Wolkenstein P, Grob JJ, Bastuji-Garin S,
Ruszczynski S, Roujeau JC, Revuz J. French people
and skin diseases: results of a survey using a
representative sample. Arch Dermatol. 2003;139
(12):1614-1619.
9. Kini SP, DeLong LK, Veledar E, McKenzie-Brown
AM, Schaufele M, Chen SC. The impact of pruritus
on quality of life: the skin equivalent of pain. Arch
Dermatol. 2011;147(10):1153-1156.
10. Holm EA, Wulf HC, Stegmann H, Jemec GB. Life
quality assessment among patients with atopic
eczema. Br J Dermatol. 2006;154(4):719-725.
11. Weisshaar E, Diepgen TL, Bruckner T, et al. Itch
intensity evaluated in the German Atopic Dermatitis
Intervention Study (GADIS): correlations with
quality of life, coping behaviour and SCORAD
severity in 823 children. Acta Derm Venereol. 2008;
88(3):234-239.
12. Zachariae R, Zachariae CO, Lei U, Pedersen AF.
Affective and sensory dimensions of pruritus
severity: associations with psychological symptoms
and quality of life in psoriasis patients. Acta Derm
Venereol. 2008;88(2):121-127.
13. Desai NS, Poindexter GB, Monthrope YM,
Bendeck SE, Swerlick RA, Chen SC. A pilot
quality-of-life instrument for pruritus. J Am Acad
Dermatol. 2008;59(2):234-244.
14. Ständer S, Stumpf A, Osada N, Wilp S,
Chatzigeorgakidis E, Pfleiderer B. Gender
differences in chronic pruritus: women present
different morbidity, more scratch lesions and higher
burden. Br J Dermatol. 2013;168(6):1273-1280.
15. Costa PT, McCrea RR. Psychological Assessment
Resources Inc. Revised NEO Personality Inventory
(NEO PI-R) and NEO Five-Factor Inventory
(NEO-FFI). Odessa, FL: Psychological Assessment
Resources; 1992.
16. Kini SP, Coleman-King S, Veledar E, et al.
Evidence of reliability, reproducibility, and validity
of the ItchyQoL in the veteran population. J Invest
Dermatol. 2010;130:S65.
17. Stewart AL, Greenfield S, Hays RD, et al.
Functional status and well-being of patients with
chronic conditions: results from the Medical
Outcomes Study. JAMA. 1989;262(7):907-913.
18. Cella DF. Quality of life: concepts and definition.
J Pain Symptom Manage. 1994;9(3):186-192.
19. Juenger J, Schellberg D, Kraemer S, et al. Health
related quality of life in patients with congestive
heart failure: comparison with other chronic
diseases and relation to functional variables. Heart.
2002;87(3):235-241.
20. McNaughton Collins M, Pontari MA, O’Leary
MP, et al; Chronic Prostatitis Collaborative Research
Network. Quality of life is impaired in men with
chronic prostatitis: the Chronic Prostatitis
Collaborative Research Network. J Gen Intern Med.
2001;16(10):656-662.
21. Jacobson AM, de Groot M, Samson JA. The
evaluation of two measures of quality of life in
patients with type I and type II diabetes. Diabetes
Care. 1994;17(4):267-274.
22. Lamé IE, Peters ML, Vlaeyen JW, Kleef MV,
Patijn J. Quality of life in chronic pain is more
associated with beliefs about pain, than with pain
intensity. Eur J Pain. 2005;9(1):15-24.
23. Ketelaars CA, Schlösser MA, Mostert R, Huyer
Abu-Saad H, Halfens RJ, Wouters EF. Determinants
of health-related quality of life in patients with
chronic obstructive pulmonary disease. Thorax.
1996;51(1):39-43.
24. Glasgow RE, Ruggiero L, Eakin EG, Dryfoos J,
Chobanian L. Quality of life and associated
characteristics in a large national sample of adults
with diabetes. Diabetes Care. 1997;20(4):562-567.
25. Kutner NG, Devins GM. A comparison of the
quality of life reported by elderly whites and elderly
blacks on dialysis. Geriatr Nephrol Urol. 1998;8(2):
77-83.
26. Evans RW, Manninen DL, Garrison LP Jr, et al.
The quality of life of patients with end-stage renal
disease. N Engl J Med. 1985;312(9):553-559.
27. Kington RS, Smith JP. Socioeconomic status
and racial and ethnic differences in functional status
associated with chronic diseases. Am J Public
Health. 1997;87(5):805-810.
28. Haring-Hidore M, Stock WA, Okun MA, Witter
RA. Marital status and subjective well-being:
a research synthesis. J Marriage Fam. 1985;47(4):
947-953.
29. Costa PT Jr, McCrae RR. Influence of
extraversion and neuroticism on subjective
well-being: happy and unhappy people. J Pers Soc
Psychol. 1980;38(4):668-678.
30. Magnus K, Diener E, Fujita F, Pavot W.
Extraversion and neuroticism as predictors of
objective life events: a longitudinal analysis. J Pers
Soc Psychol. 1993;65(5):1046-1053.
31. McCrae RR, John OP. An introduction to the
five-factor model and its applications. J Pers. 1992;
60(2):175-215.
32. Moreno-Jiménez B, López Blanco B,
Rodríguez-Muñoz A, Garrosa Hernández E. The

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 Humanities Original Investigation Impact of Chronic Pruritus on Quality of Life

influence of personality factors on health-related
quality of life of patients with inflammatory bowel
disease. J Psychosom Res. 2007;62(1):39-46.
33. Dubayova T, Nagyova I, Havlikova E, et al.
Neuroticism and extraversion in association with
quality of life in patients with Parkinson’s disease.
Qual Life Res. 2009;18(1):33-42.
34. Jelicic M, Kempen GI, Passchier J. Psychological
well-being in older adults suffering from chronic
headache. Headache. 1998;38(4):292-294.
35. Ranchor AV, Sanderman R, Steptoe A, Wardle J,
Miedema I, Ormel J. Pre-morbid predictors of
psychological adjustment to cancer. Qual Life Res.
2002;11(2):101-113.
36. van der Steeg AF, De Vries J, van der Ent FW,
Roukema JA. Personality predicts quality of life six
months after the diagnosis and treatment of breast
disease. Ann Surg Oncol. 2007;14(2):678-685.
37. Kempen GI, Jelicic M, Ormel J. Personality,
chronic medical morbidity, and health-related
quality of life among older persons. Health Psychol.
1997;16(6):539-546.
38. Martin J. Pruritis. Int J Dermatol. 1985;24(10):
634-639.
39. Yosipovitch G, David M. The diagnostic and
therapeutic approach to idiopathic generalized
pruritus. Int J Dermatol. 1999;38(12):881-887.
40. Yosipovitch G, Ansari N, Goon A, Chan YH, Goh
CL. Clinical characteristics of pruritus in chronic
idiopathic urticaria. Br J Dermatol. 2002;147(1):32-
36.
41. McCrae RR, Costa PT Jr. The stability of
personality: observations and evaluations. Curr Dir
Psychol Sci. 1994;3(6):173-175.
42. Terracciano A, Costa PT Jr, McCrae RR.
Personality plasticity after age 30. Pers Soc Psychol
Bull. 2006;32(8):999-1009.

NOTABLE NOTES

Dermatologic Food for Thought: A Word Search Challenge

Walter H. C. Burgdorf, MD; Leonard J. Hoenig, MD

Word search puzzles are fun to solve and have been around since 1968. We
thought readers might enjoy the challenge of a dermatology-related word
search,andsowehavepreparedonebasedonthethemeoffoodeponyms.
To solve the puzzle, you must first identify, from the list below, 12 food
or beverage terms used in dermatology. To do this, you need to fill in the
blanks with the appropriate food words. Each blank has only 1 word for
an answer except for number 1 (3 words) and number 7 (2 words). Please
note that the answer to number 3 is a homonym of a food name.
Once you have figured out the missing food or drink words, you must
then find them in the word search grid below in which they are hidden.
These words may be listed horizontally, vertically, or diagonally in a total
of 8 different possible directions. Some words may intersect. Answers
are provided below.
There is no time limit to do the puzzle. However, if you can solve this
word search challenge in less than 10 minutes, then you are truly a der-
matology word search champion! Good luck!
Author Affiliations: Retired (Burgdorf); private practice (Hoenig).
Corresponding Author: Leonard J. Hoenig, MD, 601 N Flamingo Rd, No. 201,
Pembroke Pines, FL 33028 (gooddocljh@gmail.com).

A T A S T R A W B E R R Y H D
H W V T H A Y F P J Q Q P Z Q

Y Y S S T S E O Y U T A F U O
X W W E Y O P L A B O B R T G

S X O E S P A G H E T T I K M
M N S P X P N O U Y O E I K P

P H Z N Y C E U A D Y U C K C 12. CHICKEN C U O Z T R A E S C A W T T Y

S I V I L C N Z A S C A H S B 11. HONEY H L Y R R E H C Y O L E G S X
10. SPAGHETTI
M M P W F K E Q O A U W T Y N
I B O X Z V A I L U G P Q P D
9. STRAWBERRY
Y V S T A A M R F L E A Y R E
C E B D Q A K F A N C O R N J
8. ORANGE
G O A R Z X A E I W K Z S R K
K R S Z W K I E A X Z R A O G
7. PORT-WINE
J N R O C N A F K A Q D B E C
E R Y A E L F R M A A T S V Y
6. MULBERRY
D P Q P G U L I A V Z X O B I
N Y T U W A O Q E K F W P M M
5. CAULIFLOWER
X S G E L O Y C H E R R Y L H
B S H A C S A Z N C L I V I S
4. SAUSAGE
Y T T A W C S E A R T Z O U C 3. CORN C K C U Y D A U E C Y N Z H P

P K I E O Y U O N P X P S M N 2. CHERRY M K I T T E H G A P S E O X S

G T R B O B A L P O Y E W W X 1. CAFÉ-AU-LAIT O U F A T U Y O E S T S S Y Y

Q Z P Q Q J P F Y A H T W V H
ANSWERS D H Y R R E B A W R T S A T A

FOOD WORDS CLUES

1. _____ SPOTS A finding in neurofibromatosis type 1 (3 words)
2. _____ ANGIOMA Also called Campbell De Morgan spots
3. _____ A heloma or clavus
4. _____ DIGIT Dactylitis
5. _____ EAR Common among wrestlers
6. _____ MOLAR Stigma of congenital syphilis
7. _____ STAIN Nevus flammeus (2 words)
8. PEAU D’ _____ Seen in inflammatory breast cancer
9. _____ MARK A type of hemangioma
10. _____ AND MEATBALLS Microscopic appearance of Malassezia
11. _____ COLORED CRUSTS Seen in impetigo
12. PLUCKED _____ SKIN Seen in pseudoxanthoma elasticum

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