INDIVIDUAL ARTICLE: Prurigo Nodularis: Current Clinicopathologic Overview and Psychodermatological Perspectives

December 2023 | Volume 22 | Issue 12 | SF365502s6 | Copyright © December 2023


Published online November 28, 2023

Naiem T. Issa MD PhDa,b,c, Hannah Riva BSc,d, Mohammad Jafferany MDe

aForefront Dermatology, Vienna, VA 
bIssa Research & Consulting, LLC, Springfield, VA 
cDr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL
dPaul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX  
eDepartment of Psychiatry, Central Michigan University, Saginaw, MI

Effect of PN on Mental Health 

Patients with PN have a more than six-fold chance of having body dysmorphic disorder (BDD) symptoms in an observational, cross-sectional multicenter study.67 BDD is defined in the DSM-5 as preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others. This study also found that BDD symptoms were significantly related to factors including higher psychological stress and feelings of stigmatization.67 This aptly draws attention to the chicken-or-egg discussion considering the interplay between the dermatological and psychological aspects in PN and demonstrates the close interrelation between the skin condition and mental health. 

The increased self-consciousness and feelings of shame and stigmatization experienced in disfiguring skin conditions can easily become preoccupying or debilitating thereby significantly affecting one's daily life. Fear of what others may think of the cutaneous lesions exacerbates the individual's stress and worsens the itching, resulting in further trauma and worsening of the lesions. Patients often report significantly worse itch and scratching when alone and becoming hyper focused on the lesions. Patients often describe avoiding social situations and purposefully altering their dress, for example, wearing long sleeves and pants even in hot climates out of self-consciousness. One study found a direct correlation between severity of PN and increased stigma scores as well as increased likelihood of abstaining from social activities.68 The study found that in the last 3 months because of their PN, 21.4% missed at least 1 day of work, learning, training, school or university; 72.9% gave up a leisure or sport activity; and 62.9% refused an invitation to a dinner or a party.68

PN also exhibits a significant psychological burden and has been linked to anxiety, depression, and suicidal ideation.69 In a multicenter study from 13 European countries, the investigators reported 19% of total patients with prurigo had suicidal ideations related to their skin condition.53 A cross-sectional study in 39 patients with PN and healthy controls found patients with PN exhibited higher serum IL-6 and lower serotonin levels, which significantly correlated with the severity of pruritus, but the association of these fluctuations with depression is not yet conclusive.69 
Mental Health Assessment Tools 

A helpful tool, in addition to clinical assessment, to assess the extent to which stress is affecting the patient's function and condition is the use of a patient survey questionnaire initially and possibly on follow-up to quantitatively track psychological measures over time. Examples of these include the Patient Health Questionnaire with 2 (PHQ-2) or 15 (PHQ-15) questions to screen for depression, or the Modified Mini Screen (MMS) for a more global assessment of depression, anxiety, obsessive-compulsive disorder, post-traumatic stress, and psychosis.70 

Other assessments useful to assess and track psychological aspects of patients affected by PN include DLQI,71 Patient Unique Stigmatization Holistic tool in Dermatology (PUSH-D),72 and Epworth sleepiness scale.73 

CONCLUSION

To conclude, PN has inextricable interplays between psychiatry, immunology, and dermatology. Growing our understanding of the psychodermatology of PN is para-mount to improving our treatment of this difficult-to-treat condition and identifying patients at risk for neuropsychiatric comorbidities that may need early intervention.

DISCLOSURES

Naiem Issa is an advisor, consultant, and speaker for Galderma. Mohammad Jafferany and Hannah Riva have no conflicts of interest to declare.

REFERENCES

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