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• W2029921630 abstract "Itch is a complex and unpleasant sensory experience that may induce the urge to scratch. It consists of multidimensional phenomena having sensory discriminative, cognitive, evaluative and motivational components. It has many similarities with pain but in contrast to pain, itch induces scratch cycles, which combine elements of pleasure with pain. Significant advances in our understanding of itch neurophysiology have been achieved in the last 6 years; these include specific C nerve fibers which transmit itch peripherally and centrally, and new itch mediators (Yosipovitch et al., 2003Yosipovitch G. Greaves M.W. Schmelz M. Itch.Lancet. 2003; 361: 690-694Abstract Full Text Full Text PDF PubMed Scopus (331) Google Scholar). Though the methods of itch assessment have improved in the last years, it is still very difficult to objectively assess all the attributes of itch. Since itch can be modulated at peripheral, spinal and supraspinal levels, these factors should be taken into account when we assess itch. Psychophysical assessment of itch intensity consists of traditional methods such as using Visual Analog Scale (VAS) ratings. Although the VAS has excellent characteristics, this technique has limitations often overlooked. Its labels may not denote the same absolute intensities to all. The VAS technique has been commonly used in assessing histamine-induced itch, which is currently the only effective method of inducing itch with a demonstrated dose-response relationship (Yosipovitch, 1999Yosipovitch G. Methodological approaches for testing anti- itch and related substances.in: Gabard B. Elsner P. Surber C. Treffel P. Dermatopharmacology of Topical Preparations- a Product – Development Oriented Approach. Springer Verlag, Berlin1999: 231-240Google Scholar). However, this technique may not mimic the chronic pruritic states where histamine has no significant role as a mediator. Techniques for evaluating itch thresholds by increasing stimulus intensity with electrical current or thermal stimuli are not accurate since the physical stimulation does not evoke pure itch (Tuckett, 1982Tuckett R.P. Itch evoked by electrical stimulation of the skin.J Invest Dermatol. 1982; 79: 368-373Crossref PubMed Scopus (93) Google Scholar). In this issue of the journalStener-Victorian et al., 2003Stener-Victorian E. Lundeberg T. Kowalski J. Opdal L. Sjostrom J. Lundebėrg L. Perceptual matching for assessment – of itch: reliability and responsiveness analysed by rank- invariant statistical method.J Invest Dermatol. 2003; 121: 1301-1305Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar apply perceptual matching, a method used for more than a decade in pain assessment for psychophysical assessment of itch in healthy volunteers and patients with eczema. The perceptual matching unit electrically stimulates the skin of the fingers, and the subject is instructed to halt the stimulus inducing electrical stimulation when the amplitude of the sensation corresponds to his experience of itch during histamine iontophoresis in the volar forearm. The test-retest reliability reported was excellent. The authors believe that this method can enable researchers to assess itch intensity in different types of itch. It would be of interest to compare their scale with other existing scales and to assess the sensitivity of this test with different doses of histamine. This study, like previous studies assessing itch thresholds with electrical stimuli, has limitations since it induces distinct sensations other than itch. Another important issue in studies evaluating itch intensity is how “severe” is one subject's itch and is this severity the same in other individuals. Moreover, do patients with severe excoriations suffer more than a patient who scratches less but reports high itch intensity with a VAS? These are complex questions with no clear answers. Other methods have been used to assess itch; evaluating the amount of scratching at night could be regarded as a quantitative reflection of itch severity. Studies using infrared video cameras have shed light on how severe itch can be in patients with atopic dermatitis (Ebata et al., 1999Ebata T. Aizawa H. Kamide R. Niimura M. The characteristics of nocturnal scratching in adults with atopic dermatitis.Br J Dermatol. 1999; 141: 82-86Crossref PubMed Scopus (60) Google Scholar). Recent studies using accelerometers, small piezo electrical transducers applied on the wrist and measuring the movement of upper and lower limbs, supposedly reflect activity related to itching such as scratching and rubbing the skin. Significant changes in limb activities were demonstrated in children with severe atopic dermatitis during the night (Bender et al., 2003Bender B.G. Leung S.B. Leung D.Y. Actigraphy assessment of sleep disturbance in patients with atopic dermatitis: An objective life quality measure.J Allergy Clin Immunol. 2003; 111: 598-602Abstract Full Text Full Text PDF PubMed Scopus (118) Google Scholar). The main drawback of these techniques is that we do not know how to translate these activities to determine the intensity of itch. Itch questionnaires provide information about the itch characteristics and severity, but again they are limited due to their subjective nature (Darsow et al., 2001Darsow U. Scharein E. Simon D. Walter G. Bromm B. Ring J. New aspects of itch pathophysiology: Component analysis of atopic itch using the ‘Eppendorf Itch Questionnaire’.Int Arch Allergy Immunol. 2001; 124: 326-331Crossref PubMed Scopus (106) Google Scholar;Yosipovitch et al., 2001Yosipovitch 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: 108-111Crossref PubMed Scopus (141) Google Scholar). Functional brain imaging is another important tool to assess itch severity. Much of our current understanding of supraspinal processing of itch is derived from studies using positron emission tomography in humans during stimulation with histamine as an itch inducer (Hsieh et al., 1994Hsieh J.C. Hagermark O. Stahle-Backdahl M. Ericson K. Eriksson L. Stone-Elander S. Ingvar M. Urge to scratch represented in the human cerebral cortex during itch.J Neurophysiol. 1994; 72: 3004-3008PubMed Google Scholar;Drzezga et al., 2001Drzezga A. Darsow U. Treede R.D. et al.Central activation by histamine-induced itch: analogies to pain processing. A correlational analysis of O-15 H2O positron emission tomography studies.Pain. 2001; 92: 295-305Abstract Full Text Full Text PDF PubMed Scopus (205) Google Scholar). These studies have shown activation of cortical regions which overlap partly with those activated with pain. Recent studies using functional MRI have an advantage over PET since subjects can be scanned repeatedly to help confirm the unique features of the itch experience (McGlone et al., 2003McGlone F. Rukweid R. Hitchcock D. Howard M. Histamine induced discriminative and affective responses revealed by functional MRI.in: Yosipovitch G. Greaves M.W. Mcglone F. Fleischer A.B. Itch- Basic Mechanism and Therapy. Marcel Dekker, New York2003: 53-62Google Scholar). Future studies assessing the relationship between regional brain activation and perceived spatial, temporal and intensity features of induced itch will provide us with invaluable data on assessment of itch. In addition, identifying neural correlates of an individual subjective experience of itch in relation to other individuals receiving the same stimulus in combined psychophysical tests and brain imaging may enable us to explain why this experience is so different among individuals. Moreover, exploring the relationship between scratching on itch psychophysics and its supraspinal activation would be an exciting venue for research. Recent electrophysiological studies in humans using microneurography demonstrated that spontaneous activity of C fibers of a patient suffering from chronic itch has an activity pattern similar to that found in histamine responsive fibers in healthy humans (Schmelz et al., 2003Schmelz M. Hilliges M. Schmidt R.O. et al.Active ‘itch fibers’ in chronic pruritus.Neurology. 2003; 26: 564-566Crossref Scopus (92) Google Scholar) and may provide another area of collaboration between neuroscientists and dermatologists in exploring different types of itch, including those related to neural damage. Using techniques such as microdialysis, which can assess biologic response to itch such as neuropeptide level, will enable us to evaluate why itch intensity differs in different body sites (Rukwied et al., 2002Rukwied R. Zeck S. Schmelz M. McGlone F. Sensitivity of human scalp skin to pruritic stimuli investigated by intradermal microdialysis in vivo.J Am Acad Dermatol. 2002; 47: 245-250Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar). As our understanding has grown it is clear that methods of itch measurement need to be developed to meet the complexity of the itch experience. A combined effort by dermatologists and neuroscientists will eventually lead us to discover the chain of events from receptors in the skin to conscious expression of its supraspinal processing of itch and the modification of this system during skin inflammation and chronic itch." @default.
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• W2029921630 title "Assessment of Itch: More to be Learned and Improvements to be Made" @default.
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