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11 May 2023
FIRST LOCAL STUDY CONDUCTED FOUND HOW ELDERLY PERCEIVED CHRONIC PRURITUS (PROLONGED ITCH), AND RESULTS MAY HELP IN PRURITUS MANAGEMENT
A first local study conducted by SingHealth Polyclinics (SHP) found how elderly perceived the condition of pruritus as a chronic "problem", rather than a disease that can be cured. Chronic pruritus is also known as a prolonged itch that last more than 6 weeks. Patients' perception of the causes was diverse due to the lack of a clear explanation by their physicians. They suggested that prolonged itch continues indefinitely, without a definite time of resolution. Patients usually help themselves through therapeutic experimentation, alternative therapy, self-isolation, avoidance behaviours, emotional disturbance and ultimately ended up with dermatological complications.
The prevalence of chronic itch increases with age, and Singapore is expected to have the ninth largest share of elderly in the general population by 2050. In an inpatient geriatric patient population in Singapore, the prevalence of prolonged itch is reported to be 48.5 per cent. Prolonged itch can significantly impact daily life, such as sleep, exercise, hobbies, and social life. It can also result in anxiety and depression.
Patients are usually left unsatisfied when symptoms recur, as symptomatic treatment fails to address the root of the condition. Frustrations with the treatment invariably affect their health-seeking behaviour, which leads to frequent doctor changes, adding to the healthcare cost. Their self-treatment with over-the-counter medications, including using traditional medicated oils or powders to relieve their symptoms, is common among local patients with pruritus. Many of them rub or scratch the areas of pruritus, resulting in excoriations, or resort to frequent washing of the site to find transient relief. Many change their eating habits and adopt special diets to relieve their conditions. Ultimately, this resulted in patients’ unwillingness to seek proper treatment for pruritus.
With the aim to explore how elderlies perceived prolonged itch, the team conducted the qualitative study at SHP-Bukit Merah, by having in-depth interviews with 13 elderlies with the condition. The participants were questioned one on one, either in-person or over the phone based on a semi-structured topic guide with open-ended questions. The questions touched on their perception of the causes of itch, the expected duration and impact of pruritus on their daily activities, emotions and their health-seeking and self-care behaviour.
“This study shed light on the illness perceptions of older patients with prolonged itch in the Singapore context. They identified the condition as a chronic, aversive problem with unclear cause, which impacted their daily lives and emotional well-being (refer to Annex A). The outcomes of this study emphasised the need for physicians and healthcare providers to explore the patient’s illness perception, and guide the patient to adapt and adopt appropriate behavior, in order to mitigate adverse skin problems”, said Dr Moosa Aminath Shiwaza, Associate Consultant, SHP-Bukit Merah. Dr Moosa is also the main author of this research paper.
Dr Moosa added that itch treatments entail both short and long-term. The usual practice involves treating the acute symptoms with oral antihistamines, oral steroids, or topical steroid creams. Most local patients with chronic pruritus are treated with sedating antihistamines, which can have negative consequences, such as falls and reduced concentration at work. Non-sedating antihistamines are safer, but curbing the symptoms require long-term usage, which adds to the pill burden of an elderly.
“The findings gave conclusions that managing pruritus should be based on a person-centric approach, by providing personalised care to patients to avoid their specific triggers and maladaptive behaviour. Targeted personalised counselling, education and psychological support should be integral in their care plan to increase patients’ knowledge of prolonged itch, and sustain their appropriate coping behaviours”, said Clinical Associate Professor Tan Ngiap Chuan, Director of Research, SHP and Vice-chair, Research, SingHealth-Duke NUS Family Medicine Academic Clinical Programme (FM ACP).
“An Itch Assessment Questionnaire (IAQ) has since been developed through the findings, and will be used for a following study to assess the magnitude and morbidity of itch in the local population. Subsequently IAQ will be used to monitor patient symptoms and severity in clinical care. The recruitment for the study will begin in the second half of 2023”, added Prof Tan.
Patients’ feedback on their experience with Chronic Pruritus, and how they manage this condition
1. “If it gets worse, it gets reddish. It's like poking, poking pain like that, you know!”
2. “So, I still don't know why, … that is the problem that I'm living with now. I don't know WHAT is the problem. So, if I don't know what is the problem, how can I find a cure for it?”
3. “I just stay at home and look after my leg… I just take care of it. I (am) scared I (would) scratch … that's why I don't want to go out… wound so ugly!”
4. “I have friends who have rash problem also. They tell me, recommend me this, recommend me that, and we try to exchange ideas.”
5. “Sometimes, at night, I can't sleep at all. Every two hours or one hour, you got to wake up.”
6. “The more you scratch, the skin gets thicker. It's very itchy … after you scratch, scratch until the skin (is) broken, it become very warm.”
7. “I just self‐medicate …I buy the cream, I apply it and then if it comes back again, (I) then just apply it, just leave it like that. I don't want to make myself so troublesome to do all this (by) seeing doctor, so many doctors.”
8. “If I go this month, they (doctors) give me (one) type of cream, then when I go another month, another doctor gives me another type of cream. So, it will be more confusing, you know.”