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Revista ABD Volume 92 Numero 4

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Revista ABD Volume 92 Numero 4 Particular characteristics of atopic eczema in tropical environments.INVESTIG The TropicalA Environment...TION 671671 s Xerosis cutis and associated co-factors in women with prurigo nodularis* Sevgi Akarsu1, Ozlem Ozbagcivan1, Turna Ilknur1, Fatma Semiz1, Burcu Bahar Inci1, Emel Fetil1 DOI: http://dx.doi.org/10.1590/abd1806-4841.20187127 Abstract: BACKGROUND: Current data regarding the associated factors of prurigo nodularis are still uncertain, except for atopic predisposition. OBJECTIVES: The purposes of this study were to (1) determine the frequencies of xerosis and other accompanying diseases of female patients with prurigo nodularis; (2) compare the demographic, clinical and accompanying disease characteristics by grouping these patients according to whether they have associated xerosis (who were subsequently subgrouped as atopic or non-atopic) or not. METHODS: In this retrospective descriptive study, 80 females with PN were categorized according to the accompanying diseases (dermatological, systemic, neurological, psychogenic, mixed, or undetermined origin). RESULTS: A total of 45 associated co-factors including dermatological in 63 (78.8%), systemic in 57 (71.3%), psychological in 33 (41.3%) and neurological co-factors in 14 (17.5%) of all patients with prurigo nodularis were detected. Xerosis was observed in 48 (60%) patients (non-atopic co-factors in 66.7% of them). The ratio of patients with mixed co-factors, dermatological+sys- temic co-factors and dermatological+systemic+psychological co-factors were found to be significantly higher in patients with xerosis compared to those without xerosis. STUDY LIMITATIONS: Our study has certain limitations such as the absence of an age-matched control group, absence of follow-up data and the fact that the diagnosis of xerosis has not been based on objective methods. CONCLUSIONS: Xerosis has been identified in more than half of the patients with PN and it has been determined that in most patients xerosis is associated especially with diabetes mellitus and other conditions related to prurigo nodularis. Keywords: Dermatitis, atopic; Female; Prurigo INTRODUCTION It is well known that impulse control disorders affecting the itch-scratch cycles.3,4 It has been demonstrated in a study with large skin (such as skin picking and neurotic excoriations) primarily affect case series that multiple lesions related to itching and PN are more middle-aged women.1,2 One of these troublesome diseases is chronic frequently observed in women with CP when compared to men. pruritus (CP, itching lasting for ≥6 weeks) which has been exten- Moreover, multifactorial, neuropathic and psychosomatic diseases sively investigated in recent years and may rarely lead to the devel- in relation with CP are at higher rates in women.3 Also in another opment of prurigo nodularis (PN) following intense and long-term study, it has been identified that the rates of decrease in quality of Received 22 March 2017. Accepted 20 August 2017. * Work conducted at the Department of Dermatology, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey. Financial support: None. Conflict of interest: None. 1 Department of Dermatology, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey. MAILING ADDRESS: Ozlem Ozbagcivan E-mail: [email protected] ©2018 by Anais Brasileiros de Dermatologia An Bras Dermatol. 2018;93(5):671-9. 672 Akarsu S, Ozbagcivan O, Ilknur T, Semiz F, Inci BB, Fetil E life with anxiety and itching intensity are higher in women when Only the diseases that were known to have the potential to lead to compared to men.4 itching and were recently correlated with PN development were PN is characterized by hyperkeratotic excoriated papulo- considered as PN-related diseases.13,16 However, a clear correlation nodular lesions that show symmetrical distribution on the exten- between all etiological factors and PN onset could not be shown sor surfaces of the body and/or extremities, the numbers of which due to the coexistence of the majority of associated underlying range from several to hundreds. Although it can be observed in all conditions in patients with PN. Using the classification of the Inter- ages and genders, it frequently affects middle-aged women with an national Forum for the Study of Itch16, our patients with PN were accompanying comorbidity.5-7 It is a rare disease and is one of the categorized according to the accompanying disease (dermatologi- most difficult conditions in terms of determining its etiology and cal, systemic, neurological, psychogenic, mixed, or undetermined treatment among chronic skin diseases.5 Although it is observed that origin). the underlying causes have formed a broad spectrum from atopic Patients with PN without xerosis (group A) and with xero- diathesis to malignant lymphomas, the data in the literature regard- sis (group B) were firstly compared for the statistical analysis, then, ing the predisposing factors contributing to the development of PN among the patients with PN and xerosis, the subgroups atopic xero- are still uncertain, except for an atopic predisposition.5-12 sis (subgroup B1) and xerosis related to other reasons (non-atopic) Xerosis cutis (dry skin) is also an important factor that can (subgroup B2) were compared among themselves. The data were contribute to the development of PN with CP and progressive itch- analyzed using SPSS software (SPSS 15, SPSS Inc., Chicago, Illinois, scratch cycle.5-7,13 Although xerosis, ever-increasing with age, often USA). The Shapiro-Wilk test was used to examine the normality of appears as being associated with an atopic condition (atopic xero- the distribution of the data. Numerical variables were described by sis), it is also a frequent symptom in some skin diseases (the most mean and standard deviation if they were normally distributed, and frequent in atopic dermatitis) and in chronic systemic diseases (such by median and interquartile range if they were not normally dis- as endocrine disorders, renal failure, liver diseases, malignancies tributed. Two samples Student’s t-test was used to compare mean and infections).13-15 Upon reviewing the literature, no study exam- values of normally distributed quantitative variables as the two ining the presence of xerosis within the conditions accompanying samples were obtained independently, and Mann Whitney U-test PN has been found. was used if the variables were not normally distributed. Qualitative In this study, the objective was first to determine the demo- variables were analyzed with chi-squared test and Fisher’s exact graphic and clinical characteristics, and the frequencies of xerosis, test. P <.05 was considered significant in all analyses. Furthermore, atopic diathesis and other accompanying diseases of female patients the Hosmer-Lemeshow goodness-of-fit test for logistic regression with PN. We also intended to compare demographic, clinical and was used to evaluate the association of each category of accompa- accompanying disease characteristics by grouping these patients ac- nying co-factors in the presence of the others. A Type 1 error rate of cording to whether they have accompanying xerosis or not and the less than 5% was considered significant in this analysis. patients with xerosis according to the presence of the current atopic or non-atopic factors. RESULTS Xerosis was observed in 48 (60%) of a total of 80 female pa- METHODS tients with PN who were included in the study, while the presence This is a retrospective descriptive study, including 80 wom- of at least one atopic diathesis was identified (atopic xerosis) in 16 en with clinicopathologically diagnosed PN who were consecutive- (33.3%) of them, atopy history was not determined in 32 (66.7%) of ly admitted to the outpatient clinic of the Department of Dermatol- the remaining (non-atopic xerosis). ogy of Dokuz Eylul University Faculty of Medicine in Izmir, Turkey, between January 2010 and December 2016. The study protocol was Demographic and clinical characteristics approved by the Local Ethical Committee (the number of Research Both the age and the PN onset age averages of the patient Ethics Committee: 2015/16-18) which follows the guidelines set by group with xerosis were found to be higher compared to those with- the Declaration of Helsinki. Patients’ files were examined, and their out xerosis (p<0.001). While the ratio of the patients whose PN le- demographic and clinical characteristics such as ages, the age of PN sions had started in the early adulthood period was higher in the onset and age distributions (early adulthood; 19-45 years, middle PN group without xerosis, the patients whose PN lesions had start- adulthood; 46-64 years, and later adulthood; ≥ 65 years), duration of ed in the later adulthood period were found to be at a higher rate in PN, distribution and site of lesions were recorded. The medical his- the group with xerosis (Table 1). tories, physical examinations and laboratory investigations as well In patients with xerosis, the age and the PN onset age aver- as the results of consultations and additional examinations required ages of the atopic xerosis group were found to be lower compared from the relevant departments when necessary in the clinical evalu- to the patients with non-atopic xerosis (p<0.001). While the ratio of ation periods of the patients were taken into account in determining patients whose PN lesions had started in the early adulthood period accompanying xerosis, atopic diathesis (allergic rhinitis/rhinocon- was more in the atopic xerosis group, patients whose PN lesions had junctivitis, bronchial asthma and/or atopic dermatitis) and other started in the middle adulthood and later adulthood period were PN-related diseases. Patients with missing data were not included found to be at a higher rate in the non-atopic xerosis group. The in the study. Xerosis was clinically determined by the presence of mean PN disease duration was also found to be longer in the atopic features such as roughening on the skin, flaking and/or fissures. xerosis group (Table 1).
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