What is pain?

Patients with psoriasis may experience skin-related pain and discomfort, a non-specific umbrella term for a variety of sensations including aching, itchiness, tingling, burning, tenderness, and cramping.^1,2

More than 40% of patients with psoriasis experience skin pain, with an average pain severity of 4.4 out of 10^2-4. Skin pain may vary based on age, sex, duration of disease, and severity.  Additionally, when people with psoriasis also live with anxiety, depression, or lack a support system, these may also contribute to increased pain.^3,5  

Why does my skin hurt?

Pain in the skin happens because of dysregulation of the inflammatory process. When there is an injury to your skin (such as scratching), the resulting tissue damage leads to the activation of the body’s immune system and defense mechanism. This in turn triggers inflammation around the injury. The skin inflammation following the release of inflammatory mediators affects the nerve endings and causes the sensation of pain in the skin.^2,6 Understanding the exact mechanism of pain in psoriasis is necessary so that effective therapies can be developed and help improve the quality of life of patients .

How is my pain severity assessed by doctors?

Before initiating treatment, clinicians and researchers usually evaluate the severity of the skin condition and the pain you are experiencing from it, in order to assess the whether your treatment is effective and tailor your therapy based on your needs. It is important to note that due to the individualized perception of the pain and no agreed-upon definition, a few standardized questionnaires are available to measure the subjective severity and nature of the pain. These include the Dermatology Quality of Life Index (DLQI), the Skindex, the Numerical rating scale (NRS), the Psoriasis Symptom Inventory (PSI), and the Psoriasis Signs and Symptoms Diary (PSSD).² Instruments such as these while helpful in a research setting are not a part of standard everyday practice, with the exception of the DLQI for patients with moderate to severe psoriasis.

Another helpful tool that clinicians use to objectively measure the severity and extent of psoriasis lesions is the Psoriasis Area and Severity Index (PASI) score. To calculate the score, dermatologists take into account the total body surface affected by psoriasis, as well as the redness, thickness, and scaling of the lesions. Studies show that there is a direct relationship between the reported skin pain and higher PASI scores.^1,7

How do doctors manage my pain?

For patients with psoriasis, pain reduction is an important factor in determining if a treatment is effective.  Thus, pain management is an important treatment goal and it is important information for you to share with your dermatologist. It is known that the severity of psoriasis influences the perception of the pain felt by patients. Therefore, one of the most effective ways of managing the pain is to treat the psoriasis itself. However, since the process of healing might take time, the short-term management of symptoms includes taking acetaminophen, or anti-inflammatory medications such as ibuprofen.

Some medications can target both psoriatic lesions as well as the pain, such as calcitriol and calcipotriol⁸, although the effects are mild. Other treatment modalities such as biologic agents, methotrexate or corticosteroids, combined with phototherapy or alone, have shown compelling results in controlling both psoriasis and pain.^9-11 These agents target the immune system dysfunction that causes psoriasis thereby helping to improve the skin. Therefore, treating the underlying psoriasis can help relieve the pain simulataneously. Finally, providing counselling and education on psoriasis as well as encouraging patients to join support groups or to reach out to patient organizations such as the Canadian Association of Psoriasis Patients, may help you improve your understanding of the disease process and symptoms and help reduce your pain.

How does skin pain affect my quality of life?

The quality of life of patients with painful psoriasis is severely affected.  The pain experienced by psoriasis patients is comparable to the pain levels reported by patients with heart disease and diabetes.^3,4  Your skin pain may interfere with sleep, mood, and enjoyment of life as well as impair function and affect interpersonal relationships.^1,12 Work productivity declines as the severity of pain increases, leading to higher absenteeism and less work activity.^13,14 Those experiencing pain may have a higher rate of psychiatric conditions such as depression and anxiety and medical conditions such as hyperlipidemia, hypertension, and diabetes.¹²

Other factors that may affect the perception of pain and quality of life is the amount of body surface area involved. Patients with more body surface involved reported feeling more pain and discomfort. However, patients with psoriasis on small but sensitive areas such as the scalp, palms, soles, and genitalia may suffer from equally severe pain and equally poor health-related quality of life.^2,12

What other parts of my body might hurt?

Beyond skin, other organs might be touched by psoriasis and cause pain and discomfort. Research suggests that patients with psoriasis may experience joint pain (psoriatic arthritis), inflammatory back pain, and nail pain. The first step in managing these, after alleviating the immediate pain (including with analgesics), is treating the underlying psoriasis and/or joint disease following the appropriate treatment regimen that you develop with your health care provider. Additionally, in psoriatic arthritis, injecting corticosteroids into the affected joint has been shown to have an effect on reducing the pain.^15,17

References

1. Ljosaa TM, Rustoen T, Mörk C, et al. Skin pain and discomfort in psoriasis: an exploratory study of symptom prevalence and characteristics. Acta Derm Venereol. 2010;90(1):39-45.
2. Pithadia DJ, Reynolds KA, Lee EB, Wu JJ. Psoriasis-associated cutaneous pain: etiology, assessment, impact, and management. J Dermatolog Treat. 2019;30(5):435-440.
3. Patruno C, Napolitano M, Balato N, et al. Psoriasis and skin pain: instrumental and biological evaluations. Acta Derm Venereol. 2015;95(4):432-438.
4. Ljosaa TM, Mork C, Stubhaug A, Moum T, Wahl AK. Skin pain and skin discomfort is associated with quality of life in patients with psoriasis. J Eur Acad Dermatol Venereol. 2012;26(1):29-35.
5. Sampogna F, Gisondi P, Melchi CF, Amerio P, Girolomoni G, Abeni D. Prevalence of symptoms experienced by patients with different clinical types of psoriasis. Br J Dermatol. 2004;151(3):594-599.
6. Jensen TS, Finnerup NB. Allodynia and hyperalgesia in neuropathic pain: clinical manifestations and mechanisms. The Lancet Neurology. 2014;13(9):924-935.
7. Ljosaa TM, Stubhaug A, Mork C, Moum T, Wahl AK. Improvement in Psoriasis Area and Severity Index score predicts improvement in skin pain over time in patients with psoriasis. Acta Derm Venereol. 2013;93(3):330-334.
8. Ortonne JP, Humbert P, Nicolas JF, et al. Intra-individual comparison of the cutaneous safety and efficacy of calcitriol 3 microg g(-1) ointment and calcipotriol 50 microg g(-1) ointment on chronic plaque psoriasis localized in facial, hairline, retroauricular or flexural areas. Br J Dermatol. 2003;148(2):326-333.
9. Bagel J, Nelson E, Keegan BR. Apremilast and Narrowband Ultraviolet-B Combination Therapy for Treating Moderate-to-Severe Plaque Psoriasis. J Drugs Dermatol. 2017;16(10):957-962.
10. Strober B, Sigurgeirsson B, Popp G, et al. Secukinumab improves patient-reported psoriasis symptoms of itching, pain, and scaling: results of two phase 3, randomized, placebo-controlled clinical trials. Int J Dermatol. 2016;55(4):401-407.
11. Lee S, Coleman CI, Limone B, et al. AHRQ Comparative Effectiveness Reviews. Biologic and Nonbiologic Systemic Agents and Phototherapy for Treatment of Chronic Plaque Psoriasis. Rockville (MD): Agency for Healthcare Research and Quality (US); 2012.
12. Korman NJ, Zhao Y, Pike J, Roberts J, Sullivan E. Increased severity of itching, pain, and scaling in psoriasis patients is associated with increased disease severity, reduced quality of life, and reduced work productivity. Dermatol Online J. 2015;21(10).
13. Korman NJ, Zhao Y, Pike J, Roberts J. Relationship between psoriasis severity, clinical symptoms, quality of life and work productivity among patients in the USA. Clinical and experimental dermatology. 2016;41(5):514-521.
14. Yao Y, Jørgensen AR, Thomsen SF. Work productivity and activity impairment in patients with hidradenitis suppurativa: a cross-sectional study. Int J Dermatol. 2020;59(3):333-340.
15. Dogra A, Arora AK. Nail psoriasis: the journey so far. Indian journal of dermatology. 2014;59(4):319-333.
16. Richette P, Tubach F, Breban M, et al. Psoriasis and phenotype of patients with early inflammatory back pain. Ann Rheum Dis. 2013;72(4):566-571.
17. Raychaudhuri SP, Wilken R, Sukhov AC, Raychaudhuri SK, Maverakis E. Management of psoriatic arthritis: Early diagnosis, monitoring of disease severity and cutting edge therapies. Journal of autoimmunity. 2017;76:21-37.