Commentary on “Capture of patient itch scores in practice reveals disparate itch impact based upon age, gender and race: A cross-sectional survey analysis.”

Patient-reported outcome measures (PROMs) provide relatively new dermatologic data. PROMs include self-reported severity levels, such as pain and itch severity, and QOL, including domains such as the impact on emotions, activities of daily living, and symptoms. As such, PROMs quantify patient-reported information that is traditionally captured in a qualitative manner. For example, rather than “a lot” as an answer to “what is your itch severity?,” self-reported scores ranging from 0 to 10 are assigned. These scores have clinical meanings assigned to them (1–3 is mild, 4–6 is moderate, and 7–10 is severe itch) (Haydek et al, 2017; Reich et al, 2012).

Dermatology PROMs have primarily been used in clinical trials as secondary outcome measures. The Dermatology Life Quality Index and the Skindex are 2 skin-specific QOL measures that have been popular (Chren, 2012; Finlay and Khan, 1994). There has been hesitation in using such measures in clinics, mostly because they would take too long to administer. Even an extra 5 minutes would extend a 15- or 20-minute appointment by 30%. Another concern is that such measures may bring up issues that would take too long in clinics to address; indeed, some dermatologists may feel that the history is superfluous and that only a physical examination is necessary.

Proponents of PROMs argue that these measures do not require extending the duration of clinic visits and yet provide valuable clinical data. PROMs yield information that dermatologists cannot obtain without asking patients in a quantifiable manner. One cannot see itch or pain. In addition, studies have shown that physicians are poor estimators of patients QOL impact (Chren et al, 1996). Thus, PROMs complement the objective measures that clinicians use during physical examination.

From a time-efficiency standpoint, Lin and Swerlick (2025) demonstrated a workflow utilizing an electronic platform to send PROM questions to patients ahead of time so that the visit was utilized for discussing the results rather than obtaining information. Self-reported pain scores are already Joint Commission on Accreditation of Healthcare Organizations mandated in the in-patient setting and should be familiar to most patients to save time. The itch scores are similar. These PROMs can guide treatment plans, set the narrative for the visit, and provide anticipatory guidance so that the visit is conducted most efficiently.

For example, a patient may present with 8 of 10 pruritus. Because pruritus greater than a score of 7 is considered “severe,” the visit should mostly be focused on the assessment and plan for ameliorating this debilitating symptom. A possible treatment plan can be tailored using high-potency topical steroids when the itch is greater than 7 and medium strength steroids when the itch is less than 7. Hopefully, if the itch is less than a 3 (considered “mild” severity), no prescription topical steroid would be needed.

As another example, a return patient with psoriasis may start complaining of itching after their psoriasis has been well-controlled with biologics. Is this new complaint of itch because of an etiology unrelated to their psoriasis (eg, systemic etiology)? Or is this the first time the patient mentions itching because this is all that is left of his psoriasis? If this patient rates his itch as a 2 of 10, then the situation is likely to be the latter. Education on emollients and adjunct topical steroids is more appropriate than ordering laboratories to screen for systemic etiologies. Valuable time is not used to explain these unlikely etiologies.

In a third example, a patient may report no itching, few other symptoms, or functional impact and yet high emotional burden from their skin condition. The agenda for the visit should focus on uncovering and addressing the reasons for the emotional burden. This may be due to the worry of recurrence/flare, feeling a lack of control, or the postinflammatory hyperpigmentation of the condition.

The study by Li and Swerlick (2025) adds an important layer to address potential health equity gaps in the treatment of itch. Certain demographics (older age, women, African American/Blacks) were more likely to describe itch. Other studies have shown that Black patients are also more likely to report QOL impact, even adjusted for severity of itch (Rahman et al, 2024; Shaw et al, 2017). Without routinely asking about the presence, severity, and impact of itch, one may miss an opportunity to help a given patient’s QOL and inadvertently widen the disparity in helping certain populations.

Finally, PROMs can be used as interventions. Although not widely studied in dermatology, data suggest that oncological PROMs may extend life and improve QOL. In one such study, an intervention group (feedback on PROM results to physicians), an attention-control group (completion of PROMs but no feedback), and a control group (no PROMs) were compared (Lu et al, 2023). The investigators found that routine assessment of QOL resulted in a positive effect on emotional well-being and better patient–physician communication regarding pain and role function without prolonging encounters. In another study, investigators found that a cohort of patients whose treatment team monitored their completed PROMs actually extended their lives compared with a similar cohort that did not have a PROM intervention (Basch et al, 2017). Similar types of studies should be encouraged in dermatology. Although few skin diseases lead to mortality, a fair number of dermatologic conditions are symptomatic and have a significant impact on QOL. Administering and assessing PROM results may allow for improvement in QOL sooner.

To encourage patients to complete and clinicians to utilize PROMs, PROMs would need to be quick to complete, and workflows and platforms need to be optimized. Rather than PROMs used in research, which are detailed and lengthy, global measures are quick to complete and yield a high-level sense of the domain in question. Li and Swerlick (2025) utilized a series of questions that included the ItchyQuant (Haydek et al, 2017), a 1-item validated cartoon-annotated self-reporting itch severity measure; a pain numeric rating scale; and the Skindex-mini, a 3-item health-related QOL instrument measuring skin illness burden in symptom, emotional, and functional domains (Swerlick et al, 2021). The Skindex-mini is a global measure that encapsulates the Skindex-29, which uses 29 questions to capture frequency of the burden.

Another option is the Standardized Dermatology Outcome Measure (SDOM), which includes the ItchyQuant, Skindex-mini, questions about the severity (clear to severe) of skin problems, whether the response to treatment is good enough (yes/no/not applicable), and side effects. The 7-item panel of questions takes <5 minutes for patients to complete (Yeung et al, 2023). Patient Global Assessments have been developed, but these have been disease specific, so it would only be applicable to patients with those particular skin diseases. Regarding self-reported PROMs, pain and itch are most relevant to dermatology. Non–cartoon-annotated 1-item visual and numeric itch and pain rating scales are widely used (Reich et al, 2012). The advantage to the cartoon-annotated ItchyQuant is that it is validated for children aged ≥6 years. The Wong-Baker Faces Scale is a cartoon-annotated self-reported pain scale (Wong-Baker FACES Foundation, 2022).

Workflows and platforms are as important as the actual PROM instruments. Patient portals can be used to send questionnaires before patient visits. Our unpublished experience has demonstrated that in a 1-year period, of the 42,247 patients assigned to the SDOM through patient portal, 49.9% completed the questionnaire at least once, which is notable considering that they did so without any reminders. Of these, 16.5% completed the SDOM in at least 2 visits. Even paper intake forms can be utilized during the time of check-in; these are not as desired because the data would still need to be transcribed into the medical record but would at least provide the clinician with PROM data.

Ideally, all electronic medical records should incorporate a minimum-standard dermatology-relevant PROM that can be pulled into the American Academy of Dermatology (AAD)’s national registry, DataDerm. If such national PROM data were available, patient care could be advanced in innovative ways in addition to expected epidemiological research. DataDerm can be used to incorporate PROMs into the development of guidelines. One example of such a guideline could be the AAD acne guidelines; if the QOL impact of acne has not improved by a certain amount, then escalation of therapy should be recommended. Similarly, for atopic dermatitis, guidelines could recommend escalation of therapy if the itch score is above 4 (moderate severity) or 7 (severe). These types of evidence-based guidelines can help clinicians convince payers to approve therapies on the basis of the QOL and symptom impact.

National PROM data can also assist in risk stratification and benchmarking of outcomes. For example, a population with an inflammatory skin disorder with worse overall itch scores may have a higher level of complexity (higher risk) than those with lower itch scores. The higher-complexity population may require more resources in terms of therapeutics, laboratory monitoring, and number of visits. This same high-complexity population may take longer to achieve desired outcomes. National PROM data can also be used to guide desirable outcomes. This guidance could take the form of a minimum self-reported severity or QOL impact or a recommended level of reduction of the symptom or QOL burden. Alternatively, if the national PROM utilizes a question similar to that in the SDOM regarding adequacy of response to treatment, perhaps the outcome of deemed “good enough” is the desired outcome for a patient population. By utilizing these data, dermatologists can set their own quality metrics and goals rather than having them set by nondermatologists.

In summary, PROMs represent subjective quantitative data that provide information regarding the impact of skin conditions and the outcome of therapy from the perspective of the stakeholder living with the skin condition: the patient. To utilize these data on a clinic level as well as on national level is not only feasible but would also enrich the patient–clinician experience and allow for dermatology to control our own metrics.

ORCID

Suephy C. Chen: http://orcid.org/0000-0002-0678-7380

Conflict of Interest

SCC receives royalties from ItchyQuant when used by for-profit entities.