Association of pain and itch with depth of invasion and inflammatory cell constitution in skin cancer: results of a large clinicopathologic study

JAMA Dermatol. 2014 Nov;150(11):1160-6. doi: 10.1001/jamadermatol.2014.895.


Importance: This study highlights a simple bedside evaluation of itch and pain for suspicious skin lesions.

Objective: To examine the correlation of pain and itch with histologic features of skin cancers.

Design, setting, and participants: This large, prospective, clinicopathologic study enrolled patients who filled out questionnaires that assessed itch and pain intensity of their skin tumors at the time of excision. Study participants were from the patient population presenting to the Department of Dermatology surgical unit at Wake Forest University Baptist Medical Center from July 1, 2010, through March 31, 2011. Study participants included 268 patients, representing 339 histopathologically confirmed cutaneous neoplasms. The following skin cancer subtypes were represented in this analysis: 166 basal cell carcinomas, 146 squamous cell carcinomas, and 27 melanomas.

Main outcomes and measures: Itch and pain associated with skin cancer at the time of excision ranked on an 11-point (score range, 0-10) numerical visual analog scale and histopathologic analysis for each neoplasm (assessment of the amount and type of inflammation, ulceration, perineural invasion, and depth of invasion).

Results: The prevalence of itch and pain across all skin cancers was 36.9% and 28.2%, respectively. However, these symptoms were mostly absent in melanomas. Pain intensity was significantly associated with the degree of inflammation (mild or none vs moderate or marked; P < .001), presence of neutrophils in the inflammatory infiltrate (predominantly mononuclear vs mixed or neutrophilic; P = .003), presence of eosinophils (present vs absent; P = .007), ulceration (yes vs no; P = .003), perineural invasion (yes vs no; P < .001), depth of invasion (P = .001), and largest diameter length of skin lesion (P < .003). Itch intensity was significantly associated with the degree of inflammation (mild or none vs moderate or marked; P = .001) and the presence of eosinophils (present vs absent; P = .02).

Conclusions and relevance: These findings support the theory that itch emanates from the upper layers of the skin, whereas pain is associated with deeper processes. This study also reports that a simple bedside assessment for the presence and intensity of pain or itch is an easily implementable tool for physicians evaluating suspicious skin lesions.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Carcinoma, Basal Cell / epidemiology
  • Carcinoma, Basal Cell / pathology
  • Carcinoma, Basal Cell / surgery
  • Carcinoma, Squamous Cell / epidemiology
  • Carcinoma, Squamous Cell / pathology
  • Carcinoma, Squamous Cell / surgery
  • Eosinophils / metabolism*
  • Female
  • Humans
  • Inflammation / epidemiology
  • Inflammation / etiology*
  • Inflammation / pathology
  • Male
  • Melanoma / epidemiology
  • Melanoma / pathology
  • Melanoma / surgery
  • Middle Aged
  • Neoplasm Invasiveness
  • Pain / epidemiology
  • Pain / etiology*
  • Pain Measurement
  • Prevalence
  • Prospective Studies
  • Pruritus / epidemiology
  • Pruritus / etiology*
  • Skin Neoplasms / pathology*
  • Skin Neoplasms / surgery
  • Surveys and Questionnaires