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 For more information about skin conditions and their treatment, contact:


Gregory J. Wilmoth, MD
Eric D. Challgren, MD
Margaret B. Boyse, MD
Laura D. Briley, MD
Tracey Cloninger, PA-C

Stephanie Pascale, MSN, FNP-C

4201 Lake Boone Trail, #200
Raleigh, NC 27607
Telephone: (919) 782-2152


4201 Lake Boone Trail, #207

Raleigh, NC 27607
Telephone: (919) 863-0073

Nothing’s More Challenging
Than a Severe Itch!

“The more challenging cases in dermatology,” observes Dr. Eric Challgren of Southern Dermatology Skin Cancer Center in Raleigh, “fall into one (or more!) of three categories. Skin problems that are hard to diagnose are among the most difficult. If you don’t know what’s causing the problem, it’s especially hard to treat.

Dr. Challgren

“We also face significant challenges from conditions that are misdiagnosed or diagnosed late. That’s particularly frustrating when the condition could be fairly easily treated if caught early,” he says.

“Finally, I’d have to say that certain conditions, such as psoriasis, belong on this list because they are so difficult for patients to tolerate.”

The Challenge of Itching Skin

It might come as a surprise to hear this, says Dr. Challgren, “but one of the most complex conditions we treat is pruritus—itching.”

Itch can be extremely complicated, he explains, “not least because it can be virtually intolerable for some patients. But it’s also a problem because pruritus stems from a wide variety of underlying causes—often hard to pinpoint.

“The more obvious causes, such as poison ivy, don’t necessarily require specialized care to identify or treat,” he says. “But in the tricky cases, a patient may already have been to multiple doctors who can’t figure out what’s causing the itching.

“At that point, we have to start ruling out potential causes. And, when we look at something as common as atopic dermatitis—a condition which, by the end of residency, we’ve seen thousands of times—you can almost hear the clicking noises in our heads, as we tick off the possibilities. And then, based on many factors, we rank-order the possibilities and continue the diagnostic process.”

But sometimes there can be non-dermatological causes for itching. That was the case when Dr. Challgren treated an older female patient. “She suffered from such severe itch that she had literally torn up her skin from scratching,” he recalls. “The usual process—looking at a long checklist of possible causes—failed to identify the source of the problem, and we ultimately ordered a chest X-ray.”

The X-ray and a subsequent biopsy revealed that the woman had lymphoma. Fortunately, once the cause was identified she was cured—and, says Dr. Challgren, the itch also went away.

“Lymphoma is by no means a typical cause for pruritus,” he says, “nor would I order CT scans or X-rays on every patient. However, with elusive cases, it’s essential to identify the underlying cause—and sometimes we simply need to dig deeper.”

Hand dermatitis is another particularly difficult itch to treat, because, Dr. Challgren explains, “the source of the problem is very hard to pin down. People use their hands so much that the itching is extremely severe, and that also complicates the process of identifying what they may have come into contact with that caused the reaction. It could be so many, many things!

“We can typically get this one under control for most patients,” he says, “but it can be a very difficult, challenging disorder.”

Delays Add to Difficulty

Still other cases, such as skin cancer, become complicated—even lethal—when patients wait too long to seek treatment. And the longer they are neglected, the more serious the problem.

“As the result of the pandemic, the past couple of years have meant too many instances of delay,” observes Dr. Challgren. “A case in point is a recent patient with a large squamous cell cancer on the back of his hand—and it had spread. He’s being treated aggressively and he might wind up doing okay, but he’s definitely in the category of ‘I wish we had gotten you in here two years earlier!’”

Patient Complications

Sometimes the challenge is not so much from the complexity of the problem, but from the impact it has on the patient. “Some skin conditions, such as psoriasis or severe eczema, are so very frustrating because they’re so visible,” notes Dr. Challgren.

“Psoriasis and atopic dermatitis may not be life threatening, but they can certainly be life altering,” notes Dr. Challgren. “Living with the impact of these conditions can lead to depression, social isolation, and mental anguish that can have a really negative effect on quality of life.”

“Although these problems aren’t inherently dangerous, the quality-of-life scores among these populations are lower than those with diseases that have higher rates of mortality. Psychologically, it’s easy to ignore your high blood pressure, but it’s not easy to ignore your psoriasis or acne or atopic dermatitis, which is right there in front of you every day.”

That complexity extends beyond self-consciousness to other conditions and risks, he points out. Psoriasis patients, for example, tend to have higher rates of heart disease, diabetes, obesity, depression, and substance abuse.
“The troublesome reality of psoriasis,” notes Dr. Challgren, “is that, while it manifests most obviously on the skin, these things all sort of flow into each other. Depression often develops from embarrassment about one’s physical appearance and leads to not fully participating in a healthy social life. Substance abuse develops secondarily to depression, both of which cause decreased physical activity and contribute to worsening obesity. Obesity causes psoriasis to get worse due to increased production of inflammatory markers from increased fat cells. And so it goes, round and round in a vicious cycle.”

Quality-of-Life-Changing Treatments

But severe psoriasis patients, who may have given up on finding an effective treatment even five years ago, now may find a wide variety of treatment options today that weren’t available previously.

“These biologic medications,” explains Dr. Challgren, “target different categories of overactive immune cells in the body. Normally, our immune cells recognize bacteria and viruses and coordinate the defensive response to such foreign invaders. But with conditions such as psoriasis, they may over-react, causing inflammation and exacerbating the condition. By targeting these overactive immune cells, the new medications are extremely effective in reducing inflammation and the visible plaques that are so distressing.”