The Importance of Adequate Hydration

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“Water is defined as an essential nutrient because it is required in amounts that exceed the body’s ability to produce it. All biochemical reactions occur in water. It fills the spaces in and between cells and helps form structures of large molecules such as protein and glycogen. Water is also required for digestion, absorption, transportation, dissolving nutrients, elimination of waste products and thermoregulation” (regulation of body temperature) (Kleiner, 1999).Hydration fact sheet- facebook (1)

cucumber-salad-food-healthy-37528mineral-water-lime-ice-mint-158821Key Facts 

Up to 2 litres of Water is lost daily due to bodily functions, such as perspiration, respiration, urination and defecation.

Diuretic substances in your diet such as caffeinated beverages, alcohol, high sugar and salty foods will increase water loss from the body.

Water requirements range from 8-10 glasses per day depending on diet and physical activity levels. As we age, we have a diminished sense of thirst and tend to drink less fluid, although water is still required. It is therefore important to ensure we drink an adequate amount of water, even in the absence of thirst.

Water can be consumed from drinking pure water as well as from eating certain foods. Depending on diet, up to 50% of your daily water intake can be derived from foods provided they are high in water content such as fruit, salad, soup and vegetables (i.e. iceberg lettuce and cucumber).

How dehydration impacts your skin condition

Key signs of mild to moderate dehydration include increased sensation of pexels-photo-136871pain, thirst, stiffness, headaches, lack of concentration, fatigue and skin problems.

The skin contains approximately 30% water. “Water intake, particularly in individuals with low initial water intake, can improve skin thickness and density and offsets transepidermal water loss (water lost through the skin surface)” (Popkin, Rosenberg & D’Anci, 2010). Hydration improves skin resiliency, elasticity and texture.

The water content in the skin contributes to important functions of the skin such as the development of a healthy skin barrier. The skin barrier guards the skin from microbial infections and infiltration of foreign substances which can cause skin flare ups.

Water deficiency can also lead to impaired skin processes, which can then worsen skin disorders such as dermatitis, psoriasis, acne and rosacea (Rodrigues, Palma, Tavares Marques & Bujan Varela, 2015).

Key tips to keeping hydrated

Create a routine: If you aren’t used to drinking water on a regular basis, start with four glasses of water a day. One glass on rising, one mid-morning, one mid-afternoon and one on retiring. This eliminates 4 out 8 glasses per day. Once you establish this routine, start adding additional glasses of water throughout the day, for example before meals

Convenience: Keep water with you at all times. Keep a refillable water bottle with you at work, in your car, and to take with you when you go on walks etc. Get used to sipping on water as part of your daily routine. Convenience is key, otherwise if it’s out of sight, it’s often out of mind!

Flavour: If you don’t like the taste of water, there are several ways to make it more enticing. Add some fresh herbs like mint, or fresh fruit, or a very small amount of juice (just enough to add a hint of flavour).

Variety: Mix up your water variety and add in some natural sparkling mineral water.

Eat foods high in water content: Eat plenty of fresh fruit and vegetables, in doing so will assist in keeping your body hydrated (this information should not replace any dietary information given by your psoriasis eczema clinic practitioner).

Be aware of cravings: if you are craving salty foods as this can be a signal from the body that you are dehydrated. Try drinking a glass of water before reaching for salty foods.

For more information on the health benefits of water and charts for daily consumption visit: https://www.nrv.gov.au/nutrients/water

Reference:

  1. Popkin, B., Rosenberg, I., & D’Anci, K. (2010). Water, Hydration and Health. National Institute of Health68(8), 439–458. http://dx.doi.org/doi:10.1111/j.1753-4887.2010.00304.x
  2. Kleiner, S. (1999). Water. Journal Of The American Dietetic Association99(2), 200-206. http://dx.doi.org/10.1016/s0002-8223(99)00048-6
  3. Rodrigues, L., Palma, L., Tavares Marques, L., & Bujan Varela, J. (2015). Dietary water affects human skin hydration and biomechanics. Clinical, Cosmetic and Investigational Dermatology4(411), 413. http://dx.doi.org/10.2147/ccid.s86822

Atopic Dermatitis (Eczema) and BACTERIAL CUTANEOUS (SKIN) INFECTIONS

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Atopic_3

Atopic dermatitis (AD), also known as atopic eczema, is a chronic inflammatory disorder that causes significant morbidity and has a wide range of allergic and non-allergic comorbid disorders.

Comorbidity is a concurrence of multiple diseases or disorders in association with a given disease. The patient with AD has an increased risk of developing one or more of a number of other diseases/conditions that share many immunological features with AD.

   Cutaneous (skin) infections including:-

   Bacterial – Staphylococcal   / Impetigo contagiosum 

    1, 2, 3, 4, 5, 6, 7

Patients with AD are highly susceptible to certain bacterial, fungal and viral infections.

They have also been noted to have an increased incidence of warts caused by the human papillomavirus (HPV), and fungal infections caused by Trichophyton rubrum and also have a higher incidence of the fungal infections:- tinea pedis, tinea unguium, tinea manuum, tinea cruris, and tinea corporis, as well tinea barbae.7

AD Patients are also susceptible to severe infections caused by herpes simplex type 1 virus (eczema herpeticum or Kaposi’s varicelliform), vaccinia virus (eczema vaccinatum) coxsackie A virus and molluscum contagiosum virus. These viral infections can cause serious complications in AD patient and if not treated promptly have the potential to be life threatening.7

Signs of Secondary Infection include:

  • Sudden flaring (worsening) of eczema all over the body.
  • Weeping crusted areas – crusts are often a golden colour
  • Clusters of pustules (yellow/white pimples).
  • Fever, Shivering and extremely painful skin.
  • Chicken pox-like blisters and sores – this can be caused by the cold sore virus and may require urgent medical attention (Kaposi’s varicelliform)

BACTERIA and ATOPIC DERMATITIS (AD)

The skin is colonized by various different species of bacteria, fungi, and viruses that together are known as the skin microbiome, mainly Corynebacterium spp., Propionibacterium acnes and Staphylococcus epidermidis.

Each person will carry a different combination of these depending upon health and environment. The colonization of bacteria on specific regions on the body depends upon the local skin environment including moisture levels, pH, and keratinocyte cell surface adhesion proteins (Skin Barrier). For instance, Staphylococcus and Corynebacterium species thrive in specific environments on the skin such as the sole of the foot and the back of the knee. Dry environments such as the inside forearm and palm of hand are more prone to harbour a mixed population of bacteria including Propionibacterium acnes. 7

Babies are born microbe free until exposure to the external environment allows for immediate colonization of their skin, this first colonization usually starts as they pass through the vagina. As the child grows and they are exposed to different environments and in physical contact with different people their microbiome will change.7

Environmental factors such as diet, age, and gender also play a role in the makeup of the skin microbial flora.7

Staphylococcus aureus (S. aureus) and Staphylococcus epidermidis (S. epidermidis) are the two most common clinical isolates of the microbiota that is normally found in the nasal passages and on the skin of healthy people. They are Gram-positive cocci found in clusters. S. epidermidis comprises greater than 90% of the aerobic resident flora found on the skin and is considered a normal inhabitant of the skin surface. Some strains of S. epidermidis produce bacteriocins that are toxic to other bacterial species such as Staphylococcus aureus. S. epidermidis can also target S. aureus can prevent S. aureus biofilm formation and growth thus promoting a stronger skin barrier and immune response.7

In AD patients, when the patient suffers skin barrier breakdown and lowered immunity both S. aureus readily colonizes the affected skin lesions. Studies have shown that between 80% and 100% of patients with AD present nasal and skin colonization by with S. Aureus, as opposed to the prevalence of only between 5 to 30% in individuals without AD. To further break down the colonization statistics S. aureus has been isolated from 55–75% of unaffected AD skin, 85–91% of chronic lichenified (thickened/ scratched) lesions and 80–100% of acute exudative (weepy) skin lesions.7, 8

Impetigo contagiosum (contagiosa)

Impetigo is a skin infection caused by Staphylococcus aureus and Streptococcus pyogenes. In Europe and colder climate regions, Staphylococcus aureus is the most common cause. Impetigo can affect any one but is more common in children aged 2yrs. – 6 yrs. of age. It is highly contagious and is spread by direct contact. Children and those affected need to be kept home from day care, kindergarten, school and work.9

Atopic_4 Atopic_5

Impetigo is commonly found in people who have skin conditions that cause impaired skin barrier e.g. eczema, scabies, fungal infections or via skin trauma e.g. insect bites. It is also common in crowded environments e.g. schools, day care centres etc. It can be spread through contact sports e.g. wrestling. Impetigo caused by Streptococcus pyogenes is common in hot humid regions.

There are two types of impetigo. The most common is called crusted or non-bullous impetigo. It starts as small blisters, which quickly burst and crust over. The other type, called bullous impetigo, causes large blisters that break easily. It is less common, and mainly affects babies.

Non Bullous Impetigo normally presents as:

  • Small vesicles that rupture, dries and forms golden- coloured, brown or even brownish black crusts/scabs.
  • Lesions can be up to 2cm in diameter.
  • Usually found on the face – around the mouth and nose, but they can also be found on the limbs.
  • In mild cases there is normally no systemic symptoms, but if it is an extensive eruption, it may be accompanied by fever and swelling.

Bullous Impetigo presents as:

  • Large fluid filled blisters > 2cm, which rupture easily.
  • May be golden in colour, brown or even brownish black.
  • The limbs and torso are more likely to be affected.
  • It is normally accompanied by fever and swelling.

Bullous impetigo is only caused by S aureus.

Atopic_6 Atopic_7

Impetigo has been commonly called “school sores”. It is important, due to the contagious nature of the condition, that hands are washed regularly and especially after having touched or scratched the impetigo lesions. Anything that has been in contact with the sores e.g. clothing or anything that has been on the sores can spread the infection to other family members, friends and colleagues. In order to prevent the spread of the condition it is very important that clothes, towels, pillows and bed linen, nail scissors, razors or toothbrushes etc. are not shared. Clothing, towels and bedding etc. should be washed separately using hot water, washing powder and a disinfectant or eucalyptus/tea tree oil added to the wash.

REFERENCES

  • Simpson EL.; Comorbidity in Atopic Dermatitis; Curr Dermatol Rep. 2012 March 1; 1(1): 29–38. doi:10.1007/s13671-011-0003-5
  • Augustin M. et al.; Epidemiology and Comorbidity in Children with Psoriasis and Atopic Eczema; Dermatology 2015;231:35–40 DOI: 10.1159/000381913
  • Deckert S. et al.; Nonallergic comorbidities of atopic eczema: an overview of systematic reviews; Allergy 69 (2014) 37–45 © 2013
  • Ellis CN. et al.; Validation of Expert Opinion in Identifying Comorbidities Associated with Atopic Dermatitis/Eczema; Pharmacoeconomics 2003; 21 (12)
  • Silverberg J.I. and Silverberg N.B.; Atopic Dermatitis: Update on Pathogenesis and Comorbidities
  • Cogen A.L. et al.; Skin microbiota: a source of disease or defence?; Br J Dermatol. 2008 March ; 158(3): 442–455. doi:10.1111/j.1365-2133.2008.08437.x
  • Williams M. R. et al.; The Role of the Skin Microbiome in Atopic Dermatitis; Curr Allergy Asthma Rep (2015) 15: 65 DOI 10.1007/s11882-015-0567-4
  • Baviera G. et al.; Staphylococcus Aureus And Atopic Dermatitis: Which Came First, The Chicken Or The Egg?; EMJ Dermatol. 2015;3[1]:92-97.
  • Petry V. et al.; Bacterial skin colonization and infections in patients with atopic dermatitis; An Bras Dermatol. 2012;87(5):729-34.
  • Leung DYM.; The role of Staphylococcus aureus in atopic eczema; Acta Derm Venereol 2008; Suppl 216: 21–27
  • Baker S.; The role of microorganisms in atopic dermatitis; 2006 British Society for Immunology, Clinical and Experimental Immunology, 144: 1–9

Christmas and the Holiday Season with Skin Conditions

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So now the Christmas and New Year holiday season is upon us and for those of you who suffer from a skin condition, this time of the year can be challenging.

We all know that the intake of alcohol can be a trigger for many skin conditions such as psoriasis, eczema, urticaria etc. It is dehydrating and dehydration impairs the skin barrier. Alcohol also has the potential to weaken one’s immune system, this makes people with skin conditions more susceptible to bacterial infections and injuries, which in turn can trigger and exacerbate their condition.

For those of you who are yeast sensitive, the intake of drinks such as beer and champagne, both of which contain yeast, most certainly will aggravate their skin condition and could cause a major flare up. Those that are gluten sensitive or suffer from Celiac disease also have to be careful with their alcohol intake as some types of liquors e.g. vodka, bourbon etc. may use a starch-source for fermentation and these starch sources e.g. barley contain gluten.

This time of the year can be emotionally challenging, if you are experiencing family or relationship difficulties, you may be experiencing considerable emotional distress, depression and even social isolation. Try to reach out to friends and support groups for support during this time. It is important that you do not isolate yourself and allow your stress levels to escalate.

If tasks such as shopping or getting the house ready cause you stress, then make sure you plan ahead and allow yourself extra time.

Food of course is a big deal at this time of the year. Catching up with friends for barbecues, lunches, dinners at restaurants or at homes is an important tradition and catch up time for all of us.

 Control on what is on the menu is often out of your hands, therefore it is important to choose your food wisely. So avoid all spicy foods or at least keep it to a minimum – if you eat spicy food at one sitting try to avoid another serve for a few days.

Avoid or at least keep to a minimum intake of tomatoes (including chutneys), smoked foods, red and processed meats. Try to select green vegetables, chicken, turkey, fish and moderate all other intake. Remember if you do have a food sensitivity, be it seafood, gluten, yeast, sugar then try to avoid it as much as possible. The golden rule is “If you ate it during one meal wait a few days before having it again”  if you can’t avoid eating it then moderation is key.

If you are eating at the home of family member or friend then don’t be afraid to tell them of your eating requirements. Most people will be only too happy to oblige by either offering an alternative that you can eat or by modifying the dishes that they are preparing.

As mentioned earlier dehydration impairs the skin barrier so drink plenty of water. It is important to try to drink between one and a half litres to two litres of water a day and critical if you are drinking alcohol.  

The most important thing is to try to enjoy your time with family and friends, don’t overdo the alcohol or food intake. Remember moderation and alternatives, drink your water, get plenty of rest. If you find yourself feeling stressed, make some time to chill out, meditate or listen to music.

 So Check List:

  • Drink water
  • Eat Greens, chicken, turkey, fish
  • Avoid tomatoes, spicy, red and processed meats, smoked foods, sugar
  • Avoid your trigger foods
  • Moderate alcohol intake 
  • Keep stress to a minimum, plan ahead & get support 

Atopic Dermatitis (Eczema) and Psychological Disorders

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Psychological Disorders: –

Depression

Anxiety

Attention Deficit/Hyperactivity Disorder (ADHD)

Autistic Spectrum Disorder (ASD)

Atopic Dermatitis (AD) is a multifactorial, immune mediated, chronic and relapsing skin disease, with significant emotional distress, sleep disturbance and Quality of Life (QoL) difficulties. 1,2,3

Most cases of AD begin in childhood or adolescence, with more than 80% of pediatric patients having persistent symptoms of itch and dry skin in adulthood. The early age of onset and disease chronicity, plus impaired quality of life weighs heavily on a child’s psychological and behavioural development. This often leads to delayed social development throughout life and very high rates of psychological and behavioural disorders.5, The impairment of quality of life caused by childhood AD has been shown to be greater than or equal to other common childhood diseases such as asthma and diabetes, emphasising the importance of AD as a major chronic childhood disease.1,2,3

AD patients have been described with lower self-competence and self-efficacy, when compared with healthy individuals and there is also a clear relationship between the prevalence of a mental health disorder and the reported severity of the skin disease. 1,2,3

Psychological stress and AD symptoms seem to form a vicious cycle. However, the exact mechanism as to how stress affects AD is as yet largely unknown. Evidence suggests that stress stimulates the hypothalamic-pituitary-adrenal (HPA) axis releasing neuropeptides and neurotrophins, which influence the development and course of AD, inducing epidermal barrier dysfunction, and lowering the itch threshold.4

Atopic_1

The current incidence of psychiatric disorders among dermatological patients is estimated at about 30-40% and the association between anxiety and depression, and AD is well documented in scientific and medical journals.1,2,3 AD and clinical depression interact closely, and causal relationships between the two conditions have frequently been observed; e.g. the onset or exacerbation of AD often follows stressful life events such as severe disease in a family member, divorce, or parental separation.5

This may reflect the psychological distress produced by both the stigma associated with visible AD skin lesions and the unpredictability of disease flares, and may be manifested by the high proportion of patients (approx. 60%) who reported being embarrassed by or self-conscious of their skin condition in various studies. The psychological burden can further negatively impact mood and QoL. Thoughts of suicide have been reported in 15% of patients in an AD population in Europe and up to 20% of individuals with severe disease.3

In Dermatology Life Quality Index (DQLI) questionnaires, approximately 46% AD patients report severe pruritus (itch) with almost 15% rating it as unbearable, 86% experience itching every day and approx. 42% state that they itch up to 18 hours per day. Nearly all patients also reported the frequent occurrence of bleeding, oozing, cracking, flaking, or drying of their skin. AD and itching has a significant impact on patient-reported sleep with approx. 68% of patients reporting that itch delayed falling asleep and occasionally or frequently woke them up at night, with up to 36% reporting that their sleep was disturbed every night. Loss of sleep may contribute to daytime sleepiness and fatigue, further reducing functional activities and adversely affecting mood and QoL due to the fact that sleep likely has a reciprocal relationship with mental health.3

Children with AD face a slightly different set of challenges and often have negative self-esteem (subjective perception of self-worth) and poor self-image (subjective perception of abilities, appearance). They experience frustration, fussiness, irritability, unhappiness, loneliness, self-consciousness and emotional sensitivity. Parents have reported that their AD children often cry, and are nervous and insecure. Researchers observed perfectionism, rigid and obsessive thought patterns, anxiety and depression, obsessive and compulsive traits in paediatric AD patients. Children with AD also have difficulties in social interaction and impaired social competence.6

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Sixty percent of children with AD experience sleep disturbance caused by their disease, with 83% reporting sleep disturbance during exacerbations. The sleep of children with eczema was characterized by problems with settling and maintaining sleep while their daytime functioning was characterized by excessive daytime sleepiness and higher ADHD and Oppositional Behaviour scores as well as poor performance in daytime activities, specifically school performance.6 Problematic behavioural patterns that include hyperactivity, impaired attention, scratching to get attention; stubbornness, aggressiveness, disruptive and oppositional behaviour have been documented. A significant association was found between Attention Deficit Hyperactivity Disorder (ADHD) and AD. It is suggested that these behavioural difficulties are possibly mediated by disturbed sleeping patterns, difficulty in coping with the discomfort of AD and its treatment, disfigurement, stigmatisation and disciplinary challenges.7

Various studies have consistently indicated an association between AD and Autism Spectrum Disorder (ASD) and ADHD which is independent of environmental exposures and other comorbidities. Particularly infant AD appears to be associated with later development of ADHD symptoms. Children with previous or prevalent AD have an approximately 43 % increased risk to be diagnosed with ADHD or to display clinical ADHD symptoms.8, 9

It has been speculated that ADHD/ASD symptoms, AD, food hypersensitivity and sleep disruption may be linked by shared pathophysiological factors and that these impairments are characterized by a relevant developmental interplay, especially in early infancy and childhood. Disturbed sleep is a characteristic feature of ASD/ADHD and eczema and may be one mediating factor in the observed associations. However, other mechanisms may also be involved such as genetic or neuro-immunomodulatory mechanisms. It has been suggested that the non-allergic activation of TH1 and TH17 cells, which mediate the inflammatory processes, may be of relevance in the association between AD and ADHD. Also excessive cytokine release may impact on the central nervous system as they are able to pass the blood–brain barrier, thus possibly affecting both neurotransmission and brain circuits which are known to be involved in ADHD and/or affecting the sleep–wake rhythm.8, 9

Recent studies have also linked sleep disturbance to obesity and hypertension (blood pressure PB) in children.  The long-term effect of increased BP are unknown in children, but it is possible that cumulative increases of BP are associated with cardiovascular disease later in life, similar to that observed in psoriasis. The mechanism of association between obesity and AD remains unknown. Previous studies have suggested that adipose (fat) tissue may directly influence the risk of AD. 10  The association between AD and in particular, central obesity – where excessive fat is stored around the stomach and abdomen, in particular, is of major concern. Central obesity has previously been reported to have particularly harmful effects on a variety of medical disorders, including asthma, dyslipidemia, diabetes, coronary artery disease, and myocardial infarction.

 

Also read our BLOGS – Stress, Anxiety, Depression – Atopic Eczema (AE)/Atopic Dermatitis (AD) and associated Itch

Stressed About Your Skin Condition – Identify Your Stressors and Your Stress Responses 

REFERENCES

  • Lewis-Jones S. (2006), Quality of life and childhood atopic dermatitis: the misery of living with childhood eczema. International Journal of Clinical Practice, 60: 984–992. doi:10.1111/j.1742-1241.2006.01047.x
  • Mina, Shaily et al. “Gender Differences in Depression and Anxiety Among Atopic Dermatitis Patients.”Indian Journal of Dermatology 2 (2015): 211.PMC. Web. 20 Oct. 2016.
  • Simpson M.I. et al.; Patient burden of moderate to severe atopic dermatitis (AD): Insights from a phase 2b clinical trial of dupilumab in adults; J AM ACAD DERMATOL MARCH 2016
  • Sang Ho Oh et al.; Association of Stress with Symptoms of Atopic Dermatitis; Acta Derm Venereol 2010 Preview
  • Sewon Kim er al.; The Association between Atopic Dermatitis and Depressive Symptoms in Korean Adults: The Fifth Korea National Health and Nutrition Examination Survey, 2007–2012; Korean J Fam Med 2015;36:261-265
  • Gouws A.; The Impact Of Atopic Dermatitis On The Psycho-Social Wellbeing Of Children And Their Families; Current Allergy & Clinical Immunology, March 2016, Vol 29, No 1
  • Camfferman D et al.; Eczema, Sleep, and Behavior in Children; Journal of Clinical Sleep Medicine, Vol. 6, No. 6, 2010
  • Schmitt J. et. Al.; Association of atopic eczema and attention-deficit/hyperactivity disorder – meta-analysis of epidemiologic studies; Zeitschrift für Kinder- und Jugendpsychiatrie und Psychotherapie (2015), 41, pp. 35-44. DOI: 10.1024/1422-4917/a000208
  • Tzu-Chu Liao et al.; Comorbidity of Atopic Disorders with Autism Spectrum Disorder and Attention Deficit/Hyperactivity Disorder; The Journal of pediatrics · February 2016 DOI: 10.1016/j.jpeds.2015.12.063
  • Silverberg J. I. et al.; Central Obesity and High Blood Pressure in Pediatric Patients With Atopic Dermatitis; JAMA Dermatology February 2015 Volume 151, Number 2

Itch (Pruritus) & Eczema

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Scratching is the natural response to itch (Pruritus) and, by definition, inseparable from it. The act of scratching not only diminishes itch, but it has been found to be rewarding and addictive. The itch-scratch cycle is a complex phenomenon involving sensory, motor and emotional components. The urge to scratch can be remarkably intense because the reward provided by scratching brings such intense relief and may also be associated feelings of pleasure and enjoyment. Recent studies have shown that rating scratching as a pleasurable experience is correlated with the intensity of the underlying itch, both in patients with chronic itch and healthy individuals.1 Various functional brain imaging studies have discovered that the itch-scratch cycle in humans can be tracked to specific regions of the brain, including areas related to reward, pain sensation, and addiction.1,2

The Itch-Scratch-Rash cycle is commonly used to describe this ongoing, never ceasing, always constant itch that makes eczema very different from many other skin condition. Eczema has often been called the “Itch that Rashes” rather than the “Rash that Itches”.3 

Itch_1

The itchier a patient feels, the more scratching of the skin that occurs and which ultimately lead to skin damage and the appearance of a red rash. Often, in chronic presentations it becomes a completely unconscious habit and patients are often not even aware that they are scratching. When a patient scratches, the skin becomes inflamed, this inflammation then causes the skin to itch even more, thus making it even harder for the patient to resist the urge to scratch. This vicious circle can become so severe that it causes sleeplessness, irritability, anxiety and stress. In extreme cases it can lead to significant excoriations (open, bloody and deep scratch wounds) on the skin or even severe lichenification (thickening of the skin) and pain. 

The Practitioner and Patient need to recognize and address various aspects of itch, including:

(1) Identification and elimination of trigger factors;

(2) Maintaining the skin barrier through emollients – Oil based and Water Based;

(3) Targeting inflammation through topical medications and systemic (oral) medications

(4) Addressing psychological and behavioural components; and

(5) Education – understanding the condition.

The sensation of pruritus can be triggered by endogenous (internal) and exogenous (external) stimuli, which activate specific peripheral nerve endings in the epidermis and dermis layers of the skin.3

Trigger Factors3

Allergies                                   House dust mites, food allergens, air-born contact dermatitis (pollen, etc.), animals (e.g. cat                                                        dander), jewellery, certain cosmetic ingredients.

Infections                                 Staphylococcus aureus, viral infections (herpes, molluscum), yeasts (eg, Trichophyton,                                                                malassezia).

Exogenous                               Soaps, solvents, wool, sweat, chemicals, toxins, cigarette smoke, smog.

Physical stimuli                       Temperature: humidity, cold dry air, clothes rubbing on the skin.

Emotional                                Anxiety/Stress /Anger/ Depression.

How to rate your Itch4

Based on the Eppendorf  Itch Questionnaire.

Rate each of the following from 0 to 4

The following describes your Itch………

  0 1 2 3 4
  Painful          
  Pulsating          
  Throbbing          
  Prickling          
  Hurting          
  Tickling          
  Stinging          
  Worse when Cold          
  Less when Cold          
  Worse when Hot          
  Less when Hot          
  Dull          
  Sharp          
  Burning          
  Feels like ants          
  Comes in waves          
  Unbearable          
  Annoying          
  Physical urge to scratch          
  Numbing          
  Relentless          
  Cruel          
  Tormenting          
  Tiring          
  Numbing          
  Severe          
  Uncontrollable          
  I only can think of the Itch          

When do you feel the need to Itch?

  0 1 2 3 4
  In the Morning          
  In the Evening          
  At night          
  At rest          
  Worse in Bed          
  After a hot shower          
  After exercise          
  After being outside          
  After being in the Sun          
  After gardening          
  After Dusting, Sweeping/Vacuuming/ Changing beds          
  After eating certain foods

  Specify

         

How would you describe the need to Scratch?

  0 1 2 3 4
  I find it enjoyable          
  It is a physical urge          
  It is compulsive          
  I forget when I do it          
  I always want to scratch          
  I find it satisfying          
  I find it pleasurable          
  It hurts but I cannot stop          
  Other –          

What action do you take when you feel the urge to scratch?

  0 1 2 3 4
  I rub          
  I scratch with my nails          
  I scratch with my fingertips          
  I scratch with my knuckles          
  I use a pencil/pen/ruler/stick          
  I rub          
  I pinch          
  I use a cold pack          
  I use a heat pack          
  I take a cold shower          
  I take a warm shower          
  I take a hot shower          
  I put the air conditioner on          
  I turn down the ducted heating          
  I dig my fingernails in          
  I bite my lip          
  I scratch until I bleed          
  I apply pressure          
  Other –          

Which areas of the body do you scratch the most?

                              Front                                                           Back

What distracts you from the urge to scratch?

  0 1 2 3 4
  Company distracts me          
  Watching Television          
  Reading a Book          
  Using a Computer/IPhone/IPad          
  Listening to music          
  Applying heat pack          
  Applying ice pack          
  Exercising          
  Doing something with my hands   (hobby)          
  Other –          

When you understand your itch, when you itch, what you do when you scratch and what distract you from scratching, you may be able to plan your approach to your itch more methodically and with more control. You may decide that you need to start a meditation or behavioural therapy class to help you control the need to scratch. You may find that you will learn the best times to apply your creams so that you circumvent the urge to scratch e.g. applying creams before gardening or mowing the lawn or doing housework etc.

What can a Patient do to avoid or control the urge to itch?

Scratching is difficult to resist because it gives the mental impression of easing the itch – but this is only for the short-term. Eventually the sensation to itch comes back – even worse that before you scratched. 

Basic tips to control the urge to itch:- 

  • Keep nails short to avoid tearing the skin when scratching. 
  • Keep cool. Over-heating can trigger the itch. Try to keep your body temperature as constant as you can, wear light layers of cotton clothes.
  • Avoid overheated rooms, keep ducted heating to a minimum, and at night keep the bedrooms cold.
  • Avoid heavy blankets and doonas – use cotton blankets if possible. 
  • Gently rub with the back of the fingers, place pressure or gently pinch the area instead of scratching. 
  • Use a cold compress 

Parents of children often ask “How can I stop my child from scratching?” And as scratching is an instinctive reaction to itching which can become a compulsive/unconscious habit, that question is not an easy one to answer. Parents can help by keeping their child’s nails short and, especially at night, by covering their hands with cotton mittens. 

With older children, it is important that you explain to them how scratching will actually make them feel worse, not better. And that their skin will become redder, more cracked and feel itchier and sorer. 

Become aware of any habits of scratching that your or your child may be developing and take especial note as whether it is at a particular time of day, or during a particular activity, such as playing sport or just watching television. If you or the parents of a child become aware of these types of habits then it is important to try to break the habit.

Nonpharmacological Treatments for the Management of Atopic Dermatitis Itch

 Cognitive-behavioural methods3,5,6

Cognitive-behavioural methods alter dysfunctional habits by interrupting and altering dysfunctional thought patterns (cognitions) or actions (behaviours) that damage the skin or interfere with dermatologic therapy. e.g. Itch-coping Training Programme or Habit Reversal Training, cognitive-behavioural methods for the reduction of itch and scratching behaviour, including self-monitoring, guidance in skin care and coping skills to manage itch- and scratch-triggering factors, stress-management methods with relaxation techniques and habit reversal. The habit reversal technique teaches patients to recognize the habit of scratching, identify situations that provoke scratching, and train them to develop a competing response practice, for example, a child who unconsciously scratches can be taught to recognize the early signs of the sensation of itch and instead of scratching be taught to clench his/her fists or place his/her hands underneath his/her legs as soon as they feel the sensation of itch.

Biofeedback5,7

Biofeedback can enhance the patient’s awareness of tension and help them to relax; improving skin disorders that flare with stress or that have an autonomic nervous system aspect. Biofeedback is a mind-body therapy that uses electronic instruments to assist patients to gain awareness and control over psychophysiological processes. The patient is connected to a machine that measures muscle activity, skin temperature, electrodermal activity, respiration, heart rate, heart rate variability, blood pressure, brain electrical activity, and brain blood flow and visually gives the patient feedback as they go through various “game” like tasks. Chronic itch, which may be somatic, emotional and cognitive, may be treated with therapies that can modulate the autonomic nervous system stress response. Behavioural biofeedback techniques that reduce stress and anxiety have been used to treat chronic pain and itch and could potentially alter the sympathetic over-activity noted in patients with AD.

Hypnosis / Meditation8

With proper training, an individual can intensify this trance state in himself or herself and use this heightened focus to induce mind-body interactions that help alleviate suffering or promote healing. The state of altered consciousness known as a “trance state” may be induced using guided imagery, relaxation, deep breathing, meditation techniques, self-hypnosis or by a trained medical practitioner. Researchers have used relaxation, stress management, direct suggestion for non-scratching behaviour, direct suggestion for skin comfort and coolness, ego strengthening, posthypnotic suggestions, and instruction in self-hypnosis. Their results were statistically significant for reduction in itch, scratching, sleep disturbance, and tension. Reported topical corticosteroid use decreased by 40% at 4 weeks, 50% at 8 weeks, and 60% at 16 weeks. For milder cases of atopic dermatitis, hypnosis along with moisturization can suffice as a primary alternative treatment. For more extensive or resistant atopic dermatitis, hypnosis can be a useful complementary therapy that reduces the amounts required of other conventional treatments.

Read also our Blogs for Psoriasis …. The same techniques can be used for Eczema

Simple Mental/Mind Relaxation Techniques Part 1 – For Psoriasis Patients

Simple Mental/Mind Relaxation Techniques Part 2 – For Psoriasis Patients

Itch_4 Itch_5 Itch_6

References

 

  • Papoiu A. D. P. et al.; Brain’s Reward Circuits Mediate Itch Relief. A Functional MRI Study of Active Scratching; PLOS ONE, www.plosone.org 1 December 2013, Volume 8, Issue 12, e82389
  • Mochizuki H. et al.; Chapter 23Brain Processing of Itch and Scratching; http://www.ncbi.nlm.nih.gov/books/NBK200933/?report=printable
  • Hong J. et al.; Management of Itch in Atopic Dermatitis; Seminars in Cutaneous Medicine and Surgery; Elsivier; doi:10.1016/j.sder.2011.05.002; Pg 71-88
  • Darsow U. et al.; New Aspects of Itch Pathophysiology: Component Analysis of Atopic Itch Using the ‘Eppendorf Itch Questionnaire’; Int Arch Allergy Immunol 2001;124:326–331
  • Shenefelt PD.; Psychological interventions in the management of common skin conditions; Psychology Research and Behavior Management 2010:3 51–63
  • Evers Et al.; Effectiveness of a Multidisciplinary Itch-coping Training Programme in Adults with Atopic Dermatitis; Acta Derm Venereol 2009; 89: 57–63
  • Tran BW. Et al.; Effect of Itch, Scratching and Mental Stress on Autonomic Nervous System Function in Atopic Dermatitis; Acta Derm Venereol 2010; 90: 354–361
  • Shenefelt PD. ;Hypnosis in Dermatology; Arch Dermatol / VOL 136, MAR 2000