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………

 01234
  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?

 01234
  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?

 01234
  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?

 01234
  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?

 01234
  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

 

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

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Atopic dermatitis may be caused by genetic predisposition and environmental conditions, including hereditary factors, allergens, and neurogenous (arising from the nervous system, or from some lesion of the nervous system) and immunological factors. However, the major contributing cause remains unknown. AD may cause psychosocial problems such as anxiety, depression, sleep disorders, emotional excitability, stigmatization, social isolation, and discrimination and on the other hand, all of these factors may also contribute to and exacerbate the symptoms of AD. Of the many factors related to atopic dermatitis, psychological stress is considered to be among the most important.1

 The psychological, physical and social impact of AD is complex and varies among different ages. The relationship of stress, anxiety, depression, not to mention feelings of stigma, shame, embarrassment, and low self-esteem all impact upon a person who is suffering from a skin condition such as AD. Research has confirmed that adults with AD exhibit high levels of anxiety, depression, and emotional excitability. Children with AD also have higher levels of emotional distress and more behavioral problems than healthy children or children with minor skin problems. Psychosocial factors contributed in the form of exacerbating factors in as high as 94% of AD hospitalized patients. Clinically, it has long been appreciated that both acute stress (stressful life events) and chronic psycho-emotional stress can trigger or enhance pruritus.2, 3, 4,5

Pruritus, or itching, is a main symptom of AD and is often one of the first presenting symptoms.

Itching leads to scratching, which leads to and exacerbates the skin lesions.

  • AD has been referred to as the “itch that rashes.”
  • The cycle of itching and scratching is considered an important factor in the maintenance of AD symptoms and is believed to be one of the first symptoms of an impending AD flare.
  • Scratching tends to cause further itching, leading to the so-called “itch-scratch cycle.” 6

Results of one study found that in patients with AD the itching intensity played an important role in determining the patient psychosocial well-being and that a relationship between pruritus and depression was also found.6

 Scratching often begins automatically in association with stress and emotions, and becomes habitual, being performed many times every day. In addition to the psychological factors, such as anger, irritation, impatience, relief, anxiety, etc., many patients say that they somehow find themselves scratching even when they do not feel itchy. Research has identified that habitual scratching is involved in the formation of the lesions of AD. The scratching is patterned, with the rash exhibiting a bilaterally symmetrical distribution over the back and normal skin remaining in the middle where the hands cannot reach, producing a “butterfly” sign. The prominent red face can also be explained by this scratching behavior.4

 This vicious cycle can cause sleeplessness in over 65% of AD sufferers leading to sleep deprivation which leads to tiredness, mood changes and impaired psychosocial functioning of the sufferer and their family, particularly at school and work. Embarrassment, comments, teasing and bullying frequently cause social isolation and may lead to depression or school/work avoidance. The sufferer’s lifestyle is often limited, particularly in respect to clothing, holidays, staying with friends, owning pets, swimming or the ability to play or do sports. For parents caring for a child with eczema, restriction of normal family life, difficulties with complicated treatment regimens causing an increased work load together with disturbed sleep can lead to parental exhaustion and feelings of hopelessness, guilt, anger and depression. And so the whole family is impacted by the condition.5,6,7

Research has suggested that some AD patients might benefit from certain psychological interventions: patients showing psychological characteristics that comprises high depression, low agreeableness and high public self-consciousness would probably benefit from psychological interventions, such as cognitive restructuring, anger management and self-assertiveness training, because these interventions might be able to modulate the extent of the personality characteristics that are associated with induced itch.8

Recent emerging research indicates that mindfulness meditation training may have beneficial effects across a spectrum of health conditions, but the mechanisms linking mindfulness meditation training with health are unknown. One striking feature of the mindfulness training literature to-date is that mindfulness training effects on disease outcomes have been observed in diseases where stress is known to trigger the onset or exacerbation of disease symptoms and pathogenesis (e.g., HIV, psoriasis, depression, pain, chronic inflammation).9   Research has indicated that relaxation techniques appear to be helpful in the treatment of patients suffering from chronic itch in patients that are open to it. And it is becoming a standard recommendation by many Practitioners and hospitals that relaxation training be considered clinically in patients who report that their itch increases during periods of heightened stress.10

The challenge for sufferers of AD is, with the aim of improving their quality of life, to help themselves to find, together with their practitioner, the best personal treatment plan and then sticking to it. The main challenges in the effective management of AD, comes down to patient adherence to the treatment plan and their emotional resilience.

 

References

  • Kwon1 J.A. et al.; Does Stress Increase the Risk of Atopic Dermatitis in Adolescents? Results of the Korea Youth Risk Behavior Web-Based Survey (KYRBWS-VI); PLOS ONE, www.plosone.org; August 2013, Volume 8, Issue 8, e67890
  • Han-Ting Wei et al.; Risk of developing major depression and bipolar disorder among adolescents with atopic diseases: A nationwide longitudinal study in Taiwan; Journal of Affective Disorders 203 (2016) 221–226
  • Buske KIrschbaum Hellhammer et al.,; Endocrine and immune responses to stress in chronic inflammatory skin disorders; 992. 231-240 (2003)
  • Sang Ho Oh et al.; Association of Stress with Symptoms of Atopic Dermatitis; Acta Derm Venereol 2010; 90: 582–588. The Journal of Clinical Investigation; http://www.jci.org; Volume 116, Number 5, May 2006
  • Kamide R.; Atopic Dermatitis: Psychological Care; Journal of the Japan Medical Association (Vol. 126, No. 1, 2001, pages 59–62).
  • Brown T.M. et al.; Assessing Pruritus Among Patients With Atopic Dermatitis: Targeted Literature and Instrument Review; https://www.rtihs.org/sites/default/files/Brown_isporposter_May2012.pdf
  • Lewis-Jones S. Quality of life and childhood atopic dermatitis: the misery of living with childhood eczema. Int J Clin Pract. 2006;60(8):984-992.
  • Schut C. et al.; Personality Traits, Depression and Itch in Patients with Atopic Dermatitis in an Experimental Setting: A Regression Analysis; Acta Derm Venereol 2014; 94: 20–25
  • Creswell J.D. et al.; Brief mindfulness meditation training alters psychological and neuroendocrine responses to social evaluative stress; Psychoneuroendocrinology (2014) 44, 1—12
  • Schut C. et al.; Psychological Interventions in the Treatment of Chronic Itch; Acta Derm Venereol 2015 Preview