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
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
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………
|Worse when Cold|
|Less when Cold|
|Worse when Hot|
|Less when Hot|
|Feels like ants|
|Comes in waves|
|Physical urge to scratch|
|I only can think of the Itch|
When do you feel the need to Itch?
|In the Morning|
|In the Evening|
|Worse in Bed|
|After a hot shower|
|After being outside|
|After being in the Sun|
|After Dusting, Sweeping/Vacuuming/ Changing beds|
| After eating certain foods|
How would you describe the need to Scratch?
|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|
What action do you take when you feel the urge to scratch?
|I scratch with my nails|
|I scratch with my fingertips|
|I scratch with my knuckles|
|I use a pencil/pen/ruler/stick|
|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|
Which areas of the body do you scratch the most?
What distracts you from the urge to scratch?
|Company distracts me|
|Reading a Book|
|Using a Computer/IPhone/IPad|
|Listening to music|
|Applying heat pack|
|Applying ice pack|
|Doing something with my hands (hobby)|
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 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.
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
- 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