Breaking The Itch Cycle

Certain Realities Require No Reminders

 Dr.Krohn On Eczema and Mental HealthIf you have eczema – or take care of someone with eczema – then certain

realities require no reminders. For instance, itching leads to scratching.
And scratching leads to . . . well, just about anything:  excoriated and bleeding
skin. Poor sleep and a foul mood the next day.  Thickened skin plaques and an
exacerbation of the eczema itself.

And then there’s the most frustrating consequence of all:

the skin damage caused by scratching leads to more itching . . . which of course causes more scratching. 

Once moderate-to-severe eczema has gone full gallop, it’s a classic Catch- 22:  The only way to stop the scratching is to stop the itching – but to stop the itching, you must stop the scratching. So how can patients with eczema manage the itch-scratch (or is it scratch-itch?) cycle? 

Below are five tips which I would recommend for the management of pruritus –
the medical term for symptomatic itching – and listed in order of importance.

1. Treat It At The Source

The most effective way to treat pruritus is to treat its underlying cause –
which in the setting of eczema would entail the effective treatment of the
eczema itself.  Eczema is a disease; itching is a symptom of the disease, but not
the disease itself.  So like anything else, if you want to fix a problem you’ve got to
get to the root cause – and in this setting, the root cause of itching is the
compromise in the skin barrier, and the associated inflammation, that defines
eczema.  Patients who have been prescribed anti-inflammatory medications,

such as topical steroids, should use them as directed.  Same goes for those who
have been prescribed the newer biologic agents, which target very specific points
in the inflammatory cascade.  And since the majority of patients with moderate-
to-severe eczema are colonized with Staph aureus, the use of an over-the-
counter body wash containing hypochlorite will reduce eczema severity at the
site of the skin lesions which are most severely affected.

2.Eliminate The Factors

You should try to eliminate the factors which aggravate your eczema.  If
there is something that does not necessarily cause the problem, but certainly
makes it worse, then we should try to do away with it.  When it comes to the
sensation and perception of itch, anxiety and other mental health conditions are
notorious aggravators of the symptom – and so cognitive behavioral therapy
(CBT) is a proven method of reducing the exacerbating factors associated with
mood disorders (most commonly anxiety and depression). 

For those in which scratching has become a compulsive behavior that is
difficult to break, habit reversal training or comprehensive behavioral intervention for tics (CBIT) are also validated steps that a patient can take under
the supervision of a therapist. 

Stress management and reduction through meditation and muscle relaxation therapy are additional techniques that have been demonstrated to reduce the perception of severity in a patient suffering from pruritus.  Complementary interventions, too, such as yoga and acupuncture, are validated means to reduce the self-reinforcing aspects of the itch-scratch cycle, as is general psychological support through typical modes of talk-based therapy. 

Since dryness and heat exposure exacerbate eczema, moisturization, maintenance of a cool environment, and use of humidifiers are  effective environmental interventions.

Finally, use of a mild skin cleanser – again, such as an over-the-counter body
wash with dilute hypochlorite, particularly if it is combined with a moisturizer like
glycerin – is an effective way to eliminate aggravating factors on the skin’s
surface, though care should be taken to avoid excessive or aggressive washing.

3. Topical Antipruritic Therapies

Apply topical antipruritic therapies to the eczema patches, particularly at bedtime.  Cooling agents – such as calamine, menthol and camphor – have long been available in topical over-the-counter formulations. 

For reasons that are not completely understood, these topical preparations reduce the sensation of itching – probably by modulating sensory conduction in nerves involved in the perception of itch, or creating a sensation that competes with the one you’re looking to subdue, and thus reducing its intensity (much like the gentle pressure of “rubbing a boo-boo” reduces the pain of the injury itself). 

Topical anesthetics, such as pramoxine or lidocaine, are widely available, and act by essentially numbing the skin – but caution is advised in its use in children, who often absorb topical medications at rates far higher than adults do.  And capsaicin – which is the ingredient found in hot, spicy peppers – also can reduce pruritus, but often produces its own burning sensation, which may be no more desirable.

4. Physical Intervention

Try a physical intervention, such as covering the most bothersome eczema
lesions with gel or hydrocolloid dressings.  A hydrocolloid is a substance
(often a cellulose-based material) that becomes a gel when water is added to it.  Unlike a moisturizer, which either traps or draws water, a hydrocolloid dressing suspends the water and physically places it directly onto the skin lesion, and in this way effectively rehydrates the dry skin associated with eczema. 

There are numerous over-the-counter hydrocolloid/gel bandages available at most retail pharmacies, both in private labels sold by the pharmacy itself and in popular brand names. 

For those who do not wish to walk around all day long covered in bandages, it would be reasonable to use these only at night. And if a hydrocolloid dressing is not readily available, you can make your own “wet-to- dry” dressing, in which a wet gauze is placed directly onto the eczema patch, and then covered with a dry one.

5. Antihistamines

If you’re doing everything else and you still can’t sleep because of the
itching, try an oral sedating antihistamine.  Antihistamines do not directly treat
pruritus in the setting of eczema, since histamine is not the mediator of itchiness (as it is, for example, in hives). 

But the older classes of antihistamines, some of which are available over-the-counter, are soporifics: they make you feel sleepy, and help you sleep through the night, perhaps even allowing you to sleep through the urge to itch.  This is a last resort approach – but one worth trying in those in which itching is interfering with the ability to sleep.

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