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SKIN CARE TODAY
2016,Vol 2, No 1
FOCUS ON ITCH
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focusing on the skin condition as a
result of the itch-scratch cycle and
the resulting distress may account for
the cosmetic concerns experienced
by people with pruritus (Bundy, 2012;
Stumpf et al, 2013).
However, the very nature of the
intense scratching response and
subsequent inflammation worsens
the appearance of the skin, which
unavoidably adds to people’s
cosmetic concerns and distress
(Stumpf et al, 2013). Similarly,
anxiety and depression can lower
an individual’s tolerance of pruritus,
which further contributes to the itch-
scratch cycle (Stangier and Ehlers,
2000; Chrostowska Plak et al, 2013).
Feelings of helplessness, low
perceived control and catastrophising
(excessive negative thinking), along
with higher levels of fatigue and
limited social support tend to be
the most important predictors of
psychosocial morbidity in patients
with pruritic chronic disease, while
ineffective coping strategies and
perceived loss of control have been
shown to intensify the sensation of
itch (van Os-Medendorp et al, 2006).
Previous research has shown
that the most effective interventions
for pruritus are a combination of
topical medications and psychological
interventions (van Os-Medendorp
et al, 2007). In many cases, psycho-
education alone can be effective
(van Os and Eland, 2004), such as
educating the patient about the
itch-scratch cycle and effective use
of topical medications. Behavioural
techniques that aim to control the
i
Manage any complications, e.g.
excoriation, infection, anxiety/
depression and any maladaptive
or persistent habits such as
incessant scratching.
Essentially, any treatment plan
should ascertain the type/cause
of itch and take steps to reduce
exposure to the triggers and cause(s)
as well as any damaging behaviours
(scratching), thereby reducing the
risk of infection while providing
symptom relief. Raap et al (2011)
describe a three-step approach to the
management of itch (
Table 1
).
Topical antipruritic preparations
Emollients represent the single
most important group of topical
preparations for the management of
pruritus. Itch commonly accompanies
dry skin conditions, e.g. atopic
eczema, asteototic eczema, discoid
eczema, gravitational eczema, hand
eczema/dermatitis, psoriasis.
Emollients
Abnormally dry skin (xerosis) is, in
itself, itchy. Therefore emollients
are recommended to rehydrate
and soothe the skin, providing an
antipruritic effect and promoting
healing. This is especially important
for elderly skin, when the natural
ageing process results in dry, itchy
and thinning skin (Watkins, 2011).
Itchy and potentially damaged
skin experienced with other skin
conditions such as scabies and
urticaria may be relieved and
soothed by emollients. However, it
is important to treat the underlying
cause of the original condition, e.g.
antihistamines for urticaria.
Enhanced emollients contain
medicinal preparations, which exert
an antipruritic effect, for example,
menthol soothes and cools the skin
and can relieve pruritus. Similarly,
emollients containing calamine
(calamine cream, calamine lotion, oily
calamine etc), lauromacrogols, urea
or lactic acid also provide short-term
relief from itch.
Other topical treatments
Other topical preparations used
to relieve itch include topical
corticosteroids, and preparations
containing crotamiton and doxepin.
Topical antihistamines and topical
local anaesthetics are also available,
however, their effect may be minor
(
British National Formulary
, 2015).
Systemic treatments
Cholestyramine is an oral treatment
for pruritus caused by biliary
obstruction (
British National
Formulary
, 2015). Other systemic
treatments for chronic pruritus,
including antidepressants (e.g.
paroxetine; doxepin), anticonvulsants
(e.g. gabapentin) and opioid
antagonists (e.g. naltrexone), focus
on the central nervous system. The
exact mode of action of systemic
medications in relieving pruritus
remains unclear and more research
is required to establish their efficacy
(Pongcharoen and Fleischer, 2015).
PSYCHOSOCIAL INTERVENTIONS
The cycle of itching and scratching
is very common in many skin
conditions and is one of the most
distressing symptoms reported by
dermatology patients (Chen and
Yesudian, 2013). Pruritus has a
significant impact on the psychosocial
wellbeing of patients and has
regularly been associated with a
range of psychosocial challenges
and high levels of morbidity
(Chrostowska-Plak et al, 2013).
The vicious circle of itching
and scratching is at the centre of
psychosocial morbidity and patients
can feel guilty and out of control
when they are caught up in a so-
called‘itch-scratch’ cycle, which
contributes to more emotional
distress. The most common
psychosocial challenges reported
by patients with pruritus include
depression, sleep changes, and
anxiety, including agitation and lack
of concentration (Yosipovitch et al,
2002; Schut et al, 2014).
Stress and anxiety can also
aggravate the frequency and intensity
of pruritus, which in turn can lead to
patients over-focusing on their skin
condition, thereby aggravating the
psychological distress experienced,
and triggering yet more itching. Over-
Did you know?
Profound and
prolonged itch can
lead to psychological
morbidities such as
anxiety and depression
as a consequence of
sleep deprivation,
sleep disturbance, loss of
concentration, feelings of
helplessness, frustration, loss of
function or daily activities, and
suicidal thoughts.