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FOCUS ON ITCH
i
itch as well as the need to scratch
(e.g. tapping another part of the body
or distraction) might help.
Addressing any sleep problems
through relaxation techniques and
stress management can be useful
ways of reducing anxiety levels
and thus improving itch. Ensuring
that the quality and quantity of
the patient’s sleep improves can
help their overall psychological
functioning, as well as potentially
avoiding further aggravation of any
inflammation through itching.
Increasing adherence to topical
medications might be appropriate
for some patients, especially the
young. Techniques for increasing
adherence include education on the
importance of topical treatments in
breaking the itch-scratch cycle and
improving sleep. Incorporating topical
treatments into a daily routine, such
as following a morning shower, will
cause minimum disruption and may
improve adherence. In more complex
cases, motivational counselling might
be required (Ehlers et al, 1995).
Identifying any maladaptive
perceptions of illness can also
be very beneficial in patients
with pruritus (Gieler et al, 2000).
Exploring patients’ core beliefs about
themselves and key perceptions
about their condition, e.g. where
the boundaries lie in relationships
between parents and children, is
important. For example, parents may
attempt to manage a child’s itch and
the child may learn to use scratching
as a way of rebelling. It is important
to work with the patient to identify
how they can gain control over their
skin condition and treatment and
improve their wellbeing (van Os-
Medendorp et al, 2007).
Patients living with pruritus can
also become entangled in a number
of vicious circles, such as the itch-
scratch cycle and poor sleep, which
worsens the condition. Treatment
combining topical preparations and
psychological interventions can help
patients break these vicious circles.
As well as being the largest
organ of the body, the skin is one of
the primary means through which
individuals relate to themselves, the
world and others, and consequently
the skin and its appearance help
people to meet core psychological
needs, such as a sense of belonging,
safety and self-esteem. Therefore,
interventions for complex and/or
severe cases of pruritus might involve
exploring how the individual relates
to themselves, other people and the
condition itself (Schut et al, 2016).
Nurses need to be equipped with
the appropriate knowledge and skills
to enable them to identify those
patients with severe and/or complex
psychosocial morbidity who would
benefit from psychological input.
As in other dermatological
conditions, identifying the
psychosocial ‘red flags’ in patients
with pruritus — such as high levels
of depressive mood; psychological
and physical symptoms of
anxiety; sleep disruption; fatigue;
relationship difficulties and limited
social support — will help the nurse
to make appropriate referrals and
potentially minimise the amount of
‘revolving door’ patients (Affleck and
Chouliara, 2014; Affleck et al, 2015).
Depressive symptoms including
catastrophising, low self- esteem and
withdrawal of social contact can also
be signs that a person might require
psychological input over and above
topical treatment.
IMPLICATIONS FOR PRACTICE
Early recognition and intervention can
improve patient outcomes. An holistic
approach to the assessment and
management of pruritus is essential
to identify underlying causes, triggers
and effective coping strategies. Early
interventions to relieve itch and
reduce scratching include lifestyle
changes, regular emollient use and
topical applications.
Nursing intervention and
follow-up are vital to the delivery
of individual care plans. The
‘coping with itch’programme was
a randomised controlled study
comparing a nursing intervention
programme (including patient
education and support, psychosocial
interventions and a recognised referral
pathway) with standard care in a
dermatology outpatients department
in the Netherlands. Patients in the
nursing intervention group visited
the dermatologist much less often
during the study period than the
control group, and the programme
demonstrated a reduction in the
frequency of itching and scratching as
well as a reduction in‘catastrophising’
and‘helpless coping’in patients (van
Os-Medendorp et al, 2007).
The following general measures
are also helpful for nurses managing
patients with pruritus (Chinniah and
Gupta, 2014):
i
Environmental considerations:
maintain ambient room
temperatures; avoid electric
blankets in bed
i
Clothing: avoid materials that
will irritate the skin or induce
sweating; avoid wool or synthetic
fabrics next to the skin; cotton and
cotton mix fabrics are preferred
i
Bathing and showering: use warm
(not hot) water; avoid alkaline
soaps; use soap substitutes and
emollients to wash, cleanse and
moisturise the skin
i
Behavioural: ‘pat’ skin dry
following bathing or showering;
rub, press or pat skin to relieve
itch instead of scratching; keep
fingernails trimmed short.
CONCLUSION
Pruritus is an uncomfortable and
subjective sensation experienced
by individuals that causes a desire
to scratch. Living with persistent
itch represents a physical and
psychological burden, which can affect
patients’quality of life. It is important
Top tip:
Identifying the psychosocial
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pruritus — such as high levels of
depressive mood; psychological
and physical symptoms of
anxiety; sleep disruption;
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and limited social support —
will help the nurse to make
appropriate referrals.
SKIN CARE TODAY
2016,Vol 2, No 1
31