Month: September 2019

Table of Content

• • • Introduction
    • Itching vs Scratching
    • Types of Scratching in Eczema
    • Consequences of Repeated Scratching
    • Itch-Scratch Cycle?
    • Scratching becomes a habit
    • How to track the scratch?
    • How to prevent scratching 
    • Tips to avoid scratching

 Introduction

An itch that cannot be scratched, this is what explains eczema which is usually recognized by a dry, red, inflamed and itchy rash skin condition. Rather the phrase can be modified as the “itch that should not be scratched” because there is only a small percentage of people who do not fall prey to scratching. The incessant and uncontrollable itch which is associated with eczema known as “scratching eczema”. One can also go with the eczema flare-up treatment to reduce the itching problem.

Apart from the medicinal treatment, it is very important to bring about a behavioral change, while suffering from Eczema. The reason being, the action of scratching will worsen the skin condition  –  eczema causes itching, itching results in scratching, and it’s the scratching which further results in worsening eczema. This thereby leads to more itch and the cycle continues.

In this article, we shall discuss various aspects of itching and scratching and eczema flare-up treatment and by the end, you shall have a clear understanding and a solution to escape from this vicious itch-scratch Cycle.

Itching vs Scratching

Often “itch” and “scratch” are used interchangeably to describe the same thing or same event and in many native languages the word used to describe these two are same. In reality and clinically too, these word means different things. To understand the treatment action for Atopic Dermatitis it is critical to distinguish between itch and scratch.

– Itch
Itch is a sensation which is defined as an uneasy irritating sensation in the upper surface of the skin usually caused as a result from mild stimulation of receptors that originates in the skin. Medically it is known as Pruritus. A person gets an itching sensation when factors such as irritants, allergens, dry skin, stimulate a nerve ending in in the nerve fibres in the epidermis.

– Scratch
As a stimulus for the itching sensation, a message is sent to the brain which sends a response and this action is called scratching. This leads to scratching eczema. Traditionally scratching is regarded as a way to relieve oneself by reducing the annoying itch sensation. However, there are even negative aspects to scratching, as one would find noxious scratching highly pleasurable. This action can very be problematic with chronic itch patients, such as ones with eczema. The patient might scratch the affected area until they no longer produce a pleasant or painful sensation. This sensation though subsides itch, which gives very short-term temporary relief further worsens the skin condition.

Actions such as rubbing, touching and pricking the skin due to itch come under the scratching activity also known as scratching eczema. Hence as a statement, we can say that

Itch is a feeling, while scratching is an action or behavior towards that feeling

Both cause an eczema flare-up and one must reduce it with eczema flare-up treatment

Types of scratching in Eczema (Scratching Eczema)

Scratching in atopic dermatitis is a little complicated than it appears from the definition which is a response to the itch. In eczema people tends to scratch due to two different reasons i. e. scratching in eczema can be classified into two categories:

1) Scratching due to an Itch (Neurogenic):  This is scratching stands as per the definition, It is a response to the signals sent by the nerve fibers due to itching sensation. In this case, a person scratches only when he feels the sensation of itching. Hence as a treatment action, one just needs to focus on treating the eczema symptoms.

2) Circumstance or behavioral Scratching (Psychogenic): This scratching is from the unconscious mind or can be said as a habit due to repetitive actions. Any behavior which is repeated number of times becomes a habit and people tend to do that action automatically with or without being required. In this case, a person may scratches due to his behavior even if he doesn’t have itching sensation.

Consequences of Repeated Scratching

“Circumstance scratching” is more dangerous as repeated scratching damages the skin layer making it thick, and red. It further does not allow eczema to heal making the eczema condition chronic. This scratch is psychologic and may result due to, boredom, while thinking, frustration, stress, etc. The treatment action for this situation requires a behavioral change know as Habit Reversal.

If one can understand these aspects of scratching and its relationship with the itch, it becomes easy to treat and improve the condition of eczema.

Itch – Scratch Cycle

Itch- Scratch cycle where the itching leads to scratch and scratching leads to itch is a well-known phenomenon.  Let us understand this cycle in a little more detail,

– In people with atopic dermatitis, when eczema flares up, immune cells send inflammatory signals to the surface, causing the itchy rash leading to an itching sensation.

-This itching sensation causes the person to scratch which in turn damages the outer layer of the skin allowing microbes and allergens to enter.

-As a response to these invaders, the immune cells continue to send signals to the surface, causing even more redness, rashes and itching even more

-Thus, resulting in more scratching and ultimately the skin barrier breaks down, and the itch-scratch cycle continues.

Scratching becomes a Habit

In normal circumstances of scratching a person scratches only when it itches, or his skin gets irritated due to a mosquito bite or any allergen. Whereas in condition like chronic eczema a person gets habituated to scratching.

When a person performs an action again and again, repetitively due to certain situation, it becomes his habit and the person tends to repeat it automatically even in the absence of that situation. Similarly, in chronic eczema, the person scratches whenever it itches multiple times and due to chronic condition, it continues for a long period of time. This now becomes a habit so much so that the person scratches frequently without any itching more than he does when he gets an itch

Hence it is very critical to put an end to this itch-scratch cycle while treating eczema. As the itching is caused due to eczema itself, the key to end it is to control your action of scratching. which will stop further damage to the skin. Meanwhile, you can treat your eczema symptom which leads to itching ultimately breaking this cycle.

How to Track the Scratch?

Any treatment starts with analyzing the severity of the symptoms, similarly, it is good to track and analyze all the episodes associated with the scratching in the first place to understand the behavior more deeply. Close people surrounding you can also be asked to help track it for you in order get a comprehensive statistic regarding the behaviour which may help to find an appropriate solution.

In order to track the scratching, one should note down factors of scratching like:

• Number of times a person scratch (a counter can be used)
• Frequency of scratching
• Circumstances or situations of scratching,
• What helps in each circumstance?
• Scratching due to itch or without the itch
• Way of scratching (rubbing, picking the skin, touching), etc.

How to prevent scratching?

Itch and scratch is something that each and every patient suffering from eczema has to face day in and day out specially when it flares. Itch is the worst thing that occurs in eczema as it is difficult to get rid of. Further adding to it the most frustrating part is trying not to scratch your itchy skin.

One of the best ways to deal with itch without scratching psychologically is holding the fist tightly for 30 secs, you can count till 30 in your mind this should help in reducing the itching sensation. If it still feels itchy than pinch or poke a nail on the skin to fool the brain. By doing this your brain shall give you a little paining sensation but will subside the itching sensation.

Other tips to avoid scratching

• Always keep your hands busy (for instance talking on the phone, watching TV with remote in hand) so that they are not free for scratching ultimately forgetting to do it.
• Another good way to avoid is not giving accessibility for scratching, try to cover the exposed skin, e.g wearing long sleeve clothing
• While changing dress, people tend to scratch for pleasure. To avoid it, be mentally prepared, undress quickly, apply creams, dress up and then distract yourself for some time to avoid scratching
• If you feel like scratching after a shower, don’t allow yourself any free time, rush to pat the skin dry with a towel, put on moisturizers, dress-up quickly and distract yourself for 10 mins
• While sleeping one may do it unconsciously, so remain alert and get up from your bed whenever you feel like scratching.
• Dealing with the child instead of saying “Stop Scratching”, distract the child with toys, sightseeing or simply, talking to them, etc.

Table of Content

• • • Eczema and Inflammation
    • Need for Topical Steroids
    • Mechanism of Steroid on skin inflammation
    • Side effects of steroidal cream
    • How to use Topical Steroid Effectively?
    • Conclusion

Eczema and Inflammation

The skin condition Eczema is mainly recognized by a dry, red and itchy rash that occurs in the patches of inflamed skin. Eczema is also commonly known as “Atopic Dermatitis” where “Atopic” refers to Allergy due to hypersensitivity reactions caused by allergens or irritants and “Dermatitis” refers to the inflamed skin. One can go with the prescription eczema cream if such symptoms appear.

In Eczema the skin appears dry, red and inflamed. The severity of Eczema depends on the level of inflammation, how much the individual scratches due to itch and whether the eczema is infected. Eczematous skin is itchy but it shouldn’t be scratched because scratching increases the inflammation, irritates the skin and further worsens the condition.

Flare-ups in eczema are different in different people and are exacerbated by different triggers in the form of Allergens and irritants. These triggers worsen eczema causing itchy rash leading to increased inflammation to the skin. In some cases, eczema gets infected which can be life-threatening and needs to be addressed immediately.

Are Topical Steroids Necessary for treating Eczema?

Eczema cannot be cured completely, the treatment of eczema lies in managing its symptoms such as inflammation, itch, rash effectively and preventing the episodes of flare-ups.

As a primary line of treatment to eczema flares, topical steroids and creams are used. Steroid creams quickly relieve the itching and reduce the inflammation. Remember, a topical treatment for eczema cannot guarantee complete relief. These steroids and creams are available in different strengths, from mild to strong, the stronger the steroid the more effective it is. One can buy creams with mild strength are available over the counter whereas the stronger ones are available only on physician’s prescription.

The strength of the steroid used is determined by the physician after examining eczema, and factors such as the severity of eczema, condition of the rash and location of the affected area. He may then suggest the best topical treatment for your eczema. It is very important to follow the instructions of the doctor or use the steroidal cream as prescribed by him. For a thick and scaly skin condition in eczema more potent steroid may be prescribed.

Mechanism of Steroid on skin inflammation

The steroids applied on the skin travels from outside to the inside of the skin. It reacts with and modifies the function of dermal, epidermal cells and cells of leukocytes which causes the inflammation of the skin.  After passing through cell membranes these steroids react with protein receptors stimulating the production of glycoprotein.

These glycoproteins called as lipocortin inhibits the production of components that are responsible for the immune reaction and thereby produces anti-inflammatory and immunosuppressive effects which ease down skin inflammation and reduces the eczema flares.

Side effects of steroidal cream

While suggesting a topical treatment for eczema, using an appropriate strength of steroid is critical, because milder than required may not heal the symptoms leading to chronic eczema condition, whereas stronger than required for longer period may lead to side effects.

When used strictly as prescribed by the doctor, the chances of side-effects though exist but are very rare. Side-effects always occur due to the inappropriate use of medication.  Many times, Side effects are only seen after continuous use of treatment with strong steroids for several months.

Apart from potency and duration of use, other factors that determining side-effects include quantity used per application and area of the body where it is applied.

Side effects due to steroids are often temporary and most of the effects only certain part of the body. Common side-effects of Steroid usage include

• Thinning of skin,
• Increase in the activity of the sebaceous gland
• The appearance of Stretch Marks
• Developing Acne
• Darkening of the skin
• Changes in skin pigmentation (white spots),
• Temporary blisters
• Some of the rare but more serious side effects consist of Cataracts, little pink bumps skin, Acne, folliculitis (pus-filled hair follicles), Adrenal Suppression

How to use Topical Steroid Effectively?

Like mentioned earlier, while treating eczema it is very important to use topical steroids and prescription eczema cream long enough to suppress the flare-up symptoms. It is recommended to use it exactly as prescribed by the physician and not to leave until the skin stops itching and the inflammation has gone away. Because the treatment is withdrawn too soon, the rash might return which may lead to more usage of steroid medication overall. Also, the next time round you might have to use steroids with greater potency, than if you had continued using it for long enough in the first place. This can cause a condition called Topical Steroid Withdrawal Syndrome or Steroid Addiction.

For effective healing, only a thin layer of topical steroid/prescription eczema cream is required, but make sure while using topical treatment for eczema it is applied enough to cover all eczema affected area. The best way to measure is to use the fingertip rule wherein squeezing cream from the tip of an adult’s index finger to the first crease of the finger should give you a quantity that is enough to spread an area of two adult palms including fingers. In common language, this measurement is called as ‘one finger unit’.

Other tips to apply steroidal cream for effective healing includes

• Applying cream briskly without any massage, rubbing hard may further damage the skin
• Use enough amount to cover the entire affected area do not leave any affected area may it be very small
• Apply enough so that after treatment the skin doesn’t feel sticky and messy.
• Apply moisturizer after putting on the steroids to increase the potency of healing

Hidden healing is important

The condition in eczema can be explained in two stages one the appearance of the skin, how it looks? dry, red, rashes, etc. and second the damages inside the skin, the inflammation, the damaged skin barrier, etc.

Similarly, treatment with topical steroids occurs in two stages in 1^st stage of healing, the normal appearance of skin is restored i.e. the skin looks good this is called as “The look Good Point” and the second one “feel-good point” on complete healing from inside or hidden healing which further reduces the possibility of a flare-up on stopping the anti-inflammatory application and recurring of rashes.

So, it is very important to continue the application beyond the look good point until the feel-good point is reached or hidden healing is accomplished. while treating chronic eczema the 1^st stage is reached in 4 to 6 weeks and takes a couple of weeks more to accomplish hidden healing.

Conclusion

As we can see topical treatment can be very effective in treating the inflammation due to Eczema, which would, in turn, reduce the itch-scratch cycle. However, it is very important to use topical steroids judiciously and as prescribed by the Doctor. Stopping too early might actually cause more use of steroids over time. There are also non-steroidal topical creams like topical calcineurin inhibitors, ask your Doctor for your options.

Table of Content

• • • Eczema and Dry skin
    • Importance of Moisturizing
    • Picking up Right Moisturizer
    • When to Apply Moisturizer?
    • How to Apply Moisturizer?
    • Moisturizing Tips

Eczema and Dry Skin

Eczema also commonly known as Atopic Dermatitis is a chronic skin condition affecting all age groups, especially babies. Eczema is characterized by itchy, red and Inflamed skin which also makes the skin very dry. The skin usually becomes dry in winter and low humid condition or when the temperature is too high, In Eczema the skin becomes dry due to loss of Moisture. Generally, the skin tends to lose moisture, but in Eczema the skin loses the moisture more quickly,so it is important to moisturize your skin. In Eczema the uppermost layer of the skin loses its property of acting as a barrier which is called Skin Barrier dysfunction. The skin fails to retain moisture and water escapes more quickly and frequently making the skin dry. In such conditions it is important to know how to keep skin hydrated.

Severe dry skin further leads to crack and in extreme case may also bleed. Cracks open up allowing the entry to bacteria providing an avenue for infection

Dry skin also causes itch. Similarly, due to barrier dysfunction, the skin also fails to prevent the entry of foreign particles including microbes such as bacteria and virus increasing the chance of eczema infection. Additionally, very dry skin can trigger symptoms of eczema and cause the area to become itchy, known as pruritis, also increasing the likelihood of bleeding due to scratching. It further worsens the condition leading to the onset of “itch-scratch cycle” which occurs with rubbing or scratching the skin causing more irritation, and thus, additional itching. Excessive dryness of the skin can cause a flare-up of eczema worsening the condition. It is always good to know about the importance to moisturize your skin.

Importance of Moisturizing

It is very important to moisturize your skin in eczema. Effective moisturizing not only prevents it from drying but also helps in protecting the outermost layer of the skin known as stratum corneum or commonly known as a skin barrier.

Keeping your skin moisturized is one of the best solutions for eczema, but it should be done in a certain fashion, at proper intervals and by selecting appropriate moisturizers to make it more effective. You need to follow the tips below to effectively moisturize your skin if you have Eczema. Know the steps on how to keep skin hydrated.

Step 1 – Picking up the best moisturizer for eczema

For best result moisturize your skin effectively. Topical applications play a major role in controlling Eczema and come in different forms such as cream, lotion, and ointment. You must always go with the application that is best for Eczema.

Types of Topical Applications

Lotion

A lotion is a low viscosity topical preparation intended for application to the skin. Since it has higher water content than creams and ointments, it is more liquid and can be applied easily to external skin with a brush, cotton wool, clean cloth or with your bare hands.

Cream

A cream is a preparation used for application to the skin. Creams are semisolid emulsions (a mixture of more than one liquid that are normally immiscible) like water and oil. Roughly water and oil in a cream preparation is 50:50. One should always use the best eczema cream for better results. Creams are of two types “Oil in Water” and “Water in Oil”. The Water in Oil creams are more moisturizing because they provide an oily barrier which reduces the loss of water from the outermost layer of the skin

Ointment

An ointment is a semisolid preparation usually containing medicinal substances, which is intended for external application to the skin.

In Brief Lotions are thinner and more liquid than Creams. Creams are thinner than Ointments. Hence lotions are easy to apply than creams but are less effective when it comes to treating eczema. Creams are easy to apply than ointments because ointments have the least amount of water of the three.

Moreover, the physician prefers ointments over creams and lotions because of less content of additives than creams and lotions which may cause side effects, Ointment also lasts longer than the other two. If applying ointment becomes messy than creams are preferred. Finally, it’s up to the preference of the patient and which one suits him. The best moisturizer is one which is used appropriately, is effective in insulating against water loss and containing no additive causing side-effects.

Step 2 – When to apply?

After selecting the best moisturizer for eczema, one should also figure out the right time and frequency to get maximum benefit in the treatment. The best time to apply the moisturizer is immediately after your shower or as soon as you are out of a bathtub.

Take a bath in warm and Avoid Hot water as it may raise the body temperature resulting in water loss. Sitting in a Bathtub for 10 –15 mins shall help tour skin soak enough moisture.

After shower Pat dry your instead of rubbing with a towel which may damage your skin further and apply the moisturizer immediately when your skin is still wet.

Reapply the moisturizer frequently at a regular time interval or as soon as the previous application dries up to retain the skin moisture effectively. The frequency may be different for different parts of the body for e.g. body parts such as hands and face which are exposed may require more frequent application. Also, do not forget to reapply whenever you wash your hands as washing hands will also wash away the moisturizers applied.

Step 3 – How to Apply?

To get the best healing from the moisturiser it is important for us to know how the moisturizer acts when applied on the skin and how to keep skin hydrated. The main objective with which the moisturizer is applied to the skin is to retain the moisture of the skin which evaporates, rather than adding water to the skin from outside.

Hence, it should be applied in a thin layer to provide insulation for the water inside the skin and not very thick because thick layer will trap the heat inside which may worsen then condition.

Eczema is very sensitive to rough treatment, do not rub hard as it may further damage the skin, a gentle touch is always ideal even applying the moisturizers. Apply the moisturizer softly but effectively covering all the skin area, especially the effected and exposed ones. While applying, apply quickly without consuming much time before the wet skin gets dried up.

Moisturizing Tips

• Bathing or taking a shower is always a good way of moisturizing the skin in eczema, just avoid extended period and hot water, instead use luke-warm water.
• A bath with an appropriate amount of bleach added to the water may give relief from eczema symptoms. Moreover, a bleach bath can kill bacteria on the skin preventing infections, reducing itching, redness, and scaling. Consult your doctor before giving it a try.
• Use moisturizer prescribed by the physician instead of over the counter as medicated moisturizers have the added benefit of reducing side effects.
• Apply topical medication if you use one before applying moisturizer to enhance the healing.
• Be sufficiently hydrated by drinking enough quantity of water and juices to keep your skin moist.
• Try wrapping your skin with a therapeutic wet bandage or use paper towels, make them wet and place over the skin and top them up with dry dressing once the bottom layer dries you can remove and replace it another wet one.
• If the climate in your area is to dry and less humid use humidifiers in your rooms to make the air moist to comfort your skin.
• While using a moisturizer or liquid cleanser (soap) use pump dispenser instead of an open container in order to avoid the spreading of the infection.
• Avoid using soap as it increases the PH level of the skin and makes it dry, instead use a gentle cleanser to avoid scrubbing with a loofah.