For those whose lives are blighted by chronic skin conditions, treatment that recognises a link with the mind offers a touch of hope
Gerry Gajadharsingh writes:
“In a Times online poll 89% of people said they would use psychotherapy to cure itching, this is a welcome response but is surprising given that many people think that having a physical problem can’t be anything to do with the mind.
The concept of psychoneuroimmunology is becoming increasingly accepted in medicine and it’s good to see Dermatologists discussing how psychological intervention can impact on physical symptoms such as chronic skin conditions.
The “itch/scratch cycle” is well recognised and trying to persuade the patient to intervene to break the vicious circle to reduce the itch, means they don’t scratch or at least reduce the scratching and gives the chance for the skin to actually heal.
Chronic itching, which lasts six weeks or more, affects as many as one in six British adults, and can be caused by anything from cancer and advanced kidney disease to thyroid problems, urticaria and skin conditions such as eczema and psoriasis. In about 8 per cent of cases, there is no known cause for the itch.
Psychodermatology (the phrase that is used) deals with both the impact that mental health can have on the skin but also the impact that skin conditions can have on mental health. It also includes teaching techniques to recognise and stop a scratching habit, which often occurs at certain times of day, such as bedtime and before and after showers.
Once a patient is aware how often they are scratching — and when — they are encouraged to find an alternative response when they feel itchy. This could be clenching their fists for 30 seconds, pinching or pressing the skin, tapping it or saying positive affirmations.
Tapping for chronic pain has long been recognised such as in Emotional Freedom Techniques (EFT), a brief stress reduction technique which combines stating a cognitive statement with somatic tapping on acupressure points.”
The Times
Louise Eccles
Most of us can relate to a maddening itch, whether from insect bites, an allergy or a skin condition, but the urge to scratch is relentless for some people.
“I used to be awake all night with itching from eczema,” says David Farmer, 68, a theatre director from Norwich. “It was really, really bad. I just could not stop scratching.”
Like growing numbers of people, rather than trying more potions and pills he turned to therapy to see if he could break the vicious itch cycle.
The British Association of Dermatologists (BAD) says demand is so high for treatment based on psychodermatology — which recognises the link between the mind and the skin — that it cannot be met.
Habit reversal therapy is one type of psychodermatology treatment that aims to alleviate chronic itching by addressing subconscious and non-stop scratching, which can be worsened by stress, anxiety, boredom and tiredness.
Chronic itching, which lasts six weeks or more, affects as many as one in six British adults, and can be caused by anything from cancer and advanced kidney disease to thyroid problems and skin conditions such as eczema and psoriasis.In about 8 per cent of cases, there is no known cause for the itch.
Farmer was introduced to psychodermatology during a coronavirus lockdown in 2020 after he contacted Dr Christopher Bridgett, a consultant psychiatrist who is one of the pioneers of habit reversal therapy for skin conditions. It began with monitoring the scratching behaviour.
Bridgett, who worked at Chelsea and Westminster Hospital in London before he retired, encouraged him to buy a “clicker”, a cheap handheld tally counter, similar to those used by door staff at events, to count his itches.
Farmer said: “For three weeks, every time I touched my body in any way — even touching my nose or my ear or something — I used the clicker. I realised that, as someone with eczema, I was habitually touching or scratching my face and body hundreds of times a day, which was making it worse.
“Scratching is a habit-forming drug rushing through your body, it makes you feel great, but of course it makes you sore and makes the eczema worse.”
For Farmer, realising how often he was scratching, even when he was not itchy, was enough to break the cycle.
He said: “The scratching had felt uncontrollable but [using the clicker] changed my habits. After just three weeks, I realised I was going to bed with no itchiness whatsoever. It was the first time I’ve experienced that … in my life. I’m not cured by any stretch of the imagination. I still get itchy, but I am so much more in control of what happens.”
Psychodermatology deals with both the impact that mental health can have on the skin but also the impact that skin conditions can have on mental health. It also includes teaching techniques to recognise and stop a scratching habit, which often occurs at certain times of day, such as bedtime and before and after showers.
Once a patient is aware how often they are scratching — and when — they are encouraged to find an alternative response when they feel itchy. This could be clenching their fists for 30 seconds, pinching or pressing the skin, tapping it or saying positive affirmations.
The itch-scratch cycle can be difficult to break because scratching provides a pleasurable, temporary relief but also becomes subconscious and automatic. But scratching the skin causes more inflammation, perpetuating itchiness, as well as breaking the epidermal skin barrier and raising the risk of infection.
Dr Alia Ahmed, a consultant dermatologist with a special interest in psychodermatology, said: “Itch is quite poorly understood in the UK because we do not research it that much and, when we do, we focus on the cause. We massively underestimate the impact of itch on people, whether it is psoriasis, eczema or an undiagnosed skin condition.
“In the US, they even have a centre of itch. They look at itching like pain and explore how to interrupt those brain signals.
“That’s what we do with habit reversal. Rather than actually scratching your skin, we try to trick the brain into thinking you have scratched it — by tapping it, for example, without damaging the skin.”
There are fewer than ten NHS psychodermatology clinics in the UK, including those in hospitals in London, Bristol and Belfast and Solihull.
A recent study by the BAD found that 41 per cent of people with long-term itchiness have fatigue, probably due to persistent sleep disruption, compared with 22 per cent of the control group, according to new research published in the British Journal of Dermatology.
Dr Alpa Kanji, a consultant dermatologist at St John’s Institute of Dermatology at Guy’s Hospital in London, who teaches habit-reversal therapy, said: “In an ideal world we would have psychodermatology departments offering this, but the focus seems to have shifted towards medication, tablets and injections.
“Those treatments are good and definitely have a place, but even if someone uses those more sophisticated treatments, if they’ve got a habit of scratching, sometimes the problem persists.
“This technique also gives the patient some control back and empowers them rather than just going to their dermatologist to get a box of creams. It can be used alongside it.”