Itching and scratching How to control eczema-related itching Contents Page

About this booklet 1 Why does eczema itch? 1 What does scratching do to the skin? 2 What makes itching worse? 3 Coping with the itch 4 Sleep disturbance 9 Further information and support from the National Eczema Society 12 Itching and scratching How to control eczema-related itching

mediators that are released into the About this skin and can make us itch. Interestingly, histamine, which makes insect bites so booklet itchy, is not related to the itch in atopic For most people, itching is the worst eczema. Therefore, antihistamines do and most uncomfortable symptom of not help reduce the itch in such cases eczema and can often be the most although sedating antihistamines difficult to treat. Itching may also lead are sometimes prescribed to help the to sleep problems for both the person person sleep.) Additionally, the nerve with eczema and their family. fibres in people who have atopic eczema appear to be altered, with This booklet explains why eczema an increase in sensory fibres. This makes you itch, how itching and can cause even the lightest touch to scratching affect your skin, and what produce a sensation of itch. These you can do to be more comfortable nerves then pass on the sensation of during the day and get a better night’s itch to the brain, and before you know sleep. it, you are scratching. This is called a neurogenic itch, due to nerve pathways Why does being activated. However, itch is not completely eczema itch? straightforward as there is another type Unfortunately, we do not know the of itch, called a psychogenic itch. This whole answer to this question. What means that the itch is also stimulated we do know is that skin affected by by psychological factors; these may eczema releases certain chemical be conscious or unconscious urges to mediators – messengers that stimulate scratch, brought about via habit or in the nerves. (There are many chemical response to stress. Scratching is one of the main causes Once I started scratching, I found of skin redness and irritation in a that it was impossible to stop. The person with eczema. It is scratching advice and help from the National that damages the skin, not the itch. Eczema Society have helped me to When the skin itches, the response “cope with these distressing bouts. is to scratch and this can become an unconscious, conditioned response. In Ruth, aged 24 other words, this is a learnt human Page ­­1 ” behaviour and quickly becomes an Once the skin has been broken, there automatic reaction, even in very small is a risk of infection. Broken skin also babies. allows irritants (e.g. fragrance, soaps and detergents) and allergens (e.g. Once you have started to scratch, you pollens and animal dander) to enter the will probably find that you continue to skin easily and cause a reaction, which do so and this leads to what is called in turn will make the itching worse and the itch–scratch–damage cycle (see may cause the eczema to flare up. below). If someone has been scratching the DRY SKIN same area for a long time, the skin will start to thicken – this is called lichenification. The skin looks like leather and can take weeks or months ECZEMA ITCHING to return to its normal thickness. Lichenification can also cause changes in the colour of the skin, making it darker or lighter. These darker or lighter SCRATCHING patches will eventually fade, but it may & DAMAGE take weeks or months. Some patients with eczema may Intense scratching often relieves have very itchy lumps which can also the itch – some people even find it become dark and thickened if the skin pleasurable (this can be another reason is scratched or picked. This is known why trying to stop scratching is so as nodular prurigo. If nodular prurigo hard) – until damage occurs when the occurs in people with darker skin, there skin is broken, and itch is replaced by is an increased risk of lighter or darker pain, causing a person to stop. In the areas becoming permanently ‘stained’. meantime their eczema has been made It is therefore important to ensure that a whole lot worse. all treatments are used effectively to reduce the risk of this occurring.

What does Fortunately, skin that has been scratching do to scratched will heal well and scarring is unusual unless the skin has been the skin? constantly picked and scratching has been intense. This means the deeper At first, scratching the skin produces layers of the skin (dermis) will be redness, and then a rash and irritation damaged and dermal damage will scar. may follow. If scratching continues, The best way to avoid scarring is to the skin can become broken and bleed. control itch. Page ­­2 l Central heating: Bedrooms and What makes bathrooms that are too warm (above itching worse? 18°C) may lead to overheating. l Sweat is a known irritant for people Almost all forms of eczema produce an with eczema, who often find that itch. The following are some of the main they itch more after sporting triggers: activities. Perspiration can be a l Dry skin will always be itchy skin, problem for children who are simply and reducing dry skin is therefore a running around during play. first-line approach to reducing itch. l Clothing: Some clothing material Dry skin, due to a defective skin can be very irritating to the skin. barrier in atopic eczema, leads to For example, wool has quite coarse, trans-epidermal water loss (TEWL), stiff fibres and these can irritate i.e. loss of water through the skin. the skin, causing it to itch. Rough We know that TEWL increases at seams, labels and loose threads can night, so this is one of the reasons have the same effect. Clothes made why itching is worse then. from synthetic material can make the skin hot, leading to itch. It is l Temperature: Changes in important to remember this when temperature can often cause the buying your child’s school uniform skin to itch (e.g. it is quite common as many are made from synthetic for the temperature of the skin materials to increase durability. to change when you are getting Wherever possible, choose 100% dressed or undressed, and when you cotton and dress in thin layers to are in bed at night). Moving from avoid overheating. hot to cold environments and vice versa can also cause itch (e.g. on l Irritants: Many substances irritate a cold day going into a centrally the skin and cause it to itch. heated house). Hot, dry heat on Fragrance, soap and detergents are a summer’s day can also cause common causes of irritation, leading itching, coupled with perspiration. to itching. Household products and chemicals can also be problematic, l Overheating: Night-time overheating causing more itching due to flaring in children is a feature of atopic eczema. eczema and can lead to loss of sleep for all the family. Applying l Allergens: Many people with emollients, especially ointments, too eczema come to know which thickly can also cause overheating substances can affect their skin by blocking skin pores. – usually through trial and error.

Page ­3 Allergens such as house-dust-mite droppings, pet dander and pollen can make itching much worse. But it is important to remember that not everyone with eczema will react to the same things, and some people will find that they are unaffected by certain allergens. Certain chemicals can also be a problem for some people. If an allergic trigger is suspected – this may be a contact allergy (caused by something that from your healthcare professional that touches the skin) or an ingested may help to reduce or control itching. allergy (e.g. food allergy, which is Using emollients (medical moisturisers) rare over the age of 2 years) – a and any other prescribed treatments referral to a specialist may be helps greatly. made. Allergy tests in a hospital Emollients setting may include patch testing, skin prick testing or specific IgE Emollients help to keep the skin well testing (previously known as RAST). moisturised, reducing dryness and Allergy testing should be performed forming a thin layer on the skin that helps to prevent water loss through the by specialists and not by ‘high skin barrier. Emollients are completely street’ practitioners. safe to use and can be applied as often l Psychological factors: Stressful as is necessary. You should apply them situations can have an effect on at least twice a day – more often if itching. People may itch in response the skin is very dry. Remember, dry to certain feelings and, for children skin will always be itchy skin! There in particular, tiredness can make is a wide range of emollients on the eczema more irritated. market, many of which are available on prescription. It may be a case of trial and error to find the emollient Coping with that suits you or your child best. Some emollients contain anti-itching the itch ingredients, called lauromacrogols, which are local anaesthetics. Treatments for itching Remember, an emollient that suits you As well as the practical tips on pages and that you use daily is the best way 6–7, there are treatments available to relieve itching skin.

Page ­­4 It is important to use emollients as soap control. Depending on the response, substitutes for washing and in the bath the steroids may be stepped down or or shower. Washing water should be up in potency. Used properly, topical tepid, as hot water can cause itching. steroids are safe to use. Always follow the instructions of your healthcare Bath emollients are available to buy but professional. do not add any extra benefit to using emollients as soap substitutes. Oats are Paste bandages and wet wraps a traditional remedy for itching, and a Paste bandages and wet wrapping muslin sack of oats can be attached to can both be helpful in reducing the a running tap, for a soothing bath. itch–scratch–damage cycle (especially Topical steroids at night, when scratching is often an unconscious action in sleep). If the eczema and itching fail to respond to emollients alone, an Paste bandages and wet wrapping – additional treatment – usually a topical especially wet wrapping – are intense steroid – may need to be prescribed as treatments used for five to seven days a short-term treatment to help reduce and should only be used if recommended the irritation and control the flare. (If by health professionals trained in the skin is itchier than usual and becoming management of eczema. It is essential red, this is an eczema flare.) Topical that you are given a demonstration of steroids reduce the eczema flare and how to apply paste bandages and wet itching, and therefore prevent damage wraps. Wrapping and bandaging can be from scratching. Sometimes people very time-consuming and should not with very itchy skin are worried topical be used to treat mild eczema. Wraps steroids may damage their skin and and bandages should not be used if the therefore avoid using them. This may skin is infected. Covering up the skin actually prolong the eczema flare, with bandages and wraps makes topical cause more itching and scratching, and steroids more potent, so only use topical lead to long-term skin damage due steroids under bandages and wraps if to the eczema itself. Before deciding advised by your healthcare professional. which topical steroid to prescribe, the Topical calcineurin inhibitors, healthcare professional will take into tacrolimus (Protopic) and pimecrolimus account the age of the patient, the area (Elidel), should not be used under paste of the body affected by the eczema, bandages and wet wraps. the severity of the eczema and other medications being taken. Usually they For more information about paste will start with the lowest potency bandages and wet wrapping, please see (strength) topical steroid required to the National Eczema Society booklet bring the eczema flare back under Paste Bandages and Wet Wraps.

Page ­5 Practical tips to reduce the cause itching, so your emollient itch should always be used whenever you wash your skin. Some people l Use emollients frequently enough find that the area they live in to prevent dry skin. Sometimes, affects their skin because of the thick applications of ointments hard water. (However, a recent can block skin pores and actually study looking at the use of water cause more itching, so apply softeners in areas with hard water often but lightly (but enough to showed no benefit www.swet-trial. make the skin glisten). Emollients co.uk) will help to keep the skin intact l After washing and bathing, pat and well moisturised, reducing the skin dry with a soft towel irritation from allergens and rather than rubbing. irritants. Reapply before the skin becomes dry again. l Use cotton sheets and blankets on beds, or low-tog (4.5) duvets filled l Always apply emollients in with manmade fibre, not feathers, smooth, downward strokes. Do not to prevent overheating in bed. rub them into the skin as this can make itching worse. For children, l Try cotton gloves or mittens, and try to make putting on emollients for babies/children, use all-in-one a positive experience, encouraging sleep-suits with built-in mittens them to stroke and soothe on to reduce the damage from their own emollients – use reward scratching the skin, especially at charts, sticking on stars for night. Sleeves with silk or cotton moisturising and not scratching. mitts can also be useful. Children can decorate their l The Centre of Evidence Based emollient pots and dispensers to Dermatology at the University of make them more fun to use. Nottingham has created stories l Keep nails short, and make sure to help children break the itch– there are no jagged edges. scratch cycle. You can access l Avoid plain water for washing these at: www.nottingham.ac.uk/ and bathing. Always use a soap research/groups/cebd/resources/ substitute or your usual leave-on psychology-and-eczema.aspx emollient to wash with and then l Aim to distract yourself or your rinse off. child from the itch. Watch a l A daily tepid emollient bath using DVD, read a book, go out or give your emollient as a soap substitute children toys to play with or an is very helpful. Water alone can activity to do.

Page ­­6 l Try not to say ‘Don’t scratch’ to children or adults who are scratching. A lot of scratching is done without the person even realising that they are doing it. Shouting at or nagging someone who is scratching could create resentment and distress and increase feelings of stress. Instead, offer to help moisturise and turn it into a soothing action. Try to substitute some other action for scratching. You may l Applying cool emollient creams or find it helpful to press a nail lotions (not ointments) that have onto the skin or pinch the skin been kept in the fridge may help, gently instead of scratching. although some people find that Clenching fists and counting to warm emollients are the most 10 also works well, especially for soothing (but don’t warm in the children. Parents and partners microwave, on the hob or in the sometimes find that if they oven, or allow to get too hot!). moisturise and massage the skin l Keep cool. Use several light gently for their child or partner, cotton layers, rather than having it helps to cut down on potential one heavy and warm layer of skin damage. clothing or bedding – that way, l For very itchy patches of skin, you can adjust the temperature to some people find a bag of suit you. Keep bedrooms cool and frozen peas or something similar ventilate rooms on a regular basis. wrapped in a towel and placed l Talk regularly to your on the skin will help. Avoid dermatologist, GP or nurse about putting ice directly onto the skin. your treatments to make sure that Children might enjoy painting a you are using what is best for picture on a flat stone and giving you at that time and that you are it a name. This can then be placed adequately treating your eczema on itchy areas to cool the skin. flares.

Page ­7 Topical immunomodulators The treatment helps people to realise Other non-steroid treatments, known when and why they are scratching and as topical immunomodulators or topical then to find an alternative to scratching. calcineurin inhibitors (TCIs), are second- They are encouraged to look again at line treatments for eczema flares and the treatments that they are using and are also used for maintenance. These to identify triggers in order to reduce the amount that they scratch. In the are Elidel (pimecrolimus) cream and long term this means less damage to Protopic (tacrolimus) ointment. Topical the skin and a reduced need for topical immunomodulators act on the cells in steroids and other treatments. Ask your the body and the skin to dampen down GP if local dermatology or psychology the immune system, which helps to departments offer habit reversal and if reduce inflammation and makes the you can be referred. Sadly, there are only skin less itchy and red. They are applied a few dermatology centres around the to the skin for six weeks to treat flares, UK offering habit reversal. and then can be used twice a week For more information about for maintenance, to try to prevent habit reversal, please see: www. further flares (this is known as weekend atopicskindisease.com. There is also a therapy). They are licensed for use in self-help book available: The Eczema treating atopic eczema in adults and Solution, written by Sue Armstrong- children of 2 years of age and over. Jones and published by Vermilion.

Habit reversal Hypnotherapy Habit reversal (also called ‘the combined Hypnotherapy is not the same as the approach’) is a behavioural technique stage hypnosis that you might have that is taught to patients by either a seen on television. Hypnotherapy psychologist or dermatology specialist or clinical hypnosis is a procedure (doctor or nurse). The programme works whereby a health professional or well in older children and adults and is researcher suggests that a person mainly for people with long-term atopic experiences changes in sensations, eczema. perceptions, thoughts or behaviour. There are many different ways to do this, including suggestions for relaxation, calmness and well-being. Children can also benefit from hypnotherapy.

There have been some studies investigating the use of hypnotherapy to reduce itching in people who have eczema. There does seem to be some Page ­­8 benefit in that it helps people to ‘see’ Why does eczema affect their itch and to learn to control it. sleep? It is important to find a properly Many people scratch in their sleep and will sometimes wake up because qualified hypnotherapist who is of this. One piece of research showed registered by the British Society of that children with atopic eczema spent Clinical and Academic Hypnosis. You 13–136 minutes each night scratching, can find this information at and scratched 20–97 times. This is www.bsch.org.uk and much more than happens with people www.general-hynotherapy-register. who do not have eczema. com During the day, it is often possible to distract yourself or your child when Sleep feeling the need to scratch, but even so it can be hard to resist the temptation. disturbance At night, distraction is much more If you or your child has eczema, it is difficult. likely that you or they will at some Once in bed, people with eczema can point have disturbed sleep. Waking get very hot and this can cause them to in the night can lead to a relentless itch. People with atopic eczema may be succession of broken nights over weeks affected by the droppings of house-dust or months, leaving you and your child mites, which live unseen in mattresses utterly exhausted and irritable. The and bedding. Again, this can mean waking in the night disturbs not just the increased itchiness at night, so do use person with eczema but affects other protective covers (ones that go all the way round, rather than just covering the family members as well. In one study top and sides of the mattress) and try to that looked at families with a child avoid sleeping on old mattresses. with eczema, the child, the parents and the siblings were all affected by sleep Waking at night can become a habit. disturbance. In severe cases the night- Children will sometimes disturb their time itching and scratching may lead parents at night in order to receive not only to tiredness and irritability but comfort and attention, and this can to lack of concentration at – or absences make life difficult. Try to avoid letting your child climb into bed with you. from – work and school. Tension and When you have more than one person stress can also arise within a family or in the bed, the environment will between partners. People with eczema become very hot and this will make and their parents or partners can be the child itch more. It is better to go deprived of proper sleep for long periods to the child’s room to give comfort of time. Inevitably, this will affect every and then be firm and let the child fall aspect of life. asleep in their own room. For advice Page ­9 (hives) to block histamine pathways. Unfortunately they do not work well on eczema itch, which does not have the same direct histamine link.

You need to take an antihistamine about one hour before going to bed as this will give it time to work and make it less likely that you will have a hangover effect in the morning.

Some antihistamines are only suitable for children over 2 years, and for on establishing good bedtime and all children antihistamines must sleep routines, visit the Sleep Council’s be prescribed by your healthcare website: www.sleepcouncil.org.uk professional. (Please note that in some If you are disturbing your partner at cases these can make children more night by scratching or being restless, active instead of drowsy.) it may be worth having an alternative You should talk to your healthcare place to sleep for a few nights when professional before giving your child your eczema is very bad. antihistamines, or before taking them Treatments for sleep yourself. disturbance If you are intending to start a family or Antihistamines are pregnant, always check with your healthcare professional regarding which Sedating antihistamines that cause antihistamines are safe for you to use. drowsiness can be useful at night. Ideally, they should only be used for a few days at a time when the eczema is very severe and you or your child is having a lot of trouble sleeping. They can be used safely in the long term.

There are a few to choose from: some can be bought over the counter from your pharmacist and others are available only on prescription. Non-sedating antihistamines are used to treat allergy and urticaria

Page ­­10 Practical tips for sleep tepid water, then apply plenty of moisturiser to soothe and cool l If you or your child is itchy the skin. enough to wake at night, it may be that the eczema is not being l Do not apply too thick a layer of well controlled. Ensure that you emollient as this can block the are applying plenty of moisturiser skin pores and make you or your and use topical steroid as child hot and sweaty. prescribed by your healthcare l If you or your child has atopic professional. For further advice eczema and you know – or on managing eczema flares and strongly suspect – that you are using topical steroids, please sensitive to house-dust-mite see the National Eczema Society factsheet ‘Topical Steroids’. droppings, you may find it useful to try to reduce house-dust-mite l Avoid the use of soap when levels by vacuuming frequently, washing, and ensure that dusting with a damp cloth and bedding and clothing that touch the skin are made of cotton using house-dust-mite-proof (ideally 100%), bamboo or silk. covers for the mattress and Remember to use low-tog, fibre- bedding. filled duvets, all year round – in l If you have pets, do not allow the summer you or your child them in the bedroom as dander will probably only need a sheet. can irritate eczema and set off l Paste bandages and wet wraps a bout of itching. (The advice can help to protect the skin about vacuuming frequently and from scratching and rubbing (see damp dusting applies equally to page 5). areas where pets have been, and l Keep emollients at hand at night it is important to wash hands and put them on as soon as you and moisturise after handling or your child wakes up itching. animals.) l Keep bedrooms cool, especially at l Sometimes disturbed sleep night (18°C or below). can cause a lot of tension in l You or your child should wear families and between partners. loose-fitting pyjamas or a light Talking about the effect that cotton nightdress. eczema is having upon sleep l About an hour before going to and being honest about how bed, take a bath or shower in you feel is vital.

Page ­11 Further information and support from the National Eczema Society

More information than can be given advice or opinions on treatments in a booklet of this size is available prescribed by your healthcare from the National Eczema Society. We professional. We do, however, offer have other booklets including: a wealth of practical information l Childhood Atopic Eczema about the day-to-day management of l Living with Eczema eczema and the different treatment l A Guide for Teenagers with options available. Eczema l All about Contact Dermatitis The Helpline is open to all UK l Paste Bandages and Wet Wraps residents who are affected by eczema. Please allow five working days for Booklets can be ordered from our website or from our Helpline. us to reply to you if using email. We are not able to answer queries from Website: www.eczema.org non-UK residents as terminology, Helpline: Telephone* 0800 089 1122 healthcare systems and treatments (Monday to Friday 8am to 8pm) may differ in your country of * Calls are free from UK landlines. Charges vary from mobiles. residence, which may cause confusion. Email: [email protected] In addition, the National Eczema We are proud of the wealth of Society publishes Exchange, a information available on our website quarterly magazine packed with: about types of eczema and treatments l articles on eczema management and recommend you visit it whenever l features by people with eczema you need information. It is updated frequently. sharing their experiences l treatment and research news Our confidential telephone and email Helpline is at the heart of our work, l experts’ replies to your questions. providing information, support and You can subscribe to for reassurance to thousands of people Exchange struggling to cope with eczema. We £20 p.a. at www.eczema.org or by are not medically qualified and do calling our membership team on not diagnose, prescribe, give medical 020-7281 3553.

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The information in this booklet is only a general guide. Individual circumstances differ and the National Eczema Society does not prescribe, give medical advice National Eczema Society or endorse products or treatments. We hope you will 11 Murray Street find the information useful but it does not replace and Camden should not replace the essential guidance given by your London NW1 9RE doctor and other healthcare professionals. Booklet written by Jill Peters RGN BSc (Hons) DipNP, Eczema Helpline: 0800 089 1122 Nurse Prescriber. email: [email protected] www.eczema.org Revised edition reviewed and updated in May 2018 by Julie Van Onselen, Dermatology Nurse Adviser to the National Eczema Society. The National Eczema Society is Designed and produced by www.dewinter.agency registered as a charity in England and Wales (No.1009671) and in Scotland ©The National Eczema Society 2018. (No.SCO43669) and a company limited All rights reserved. You must have our written by guarantee (No.2685083). Registered Office: 11 Murray Street, permission to electronically or mechanically reproduce London NW1 9RE. or transmit this publication or any part of it.