More on habit-reversal for eczema treatment

After meeting Mei and CK Bridgett on Twitter I have done a little bit of research on the "habit-reversal" technique Bridgett is so keen on for eczema patients.

I like the idea very much. Through my entire life the only attitude I have gotten from doctors (GPs and dermatologists) about my eczema is that there's nothing you can do for the patient except prescribe topical corticosteroids. Nobody has ever addressed nervous or compulsive behavior, which is certainly a component.

In his website/book, Bridgett, a psychiatrist, refers to a number of the original papers on the habit-reversal technique. I printed them out and read them, and you can too.

Behavioural treatment of scratching in patients with atopic dermatitis (1986) 

A 17-patient study, finding that behavioral change (clenching hand into fist, or grasping an object) plus hydrocortisone cream improves skin quality twice as much as hydrocortisone cream alone (but did not affect bouts of intense itchiness).

The effect of combined topical steroids and habit-reversal treatment in patients with atopic dermatitis (1989) 

A 45-patient study, where behavior training (fist-clenching &/or pinching the itchy area to cause pain) + steroid reduced scratching by 90% compared with 75% for steroid alone.

Habit reversal: a turning point in the treatment of atopic dermatitis (1993)

A conversational speech by Peter Noren, very readable, in which he explains how parents can apply the technique to children. Noren rightly laments the poor attitude of many doctors and insists on a positive outlook by both doctor and patient, and deeper involvement by the doctor.

I have to say that these studies are pretty small in size. I wonder whether anyone's ever conducted a study of, say, 200 or 1000 patients, which would give you more confidence in the results. Soon I hope to conduct a very small study (one patient: me) and publish the results on this blog. What's stopping me? I have to get psyched up to make little marks on a piece of paper each time I scratch, and to poke my skin with my fingernail in public.

Last year I spoke to Martin Steinhoff about his plans for an integrated itch center at the University of California, San Francisco (where I work). At the time Steinhoff did not mention behavioral coaching, but I'd like to ask whether he would consider a psychiatrist or behavioral coach as an essential member of such a center.

Controlling scratching and modeling how to behave for your kids

If you've got eczema, you scratch. And sometimes you scratch in front of others--either you're not aware that you're doing it, or you are but you're nervous, or you've just got that itch that needs dealing with. You can control it when you really need to--say you're on stage presenting a talk at a conference. As soon as you're out of the spotlight, you give in to the urge.

But sometimes you get called on it. "Hey, why are you scratching?" Or you can tell someone's noticed. And that's embarrassing. Because it's not socially acceptable to do it in public. Like picking your nose or masturbating, scratching is something that most people do privately if they want to keep their jobs and spouses.

So how do you explain to a child with eczema that they should try not to scratch in public? Given, of course, that some outbreaks are unbearably itchy and you can't help yourself. I'm talking about scratching that you could control if you wanted to.

This hasn't come up as an issue for us yet, but I've been thinking about it. You know that just telling your kids to do something is not enough.You have to model the behavior yourself. I know this well. Just this week (as a New Year's resolution) I started eating raw vegetables, instead of my usual chips or chocolate, in front of the kids during their dinnertime. Whaddya know? All of a sudden Voov wants a carrot stick. Shmoop can't get enough kohlrabi.

If Voov, currently two and three quarters years old, grows up with eczema, as she shows every sign of doing, I'd like her not to scratch unduly in public. They'll eat you alive in high school for that. So, as her eczema-afflicted dad, I need to try not to scratch in front of her.

I admit it. Around my kids, I usually behave as if they're not even there, when it comes to personal matters. When your kids like to barge into the bathroom and closely examine your butt as you're toweling off after a shower, it's hard to follow Miss Manners' code of conduct once you're fully dressed. So I often find myself vigorously scratching my feet, or picking at my scalp, in front of Voov.

Really, I need to smarten up and stop this; act as I would in front of my boss. Because the only way she's going to know how to control herself, to the extent it's possible with eczema, is if I show her that it can be done.

I'm hoping I can speak to a behavioral expert about this and learn some tips about controlling compulsive scratching--an issue that I wouldn't be surprised to learn is connected to OCD. If I do learn anything, I'll blog about it.