Scalp eczema therapy: a work in progress

Last year I wrote about scalp eczema. The post is one of the most-read on this blog. Good news: I’m going to write about it again! The reason: once again, scalp eczema is a problem for me.

My scalp trouble seems to follow a yearly cycle, and it might have something to do with pollen, since I had it last spring. Or it might be just that I started swimming again a few months ago. There’s no getting around the fact that swimming is bad for my skin. (I swim, nevertheless, because it’s good for my back.)

I just get this ridiculously dry scalp that starts breaking out into itchy patches. It is extremely hard not to pick at and scratch.

It seems to be a three-part problem: inflammation, dryness, and bad habit.

To treat the inflammation I rub in steroid, which is bad because 1) it’s quite strong (fluocinonide ointment) and 2) it hardly works at all.

I also use a tar shampoo, T-Gel. I love tar shampoo—it’s got a great bite to it and knocks the itch out for a few hours. But it’s a shampoo, made from detergents, which wash oils out and leave my scalp screaming dry.

I realized that the tar shampoo was part of the problem, so now I use it only once a week.

I used to follow tar shampoo with jojoba oil. Jojoba is an expensive, fine-grade natural oil that comes from the seeds of a Mexican desert plant. It is my conclusion that jojoba is a waste of time and money. It doesn't do much besides run down behind your ears and make your neck greasy.

Now I follow my tar shampoo with Aveeno Daily Moisturizing lotion. That's right, I rub it all over my head. It dries to a shellac and makes me look like my grandfather when he used Brylcreem back in the 1950s. Aveeno is good both because it contains soothing oatmeal extract and dimethicone, a rubbery polymer that holds moisture well.

This is not a perfect solution, and a bit disgusting. But it’s better than rubbing in strong steroid ointment out of desperation, I think.

In order to use the Aveeno lotion (to get more of it on my scalp and less on my hair), I buzz my hair short. I’ve got a home barber kit for this. I use the 0.5” or 0.75” attachments. I gave myself a haircut last week, after waiting several months for my scalp eczema to go away so I could go to the barber.

I’m not super-keen on Aveeno for this though. I am going to try shea butter, which at least has the virtue of being a bona fide hair product.

I am surprised that very few commercial companies, if any, make moisturizing scalp lotion. You’d think there would be a market for it. Cosmetics companies seem to approach this as a conditioner problem, as if we’re all worried about how beautiful and manageable our hair is. Well I’m not. I’m a 41-year-old balding man and I have no use for conditioner.

Ironically, Kamedis, the Chinese herbal therapeutics company whose skin lotion I reviewed recently (and none too positively) makes scalp lotion for eczema. Maybe I should give that a shot!

* * *

Let’s not forget that my bad habit of picking at dry skin and scabs on my scalp is part of the problem too. I know that it’s possible to quit the habit to some degree by undergoing habit-reversal training.

There are two phases to habit reversal. In the first, you count how many times you touch, pick, or scratch yourself during the day. In the second, you train yourself to recognize that you're about to scratch, and to resist the urge, either by clenching your hand or digging your nails into your palm. 

Here’s the barrier that prevents me from self-training—I don’t own a simple digital counter that would enable me to keep track of how many times I am scratching. Last time I tried habit-reversal, I made pencil marks on the back of a business card. I touch my head more than 500 times a day, apparently. It's a pain to have to keep making pencil marks.

I just looked on Amazon. This is what I want. Isn’t it ridiculous that I am not able to stop picking at my scalp because I don’t have a little clicker device that costs less than $7.00? I just bought it.

Habit reversal works for scalp itching

Training myself in habit-reversal, to replace compulsive scratching with more socially acceptable behavior, has not been easy.

It's hard because you have to be on all the time. You have to intercept those impulses to scratch before the action happens. Of course the goal is to make the behavior automatic, so you don't have to consciously think about it, but you do at the start.

And I fail all the time. I'll just discover my hand doing something it's not supposed to, and I'll have to yank it away. Fortunately the inventors of habit-reversal acknowledge that you'll fail. You just have to try your best.

I haven't quantified the results yet but I do see one significant improvement. I've been able to stop scratching my scalp, especially on the days that I wash my hair with shampoo (tar shampoo, naturally). Just a few weeks ago, my scalp was covered with dry skin and little scabs that I was picking at. It's annoying to feel itchy all the time, and everyone knows how embarrassing dandruff is.

But, in this completely unscientific experiment lacking any sort of control, I observe that I am hardly scratching my head at all any more. To some extent, I have broken the itch-scratch cycle for this specific behavior. And that's great.

However, elsewhere on my body, particularly the backs of my knees, I've got red and inflamed skin from scratching that I haven't brought under control. It's like a different type of itch, although there's certainly a psychological contribution.

My ability to implement habit-reversal is strongest in the morning. Later in the day--especially after I get back from work and the circus of getting the kids through bathtime and into bed begins--the stress mounts and I find myself scratching various places vigorously. (Not the scalp though.) I'd guess that's because whatever part of my brain I need to control scratching is busy thinking about how to keep the kids disciplined instead. Or it could just be that the urge to scratch gets brought on by stress, and there's little more stressful than fighting with your two- and five-year olds to brush their damn teeth and get into the tub and stop trying to drown your sister and stop whining and crying about how she's got your rubber dolphin, etc.

I need some stress-reduction technique--something more powerful than the beer I open after the kids are in bed.

First day of the habit-reversal regimen

This is the first day of the self-training phase of my habit-reversal project.

It's gone pretty well so far, probably helps that I'm not having a flare-up or a stressful day.

Yesterday by 7 pm I'd logged 503 separate scratching events, by making marks on business cards--a convenient, inconspicuous data storage medium. Roughly half of the events occurred before lunch and half afterward. As I mentioned yesterday, a surprising number of the events involved nervous touching of the face, to quell tiny itches or crawling-ant-like sensations.

Making marks on business cards is a tedious way to enter data. (Really, you need a clicker or some kind of smartphone app.) I lost interest in doing it toward the end of the day and probably under-reported my scratching. And then, at 7 pm, bedtime for the kids started and I gave up entirely. But the point is that I expect habit-reversal to have a significant effect, and after two weeks I'll repeat the measurement--I hope to see the scratching drop down to less than 100, possibly 50, events.

Today I've had some luck intercepting scratch attempts before my nails hit skin. I've been clenching my fist on whatever side is affected. If I feel a more intense itch, I've been pressing a nail hard into the itchy spot, which does seem to reduce the itch, sometimes to the point where I forget about it.

One problem is that many of the itches originate on my face, and poking your fingernail into your skin leaves a dent and sometimes a blanched spot. I am not sure this is more socially acceptable than scratching. But, so I understand, habit reversal breaks the itch-scratch cycle, and eventually I'll feel fewer itchy sensations on my face.

Often after I wash my hair, my scalp is particularly dry and I tend to pick at it. Then I get scabs or dandruff. Eww! This behavior is largely nervous and compulsive and I hope to eliminate it by habit reversal.

Habit reversal: The hyperactive monkey records scratching events

Today, as the first part of an effort to reduce the frequency of obsessive scratching that contributes to my problems with eczema, I counted the number of times that I scratched throughout the day--every motion, whether a light skin brush or a deep nail dig, that I made to relieve an itch or satisfy a nervous compulsion.

My method was hardly high-tech. I made marks on the back of a business card. (Possibly the most practical use I have made of one.) In fact I made so many marks by noontime (254) that I ran out of space and had to start a second one.

A highly scientific data collection method.

These are separate events. Wow, I knew I had an issue with this but I wasn't aware I scratched so often. And that's the point of this stage of the habit-reversal process: to become aware of the scratching, so you can make a conscious effort to recognize the motion and stop it.

Usually, from what I gather, patients use some sort of clicking device instead of making marks. I bet that you could go further and use a smart device that records the time of each scratch. That way you could see when intense bouts of scratching occur through the day, and link them to triggers, and perhaps deal with issues psychologically.

Also best would be an initial step to record scratching events that the patient is not aware are being recorded. All day today I have gone through this thought process:

1. unconscious urge to scratch
2. motion to scratch
3. realization that I'm doing it
4. stop! Don't do it!
5. no! It's OK to do it and record it!
6. scratch. oh yeah.
7. repeat

Even marking the stuff down is weird. You can see that instead of making marks in some places I have written down numbers. I did this when I couldn't use a pen and had to keep track in my head--like when I was changing the kids' diapers, or riding the subway, or talking to someone in the office.

I'm glad that I only have to do this once at the start and once later on. It's really interfering with getting work done.

Several things are interesting. For example, the number of times I sneakily merge a scratch with a motion that would otherwise seem natural, such as smoothing my hair (or what's left of it). Also, the vast majority of scratch entries so far correspond to nervous touching of my face and head.

What an interesting process. Even better if the psychological training works and I can stop looking like a hyperactive monkey.

A wider perspective on habit reversal to reduce eczema scratching

I've done as much armchair research as PubMed will allow, and I've found that the psychological technique called "habit reversal" seems to be a valuable component of total therapy for eczema—but it's not covered much in the scientific literature, and in my personal experience, it’s almost completely ignored by the medical system.

Why? There’s little profit in it, sure, but it’s also unsexy—it requires patients to commit to a training regimen and then not deviate from proper practice, and it requires repeated input from nursing staff and a medium-term follow-up. It’s low-budget, time-consuming, and probably effective. But only when combined with traditional therapy such as topical steroids.

Habit reversal is a technique to reduce obsessive, compulsive scratching not generated by intense itch. The patient, instead of scratching, clenches his/her fist, and/or applies strategic pain to the itchy area by poking it with a fingernail.

I searched on PubMed and read the papers I could access on the topic. Here are the two that were most informative, besides the ones by Noren and colleagues that I wrote about previously:

Habit reversal training for the itch-scratch cycle associated with pruritic skin conditions (2007) An instruction manual for nursing staff. The authors are from Australia. They recommend four training sessions spaced a week apart, with a follow-up session one or two months later.

The effects of psychological intervention on atopic dermatitis. A systematic review and meta-analysis (2007)  The authors, from the UK and Japan, consider eight journal articles studying psychological treatment for eczema. Their conclusion: “Taken together, the most effective psychological intervention for AD would seem to be a combination of stress-managing psychotherapy, relaxation techniques and habit reversal behavioral therapy.”

Interesting. Habit reversal is not the only game in town when it comes to psychology. Someone even tried aromatherapy, but it didn't pan out.

It’s time for me to give habit reversal a shot. I’m going to train myself starting next Monday. In the initial phase, “registration,” you record how many times a day you scratch. The point is to make the patient conscious of scratching action that was previously unconscious. I’ll be making little marks with a pencil on the back of a business card. When I’m done for the day, I’ll post a photo of the card.

Control obsessive scratching using psychology

This morning I washed my hair (or what's left of it) with tar shampoo. Rubbed some jojoba oil into my scalp, but a few hours later at work I found myself absent-mindedly picking at scabs and dry skin on my head. I wasn't even itchy. It was a bad habit, a sort of obsessive compulsion, which I've had for many years, and which is exacerbated by stress. And with modern life, there's no shortage of stress. Deadlines! Email! Car trouble!

The picking and scratching start up the vicious cycle of eczema--the itch irritates the skin, which generates more itch, which means more scratching. You'd think there'd be a way to break the cycle at some point--where the itch is psychological, and perhaps subject to more control than physical itch. OCD-type scratching is the one aspect of eczema that can be blamed on the patient.

And in fact there IS a method that doctors have developed in the clinic to control psychological aspects of eczema. It's not new, but it's new to me. It's called "habit reversal", and it's employed by Christopher  Bridgett (on Twitter as @ckbridgett. He gives good tweet) at Chelsea & Westminster Hospital in London. I'm sure other doctors use similar techniques elsewhere.

Hat tip to @MarcieMom on Twitter, on whose excellent blog Eczema Blues I learned about Dr Bridgett.

Habit reversal was originally developed in Sweden in the late 1980s, based on earlier work in the US. You can find most of the details here. In fact you can (as I have done) print the pages out from the book, "Atopic Skin Disease: a Manual forPractitioners," by Christopher Bridgett, Peter Noren, and Richard Staughton.

Habit reversal, applied to eczema, consists of four basic elements:

1. the patient "registers" the behavior, using a clicker or some form of counter, to count the number of times he or she picks or scratches throughout the day. This is key because to control the behavior one must be aware of it. (I often find myself scratching, having started unconsciously.)
2. thereafter, when the patients realize they have the urge to scratch, they try clenching their fists--this stimulates the motor neurons and muscles involved in scratching.
3. if this doesn't work, the patient tries pinching the itchy area, or poking a fingernail into it, to provoke pain that quells the itch.
4. later, the patient follows up with the doctor, who prescribes steroids or other anti-inflammatories to reduce itch that can't be controlled using the first two methods.

The authors report a study in which scratching frequency was reduced by 90% after four weeks in a group using this method (habit reversal + steroids) versus 70% for a group using just steroids.

Sounds like a good thing to try. I have to figure out how to apply it to myself. There’s got to be an iPhone app out there that I can use as a counter!