"Do not scratch your itch. Ever."

When characters like Donald Trump set the standard on Twitter it's hard to get worked up about any single tweet in particular.

Nonetheless, yesterday a tweet in my feed got me riled.

Claudia Aguirre is scientific communications manager at Dermalogica, a skincare/cosmetics company headquartered in California.

The tweet apparently came from an audience member in a talk Aguirre was giving in Antwerp, Belgium. [update: via Twitter, Aguirre implied that I took her words out of context, since she says the talk was not about eczema.]

Aguirre has tweeted the "don't scratch"/eczema message a couple times that I've seen, so my conclusion is that she believes it.

For the record, Aguirre does understand that eczema is a complex problem with many causes and treatments. If you like 17-minute YouTube videos, she's got one for you.

But “don't scratch”? That would be nice. I've spent my whole life trying to pull that off. 

With my customary tact, I made my opinion known. Aguirre replied. My man Gary beat me to the punch.

The problem: you can TELL someone not to scratch, but it doesn't work. It’s not that you won’t stop, it’s that you can’t stop. Google "eczema don't scratch" and the results fall into two main categories: pages advising you not to scratch your eczema, and pages from outraged eczema patients and parents saying that this is bullshit. (See this recent discussion on the NEA forum.)

Not only does it not work, telling people to stop scratching makes them feel bad. They already suffer from the itch, sores, and shame of eczema; now you’re telling them they don’t have any self-control. They then believe it’s their fault they look and feel the way they do.

The urge to itch in cases of extreme eczema is so intense that willpower is no defense. Not to mention that willpower is irrelevant while you're asleep, which is when many patients scratch.The intensity of eczema itch is hard to believe. I know, because I and my daughter have eczema, and when she’s itchy and I’m not, I can hardly understand what she’s going through. But when I’m itchy, it’s like a demon has possessed me, like Linda Blair’s character in The Exorcist.

So is it possible to exorcise the demon?

• Topical steroids give you some control, but not many people would claim they are the answer.
• Yoga and meditation: meh.
• Keeping your hands busy with art or a musical instrument might work  as long as you keep doing that activity. Once you stop, the itch starts.
• I am aware of a handful of psychiatric techniques, including habit reversal, made popular by Christopher Bridgett in the UK. I like habit reversal, and believe that it works to reduce habitual, nervous scratching—and thereby calm the itch/scratch cycle and bring overall relief to a degree. But it’s not a solution for everyone. It takes work, and commitment, and for some people, habitual scratching is not the dominant factor in their eczema. (E.g. I get eczema on my face which is caused by pollen. I get outbreaks caused by weather, exercise, food triggers, dust mites, animal dander and stress.)

Dr. Aguirre, you say it’s possible for eczema patients to stop scratching. Would you mind telling us how?

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.

Itch, and scratch relief, depends where it is on the body

A new study [media summary] by itch guru Gil Yosipovitch and colleagues at Wake Forest University has shown that the intensity of itch, and the pleasure of relieving it by scratching, depends on the precise location on the body that a standard itch stimulus is applied.

In standard studies of itch (and, one would presume, creams and ointments designed to relieve it) the usual site of focus has been the underside of the forearm. But Yosipovitch and colleagues, who compared itch on the forearm, the back (slightly to one side of the spine, near the middle) and the ankle, find that itch is sensed more intensely on both ankle and back, and the pleasure of scratching lasts longer on the ankle--even after the itch has dropped off--than on the forearm.

They used "cowhage spicules," which I think are akin to nettle spines, to cause the itch, and a standard laboratory scratching brush to relieve it in 18 volunteers. The paper, which is open-access, doesn't mention whether any of the volunteers had eczema. This matters, I think, because you'd expect eczema patients to perceive and respond to itch differently than "normal" people.

The authors, in their discussion section, speculate on why itch intensity and scratch relief differ across the body. They discuss various types of nerve fibers that might be responsible, but come to no conclusion. Really the paper just poses a question: why are these differences there? And we could expect, in following work, that they might narrow the answer down to the presence or absence of nerve types. It's clear that the mechanism of itch and relief is far from understood.

[It occurred to me later that maybe this research points to the need for different anti-itch treatments for different parts of the body. Whether they work or not, I can imagine companies claiming that various ointments and creams are optimized for your hands or whatever.]

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.

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!

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.