Peer Reviewed

Original Research

Is There a Missing Link in the Care of Atopic Dermatitis? A Mind-Body Technique May Help Stop the Habitual Scratch

Volume 60 - Issue 4 - April 2020

AUTHOR:
Shih-Wen Huang, MD

AFFILIATION:
Division of Pulmonology and Allergy, Department of Pediatrics, University of Florida College of Medicine, Gainesville, Florida

CITATION:
Huang S-W. Is there a missing link in the care of atopic dermatitis? A mind-body technique may help stop the habitual scratch. Consultant. 2020;60(4):3-5. doi:10.25270/con.2020.04.00001

Received July 23, 2019. Accepted September 5, 2020. Published online September 10, 2020.

DISCLOSURE:
The author reports no relevant financial relationships.

CORRESPONDENCE:
Shih-Wen Huang, MD, Department of Pediatrics, Box 100296, Gainesville, FL 21610 (huangsw@peds.ufl.edu)

 

ABSTRACT: Atopic dermatitis (AD) is a chronic inflammatory skin disease characterized by itchy, dry, and inflamed skin of variable severity that affects up to 25% of children worldwide. Nearly 50% of these cases persist into adulthood. Despite advances in understanding of its pathogenesis and the availability of new treatments, the relapsing nature of AD is still difficult to manage. In large part, this is due to patients’ inability to manage the habitual scratching of itch that creates a vicious cycle of repeated insults on skin that lead to flareup. In this report, we introduce a simple mind-body concept to instruct patients to manage the chronic itch by squeezing their hands. Teaching this simple mind-body skill could instill confidence in patients of various ages and enhance the efficacy of managing chronic disease such as AD.

KEYWORDS: Atopic dermatitis, pruritus, mind-body technique

 

 

Atopic dermatitis (AD) is a chronic inflammatory skin disease characterized by itchy, dry, and inflamed skin of variable severity, affecting children and adults.1,2 AD is known for its relapsing and remitting clinical course. It has been estimated that in the United States alone, AD affects 5% to 25% of the pediatric population, and its incidence is increasing. Typical onset is usually before the age of 5 years; its severity improves with age in many cases, but nearly 50% of those affected have persistence into adulthood. The risk factors for AD include a family history of atopic triad (70%) or mutations of the filaggrin gene.1,2

The cardinal features include dry skin and severe itching. They are divided into 3 clinical phases: acute, subacute, and chronic. The essential features of AD include pruritus, eczema, age-appropriate distribution on skin, and chronic and relapsing history.3 The pathophysiology is complex, and the current thought is that patients have barrier dysfunction that leads to immune dysregulation—the so-called outside-in theory—or that immune dysfunction leads to the breakdown of barrier—the so-called inside-out theory.4

The current management plan for AD includes infrequent bathing, avoiding foods or allergens that trigger AD, and helping patients develop a skin care plan and encouraging them to follow it. Clinically, we encourage patients to use moisturizers (lotions, creams, and ointments) and to take short baths or showers with the use of nonsoap cleansers to reduce dry skin.5 Hypochlorite has disinfectant and antimicrobial properties; thus, it is recommended for a dilute bleach bath.6 Antihistamines are frequently prescribed for the control of pruritus7; they are particularly useful for sedation during sleep. Topical corticosteroids of lower or higher potency are often prescribed depending on the severity of the disease.8 Topical calcineurin inhibitors are often used for their steroid-sparing effects.9 A topical phosphodiesterase 4 inhibitor (crisaborole ointment, 2%) has been recently recommended when other topical treatments have failed to achieve satisfactory results.10 In more severe or recalcitrant cases, the addition of phototherapy, the use of systemic immunomodulators (systemic corticosteroids),11,12 or the use of biologic therapy such as dupilumab13 have been reported to achieve better results.

What Is Still Missing in the Treatment of AD?

In spite of all the efforts listed above, many patients are not happy with the clinical progress of AD, which is typically relapsing in nature.3,14 Earlier, in my own follow-up of more than 500 patients under the age of 18, nearly 75% of patients or their parents were still unhappy with the results. The most common complaint by the patients (older than age 5, who could express their feelings or suffering) was their inability to control intense itching. It was inevitably followed by intense scratching, and that has significantly affected their quality of life.

Children were especially upset that the frequent scratching affected their attention span in the classroom or social interaction with peers. More importantly, it affected their quality of sleep. This, in spite of the fact that all the treatment plans described above are aimed to correct those deficiencies. From their complaints, however, it is apparent that the strategy to curtail scratching has not been taught to patients when the treatment plan for AD was discussed.

Why Scratch Exacerbated Itching?

Several mechanisms have been proposed to explain the severe pruritus experienced by patients with AD. Other than the drying effect of the leaky skin due to filaggrin mutation and the presence of histamine in the skin, skin infection would intensify the pruritus, as well. It has been shown that patients with AD have a higher incidence of Staphylococcus aureus infection.15,16 Furthermore, immunoglobulin E against S aureus exotoxin has been reported,17,18 which serves to release more histamine under the skin. It is also known that intense scratching alone could help release more cytokines under the skin where inflammation is ongoing.19,20

The scratch is a natural response for anyone who tries to remove discomfort from the skin. However, in case of AD, the scratch on the skin has very obvious detrimental effects. First, it helps injure the surface of the skin. Second, it would inevitably be followed with a superficial skin infection. Third, it would intensify the itch more. It helps create an endless vicious cycle in spite of the fact patients are receiving the treatments mentioned above. Furthermore, the patients’ frustration only makes the matter worse. The end result is the management of AD could become a long struggle for many patients.

A New Strategy to Halt Habitual Scratch in AD

When medications and other medical interventions do not help stop habitual scratch, introducing a new concept of mind-body control or a holistic approach may help patients manage the problem easier. More than 12 years ago, we began teaching all my patients with AD who were 5 years and older about this technique. The steps are as follows:

1. When the itch overwhelmed the patient, we let him or her imagine the scenario that a “bad energy” is flowing randomly in the body nonstop. We explained that if he or she starts scratching, it only worsens the flow of the bad energy.

2. Explain to the patient that he or she must invent a way to let this “bad energy” out of the body peacefully without using a scratch.

3. Instruct the patient to bring both hands together and squeeze as shown in the Figure. The squeeze must be hard enough to turn the knuckles white.

Squeezing Hand Technique
Figure. The technique of squeezing hands.

4. The patient must learn to imagine that with the tight squeeze of hands, he or she can move bad energy and let it flow from the shoulders, down to the arms, the forearms, and the hands, and finally it is squeezed out from the fingertips.

5. The attempt is to squeeze hands for at least 15 seconds. Teach patients to count 15 seconds by calling one-one thousand, two-two thousand, three-three thousand, and so on, to 15-15 thousands.

6. The patient is then allowed to relax the squeeze. When the urge of scratch returns due to itch, he or she has to repeat 15-second squeeze. Patients can repeat this exercise whenever the urge to scratch returns.

We have formally registered a total of 231 patients with AD for this exercise. After 6 months, we noted that 203 of the patients (92%) still remembered to practice this exercise. Among them, 45% used this technique less than once a week. Meanwhile, the improvement of skin lesions was very dramatic—60% of them needed a topical steroid cream only on an as-needed basis, and 50% were able to use an oral antihistamine only on an as-needed basis.

Overall, the feedback from the patients and their parents was uniformly positive. Other than seeing the improvement of AD/eczema, they thought the hand-squeeze method really helped them to manage the itch.

When asked why they cared to continue squeeze exercise for so long, they offered the following reasons: It requires no medication; it is easy to practice at anytime, anywhere (in the classroom or any public place); and it can be safely done without attracting attention from others. We found the most satisfactory responses were reported by teenagers and adults who had facial AD or eczema.

Conclusion

The availability of new medications to manage AD has improved the outcome of this chronic skin disease significantly. However, the nagging problem of incessant or habitual scratch often compromises the effect of the medical management. This made us wonder whether a link is missing in our treatment strategy for AD. Addition of mind-body technique like the hand-squeeze method may help fill the void. It allows patients to manage the habitual scratch more effectively. The best benefit of this approach, however, is allowing the patients to realize that they could manage the problem with a relative ease by themselves.

REFERENCES:

  1. William H, Robertson C, Stewart A, et al. Worldwide variations in the prevalence of symptoms of atopic eczema in the International Study of Allergy and Asthma in Childhood. J Allergy Clin Immunol. 1999;103(1 pt 1):125-138. doi:10.1016/s0091-6749(99)70536-1
  2. Shaw TE, Currie GP, Koudelka CW, Simpson EL. Eczema prevalence in the United States: data from the 2003 National Survey of Children’s Health. J Invest Dermatol. 2011;131(1):67-73. doi:10.1038/jid.2010.251
  3. Eichenfield LF, Tom WL, Chamlin SL, et al. Guidelines of care in the management of atopic dermatitis: section 1. Diagnosis and assessment of atopic dermatitis. J Am Acad Dermatol. 2014;70(2):338-351. doi:10.1016/j.jaad.2013.10.010
  4. Ong PY. Moving toward a more precise treatment of atopic dermatitis. Ann Allergy Asthma Immunol. 2018;120(1):3-4. doi:10.1016/j.anai.2017.10.013
  5. Gelmetti C, Boralevi F, Seité S, et al. Quality of life of parents living with a child suffering from atopic dermatitis before and after a 3-month treatment with an emollient. Pediatr Dermatol. 2012;29(6):714-718. doi:10.1111/j.1525-1470.2012.01817.x
  6. Huang JT, Abrams M, Tlougan B, Rademaker A, Paller AS. Treatment of Staphylococcus aureus colonization in atopic dermatitis decreases disease severity. Pediatrics. 2009;123(5):e808-e814. doi:10.1542/peds.2008-2217
  7. Schneider L, Tilles S, Lio P, et al. Atopic dermatitis: a practice parameter update 2012. J Allergy Clin Immunol. 2013;131(2):295-299.e1-27. doi:10.1016/j.jaci.2012.12.672
  8. Hanifin J, Gupta AK, Rajagopalan R. Intermittent dosing of fluticasone propionate cream for reducing the risk of relapse in atopic dermatitis patients. Br J Dermatol. 2002;147(3):528-537. doi:10.1046/j.1365-2133.2002.05006.x
  9. Chen S-L, Yan J, Wang F-S. Two topical calcineurin inhibitors for the treatment of atopic dermatitis in pediatric patients: a meta-analysis of randomized clinical trials. J Dermatolog Treat. 2010;21(3):144-156. doi:10.3109/09546630903401470
  10. Paller AS, Tom WL, Lebwhol MG, et al. Efficacy and safety of crisaborole ointment, a novel, nonsteroidal phosphodiesterase 4 (PDE4) inhibitor for the topical treatment of atopic dermatitis (AD) in children and adults. J Am Acad Dermatol. 2016;75(3):494-503. doi:10.1016/j.jaad.2016.05.046
  11. Krejci-Manwaring J, Tusa MG, Carroll C, et al. Stealth monitoring of adherence to topical medication: adherence is very poor in children with atopic dermatitis. J Am Acad Dermatol. 2007;56(2):211-216. doi:10.1016/j.jaad.2006.05.073
  12. Tan J, Linos E, Sendelweck MA, at al. Shared decision making and patient decision aids in dermatology. Br J Dermatol. 2016;175(5):1045-1048. doi:10.1111/bjd.14803
  13. Beck LA, Thaçi D, Hamilton JD, et al. Dupilumab treatment in adults with moderate-to-severe atopic dermatitis. N Engl J Med. 2014; 371(2):130-139. doi:10.1056/NEJMoa1314768
  14. Silverberg JI, Gelfand JM, Margolis DJ, et al. Patient burden and quality of life in atopic dermatitis in US adults: a population-based cross-sectional study. Ann Allergy Asthma Immunol. 2018;121(3):340-347. doi:10.1016/j.anai.2018.07.006
  15. Wang X, Shi X-D, Li L-F, Zhou P, Shen Y-W. Classification and possible bacterial infection in outpatients with eczema and dermatitis in China: a cross-sectional and multicenter study. Medicine (Baltimore). 2017;96(35):e7955. doi:10.1097/MD.0000000000007955
  16. Asch S, Vork DL, Joseph J, Major-Elechi B, Tollefson MM. Comparison of bleach, acetic acid, and other topical anti-infective treatments in pediatric atopic dermatitis: a retrospective cohort study on antibiotic exposure. Pediatr Dermatol. 2019;36(1):115-120. doi:10.1111/pde.13663
  17. Bogdoli AM, Dyga W, Antoszczyk G, et al. Molecular methods of diagnosing allergic sensitization in patients with atopic dermatitis and infected by with Staphylococcus aureus. Przegl Lek. 2016;73(12):818-822.
  18. Tsutsui H, Mizutani H, Nakanishi K. Contribution of interleukin 18 to the development of infection-associated atopic dermatitis. Curr Probl Dermatol. 2011;41:93-103. doi:10.1159/000323302
  19. Murota H, El-latif MA, Tamara T, Amano T, Katayama I. Olopatadine hydrochloride improves dermatitis score and inhibits scratch behavior in NC/Nga mice. Int Arch Allergy Immunol. 2010;153(2):121-132. doi:10.1159/000312629
  20. Furue M, Yamamura K, Kido-Nakahara M, Nakahara T, Fukui Y. Emerging role of interleukin-31 and interleukin-31 receptor in pruritus in atopic dermatitis. Allergy. 2018;73(1):29-36. doi:10.1111/all.13239