As parents of children with moderate to severe eczema, and leaders of patient organizations that serve children and families impacted by the condition,
we know firsthand how difficult it can be to keep a child with eczema from scratching. In spite of constant reminders, children with eczema are often compelled to scratch by an almost hypnotic itch. We have seen our own children’s skin bleed from the relentless clawing, and the speed with which it destroys hard-won progress on healing damaged skin. Stopping the scratching feels urgent and desperate, like one of the only tools you have to fight a condition that is making your child and family miserable. For those of us who have known severe, uncontrolled eczema, scratching isn’t just a setback or a bad habit; it seems like the first step off a cliff into an abyss–a place of raw, painful skin, infections, sleepless nights, anxiety, hopelessness–from which it’s exceedingly difficult to claw your way back out.
One of the hardest aspects of managing a child with moderate to severe eczema is the woefully inadequate and few treatments we have for addressing its most challenging symptom: itch.
Too often parents and health care providers are left to make do with just one tool at their disposal: reminding the child to “stop scratching.” Recently, an adult eczema patient that participated in a panel discussion at the European Academy of Dermatology and Venereology recounted the deep shame and self-loathing he felt about his scratching behavior. He recalled how he would sneak off to scratch in private when his parents admonished him for the habit. For a skin condition that takes such a dramatic toll on quality of life and self-image, this additional layer of disapproval can be devastating.
Why can’t patients with eczema just stop scratching? If you ask patients they will tell you that the itch they experience is all-consuming and bone deep. Itch is a hallmark of the disease and a major characteristic in the diagnostic criteria.1 Patients and caregivers identify it as the most difficult and vexing symptom associated with eczema.2,3 It interrupts whatever they are doing and demands to be addressed. Eczema itch wakes children up from slumber and compels them to scratch through the night even when they are exhausted. Yet, it can never be fully quelled. Even adults with eczema describe an urge to itch that can’t be ignored–as one physician who developed eczema later in life stated: “Unless you’ve walked a mile in my eczematous-laden shoes, you can’t know how hard it is to ‘NOT SCRATCH!’ I’ve found myself in a checkout line or quietly listening to music and discovered one hand on the back of my neck subconsciously scratching away like a man possessed.”4
Perhaps most damaging, patients report a sense of shame and anxiety related to their eczema and itch.5 People stare when they scratch in public. Parents chastise them for it. They blame themselves when they can’t stop. This dynamic also affects the parent-child relationship. Children want to please their parents but become frustrated that they can’t live up to expectations; parents sometimes interpret their child’s insistence on scratching as defiance. A cascade of evidence suggests eczema and itch, its primary symptom, leave psychosocial scars that persist into adulthood and manifest as anxiety, depression, and other mental health conditions.2,6
New Paradigm
How can we change this paradigm to better serve children with eczema?
While there are currently few effective treatments for itch in children, we do have treatments for eczema, and the best strategy for reducing itch is to get the eczema under control. For close to half a century very little progress has been made on developing new treatments for moderate to severe pediatric eczema, but fortunately, more effective treatments options are now emerging, including several that are demonstrating powerful effects on itch.7
Second, there are alternative and behavioral health approaches to itch that are also showing promise. For example, acupressure, or simply pressing on certain part of the body, has been shown to reduce itch in two clinical trials.8
Behavioral health interventions, too, can help children manage itch. Habit reversal, or replacing scratching with a different behavior and rewarding that new behavior, has been shown to be an effective approach, especially for habitual itch, which can emerge during times of stress or even when children think about itch.8
Relaxation techniques may also help children experiencing itch by reducing their anxiety related to the sensation; one study found that progressive relaxation reduced itch and improved sleep in adults with eczema.8
Finally, parents report distraction with toys, games, movies, or other engaging options can help redirect a child’s attention, and ice packs and massage are also widely used techniques to calm the sense of itch.
While imperfect, all of these strategies offer ways for children with eczema to get help when itch becomes unbearable and they’re compelled to scratch–options that don’t assume they can stop through willpower alone. If we reacted to itch, the way we do to pain, we might comfort the child, and find ways to relieve the unpleasant sensation. We wouldn’t tell the child to stop crying. It’s time to embrace a similar approach for how we approach itch in children with eczema–with compassion and a helping hand. And it’s time to accelerate the development of treatments that effectively address the nagging, bone-deep itch experienced by people with eczema. n
Ms Capozza is the founder and director of Global Parents for Eczema Research. Ms Redding is the chief executive officer of Eczema Outreach Support in Scotland.
Disclosure: The authors report no relevant financial relationships.
References
1. Hanifin JM, Rajka G. Diagnostic features of atopic dermatitis. Acta Derm Venereol (Stockh). 1980;60(suppl 92):44-47. doi:10.2340/00015555924447
2. 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
3. Wheeland RG. My new insight on eczema. Dermatology Times. 2019:40(5). https://www.dermatologytimes.com/dermatology/my-new-insight-eczema. Accessed January 2, 2020.
4. Chernyshov PV. Stigmatization and self-perception in children with atopic dermatitis. Clin Cosmet Investig Dermatol. 2016;9:159-166. doi:10.2147/CCID.S91263
5. Dalgard FJ, Svensson Å, Halvorsen JA, et al. Itch and mental health in dermatological patients across europe: a cross-sectional study in 13 countries [published online September 3, 2019]. J Invest Dermatol. 2019. doi:10.1016/j.jid.2019.05.034
6. Paller AS, Kabashima K, Bieber T. Therapeutic pipeline for atopic dermatitis: end of the drought? J Allergy Clin Immunol. 2017;140(3):633-643. doi:10.1016/j.jaci.2017.07.006
7. Lee KC, Keyes A, Hensley JR, et al. Effectiveness of acupressure on pruritus and lichenification associated with atopic dermatitis: a pilot trial. Acupunct Med. 2012;30(1):8-11. doi:10.1136/acupmed-2011-010088
8. Schut C, Mollanazar NK, Kupfer J, Gieler U, Yosipovitch G. Psychological interventions in the treatment of chronic itch. Acta Derm Venereol. 2016;96(2):157-161. doi:10.2340/00015555-2177
