I have been a regular outpatient at the Dermatology department of Homerton University Hospital in Hackney East London since 1995. During this time I have been followed by 3 consultants who helped me deal with my severe skin condition. I have been seeing my third and current consultant for at least 8 years. She tried hard to get me on immuno-suppressants and after a couple of attempts that didn’t work out because of side effects we have now settled on Azathioprine. In 2011 she asked me to see a dermatology nurse to try a new kind of treatment called Behaviour Modification Therapy.
Having ‘inherited’ my atopy from my father like the rest of my siblings, I suffered from asthma and rhinitis since childhood and was always prone to developing eczema. Genes can only make you susceptible to a disease which needs a trigger, emotional or otherwise, to start off. While asthma and rhinitis are respiratory allergies, eczema has more to do with dry skin. Very dry skin becomes itchy, which leads to scratching that causes inflammation and eczema. The inflammation causes more itching, which in turn initiates scratching, and so goes the merry round. This vicious circle has 3 levels: 1- dry skin, 2- itching and 3- scratching. The conventional treatment can only address level 1, with emollients, and level 2, with topical steroids. Enter Behaviour Modification Therapy whose objective is to break this vicious cycle.
If we compared the skin to a brick wall, we could say that in a normal skin the bricks are closely glued together by cement. With no cracks or empty space between them, there is no way for the moisture to escape out, or the outside irritants to get in. In a skin damaged by eczema, the barrier lacks natural oils (cement) to hold the bricks together. As a result the moisture evaporates quickly and the irritants get in easily. The inflammation and itchiness are a natural reaction to irritants. Scratching is the quickest way to stop the itching and thus damages the skin further.
Eczema can only improve if we use three levels of treatments. We said that emollients can form an outside barrier to keep the irritants out and the moisture in. The topical steroids (cream and ointment) will calm down the inflammation. Behaviour Modification Therapy will address the problem of scratching. Only if we stop the scratching will the skin have a chance to heal.
Pruritus (from the Latin prurire meaning ‘be sexually excited’) is the medical term for itch. Merriam-Webster dictionary defines it as ‘localized or generalized itching due to irritation of sensory nerve endings’. While checking the word itch in Wikipedia, I found confirmation of the pleasurable aspect of pruritus:
‘Scratching has traditionally been regarded as a way to relieve oneself by reducing the annoying itch sensation. However there are hedonic [characterised by pleasure] aspects of scratching as one would find noxious [destructive] scratching highly pleasurable. This can be problematic with chronic itch patients, such as ones with atopic dermatitis, who may scratch affected spots until it no longer produces a pleasant or painful sensation instead of when the itch sensation disappears. It has been hypothesized that motivational aspects of scratching include the frontal brain areas of reward and decision making. These aspects might therefore contribute to the compulsive nature of itch and scratching.’
In the beginning, scratching is a conscious reaction to stop a skin irritation. With time and repetition it becomes an unconscious habit. The first step of Behaviour Modification Therapy is to help the patient to be watchful of his response to the itch stimulus. One way to become aware of the scratch reaction is to measure its frequency. The patient is not asked to avoid scratching, just to register the rate of recurrence. At my first appointment with the nurse, she gave me a booklet and a hand counter and asked me to press it every time I scratched. She pointed out that scratching didn’t just mean scraping the skin with my fingernails, but all picking, rubbing and touching in response to itch. At the end of the day I was to register in the Behaviour Modification Therapy booklet the number of times I scratched every day for a week (7 days). The first day the number was near 500, the seventh day it was down to just above 100. I was also to make a note of any particularly scratchy situations, in my case these occurred after meals. Just by becoming aware and watchful of my noxious habit I was able to reduce it considerably in a short period of time.
The second part of the programme is to address the three levels of the eczema mentioned above:
Level 1 – Dry skin: use an emollient as often as possible especially on the face. Drinking more water will help, at least 2 litres a day (the recommended amount for an adult) and more if you can. Unfortunately, because of a swollen prostate (very frequent urinations) I can hardly manage 1 litre.
Level 2 – Itching: use topical steroids aggressively. Start with a strong steroid twice a day for a few days then reduce gradually, and do not stop as soon as the skin looks good. When your skin has cleared there is still some hidden healing to achieve. The Behaviour Modification Therapy booklet states that ‘Fear of side-effects often results in inadequate treatment, with frequent and rapid relapses… There is more risk of developing chronic eczema with weak steroids, or with too short a treatment period, than of developing side effects from strong steroids.’ The mistake I made is to fall into a long term routine of using weak steroids consistently which resulted in cortico-dependency.
Level 3 – Scratching: use the habit reversal technique to change your behaviour. Continue registering the daily frequency of scratching for another couple of weeks. Change the old behaviour (automatically moving the hand towards the itching part then scratching) into a new behaviour (squeeze your fist for 30 seconds then pinch the itchy area). To remind yourself, put a sign in the bathroom, bedroom, etc. that says ‘STOP SCRATCHING!’ Avoid situations that provoke scratching (e.g. hot bathes or food that triggers itching, in my case sugary snacks). For situations that are unavoidable use damage limitation (e.g. after meals I feel very itchy, so I use the emollient just before and after eating).
This is just a quick overview of the Behaviour Modification Therapy. Practised with discipline, it can replace long-standing severe atopic eczema with only short periods of relapse. If you think it can be beneficial to your condition or a loved one’s, talk to your GP or dermatologist who might be able to refer you to a nurse or hospital department offering this treatment. The handbook I was given was a synopsis from the following book:
Bridgett C, Noren P, Staughton R: Atopic Skin Disease: A Manual for Practitioners Wrightson Biomedical Publishing Ltd (1996)