Introduction

Have you ever had dry skin especially in winter, causing itchiness, scratches on your skin and peeling of the skin? Imagine if this itching sensation was constantly present causing scratches and even thickening of the skin. These are the symptoms affecting people with neurodermatitis, a chronic skin condition that causes an intense need to scratch causing significant harm to one’s daily wellbeing.¹ While medicines and ointments are used to manage the symptoms and prevent damage to the skin, one of the mainstays of treating the cause of neurodermatitis is psychological therapy. Behavioural therapy and habit reversal training have proven to be effective modalities of treatment with promising reviews. Let us explore this condition, the potential causes and things you can implement to manage this debilitating chronic condition better.

Understanding neurodermatitis

Neurodermatitis, also known as lichen simplex chronicus, is a skin condition that results in an intense need to scratch at the skin without any notable triggers such as allergens, environmental changes or injury. The intense itching results in deep scratch marks (also known as excoriations) that eventually lead to the thickening of the skin. It can present as thick, scaly plaques on the surface of the skin. The itching often worsens at night, affecting the quality of sleep and affecting the overall quality of life.^1,3

There are special nerves in the skin that help us with the sense of touch. Sometimes these nerves get triggered, resulting in an intense itching sensation. The resulting scratching causes inflammation in the cells in the skin, further triggering the nerves, increasing the intensity of the scratching. So, each time a person scratches at their skin (when they get the itching sensation) the intensity of the sensation increases, resulting in more scratching and so on.² This characteristic compulsive itch scratch cycle results in the diagnosis of neurodermatitis.

Symptoms of neurodermatitis

Over time, the scratching can result in the skin to thicken and look darker and leathery, when compared to healthy skin. Affected areas can develop thick plaques, which can be deep reddish brown or violet in colour.³

Commonly affected areas include:

• Back of the neck
• Scalp
• Wrists
• Ankles
• Genital regions ^3,4

Diagnosis and treatment

It is essential to consult with your GP if you feel like you might have these symptoms discussed in the previous section. Your GP will assess your symptoms, take a comprehensive medical history and examine your skin lesions. If suspected, you will be referred to a dermatologist who will then conduct some blood tests, allergy tests and further clinical examinations to diagnose the condition. Current treatments for neurodermatitis include:

• Steroid creams
• Medicated moisturisers, also known as emollients⁴
• Behavioural therapy, including habit reversal training (to break the itch scratch cycle).⁵

What causes neurodermatitis?

The exact cause of the condition is not known. Some potential causes can be:

• Genetic predisposition: having a family history of skin conditions, asthma, allergies can make the person prone to developing the disease⁶
• Complication of eczema or psoriasis: people diagnosed with eczema or psoriasis are more prone to developing neurodermatitis¹
• Environmental factors: such as heat, humidity and allergens can worsen symptoms. Sometimes, certain perfumes, detergents or other chemicals in the environment can provoke symptoms¹
• Abnormalities of the nerves in the skin: the nerve fibres in the skin can sometimes become hypersensitive, triggering the itch-scratch cycle
• Stress and anxiety: emotional stress is also known to trigger the condition⁷

Behavioural therapy: an overview

The itch-scratch cycle in neurodermatitis develops into a compulsive habit, which intensifies the intensity of the condition. While creams such as steroid creams can be used to address the plaques and protect the skin, a holistic treatment plan should include addressing the behavioural aspect of the condition. Behavioural therapy, including habit reversal training, is proven to be very effective in reducing the compulsive need to scratch. ⁸

A behavioural therapy approach to neurodermatitis

The approach focuses on making the person aware of their itching sensation and curbing the need to scratch. Some techniques include:

• Identifying triggers: tracking the itching and scratching episodes in a diary can help identify potential triggers such as stress, environmental factors, specific triggers such as a particular soap or detergent
• Awareness training: Simply being aware of the scratching episodes can help identify the early signs of itching. This is particularly important as these episodes happen during the night and can affect sleep
• Alternative responses: patients are given alternate behaviours to replace scratching, thereby preventing the itch-scratch cycle from progressing. Alternative behaviours include gentle tapping or applying pressure to the itchy area to distract from the itching sensation
• Relaxation techniques: Stress and anxiety can intensify the condition. Relaxation techniques such as deep breathing exercises, stretching, mindfulness and meditation are some of the techniques that can be incorporated to reduce stress-related itching urges⁸

Habit reversal training

Habit reversal training is a structured form of behavioural therapy developed to address compulsive, repetitive habits and can be used for the itch-scratch cycles seen in neurodermatitis. Habit reversal plans are carefully created based on the individual's unique medical history by experienced behavioural therapists, counsellors, and psychologists specialised in this field.⁹

Components of habit reversal training:

• Awareness training: the first step is to increase awareness of triggers of itching and early signs of the sensation
• Competing response: Replacing harmful behaviours (scratching) with safer alternatives (gentle tapping or pressure)
• Social support and environmental modification: Some changes can be made to the individual's environment such as wearing comfortable clothing, using medicated moisturisers before sleeping, wearing gloves, keeping nails short and filed, as creating a stress-reducing routine⁹

Adding habit reversal training alongside medical interventions such as steroid creams and antihistamines can help address the behavioural aspects of the condition and break the itch-scratch cycle.

Effectiveness of behavioural therapy and habit reversal training

Some of the proven benefits of these measures include:

• Reduction in itch severity: The itching sensation never really goes away, but behavioural therapy can help curb the scratching behaviour significantly
• Improvement in skin lesions: as the itch-scratch cycle is gradually broken, there is a reduction in the inflammation and subsequent thickening of the skin. When the scratching stops, the appearance of the skin improves as the lesions heal
• Long-term benefits: neurodermatitis is a chronic condition, which means that these itching sensations never really disappear completely. The techniques learnt during habit reversal training help develop lifelong skills to manage the condition in the future
• Accessibility of therapy: habit rehearsal techniques are easily understandable and straightforward. The therapy duration is approximately 4 weeks, ensuring a speedy implementation in the daily routine^5,9

Habit reversal training has proven to significantly improve symptoms, reduce urges to scratch and improve the quality of sleep. This, however, does not mean that you can stop taking the medicines and creams prescribed to manage symptoms. If symptoms get severe, follow-up with your dermatologist is vital.

Some concerning symptoms of neurodermatitis can be:

• Significant scratching leading to bleeding
• Signs of infection such as blisters or pus at the site of the plaques
• Thick, dark plaques of the skin with hair loss in the affected area
• The itching affects your sleep and daily routine significantly^1,2

Challenges of habit reversal training

The major challenge with this therapy is keeping up the motivation to be consistent with the therapeutic techniques. It is vital to trust the process and keep incorporating therapeutic alternatives to scratching behaviours. If you need additional support or adjustments to the treatment, it is vital to attend regular follow-ups with your healthcare providers.⁵

Living with neurodermatitis

Neurodermatitis, in its severe stages can be a debilitating condition, especially when left untreated. Some of the things that you can implement while you wait for treatment as well during treatment, include:

• Implementing a simple skin care regimen: using mild, fragrance-free products including soaps, shampoos and moisturisers, can reduce potential triggers
• Managing stress: Meditation, light exercise and journaling are known to help manage emotional and psychological stress¹⁰
• Adequate diet and hydration: ensuring a balanced diet and hydration while avoiding processed foods can help with overall health and immunity
• Creating a sleep routine: maintaining sleep hygiene is important to ensure you can get restful sleep. Reducing screen time, having consistent sleep and waking times, avoiding caffeine at least 8 hours before your bedtime, are some of the ways you can ensure better quality of sleep⁵
• Keeping a trigger diary: Noting down scratching episodes and circumstances that could have potentially triggered them can help you understand your itch-scratch cycles better

FAQs

How do you manage Neurodermatitis?

Management of neurodermatitis involves a multi-faceted approach. It includes addressing triggers such as stress and skin irritants, using topical treatments like corticosteroids or medicated moisturisers to reduce inflammation, practising good skin care habits to prevent dryness and scratching, and sometimes incorporating behavioural therapies like habit reversal therapy or cognitive behavioural therapy to manage itching and improve quality of life.¹

What is the root cause of neurodermatitis?

The exact cause of neurodermatitis (lichen simplex chronicus) is not fully understood, but it is believed to result from a combination of genetic predisposition, environmental factors, and psychological triggers. It often begins with localised itching or irritation, leading to repeated scratching and thickening of the skin. Stress, anxiety, and other emotional factors can exacerbate symptoms.^3,10

Does neurodermatitis ever go away?

Neurodermatitis is a chronic condition characterised by cycles of itching, scratching, and skin thickening. While symptoms can fluctuate over time, the condition typically requires ongoing management to prevent flare-ups and reduce discomfort. With proper treatment and lifestyle modifications, many individuals can experience significant improvement in symptoms, although complete resolution may vary.²

How do you mentally resist itching?

Mentally resisting itching involves techniques to distract oneself from the urge to scratch and manage the psychological aspects of itching. Strategies include mindfulness meditation, relaxation exercises, cognitive behavioural techniques such as cognitive restructuring (changing thoughts about itching), and habit reversal therapy (substituting scratching with alternative behaviours).⁹

What is the psychological treatment for itching?

Psychological treatments for itching focus on addressing the emotional and behavioural aspects of chronic itch conditions like neurodermatitis. These treatments may include cognitive behavioural therapy (CBT), habit reversal therapy (HRT), relaxation techniques, mindfulness-based therapies, and stress management strategies. These approaches aim to reduce the urge to scratch, improve coping skills, and enhance overall quality of life.^5,9

What is new in the psychology of chronic itch?

Recent research in the psychology of chronic itch has explored various psychological interventions to complement traditional medical treatments. Innovations include virtual reality therapy to distract from itching sensations, neurocognitive approaches to understand brain mechanisms involved in itch perception, and personalised behavioural therapies tailored to individual needs and triggers.¹

Summary

• Neurodermatitis, also known as Lichen simplex Chronicus, is a chronic skin condition that causes intense itching sensations followed by intense scratching, resulting in the characteristic itch-scratch cycle.
• Symptoms include an intense, seemingly unstoppable urge to scratch. The skin becomes darker and leathery-looking when compared to surrounding healthy skin. There can be reddish brown to violet plaques.
• While the causes are not known, it can be due to a genetic predisposition, complication of eczema or psoriasis, allergic processes, environmental irritants or psychological or emotional stress.
• Diagnosed by dermatologists, this condition is managed by steroid creams, medicated moisturisers and sometimes medications (in severe cases).
• Behavioural therapy, including habit retraining is proven to be very effective in reducing the urges to scratch, thereby breaking the itch-scratch cycle.
• Habit reversal aims at tracking triggers, encouraging self-awareness, creating alternative behaviours to scratching and establishing routines that help improve quality of life and preserve the skin.
• Along with medical and behavioural treatment, ensuring a consistent sleep routine, balanced diet and exercise as well as being consistent with the habit reversal techniques, are key to managing this condition.