Introduction

Neurodermatitis is a common inflammatory and allergic skin disease characterised by a repeated itch-scratch cycle. Its common form is also known as Lichen simplex chronicus (LSC) and results in thickened skin areas due to repeated rubbing or scratching.¹ The scalp, neck, ankles, genital region and extremities are the common regions affected by it. 

The association of neurodermatitis with dryness, scaling, or erythema is, same as many other dermatologic conditions, which sometimes makes diagnosis difficult. Emotional or psychological disturbances such as anxiety or depression, compulsive habits, venereophobia and dissociative experiences are reported to contribute to the disease.² Studies report that patients with neurodermatitis have an association with sleep disturbance, psychosocial burden, worse social relationships, poor flexibility, sexual dysfunction and low quality of life.³

Medications like antihistamines, corticosteroids, antiepileptics, immunomodulators and antidepressants are recommended by clinicians to control the condition.⁴ All of these may alleviate the symptom for a while, but provide considerable side effects like burning, dryness, erythema and hyperpigmentation. The treatment for neurodermatitis targets to control itching, prevent scratching and address underlying causes. 

However, even with successful treatment, the condition often returns and leading to the management of neurodermatitis is tough and challenging. Therefore, side effects of conventional medications have directed dermatologists as well as patients to seek other effective measures or treatments for neurodermatitis which will be discussed here and will help in alleviating the condition.

Natural therapies

Natural therapy is a combination of methods to treat the physical and mental well-being of a patient. It includes herbal remedies based on traditional Chinese herbal medicine, a balanced diet with nutrition and the application of essential oils or natural moisturisers to hydrate and moisturise the skin to prevent itchiness and scratching which is mentioned here. 

Herbal remedies

Traditional Chinese herbal medicine (CHM) can be administered orally, topical (on the skin), or in injectable forms. In this, part of a plant is used for the treatment such as roots, stems, bark, leaves, seeds or flowers. The standard practice of CHM uses a combination of many herbs in different compositions for a patient based on individual conditions. 

Chinese herbal tea provided anti-eczematous benefits in European patients including children and adults for short-term treatment. The herbal decoction was a combination of various plant extracts and significant improvement was reported in the parameters including itch, improved sleep, and a decrease in erythema of around 90% of the treated group.⁵

Many plants are used in natural therapies due to their medicinal properties which include:

• Arnica: It contains an active ingredient known for its anti-inflammatory effect
• Calendula: Components like carotenes, flavonoids, and triterpene alcohol present in it provide anti-inflammatory and antimicrobial effects
• German chamomile: The wound healing, antimicrobial and anti-inflammatory effects of German chamomile are attributed to inhibiting histamine release thus relieving itchiness
• Tea tree oil: It has fungicidal and bactericidal effects
• Lavender oil: This provides calming and soothing effects on the skin
• Peppermint oil: It has a cooling sensation and itch relief

In contrast, hypersensitivity reactions, nephrotoxicity, agranulocytosis, and problems related to heart muscles and lungs (respiratory distress syndrome) were noted in a few groups after ingesting Chinese tea. Herbal therapy seems an efficient treatment in some patients but poses a risk of toxicity as a side effect. Therefore, close monitoring of kidney and liver-related parameters is required before, during, and after therapy.

Diet and nutrition

The exacerbation (increase in severity) of itching or irritation caused by food allergens is now probable enough. In many clinical departments food allergen testing procedures have been incorporated for oral provocation testing and dietary consulting. However, it is essential to critically interpret allergy tests by experienced physicians. If it is not, the elimination of several foods, based only on positive allergy tests, often remains ineffective and harmful. 

A balanced diet should be adopted without bearing medical and diet risks like deficiency of vitamins, minerals or malnutrition and weight loss must be taken into account. An anti-inflammatory diet consisting of foods rich in omega-3 fatty acids, antioxidants and probiotics to support gut health and immune function has to be considered. In addition to this, a prescribed diet should not be a risk for the patient linked to psychological and social well-being. It may decrease the quality of life and may worsen neurodermatitis as a trigger factor, incorporating additional stress. However, till now there is no generally favoured type of diet for patients with neurodermatitis.

Hydration and moisturising

Baths or soaks called balneotherapy is one of the parts of natural therapy involving immersing the skin in a mixture containing a variety of substances. This is used to wash away old medications and remove crusts or scales to alleviate itching and inflammation. They are helpful for various disorders involving large skin areas, by moisturising skin or relieving dryness, reducing inflammation and itchiness of the skin.⁶ Natural moisturisers including coconut oil or shea butter and other natural emollients like aloe vera gel or oatmeal baths are used. They can be useful to reduce the severity of the disease when incorporated with conventional topical antimicrobial treatment.

Natural therapies with conventional treatment plans provide promising results by minimising the post-treatment side effects of medicinal care. The assumption that restrictive diets and herbal remedies are harmless, requires more research studies. The allergic reaction toward a food allergen is enough to reduce the quality of life and the allergens are easy to avoid. Alternative therapies like acupuncture, aromatherapy, homoeopathy and mind-body techniques can be potential measures to cure neurodermatitis are described ahead.

Alternative therapies

In the conventional treatment of neurodermatitis, if the condition worsens, nontraditional treatments are used such as the application of a solution to the itchy area containing aspirin and dichloromethane, an injection of botulinum toxin (Botox®), phototherapy, or light therapy (can not be used on genitals). Traditional surgery is also performed to remove the itchy area or cryosurgery to destroy unwanted tissues. These methods do not apply to every patient with neurodermatitis, so some alternative therapies are now used in combination with traditional treatments which are mentioned here.

Acupuncture

Acupuncture is a part of traditional Chinese medicine that has been used to treat dermatologic disorders and a wide range of other medical conditions. It reduces stress, inflammation, and promotes overall skin health. In a study, acupuncture showed statistically significant improvements in 17 of 24 patients with neurodermatitis in comparison with placebo acupuncture, alternative treatment options, and no intervention.⁷

Cupping therapy (CT) in acupuncture is one of the most effective and considerable methods in the history of China and Egypt. CT is reported to relieve the symptoms and relapse of neurodermatitis for a long time and provided satisfactory results in migraine headaches, psoriasis and others also.¹

Mind-body techniques

Mindfulness-based cognitive hypnotherapy is a form of hypnotherapy useful to improve mental, physical, emotional or spiritual aspects through immunologic mechanisms affecting skin disorders and it incorporates cognitive-behavioural therapy and mindfulness.⁸

Therapy such as focused meditation, hypnosis, cognitive hypnotherapy, and mindfulness meditation are considered for improving various skin disorders including acne, alopecia areata, atopic dermatitis, herpes simplex, neurodermatitis, nummular dermatitis, psoriasis etc.⁴ Yoga helps to detox the body, promotes relaxation and skin rejuvenation and exhibited reduced inflammatory response.⁹

Homeopathy

In Western industrialised countries, the predominance of allergic disorders has steadily increased in the last three decades. The short-term effects of medicines on allergic problems have directed patients to clinicians for complementary treatment methods like homoeopathy. In homoeopathy, diluted substances are used to trigger the natural healing response of the body. For the treatment of neurodermatitis hydrocotyle, thuja, graphite and sulphur are commonly used.¹⁰

In a study was conducted on 44 patients undergoing conventional medication therapy. Here, 21 patients have discontinued at least one medication, and the remaining 38% of patients have reported a reduction in dose of at least one medication without any side effects during the treatment.11 In the patients undergoing homoeopathic treatment, symptoms have improved substantially, and the use of conventional medication dose can be reduced. The effects indicate the potential for improving therapeutic measures to reduce healthcare costs.

Aromatherapy

Skin conditions such as eczema, psoriasis and dermatitis like neurodermatitis, are generally treated by conventional therapy using medicines. But their short-term and undesirable effects including dryness, skin thinning and erythema have caused poor patient compliance. Therefore, patients seek complementary treatment with herbal plant-based products like essential oils (EOs). 

Tea tree (Melaleuca alternifolia) oil has been the most studied EO and other EO are eucalyptus (Eucalyptus globulus) oil, ajwain (Trachyspermum ammi) oil and cedarwood (Cedrus libani) oil. Frankincense (Boswellia spp.) oil and kānuka (Kunzea ericoides) oil have positive effects in the treatment of psoriasis and eczema. These are also used for acne treatment with fewer adverse impacts compared to conventional treatments but for conclusive evidence, further research is required.¹²

The treatment of neurodermatitis involves not only various conventional, natural and alternative therapies but also measures to prevent it for a long time by modifying lifestyle which are discussed ahead.

Lifestyle modifications

Neurodermatitis, which requires a unique treatment plan for each patient recommended by a dermatologist, does not heal without treatment. The main concern here is to obstruct the itch-scratch cycle. Despite the medical treatment and other therapeutic methods, self-care measures help to manage neurodermatitis such as:

• Use cool, wet clothes: They may soothe the skin and provide relief from itch. A cool and wet cloth can be put on the affected skin area for a few minutes before the application of medicated cream, it will help the cream soak into the skin
• Apply cooling lotions: Use calamine lotion or a lotion containing camphor or menthol.
• Cover the affected area: Bandages or dressings can be used to protect the skin and thus prevent scratching particularly during sleep
• Keep your nails trimmed: Short nails may prevent damage to the skin, especially scratching while asleep
• Have short, warm baths and moisturise your skin. Prepare your bath with warm water, and use mild soaps with less dyes or fragrance-free. After each wash, pat your skin dry and use a moisturiser with more plant-based ingredients
• Avoid triggers: Recognise what brings on a recurrence and abstain from it. For instance, if a stressful situation triggers itching, then try to learn stress management techniques such as mindfulness, meditation, and deep breathing exercises
• Healthy sleep practice and physical activity: Improve sleep hygiene with a regular sleep schedule and restful environment. Introduce physical exercise to the daily schedule to promote overall health and also to reduce stress

The management of neurodermatitis becomes difficult due to a poor understanding of the responsible factors of the condition.⁵ The lack of studies based on patients with neurodermatitis presents few targeted therapies and the lack of evidence-based guidelines or summaries for guided treatment increases the difficulty in its treatment. This article suggests possible natural and alternative therapies with lifestyle measures that can be adopted to treat and prevent neurodermatitis.

Summary

The itch-scratch cycle associated with Neurodermatitis leads to itchy, dry, scaly skin patches on the affected area. It results in the recurrence of the skin condition and causes difficulty in treating neurodermatitis for a long time. Neurodermatitis does not heal by itself and triggering factors like emotional stress or mental imbalance, poor hygiene and food allergens may worsen the condition. This impacts sleep quality, daily activities, mental peace, sexual function and quality of life adversely. Therefore, it needs to be treated with the help of clinicians or dermatologists for individual care plans for patients. 

Medicines are useful to treat it for a short period, but they require other therapy methods and lifestyle modification plans to manage it. Natural therapies such as herbal remedies using plant extracts, diet and nutrition including anti-inflammatory, probiotics, antioxidant-richantioxidant rich foods and avoiding food allergens yielded promising results. Acupuncture, mind-body techniques, aromatherapy or homoeopathy as alternative therapies have the potential to treat neurodermatitis and other skin conditions with more research evidence.