Introduction

Dermatitis is a general term used for a variety of skin conditions characterised by skin inflammation and numerous symptoms, including itching (pruritus). Dermatologists have identified more than sixty types of dermatitis, with neurodermatitis being one of them.¹ Specifically, neurodermatitis, with its most common form Lichen simplex chronicus, is a chronic dermatological condition, where itching and inflammation are present at specific parts of the skin. Localised chronic itching is the initial symptom of this condition, which can eventually lead to scaly, thickened patches (plaques) due to extensive scratching. It is a common and bothersome condition, which can markedly affect the quality of life of individuals.²

Approximately 12% of the general population is estimated to be affected by neurodermatitis. The condition mainly occurs in people assigned female at birth compared to those assigned male at birth, with a 2:1 ratio, and is predominantly observed in individuals aged 30-50.² The underlying causes of neurodermatitis are primarily related to psychological factors, with stress and other emotional disturbances triggering repeated and cyclic intense scratching and itching, potentially leading to plaque formation and further discomfort. Additionally, neurodermatitis may appear as secondary to other dermatoses like psoriasis. Treatment typically targets healing the skin through occlusive treatments, topical therapies with pharmacological agents, or oral medications. Non-pharmacological management is also highly advised to address the psychological nature of neurodermatitis, particularly in patients unresponsive to initial treatment.³

Psychological interventions

Psychotherapeutic approaches have revealed beneficial results for neurodermatitis treatment. From cognitive behavioural therapy to stress management, patients can manage to cope with the psychosocial factors associated with the condition.

Cognitive behavioural therapy (CBT)

CBT has been proven effective in interrupting reflex scratching to the sensation of itch and diverting patients’ focus from pruritus. Therefore, this kind of therapy may alter the repetitive cycle involved in neurodermatitis and offer long-term behavioural changes, particularly by:⁴

• Stimuli control:

This technique is essential for managing automatic scratching behaviours and it initially involves guiding patients to realise what situation could trigger scratching. Then patients are advised to keep their hands busy on these occasions e.g. holding a rubber ball while watching TV or holding the steering wheel with both hands while driving. This technique aims to make scratching more difficult and limit the reward feeling associated with the repeated action. 

• Habit reversal training:

This other important technique involves three key steps: awareness and recognition of the scratching pattern, and feelings and behaviours before it occurs, like repeated warning signals; competing response training, mostly by crossing arms or squeezing fists, when the patient recognises a warning signal or realises that scratching has started; and social support from the patient’s close environment.

• Cognitive restructuring:

This technique is based on recognising and addressing the negative thoughts that usually precede scratching and changing recalcitrant emotions with the help of psychotherapy.

Stress management and relaxation techniques

Stress reduction techniques have demonstrated psychotherapeutic benefits in various skin disorders, including neurodermatitis. Aiming to teach patients how to reduce stress and improve their interaction with their condition, these interventions can have significant mental and physical effects. Common practices include:⁵

• Meditation:

A helpful adjuvant therapy to neurodermatitis and chronic pruritus. Patients following meditation courses have reported improvement in itching severity, sleep quality, overall quality of life, and better management of stress.

• Progressive muscle relaxation (PMR):

This method is used  to achieve mental and physical relaxation by contracting and relaxing specific muscles while focusing on this particular task. PMR can reduce pruritus and sleep loss and improve the psychological parameters of patients.

• Music therapy:

U-sequence music therapy is another relaxing technique that has been tested for its effects on chronic pruritus. Patients undergoing this therapy with individualised music following the U pattern have shown a significant reduction in itching intensity.

• Massage therapy:

A massage routine from a professional therapist or an instructed caregiver can have positive results in dermal lesions, improving redness, lichenification, scaling, excoriation, and pruritus.

• Hypnotherapy:

Hypnotherapy may have some benefits for various skin conditions like eczema and atopic dermatitis. With this method, patients can change their perception of sensations, i.e. convince themselves that their skin is cool and comfortable. Only a little evidence supports the effectiveness of this method, which is usually combined with other treatments like biofeedback and relaxation techniques.

Physical interventions

Part of the typical intervention for neurodermatitis is the utilisation of occlusive dressings. By placing a plastic film or hydrocolloid dressings in the area, a physical barrier is created, which prevents scratching. This approach, which is usually accompanied by pharmacological treatment, can improve the skin barrier damage, and reduce itching, while also facilitating topical cream absorption.²

Specifically treated garments may also play a significant role in numerous skin disorders and chronic itching. Bioactive textiles, which include garments that have been treated with specific materials and show antimicrobial and anti-inflammatory properties, could potentially be broadly useful in relieving pruritus. Seaweed-silver garments, zinc-oxide-treated clothing, tourmaline-infused textiles, and other treated silk garments, such as DermaSilk^®, have been tested for their antipruritic effects, and have caused significant reductions in the severity of itching.⁶

Light and surgical therapies

Phototherapy

Ultraviolet (UV) A and B therapy has been suggested as a potential treatment option for severe cases of neurodermatitis and other chronic pruritus conditions.³ Combination therapy with UVA and narrowband UVB, or UVB monotherapy primarily acts by modifying inflammation on the site, potentially attenuating pruritus. UVA is typically used along with a photosensitising agent, psoralen, but carries a higher risk of developing skin cancer like melanoma and squamous cell carcinoma. Narrowband UVB therapy, on the other hand, has demonstrated a lower risk for carcinogenesis. Overall, appropriate counselling on risks and costs is pivotal when choosing this kind of therapy.⁶

Surgical intervention

In specific cases of long-lasting neurodermatitis, where all other treatment options have failed, surgery, specifically cryosurgery, or other surgical excision techniques may be used for small lesions.³

Electrical and soundwave therapies

Electrical nerve stimulation

Transcutaneous electrical nerve stimulation (TENS) therapy is another method used particularly in patients with neurodermatitis who are not responsive to pharmaceutical interventions. It involves the utilisation of pulsed electrical current applied onto the skin through cutaneous patches, which can alter the neuronal transmission of specific nerve fibres and limit pruritus. In fact, in a study with 22 patients with neurodermatitis, a reduction in itching was seen in 50%-80% of patients. Despite its low cost and possible effectiveness, TENS is not the treatment of choice for chronic pruritus and is also associated with some contraindications; it should not be used for diffuse itch, for areas around the eyes or in front of the neck, in pregnant individuals, and in people with seizure disorders or pacemakers.^2,6

Focused ultrasound

High-intensity focused ultrasound (HIFU) is used to treat neurodermatitis, specifically in the vulva region. It is a non-invasive method, using directed ultrasonic beams that increase the temperature at specific sites and cause cell death and restoration of normal tissue. While this method shows promising results in vulvar neurodermatitis management, the incidence of recurrence and burns is possible and thus treatment should follow careful measures. Low-powered HIFU has also been recommended as an alternative, demonstrating similar results and fewer incidences of burns.⁷

Alternative medicine

Another approach to neurodermatitis treatment, after the first-line pharmacological therapy and adjuvant therapies mentioned above, is the use of herbal remedies and Ayurvedic treatment. These methods, although necessitating further research to validate their efficacy, may include natural components, which are known for their antimicrobial, anti-inflammatory, and anti-pruritic properties and can potentially aid in chronic pruritus alleviation in various dermatological conditions. For instance, Chinese herbal medicine, with herbs such as Saposhnikovia divaricata, Glycyrrhiza glabra (licorice), Sophora flavescens, has been found efficacious in reducing itching and limiting recurrence, either when used alone or in combination with Western medicine. Furthermore, various herbal remedies from Ayurvedic medicine like Kriminashaka Vidanga, Khadira, and Haridra (turmeric), which focus on the management of doshas, may be promising for neurodermatitis management, according to limited case studies.^8,9

Ultimately, acupuncture is also a propitious supplementary treatment for neurodermatitis, although further studies are needed to strengthen this notion. Specifically, acupuncture may offer various advantages like itching relief, skin repair, and stress alleviation thereby improving symptoms of neurodermatitis,  reducing the rate of recurrence and improving the rate of treatment.¹⁰

Summary

Neurodermatitis is a chronic skin condition associated with localised itching and inflammation. The extensive scratching of these areas can lead to thickened, scaly plaques that further exacerbate the clinical image. Various aetiologies have been identified for inducing the itch-scratch cycles of neurodermatitis and mostly involve psychological factors, and in some cases, other underlying dermatological conditions. Diagnosis of the exact causes of this skin problem is essential for following the appropriate treatment method.

While the first line of treatment for neurodermatitis relies predominately on pharmacological agents and topical creams, numerous supplementary non-pharmacological methods have been suggested and analysed for their potential beneficial properties. Specifically, addressing psychological factors, like stress, with CBT, and relaxation techniques, can lead to improvement and itching reduction. Additionally, practical methods such as occlusive dressings, light and surgical interventions, and electrical and ultrasound therapies have shown promising results in specific cases of neurodermatitis. Finally, alternative treatment with the use of herbal remedies, and acupuncture may be beneficial. 

Not all of these methods have been experimentally proven to help with neurodermatitis and may require further investigation. However, addressing the emotional aspects of the condition following certain approaches can be significantly helpful to some individuals, specifically when done with the guidance of a medical professional.