Dealing with chronic itch holistically
Would you rather suffer pain than itch?
There is no local study but it is estimated that chronic itch affects about 10 to 15 out of every 100 people in Singapore. There are overseas reports of people with chronic itch (or pruritus), who have scratched all the way to their bones, creating deep ulcers. If untreated, this could lead to infection and even death, quoting Dr Tey Hong Liang, a consultant dermatologist in charge of the itch clinic at the NSC. He added that people have only begun, in the last 10 years, to understand that, like chronic pain, chronic itch is not just a symptom of a problem, but a problem in itself.
The clinic, which is open every Friday afternoon, does not accept walk-ins. Patients are usually referred by dermatologists at the NSC. The number of patients seen is capped at nine so that doctors can spend more time on each patient. Some patients were itching badly from skin diseases, such as eczema or psoriasis, but their itch was out of proportion to the severity of their skin conditions. About six out of every 10 patients however, were itching from an unidentifiable cause. Many have scratched at their itch until lesions, such as red hardened bumps, appeared all over their bodies.
What the causes are
While skin diseases are the most common cause of chronic itch seen at the itch clinic, Dr Tey said there are other causes too. These include diseases such as cancer, kidney problems and psychological problems such as depression and anxiety. What is more uncommon is itch caused by problems with the nervous system, such as stroke, he said. At the itch clinic, blood and imaging tests are done to rule out causes due to diseases and neurological problems. The dermatologist will also try to find out if psychological issues play an important role.
For instance, a 10-year-old girl with mild ezcema was seen at the clinic. Her parents said she had been waking up every night for the last few months, complaining of severe itch. It turned out that her daily schedule, which included extra-curricular activities, had taken a toll on her. The stress had amplified her itch and made her wake up at night. The doctor and nurse at the clinic discussed ways with her parents to cut down on her activities. She soon stopped waking up at night complaining of severe itch. When more serious emotional problems are involved, referrals will be made to a psychiatrist or psychologist.
For instance, a 60-year-old woman was referred to a psychiatrist for severe depression. She had complained of severe itching around her private parts, which disturbed her sleep at night. It became apparent upon further questioning that she was depressed over her husband’s affair with a prostitute. The woman, who only wanted to be known as Mrs Tan, was given a cream with anti-itch and anti-inflammatory properties. She told Mind Your Body that her itch is now 80 per cent better.
Medications play an important role in helping patients with chronic itch, said Dr Tey. While paracetemol can be used to treat all kinds of pain, there is no similar effective medicine for itch. For years, antihistamines have been used to relieve itch for patients. It may work for the itch caused by insect bites, which work along a pathway that involves histamine, a chemical in the skin. But it may not be useful for most cases of chronic itch.
Research over the last 10 years has shown that a pathway which involves another chemical in the skin, protease, may be more important in chronic itch. New medications which work along this new pathway are being developed. In the meantime, dermatologists sub-specialising in itch, such as Dr Tey, are using existing medicines used for other purposes but which also have an effect on this new pathway. For instance, a medication used to treat neurological pain was found to help Mr Lee Pak Kow. He had chronic itch as a result of progressive kidney disease and had scratched until red rashes appeared all over his body. The 65-year-old said: “After taking the medicine, about 80 to 90 per cent of the rashes are gone.”
Why we feel itchy
The sensation of itchiness usually comes about when the nerves on the skin are stimulated by, for instance, an insect bite or a skin condition such as eczema. When this occurs, a signal is sent through the itch pathways via the spinal cord to the brain. The signal tells the brain, “itchy” and the person feels itchiness. Toxins produced in the body due to cancer, poorly functioning kidneys or liver problems can also stimulate the nerves in the skin and cause itchiness.
Also, anything that stimulates the nerves along the itch pathways, such as a stroke, depression and anxiety, can also trigger it. Once someone experiences itchiness, his brain will send another signal to the muscles in his fingers to prompt him to scratch. But scratching causes injury to the skin and releases inflammatory substances which make a person want to scratch more. This creates a vicious itch-scratch circle which can lead to infection, pigmentation and the thickening and scarring of the skin. There are ways to break the circle.
Here are some tips from the Itch Clinic’s patient education pamphlet:
- Recognise and avoid itch triggers
- Bathe in cool water instead of warm water
- Use mild and low pH cleansers
- Wear loose cotton clothing (to better absorb sweat)
- Maintain a cool environment
- Keep fingernails short
- Avoid scratching on skin directly with your nails: use a soft sponge or pat the itchy area, or gently scratch the surrounding of the itchy area
- Keep moisturisers in the refrigerator – the cold sensation can help to reduce itch