Chronic itch, also known as pruritus, can be extremely uncomfortable and affects people’s lives in many ways. Poor sleep, problems concentrating, lowered sex drives and depression can all be attributed to the debilitating effects of chronic itch. Treating chronic itch can be very problematic, and in many cases involves trying a variety of methods, searching for the right treatment option to provide some level of relief to the suffering patient.
There are four major types of itch: itch that originates from the skin; chemically-induced itch, itch related to damaged nerve fibers or internal diseases such as chronic renal failure or liver disease; and itch based on psychiatric reasons. Each of these types of itch requires a distinct treatment regimen. Itch related to dry skin, for example, is best treated with topical treatments containing emollients. People with itch based on psychiatric reasons should expect an oral treatment for itch, combined with antipsychotic medications.
A major concern physicians have with the treatment of chronic itch is the effect of constant scratching on the concerned area. Scratching an itchy area leads to increased inflammation, which causes further itching and scratching. A good treatment regimen will take this cycle, known as the itch-scratch cycle, into consideration and will aim to interrupt it while treating the concerned area.
Topical therapy refers to any medications that are directly applied to the skin. The medications can come in many different forms. The most common are creams, lotions, ointments, lotions, and gels. The choice often depends on the location and patient preferences.
Topical Creams are semisolid emulsions of oil usually designed to absorb into the skin. They are often water based, white, and non-greasy. They should be stored in cool places and the containers should be tightly closed to prevent evaporation.
Topical Ointments are emulsions of water droplets suspended in oil that do not absorb. They are oil based and appear greasy and clear. Although messy, they provide an occlusive dressing and allow for maximum penetration of the medicine.
Topical Lotions are suspensions of powder in water. They may require shaking before application. After the lotion is applied, the water evaporates and leaves a fine powder on the skin. Immediate itch relief occurs as the water evaporates and the skin cools.
Topical Gels are semisolid emulsions, clear, and often sticky. Some gels are alcohol based and may cause dryness.
Emollients are a type of topical treatment typically used as the first line of therapy for patients with chronic itch. Many cases of chronic itch cause a breakdown of the barrier function of the skin, and emollients help restore this function. Emollients contain substances, such as lipids, that seal in moisture and allow the skin to restore itself; it is typically suggested that patients apply emollients immediately after bathing.
Low pH cleansers and moisturizers also assist in restoring the barrier function of the skin by maintaining the acidic pH of the skin’s surface and reducing the irritative effects of itching.
Cooling agents can also assist in relieving the effects of chronic itch. These over-the-counter treatments contain substances like menthol, camphor, or phenol, which provide cold therapy, a treatment method that can minimize the itch sensation.
Topical corticosteroids: The most common topical treatments involve topical corticosteroids. These anti-inflammatory agents come in different strengths. As you move up in strength, there is greater chance the agent will work, but there is also a greater risk of side effects. These side effects include atrophy of the skin, which may lead to skin fragility, easy bruising, and stretch marks. Other side effects include acne, folliculitis, rosacea, reduced wound healing, excess hair growth, and allergic reactions. For a complete list of side effects, make sure to read the pharmacy pamphlet.
Topical anesthetics, such as pramoxine and EMLA cream affect both pain and itch receptors. In many cases, these anesthetics are combined with cooling agents to amplify their efficacy.
Topical antihistamines are thought to block histamine release and decrease itch. Their use, however, is limited by the high number of allergic reactions.
Bathing agents such as rice bran broth, hot water for psoriasis, miscible bath oils or vegetable oils, colloidal oatmeal baths, tar baths and sodium bicarb baths can also assist in soothing the sensation of itch.
Suggestions for reducing the sensation of itch
- Take shorter showers/baths and bathe in cool or lukewarm water, instead of hot water
- Use mild and/or low pH cleansers and moisturizers. Try not to use any cleansers that contain alcohol. Apply these moisturizers immediately after you take a bath. This will help your skin keep the moisture from evaporating.
- Use a humidifier.
- Avoid wearing wool or tight clothing.
- Keep your home cool.
- Try not to eat spicy foods.
- Minimize your alcohol intake.
It’s a Wrap: The Use of Wet Pajamas in Wet-Wrap Dressings for Atopic Dermatitis
Atopic dermatitis (eczema) is a skin disease of chronic inflammation exacerbated by acute flares that commonly affects infants, children, and adults. Therapies generally include emollients, topical corticosteroids, topical immunomodulators, and systemic immunomodulators, along with recognition and avoidance of aggravating factors. Wet-wrap treatments are an important and powerful tool in the management of severe atopic eczema, such as erythrodermic atopic dermatitis and acute flares of atopic dermatitis. We propose a method for outpatient treatment of adults and children with acute flares of atopic dermatitis using a low to moderate strength topical corticosteroid, and utilizing pajamas as the wet-wrap garment. The treatment should be done once daily for one week, and left in place for 12 hours each day. It may then be repeated once weekly, if needed. A short course of one week treatment has a significant effect in improving patients' itch, eczema, and overall well-being.
The following describes our use of wet-wraps for short-term outpatient treatment of moderate to severe atopic dermatitis.
- The patient should take a lukewarm bath using a mild, soap-free cleanser.
- A low or medium potency topical corticosteroid should be applied to all of the areas affected by atopic dermatitis, applying it in the direction of hair growth.
- A non-medicated emollient should then be applied to all of the skin.
- A warm wet layer is then applied over the treated skin. This is done most conveniently by moistening a pair of form fitting pajamas. The pajamas should be soaked in warm, clean water, and wrung out, so that they are not dripping, and worn such that there is contact between the moist garment and the treated skin.
- Over the wet pajamas, a dry pair of pajamas or other form fitting soft garment, preferably made of cotton, is worn.
- The wet layer of pajamas should be periodically re-moistened, most conveniently by using a spray bottle of clean, warm water. Ideally this would be performed every 2 hours.
- This is left in place for at least 12 hours.