Recognizing habitual scratching in atopic eczema

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author/source: DrB

As dermatologist Dr Jon Goulding explains in his review of The Eczema Solution in the British Journal of Dermatology,

"habitual scratching... plays a major role in exacerbating and perpetuating AD"

[AD = atopic dermatitis, also called both atopic eczema and atopic skin disease].

Although a number of other experts have written in the Journal of the American Academy of Dermatology "habitual scratching ... may be overdiagnosed in patients with AD"  [see a recent discussion in JAAD] the clinical recognition of habitual scratching, a common and important complication of having atopic eczema, is not difficult, but seems often overlooked by practitioners assessing atopic eczema for treatment. Unfortunately it is not mentioned either as a focus for treatment in clinical guidelines.

Habitual scratching leads to lichenification, the process resulting in rough, thickened skin that is dry and itchy, sensitive to acute flare-ups and resistant to conventional treatment. This chronic eczema responds well to The Combined Approach.

In clinical assessment the first step is to ensure the term "itching" is understood as a sensation, something that can only be felt, while the term "scratching" refers to an action, something that can be witnessed by others.

Then the key question to ask is "How much of your scratching comes from itch?".

When 50 consecutive patients with long-term atopic eczema where asked "What percentage of your scratching is due to itch?", the average response was 60%.

The next step is to ask about eczema flare-ups:

"Eczema comes and goes: when your eczema flares up, how long does this last? Is it days, weeks or months?"

Then ask

"When it settles down, how long is it to the next flare-up? Is it days weeks or months?"

Then ask

"Between flare-ups, is the skin in places still thick and roughened?" 

On examination finding areas of lichenification, often with excoriations, confirms the diagnosis.

The distribution of these areas is often characteristic*: on the head, look at the forehead, under the eyes, under the nose, at the angles of the mouth, and behind and under the ears. On the limbs, look at and feel especially the skin of the hands and wrists. The neck may often be affected. Elsewhere on the trunk of the body the skin may be spared by the usual protection of clothing, but areas may still be found, especially on the lower back and buttocks, and under the breasts. Favourite areas to scratch are sometimes the last to heal using The Combined Approach. 

*See VIDEO "An introduction to the clinical features of Atopic Eczema" Dr Richard Staughton, Consultant Dermatologist, London, UK

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Reference 

 Response to ‘‘Comment on: ‘When does atopic dermatitis warrant systemic therapy? Recommendations from an expert panel of the International Eczema Council’’’  J AM ACAD DERMATOL AUGUST 2018