I'm Itching to Tell You About Itching
It is said, “chronic itch is the skin equivalent to pain.” Itching disrupts sleeps, limits your activities, diminishes your concentration, and generally is quite maddening. We will scratch, claw, and tear our skin up to satisfy that annoying itch sensation. It is poorly understood by modern medicine but the burden on patients is very real and taxing to even the most stoic of individuals. A psychological component complicates its definition and study, as just thinking about itchy things can cause you to itch. We humans are also subject to what I call “copycat itch” or “contagious itch”. If you see someone scratching, you might start itching and scratching yourself just by watching. Yawning can be a similar copycat phenomenon. The visual stimuli of either is often enough to generate the sensation in you. Studies show that individuals with chronic itching have a poor quality of life index when measured against cancer and heart failure patients. I am often told “Doc, I'd rather be in pain than itch”. After a recent episode of poison oak I suffered, I empathize with this statement much more closely. Itch and pain are common sensations in the human body. The mechanisms of chronic pain have received careful study and billions of dollars from pharmaceutical companies and the National Institutes of Health over the last decades. Chronic itch, in comparison has received a fraction of that. It's the forgotten symptom. After ruling out a nightmarishly long list of potential causes for itching, most patients end up with conventional treatments that have changed little over the last thirty years. Antihistamines, calamine lotions, topical cortisones, and oatmeal baths are the main treatments. Camphor is an old dermatologic standby. Camphor is quite a useful compound. It can serve as an air freshener, moth repellant, cooking ingredient, embalming fluid (don't ingest), and even a temporary treatment for itchy skin. It is derived from the wood of the camphor laurel, usually found in Borneo or Taiwan. Some other plants contain camphor, such as rosemary leaves and various mints. Camphor is absorbed through the pores and gives a cooling sensation similar to menthol. Sometimes I'll have more distressed patients use products formulated for sore muscles instead of itch. These contain usually 5-10% menthol and some topical aspirin. If kept in the refrigerator between uses they offer great relief and can be used as often as needed. The use of menthol for skin irritation goes back thousands of years in ancient China and is very safe. I also have patients purchase topical numbing creams that available without a prescription. Benzocaine and lidocaine are readily available in many forms from hemorrhoid creams to sunburn treatments and can be used to deaden the more problematic areas as needed. For absurd reasons, the FDA will not allow many of these effective products to be marketed as “itch relief” products. I reviewed the FDA regulations on this and was frustrated to learn that it has not been updated since 1983 in any real fashion. Skin treatments have come a long way since parachute pants and Tang. Thus patients wander around the drugstore buying the same old stuff decade after decade due to antiquated federal regulations. Sometimes doctors utilize medications “off-label” like antidepressants and antipsychotic medications with varying degrees of success. Low doses of seizure medications can be particularly useful in dampening the nerve pathways on unexplainable itching. Ask your doctor about any unconventional treatments they are comfortable prescribing. One common problem I encounter in my older patients is itching of the back. Many times this is caused from a variety of harmless growths that itch or rub on bra straps. Sometimes a skin cancer is the culprit. Often there is nothing for me to appreciate but some dry skin and scratch marks. These latter patients are likely over washing their skin. We learn our bathing and washing habits at a young age. We are taught to scrub, suds up, and get behind the ears. Young adults love soaking in hot baths and taking long showers (if you have a teenager, I'm sure you agree). These bathing habits become ingrained in us. As we age, our daily activities change but our bathing habits do not. Skin that could once tolerate daily washing loses its ability to retain moisture and starts to thin considerably. The once sweaty and soiled lumberjack who is now retired is probably still washing himself like he did thirty years ago. And the busy housewife of yesterday, who maybe does a little gardening today, still scrubs her skin the way she has since childhood. I tell my older patients with dry skin to take a “sailor's bath”—use a gentle soap on the genitals, buttocks, and armpits and just let some warm water run over everything else. After giving me a sacrilegious look or thinking I am some sort of “hippy” doctor, some agree to try it. Most get better. There is no need to scrub your arms, back, and legs daily if you don't get dirty or sweaty. It robs the skin of its natural protective lipids and oils and allows for more water loss. The drier it gets, the itchier it gets. If you are practicing good skincare but still suffer from chronic itch, you need a checkup. The range of diseases that cause itching is endless. Parasites, liver failure, kidney failure, lymphoma, diabetes are just a few of the more concerning entities. Skin allergies to detergents, plants, perfumes luckily are much more common. Taking morphine, vicodin, or some other strong painkiller? Itching can be expected. If the cause is not readily apparent consider that your body is trying to tell you something and see your doctor. Itching is not always a skin-deep issue. Sometimes we will see people who probably had a real cause to itch at some point in the past. For some reason, long after they should have gotten better, they still itch. Enter the “Itch-scratch-cycle”: Scratching begets itching at some point; and itching spawns more scratching. So on and so on ad infinitum. If you dig at your skin long enough, somehow you reprogram the nerves to actually generate an itch signal. Thus, you keep itching even though whatever the initial cause was is long gone. This type of chronic itching can often develop a gratifying hedonistic element to it even while it is driving you crazy. One of the most fascinating and saddening problems in dermatology is when people suffer delusions of skin infestations. A variant of this is the delusion that fibers or threads are being extruded through the skin. People will begin to perceive any bump, lint, or particle on their skin as abnormal. They compulsively gather “evidence” and bring it into the office in Ziploc bags for examination. Microscopic examination usually reveals normal particles all of us have on us. This explanation is nearly always met with “well I guess I didn't collect the right stuff” or passionate anger that I did not confirm their belief. It is not unusual for these patients to have visited multiple physicians and told the same thing over and over. Usually they scoff at entertaining the notion of seeking mental health assistance. While most of these patients just pick themselves silly, others claw at their skin with pocketknives and dinner forks. This leaves permanent scars and disfigurement behind. For unknown reasons, women suffer from this much more than men do. Often times these people are very high functioning individuals with no prior mental health issues. Sometimes they are methamphetamine users. Regardless of the circumstances it is difficult to watch other human beings mutilate themselves and suffer needlessly. Since itching is quite poorly understood, some of my most perplexing and challenging patients are my “itch patients”. I affectionately call them this because modern medicine has failed to identify what plagues them. When the proverbial “million dollar workup” and conventional treatments have failed, they often are labeled “crazy” or “neurotic” by the medical establishment. (much easier to blame the patient than our own shortcomings as doctors right?) Perhaps many patients will eventually turn out to have a mild form of mental illness or be methamphetamine users? Based on my experience, I think most chronic itchers will eventually be classified within a whole spectrum of syndromes that are currently not elucidated or understood. After all, women experiencing premenopausal dysphoria (aka PMS) were once considered “hysterical” and institutionalized. Perhaps soon the treatment of itch will emerge from the Stone Age. Until then, hang in there.
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