The itch-scratch cycle is an important factor that drives eczema flare-ups. The process is surprisingly complex and is strengthened over several years. In this blog, we'll uncover the 4 stages of the itch-scratch cycle, how to reliably break the process and other tips you can use to tackle the cycle.

The Eczema Itch

As individuals with eczema, we’re more likely to be caught up in intense itchy periods. Over many years, we become accustomed to the process and sometimes even forget that we’re scratching! But sadly, this itching can do a lot more underlying damage.

A group of researchers wanted to explore these effects. They did this by using a scratching tool on a group of patients with ‘normal’ skin, i.e. without eczema. Over several weeks, they consistently used the device on these participants and looked at their skin under a microscope. The results were staggering because their skin looked exactly like eczematous skin. 🤯

That’s right, even those without eczema end up with eczema-appearing skin if they scratch. So it turns out that scratching actually causes a lot of damage.

And it’s all do to with the itch-scratch cycle…

The Eczema Itch-Scratch Cycle

The itch-scratch cycle is a self-perpetuating process that begins, quite simply, with an itch. This might be caused by a variety of triggers, such as dry skin, irritants, or allergens. In response, you scratch the itch, which provides temporary relief. However, scratching can damage your skin’s protective barrier, making it easier for irritants to penetrate and cause inflammation.

The body reacts to this inflammation by releasing more histamines, substances that cause itching. Thus, you feel the urge to scratch even more, leading to further inflammation and itching, perpetuating the cycle. Furthermore, chronic scratching can lead to skin thickening (lichenification), which results in even itchier skin. This cycle can significantly impact quality of life, often leading to poor sleep and psychological distress.

The Stages Of The Itch-Scratch Cycle

There are 4 steps involved in the Itch-Scratch cycle:

Step 1: Dry Skin - Normally, our skin acts as a shield to keep out harmful substances and keep in essential moisture. However, in eczema, certain proteins (like filaggrin) that help maintain this barrier are compromised, leading to moisture loss and dry skin. This process causes skin damage which signals to the brain that our skin is in pain. For eczema sufferers, this 'pain' is actually interpreted as an itching sensation that makes us want to scratch. Dry skin is one of the most common symptoms of eczema, which results from a defective skin barrier.

Step 2: Itch - from a biological perspective, itching or 'pruritus' is a complex sensation. The itch is not just skin deep; it's a complex interplay of immune responses and nerve signalling. When the skin is dry and damaged, inflammatory cells (like T-cells) release proteins that can trigger nerve fibres, leading to an itchy sensation.

Step 3: Scratching - because our brain sends us signals that we’re itchy, we end up scratching. Scratching temporarily interrupts these 'itchy' brain signals. However, it also causes skin damage, which leads to the release of pro-inflammatory cytokines like interleukin-31 (IL-31). These cytokines intensify the itch sensation and promote inflammation, leading to an escalation of the itch-scratch cycle.

Step 4: Eczema - This skin damage and the inflammatory chemicals lead to worsening eczema. In turn, our skin becomes even drier, and the process continues.

Notice how this process can become an infinite loop. Over time, this causes what is known as chronic eczema. This is the pigmentation of the skin resulting from constant scratching and can be challenging to overcome. Fortunately, there are evidence-based techniques to break and reverse these skin changes.

Breaking The Eczema Itch-Scratch Cycle

This process requires a coordinated strategy to tackle. Simply using emollients alone won’t tackle the process. Nor will forcing yourself to stop scratching because the evidence suggests that we even itch during our sleep. Instead, it’s essential to appreciate and tackle all four stages and use them together:

Stage 1 - Tackling Dryness

This involves applying emollients to act as a second skin. By reducing dryness, we’re preventing skin damage and helping to dampen the itch sensation. Other techniques that have been shown to tackle this process is wet-wrapping/slugging. Take a look at this guide for more information on the process.

Some products that can help with the dryness associated with the itch-scratch cycle include:

• Aveeno Eczema Therapy Cream

• CeraVe Moisturizing Cream

• Cetaphil Moisturizing Cream

• Eucerin Eczema Relief Cream

• Vanicream Moisturizing Cream

• Aquaphor Healing Ointment

• La Roche-Posay Lipikar AP+M Lotion

Stage 2 - Reducing Itching

Building Awareness

One of the most important parts of the process is to become aware of your itching habits. WIthout knowing when you're feeling itchy/scratching, it's impossible to break the process. As part of the Proton Health Itch-Scratch programme, we'll introduce you to the Scratchometer. This is a novel tool that helps you track your itching and scratching habits to build this awareness.

Skincare Products

Eczema flare-ups can also leave our skin vulnerable to which can cause infections and heighten the itch response. By using steroids, skin damage is reduced, and the urge to itch is considerably less. Alternatives that you can use include Niacinamide which is the natural compound Vitamin B3. This is a non-steroidal therapy that has been shown to have anti-redness, anti-inflammatory and anti-itching effects.

Other Tips

Over-the-counter antihistamines can also help manage itching, particularly at night. If you're struggling with night time itching, our partners at Eczema Clothing can help. They've created tailored garments that are designed to help prevent and reduce the damage of nighttime scratching. Applying a cool compress can also provide relief. For more severe itching, a healthcare professional might prescribe medications that specifically target immune proteins causing the itch.

• Collidal Oatmeal products

• Menthol cream

• Eczema Relief Cream

Avoiding Itching Triggers

It's important to be aware of the following triggers which have been shown to induce itching. Avoiding these can go a long way to reducing the sensation.

1. Fabrics: Wool and synthetic materials can cause irritation and increase itching. Opting for soft, breathable fabrics like cotton can help reduce this.

2. Laundry Products: Some individuals may find their skin reacts to certain laundry detergents or fabric softeners. Using hypoallergenic laundry products can be a beneficial step.

3. Food: While it varies from person to person, common food triggers include dairy products, eggs, nuts, seeds, soy products, wheat, and other gluten-containing foods.

4. Environmental Factors: Dry air, particularly in winter months or in air-conditioned rooms, can worsen itching. Using a humidifier can help maintain skin moisture.

5. Allergens: Dust mites, pet dander, pollen, and mould can trigger eczema flare-ups and itching. Regular cleaning and using allergy-proof covers on bedding can help manage these allergens.

6. Heat and Sweat: Overheating and sweating can also trigger itching. Dressing in layers and keeping cool, especially during physical activity, can help manage this.

7. Skincare Products: Some skincare products, especially those containing fragrances, alcohol, and certain preservatives, can irritate the skin and increase itching. Opting for fragrance-free, hypoallergenic products is usually a safer choice.

Remember, triggers can be different for everyone, and what causes itching in one person might not affect another. You can find more information on discovering the causes of your flare-ups in our guide here.

Stage 3 - Habit Reversal

The itching sensation can become so great that we end up scratching. But, unfortunately, this is the stuff that does the real damage. So we can use habit-reversal techniques to help prevent itching. By building up awareness of your itching habits you'll be much better placed to reverse your itch-scratch habit. You can achieve this by using what's known as a competing response.

The idea is that instead of scratching whenever you feel itchy, you do something that's much less harmful instead. This might include clenching your fist, using a safe scratcher such as the devices made by our partners at Cosi Care or using our habit-reversal tools within the app. The idea is to reverse your habit and ultimately use your competing response instead. This process alone has shown to cure eczema in many patients that have completed this process in full.

Stage 4 - Eliminating Stress

The final stage to dampen the entire cycle is stress. The stress-eczema cycle has been shown to be an important trigger for causing eczema and increasing the itching sensation. To tackle this process, techniques like mindfulness, relaxation therapy and muscle relaxation have been shown to significantly reduce and break this cycle.

The Proton Health programme also features the worlds first Itch-Scratch Behavioural Therapy. This pioneering technique involves a combination of audio guided sessions, reflection techniques and CBT that help to dampen stress and improve overall mental health. All of which has shown to break the stress-eczema cycle.