Ask #SkinishMom – How to Distract my Kid from Scratching Eczema?

Have a skin, eczema or parenting question? Ask #SkinishMom

Have a skin question? Want to vent on raising an eczema child? Or simply chat with a mom who doesn’t judge? Write in via comments and your question will get a reply (on or off the column). Or #SkinishMom on twitter!

To the #SkinishMom:

Help! My kid won’t stop scratching and it’s getting impossible to keep him from it. Any ideas?

One tired mom

I know! It does get impossible sometimes to stop scratching, many times I feel like I’ve run out of eyes to watch out for it, ears to listen for it and saliva to remind not to scratch. Here are the ‘crazy’, desperate distraction tips that I’ve come out with over the 5 years. Of course, the eczema ought to be controlled too, otherwise it’s kinda unfair to expect the kid not to scratch. So here goes my quirky anti-scratching tips!

49 eczema cartoon

Art – You can’t paint and scratch at the same time, that’s why my bag always has an activity book and my home is stock full of them.

Burst bubble – If you’re wary of the bubble (soap) on your kid, use a long straw to burst the bubble instead.

The things that can be irritant! Eczema child and contact dermatitis

Cloud imagination – this works if you’re out in the park and your kid starts scratching, start spying shapes in the cloud.

Dance – It’s quite difficult to dance and scratch at the same time!

Eat – this is one fav technique of grandparents, not very ideal but to them, it’s better than scratching. I would choose physical activities to burn off the extra calories after.

Force it – If your child is still a baby, you may have to hold her hands whenever you’re able to limit the scratching. There are very few distraction techniques for baby since they can’t engage in as many activities (except scratching).

89 eczema cartoon

Go get it – Sometimes I get my kid to get something which works to stop the scratching for a while.

Hold on to it – Same thing – can’t scratch if you’re holding onto something.

Ice – Anything cold – ice cube (works to distract in a restaurant waiting for food) or ice pad work.

Ice can really entertain Marcie, especially when I run out of coloring paper at restaurant!

Ice can really entertain Marcie, especially when I run out of coloring paper at restaurant!

Jello – Making jello takes up time, likewise pizza. I like jello though – eating a chilled one distracts scratching too.

Kiss – Kissing is distracting too! Be careful of your saliva irritating her skin though.

Lie – this one is tricky! But sometimes I tell my kid to look at this or that when there’s nothing special, then think of something special about it.

Monopoly – A board game that requires to keep moving the token, getting title deeds, counting fake money and engages the brain.

Noodles with chopsticks – This one is challenging and maybe the fingers get too tired to scratch after!

On the light, Off the light – Worked for me for a while when my kid was a toddler and amused with the car light.31 eczema cartoon

Play dough – This is fabulous, not too dirty but be sure the child understands not to eat it.

Quit saying stop scratching – At different age, you may want to actually stop saying that and watch if your kid still scratches when you’re not paying attention to it. Read about reinforcing positives, instead of focusing on what not to do here.

RelaxStress can be ‘caught’ by your kid, so relax and see if it helps.

Sing – Sing a funny noise, skin-related or not. Make up songs of My Little Pony, Frozen or about anything!

Tickle – this one always works!

Unite – whatever distraction tips (somewhat equal parenting style cos there’s so much time devoted to distracting an eczema kid), you and your spouse must be united and agree.

Vacation – many people have improved skin during vacation, we don’t really know why. But hey, with more new things to do, a vacay may just work to snap out of the routine scratching.

67 eczema cartoon

Waste some toilet paper – Maybe get lower quality ones for tearing! (Potty training an eczema kid is a whole different ball game.)

80 eczema cartoon

Xtreme measures – my own extreme is having to secure, swaddle, tie (is there a more politically correct word?) my baby’s hands for a minute, while I make her milk. It was a very difficult period of time.

You – don’t forget TLC for yourself.

Days when the AIR seems to have gone out of ME - Mom Says Eczema Cartoon

Deflated

Zzz – Only if prescribed by doctor, you can try antihistamines to help your kid sleep better (not knock him out!).

Eczema Research News – Do Antihistamines work?

Will Antihistamine Work for Eczema?

Will Antihistamine Work for Eczema?

This is part of a quarterly round-up of some of the recent eczema-related studies, so that we can be aware of possible treatments and their efficacy (and I can also keep myself updated with the latest eczema research!)

Today’s topic is on Antihistamines, do they Work? I’ve read in forums that some patients swear it helps with the itch, while others swear at it for being totally useless. What’s the research in this area? I’ve found a few studies online, but before we go into them, let’s get some Antihistamines’ basics.

What are Antihistamines?

Antihistamines are medication that are taken orally to block the activity of histamine at skin H1 receptor sites, thus alleviating itch. The older generation of antihistamines is sedative, usually prescribed to relieve itch and scratching at night.

Backtrack a step for some of you to understand the rationale – One of the characteristic of eczema is itch, which triggers patients and children with eczema to scratch at the inflamed skin/ lesion. Scratching worsens the skin inflammation, exacerbating the itch-scratch cycle. Scratching also thickens the skin, further breaks down the skin barrier and risks infection. Thus antihistamines are prescribed to alleviate the itch, to reduce scratching.  More on scratching here.

There are broadly two types of antihistamines,

1) the sedating types such as alimemazine, chlorphenamine, cyproheptadine, hydroxyzine and promethazine.

2) the non-sedating types such as cetirizine, levocetirizine, loratadine, desloratadine and fexofenadine. Supposedly, the non-sedating type can bind more selectively to the H1 receptors and last longer for 24 hours but many reported not effective.

How are Antihistamines supposed to help Eczema patients?

Oral H1 antihistamines have been prescribed for eczema patients, usually for their sedative effects. It appears that the sedating type is more commonly concurred to relieve itch better than the non-sedating. However, longer than 2 weeks’ use have been described to render sedating antihistamine ineffective to the patient.

Can Antihistamines be prescribed for Children with Eczema?

Yes, studies had been conducted for children from age 1, and different antihistamines have different age limits and the dosage depends on the weight of the child. Read that hydroxyzine is not recommended for below 6-month eczema baby and promethazine and alimemazine not for children under 2 years old.

Are there side-effects to Antihistamines?

Antihistamines may cause side effects such as drowsiness, headaches, constipation, dry mouth and blurred vision, and worsen condition such as glaucoma and retention of urine.

What’s the verdict on Antihistamine on Eczema?

After reviewing PubMed, it appears that it is difficult to isolate the effect of antihistamine as trials undertaken had used antihistamines as an add-on therapy (imagine which eczema patient would take part in a study that prohibit you from moisturizing and treating your eczema, insisting you consume only antihistamines!). Therefore, there is no conclusion as to whether antihistamines work. Based on a selection of antihistamines’ studies published on PubMed, cetirizine improved eczema (along with topical treatment) while chlorphenamine did not show difference in alleviating scratching at night. Hydroxyzine reported to work better than cyproheptadine in another study.

As you can see, there’s no clear conclusion on whether antihistamine is useful, neither is there clear study on whether the sedating type is more useful than the non-sedating. What is your experience? Do share in the comments, greatly appreciate!

Women Itch and Scratch Differently from Men

Gender Men Women Pruritus Itch Eczema Blues This study is published in June 2013 British Journal of Dermatology and I think it wasn’t reported as much as many are reporting the link between antibiotics and babies developing eczema. But I do think this study is interesting:

1. Study is on “Gender differences in chronic pruritus: women present different morbidity, more scratch lesions and higher burden

2. A study of 1037 patients

3. Found women had more “localized itching occurring in attacks, with stinging, warmth and painful qualities”, more visible scratch lesions and greater impact on their quality of life

4. Study is useful in future sex-specific diagnostics or even therapeutics in pruritus as suggested by one of the researcher.

Parenting Tips for Eczema Children – Distracting from Scratching

Tips Scratching Eczema Distraction

For the past week, I took to Twitter to ask parenting experts their tips to distract eczema children from scratching. Why?

Because I realized that close to 2 years after this post – Saying (or Shouting) Stop Scratching to your Eczema Child, communicating effectively (other than shouting stop scratching) remains a difficult task for many families with eczema children, including myself!

So here are the responses, and many other friends around the world on Twitter also chipped in their tips! Add yours to the comment, and also let me know which one works best for you!

Tips from Parenting Experts & Expert Moms

Shara Lawrence-Weis, mother of 4  with background in education, early childhood & nanny work.

“Scratching might hurt your skin. Let’s think of other things you can do to help the itching.”

Dr Lynne Kenney, mom, mother of two, a practicing pediatric psychologist and author of The Family Coach Method.

“Did u know scratching is self-reinforcing cause it can release dopamine? Distraction from scratching is about finding other ways to use ones hands and still release dopamine (link)”

Erika Brodnock, mum of 5 & CEO of Karisma Kids that helps raise happy, confident & creative children.

“Gently patting the itchy areas while singing a song distracts in very itchy moments!!”

Dr Melissa Arca, Pediatrician, mom of two, writer, and blogger at Confessions of a Dr Mom.

“Empathize: “Ooh, I know you’re itchy”. Action: “Let’s put some lotion on instead of scratching.”

Shadra Bruce, creator of MomsGetReal.com and also an author.

“Keep their hands and minds off the itch by keeping then focused on being creative! Arts, crafts, and hands-on helping moms.”

Mary Hartley, RD, Nutritionist, with her own practice

“Time to get moisturized!”

Shonette Bason, mom of 4 children and works full time as an outstanding primary teacher, author and consultant trainer for Early Years Education.

Dough Disco (practising finger muscle control with dough and music!) is good for hands distraction!”

Ann Wu, MD, MPH, mom to eczema kids, Pediatrician and asthma researcher at Harvard medical school

“I usually say, “I know–it feels so good to itch! But I don’t want you to look like a red bean popsicle.”

Tips from Tweeps (friends who tweet):

I admit I do say Stop Scratching! followed by Put on some lotion! – Maria Wen Adcock, BiculturalMama

Today I fashioned some footed pajamas…using Egyptian magic cream and seeing what happens and it worked great. For the first time in almost a year, he slept without one scratch…I stayed up all night watching tho – Veena Goel Crownholm, Tiarastobabies

Perhaps – “It’ll hurt” – Harleenas

Sitting in a bath with some baking soda – MVOrganics

Depends on itch. if unthinking idle itch can simply put something in child’s hands, or distract non verbally. also need to accept that true burn of ezcema canNOT be ignored. so it depends on the habits and state of eczema flare – SarahJChapman

Depending on age, u could discuss beforehand and have a keyword that u both decide on that you say to remind them to stop. – Michelle Winters, Pediatric Sleep Consultant VASleepCoach

Make it a game: ‘I bet you can’t leave your arm alone’ – Ali_Nguyen

If you reduce the itch then hopefully they will stop scratching! – Dermasilk

SOMEONE manages TWO kids!

Jennifer shares on managing a second child when the first has eczema

Jennifer shares on managing a second child when the first has eczema

This is a new series focused on personal journey with eczema while managing a certain aspect of life. Today, we have Jennifer Roberge, whose eldest son Tristan has had eczema from three-month old and shares how she manages taking care of him while having another child. Jennifer is a blogger at It’s an Itchy Little World and a mompreneur who started her own company and online store The Eczema Company – she’s a return guest on my blog and you can read her first interview on her mompreneur journey here. Marcie Mom: Hi Jennifer, thanks for taking part in my 2013 blog series ‘Someone has Eczema’! Share with us a little on the severity of Tristan’s eczema when you were pregnant with your second child; was it tiring even before the second one was born?

Jennifer: During my pregnancy, Tristan (just shy of two years) had severe eczema behind his knees, around his midsection, around his ankles, wrists, and hands. It was dry, flaky, inflamed, and extremely itchy. My husband and I would lie awake with him at night trying to help him settle back down to sleep and try to forget the incredible, over powering urge to itch. So, we weren’t sleeping well to begin with – add to that the end of my pregnancy where sleep tends to evade mothers to be. They weren’t the easiest of times, that’s for sure. The eczema worsened after the baby was born, and continued to cover his body. Around three he was 90% covered, head-to-toe in eczema and resembled a burn victim. It was a difficult balancing act, trying to prevent my son from tearing up his fragile skin and managing an infant.

Marcie Mom: I know that Tristan has allergies too. Did you manage to figure out what’s triggering the majority of his eczema flares and his allergies before the birth of your second child? And did being able to manage somewhat his eczema helped in your decision to have a second child?

Jennifer: To be completely honest, when we decided to have a second child, Tristan’s skin was much less severe, so his condition didn’t really play much of a part in our decision. When things started to worsen during the pregnancy, my goal was to determine all of Tristan’s triggers and to get control over his eczema before the baby was born, but it didn’t happen that way. We hit rock bottom after the baby was born and when Tristan head-to-toe, severe eczema. No one in the house was sleeping, so we went for extreme methods and did a full elimination diet and saw results within days. It was nothing short of a miracle for our family.

Marcie Mom: Do share with us how you manage the breast-feeding, taking care of a new born, when Tristan I suppose do still need attention to his eczema and allergies? What was the toughest part?

Jennifer: Tristan needed constant supervision back then, not because he was only two, but because he’d scratch his skin raw if we left him alone for a minute. So, breast-feeding was extremely difficult. Tristan was very jealous and wasn’t a fan of my alone time with the baby during nursing, so when I was alone with the children, I’d cover Tristan’s hands with ScratchMeNot mittens and distract him with a book during nursing. Yes, I managed to learn how to read to him breast feeding! I also remember I relied on an infant wrap a lot during the first few months. I’d have my baby safely attached to me and I’d have free hands to help Tristan when he needed me. The wrap was essential back then. What was the hardest part of it all? When no one was sleeping – not the baby, not Tristan, not my husband or I. It’s one thing getting up to nurse throughout the night, but add to that frequent wakings and hours spent with an uncomfortable toddler that will do anything in his power to scratch until he draws blood.

Marcie Mom: One final question – what word of encouragement would you give to someone who just found out she is pregnant with a second child while the eldest has eczema?

Jennifer: Buy a good infant wrap or sling. Try to work on determining your child’s eczema triggers before the baby arrives – we waited to late. If your child wakes a lot during the night, try rotating nights with your partner. One night you take all the shifts with your restless child, the next time it’s your partner. And nap as often as you can to catch up on lack of sleep.

Marcie Mom: Thanks Jennifer for sharing your personal journey, it definitely strikes a chord with many moms out there!

SOMEONE managing Bedtime

Lok kids

Mommy Lok shares on managing bedtime

This is a new series in 2013 focused on personal journey with eczema while managing a certain aspect of life. Today, we have Vida Lok, whose 4 year-old son has had eczema since he was a few months old and shares how she manages bedtime for her son. Vida blogs at MommyLok on her three children and book reviews written by her daughter.

Marcie Mom: Hi Vida, thanks for taking part in my new blog series ‘Someone has Eczema’! Can you share with us the severity of your son’s eczema and which are the triggers you’ve figured out?

Vida: Hi Marcie Mom!  My pleasure and thank you so much for blogging specifically about eczema.  I know this issue causes heartaches for many parents, including myself.  The worst of my son’s eczema is primarily focused on the hands, feet and neck area (up to the ears).  His skin can get so irritated that it causes bloody cracks all over his fingers and also at the bottom of his earlobe.  Many times, I wake up to find blood spots all over the pillow and bed sheets.  As for triggers, I haven’t determined what they are specifically though I would say it’s primarily weather-related.

Marcie Mom: Bedtime is the most difficult time to manage eczema for our children; the scratching intensifies when we just want to shut our eyes! Is your son sleeping well through the night, and what preparations do you take before, during sleep to minimize the scratching damage?

Vida:  At 4 years old, I was hoping that he would be sleeping on his own by now. However, he still wakes up (I’d say at least 6 nights out of the week) screaming in the middle of the night because he is so agitated.  It’s been a frustrating (and tiring) 4 years of this nightly routine.  Children just do not deserve this sort of torment!  Every day after his shower, we moisturize (mineral oil, creams and Vaseline) and then once again right before he sleeps.  However, like my daughter who has suffered through the same thing, all the moisturizers just seem to dry up upon contact to his skin.  It just does not seem to provide much relief.  We also use the humidifier since winter is so dry, but it hasn’t had much of an effect on his relief either.  The most effective preparation we have is to make sure that his fingernails are filed down every couple days to minimize the intensity of his scratching.

Marcie Mom: Many parents would love to figure out a way to get their children to sleep throughout, and for us, parents with eczema children – sleeping without scratching is already a dream come true! Is there a ‘magic’ trick that you’ve figured out, or anytime when your child slept without the scratching?

Vida: I really wish I could be that miracle mom and share the secrets of “curing” eczema for all the children who suffer from it.  However, sadly, I just have to wait for those occasional lucky nights where my son’s eczema is slightly better than the previous nights and he can sleep a bit more comfortably.

Marcie Mom: One final question – is it difficult to manage bedtime for your toddler, when you’ve another two children to take care of? How did you get them all to bed?

Vida:  You can say it’s a bit difficult!  My two sons share a room so that causes a problem right there (they’re too tempted to play and talk all night!)  Though sometimes it helps because if my toddler sees my older son going to bed, it’s easier to convince him that he should be in bed, as well.  My daughter is 8 years old now so she’s a little easier to manage (and also because bribery is more effective on her!)  As with most kids, I’m sure, some nights are easier than others.  I try to spend as much time with them at nighttime (since I work during the day, bedtime is where I get to spend quality time with my children) so some nights they actually look forward to bedtime.  Those other nights?  If I’m repeating myself over and over again to them (“It’s bedtime, go to sleep!”), they’ll eventually settle down because they’re tired of hearing me be so annoying!

Marcie Mom: Thanks Vida for taking time to share your bedtime journey, I’m sure many many parents out there can identify with your sharing! and yes, bed time is quality time for me too!

Vida:  Thank YOU for allowing me to share!  And best of luck to all the parents out there.

Best of 2012 MarcieMom Eczema Twitter Tips – On the Emotional side of things..

For those of you who follow me on twitter (my twitter handle, ie twitter name is @MarcieMom), you would know that I tweet an eczema tip daily. For every wednesday of this final month of 2012, I’m celebrating and sharing the best of 2012 eczema twitter tips with you… via a blog post.

It’s a celebration because you’ll see that over the course of this year, I’ve drawn many cartoons that resonate with moms and dads! of eczema children – we all face similar issues, related to high stress and poor sleep. You will also see that EczemaBlues.com is blessed with having renowned doctors and experts throughout the world, lending a hand to parents. Enjoy!

17 of 366 MarcieMom Eczema Tip – Don’t keep saying ‘Stop Scratching!’, rewarding your child for not scratching is more effective (I know, I’m guilty of it too!)

I may not be shouting so loud, but I am SCREAMING inside..

27 of 366 MarcieMom Eczema Tip – Don’t feel guilty parenting your eczema child; You’re the Best Parent for your child

A support group helps with supporting each other in our parenting journey of kids with eczema!

29 of 366 MarcieMom Eczema Tip – Don’t blame on the ‘bad gene’ if child’s eczema is inherited from your spouse. It only creates tension.

Family Tree – Who has Eczema?

42 of 366 MarcieMom Eczema Tip – It’s Sunday and time to take a break & that includes getting off the net searching eczema information!

I remembered I was all nerves googling late into the night, when already tired from taking care of baby

153 of 366 MarcieMom Eczema Tip – Parenting eczema kids is complicated by scratching, don’t feel guilty and over-compensate

One guest I’ve known this year, is Sue Atkins, a parenting expert. You can see the post where she advises on discipline for eczema kids here.

Interview with Sue Atkins, The Parenting Expert

158 of 366 MarcieMom Eczema Tip – If scratching is habitual, consider combining conventional treatment with habit reversal

A repeat guest on my blog this year is Dr Christopher Bridgett, who is a psychiatrist with an interest in dermatology and written a manual that helps practitioners work with parents to reverse the habitual scratching, read here for more.

Parents noting child is scratching (picture credit atopicskindisease.com)

320 of 366 MarcieMom Eczema Tip – Be mindful of sharing what has worked for your child, everyone’s skin is different

Isn’t that so true? Do drop me a comment so that I know my sharing in this blog has worked for you, and also if it hasn’t! Do also help to share on your facebook the blog posts you like, will help me get these labored posts to more parents! Thank you!

Combined Approach Series – Stress, Attitude and Habit Reversal

Parents see an acute flare that needs treatment

This is a 4 post series centered on ‘The Combined Approach’ that is explained in the ‘Atopic Skin Disease’, a manual for practitioners authored by Christopher Bridgett, Peter Noren and Richard Staughton (copy of book viewable by joining here). The Combined Approach uses habit reversal to stop habitual scratching in atopic eczema. Dr Christopher Bridgett has previously helped in Friday Doctor Q&A from November 2011 to February 2012 and MarcieMom has invited him to share more about the Combined Approach.

Three Levels of Treatment

In the manual ‘Atopic Skin Disease’, three levels of treatment are stated, namely:

1. Emollient Therapy

2. Steroid

3. Habit reversal

It is advised in your manual that steroid should not be used without follow-up moisturizer but moisturizer can be without steroid application. In the course of recovery, level 3 can be stopped first, followed by 2 and 1. We’ve covered the basics of all three levels in previous posts. There are some further dimensions in the management of eczema as follow:

1. StressStress is one of the possible triggers for eczema. Can you help a parent to identify when a child is stressed and how to see if the child is stressed because of the eczema or because of something else? How can a parent help a child to relax?

Dr Bridgett:

Stress can cause emotional upset – unhappiness and apprehensiveness for example in anyone, young or old. In a child this may include tearfulness, and avoidance behaviour, just as in an adult. Certainly having eczema itself is stressful, for both the child and the parents. Careful observation may clarify if something else is the source of stress: stress comes from common causes, even for the youngest child, and family upsets may be especially important to think about. If there are no other causes and the eczema is troublesome, then adequate treatment of the eczema will be stress relieving – for everyone.

Helping a child to relax usually involves simple acts – giving attention, and comfort, with suitable play, and amusing distraction. Reading a favourite story is a tried and tested bedtime means of inducing relaxation and sleep. But when a child is stressed, enabling relaxation is more difficult, especially if the causes of stress are not identified and dealt with.

2. Attitudes – Positive attitudes are suggested in your manual, such as ‘Manage, Don’t be Managed’ and to be careful so the doctor/nurse does not to ‘spread’ helplessness during a consultation. Should a patient comes across a doctor who is passive about managing the eczema, what can he/she do to change the doctor’s attitude? (Obviously, the other choice is simply switch doctor! But as a service to other patients, someone ought to say something!)

Dr Bridgett:

I find myself saying something about this all the time! Of course the responsibility for a successful visit to a doctor rests with all those involved. Each person should consider first what they themselves can do, rather than seeing any problem as caused by someone else. Some really useful ideas about this were covered when Jennifer talked to me: see http://atopicskindisease.com/articles/20111216 This might make a good topic for people reading this post to comment on here: I suggest your readers share their thoughts and experiences with you.

At some health centres and doctors surgeries there are patient discussion groups to allow people to share ideas on how things can be improved. Has anyone had experience of such a group? Does your doctor ever conduct a patient satisfaction survey?

Review of Habit Reversal

In The Combined Approach, follow-up visits include asking the patient or parent their (i) scratching frequency (ii) when there’s most scratching (iii) % of scratching from itch (iv) severity of eczema (v) % new eczema vs old and (vi) where most eczema. If a parent cannot find a doctor or convince their current doctor to implement the Combined Approach, can the parents implement this on their own without a doctor doing the follow-up (i.e. monitoring scratching on their own)?

Dr Bridgett:

The questions that you detail are in the first stages of The Combined Approach, during the first 4 to 6 weeks when habit reversal is important. The later part of the programme we call follow-up, and then vigilance for acute flare-up is the important emphasis, with early and energetic treatment with topical treatment being the order of the day. Habit reversal is not important long term. It is optimal topical treatment that is essential to maintain the progress that The Combined Approach achieves.

How to use The Combined Approach depends on the resources available. The clinic-based format is very effective, but if it is not feasible a self-help format is a good alternative, as discussed at http://atopicskindisease.com/categories/20110423_18 (joining is necessary to read this, but joining www.AtopicSkinDisease.com is still free!).

Hopefully blogs like this, and websites like www.AtopicSkinDisease.com will now gradually help everyone everywhere to discover how to treat atopic eczema successfully. There is no need now for anyone to necessarilyLive With Eczema: there is now a possibility to learn how to Live Without Eczema.

MarcieMom: Thank you Dr Christopher Bridgett for taking time to explain The Combined Approach. I’m certainly very glad to collaborate on this series with you. Should there be more questions from parents, I’d certainly invite you for another Friday Doctor Q&A!

Combined Approach Series – Eliminate Habitual Scratching

Combined Approach – Parents noting child is scratching

This is a 4 post series centered on ‘The Combined Approach’ that is explained in the ‘Atopic Skin Disease’, a manual for practitioners authored by Christopher Bridgett, Peter Noren and Richard Staughton (copy of book viewable by joining here). The Combined Approach uses habit reversal to stop habitual scratching in atopic eczema. Dr Christopher Bridgett has previously helped in Friday Doctor Q&A from November 2011 to February 2012 and MarcieMom has invited him to share more about the Combined Approach.

Development of a Nervous Habit

I read in your manual ‘Atopic Skin Disease’ of how a nervous habit develops, namely:

1. Normal initial specific response to an injury (or itch)

2. Increased frequency by positive reinforcement that leads to

3. Behavior (or scratching) becomes automatic

4. The habit generalizes to cause more situations precipitating the behavior

5. Decreased personal and social awareness

Also illustrated in your manual, another habit is introduced to reverse the scratching:

1. New habit is opposite to the old habit

2. Can be maintained for several minutes

3. Socially acceptable and compatible with normal activities

4. Strengthen muscles antagonistic to those of old habit

The techniques used in Noren and Melin, 1989 study mentioned in Atopic Skin Disease are:

1. Clenching fists and counting to 30 as an alternative to habit of scratching

2. Pinching the skin where it was itching as an alternative to itch-provoked scratching

Can you explain to our parents how to tell their child to clench fist and pinch skin? Is this something that can be understood by young children? And will pinching skin lead to the child using painful techniques to get rid of scratching? (I read in your manual not to say ‘Stop Scratching’, just as I’ve posted!)

Dr Bridgett:

The method of clenching a fist, then pinching the skin, is only suitable for older children, who are able to understand the instruction, and can accept responsibility for following the recommendations. The younger child requires a different approach which sees the parents as responsible for the treatment, with an adapted programme in between: see http://www.atopicskindisease.com/articles/20120115

So, no pinching small children please!

And yes – it is important to avoid saying “Stop Scratching” – you are quite right, of course!

Homework: Registering Scratching Frequency

In The Combined Approach, the first homework assignment to patients is to register the scratch frequency. This aids in the analysis of the scratching habit, following an ABC format of understanding the antecedents, behavior and consequences. Do you normally explain the ABC to patients before requesting them to register their scratching frequency? How can a parent help explain this to a young child? How can a parent help a child to count the scratching?

Dr Bridgett:

The explanation of the ABC normally comes after registration, as part of the instruction of how habit reversal works. See the patient handbook for Older Children: http://atopicskindisease.com/categories/20110503_1

The younger child has a different treatment programme, without any counting of scratching: for the younger child it is the parents who are responsible. They can achieve awareness of the childs behaviour without using a counter. See http://atopicskindisease.com/articles/Mark

MarcieMom: Thank you Dr Christopher Bridgett for explaining habit reversal that is part of The Combined Approach. In our next post, we will understand the three levels of treatment and conclude the series.

For previous posts in this series, see

Habit Reversal

Topical Treatment

Stress, Attitude and Habit Reversal

Combined Approach Series – Topical Treatment

This is a 4 post series centered on ‘The Combined Approach’ that is explained in the ‘Atopic Skin Disease’, a manual for practitioners authored by Christopher Bridgett, Peter Noren and Richard Staughton (copy of book viewable by joining here). The Combined Approach uses habit reversal to stop habitual scratching in atopic eczema. Dr Christopher Bridgett has previously helped in Friday Doctor Q&A from November 2011 to February 2012 and MarcieMom has invited him to share more about the Combined Approach.

Explaining Topical Treatment – Moisturizer

As we understand last week, The Combined Approach includes topical treatment using emollient and steroid. Moisturizing is a HUGE part of topical treatment, as emollients both lubricate and moisturize. Dr Bridgett’s advice on moisturizing is Thinly, Gently, Quickly and Often. There are a few other points mentioned in the ‘Atopic Skin Disease’:

  1. Thinnest possible application without ‘rubbing it in’
  2. More on exposed areas such as the head, neck and hands
  3. Pump dispensers preferable to open tubs due to bacteria infection
  4. Applying topical steroid first, then emollient over both the skin and the steroid
  5. Cream preferred over lotion

Can you explain why thinnest possible application is preferable for emollient? (I’d usually slather on my child as I find applying a thin layer leads to more rubbing to spread the emollient)

Also, can you explain why topical steroid first? (I’d written on this here and it does generate some discussion!)

Can you explain why cream is preferable over lotion?

Dr Bridgett:

Your three questions answered:

  • Thin applications of moisturizer allows heat to escape, but insulates against water loss.
  • If moisturizer is applied often enough, when the steroid is applied directly onto the eczema, it is applied to skin that has been recently moisturized. We get then the best results by putting moisturizer on over topical steroid, and moisturizing all the skin, not just that which has the eczema.
  • The thicker the moisturizer, the better the moisturizing effect. Also, often there are less additives in thicker moisturizers, as thicker moisturizers “keep” longer. There is less chance that a sensitivity reaction will occur with an ointment, compared with a cream. See http://atopicskindisease.com/articles/20110801

Explaining Topical Treatment – Steroid

It is stated in ‘Atopic Skin Disease’ manual that steroid cream work by inhibiting protein synthesis, secretion of products, cell division and migration of cells. The epidermis can benefit from reduced cell division, and the dermis from reduced cellular and lymphokine activity. Can you explain what this means, and why it is important to continue steroid treatment after epidermis healing (‘2-stage in steroid effect’)?

Dr Bridgett:

It seems the steroid anti-inflammatory effect is partly achieved by reducing over-activity in the skin, allowing natural healing then to lay down healthy skin again. By the time the seems good to look at, the healing is not complete through and through – there is more that is needed under the surface, so we recommend continuing with the topical steroid, beyond The Look Good Point: do not stop too soon. See http://atopicskindisease.com/articles/TT7

Many parents are very concerned with the skin-thinning side effects of steroid and also the ‘withdrawal’ symptoms once steroid treatment is discontinued. I read in your manual that side-effects are associated with inappropriate use of topical steroid and the risk is usually inadequate treatment (i.e. stopping steroid cream too early or using one of too low strength). How do you normally convince parents that steroid cream is safe? And what guidelines would you give them to gauge if the steroid cream of correct potency, frequency and amount is used?

Dr Bridgett:

Steroid side-effects come especially from using topical steroids long-term and in an unsupervised way. The method we use in The Combined Approach includes more supervision than is usually given, with a programme of several clinic visits, involving careful discussion of all anxieties and concerns. Using The Combined Approach, including therefore habit reversal, which allows natural healing alongside the good steroid effect. Then less topical steroid is used overall, for good effects, not side effects!

We offer information about the potency groups of the topical steroids, and how they are usually used. The thicker the skin, the stronger the topical steroid to be used. See http://atopicskindisease.com/categories/20110423_11

Each application of any cream needs to be sparingly applied – whether it is an emollient or a topical steroid: only a shine is required.

MarcieMom: Thank you Dr Christopher Bridgett for explaining the topical treatment that is part of The Combined Approach. In our next post, we will understand more on habit reversal techniques.

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