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00:00:00:00 - 00:00:27:18
Dr. Kim
Itch has been really sidelined for hundreds of years in the field of medicine, it has been largely considered a nuisance, not much of a medical problem. But more importantly, scientifically it was always thought for a long time that if we just studied pathways, that immediate pain, that we would inadvertently be able to address itching in a way.
00:00:27:18 - 00:01:06:12
Dr. Kim
But the discovery that I'm talking about was quite seminal because it established that itch is real, it's scientific, it has a molecular basis, it's distinct. And then that, of course, a huge implication for diseases like eczema, where itch is really the kind of main symptom. What's remarkable is when you think about how intuitive this has been to us, until just say, in the last few years, it wasn't really well understood how inflammation leads to itch, or rather how scratching leads to inflammation, that leads to itch.
00:01:06:14 - 00:01:26:23
Dr. Kim
And, you know, and I'm now describing the cycle to you. It's the number one symptom we see, yet we have such a simple question that, you know, a 5 year old child could ask me, "Why do we itch?" You know, "Why in my rash do I itch?" We didn't know that, and that had been the focus. And that's what we've kind of unraveled in recent years,
00:01:27:00 - 00:01:50:22
Dr. Kim
different protein called cytokines that we thought stayed completely confined to the immune system, directly interact with the nervous system. Factors that come from the barrier, what we call the epithelial barrier of the skin, the brick and mortar structure, the release factors that then stimulate the nerves. So now we're starting to understand why dry skin itches, why does inflammation, why does my rash itch?
00:01:50:24 - 00:02:17:13
And then there are ways in which you can just itch just from your nervous system itself, just being overactive. The field of eczema was going after the inflammatory mediators that promote the rash in eczema. And what our work has focused on, and what we've uncovered, is that it turns out a lot of these factors, that actually are pro-inflammatory, also act on the nervous system and drive itch directly.
00:02:17:13 - 00:02:37:02
Dr. Kim
So now these therapeutics are coming. So there's a lot that can be done. Drugs like Dupixent worked really well, for itch, too, not just the eczema, but the itch that underlies eczema, so even if you don't have much rash, you got the Dupixent, it will anesthetize your nerves. That's what we think. New drugs that are coming our JAK inhibitors,
00:02:37:02 - 00:03:05:16
Dr. Kim
no question. They have very potent anti-itch properties. And they're all, I think, in Phase 3 clinical trials now, and so they will be approved shortly in the next year or two years. And there's a lot coming in in that regard. So the reality is, is that if a patient's motivated, and the provider's motivated, you know, we could get patients tremendously better with these old-school techniques.
00:03:05:18 - 00:03:23:16
Dr. Kim
That was never really the issue. The issue was that it was an incredible burden on the patient to do this. You know, I can go through with you, and teach you how to soak and smear the right way, go home and sit in a bathtub for 20 minutes, put the ointment on. But I can also tell you, that I can't,
00:03:23:18 - 00:03:51:08
Dr. Kim
even as someone who treats eczema, I can't consistently put a moisturizer on daily. It's very hard, you know, it's not because I don't want to, it's just life gets in the way, or, you know, these people still have jobs. They still have children to take care of, you know. So I think that just, you know, what it really is, is that you, there are things we can do to get people better, but it has to be realistic, too.
00:03:51:10 - 00:04:10:03
Dr. Kim
And it has to be consistent with what they can do in their daily life. A lot of times it still remains a mystery, but there are certain kinds of triggers that can set different people off. And they're not always the same thing. And for instance, you might have a patient, and every eczema patient is a little different,
00:04:10:05 - 00:04:34:17
Dr. Kim
but there are patients, for instance, who just are sponges for bacteria. So when their eczema is great, they do really well. And then- but then what happens one day, is they get a little bit too much eczema, they scratch too much, and then suddenly some bacteria gets in there and it lights it on fire. And a lot of patients don't know that that's what's happening.
00:04:34:20 - 00:05:04:06
Dr. Kim
They just think their eczema's just taking control of their body and then come in. And I say, "Look, you know, when you see cracked skin like this, that's a little oozy, that's quite pink, it's open, that's when you have bacteria and you need to call me." And then we'll, you know, put a topical antibiotic, we might have to agree to an oral antibiotic, you know. And you know, it's unfortunate because just knowing that can save- reduce the number of flares tremendously in a year, or completely avert the flare.
00:05:04:08 - 00:05:22:18
And you know, just not having that information will result in patients sometimes for months, flaring, until they come in and decide to see us.
Itchy skin is the main symptom of eczema — a chronic condition triggered by an abnormal immune response. Eczema affects more than 31 million people in the United States. There are several types of eczema, all of which can cause itchy skin.
To learn more about itchy skin and eczema, MyEczemaTeam spoke with Dr. Brian Kim, associate professor of dermatology and codirector of the Center for the Study of Itch and Sensory Disorders at Washington University School of Medicine in St. Louis, Missouri. Dr. Kim specializes in atopic dermatitis, and the groundbreaking research at his center is opening avenues for new immunotherapy treatments for itching.
In the past, itching was considered a minor symptom and largely ignored by doctors. But Dr. Kim explained that itching is now understood to be a skin condition with particular physiological characteristics. “Itch is real. It’s scientific. It has a molecular basis. It’s distinct. And that, of course, has huge implications for diseases like eczema, where itch is really the main symptom,” he explained.
00:00:00:00 - 00:00:36:07
Heather
Dr. Kim, if you could just talk to us a little bit about some of the issues that come up around itching and in particular, I'm thinking about the impact on your ability to get a good night's sleep. Can you talk to us about what your experience has been with patients?
Dr. Kim
Yeah. We know intuitively if you're itching and you're scratching that it can be miserable enough that you can't sleep, which is very common amongst my patients.
00:00:36:07 - 00:00:59:21
Dr. Kim
And the concern there is that as you start to lose sleep, that you actually start to have a lot of other health adverse effects to your health as well. And then that kind of feeds forward. So that's a major concern and you start to develop a lot more actual health problems, in general, just that your overall health is not
00:00:59:21 - 00:01:23:19
Dr. Kim
well, you know, there's lots of studies showing how sleep impacts many different kinds of outcomes, but also that it can actually drive up a level of kind of anxiety. And maybe even the itch itself that you're causing a lot of physiology that's just not very well, not restoring itself to kind of health and that itching just continues to get worse.
00:01:23:19 - 00:01:47:05
Dr. Kim
So it's a major concern, and we've actually done some studies. I won't get into great details, but what we've done is actually been able to measure using devices, people who are actually scratching at night while they're sleeping, so they're not even necessarily aware that they're scratching, but in the moments when they're actually scratching, they actually go into lighter stage of sleep.
00:01:47:07 - 00:02:12:03
Dr. Kim
So even unbeknownst to them, even if they think they slept the whole night, they may not even be actually sleeping as well as they thought, which could actually have a lot of downstream health consequences as well. So it's not just simply that you're waking up and you're completely conscious, but the quality of your sleep may also be disrupted.
Itchiness is a constant problem for people with eczema. MyEczemaTeam members often describe their frustrations with this pervasive symptom.
“I think that most patients come in actually having suffered for years,” said Dr. Kim. He explained that doctors often get a very narrow snapshot of someone’s eczema because their patients may come in on a good day.
Dr. Kim added that some people with eczema may be so accustomed to symptoms like itching that they may not let their doctors know how bad they’re feeling. “I think that’s where we get it wrong,” he said. “I think the thing that’s important to understand, for me as a provider, is that if you’ve never had a disease-free life, your expectations are incredibly low.”
“In recent years, medical science has made important discoveries about how the immune system interacts with the nervous system to cause itching,” Dr. Kim said. People with eczema have disorders with type 2 cytokines — proinflammatory proteins in the immune system that function to signal nerves that make you feel itchy. Two specific proteins in this signaling pathway — interleukin (IL)-4R-alpha and Janus kinase 1 (JAK1) — are activated. New drugs can block these targets.
This breakthrough has helped create a clearer picture of how an immune reaction breaks through the skin barrier. “Now we’re starting to understand why dry skin itches,” Dr. Kim said. “Why does inflammation itch, and why does my rash itch? And then there are ways in which you can itch just from your nervous system itself just being overactive.”
One of the keys to preventing itch is to understand what makes eczema flare. “A lot of times, it still remains a mystery. But there are certain kinds of triggers that can set different people off,” said Dr. Kim. “And every eczema patient is a little different.”
Inflammation that causes eczema can be triggered by problems with the immune system and skin barrier, as well as external environmental factors and allergens.
Dry skin tends to be an ongoing problem for people with eczema. Skin can feel rough, flaky, brittle, and itchy. When skin cracks or is broken from scratching, bacteria can get into the skin and cause a flare. It’s estimated that between 20 percent and 30 percent of people with atopic dermatitis have a gene mutation that causes a deficiency in filaggrin (a protein that strengthens the skin barrier).
“There are patients, for instance, who just are sponges for bacteria,” said Dr. Kim. One hypothesis is that people with eczema have “leaky skin” that has tiny fissures. These breaks in the skin barrier prevent it from retaining moisture or protecting itself.
Dry weather — particularly in the winter — can also cause skin to become dry, as many members of MyEczemaTeam attest. “My face is irritated and getting flaky and itchy. It hurts. I hate the winter, so extra dry,” one wrote. The air in winter tends to be drier due to low humidity, and indoor air can become dry from heating. Sudden changes in temperature can also cause itching.
Washing your hands a lot can also cause dryness. Constant handwashing can be a problem for people with eczema who work in restaurants or healthcare. “It’s often very much an environmental issue, an occupational issue,” said Dr. Kim. “A lot of people with hand eczema are people who do work with their hands. They have their hands in water a lot.” Also, when rates of contagious diseases, such as COVID-19 or the flu, are higher, people tend to wash their hands more often.
Environmental chemicals such as cleansers, perfumes, soaps, and lotions can irritate sensitive skin in people with eczema and trigger itchy flare-ups. Products with fragrances, alcohol, and other chemical additives are especially irritating for people with eczema.
External allergens like dust mites and pet dander are also triggers for eczema flares. Food allergies have been linked to eczema flares as well, but research has been inconclusive. Although keeping a diary to track the relationship between food intake and symptoms may give some clues, there are currently no reliable tests for determining a clear connection between eczema and allergic reactions to food.
Psychological and emotional stress has long been associated with eczema flare-ups. Stress can trigger eczema because it can make the body release certain hormones that may lead to an immune response. This connection between the brain and the immune system is not fully understood, but it’s an area of ongoing research.
Scratching itchy skin will increase inflammation, which perpetuates itching. This cycle can lead to broken skin and skin infections. “You don’t have to be a scientist to mention the itch-scratch cycle,” said Dr. Kim. Itching and scratching may have evolved in animals to warn them of pests, so they could scratch them off. While animals still have protective fur, humans have evolved to have exposed skin that’s easily damaged by scratching.
MyEczemaTeam members are all too familiar with the itch-scratch cycle, which they often express:
Dr. Kim explained that different forms of eczema are treated similarly. “There are so many flavors of eczema, but we actually use a lot of the same tools and coach people the same way,” he said.
Dr. Kim stressed that eczema can progress and lead to other complications if left untreated. “There are a lot of theories that if you have eczema in childhood, and if it’s not well taken care of, it puts you at a significantly higher risk for asthma, food allergies, and things like that,” he said.
Restoring moisture to the skin barrier is one of the most effective skin care treatments for eczema and itchy skin. But skin care routines for daily moisturizing take time, and many people with eczema may not have that. Bleach baths, bathing and moisturizing (also called “soak and seal” or “soak and smear”), wet wraps, and consistent moisturizing throughout the day are protocols that can be very beneficial.
“If a patient's motivated and the provider’s motivated, we could get patients tremendously better with these old-school techniques,” said Dr. Kim. “That was never really the issue. The issue was that it was an incredible burden on the patient to do this.”
Over-the-counter moisturizers for treating eczema have also gotten better, Dr. Kim explained. Many products are now available for people with eczema that don’t contain irritating chemicals. Still, some of the most effective products are not always the most desirable. “Vaseline is probably still the best moisturizer in the world,” said Dr. Kim. “The issue is it’s incredibly thick. It’s very greasy.”
Topical treatments are applied directly to affected skin and come in the form of creams, gels, ointments, and foams. For moderate to severe eczema, oral medications (taken by mouth) or injections are also available. Eczema treatment options that may reduce inflammation and itching include:
Topical probiotics —therapies that include types of healthy skin bacteria — are currently being studied as a treatment for eczema. Researchers believe these medications may help eczema symptoms by balancing the good versus bad bacteria living on the skin.
On MyEczemaTeam, people share their experiences with eczema, get advice, and find support from others who understand.
How do you manage itchy skin? Have you talked with your dermatologist about treatments? Let others know in the comments below.
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I find my scalp feel greasy about 2-3 days after I’ve showered. So I now shampoo my head every other day. It feels much better when I do that but I really don’t want to have to do it every day.
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