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Itchy skin is the main symptom of eczema, a chronic condition triggered by an abnormal immune response. Eczema affects as many as 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 co-director 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 largely ignored by medicine as a minor symptom, 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.
Itching 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 they 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 are 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, pro-inflammatory proteins in the immune system that function to signal nerves that produce itch. Two specific genes are activated in this signaling pathway — interleukin (IL)-4Rα and Janus kinase (JAK)1 — and new drugs are in development to block them.
This breakthrough has helped create a clearer picture of how an immune reaction breaks through the epithelial tissues of 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 triggers eczema to 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 both internal problems with the immune system and skin barrier, and external environmental factors and allergens.
Dry skin is a chronic problem for people with eczema. Skin can feel rough, flakey, brittle, and itchy. When skin cracks, or is broken from scratching, bacteria can get into the skin and cause a flare. Some people with eczema 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 and cannot retain moisture or protect against pathogens penetrating the skin barrier.
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 flakey and itchy. It hurts. I hate the winter, so extra dry,” said one member. The air in winter tends to be more dry due to low humidity, and inside air can become dry from heating. Sudden changes in temperature can also cause itching.
Excessive washing of hands can also cause dry skin, and can be a problem for people with eczema who work in restaurants or health care. “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.” People are also washing their hands more often during the COVID-19 pandemic.
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. There are no 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 causes the body to release hormones that may cause an immune response that triggers eczema. This complex relationship between the brain and the immune system is not fully understood, but is an area of research in the field of psychoneuroimmunology.
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. But animals have protective fur, while humans evolved to have exposed skin that is damaged from 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 more 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. Routines for daily moisturizing take time, and many people with eczema may not have the spare time or patience, given the demands of school, jobs, and families. 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.”
Meanwhile, over-the-counter moisturizers for treating eczema have gotten better, Dr. Kim explained. Many products are now available for people with eczema that do not 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 the skin and come in the form of creams, gels, ointments, and foams. Other treatments can be taken orally or by injection.
New immunotherapy drugs that can inhibit pro-inflammatory proteins are emerging. Dupixent (Dupilumab) is a biologic given by injection that inhibits interleukin proteins IL-4 and IL-13 in the immune system. The drug was approved in 2017 for treating eczema and has shown strong results in some people.
A new topical JAK inhibitor is also in clinical trials and may be approved soon. “I think it has high promise,” said Dr. Kim.
At MyEczemaTeam, you can join more than 32,000 people who are living with eczema or caring for someone who has it. Members often discuss their eczema symptoms — including itching — and tips for soothing them.
Here are some recent conversations on MyEczemaTeam about itchy skin:
How do you manage itchy skin? Have you talked with your doctor about treatments? Do you have any home remedies that soothe the skin? Share your tips in the comments below or on MyEczemaTeam.
Dr. Kim is co-director for the Center for the Study of Itch and Sensory Disorders and associate professor of medicine at Washington University School of Medicine in St. Louis. Learn more about him here.