Apr 1, 2022


Dr. Tarbox: Hello and welcome to "Skincast," the podcast for people who want to learn how to take the very best care of the skin they're in. My name is Michelle Tarbox and I'm an associate professor of dermatology and dermatopathology at Texas Tech University Health Sciences Center in beautiful sunny Lubbock, Texas. And joining me is . . .

Dr. Johnson: Hey. This is Luke Johnson. I'm a pediatric dermatologist and a general dermatologist with the University of Utah.

Dr. Tarbox: Today, we're going to talk about ways to take care of the meaningful sensation of itch. It is such a troublesome problem for patients and people really can suffer with it. So we've previously discussed what can cause itching and why it's so uncomfortable. Now let's talk about what we can do about it.

Dr. Johnson: And we discussed that just discussing itch makes me itchy, so hopefully discussing how to treat it will make me not so itchy.

So there are lots of different ways to treat itch, and as we discussed in our last episode, there are lots of different reasons why people can be itchy. So to start out, we start with the safest things that are effective for at least a lot of different types of itch, and we start off with just being gentle with your skin. I think we've talked about gentle skin care before.

What exactly dermatologists mean by gentle skin care is perhaps a little bit up in the air, but in general you want to avoid things like harsh soaps and harsh cleansers and irritating cosmetics, and just use gentle things on your skin instead.

Dr. Tarbox: I like to tell people to kind of think about how they would take care of a baby's skin. When we think about our skin, it's actually kind of like a living, breathing fabric. Its job is to protect us from the outside world, and it's designed to be able to do that by itself. We interfere with that function a lot by what we put on the skin. So we use a lot of things that can be potentially irritating, like harsh detergents. We also add things that might cause irritation, such as fragrance and other topical products with harsh preservatives.

So when you have itchy skin, really babying that skin is key. Very gentle cleansers that don't remove too many of the essential oils from the skin, that don't strip that natural oil that's there to protect it, and then things that aren't heavily fragranced to be irritating, using good gentle moisturizers that replenish the moisturization of the skin.

Dr. Johnson: We've talked about some specific products in other episodes, but white Dove bar soap tends to be a good choice if you're just looking for a soap to use in the shower, for example. By the way, we're not getting paid by any manufacturers of these products.

Dr. Tarbox: Not sponsored.

Dr. Johnson: Then for your face, just a gentle facial cleanser. There are lots of brand out there that make good ones, like CeraVe and Cetaphil and Aveeno and a bunch of others. So those are good choices for the face.

And then beyond that stuff, moisturize your skin. Dry skin can be super itchy, so if you want to go after your itch, you can moisturize your skin. I've had a number of patients, and not to stereotype them, but many of them were adolescents. They're kind of itchy, but they just don't want to be bothered to put moisturizer on their skin. So if you rather would be a little bit itchy than put moisturizer on your skin, that's your choice. But if you would like to moisturize your skin, and I think we've talked about this before as well, the thicker and greasier they are, the more effective they are at moisturizing your skin.

So I didn't realize this until I became a dermatologist, but moisturizers do not work by adding moisture to your skin. They work by preventing your own moisture from evaporating away from your skin. That's why the thick, greasy ones that prevent your own moisture from evaporating away tend to be the most effective.

I like plain old Vaseline or petroleum jelly. It's cheap, does a good job, but it's messy, so it's not for everybody. I also like shea butter and coconut oil. And then anything that's got to be scooped out of a jar or squeezed out of a tube is going to be more effective than things that pump out of bottles. Though if you're just a little dry or a little itchy, then the things that pump out of bottles might be fine and are more convenient.

Dr. Tarbox: If you've gotten past the moisturization stage, you're doing your gentle skin care, and you're still itchy, there are some things that are available over the counter that can help with itch. One of my favorite ones is an ingredient called pramoxine, which is actually a topical anesthetic that's very good at treating itch and it's very gentle to the skin. So you can get topical products with pramoxine over-the-counter such as Sarna Sensitive, which is a cream that's made for treating itch, as well as the CeraVe anti-itch cream or lotion, which also contains pramoxine, which is very helpful for itching.

What else can you use topically?

Dr. Johnson: Some people will use topical Benadryl, but Benadryl is not great topically. No offense, Benadryl. The generic name for Benadryl is diphenhydramine, and if it's in a cream, it doesn't really do anything. But you can take antihistamines like Benadryl or others by mouth and that can help with itch if your itch is related to histamine. They are antihistamines after all. The main itch that's related to histamine are hives. So if you get hives, then think about an antihistamine. There are a lot of them out. There are generic names. There are brand names. You want to use a non-sedating when you don't want to be sleepy. Xyzal or levocetirizine, that's two names for the same thing, is one of the least sedating ones. And then Benadryl or diphenhydramine is one of the more sedating ones that you might want to use in the evening.

Dr. Tarbox: And do remember that antihistamines can make you sleepy. They may also interact with other medications, so if you take a lot of other medications, you may want to discuss with your doctor which antihistamines would be safe for you to use.

What are the kinds of topical things over the counter might people use, Luke?

Dr. Johnson: Dermatologists love topical steroids, and there's a reason we love topical steroids. They are effective and safe. So the over-the-counter topical steroid that is available is hydrocortisone 1%. It's totally safe to use. You could use it on your face every day forever and you would probably be fine. You can put it on babies. It's pretty wimpy. It's so wimpy the dermatologists sometimes look at it and say, "Is that doing anything beyond just being a moisturizer?" It probably is. There's a little bit of hydrocortisone in there. We have access to much stronger ones if you want to use prescriptions, but you might not need it.

So if you're a little bit itchy, especially if the skin looks a little bit pink plus is itchy, that could mean there's some inflammation there, and steroids are really good at calming down inflammation. So you can start with a hydrocortisone product. The ointment tends to work better than the cream. So if you can find hydrocortisone 1% ointment, that's the strongest topical steroid you can get over the counter and is still very, very safe.

Dr. Tarbox: If the itch is still uncontrollable past those different control mechanisms, sometimes dermatologists will turn to something called light therapy where we actually use some of the properties of natural light to help control itching. How do you use it, Luke?

Dr. Johnson: Light therapy is also called phototherapy, so if you've seen that or heard us talk about it, that's the idea. And the way I like to explain it is that there is a particular wavelength of light that helps calm down the immune system in the skin. The immune system is often involved in itch, so this tends to be effective for lots of different kinds of itch.

It's very safe, can be quite effective depending on the person. The main problem is that it is inconvenient. Not all dermatologists, but a lot of dermatologists have machines that produce this wavelength of light, and the machines often look like little closets, little rooms, or sarcophagi. You go stand in one and then this special light shines all over your skin.

The problem is you have to do it three times a week for at least three months to really see if it's helpful, which is not convenient because you have to drive to the dermatologist's office three times a week for three months probably during normal work hours or school hours. You're not really in the machine for very long, usually just one to three minutes, but it's the commute and everything that's really a hamper. But if you can make it work for your schedule, it can be a good idea.

Dr. Tarbox: And we sometimes also use outdoor sunlight for patients who are itchy when they can't get into the doctor's office. That does have to be done with some thought because, of course, sunlight can also cause sunburns, and in high doses over long periods of time can cause skin cancer.

So if you do have a chronic itching problem that's not under control, you may need some guidance on how to use some of these mediators to help improve the itching.

What about other medications, Luke? Is there anything else available to treat itch?

Dr. Johnson: Oh, yes. Itch fortunately, over the past five years or so, has been the subject of more research than in the rest of human history. We're finally believing Dante, that it is miserable to be itchy.

So if you've tried a bunch of this stuff and you're still itchy, then a dermatologist or another doctor might prescribe you various types of medicines to help you out. The first part of our job is to figure out if we can identify what exactly is making you itch. So dermatologists or other doctors might do some lab work, for example, to see if there's a problem with your thyroid, for example. Or we might do a skin biopsy where we take a little piece of your skin so we can look at it under the microscope to see if that might shed some light on why you might be itchy.

So depending on what's going on will help us decide what kind of medicine that we should use. For example, if you have thyroid disease, then you can take thyroid medicine. That should help your itch.

Otherwise, sometimes we're stuck using other therapies that are useful for various types of itch. So for example, we can use the type of medicine we call systemic immunosuppressants. They have several different names like Methotrexate and Azathioprine, and they're pills that you take by mouth that just calm down your immune system overall. So as you might guess, they have some potential significant side effects. That said, most people who take them do fine and they can lead to a lot of relief.

Dr. Tarbox: When we face chronic itch, sometimes patients will also have distress in the form of sleep loss. Some patients experience anxiety. Others experience depression. And of course, these are very important things to treat.

We've also found that addressing the patient's internal environment through means such as cognitive behavioral therapy can improve the sensation of itch as well as the suffering that comes from it.

So some patients improve from understanding and having a sort of presence mindset when they're dealing with itching, sort of an acceptance, "Yes, I'm itching right now. It doesn't mean anything bad is going on. This is what I can do to help make this feel better." A little bit of a wellness approach to dealing with chronic itch when there's not a whole lot else we can do, but that can also be beneficial. And treating that internal environment can sometimes lead to some resolution of the skin symptoms.

Dr. Johnson: On a personal note, when the pandemic started, I began a meditation practice, mindfulness meditation, and I think it has helped me out. Not that I was necessarily having a problem with itch, but this business of mindfulness and just being present and feeling the body's sensation and not getting wrapped up in the sensation but just noticing it and acknowledging it, I can understand why that would help somebody who is itchy get over it. Not the way the mindfulness people would describe it, but . . .

Dr. Tarbox: Cope with it. They can cope with it.

Dr. Johnson: Adjust your perspective on it.

Dr. Tarbox: Yeah. I think that's great. And even for some patients, hypnosis has been helpful for treating itch. So there are lots of different ways to go after chronic itching. It is one of those final frontiers in dermatology that we've got a lot of interest in, and there are new medications coming out to help treat it. But now that we understand how we can help prevent the itching, how we can treat our skin when we do itch, and ways we can cope with it when we can't get rid of the sensation, hopefully we can make everybody just a little bit more comfortable.

Dr. Johnson: Before we say goodbye today, I just want to talk about a couple more prescription medicines that are available just because I think they're cool and maybe you'll think they're cool too.

So if your doctor thinks that there's something going on with your nerves, your nerves are extra twitchy or firing and that's what's making you itchy, then they might prescribe a medicine called Gabapentin, or there's a similar medicine called Pregabalin. Those can help as well. They're quite safe, though again they can make you a little bit drowsy, kind of like antihistamines, if they're given in high enough doses. But they can be pretty effective.

Cells in your body talk to each other with little tiny chemicals and some of those chemicals have a special name. They're called interleukins, and I'm not just saying that because my name is Luke…

Dr. Tarbox: They're not “interMICHELLEns”? Come on, man.

Dr. Johnson: No “interMICHELLEns” out there. There's a whole bunch of them and they all have numbers, and in medicine we abbreviate interleukin as IL. So there's IL-4 and IL-13 and all kinds of ILs. But it's been discovered that IL-31 is strongly associated with itch, and so there's a new medicine that's in development nemolizumab. It has shown to be very effective for people who are itchy if they have particular itchy dermatologic conditions like eczema or even just itch and we're not really sure why. So if you are really itchy and you've tried a bunch of stuff and nothing has helped, there is hope on the horizon.

Dr. Tarbox: Well, thank you guys so much for joining us today. We've really enjoyed having you here to learn how to take better care of the skin you're in. Luke, you and I have another podcast.

Dr. Johnson: We sure do sure do. It's called "Dermasphere." It's intended for dermatologists and for the dermatologically curious. So if you're like us and kind of nerd out on a lot of the science aspects of dermatology, then you might want to check it out.

Thanks, of course, to our institutions. Thanks to the University of Utah for supporting the podcast, and thanks to Texas Tech for lending us Michelle. And thanks, of course, to you, listeners, for hanging out with us today. We will see you next time.