BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CASE NOTES
Programme 5. - Itching
RADIO 4
TUESDAY 06/06/06 2100-2130
PRESENTER: MARK PORTER
REPORTER: CAROLINE SWINBURNE
CONTRIBUTORS:
TONY BEWLEY
CHRISTOPHER BRIDGETT
SUZANNE MCDONALD
CATHERINE WILLIAMSON
PRODUCER: PAULA MCGRATH
NOT CHECKED AS BROADCAST
CLIP
It came to be a bit of a phantom or a ghost that was following me around and in some cases left me so tired from what I was going through that I felt positively drugged out.
Well you try not to do it in front of people but then you still have to go and find a private place and have a big scratch, you know. You probably think we've got something nasty if we start scratching.
PORTER
Today's programme is all about itching - in particular itching without an obvious underlying cause like eczema or prickly heat.
I'll be finding out how unexplained itching can be a sign of underlying health problems - particularly during pregnancy.
I'll also be discovering why older people are so prone to bothersome itch - and what they can do about it.
And I meet a man whose life has been literally transformed by a simple behavioural technique that is helping him control the urge to scratch.
But first, why do people with apparently normal skin develop an itch? Tony Bewley is consultant dermatologist at Whipps Cross and the Barts and London Hospitals.
BEWLEY
Well the first thing we do is sit down with the patient and we want to find out where they're itching, how long they've been itching for, whether there's anything to see on their skin, whereabouts on their body has been itching. We want to go into a full history really, we want to ask about what sort of medication they've been on, where they've been travelling to and whether there's anything that relieves the itch or anything that gets it better and what sort of treatments that they've been having so far from their healthcare professionals.
PORTER
Well let's assume that there isn't an obvious skin cause that you can see or ascertain, how do you go about investigating these people?
BEWLEY
Well as I say the first thing that you do is you take a history and you'd go through carefully to find out whether they have any other skin disease and quite frequently itching can be a precursor of skin disease that is about to develop. So, for example, we know that patients who get a - common for dermatologists - condition called bullous pemphigoid where they get lots of blisters, tends to happen in the elderly. And we know that before they start getting blisters this particular population can sometimes have profound itch and then months later all of a sudden they start getting blisters. So we're always careful that this may be a precursor of something else that's going on. But then again we may find that there is no other skin disease and that the skin is absolutely bang normal. And then we start worrying about what could be driving this, so could this be a problem internally and in particular we'd worry about the kidneys, whether there's some kidney disease, we'd also worry about the liver and whether the liver is functioning well enough, we'd worry about the thyroid gland and we know that an underactive gland can cause itching and dryness of the skin. And then after we've taken a history from our patient then we'd want to have a look at the skin and there maybe things that will give us guides to what is the underlying cause. So we'd certainly look at the dryness of the skin and we'd want to have a look inside the mouth and see if there's any problems going on inside the mouth. And we'd certainly look at the nails, quite often the nails can give you quite a lot of information about what's going on internally within the body, so we can look to see whether there's any evidence of any iron problems or any thyroid problems or any kidney problems or any liver problems. So we'd have a good look at the patient first of all and then we'd go on to do some tests.
PORTER
And the tests presumably you're looking for - I mean we're talking blood tests on the whole are we?
BEWLEY
Absolutely so. Well mostly we're talking blood tests but to start off with we'd certainly do a blood count to look at the blood cells in the blood. We also want to test the kidney function, so we'd want to look at the urea and the creatinine. We want to do liver function tests, thyroid function tests and then we'd also for completion sake check the blood sugar.
PORTER
They're quite a diverse range of underlying problems and I suppose it stresses that itching can be quite an important symptom, there can be some quite significant underlying causes but is there a common pathway or are all of these causing itching in a different way?
BEWLEY
Well the short answer to that question is that we don't know what causes itch and we know that itch has been a symptom for just millennia, so we know from ancient Egyptian scripts that itching was something that was recognised many, many, many years ago. But we don't really fully understand what the pathways are for itch. We do know that itch is generated via nerves that connect the skin to the brain and these nerves are called C nerves - C fibres - and they tend to be rather slow conducting fibres and they seem to be related, though probably not the same as, pain fibres. And they travel from the skin in the spinal cord to the brain and at the brain they release their messages to the brain which then raises the sensation of itch in our consciousness. And the whole point of raising that sensation of itch in our consciousness is that we then have something that will relieve that itch and that's usually scratching.
PORTER
And I suppose the reflex of scratching itself can affect the skin which in some cases could perpetuate the itching as well.
BEWLEY
Absolutely. I mean the reflex of scratching, of course we all know that lots of animals scratch, so dogs, for example, might scratch when there's an insect within their coat. So we do know that scratching is probably beneficial to some extent, so in our ancestry we may have developed this reflex to try and get rid of insects or parasites or mites that might have been on our skin. But of course these days there isn't often that kind of a problem and the whole itch scratch cycle is set up for all sorts of reasons and that might be skin disease or it might be disease of the nerves within the skin or it might even be something going on within the brain itself.
PORTER
Edward suddenly developed an itch two years ago - and it started off a vicious cycle: scratching damaged his skin making him prone to eczema, which in turn made his skin itchy, which made him scratch.
EDWARD
Well it began in July 2004, Friday 15th I think if I remember correctly, and I woke up at somewhere approaching 2 o'clock in the morning with an itching feeling all over my forehead and in the back of my jaw area, near where the lymph glands are there. And it was just like rampant pins and needles in those areas, which caused me to scratch and then scratching developed across my scalp, across my shoulders, down my arms, round my lower back to the backs of my knees. And within a very short period of time I was hugely scarred and really from that date I had a sleep pattern that was hugely out of whack, I'd wake up for an hour at night with this itching, then take time to go back to sleep, wake up again at say 9 in the morning but sort of really drugged out, as if I'd lived two days and two nights in 24 hours.
BRIDGETT
Itching is a sensation which originates in the skin and travels up sensory nerves to the brain. While scratching strictly speaking is a behaviour, it's an action.
PORTER
Dr Christopher Bridgett is a psychiatrist with a special interest in the relationship between itch and scratching. He works alongside dermatologists in the skin clinic at the Chelsea and Westminster Hospital where he teaches habit reversal techniques to try and help patients control their scratching.
BRIDGETT
It's linked with picking, squeezing, rubbing, cutting and touching the skin. These are the common grooming or preening behaviours. And they can occur without itch. They're associated with a variety of common experiences like frustration, boredom, stress, tiredness, idleness, even thinking - the cartoonist will draw somebody thinking and the character will be scratching his head.
PORTER
Yeah I mean that's something that I do myself, I often scratch my head when I'm thinking. But can that get - I mean can we do that sort of scratching subconsciously so much that it actually causes problems in the skin?
BRIDGETT
Certainly in our - with our experience helping people with age atopic eczema, which is one of the common skin conditions, when it's acute, when it flares up is very itchy, leads then to reflex scratching but the scratching becomes an issue on its own, insofar as scratching is part of the human repertoire of behaviours associated with all those experiences I mentioned - frustration, boredom, stress, tiredness - and if you go into the scratching behaviour of an individual with atopic eczema you'll discover that they scratch about say 50% of the time due to itch and the other 50% will be due to circumstances. And if you give them a hand tally counter to measure the frequency of their scratching they then can see how the scratching will predominate at the end of the day, for example, or when they're taking their clothes off or when they're in the bathroom and at those times the skin isn't necessarily itching at all.
EDWARD
I wore cotton gloves at night, I slept on the duvet in a sheet to try and keep myself cool and I also tried things like when the itching was really bad sleeping with an ice block on my head, going and having a cold shower before I went to bed - those measures were DIY fixes, they weren't very effective at all. Dr Bridgett's put me on a regime of habit reversal which will take something like six to eight weeks, whereby it is designed to remove what is effectively a conditioned reflex from my day to day living. And this has already worked, I've been to see him now - I'm in day 10 and I have a clicker which I use every time I feel that I go to make a scratch on the place where it's itching and this has really flagged up for me just how often I was doing this. The number that I started with and the number I'm now on now are hugely different, I was something like 630 and I'm now on 25.
BRIDGETT
The first substitute behaviour is to tuck the nails of the hands into the palms, making a fist lightly, and to fix the arms by the side for 30 seconds. At the end of which if there's an itch the patient is taught to touch the skin that's itching with a nail or to pinch the skin that's itching until the itch has gone.
PORTER
We spoke to Edward Donald, one of your patients, who when he initially saw you was scratching 600 times a day, now he's down to just 25 episodes and that's just 10 days into his treatment, how representative is that of the sort of response that you can get?
BRIDGETT
Well it's at the very good end of the response rate. I would normally expect people to reduce their scratching by 50% over two weeks but clearly he's rocketed on and it goes to show in his case a great deal of his behaviour was habit and we'll be looking at this when I next meet him.
PORTER
But overall what proportion of your patients respond well to the therapy?
BRIDGETT
From my point of view 60% of patients who complete the programme do well. Another 20% do reasonably well and there's a final 20% who fail and they fail for various reasons, some of those come back for another treatment course later.
PORTER
Dr Christopher Bridgett talking about habit reversal techniques - sometimes known as the Noren habit reversal system - about which more information will be available on the Radio 4 action line and our website - contact details at the end of the programme.
First, let's get back to the underlying causes of unexplained itch. Tony Bewley again.
BEWLEY
I work in eastern London and many of the Asian patients are young women who have a young family and are still having regular menstrual flows and so their intake of iron may be less than the amount of iron that they're losing. And over time that leads to their body being relatively iron depleted. And it's not at all just isolated to the Asian community, it's very much a problem with the white community or the Afro Caribbean community or any other community for that matter too.
PORTER
And you're confirming the diagnosis of iron deficiency presumably - I mean we've talked about the techniques that you're using, the person might have other symptoms such as anaemia, a pallor, breathlessness or whatever but the acid test is going to be a blood test.
BEWLEY
Absolutely so, we sit down with the patient and we'd explain that we were worried that they may have low iron stores and it does seem to be low iron stores that is relevant. So many of these patients will not be anaemic, so they will not be pale, but their iron stores are very low indeed. One of the things that we know if you're low in iron is that your skin gets very itchy and that your nails can be rather fragile and now grow quite so well and actually that in fact your hair doesn't grow quite so well. So we find that younger women who find that their hair is getting a bit thinned it may be because their iron stores are really rather low. We know that the best way to absorb the iron is to take iron supplements or have an increased amount of iron in your diet. But you have to take those supplements with something that's slightly acidic, so for example we'll say to lots of our patients well look why don't you consider having some lovely spinach and then squeeze some lemon juice over the top and give that a whirl and see if that brings up your iron levels. But if they want to take tablets we say fine take some tablets and take it with a glass of orange juice and you may find that that puts up your iron levels.
PORTER
What about the response rate - how quickly would the itching get better because presumably I mean you've identified this as the cause, it may not be the cause, you've found iron deficiency therefore you treat it, how quickly would you expect to see the response?
BEWLEY
What's astounding is that these patients get better so quickly and they're so happy and so relieved and they come up to us and almost - but don't - give us a big kiss.
PORTER
Well iron deficiency isn't the only hidden cause of itch that's most common in women of childbearing age. Itching is a common complaint in pregnancy too. As many as one in four pregnant women complain of it - mainly around their expanding tummies. Usually it's harmless, but in around one in a hundred pregnancies it may be a sign of obstetric cholestasis - or OC - an often missed liver problem that can lead to premature labour, foetal distress and, in worst case scenario, even still birth. Obstetric cholestasis often runs in families and if a woman develops the problem in one pregnancy, then it's almost sure to happen in future pregnancies. Caroline Swinburne reports.
ACTUALITY
Rose's up. That's it you put your two feet together. Whose face is that - is that Fifi's or Bumble's I can't see that one.
Fifi.
Oh that's Fifi, well put that over there then is it.
That's Fifi.
What's that bit?
SWINBURNE
Suzanne McDonald plays with her younger daughter, three-year-old Grace. Grace and her older sister Shona were both born prematurely and Suzanne's first child was stillborn. Although Suzanne displayed clear symptoms the condition was undiagnosed throughout her first and apparently straightforward pregnancy.
MCDONALD
No morning sickness, no aches, pains, absolutely nothing until I was in the second trimester and started to have very severe itching on my nipples. It was a very intense itch, it wasn't something that scratching was alleviating - normally you get a rash - like a rush of adrenaline or something when you've found a gnat bite and you've got it and you can scratch it, there was no relief by itching or scratching the itch. So it was very, very intense, under the skin, couldn't get to it type of itch. I did mention it to a midwife who explained to me that was very common in pregnancy and to try some E45 cream.
SWINBURNE
At 34 weeks into her pregnancy Suzanne suffered stomach cramps and was taken into hospital.
MCDONALD
The midwife couldn't find the heartbeat with the monitor. She then got the sonic aid, tried to do it that way and at that point then obviously realised that there must have been a problem and they then brought in a portable ultrasound machine and it was then that they advised us that they could find no heartbeat. And I do recall my husband saying so what does that mean then and they explained to us that the baby had actually died. No reasons why, they didn't understand why, they couldn't tell me why and it was just absolute devastation and disbelief and it was during part of this that my husband was explaining that the only thing that I'd ever complained about during the pregnancy was this itching and then obviously alarm bells started to ring with the registrar, liver function tests were carried out and they then realised that my liver count on the liver function test was extortionately high and that's the first time we heard the condition of obstetric cholestasis mentioned.
SWINBURNE
Bile produced in the liver normally flows into the intestines to help with the digestion of food. When a woman has OC this flow is reduced and this leads to a dangerous build up of bile acids in the blood. It's been shown that prematurity and foetal distress occur more frequently in women with high bile acid levels in the blood, possibly because they interfere with the baby's heart and cause cardiac arrest. At Queen Charlotte's Hospital in West London consultant physician Dr Catherine Williamson cares for women with medical problems in pregnancy. She says if a woman suffers itching it's vitally important she's tested for OC.
WILLIAMSON
The standard liver function test checks chemicals that are released by the liver if there's any harm done to liver cells. If they are abnormal I think it's important to check the bile acids or if somebody continues to have the same itch, even if their liver tests are normal, I would recommend in my own practice checking bile acids.
MCDONALD
I mean when I realised that a simple blood test could detect this condition, that's when I got really angry. They could have intervened and everything could have been oh so different.
SWINBURNE
When the condition is correctly diagnosed women can be prescribed creams to help relieve the itch. There are also drugs which may help to improve the liver function and return bile acid levels to normal.
WILLIAMSON
A few months ago there was a big study from a Scandinavian group that compared two drugs, one is called ursodeoxycholic acid, might be easier to call it Urso and the other is dexamethasone which is a steroid. And their results indicated that women who have raised bile acids, above a threshold level, which we think may relate to complications, that group respond well to Ursodeoxycholic acid in terms of improved itch and improved liver tests and reduction in the bile acids. They didn't have such encouraging data for dexamethasone and most of the other drugs that have been tested in studies haven't been so obviously useful. The other thing that is often given is vitamin K. Because this is a liver disorder it may affect the way the liver makes the factors that help us clot when we have a bleed and therefore it seems a sensible idea to give vitamin K. Although again no big comprehensive study has been done to prove that.
SWINBURNE
Essentially women with the condition must be carefully monitored and if necessary may be delivered early. When Suzanne McDonald became pregnant for a second time she insisted on a referral to the team at Queen Charlotte's. Here she had regular blood tests and was treated with Urso. All the same her condition soon gave cause for serious concern.
MCDONALD
When I was 29 weeks pregnant and the liver function test was just going up and down, up and down and because the Urso wasn't working and then I started to get the very dark urine again and then the day that or the night before she was actually delivered I started to get itching in my fingertips and kind of a sensation in my feet but not really an itching and it was then they took further blood tests and I was being tested then every day and it was then that they decided delivery had to be done that day.
WILLIAMSON
Within our own group we're mainly trying to understand what causes the condition. So we're looking at genetic factors and we're looking at how the female hormones can cause abnormal handling of bile acids by the liver.
SWINBURNE
Even if things have improved in the past few years amongst medical practitioners Suzanne McDonald still thinks the condition should be much more widely publicised, especially amongst pregnant women.
MCDONALD
You see even on the television all these pregnancies - preeclampsia and other conditions are taken so seriously on the soap operas even, I've never yet seen anybody on the television with cholestasi. And all the mums that I've met from the nurseries and playgroups and schools, mother and toddler groups, none of them have heard of obstetric cholestasi.
PORTER
Suzanne McDonald talking to Caroline Swinburne. As I said before that report, itching is a common complaint in pregnancy and normally nothing to worry about - but always mention it to your midwife or doctor, especially if it affects parts of the body other than your tummy, particularly your palms or soles, a common complaint in women with OC.
Now back to Tony Bewley and another cause of unexplained itching - over-zealous personal hygiene combined with the inevitable passage of time.
BEWLEY
The older that we all get the drier our skin becomes and the less able our skin is at producing the oils that are part of our skin barrier. So in young adults we know that the oil production is rather high and that can lead to even problems such as acne. And we know that the oil that the skin produces is not uniform all over the skin, so we know that we're much more oily on our face and in the middle of our chest and we're much less oily on our lower legs. So one of the commonest places to get itchy skin in the elderly is on the lower legs. And then that compounded with Western culture, where we all shower about a million times a day and use lots and lots and lots of soaps and detergents and wash away the small amount of oil that our skin is producing then that can lead to relative loss of even the small amount of oil, so the skin gets dry and when the skin gets dry it gets unbearably itchy.
PATIENT
It started about five years ago. First in my scalp, identify my scalp starts itching, especially the front of my forehead. And there's a little patch at the back here, one little spot at the back, that itches all the time. And the front of my head it's getting so tender, you know, very tender from this - from the continuous itching. And I don't scratch, I try not to scratch, I give it a pat sometimes when it's too bad because I can imagine if I scratch it, it will all get sore. As it itch the hair it falls out, which if you notice you can see that - how the hair - and I'm a person who used to have a lot of hair in the front and it's gone all thin from the itching. And then at the bottom of my feet - both feet - right at the soft part of my feet start itching and you know if you scratch it you get all blistery, so I try not to scratch which makes it even more frustrating. Sometimes I'm out at the movies if I'm out at the pictures and sitting down and my two feet are itching and my scalp is itching it's very uncomfortable, very embarrassing. Sometimes I go to bed at nights and I can't sleep, my scalp's itching, the bottom of my feet itching. The doctor has given me cream and lotion for the scalp. The lotion for the scalp, the cream for my feet and the rest of my body. But using these creams and things it helps a little bit but it doesn't stop it, that's the thing.
BEWLEY
And you don't have to spend hours putting moisturising creams on the skin, it's very simple you just - couple of minutes and you quickly smear some nice moisturising cream onto the skin, making sure that you move down the skin in the direction of the hairs rather than against the direction of the hairs because we know if you go against the direction of the hairs you can force moisturising cream into the hair follicles, which can lead to spot formation or follicle - folliculitis formation. And if you do that very quickly a couple of times a day, say, for example, when you step out of a shower or before you go to bed at night then that will give you excellent barrier function and give you a really nice smooth skin. If it doesn't settle though we have got other tricks up our sleeve and that can be antihistamine tablets, some of which can make you feel a bit sleepy but some patients who have had itch for a long period of time are rather sleep deprived and they like the idea that something's going to give them a bit of relief from their itch and actually make them feel a bit sleepy so that they have a reasonable night's sleep.
PATIENT
He decided to prescribe some antihistamine tablets for me, they didn't really help very much to start with but he said you had to take them for quite a long period of time for them to make any difference. Then it just seemed to calm down and more or less stop but that took about three months for it to really improve at all. I've been on them on and off about four months or so. But you can actually take antihistamines indefinitely.
BEWLEY
And if that doesn't work then we have other tricks up our sleeves like sunlight treatments, what we call photo therapy, where a patient can go into a specialised cabinet and have what's called narrow band UVBs. So sunlight treatment with all the more nasty wavelengths of sunlight removed and just the relatively safe wavelengths exposed to the skin. We know that it can help the skin cells to mature more evenly and more effectively, we know it can promote greater oiliness of the skin and so repair some of the skin's barrier function. We know that it can thicken the skin and again repair some of the barrier function of the skin. And we know that it can sometimes have an effect on the immune system of the skin and so switch off any inflammation of the skin which is driving some of the itch.
PORTER
Clearly there must be a group of people in whom you look for all these different causes of itching, you find nothing?
BEWLEY
Unfortunately, despite all our sitting down with patients and examining the patient and doing the appropriate tests there are a group of patients for whom we can find absolutely no cause for their itching and that's not that rare. We say okay we can't find a cause for your itching but we have got ways of making this better. And patients for whom - who have had this intractable itch for a long time again are often so relieved to have the itch settled that they don't mind the fact that actually doctors don't know what the cause of their itch is.
PORTER
Consultant dermatologist Tony Bewley.
If you have any queries arising from the issues raised in today's programme then please call the action line or visit the website - details of both in a moment.
Next week's programme is all about arthritis. Non steroidal anti-inflammatory drugs, like ibuprofen and diclofenac, are the mainstay of therapy for most people with arthritis, but recent research has suggested that some types may double the risk of heart attack. We'll be looking at the facts behind the headlines. And if you are taking anti-inflammatories, and have been worried by the recent reports in the press, then we'd like to hear from you - I'll be putting your queries direct to consultant rheumatologist David Eisenberg.
To get in touch call the action line on 0800 044 044, or e-mail me via the website at bbc.co.uk/radio4.
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