Habit Reversal and the Combined Approach

An approach that combines behavioural modification with optimised topical treatment is helping people break the cycle of scratching and get on top of their eczema flares. Dr Alpa Kanji explains how it works. This article was published in Exchange 178, December 2020.

Eczema can be a highly distressing condition to live with. The psychological burden of living with a chronic skin condition may be substantial, causing feelings of social isolation, embarrassment and low confidence. Even its physical effects – itchiness, sleep disturbance, sore, broken skin resulting from scratching – take their toll on people’s emotional well-being.

The problem with scratching

A key feature of eczema is the itch. It is understandable that many people respond to this by scratching, picking or rubbing the skin to get relief. However over time, this scratching behaviour can become generalised and habitual. The person then starts scratching in response to other stimuli such as stress, tiredness and even boredom – often without being aware of what they are doing.

The mainstays of eczema treatment are emollients and topical steroid creams.

Emollients help to strengthen the skin barrier and reduce the dryness, while topical steroids have an anti-inflammatory effect on the skin. However, as long as there is habitual scratching, the skin never fully heals and the eczema persists.

This longstanding eczema is referred to as ‘chronic’ as it persists for weeks and months in contrast to the short-lived flares of eczema, which are ‘acute’. Chronic eczema can be recognised by thickened, leathery skin in easy-to-reach places. Once the habitual scratching is ‘switched off’, this skin returns to normal.

How habit reversal can help

To fully heal the skin and eradicate the chronic eczema, we need to address the habitual scratching and rubbing: enter habit reversal.

Habit reversal is a behaviour modification approach originally used by psychologists to successfully eradicate nervous habits such as hair pulling and nail biting. This technique was first adopted for people with eczema by Dr Peter Norén, a Swedish dermatologist. Habit reversal is simple and easy to learn and helps reduce scratching behaviour, allowing chronic eczema to heal.

The combined approach

When habit reversal is used alongside optimal topical therapy (in other words, steroids and emollients), this is known as the ‘combined approach’. This approach was first introduced to the UK in 1989 by doctors Richard Staughton and Christopher Bridgett and became established at London’s Chelsea and Westminster Hospital.

The combined approach typically involves a series of four-to-six consultations over two months. First, we help the person to develop an increased awareness of their scratching behaviour and associated stimuli by recording episodes of touching, scratching or picking the skin, using a tally counter. Then we teach them how to minimise the number of scratching episodes. Once the scratching stops, the skin can heal.

Active participation is an essential aspect of this programme: we teach the person how to help themselves and give them homework to do after each session. We monitor their progress through the tally counts, as they record the number of scratching episodes each day. These may start off ranging from 100 to 1,000 episodes per day. By the end of the programme, they should be substantially reduced.

Next, we optimise the person’s medication. We may prescribe stronger preparations for the short duration of the programme in a safe and supervised manner.

Does it work?

This simple technique has been shown to work. Several published studies have shown a reduction in chronic eczema when habit reversal is combined with optimal topical treatment, compared to topical treatment alone.

The combined approach can be very empowering as people begin to realise that their efforts have a direct, positive impact on their skin. This promotes attitudes of active optimism and self-help, which are important aspects of this programme.

Once the person has successfully completed the programme, we show them how to recognise and eradicate eczema flares quickly, by applying topical treatment correctly. We discuss their triggers for flare-ups and help them to separate those into ‘avoidable’ versus ‘unavoidable’. This makes it easier for them to manage acute eczema.

Over time, the number of acute relapses decreases and the period of remission between each episode becomes longer. Skin with a tendency for eczema can be dry, so the person may need to keep using emollients, but there is usually much less need for the ongoing routine use of topical steroids. Some find that the years of struggle with chronic eczema are replaced with eczema-free skin. This can have a profound effect on well-being, positively impacting many aspects of daily life.

Where is it available?

This programme is available to a limited number of adults and older children at the Chelsea and Westminster Hospital. It is also being offered at several centres in the UK but may not be readily available to everyone who may benefit from it. Former patient Sue Armstrong-Brown details each step of the programme in a self-help book entitled The Eczema Solution, which documents her journey and her experience of the programme.

Case Study: Ilaha Akhbar (19) describes the combined approach from a patient’s perspective.

I have had eczema since childhood and used many creams, ointments and stronger oral medications to try to control it. Most recently I was taking ciclosporin tablets but my eczema did not significantly improve and I was experiencing headaches so had to stop taking it.

I was due to be seen in clinic for consideration of dupilumab – a newer medication taken by injection. In the meantime, I was offered a clinic appointment to learn the combined approach and habit reversal. I was sceptical when I heard about this and thought it might be another series of ‘verbal’ appointments.

My first appointment did involve a lot of discussion. I learned the difference between ‘itch’ (a sensation) and ‘scratch’ (an action). Reducing the habitual scratching was a key aspect to breaking the itch–scratch cycle, which – along with intensive topical treatment – could eliminate the longstanding eczema. I was given a tally counter to log each episode of scratching or touching the skin and this gave me a simple way to track my progress.

I was taught to replace my scratching behaviour with 30 seconds of fist clenching until the urge to scratch subsided. I developed increased awareness of the times I scratched the most and was able to develop creative strategies with Dr Kanji to help minimise this, which have gradually become second nature. Post-shower scratching was habitual. Now, showering is preceded by an organisation of my creams and clothes so that afterwards I can rapidly get dressed, minimising scratching.

I was also taught how to apply my steroids creams and moisturisers effectively. Seeing the number of scratches decrease on a weekly basis gave me confidence that I was making progress and made me feel more optimistic. If this worked, it would mean avoiding powerful drugs in the future.

A few months later, the longstanding eczema was almost completely gone so I no longer needed to start dupilumab injections as was previously planned. I still experience flares of acute eczema, mostly associated with increased levels of stress, but I now have a set of tools that I can combine with the rest of my treatment regime to keep flares of eczema to a minimum.

Find out more

The Eczema Solution, by Sue Armstrong-Brown, is available on Amazon and other bookshops. If you decide to work through the book, consult with your GP or dermatologist.

To find out more about the combined approach and related topics, go to www.atopicskindisease.com.

With thanks to Dr Christopher Bridgett for discussion and feedback on this article.