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Habit Reversal Tip #4: Habitual Scratching
In English the words "itch" and "scratch" are often used inter-changeably - to understand habit reversal as part of the treatment of chronic eczema it is useful to distinguish these two words.
An itch is a feeling,but a scratch is an action.
At assessment consider the question "How much of the scratching is due to itch?". Sometimes, especially before registration, the first answer is "Well, most of it". But more often the response is "About 50%" or "Only some of it". When the answer is a definite "All of it" it is worth checking the diagnosis.
There are therefore two types of scratching with atopic eczema:
1. Due to itch - especially when eczema is acute, or is a "flare-up"
2. Due to habit - characteristic of chronic, or longstanding eczema
Scratching - including touching, rubbing and picking - the skin because of itch is easy to understand. Habitual scratching needs explaining. The patient handbook reasons that any behaviour that is repeated often enough becomes automatic, done without thinking and this learning process links the behaviour with the circumstances - so that then every time the circumstances present themselves, the behaviour tends to recur - automatically, without thinking, and without itch.
It is also true that certain situations proke non-itch scratching anyway - more in some people than in others - without there ever having been any itch. This has been called "the traffic light phenomenon" because, although this scratching is partly opportunistic, it tends to occur with frustration. It can also be provoked by idleness and boredom, or even just "thinking". Scratching with emotional upset is also part of this picture, though sometimes then itch is also provoked - psychogenic pruritus.
Habit reversal techniques are especially important to tackle habitual scratching, but will also deal with itch scratching - this is important, as at any given time with chronic atopic eczema there can also be acute eczema, as part of the picture.
Understanding that scratching is not only due to itch helps to explain the role of habit reversal in the treament of atopic eczema. Scratching without itch occurs especially when the opportunity allows - during undressing and dressing for example - but also with frustration, boredom and even with "thinking". This is the "traffic-light phenomenon".