Getting rid of stubborn itching

It seems like a straightforward subject, but when I was asked by an Intelligent Medicine listener about how to get rid of a stubborn itch, I undertook some research. Boy, was I surprised!

There are myriad causes of itch, medically-termed pruritus, and a wide array of solutions. Solving stubborn itch problems is not simply a matter of applying some steroid cream with a little local anesthetic like lidocaine, or taking oatmeal baths.

A vicious cycle

Itching may seem to be localized in the skin, but it’s often amplified by brain circuits via a process called “neural activation”. It’s not “all in your head”, but calming overactive brain centers associated with nociception—unpleasant sensations—can help break the cycle of chronic pruritus.

Itching can be caused by external factors like an allergen or a bug bite, or driven by an internal trigger like histamine overload—sometimes called mast cell activation syndrome (MCAS)—or a liver or kidney problem.

Dry desiccated skin due to a vitamin or mineral deficiency or lack of essential fatty acids can promote skin itching. I often tell patients and followers that smearing expensive potions on their skin may be less effective than consuming key nutrients: “Get a lube job from within!”

That’s where veterinarians outperform medical doctors. They frequently see dogs and cats with the “mange”—itchy, flaky skin that prompts intense scratching or licking. They’re keen to recommend nutritional supplements, rich in Omega-3 fatty acids, zinc and other antioxidants; the formulas are often hypoallergenic, free of culprit proteins; by contrast, their MD counterparts seldom consider nutrition as a contributor to skin conditions 

Why does a bug bite itch more after you eat?

I’ve noticed a funny thing after I get a bug bite. The cardinal rule is “Try not to scratch!” The physical pressure on the skin damages skin cells, creates more inflammation, and releases more histamine. Persistent scratching sets up an “itch/scratch cycle.” So, I stoically endure, distract myself, and usually the itch abates.

But hours or even days later, after I eat, the bug bites seem to reactivate, causing a resumption of itching. Weird! This is because eating causes more blood flow to the skin, delivering immune cells and histamine. The amplification is even more pronounced if you eat histamine-rich foods like cured meats, aged cheeses, fermented foods, or red wine. Sugary or high-glycemic foods can also be triggers. Additionally, eating flips our autonomic nervous systems into parasympathetic (rest and digest) mode, which renders you more susceptible to allergic reactions. 

A bug bite can even set off a nasty chronic itch called an “id reaction” which may be away from the original bug site or skin irritation, representing a delayed hyperactive immune reaction. Topical, oral or even heavy-duty injectable immunosuppressant drugs may find a role in treating these cases. 

Infections

And yes, skin infections can cause itching. Fungi, especially, can exacerbate skin inflammation—ask any woman who’s experienced the misery of a vaginal yeast infection. Many prescription skin formulas combine topical steroids with antifungals. Patients often obtain relief by adhering to a low-carb Candida diet.

Alternatively, parasites may cause skin symptoms. Microscopic mites can burrow into the skin; GI parasites can generate antibody responses that heighten body-wide itch. Identifying and eradicating the invaders is a prerequisite to recovery.

A maddening itch can sometimes accompany a viral infection caused by a reactivation of a prior bout of chickenpox—shingles. It’s not in the skin; it’s in the nerves. Hence, it may require powerful nerve meds to quell. 

Could it be a sign of something else?

Persistent body-wide pruritus may be indicative of a deeper problem. In a type of liver problem called cholestasis, bile ducts within the liver become blocked and bile residues accumulate in the skin. This can occur in pregnancy, where hormone changes can sensitize skin anyway, but a more serious condition called intrahepatic cholestasis of pregnancy can cause temporary misery. A well-researched remedy is the supplement Sam-E. 

Alternatively, severe persistent itching may be a sign of kidney failure—or be an occasional herald of lymphoma or leukemia.

Obscure fact: While a keto diet may help eliminate food allergen-caused itching, some people just embarking on keto may experience an itchy, red “keto rash” on their neck, back and shoulders. Called prurigo pigmentosa, it may be relieved by easing up on carb restriction for a while.

There’s also exercised-induced itching, sometimes with hives, surprisingly common among runners. For swimmers like me, prolonged immersion in chlorine can produce itchy rashes—for which the only solution seems to be to limit pool time.

MCAS

Mast cell activation syndrome (MCAS) is a condition underlying chronic itch and other systemic symptoms. Its hallmark is elevated levels of histamine and other substances released by hyperactive mast cells. Unlike seasonal pollen allergies, and anaphylactic reactions to food or insect stings, MCAS sufferers are their own allergy factories; they’re generating symptoms from within due to a complex interaction of genetics and triggering factors like environmental toxicity, microbiome imbalances, hormonal fluctuations, pathogens, and nutritional deficits. 

Antihistamines may relieve symptoms, but expert help may be needed to unravel the underlying causes of MCAS.

Breaking the vicious cycle of neural activation

Once a skin reaction because chronic, especially when it creates a vicious cycle of itch/scratch, a two-way skin/brain circuit may be established that perpetuates the misery. Brain centers associated with nociception—the body’s awareness of unpleasant sensations—become hyper-aroused.

Pruritus specialists may deploy antidepressants, nerve pain drugs like Neurontin or Lyrica, or even drugs ordinarily used for obsessive-compulsive disorder to calm the brain and break the vicious cycle. New selective opiate drugs are being developed that target the nerves without the sedating effects of common opiates; paradoxically, some people experience itching when they take traditional opiate painkillers like codeine. 

Substance P blockers (known as NK-1 receptor antagonists), originally developed as non-sedating and non-addictive alternatives to opiate painkillers, are an emerging class of oral medications used to treat severe, chronic, or refractory itching.

There’s even a role for CBT (cognitive behavioral therapy) in combatting debilitating pruritus. They can’t wish their itch away, but subjects learn to “contextualize” their symptoms by not allowing them to become the bane of their existence. 

Finally, researchers are exploring the use of transcranial magnetic stimulation (TMS), the external application of powerful magnetic fields that converge on specific brain regions, to tamp down neural activation in hardcore itch sufferers.

What works

Common skin treatments include soothing emollients, topical steroids, antihistamines, or anesthetics like lidocaine. Innovative formulas even incorporate topical ketamine, which “reboots” nerve impulses from the skin. 

Urea is a common ingredient in anti-itch formulas due to its ability to attract moisture to skin cells. Common nutrients added to natural skincare products include niacinamide, bioflavonoids like quercetin or grapeseed, antioxidants like C and E, linoleic acid, and vitamin D.

An innovative application of cosmeceutical technology to skin itch is a newly-discovered B12 topical. Clinical studies have demonstrated that Vitamin B12 creams significantly reduce itching, scaling, and dryness associated with atopic dermatitis (eczema) and psoriasis. It works by scavenging excess nitric oxide, a compound whose over-production in skin lesions can cause redness and itching. B12 also seems to curb inflammatory cytokines. 

For some, moisturizing with extra virgin coconut oil provides relief from itching; for minor inflammation, aloe vera delivers benefits. 

Finally, there’s capsaicin, a derivative of hot peppers. It works by “fighting fire with fire”; application of capsaicin to itchy areas initially stimulates skin receptors, but it ultimately exhausts their stores of substance P, a chemical messenger responsible for pain and itch. Care must be taken to avoid applying it to open wounds or broken skin. 

It turns out there’s a lot to know about a simple condition like skin itch—a myriad of causes, requiring skillful diagnosis, as well as a plethora of treatment options, both natural and pharmaceutical. Email us via questions@drhoffman.net to share your favorite itch solution!