Habit Reversal Information

An interesting discussion from atopicskindisease.com about a more behavioral approach to dealing with the itch-scratch cycle of eczema, and how the common complication of lichenification can be both recognized, and effectively treated.

Habit reversal and chronic atopic eczema in childhood

Dr Christopher Bridgett, Psychiatrist, London, UK, & Dr Peter Norén, Dermatologist, Uppsala, Sweden

Much of the focus in the standard treatment of atopic eczema aims to deal with acute flare-up, or inflammation, and one of its main symptoms: itchiness. The related unremitting itch-scratch cycle is familiar to everyone involved. But when scratching because of itch is repeated often enough it can become a habit – then scratching happens without itch, and without awareness. This damaging complication of atopic eczema reduces the effectiveness of usual treatment.

The red, dry, thick and flaky skin above is chronic atopic eczema, also called lichenification. It has been caused by habitual rubbing and scratching. Where the skin has been protected by a shoe, it is clear of eczema.

When chronic atopic eczema happens like this, saying “Stop Scratching” can only make things worse….and wearing gloves and keeping nails short… may not help.
It is important therefore that a recent Swedish study – see below – has demonstrated that what is effective for chronic atopic eczema is a treatment program that combines habit reversal, a behavior modification technique, with optimal topical treatment.

For success with habit reversal some preparation is needed. First, understanding the problem is important – then, making some time to solve it: perhaps 3 or 4 weeks. The program is simple and easy to learn. It is carried out at home, but help from others may be needed.
Before starting habit reversal, awareness of what is happening is necessary. Over a few days a younger child is observed to see especially when, where and how scratching and rubbing is happening. For older children scratching episodes are counted on a counter, and totals recorded.

Once this awareness training has been completed, habit reversal is started. For all scratching and rubbing by younger children someone needs to be there to provide simple skin-safe diversions and distractions: hand holding, drawing activities, and playing games – all without saying “stop scratching”. Plans are made in advance, especially for difficult situations. Older children can help themselves by learning how to make fists for 30 seconds instead of scratching, then pinching any itch until it goes away. Others can help by giving positive prompts! With persistent practice habit reversal works really quickly.

It is important for success with this program that prescribed creams and ointments are used correctly at the same time as habit reversal. With this combined approach – habit reversal and optimal topical treatment – chronic eczema can heal quickly.

Then it is important to know how to keep the skin in good shape by dealing quickly with eczema flare-ups.

You can find out more habit reversal and atopic eczema at www.atopicskindisease.com.


The positive effects of habit reversal treatment of scratching in children with atopic dermatitis: a randomised controlled study
Norén, P et al (2018) British Journal of Dermatology 178 (3): 665-673.