“EMD Urgent Protocol” reduces scratching behavior in atopic dermatitis and pruritus nodularis

A patient with severe and long-standing eczema asked clinical psychologist Du Douxen to treat her complaints with EMDR (Eye Movement Desensitization and Reprocessing). This technique was developed to treat trauma, but given the severity of the complaints, it is worth a try. And with success. As a follow-up, research was conducted on patients with atopic dermatitis and pruritus nodularis. These subjects gained more control over their scratching behavior via EMD – without R: the urge to scratch was significantly reduced or even disappeared.

The intervention we applied, similar to Do Doeksen, is relatively simple, explains Mathijs de Veer. He works as a medical psychologist and PhD candidate at Erasmus MC. In collaboration with the Department of Dermatology, he conducts research into psychological treatments for scratching behavior, under the supervision of Leoniki Kranenberg, associate professor/mental health psychologist, and dermatologist Rick Walbor Spuy, MD. “In our therapy, we work to reduce the strong urge to scratch, without working with the past as with EMDR,” Kranenburg says. “We are not reprocessing, but we are working on desensitization, which reduces cravings.”

Scribble in ideas

“We do this by first asking patients how serious the desire is,” De Vere adds. “It is not the degree of itching, but how high the urge is on a scale from 0 to 10. Then we ask them to think about where they feel the strongest urge to scratch and to do in their mind what the body wants, such as scratching the hardest. At the same time we distract the patient, For example by following the movements of our fingers or the light with our eyes. As a result, there is no room in their mind to think about the desire and scratch. You keep repeating this – scratching your imagination and distracting yourself over and over again – until the desire completely subsides. When the desire disappears, they may make the spot white In their minds. This technique comes from hypnotherapy. The color white means a quiet place that has been adequately treated. For example, in the first session, you visit all the places on the body where patients feel like scratching. You can usually “treat” all the areas Within one hour.

distraction

The study includes 4 moments of contact: two treatments and two telephone calls. De Vere: “It turns out that follow-up is very important to keep motivating people. We do it 3 days after the first session and after the second session. The intention is that people also do these exercises at home when they feel like scratching. In your particular case – at home or At work or on public transport – it’s a bit strange to follow your finger. It’s about distraction. Patients can also play games on their phones like Tetris. The point is that they are doing something that requires cognitive effort and at the same time scratching the surface of the imagination. The decreased desire gives the skin More rest allows it to heal better, so that new crusts or wounds do not form again.

Useful insight

In addition, a very simple app was developed that allows research participants to indicate on their phones whether they have been scratched. The app only has two options: When people scratch, they check it in the list. At the end of the day they point out how bad the itching was that day and how bad the scratching was. Kranenburg: “Objective and subjective assessment: If very few moments of scratching are recorded that day and the patient indicates that the scratching was very serious that day, then something is wrong.” A second study has now been completed with 5 patients with pruritus nodularis. The results will be announced next year. This second study lasted 8 weeks and yielded several measurement points. Although the amount of research is limited, well-founded statements can still be made based on these data. Kranenburg: “Moreover, people report that recording alone has made them more aware of their behavior. This insight is also helpful; in this way, the study itself acts almost as therapy.”

Joint outpatient clinic for dermatology and psychology

Erasmus MC has a joint clinic of dermatology and psychology. According to de Vere, collaboration between dermatologists and medical psychologists is very important. “As psychologists, we can really offer a lot to dermatology patients, in different fields. We can also apply this new method to more skin diseases. It is gratifying for dermatologists to see that it works, especially in patients with pruritus nodularis who Sometimes they can’t handle the medication on their own.It actually gives the patient a boost if they can reduce the urge to scratch on their own.

incentivize

“Motivation is very important to the EMD method,” Kranenberg says. “It’s about changing behaviour, and that’s difficult, especially because you know that scratching brings relief in the short term. Patients from the first study were contacted after one year to hear how they were doing. Sometimes exercise was no longer necessary and motivation had decreased for some. So Motivation remains an important point of interest.”

More research

EMD technology is already being used more in practice, but research is needed to prove its impact. For his PhD, de Vere will set up a randomized controlled trial (RCT) with a large number of patients. “Then we can hope to expand this technology. This will also help dermatologists and save time for medical psychologists. The CBT (Cognitive Behavioral Therapy) program takes much longer, consisting of 7 treatment sessions and 3 follow-up sessions. So it is a win-win for dermatologists , for the patients themselves, and for the psychiatrists. If dermatologists in other centers are interested, they can certainly contact us to share our experience with them.

Scratching behavior in eczema patients

The first study included 5 patients with moderate to severe eczema. They all began recording scratching behavior on the same day using a mobile phone app. Night scratching was recorded by the smartwatch app. The total duration of the study was 46 days and was the same for all patients. The treatment consists of two sessions using a new treatment protocol for urgent cases. In addition, standardized measures were used to assess disease activity, quality of life, and self-control.

Figure 1. Scratching behavior in patients with eczema at baseline (A) and during intervention (B)¹

Over time, scratching behavior decreased in all patients. During the baseline phase, scratching behavior fluctuated significantly and a slight negative trend was visible, indicating a decrease in scratching behavior. During the intervention, disease activity decreased and self-control and quality of life improved. Nocturnal scratching behavior did not change. These first positive results regarding daytime scratching behavior, disease activity, quality of life, and self-control appear promising and have prompted further research.

reference

1. De Vere M, Walbor-Spoeg R, Heijnen DG, et al. Reducing scratching behavior in atopic dermatitis patients using an EMDR treatment protocol for urgency: a pilot study. FrontMed (Lausanne). 2023 Apr 4:10:1101935. doi: 10.3389/fmed.2023.1101935