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The Itch Scratch Cycle in Atopic Dermatitis
The Itch–Scratch Cycle in Atopic Dermatitis: Disease Burden and Management Strategies

Released: April 11, 2025

Expiration: April 10, 2026

Heather Woolery-Lloyd
Heather Woolery-Lloyd, MD
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Key Takeaways
  • AD affects both patients and their family/caregiver(s) alike, with quality of life becoming more negatively affected as disease severity increases.
  • Itch is the most burdensome symptom of AD and treatment options to control itch are needed.
  • Patients should be prescribed systemic agents, including biologic therapies, when topical therapies have been optimized and AD cannot be controlled.

The following commentary dives deeper into the burdens associated with and management of atopic dermatitis (AD) from the patient, family/caregiver, and healthcare professional (HCP) perspectives.

What is the impact of living with AD for patients and their family/caregiver(s)?
AD has a tremendous impact on both patients and their family/caregiver(s). The most burdensome symptom of AD for all patients is itch (or pruritus). How it manifests in children and adults is similar, but there are some nuances between the two. In children, itching at night interferes with sleep, and it is clear how important sleep is for children’s development and ability to concentrate and perform in school. From patients’ perspective, no child wants to be seen scratching all the time or have the lesions that can appear across the body. Therefore, AD can affect children’s self-esteem and the types of friends they make, including the potential of being excluded from certain friend groups because some children may not want to play with a child who has severe AD.

From the parents’ perspective, AD also has an incredible impact on their quality of life. Parents often are awoken at night to apply medication (eg, topical therapies) when their child is itching. Children with AD also must follow incredibly specific bathing rituals. For example, they might have to do bleach baths if it has been recommended by their HCP. Sometimes, children need wet wraps, which are recommended for those with severe disease, where the parent wraps the child’s limbs up—almost like a mummy—at night. Furthermore, special pajamas must be purchased and blood can stain sheets because of chronic scratching. So parents might have to change their child’s bedsheets more frequently, especially in cases where the child needs a lot of ointments. All of this work is increased with the severity of a child’s AD. These are just a handful of examples as to how AD affects patients’ parents. It is common for caretakers to spend 1-2 hours/day caring for a child with AD. This includes applying therapies and moisturizers, following specific bathing regimens, and doing laundry, including the need to wake up at night for some of these tasks and the related loss of sleep. AD can cause adult patients to miss work. A study found that patients with mild AD reported a mean loss in work productivity of 2.4 hours per week, whereas patients with severe AD reported a mean loss of 9.6 hours per week.

AD and Building Interpersonal Relationships
Among young people who may be dating, AD can affect relationships and one’s ability to be comfortable with meeting new people. Patients may feel the need to explain their disease to others, which can be embarrassing for them. Furthermore, those who have had AD their whole life can feel frustrated and may give up on treatment. I have had patients express frustration with their treatment and lack of disease control, as well as a wish to give up, because they have had this issue their whole life.

In addition, depression is a significant issue that affects patients’ ability to date and form relationships. In my practice, I have seen patients who are embarrassed and tell me, “I do not know what to say when I go on a date. I do not want people to see my skin. It is embarrassing.” Then there is the stigma associated with itching. No one wants to be at school, at work, or on a date constantly itching. I had one patient tell me that someone in their work’s human resources department reached out to them and asked if what they had was contagious. This issue is also seen in children with AD, where parents feel they must explain to teachers and others that their child is not contagious. Sometimes, parents will have a special day to explain to their child’s peers that AD is not contagious and is a disease caused by the immune system, so that the other children who are naturally curious can understand what is going on with their peer’s skin.

How can itch, in the context of AD, be treated?
As discussed above, patients lose their ability to concentrate because of itch. When I see patients who are frustrated with their itchiness, I first acknowledge and validate their feelings. I also tell them that in some ways, itch is worse than pain because we can treat pain. Furthermore, the stronger the pain reliever, the more we can control pain. But we truly cannot control itch. Although patients can take antihistamines to sleep, there are no phenomenal treatments for just itch. There clearly is room for improvement to treat itch.

What are some of the practical tools that can be used to measure itch and guide AD treatment planning?
The tool that I personally use, and I work with in clinical trials, is the numerical rating scale (NRS). There are 2 types of NRS scores in AD: mean itch intensity and peak pruritus NRS (PP-NRS). In AD studies, researchers can use both because they are helpful for different reasons. Furthermore, both NRS measures use a 0-10 scale, where 0 correlates to “no itch” and 10 correlates to “worst itch of all.” Regarding mean itch intensity, HCPs can ask patients, “What would you say your average NRS score has been over the past day?” In studies, this often is measured over the past week, which provides an overall feel for the level of itch that the patient is experiencing.

What this average score does not measure is the worst level of itch patients experience. This is captured by the PP-NRS, which is used in AD studies and indirectly in clinic visits. PP-NRS can inform HCPs of the worst level of itch patients experience in the past 24 hours. Even though patients might have a mean itch intensity of 3 or 4, they could have had an itching attack the night before where they almost ripped their skin apart—a PP-NRS of 8 or 9. For that reason, I think both NRS scores are helpful. Although it is good for HCPs to understand patients’ overall itch, their PP-NRS score will inform us of a flare or severe bout of itching, which is very common in AD.

How do you decide when and how to step up therapy for patients with AD and chronic itch?
There are 2 ways to think about therapy progression in AD, and patients will guide your process in most cases.

Regardless of disease severity, however, HCPs should ensure patients are following an appropriate bathing routine because skincare practices are almost as important as prescribed treatments. For example, patients should not use scented soap or hot water, as these can aggravate AD. I always discuss the importance of bathing and skincare with patients before prescribing pharmacologic therapies. This is because HCPs might see patients with the worst case of AD imaginable, but patients are using a harsh cleanser, they do not use moisturizer, and they take long, hot showers. Simply changing the patients’ skincare routine can significantly improve the skin barrier and reduce AD severity. Therefore, it is critical for HCPs to establish what patients’ nonprescription skincare routine is like.

The first approach to treatment comprises patients with mild to moderate AD, who should be started on topical therapies first. This is because we want to start treatment with the least invasive option and only progress to the most invasive option if necessary. AD often progresses over time, as patients may present with mild disease and experience flares. If patients are moisturizing correctly and using fragrance-free and pH-balanced cleansers, then I step up to a systemic agent. For those with mild to moderate AD, they might have been treated initially by their primary care provider (PCP) with topical corticosteroids and saw no improvement. In this case, dermatologists can add a more effective topical therapy like ruxolitinib cream, more potent topical corticosteroids, or a combination of the 2 to the treatment plan. Although PCPs may only feel comfortable with prescribing hydrocortisone and triamcinolone (low- to moderate-potency topical corticosteroids), dermatologists should feel more comfortable with using high-potency options as needed.

Systemic Therapy for AD
For many patients, the next step in treatment would include a biologic like dupilumab—the guideline-recommended first-line systemic agent that is well tolerated and has a good safety profile. Dupilumab is approved by the FDA to treat patients aged 6 months or older with moderate to severe AD. If patients’ disease does not respond to or is not well controlled with a biologic therapy, then dermatologists could consider oral JAK inhibitors. But this determination, again, should be patient-directed. There are other, more potent immunosuppressants that are systemic, such as IL-13 inhibitors and IL-31 inhibitors, that I generally do not prescribe, but I will refer patients to the appropriate specialist if I think they would benefit from these.

The second approach to AD treatment concerns patients who present with severe disease. These are the patients who walk in the door with worst case possible scenario, and HCPs should go straight to systemic therapies, whether dupilumab or an oral JAK inhibitor, when considering treatment. I never start patients on topical therapies knowing that they have severe AD at baseline.

Your Thoughts?
How often do you see biologic agents fail patients with moderate to severe AD? You can get involved in the discussion by answering the polling question and posting a comment below. To learn more about this topic, join our live webinar on April 26, 2025.

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How comfortable are you with prescribing biologics for patients with moderate to severe AD?

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