Neurodermatitis (Lichen Simplex Chronicus) Treatment in Ankara, Turkey

Lichen simplex chronicus is an inflammatory dermatosis characterized by the thickening, hardening, and accentuation of skin lines as a defense mechanism of the skin against chronic scratching, rubbing, and friction. Also referred to in clinical practice as neurodermatitis, this condition develops as a result of the “itch-scratch cycle” in which the sensation of itching in the skin and mechanical trauma feed each other. Lichenified plaques, which generally focus on a single area and cause the skin to take on a leather-like appearance, are in fact not the result of an underlying skin disease but a concrete consequence of the physical trauma to which the skin is exposed.

What Is Lichen Simplex Chronicus and What Changes Does It Cause in the Skin?

Lichen simplex chronicus is a defense response of the skin to chronic trauma. When healthy skin is constantly scratched, rubbed, or exposed to friction, it begins to thicken its outermost layer, the epidermis, in order to protect its lower layers. We call this process “lichenification” in medical terminology. When lichenification develops, the skin loses its elasticity, becomes coarse, and its natural lines deepen and become prominent, just like tree bark or leather.

This thickening is actually a well-intentioned effort by the body; it is trying to create a shield against the mechanical impact coming from the outside (that is, your nails). However, this is where things go wrong. Because thickened and hardened skin has much more sensitive nerve endings than healthy skin, and the itch threshold decreases. In other words, as your skin thickens, paradoxically it starts to itch more. Even a slight touch or contact with fabric that would not normally bother you can trigger a severe itching crisis in that area. As a result, itching causes scratching, scratching causes thickening, and thickening causes itching again. The most difficult part to treat is this mechanical cycle itself.

What Are the Symptoms of Lichen Simplex Chronicus?

Although the symptoms of this condition may vary from person to person, there are some common features we see in patients in whom the condition has become established. The lesions are generally in the form of a single plaque, but they may sometimes be seen in several different areas of the body at the same time. The most prominent feature is the tissue change in that area that the patient constantly reaches for.

The physical symptoms we frequently encounter are as follows:

• Marked thickening of the skin
• Darkening of the skin color
• Deepening of skin lines
• Scaling
• Crusting
• Scars
• A feeling of hardness in the skin
• Redness

In addition to these symptoms, patients complain especially of severe itching attacks that increase at night and wake them from sleep. The itching is sometimes so intense that the person cannot stop scratching until they bleed. This condition not only damages the skin but also deeply affects the person’s quality of life, sleep pattern, and social life.

Why Can the Itch-Scratch Cycle Not Be Broken?

The “itch-scratch cycle” underlying Lichen Simplex Chronicus is much more than a simple matter of willpower. It is a neurological and biochemical process. When your skin itches, the nerve endings send a signal to your brain. The brain receives this signal and tells you to “scratch there” to get rid of the unpleasant sensation. When you scratch that area with your nails, you create a slight feeling of pain. This pain suppresses the itch signal at the spinal cord level for a short time. In other words, that “what a relief” feeling you experience when scratching is actually the pain masking the itch.

However, this relief is very short-lived, and the price is heavy. During the act of scratching, you break down the cells in the skin. Chemicals such as histamine and cytokines, which create inflammation, are released from these broken cells. These chemicals stimulate the nerve endings even more. This time the brain receives a stronger itch signal and compels you to scratch more intensely. Over time, this becomes a “learned behavior” in the brain. Even if your skin is not itching anymore, your hand automatically goes to that area when you are stressed, watching television, or idle. That is why I often say to my patients, “Scratching is like pouring gasoline on a fire; you think you are putting it out in that moment, but in fact you are fueling the flames.”

What Are the Factors That Trigger This Disease?

Lichen Simplex Chronicus is not a disease that appears out of nowhere. There is usually an underlying trigger or a predisposing condition. These triggers are sometimes environmental, sometimes physical, and sometimes psychological. A different combination may be the culprit in each patient. However, the common point is the disruption of the skin barrier integrity and the lowering of the itch threshold.

Some factors that can initiate or exacerbate the disease are as follows:

• Insect bites
• A history of eczema
• Dry air
• Increased temperature
• Sweating
• Synthetic clothing
• Wool garments
• Stress
• Anxiety
• Food allergies
• Contact dermatitis

Especially individuals with atopic dermatitis (allergic eczema) are much more prone to this disease. The skin of these individuals is congenitally drier and more vulnerable to external factors. Even a simple sweater tag or mild sweating can trigger an itching crisis that lasts for months in an atopic individual.

In Which Areas of the Body Is Lichen Simplex Chronicus Seen?

One of the most interesting features of this disease is that its locations are not random. As a rule, Lichen Simplex Chronicus is seen only in areas that the patient’s hand can easily reach. For example, seeing this disease in the exact middle of the back, that is, in an area that the hands cannot reach, is almost impossible. This is the greatest evidence of the direct relationship of the disease with mechanical trauma (scratching).

The areas where the disease most frequently settles in the body are as follows:

• Nape of the neck
• Scalp
• Ankles
• Front of the legs
• External genital area
• Elbows
• Outer surface of the arms

Especially in female patients, the point where the scalp ends at the nape of the neck (Lichen Nuchae) is one of the most frequently involved areas. Here, it manifests itself with constant itching and scaling. In men and women, the ankles are frequently targeted due to the pressure exerted by sock elastics or being covered طوال the day. Involvement of the genital area is the form that patients are generally hesitant to mention but that most severely impairs quality of life.

Which Methods Are Used When Making the Diagnosis?

To diagnose Lichen Simplex Chronicus, it is usually sufficient to listen to the patient’s history and carefully examine the lesion. During the examination, your doctor will look at the thickness of the lesion, the prominence of the skin lines on it, and its color. In addition, the doctor will try to understand the character of the itch with questions such as “When did this itching start?”, “Does it wake you up at night?”, and “Does it increase when you are stressed?”

Some supportive methods used to confirm the diagnosis are as follows:

• Dermoscopy examination
• Fungal test
• Blood tests
• Skin biopsy
• Patch test

Dermoscopy is a special device that allows us to examine the skin by magnifying it and helps us see the characteristic vascular structure of lichenification. If the appearance of the lesion resembles a fungal infection or psoriasis, a skin scraping may be taken and examined under the microscope. In very rare situations or in treatment-resistant cases, it may be necessary to take a small sample from the lesion and send it to pathology (biopsy). This is important both to confirm the diagnosis and not to miss another underlying skin disease.

Which Medications Are Used in Medical Treatment?

The main goal of treatment is to stop the itching and return the thickened skin to its former healthy state by thinning it. However, the skin has become so thickened that ordinary moisturizers or mild creams cannot penetrate this barrier and have an effect. Therefore, strong agents are generally preferred in treatment. In the first step, cortisone creams or ointments that suppress inflammation and relieve itching are used. The strength of these medications is adjusted by the physician according to the thickness of the lesion and the area where it is located.

The main groups of medications used are as follows:

• Cortisone ointments
• Calcineurin inhibitors
• Antihistamines
• Keratolytic creams
• Moisturizers

To increase the effectiveness of treatment, the “occlusive dressing” method is frequently applied. In this method, after the medication is applied, the area is covered with plastic wrap or special medical dressings. This procedure serves two purposes: First, it increases the absorption of the medication through the thick skin by 10 to 100 times. Second, it physically prevents the patient from scratching that area. If the plaques are very thick and do not respond to creams, the cortisone medication may be injected directly into the plaque with a needle by the method we call “intralesional injection.” This provides very rapid and effective thinning.

How Do Stress and Psychological State Affect Lichen Simplex Chronicus?

There is a very valid reason why this disease is sometimes called “nervous eczema” among the public. The skin and nervous system originate from the same root during development in the womb. Therefore, the storms breaking out in our emotional world create waves on our skin. Many patients with Lichen Simplex Chronicus notice that their itching attacks flare up during stressful periods, exam times, days when work intensity increases, or moments of sadness.

Stress causes the release of hormones such as cortisol and adrenaline in the body. These hormones weaken the barrier function of the skin and cause the nerve endings to remain “on alert.” A tiny stimulus that you would not normally feel is interpreted by your brain as severe itching when you are stressed. In addition, in some people the act of scratching is used as a way to release subconscious tension. The patient tries to relieve the stress of the day by scratching their leg or nape in the evening at home. Therefore, during the treatment process, it is not enough just to apply cream to the skin; the patient’s ability to achieve mental calmness, receive psychological support if necessary, or learn relaxation techniques directly affects the success of the treatment.

What Are the Natural Methods and Care Recommendations That Can Be Applied at Home?

The medications prescribed by your doctor are the basis of the treatment, but the lifestyle changes you make at home accelerate the healing process and prevent the recurrence of the disease. Remember that your skin is currently in a “repair” process and you need to treat it gently. The most important rule is not to scratch, no matter what. Although this may seem impossible, when the urge to scratch comes, you should use alternative methods instead of your nails.

Some care recommendations you should pay attention to at home are as follows:

• Keeping the nails short
• Applying a cold compress
• Using moisturizer frequently
• Wearing loose clothing
• Washing with lukewarm water
• Avoiding scrubbing with a bath mitt
• Choosing fragrance-free products

When an itching crisis comes, placing a towel kept in the refrigerator or an ice pack on the itchy area temporarily numbs the nerve endings and relieves the sensation of itching. This method is the safest way to relax without damaging the skin. In addition, keeping your nails blunt and short minimizes the damage to the skin caused by unconscious scratching during sleep at night. Hard cleansing tools such as bath mitts or loofahs should definitely be avoided, as they will further irritate the already sensitive skin.

How Is Lichen Simplex Chronicus Managed in the Genital Area?

The genital area is the area where the skin is thinnest and most sensitive, and where the nerve network is also very dense. Lichen Simplex Chronicus in this area is quite physically and emotionally exhausting for patients. The fact that it is a constantly moist and closed environment is one of the factors that make treatment difficult. The approach in this area should be gentler than in other areas of the body.

The points requiring special attention for this area are as follows:

• Cleaning only with water
• Cotton underwear
• Staying away from soap
• Not wearing tight pants
• Not using wet wipes
• Not using daily pads
• Sleeping without underwear at night
• Using barrier cream

Using soap, shower gel, or special intimate washing gels in genital area cleaning disrupts the natural flora and oil layer of the area. This leads to dryness and therefore more itching. Cleaning should be done only with lukewarm water and the area should be dried gently, without rubbing. Not wearing underwear at night while sleeping, or preferring very loose pajamas, allows the area to breathe and reduces friction, thereby relieving nighttime itching. In addition, zinc-containing barrier creams (diaper rash creams) may be used to protect against the irritating effects of urine and sweat.

What Problems Arise If It Is Left Untreated?

Many patients may postpone or ignore treatment by thinking, “It is only itching, it will pass somehow.” However, Lichen Simplex Chronicus is not a disease that subsides when left on its own. On the contrary, skin that is left untreated and constantly scratched can lead to more serious complications over time. The continuous disruption of skin integrity invites microbes from the outside world.

The possible problems that may be encountered if left untreated are as follows:

• Bacterial infections
• Permanent stain formation
• Lightening of skin color
• Development of scars
• Sleep disorders
• Increased anxiety
• Social isolation
• Risk of malignancy

Bacteria entering through cracks opened in the constantly scratched area may cause deep skin infections such as cellulitis or abscesses, which are painful and require antibiotic treatment. In addition, chronic inflammation lasting for years may leave permanent dark brown spots on the skin or, conversely, whitened areas. Although very rarely, it has been reported in the literature that in untreated cases lasting for decades, skin cancer types such as squamous cell carcinoma may develop on the basis of a chronic wound. For this reason, it is of vital importance that this condition, which appears as simple itching, be taken seriously and treated under the supervision of a dermatologist. Remember that early intervention protects both your skin and your mental health. Although the treatment process does not yield results overnight, it is possible to heal completely with a patient and consistent approach.