Starting from Scratch: Treat Your Itch!

Dr. Diego Ruiz da Silva returns to dive deep into effective treatments for chronic itching, explaining why antihistamines often fall short and highlighting more successful approaches. His expertise from running a dedicated itching clinic offers practical solutions for one of dermatology's most frustrating and persistent problems.

• Antihistamines only effectively treat specific types of itch like hives, despite being widely recommended
• Moisturizing is crucial for all itching conditions as it repairs the skin barrier that protects against irritants
• Thick, bland moisturizers applied right after bathing are most effective for locking in moisture
• Natural supplements like omega-3 fatty acids and oral ceramides can help manage itch from within
• Off-label neurological medications like gabapentin can interrupt the itch-anxiety cycle
• Phototherapy using narrow-band UVB light effectively reduces inflammation 
• Home phototherapy units are becoming more accessible and may be covered by insurance
• Neuropathic itching may respond to medications borrowed from pain management

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Transcript

Introduction to Dr. Diego Ruiz da Silva

Speaker 1 0:00

Welcome to Dermot Trotter Don't Swear About Skin Care where host Dr Shannon C Trotter, a board-certified dermatologist, sits down with fellow dermatologists and skincare experts to separate fact from fiction and simplify skincare. Let's get started.

Speaker 2 0:18

Welcome to the Dermot Trotter Don't Swear About Skin Care podcast. I've got a repeat guest on here today, Dr Diego Ruiz da Silva, who's back with us, an Ivy League trained dermatologist who practices currently in Virginia Beach. He was born in Brazil and raised in South Florida. He attended medical school at the University of Pennsylvania and subsequently completed his internship and dermatology residency at the Hospital of the University of Pennsylvania, where he actually ran a clinic totally dedicated to itching. He developed an expertise in chronic itching there, inflammatory skin rashes and diseases, psychodermatology and dysesthesias, as well as specializing in skin of color, skin cancer and aesthetics. There's just nothing he can't do, but I'm excited to bring Diego back here today because he's going to talk with us more about itching, because it's going on right now and somebody out there I know you've experienced that chronic itch. That really is something you just can't satisfy, and last time we had him on he really went into detail about it, but now we're going to focus on how do we fix it. So welcome back, Diego. It's great to have you here.

Speaker 3 1:20

Thank you so much for having me, Shannon. I'm really happy to be here with you guys and chat about this important topic near and dear to my heart.

Antihistamines and OTC Options for Itch

Speaker 2 1:26

I think itching. As you know we've already done a nice overview of talking about you know sort of the background of it. People really want to know, though, just how do I get rid of it, and you know you go to your local drugstore and you always see. You know anti-itch pills and I think antihistamines are the ones that people are like. Oh, I know about those. You know I take this antihistamine because I got seasonal allergies and I heard it can help with itching. What do you tell people Like are antihistamines relevant for chronic itch or certain circumstances where you think they're useful?

Speaker 3 1:53

That's such a good thing for you to bring up, especially because it's easily accessible and something that's familiar to all patients. So you know, I think the number one thing to know is that antihistamines historically were the medication of choice, even back when they were prescription and now over-the-counter for itching. But as our understanding of itching has evolved, it seems like histamines are only driven in a few causes of itching, primarily hives. So everyone's kind of familiar with hives, although sometimes patients well, they'll say they're hives but you're not actually sure. Or it ends up looking like something else. Once they show well, they'll say they're hives, right, but you're not actually sure. Or ends up looking like something else. Once they show us, they'll show the doctors right. So I always encourage honestly a patient to Google a picture of hives if they feel like they're having hives.

Speaker 3 2:31

But the reality is that antihistamines are relatively harmless. If anything, they could have the side effect of making you sleepy, which is kind of a good thing when you have tried. But a lot of people will be dissatisfied after only using antihistamines. And since you mentioned over-the-counter, I think that kind of goes along with anti-itch lotions that you can get over-the-counter, like almost every major skincare brand has one now, like CeraVe and Sarna. I think Eucerin has one, so there are a lot of these other itch lotions out there. And then cortisone I think people are very familiar with that over the counter, so these things can all help itching of any kind. It's just not a one size fits all if that makes sense.

Importance of Moisturizing for Itch Relief

Speaker 2 3:11

No, totally, and I think that's important for people to get, because how often you go in and they're like, yeah, I just popped this antihistamine but my itch isn't any better, and how disappointing to find out. You know, and I think it's shocking for them but really good to highlight, like you said, it just might not be the best solution for their type of itch or the real reason why they're itching. And you mentioned some of those lotions or moisturizers that can be used for itch In general. What do you tell folks about moisturizing their skin, because I'm a big proponent, like I tell people, regardless of why you're itching, no matter the cause, good skincare is important because if your skin is irritated or dry, which can lead to inflammation, it's just going to make whatever itching you've got worse. Do you kind of subscribe to that or recommend a particular regimen?

Speaker 3 3:55

A thousand percent. So you know, I'd say that the number one thing that we've known for a long time is that a lot of itching is either due to, or involves issues with the skin barrier. So, essentially, think of your skin barrier as kind of like the wall between our inside and outside world, and you can easily think about it in terms of toxins, pollutants God forbid smoke in the air and these things that we see from fires, like what's going on in California right now. Right, all these things if they get into your skin, they cause inflammation and they cause itching, irritation, rashes, et cetera, and the drier your skin is, the more that that barrier is damaged. So some people are, it's just they're born that way. You know, it's like usually the kids you see with eczema when they're, when they're born in that early childhood. But all of us essentially as adults, slowly develop that more and more as time goes on, depending on what climate you live in, depending on climate change and the weather and the toxin and pollutants. The more your skin dries out, the more easily these things are going to get into our skin and cause itching.

Speaker 3 4:52

So I recommend my patients to be really diligent with a thick, bland moisturizer not usually the most cosmetically elegant ones, and I'm not saying you have to, you know, smear Vaseline on your face. But essentially you know, something like I really like Eucerin advanced repair cream. I really like, uh, the, you know, cerave, just regular cream that comes in a jar, things that come in a jar, uh, instead of like a pump bottle, usually a little bit thicker, richer and you may not need this all the time, but especiallyions, you know, I really like the Roche-Posay as well. They have a triple repair cream that I have a success with with a lot of my patients and I say, you know, the next question is often well, how many times a day, you know, because it kind of wears off a little bit throughout the day, right?

Speaker 3 5:34

Well, I say the best time to do it is right after taking a shower or a bath. You want it to be a little moist still and then you really kind of lock that moisture in. It's very helpful, but I mean, honestly, as many times of the day as a day as you'd like. I have some patients who apply their moisturizer, at least to certain portions of the body, two, three, four times a day, and that's great, but some people just do it right after the shower or bath, and that's okay too.

Speaker 2 5:57

Yeah, I don't know the the idea of having that itchy, dry skin. It's a lot of worker maintenance, but I like to tell them you know it's going to be the type. But you picked a moisturize with. You mentioned some great ones. I think that people love and we've shown that they can really help repair that barrier.

Speaker 2 6:15

But frequency does matter, you that you talk about that with the frequency and, of course, like particular products that can really help Because you know, along the product line now you've probably seen this, and I get this from patients too all the time the trend is, you know, when they're looking at treatments or solutions. Now you know really people are wanting something that they think of as being more natural, because they often equate that obviously with being safer.

Natural Supplements for Managing Itch

Speaker 2 6:43

But you and I are not the case, which is a whole nother podcast, but it's somebody that's coming in and they're like, okay, well, what can I use, maybe from a lotion or moisturizer perspective? Or what do you feel like from the standpoint of you know, are there supplements or other, what people might consider to be sort of natural remedies to help with their itching?

Speaker 3 7:03

Yeah, absolutely. The last thing I'd step back to say on the moisturizer piece is that I think it's often ignored and probably one of the most key things, because even later we'll talk a bit about some prescription medications, either pills or injections, and that that you know, barrier repairing the skin, keeping it away from from things that are harmful, letting the moisture escape the body. So and then oh sorry, and this is the last thing I want to say to that I completely blank on saying earlier that I feel like a lot of times people want to know what the best moisturizer is Right and I think the reality is that there is no single best for every person because we're all individuals. So I recommend you guys who are listening, you know, ask your dermatologist. Do you have samples?

Speaker 3 7:49

A lot of people do, and I often will give like three or four of the ones I mentioned, maybe even extra if a rep has brought in something new, because I say what's the best right is what doesn't irritate your skin and what you like the way it feels. It's kind of like sunscreen. If you don't like the way it feels, oh doc, you said that was the best, but it feels gross. But they're not, you're not going to use it. I mean, you might if you're desperate, but you're not going to make it a part of your general routine.

Speaker 3 8:11

So that's the last thing I was going to say there.

Speaker 2 8:13

No, it's good that you mentioned that Cause that's a real personal choice.

Speaker 2 8:24

You know, I feel like the best moisturizer is the one. You're forget about that and the other thing too, I think, because these moisturizers that can be really effective or over the counter, people don't think they're as important as the prescription aspect either, because we always think, oh, prescription must be better because it is prescription and maybe it's better obviously for sometimes primary treatment. But I think in the world of dermatology we have very effective moisturizers. We don't really have many prescription moisturizers truly left anymore that we would prescribe, and so they can get really good benefits from things that are over the counter. It doesn't mean that it's really subpar, I think that's it. Yeah, like you mentioned.

Speaker 3 8:57

You are exactly right and, to segue into what you asked me about, like natural things that people can do that are typically over the counter as well. So three main things that I recommend One is omega-3. So specifically, omega-3 supplementation, or fish oil as people often will call it, is something that can help a whole lot with just kind of like overall moisture retention and anti-inflammatory in the skin and then also has that added benefit of just being something that's good for you. You know that has been shown to have, you know, brain health, heart health, so it's good in all those kinds of ways.

Speaker 3 9:26

And then a couple of other things are oral ceramides. So these are essentially, you know, people think of ceramides as like a compound that's a part of the skin barrier that you can apply topically in moisturizers, which certainly you know that's good in moisturizers, but there's an oral form that folks can take as well. That can help. Those are the two main things that I recommend, and these are not things that are very pricey. They can be found on Amazon in health food type stores, and these are things that may or may not make a huge difference, right, but at least you know that they're not harming you and could be helping with your overall health.

Off-Label Medications for Chronic Itch

Speaker 2 10:00

Have you ever used L-histidine I know that's talked about sometimes for itching or anxiety.

Speaker 3 10:05

Yeah, so I have used L-histidine I for itching or an accident. Yeah, so so I have. I have used, uh, l-histidine. I haven't had great success with it personally. And then there's another thing called quercetin that's why I didn't mention it which is another over-the-counter supplement. Um, so you know, that's the reason I didn't mention those. But certainly you know, if a patient tells me they tried it and it's helpful, I keep that as part of their and I think, as long as they're using those, things appropriately.

Speaker 2 10:34

sometimes I tell patients okay, I don't know how much it may help you, it's kind of a risk benefit. It's probably not harmful for us to try it so if there's a benefit, especially if you're on a good avenue.

Speaker 3 10:40

But yeah, I've kind of seen Probiotics actually fit in that category too, right? Something that's kind of overall good for you and we're realizing in medicine that our gut bacteria and kind of the health of our gut.

Speaker 2 10:55

Bacteria seems to play a role in basically every disease, in like humans, though, and probably animals too, exactly exactly. Well, I think you know. The other piece, too is, once you kind of switch from these over-the-counter medications you know you've probably talked with your patients about okay, let's look at prescription options, and some of you out there may have had a prescription option given to you that you kind of looked twice at. Or when you went to the pharmacy and filled it, it looked like, you know, this is actually a medicine used to treat depression or anxiety. But wait, my doctor gave it to me for itching. So have you ever used medications like this that are truly indicated to treat anxiety, depression, and use them in the itching space, and when do you think, if you've used them, that's a good idea to do so?

Speaker 3 11:31

Yeah, sham, thank you so much for bringing that up, because it's one of the biggest problems, I think, in the itch world. As an audience, you guys should all know that chronic itching is. We're only in the beginning of people caring about this and studying it and inventing medicines for it and taking it seriously. Almost everything we use is what we call off-label, meaning it doesn't, it's not officially approved by the FDA to treat that, and so we're borrowing from other specialties things that are approved for certain things that have just been shown to help itching, and so, as I call them, the kind of like neurologic or psychiatry related medications. Neuropathic medications can actually help with itching of any kind, so they're wonderful. So that includes medications like gabapentin, mirtazapine, ssris, which are like the general class of like antidepressants.

Speaker 3 12:13

These are all things that have been shown to basically slow the nerve conduction of itch signals to your brain and that's what actually makes you feel itchy. Right, the inflammation in one's body let's say you have inflammatory itch is making these itch signals go up to your brain, and if you're blocking that, although you're not necessarily doing anything to the inflammation, you'll feel less itchy, you can become more comfortable. But the challenge is, you know, if that's not well explained to the patient. The patient sometimes feel like a guinea pig or like, oh, did the doctor just think I'm crazy? Like that's something my patients have asked me before. They think that it's all in my head. It's kind of funny actually. I always like to say, well, it is in your head only. In so much as that. Everything's in our head, right, our brain controls the way we feel and the way we do things. So like, yeah, the itch sensation. If they cut your nerves you wouldn't feel itchy anymore.

Speaker 3 12:55

But obviously we're not, we're not going to do that. But you know, essentially it just kind of're feeling is making you feel itchy. So that's the first thing. The second thing is actually feeling itchy chronically over years and feeling kind of hopeless can make you depressed or make you more anxious, and then the more depressed and anxious you are, the itchier you feel. So you see how this negative cycle, kind of like continues. So that can be a big problem and anybody's going to feel down going through something like that.

Speaker 3 13:26

Patients have been going through it for 20 years and never been addressed. So that's where these medicines can help them feel better from a mental health perspective, but then also help with the itching. So it's a win-win. And then the third category is a lot of some not all some of these medicines have the side effect of making you sleepy. Okay, so then I tell folks you take it at bedtime. A lot of itchy people have trouble sleeping to begin with. So it's kind of a win-win all around. And it's something that can be easily mixed with lots of our other things, with our moisturizers, with our injections, which other therapies we'll talk about. And so it's good for you as a patient to know, because, especially where I see trouble is. Sometimes the pharmacist will tell the patient like oh, your doctor gave you this for your itching. Well, this is for anxiety. I wouldn't take that if I were you and they.

Speaker 2 14:07

Yeah, that's a really good point. I think we just have to stop and make sure you know that we're telling our patients exactly what we're doing with that, so you know people don't get upset about what we're using it for. But we have to get creative. In dermatology We've got a lot of things we don't, we don't have perfect treatment options for, and we got to look at how things actually happen in the body, go after the reason it's happening, and so we have to use medicines aren't necessarily approved to do so.

Speaker 1 14:29

The anxiety.

Phototherapy for Treating Itch

Speaker 2 14:30

You know that you mentioned too. It is a vicious cycle. We see this all the time and people are like is my anxiety causing my itching or is itching causing anxiety? And in the end, does it matter? We're going to hopefully address all of that for you because we do take kind of a complete approach, I think when you're treating itching like that for a patient so kind of ironic, in dermatology you know we are telling people to stay out of the sun at times or, you know, do great sun protection because we're worried about skin cancer. And then, ironically, we use light therapy or phototherapy to treat a lot of skin conditions, one of which is itching. So I wanted to pick your brain to kind of help our listeners out there understand when do we use light therapy for itching and why do we think it actually even works?

Speaker 3 15:08

That's a great point. So light therapy has been around for a really long time If you look in history. Actually, like the ancient Egyptians were using it to treat various different skin conditions. They were essentially using like plant matter that they would put all over their skin and then they would lay out in the sun. And it was essentially.

Speaker 3 15:23

The thought is that the UV radiation basically removes inflammatory cells away from the skin back into the body and kind of removes those signals that are going to the brain to tell you that you're itchy. Now the interesting part is that in that old school form of like you literally using the natural sun, it is harmful, it can cause skin cancer. It has all wavelengths of ultraviolet light, including the good kind and then also the skin cancer causing kind. So then in modern days now, with these phototherapy booths, as we call them, or light boxes, kind of the general term lay people term there's very targeted we'll call narrow band UVB. So it's just that narrow spectrum of UVB light therapy, not all the other spectrums, that can possibly cause skin cancer. In fact this has been studied now for decades and many, many thousands of patients have shown no increased risk of skin cancer. So very safe, very effective for itching of any kind and also other skin conditions. So oftentimes I'm using that in combination with other treatments or even as a solo treatment.

Speaker 3 16:19

The biggest challenge for you patients to know out there because a lot of times patients are excited about this if they've heard about it is that it's just a little cumbersome, right? If the light booth is in the office, you would have to come to the office three times a week and they're short visits. But if you work or depending on your life routine, that could be difficult. So that's number one. Number two is insurance coverage. So oftentimes it can be covered by insurance, but I've had situations where a copay can be $50. Someone might say, hey, okay, $50 doesn't break the bank, right, but if you're spending $150 every week, you're going three times a week, that's a whole lot, right, it adds up.

Speaker 3 16:52

And then the third piece of it is I've gotten really excited about home phototherapy units, where your insurance essentially covers the purchase of a home light box like what we use in the doctor's office is delivered to your home and it's kind of all scientific now. It's like pre-programmed like a smart AI robot and we program it to know exactly what to do and then you do your treatments at home. That's kind of the best. As I say, once they give it to you, they can't take it away, all right. So even if your insurance changes or if you become uninsured, god forbid, or something happens, it's yours and we can always walk you through how to how to use it. So if insurance covers it, I recommend asking about it.

Neuropathic Itch Treatment Options

Speaker 2 17:23

That that is a really, I think, a good thing for patients that realize we could do that at home. Because you're right, I think, the treatments, the time away from work, the cost you know in the textbook. Obviously for certain conditions they'll say, oh yes, next option, do this, but practically speaking it doesn't always work. So the home option is really great for patients. Now, kind of moving on from that, like going from light therapy, one of the types of itching we've touched on a little bit but I wanted to kind of have you highlight was neuropathic itching and, again, maybe treatment for that. Some of these medications that people are like yeah, I know somebody that's on this one that I think somebody is using for their neuropathy or they've had some condition you know, or maybe even like fibromyalgia, but now they're using it for itching. Where do you feel like that fits a role in the treatment of itching, especially if people think it's, you know, related to actually kind of the nerves just misbehaving or misfiring in?

Speaker 3 18:11

this? Yeah, great question. So this plays out what we were talking about earlier, because a lot of those neuropathic medications are also used kind of in the neurologic and psychiatric world and and not necessarily approved for dermatology. Probably the most common one that I'd like for people to know about is gabapentin, very common medicine used for chronic pain, used for neuropathy like that sometimes people with diabetes get, or other neuropathic conditions, and also just used for itching. In general helps slow down that, that um, your nerve transmission of itch signals to your brain, and also as a side effect of making you a little sleepy too, which is of course, good, like I said earlier, when, when patients are super itchy, and that can be combined with any other medicine and also just used alone. So that's a, that's a. That's the first one I want guys to know about, in case the doctor brings up you're not surprised by that. It's kind of nice that patients are familiar because they usually know oh yeah, my uncle's on that or you know as a family member or something like that.

Speaker 3 18:56

But then some off the beaten path things I want to mention too, because not every dermatologist knows how to use this or has even heard about it. But I've had to pull out of my bag of tricks when certain conventional things aren't using are, is medical marijuana. So that's something that has been shown to help both in like the traditional way people think about smoking or consuming an edible like from a medical marijuana store. Nowadays that is legal, or just the old school method, but back when, like recreational marijuana excuse me was illegal everywhere, we had a pill like a pharmaceutical pill called dronabinol, or Marinol is another name for it. That's used for like to stimulate appetite in cancer patients. But then they started noticing that it can help with a lot of other things too. So neuropathic itching is one thing that that can help with. Certainly, when you're using something like that you got to be worried about do you drive for a living? Do you operate heavy machinery, right, I guess, as you'd imagine, because you can't be on that and functioning throughout the day per se, but it is an option for some patients.

Speaker 3 19:48

And then butorphanol is a nasal spray of all things. I'll be like oh, that's odd, that's kind of like an opiate derivative, but it's not like you know. It's not like you know what people think of, like a narcotic, like oxycodone or or you know, vicodin or something like that it's not really used for pain often and it doesn't give you like a high or, you know, uncomfortable feeling. It just again helps with that nerve conduction. It seems to block the itch signals and has a very low potential for addiction. Obviously we never want to get someone addicted while we're trying to fix one problem. So that's something I've used for some patients too, and that's more of an episodic thing. It wears off. It typically kicks in for about six to eight hours, but for a patient who's desperate and super know, I'm not, I'm a fan of puns.

Speaker 2 20:32

I'm just going to say we're going to have to end there on a high note. Those were great things. So cause I think you're going to start some conversations now with our audience and their dermatologists about itching. You know your first episode was fantastic. This one even better to really dive in to how do we treat this effectively and what. What are those options? So I want to thank you, diego, so much for coming on again and chatting with us about kind of the treatment approach and the various things that are available for our listeners out there If they want to find you. Do you mind sharing where they can locate you?

Closing Remarks and Future Topics

Speaker 3 21:01

Yeah, so probably the best places would be on my professional Instagram page, which is married, underscore to underscore dermatology, so married to dermatology or, if you're on LinkedIn, I'm pretty active on there as well, and I'm happy to connect with anybody, and you know I like to share information. And the last thing I wanted to mention, shannon, which I'd be happy to come back for another episode to talk about, is that the conventional medicines that we use also to treat eczema, for example, or atopic dermatitis, can be used for chronic itching of many different sorts too. So a lot of times you know when you don't. When you're officially diagnosed with eczema, your doctor may not bring this up as a treatment option, but they probably should, and you should probably ask if they haven't, because there are so many, both pills and injections, that work very well, many that are quite safe, and I'm happy to talk more about those in the future with you.

Speaker 2 21:47

Hey, I'll take you up on that for sure. It was great to have you back on again. Thank you all for listening and stay tuned for the next episode of Dermot Trotter. Don't swear about skincare.

Speaker 1 22:06

Thank you. Take care, trottercom. Don't forget to subscribe, leave a review and share this podcast with anyone who needs a little skincare sanity. Until next time, stay skin smart.