Journal Logo

Systematic Review

Nonpharmacologic interventions for chronic pruritus

Bonchak, Jonathan G. MDa,; Lio, Peter A. MDb

Author Information
doi: 10.1097/itx.0000000000000031
  • Open

Abstract

Chronic pruritus, traditionally defined as itch persisting for >6 weeks, is a common affliction that can be associated with cutaneous or systemic disease, or may be idiopathic in nature. It affects patients of all ages and backgrounds and seems to have no predilection for sex or socioeconomic status1. The lifetime prevalence has been estimated between 22% and 26%1. It accounts for millions of outpatient clinic encounters every year2. Pruritus is associated with significant morbidity ranging from sleep disturbance to suicidal ideation in both pediatric and adult patients3.

The pathophysiology of pruritus is complex and multifactorial. An intricate and incompletely understood interplay between cytokines, sensory neurons, and a variety of cutaneous and central nervous system receptors and effector cells are responsible for the development of itch. Scores of therapies exist, with enormous variation in efficacy, for the amelioration of itch. Drugs aimed at virtually all of the aforementioned pathogenic factors in pruritus have been trialed or are being developed.

Nonpharmacologic therapies for chronic pruritus encompass a variety of methods for altering itch signaling or for changing the patient’s perception of pruritus. Although some of these interventions may be used as monotherapy, they are usually best utilized in combination with more conventional pharmacologic antipruritic therapies. This review evaluates the current understanding of the mechanisms and efficacy of these nonpharmacologic interventions and serves to expand the dermatologist’s armamentarium against chronic pruritus.

Phototherapy

Light has been used for millennia in the treatment of skin disease. Ultraviolet light attenuates cutaneous inflammation and its use is commonplace in the treatment of skin disorders. However, there is some evidence to suggest that outside of the dermatology community, there is less experience with the utilization of phototherapy4. The mechanism by which phototherapy works remains obscure. UVB radiation, given its limited penetrance into the skin, appears to primarily modify inflammation via epidermal keratinocytes and Langerhans cells. Its antipruritic effects are due, in part, to alteration of mast cell membrane phospholipid metabolism which attenuates histamine release5. UVA light affects a wider host of inflammatory cells including T lymphocytes, mast cells, and dermal dendritic cells6. UVA is typically administered along with psoralen, a photosensitizing agent, and in this setting it carries a higher risk for carcinogenesis than narrowband UVB therapy. Long-term UVA phototherapy with psoralen is associated with development of melanoma and squamous cell carcinoma7. Although UVB radiation is generally considered carcinogenic8, long-term narrowband UVB therapy likely confers little risk for skin cancer9.

A European study in 2016 compared the efficacy of combination UVA (320–410 nm, peak 351 nm) and narrowband UVB (nbUVB) therapy with nbUVB monotherapy for chronic pruritus associated with eczematous dermatitis, psoriasis, prurigo, and pruritus sine materia. Enrolled patients were treated 3 times weekly for 16 weeks. Forty-five patients completed the study. All subjects reported statistically significant improvement in pruritus, quality of life measures improved for all enrolled, and there was no significant difference between the monotherapy and combination therapy groups10.

There are dozens of trials from the past century recommending the use of various phototherapies for inflammatory, pruritic skin disease. However, relatively few original studies have been published in the past decade. In general, the efficacy, tolerability, and safety profile of phototherapy is favorable. The commonest diseases associated with chronic pruritus that respond to phototherapy include psoriasis, atopic dermatitis (AD), mycosis fungoides, prurigo nodularis, uremic pruritus, lichen planus, and cutaneous mastocystosis11.

Although less expensive than some pharmacologic therapies, office-based phototherapy can be costly. A 2006 cost-effectiveness study for psoriasis estimated in-office phototherapy to cost between $4500 and $5700 per year (inflation-adjusted)12. Home nbUVB therapy is more cost-effective, associated with better adherence, and has comparable efficacy13. When these options are not practical, some patients may benefit from treatment at tanning salons or heliotherapy. This option necessitates a conversation with the patient about skin cancer risks. Despite the obstacles, phototherapy remains an important nonpharmacological option for many patients.

Nerve stimulation therapy

Transcutaneous electrical nerve stimulation (TENS) is a modality that utilizes electric current, applied with cutaneous patches, to treat a variety of disorders. It has been leveraged for the treatment of pain for decades14, but attention has turned to its use as an antipruritic therapy in recent years. The mechanism by which this intervention attenuates itch and pain is, in large part, due to inhibition of C fiber-mediated neurotransmission, a phenomenon known as “gating”15. Interestingly, TENS also attenuates expression of proinflammatory cytokines in wound healing16, suggesting its antipruritic effect may have a more involved mechanism than originally thought15.

Mohammad Ali and colleagues investigated the efficacy of TENS for chronic pruritus associated with AD, Lichen Simplex Chronicus (LSC), and hepatic pruritus. Patients were treated 3 times weekly for a maximum of 12 sessions. TENS electrodes were applied to patients’ pruritic lesions for 30 minutes per session. Patients reported statistically significant improvement in pruritus at 2 weeks and 4 weeks. AD and LSC patients experienced more marked improvement of pruritus compared with the hepatic pruritus group. The antipruritic effect was persistent 1 month after completion of the study for the AD and LSC group, but not for the hepatic group. Tolerability was excellent and side effects were minimal17.

TENS has been used to effectively treat pruritus associated with mixed-thickness flame burns in one patient18. Patients with eczematous dermatoses and 1 patient with scrotal neuropathic pruritus of years-long duration reported “good” itch improvement after using TENS19.

TENS devices are available for purchase without prescription and can cost less than a topical steroid in some cases. Nerve stimulation should not be done near the eyes or on the anterior neck, which can trigger a vasovagal response. Patients who are pregnant, have a seizure disorder, and those with pacemakers should not use TENS, but there are few contraindications to its use otherwise. Nerve stimulation represents an infrequently utilized, inexpensive intervention that may be useful particularly for patients with chronic pruritus limited to discrete skin lesions rather than those with diffuse itch.

Meditation

Meditation can significantly decrease perception of pain in the presence of noxious stimuli. Activation of the primary somatosensory cortex, responsible for perception of both pain and pruritus, is reduced in the presence of noxious stimuli in meditating patients in magnetic resonance imaging studies20.

Chen and Jhaveri enrolled 10 adults with chronic pruritus in an 8 week meditation course to evaluate the effect of this modality on self-assessment of pruritus severity. Subjects who completed the course reported improvement in pruritus, quality of life, sleep quality, and ability to cope with stress21. These preliminary results indicate that meditation can be an effective adjunctive pruritus therapy, but interpretation of these positive results is limited by small study size.

Acupuncture

Acupuncture has been used for millennia to treat a wide range of conditions and is a cornerstone of traditional Chinese medicine. The mechanisms by which acupuncture is thought to work within traditional Chinese medicine are perhaps more philosophical than evidence-based, but there are scientific interpretations for some of the findings22. Rigorous blinded clinical trials for acupuncture are inherently difficult to design. Many purported benefits of acupuncture therapy are indistinguishable from placebo effects, and studies touting therapeutic benefits of acupuncture are prone to bias in reporting23. Although the sea of literature supporting acupuncture for various diseases is mixed, there is some evidence that it may be beneficial for pruritus.

A 2005 investigation of acupuncture for uremic pruritus showed marked reductions in itch scores. Patients receiving thrice-weekly acupuncture for 1 month experienced an ~45% reduction in pruritus compared with placebo, which was maintained 3 months after treatment24. Lee et al25 similarly found acupressure to be efficacious in relieving AD-associated pruritus in a small pilot study of 15 patients. Both studies targeted the “Large Intestine 11” acupuncture point which is located adjacent to the lateral epicondyle of the humerus. There are other limited reports of acupuncture for the treatment of uremic pruritus26 and AD27,28, but interpretation of these results is limited by small study size, experiment design, and/or small clinical effect compared to placebo.

The mechanism behind the apparent antipruritic effect of acupuncture remains unclear. Pfab et al28 treated patients with AD with twice-weekly acupuncture treatments lasting twenty minutes each. They suggested that decreased basophil activation, which was observed in the treatment group, may help explain why acupuncture apparently quells itch. This effect was reported to be statistically significant, but P-values were not provided in the publication. Further, the control group did not receive any placebo or “sham acupuncture,” which may muddy the results of this study.

Murine studies suggest that acupuncture may affect transient receptor potential pathways29 or κ-opioid receptor activation30, but these studies likewise suffer from flaws in design. Alternatively, acupuncture may directly alter activation of C fibers which are responsible for transmission of pruritus31. While this ancient treatment approach continues to be utilized, much remains to be elucidated in terms of its modern use.

Psychotherapy

Psychotherapy represents a vast and varied field that can be leveraged to alter the perception of itch or behaviors associated with it. Further, these methods may decrease anxiety or sleep disturbances associated with chronic pruritus. As with many nonpharmacologic interventions for itch, the bulk of the psychotherapy literature focuses on AD-associated itch, but these methods can probably be effectively deployed for other chronic pruritic conditions.

Cognitive-behavior therapy (CBT), applied to chronic pruritus, guides patients to change “dysfunctional” thoughts or actions in order to improve their ability to cope with itch and to reduce frequency of scratching32. Ehlers et al33 conducted randomized trials to assess various methods of psychotherapy on the severity of symptoms, including itch, in AD. Patients were enrolled in 12 weekly group sessions and received either dermatologic educational sessions, CBT, relaxation therapy, or a combination thereof. All arms showed significant improvement in patient-reported measures of pruritus severity and frequency of scratching. The group receiving CBT along with dermatologic education showed a statistically significant reduction in topical steroid use compared with those receiving dermatologic education only.

Similarly positive results have been achieved with CBT in case reports of pediatric patients with severe AD34,35. CBT may be useful in breaking the “itch-scratch” cycle associated with prurigo nodularis36. However, its utility in psoriasis may be limited. In a randomized controlled trial of internet-based CBT for psoriasis, there was no significant improvement in pruritus37.

Habit reversal training is a variant of CBT originally developed to treat tic disorders but may also be useful in chronic pruritic skin disorders. Although quality studies are lacking, habit reversal training may be useful in treating itch associated with AD, prurigo nodularis, or other pruritic conditions38,39.

In children with AD, support groups improve quality of life measures and decrease patient-rated itch severity. Weber et al40 enrolled both patients and their parents in support groups that met every 2 weeks for 6 months. Children in the intervention group reported pruritus once or twice weekly, versus the control group which reported daily pruritus at the conclusion of the study.

Hypnosis is a form of psychotherapy that induces a “trance state” by use of deep breathing, meditation techniques, or guided imagery41. Hypnotizability is highly variable among patients which makes critical analysis of this modality somewhat challenging. Further, the quality of hypnotherapy studies is varied42. There is some evidence to support hypnosis for disorders of pain, sleep, and anxiety43,44. However, few rigorous studies of hypnosis for pruritus exist. Positive results have been reported with hypnotherapy combined with other well-established forms of psychotherapy such as biofeedback, relaxation therapy, or stress management for AD45 and chronic urticaria46.

Cryotherapy

Cryotherapy for the treatment of pruritus leverages cutaneous physiological changes that occur at cold temperatures to reduce the neurotransmission of itch. This probably occurs as conduction along cutaneous C fiber and Aδ nerves is altered at low temperatures47. Cryotherapy has not been studied extensively for pruritic skin disorders. As cryochambers are not widely accessible and liquid nitrogen cryotherapy is associated with skin atrophy and dyschromia, cryotherapy has not gained much traction as a treatment for chronic pruritus.

To date, there has been only 1 study to investigate the effects of whole-body cryochamber therapy for pruritus. A Finnish study47 enrolled patients with AD into a thrice-weekly whole-body cryotherapy regimen. Patients underwent 1 month of treatment which involved spending 1–3 minutes in a series of 3 increasingly cold chambers, the last of which reached −110°C. A modest decrease in VAS-rated pruritus from 46 to 31 was achieved, though there was no comparison placebo. Three patients reported mild acral frostbite during the study.

Cryotherapy for small plaque psoriasis may improve disease severity but is associated with hypopigmentation and atrophy48. Waldinger and colleagues used liquid nitrogen cryotherapy to treat a patient with severe prurigo nodularis. Treatment resulted in remarkable improvement of skin lesions and pruritus which was maintained for three months49. Positive results have also been reported in chronic pruritus ani. Liquid nitrogen, applied in 2–3 second bursts to the anus, ameliorated itch but was associated with intraprocedural pain and drainage at the treated area lasting several days50.

Textiles

Clothing may play a role in relieving or exacerbating chronic pruritic skin disease51. In the past decade, several new textiles, treated or created with bioactive materials, have been developed to treat AD in particular. Clothing with anti-inflammatory or anti-pruritic properties could eventually become an important tool in treating itch, especially if there is enhanced adherence compared with application of topicals multiple times daily. Although these garments have been studied primarily in the context of AD, they may have a role in treating other nonatopic pruritic conditions.

Silk has been the subject of many studies for treatment of AD. In a 2016 randomized clinical trial of 282 pediatric patients, Thomas and colleagues sought to determine if silk clothing improves outcomes in AD. This study found no significant improvement in measures of AD severity, nor any improvement in pruritus as measured by POEM scores51.

However, silk garments impregnated with anti-inflammatory or anti-microbial agents appear to significantly ameliorate AD symptoms. A double-blinded 2013 Italian study comparing DermaSilk (clothing treated with a proprietary agent called AEGIS) with cotton clothing showed statistically significant reduction in both pruritus and volume of topical corticosteroid used in infants aged 4–18 months. Other DermaSilk studies have demonstrated improvement in AD-associated pruritus, achieving improvement similar to that seen with topical corticosteroid use52.

Combination seaweed-silver treated garments have emerged as a therapeutic textile for AD. The purported mechanism involves a combination of the anti-staphylococcal and anti-candidal activity of silver combined with barrier-restorative properties in seaweed53. A 2011 Korean pilot study reported significant improvement in pruritus as measured by SCORAD, but did not publish detailed measurements of pruritus54. A similar study by Araújo et al55 showed impressive reductions in pruritus severity and SCORAD, but results did not reach statistical significance as the placebo was unexpectedly efficacious.

New medical textiles are emerging at a rapid pace as these studies have been largely positive in AD. Clothing treated with zinc-oxide showed modest improvement in AD-related pruritus, but the pilot study did not include a placebo arm56. A novel textile containing tourmaline, which emits infrared radiation and is anion-producing, achieved statistically significant reduction in pruritus compared with cotton clothing in patients with AD57. Textiles coated with a chitosan biopolymer afforded improvement in overall severity of AD, but no significant improvement in pruritus specifically58. Textiles are perhaps an under-recognized treatment option for chronic pruritus. Further studies are warranted in this burgeoning field.

Conclusions

These nonpharmacologic therapies are a diverse group of treatments that are generally well-tolerated and deserve further investigation. They range from commonplace light therapy to radiation-emitting textiles that act synergistically with conventional medications to ameliorate chronic pruritus. These therapies may, in some cases, serve to decrease reliance on systemic agents and thus mitigate adverse effects associated with them. Although many of these modalities have been studied in the framework of chronic pruritus associated with AD, their antipruritic effects likely extend to other conditions of itch.

Conflict of interest disclosures

The authors declare that they have no financial conflict of interest with regard to the content of this report.

References

1. Carr CW, Veledar E, Chen SC. Factors mediating the impact of chronic pruritus on quality of life. JAMA Dermatol 2014;150:613–20.
2. Shive M, Linos E, Berger T, et al. Itch as a patient-reported symptom in ambulatory care visits in the United States. J Am Acad Dermatol 2013;69:550–6.
3. Gupta MA, Pur DR, Vujcic B, et al. Suicidal behaviors in the dermatology patient. Clin Dermatol 2017;35:302–11.
4. Sharma JK, Miller R, Murray S. Chronic urticaria: a Canadian perspective on patterns and practical management strategies. J Cutan Med Surg 2000;4:89–93.
5. Imazu LE, Tachibana T, Danno K, et al. Histamine-releasing factor(s) in sera of uraemic pruritus patients in a possible mechanism of UVB therapy. Arch Dermatol Res 1993;285:423–7.
6. Krutmann J, Morita A. Mechanisms of ultraviolet (UV) B and UVA phototherapy. J Investig Dermatol Symp Proc 1999;4:70–72.
7. Valejo Coelho MM, Apetato M. The dark side of the light: phototherapy adverse effects. Clin Dermatol 2016;34:556–62.
8. Valejo Coelho MM, Matos TR, Apetato M. The dark side of the light: mechanisms of photocarcinogenesis. Clin Dermatol 2016;34:563–70.
9. Hearn RMR, Kerr AC, Rahim KF, et al. Incidence of skin cancers in 3867 patients treated with narrow-band ultraviolet B phototherapy. Br J Dermatol 2008;159:931–5.
10. Maul JT, Kretschmer L, Anzengruber F, et al. Impact of UVA on pruritus during UVA/B phototherapy of inflammatory skin diseases: a randomized double-blind study. J Eur Acad Dermatology Venereol 2017;31:1208–113.
11. Lim HW, Silpa-Archa N, Amadi U, et al. Phototherapy in dermatology: a call for action. J Am Acad Dermatol 2015;72:1078–80.
12. Miller DW, Feldman SR. Cost-effectiveness of moderate-to-severe psoriasis treatment. Expert Opin Pharmacother 2006;7:157–67.
13. Rajpara AN, O’Neill JL, Nolan BV, et al. Review of home phototherapy. Dermatol Online J 2010;16:2.
14. Gildenberg PL. History of electrical neuromodulation for chronic pain. Pain Med 2006;7:S7–S13.
15. Almeida TCDC, Figueiredo FWDS, Barbosa Filho VC, et al. Effects of transcutaneous electrical nerve stimulation (TENS) on proinflammatory cytokines: protocol for systematic review. Syst Rev 2017;6:139.
16. Gürgen SG, Sayin O, Cetin F, et al. Transcutaneous electrical nerve stimulation (TENS) accelerates cutaneous wound healing and inhibits pro-inflammatory cytokines. Inflammation 2014;37:775–84.
17. Mohammad Ali BM, Hegab DS, El Saadany HM. Use of transcutaneous electrical nerve stimulation for chronic pruritus. Dermatol Ther 2015;28:210–5.
18. Whitaker C. The use of TENS for pruritus relief in the burns patient: an individual case report. J Burn Care Rehabil 2001;22:274–6.
19. Tang WY, Chan LY, Lo KK, et al. Evaluation on the antipruritic role of transcutaneous electrical nerve stimulation in the treatment of pruritic dermatoses. Dermatology 1999;199:237–41.
20. Zeidan F, Martucci KT, Kraft RA, et al. Brain mechanisms supporting the modulation of pain by mindfulness meditation. J Neurosci 2011;31:5540–8.
21. Chen SC, Jhaveri M. The efficacy of meditation for treatment of chronic pruritus: a pilot trial. J Invest Dermatol 2015;135:S41.
22. Shen J. Research on the neurophysiological mechanisms of acupuncture: review of selected studies and methodological issues. J Altern Complement Med 2001;7(suppl 1):121–7.
23. Gorski DH. Integrative oncology: really the best of both worlds? Nat Rev Cancer 2014;14:692.
24. Che-yi C, Wen CY, Min-Tsung K, et al. Acupuncture in haemodialysis patients at the Quchi (LI11) acupoint for refractory uraemic pruritus. Nephrol Dial Transplant 2005;20:1912–5.
25. Lee KC, Keyes A, Hensley JR, et al. Effectiveness of acupressure on pruritus and lichenification associated with atopic dermatitis: a pilot trial. Acupunct Med 2012;30:8–11.
26. Kiliç Akça N, Taşci S. Acupressure and transcutaneous electrical acupoint stimulation for improving uremic pruritus: a randomized, controlled trial. Altern Ther Health Med 2016;22:18–24.
27. Pfab F, Huss-Marp J, Gatti A, et al. Influence of acupuncture on type I hypersensitivity itch and the wheal and flare response in adults with atopic eczema—a blinded, randomized, placebo-controlled, crossover trial. Allergy 2009;65:903–10.
28. Pfab F, Athanasiadis GI, Huss-Marp J, et al. Effect of acupuncture on allergen-induced basophil activation in patients with atopic eczema: a pilot trial. J Altern Complement Med 2011;17:309–14.
29. Tsai K-S, Chen Y-H, Chen H-Y, et al. Antipruritic effect of cold stimulation at the Quchi Acupoint (LI11) in Mice. BMC Complement Altern Med 2014;14:341.
30. Han J-B, Kim CW, Sun B, et al. The antipruritic effect of acupuncture on serotonin-evoked itch in rats. Acupunct Electrother Res 2008;33:145–56.
31. Carlsson CP, Wallengren J. Therapeutic and experimental therapeutic studies on acupuncture and itch: review of the literature. J Eur Acad Dermatol Venereol 2010;24:1013–6.
32. Kuhn H, Mennella C, Magid M, et al. Psychocutaneous disease: pharmacotherapy and psychotherapy. J Am Acad Dermatol 2017;76:795–808.
33. Ehlers A, Stangier U, Gieler U. Treatment of atopic dermatitis: a comparison of psychological and dermatological approaches to relapse prevention. J Consult Clin Psychol 1995;63:624–35.
34. Stein TR, Sonty N, Saroyan JM. “Scratching” beneath the surface: an integrative psychosocial approach to pediatric pruritus and pain. Clin Child Psychol Psychiatry 2012;17:33–47.
35. Arkwright PD, Stafford JC, Sharma V. Atopic dermatitis in children. J allergy Clin Immunol Pract 2014;2:388–95.
36. Craig-Müller SA, Reichenberg JS. The other itch that rashes: a clinical and therapeutic approach to pruritus and skin picking disorders. Curr Allergy Asthma Rep 2015;15:31.
37. van Beugen S, Ferwerda M, Spillekom-van Koulil S, et al. Tailored therapist-guided internet-based cognitive behavioral treatment for psoriasis: a randomized controlled trial. Psychother Psychosom 2016;85:297–307.
38. Daunton A, Bridgett C, Goulding JMR. Habit reversal for refractory atopic dermatitis: a review. Br J Dermatol 2016;174:657–9.
39. Bridgett C. Habit reversal therapy: a behavioural approach to atopic eczema and other skin conditions. Practical Psychodermatology. Oxford, UK: John Wiley & Sons Ltd; 2014:66–71.
40. Weber MB, Fontes Neto Pde T, Prati C, et al. Improvement of pruritus and quality of life of children with atopic dermatitis and their families after joining support groups. J Eur Acad Dermatol Venereol 2008;22:992–7.
41. Shenefelt PD. Biofeedback, cognitive-behavioral methods, and hypnosis in dermatology: is it all in your mind? Dermatol Ther 2003;16:114–22.
42. Ersser SJ, Latter S, Sibley A, et al. Psychological and educational interventions for atopic eczema in children. Cochrane Database Syst Rev 2007:CD004054.
43. Becker PM. Hypnosis in the management of sleep disorders. Sleep Med Clin 2015;10:85–92.
44. Zech N, Hansen E, Bernardy K, et al. Efficacy, acceptability and safety of guided imagery/hypnosis in fibromyalgia—a systematic review and meta-analysis of randomized controlled trials. Eur J Pain 2017;21:217–227.
45. Stewart A, Thomas S. Hypnotherapy as a treatment for atopic dermatitis in adults and children. Br J Dermatol 1995;132:778–83.
46. Shertzer CL, Lookingbill DP. Effects of relaxation therapy and hypnotizability in chronic urticaria. Arch Dermatol 1987;123:913–6.
47. Klimenko T, Ahvenainen S, Karvonen S-L. Whole-body cryotherapy in atopic dermatitis. Arch Dermatol 2008;144:806–808.
48. Nouri K, Chartier TK, Eaglstein WH, et al. Cryotherapy for psoriasis. Arch Dermatol 1997;133:1608–9.
49. Waldinger TP, Wong RC, Taylor WB, et al. Cryotherapy improves prurigo nodularis. Arch Dermatol 1984;120:1598–1600.
50. Detrano SJ. Cryotherapy for chronic nonspecific pruritus ani. J Dermatol Surg Oncol 1984;10:483–44.
51. Thomas KS, Bradshaw LE, Sach TH, et al. Silk garments plus standard care compared with standard care for treating eczema in children: a randomised, controlled, observer-blind, pragmatic trial (CLOTHES Trial). PLoS Med 2017;14:1–23.
52. Senti G, Steinmann LS, Fischer B, et al. Antimicrobial silk clothing in the treatment of atopic dermatitis proves comparable to topical corticosteroid treatment. Dermatology 2006;213:228–33.
53. Fluhr JW, Breternitz M, Kowatzki D, et al. Silver-loaded seaweed-based cellulosic fiber improves epidermal skin physiology in atopic dermatitis: Safety assessment, mode of action and controlled, randomized single-blinded exploratory in vivo study. Exp Dermatol 2010;19:9–15.
54. Park KY, Jang WS, Yang GW, et al. A pilot study of silver-loaded cellulose fabric with incorporated seaweed for the treatment of atopic dermatitis. Clin Exp Dermatol 2012;37:512–55.
55. Araújo CP, Gomes J, Vieira AP, et al. A proposal for the use of new silver-seaweed-cotton fibers in the treatment of atopic dermatitis. Cutan Ocul Toxicol 2013;32:268–74.
56. Wiegand C, Hipler UC, Boldt S, et al. Skin-protective effects of a zinc oxide-functionalized textile and its relevance for atopic dermatitis. Clin Cosmet Investig Dermatol 2013;6:115–21.
57. Kim SH, Hwang SH, Hong SK, et al. The clinical efficacy, safety and functionality of anion textile in the treatment of atopic dermatitis. Ann Dermatol 2012;24:438–443.
58. Lopes C, Soares J, Tavaria F, et al. Chitosan coated textiles may improve atopic dermatitis severity by modulating skin staphylococcal profile: a randomized controlled trial. PLoS One 2015;10:1–14.
Keywords:

Nonpharmacologic; Phototherapy; TENS unit; Acupuncture; Meditation

Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The International Forum for the Study of Itch.