The relationship between stress and three common skin conditions
The nervous origins of some aspects of AD were indicated by the French Dermatologists Brocq and Jacquet  when in 1891 they coined the term neurodermite for what would now be seen to be the lichenification of the skin characteristic of chronic AD. Such chronic eczema is found in areas that are easy to scratch and rub, for example the face, neck and hands. In the 1950s it was shown by using a scratching machine on normal skin that scratching alone can produce the histological findings seen in chronic AD . In the 1980s a behaviour modification technique called habit reversal was combined with standard topical treatment for AD and a strong correlation found between reduction in scratching and improvement in skin status . This research has led to the development of The Combined Approach, a treatment programme for routine clinical use. The management of stress is one of the important parts of this programme.
A Treatment Programme for Adults and Older Children1
The practitioner’s manual  sets out protocols for several clinic visits over 5–7 weeks, with the initial visit devoted to assessment, and subsequent visits for the introduction of treatment, then troubleshooting and finally the planning of follow-up (Fig. 12.2). Keeping to this structure of a treatment programme is important. Each stage is supported by reference to a patient handbook and a website  devoted to the programme. As an exercise in behavioural dermatology The Combined Approach thus has a strong educational element, with an emphasis on the patient’s perspective, and what takes place away from the clinic, between appointments. There is a recognition in the approach of an important need to empower the patient, and others too, with an active optimism. This new attitude should replace what is otherwise often seen: a somewhat passive pessimism associated with both having, and treating, chronic AD. With The Combined Approach patients can be shown how to control their dermatitis, rather than continuing to allow it to control them.
The combined approach treatment stages
At the first visit
assessment can usefully include a review of quality of life effects from chronic AD, and the role that stress is seen to play in causing eczema to flare up. High scores on quality of life effects can be an indication of the level of stress caused by AD , while reported association between acute flare-ups and stressful life factors indicate how stress is implicated as a causative influence. For many the treatment programme improves the skin status dramatically within 2 weeks of starting treatment. With this any reported stress associated with having AD is immediately relieved. One of the first knock-on effects is improved sleep, for the patient and for anyone who sleeps with them. Specific stress management techniques are not usually therefore considered until the third clinic visit – see below. Assessment is completed by the patient being given a hand tally counter to be used over a week before the second appointment, to record the baseline frequency of scratching. This enables increased awareness of how the normal scratching response to an itch has become an abnormal automatic, unconscious and habitual self- damaging behaviour, linked not only to itch, but also triggered by a range of circumstances and emotional states, including stress. The tally counter remains involved throughout the programme to measure progress with habit reversal. Subsequently the counter is often identified as the most useful part of the programme. It represents the stress-relieving and welcome sense of relief that comes with learning how to achieve control over what has previously been counter-productive, habitual skin damaging behaviour.
The second visit
completes assessment and introduces the treatment programme. The patient’s record of scratching frequency and associated circumstances is reviewed and the discussion is usefully expanded to note methods of scratching employed. All methods of mechanically stimulating the skin are regarded as potentially damaging, including rubbing and massaging. Any use of implements or aids to scratching need to be identified and understood to be now undesirable.
The Combined Approach adds optimised conventional topical treatment to habit reversal training: there are therefore three levels of treatment, one for each of the three levels of the vicious circle that is operating with chronic AD (Fig. 12.3). It is relevant to note here that each level of this circle – dry skin , eczema and itch , and scratching  – may be exacerbated by psychological stress. Often it emerges at this stage that the principles of conventional treatment are poorly understood and the use of recommended topical treatment has been haphazard and inefficient . With The Combined Approach, maximising the effectiveness of emollients and topical steroids is important, and this is both discussed in detail, and supported by the content of the patient handbook and by reference to the programme website (www.atopicskindisease.com). Instruction in habit reversal follows review of the experience of recording scratching and rubbing behaviour over the first week of the programme. The frequency is often more than initially expected by the patient, and the link not only to itch but also to circumstances, activities and stress, is confirmed by the use of the hand tally counter.