Definition

Lichen simplex chronicus or neurodermatitis is a long-lasting skin inflammation disease characterized by itching and thickening of specific skin areas that experience repeated scratching or friction. Neurodermatitis is non-contagious and not dangerous. The slow thickening of the skin, caused by repeated scratching or friction, is called lichenification. The most commonly affected areas include the neck, elbows, wrists, feet, or anus. The symptoms of neurodermatitis are generally exacerbated by unstable emotions, stress, or anxiety.

Causes

The exact cause of neurodermatitis is unknown, but psychological factors play a significant role in its occurrence. People who tend to experience severe stress are very susceptible to this disease.

Neurodermatitis starts with itchy skin. This itchiness triggers scratching or rubbing, leading to skin thickening. This thickened skin remains itchy, prompting further scratching, which leads to even more thickening, forming a continuous itch-scratch cycle if left untreated.

Conditions that can trigger neurodermatitis include:

• Insect bites
• Scars, such as those from skin injuries or post-herpes wounds (shingles)
• Skin protection disorders such as eczema (atopic or allergic dermatitis), dry skin (xerosis), psoriasis
• Circulation disorders in the legs (such as varicose veins or venous insufficiency)
• Psychological factors such as anxiety, emotional stress, and obsessive-compulsive disorder. Some studies suggest that emotional disturbances are associated with the sensation of itching followed by constant and repeated scratching in specific body areas.

Risk factor

Neurodermatitis can occur at any age, race, and in both genders. It is estimated to affect 12% of the population, most commonly found in middle-aged to older adults. The peak incidence is between 30 to 50 years of age, linked to a significant increase in stress at that age. Women are also noted to suffer from neurodermatitis twice as often as men.

Symptoms

Neurodermatitis can appear as one or more patches. Although it can occur anywhere on the body, it most commonly affects areas within easy reach, such as:

• The inner wrists, forearms, and elbows
• The sides of the back or neck
• The upper thighs, knees, shins, ankles, and tops of the feet
• The genital area, scrotum, anus
• The scalp

The affected skin in neurodermatitis appears thick, rough, dry, and scaly, with clearly visible skin lines. Thickening makes the skin appear darker, especially noticeable in darker-skinned individuals. The size of the skin lesions can vary from 3 to 10 centimeters.

• 1-2 very itchy patches can appear on the skin surface, usually linear or oval with clear edges. Patch size can range from 18-60 cm.
• Itchiness can be felt at any time.
• Itchiness worsens with stress, anxiety, or unstable emotions, but in some cases, it can be felt during rest or sleep.
• The hallmark symptom of neurodermatitis is that the more you scratch, the itchier it becomes. Frequent scratching leads to thicker, scaly skin and may cause open wounds from continuous scratching. Over time, these areas become darker than the surrounding skin.
• The condition is intermittent and can recur, often triggered by excessive stress or appearing during rest, with the itch disappearing during activity.

The main symptom of neurodermatitis is itching, especially intense at night or during inactivity. Symptoms can resemble atopic dermatitis (eczema) and psoriasis. In eczema, itching can occur in various locations, often in folds. In neurodermatitis, itching usually appears in one location. In psoriasis, the skin thickens in several locations, with silvery scales, unlike neurodermatitis. 

Diagnosis

Diagnosis of neurodermatitis includes a review of medical history and a physical examination. The doctor may also perform additional tests such as dermoscopy to examine the affected skin more closely. If the diagnosis is still uncertain, further tests may be recommended.

Tests that can be conducted to diagnose neurodermatitis include:

• Allergy tests if itching is suspected to be due to an allergic reaction
• Swab tests on the skin if itching is suspected to result from a skin infection
• Fungal tests to identify skin disorders and rule out sexually transmitted infections
• Skin biopsy to rule out psoriasis
• Blood tests

In addition to diagnosis, it is also important to identify the cause of neurodermatitis with specific tests. For example, patch tests can rule out allergic dermatitis as a cause. If neurodermatitis occurs in the genital area, tests for fungi can identify similar complaints. A skin biopsy can rule out psoriasis. Blood tests may be conducted to check for elevated antibody levels associated with allergies.

Management

The primary therapy for neurodermatitis is to stop scratching. However, this can be challenging once the itch-scratch cycle has started. To address this, doctors may recommend one or more of the following treatments to reduce itching and scratching:

• Aggressive skin moisturizing techniques
• High-potency corticosteroid creams or ointments for up to three weeks for very thickened skin
• Creams containing salicylic acid or urea to aid corticosteroid absorption
• Antihistamines, especially taken at bedtime, to prevent recurrence in allergic tendencies
• Direct corticosteroid injections into the affected skin areas
• Phototherapy with UVA/UVB light and photochemotherapy for severe cases
• Antidepressants for stress-related neurodermatitis
• Doxepin or capsaicin creams
• Tacrolimus or pimecrolimus creams
• Topical or oral antibiotics if infection is present

In addition to medical therapy, psychological treatments such as psychotherapy and psychiatric medications, such as anti-anxiety drugs, can be used for cases linked to psychological factors.

Surgical treatments like cryosurgery and the surgical removal of neurodermatitis (in severe cases not improving with medical therapy) can also be considered.

Home care measures include:

• Covering neurodermatitis areas at night to prevent scratching during sleep
• Keeping nails short to avoid skin injury from scratching
• Using moisturizers to reduce itching, choosing oil-based creams or ointments for better protection
• Applying hydrocortisone cream to reduce itching, though it should not be used on genital areas unless prescribed by a doctor
• Using antibiotic ointment on wounds caused by excessively dry skin to prevent infection

Complications

Complications from neurodermatitis include:

• Wounds from continuous scratching
• Bacterial skin infections from scratching wounds
• Permanent scarring
• Itchiness causing sleep disturbances, sexual relationship issues, and reduced quality of life

Prevention

Prevention of neurodermatitis involves managing or avoiding triggers such as dry skin, emotional stress, and skin disorders like allergic dermatitis. Steps include:

• Using moisturizers
• Avoid allergens like smoke, dairy products, pet dander, perfumes, etc.
• Stress management through meditation, yoga, exercise, or psychotherapy

When to see a doctor?

Consult a doctor if:

• Home care measures do not improve symptoms
• The affected skin area expands
• There are signs of infection, such as pain, redness, discharge from the affected skin, or fever

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