The 62-year-old woman shifted in her seat. The flight to Honolulu was full, the mood a little giddy. The unbroken ocean and sky filled the window. She and her daughter were four hours into the trip from Los Angeles to the wedding of a close family friend; it was going to be a great week. Then, she caught herself scratching lightly at a place on her forearm, just below the crease of her elbow. She lifted her arm to look at the spot. Nothing there. Immediately she was filled with dread.
She reached over her head to touch the call button. She needed ice, lots of ice, and she needed it right away. The mild itch had already exploded into spasms of an intense sensation — it seemed wrong to call it an itch; surely there was a better word for it. The fierce intensity of the feeling shocked her. It was a feeling that insisted she scratch. Except scratching never helped. And she had the scars to prove it.
She had suffered episodes of itching like this a few times in the past couple of years, though never quite as bad as it was on this flight. Her doctor back home had no idea what caused the crazy itch or what more she might do about it. These attacks came out of nowhere but immediately brought life to a standstill as she tried to ease the unbearable sensation. A bout could last for hours and almost always ended with her arm a bloody mess. When her daughter first saw her mother raking her nails over the invisible injury and the distress she felt fighting this unwinnable battle, she had offered her a Valium. And it helped. The itch was still there but the intensity somehow lessened.
On the flight, the woman retrieved the pills she now carried with her all the time. The little bags of ice brought by the flight attendant melted slowly, numbing the hand that pressed them against her arm and easing the itch. She knew from experience that as soon as the ice was removed, the itch would roar back. The attendant brought an ice bucket. But within the hour, she needed more ice. More Valium. She was drenched with the condensation. Her clothes were dotted with blood. She didn’t care. She just had to get through it.
The Valium and ice had done their job by the time the plane landed. The two women went to their hotel. The older woman went up to her room, closed the curtains and tried to manage the fear and the pain. The itch was gone, but her arm ached from the self-inflicted injuries. Two days later, the itch was back, this time on the other arm. She didn’t make it to the wedding. The unpredictable need to scratch was too grotesque for her to risk having to do it in public. Instead, she went to doctors. She saw four dermatologists during the trip. None had any idea of what was wrong or what she could do about it.
A Doctor Who Loves Tough Cases
She had long since tried the usual remedies: antihistamine creams and pills; steroid creams; hot-pepper lotions; oatmeal baths; acupuncture. All completely useless.
After that trip, the frequency of the attacks ratcheted up. Instead of a couple of attacks a year, she might have a couple a month on one arm or both, day after day, sometimes for weeks. She saw dermatologists, neurologists, rheumatologists and naturopaths. It was her psychiatrist who finally recommended that she see Dr. Robert Michael Hartman, a dermatologist in Encino, just west of her home in Los Angeles. He mostly saw children, but according to her psychiatrist, who knew him, he loved tough cases.
She sat in Hartman’s office a few months later, her scabbed and scarred arms exposed by the shapeless cotton gown the nurse provided. As she told her story, the doctor examined her. He noted that the injuries were limited to the upper and outer regions of her forearms. “You need an M.R.I. of your cervical spine,” he said. “You have brachioradial pruritus.” Her itch was caused by an injury to a nerve in the lower part of her neck, he told her. After four years of looking, she had an answer in under five minutes.
Brachioradial pruritus is a neurogenic itch caused not by anything in the skin but by nerves sending out a kind of distress signal. Nerve fibers emerge from the spinal cord through holes in the vertebrae, known as foramina, and travel through the body to the region they cover. Each tiny nerve has a specific assignment, and nerves emerging from the vertebrae in the neck, known as the cervical spine, handle sensations from the head, face, neck, upper back, shoulders and arms. Hartman suspected that an M.R.I. would show something there aggravating these tiny fibers.
The nerve fibers that transmit itch, like those that transmit pain, are not covered by the myelin sheath that encloses most nerves. Perhaps that makes them easier to damage. The patient did get an M.R.I., and it did show some degenerative disease in the lower vertebrae in her neck. How was Hartman able to make this diagnosis so quickly when so many others failed? He told her: He’d seen it before.
So now the woman knew what she had. But what could she do about it? Again, no one seemed to know. One neurologist suggested a medication called gabapentin, a drug often used to treat pain that originates from the nervous system. Low doses didn’t help, and higher doses made her “loopy.” She saw neurosurgeons to determine if the vertebrae could be fixed. They couldn’t be, she was told. She tried physical therapy. It felt good but didn’t touch the itch. She tried lidocaine patches and lidocaine shots. Useless. One doctor put her on medical marijuana. That helped a little but gave her palpitations.
Treatments That Worked, for a While
Finally, six years after her diagnosis, she was referred to Dr. Raymond Cho, a professor of dermatology at the University of California, San Francisco. He was a researcher with a strong interest in chronic rashes. He was friendly and interested, and the woman liked him immediately. The skin on her arms was a mess. There was no rash, but the area that had been scratched the most — from her elbow, down toward the wrist — was leathery from the repeated trauma.
There was, Cho told the woman, a relatively new drug that had been approved for something known as atopic dermatitis, or eczema. Although it’s common, this skin disorder is still not well understood. Like brachioradial pruritus, eczema is intensely itchy. Maybe this medicine, a monoclonal antibody that blocks certain inflammatory chemicals known as cytokines, could work for her, Cho told her. Insurance companies didn’t love the drug because it was so expensive, but he thought it might be helpful. And it was. The attacks became less frequent, and when they came, the itch was somehow less intense.
But nearly a year later, the drug seemed to stop working.
Now what? The woman went to see Cho again, displaying her red, scabby arms. Her itch was clearly inflammatory in nature, Cho told her. That’s why the first drug worked. The question was whether other anti-inflammatory drugs would, too. The easiest way to find out was to try a more powerful medication, like prednisone. If that was helpful, they could move on to more targeted and less risky therapies. She agreed to try a six-week course. The result was miraculous. For the first time in more than a decade, she was completely itch-free.
She couldn’t stay on prednisone; the side effects of long-term use — weight gain, bone loss, diabetes, hypertension — were too serious. So she was started on another anti-inflammatory drug, methotrexate. That was a year and a half ago. It worked beautifully — until a couple of weeks ago when she was shocked by a new itch. It scared her, and she is thinking about trying prednisone again. But Cho has encouraged her to be patient. “It is just one episode, and it wasn’t as bad as it has been,” she told me when we last spoke. “I’m not giving up on it yet.”
It’s frustrating for the patient, Cho acknowledged. “Until recently we didn’t know much about itch. It wasn’t taken seriously. But researchers and drug manufacturers are finally coming around to see this as a huge quality-of-life issue.” They are making progress, he tells me, but it just takes time.
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