Dermatologist Dr Kok Wai Leong explains why the itch–scratch cycle happens causing atopic dermatitis itch, and how newer targeted therapies are changing eczema care.
For those living with atopic dermatitis (AD), the itch – the hallmark of this condition – is not an occasional bother. It is constant, lingering in the background of daily life. It flares up without warning at its own convenience, making an appearance during important events during the day, or simply resurfacing at night when the body is trying to rest.
Eventually, this intolerable state is perceived as normal. The scratching, the broken sleep, and the meticulous avoidance of specific skin triggers are routines that become interwoven into everyday existence.
But should living with eczema feel this inevitable?
According to Dr Kok Wai Leong, a dermatologist at Dermatology Collective Clinic & Surgery, many patients underestimate how deeply the condition affects their daily functioning.
“In my practice, I find that the most disruptive symptom is itch – which can be persistent and intense.” says Dr Kok. “Due to the severe itch, sleep disruption is common. Many patients wake up multiple times a night scratching, which leads to chronic fatigue, difficulty concentrating, mood changes, and reduced productivity at work or school.”
When sleep is repeatedly interrupted, the consequences ripple into the daytime. Over time, the condition can also affect emotional wellbeing. Beyond physical discomfort, visible eczema lesions can also carry a social burden.
“Visible rashes on the face, neck, or hands can affect confidence and self-esteem.” Dr Kok explains. “Patients may avoid social events, hobbies and activities like sports, or even intimacy.”
For individuals with moderate to severe disease, studies show that the impact on quality of life can be significant.
Why the Itch–Scratch Cycle Persists
Many people with AD feel trapped in a repeating cycle: itching, scratching, temporary relief, and then another flare.
Dr Kok notes that treatment can sometimes plateau for several reasons.
One common factor is undertreatment, particularly when patients are hesitant to use prescribed medications. Often, topical steroids are prescribed to manage the condition. Some patients are afraid to use them consistently because of concerns about side effects.
Others stop treatment prematurely once their skin appears better. However, eczema is driven by inflammation beneath the surface, and consistent management is essential.
“AD is a chronic inflammatory condition that fluctuates with time. Regular application of multiple treatment modalities can be frustrating, and some patients may become ill-adherent to the treatment regime.” Dr Kok shares. “It takes self-discipline and consistency, and this can be overwhelming for young kids or burdensome for those who require caregiver attention.”
For some patients, the itch itself worsens the condition.
“The more you itch, the more you scratch, and this drives a cascade of inflammation and signals that causes the symptoms to worsen.” he explains.
When this cycle intensifies, previously effective treatments may stop working as well.
The Role of Daily Skin Care
Despite the frustrations of managing AD, some foundational strategies remain essential.
Moisturising regularly is one of the most important steps.
“First, start with daily and regular moisturising. This helps restore the skin barrier, lock in moisture in the skin, and lower the possibility of reactions to irritants and allergens.” Dr Kok explains.
He also emphasises gentle skincare habits, such as using soap-free cleansers, taking shorter showers, and wearing soft, breathable fabrics. Identifying triggers can also help reduce flare-ups, although triggers vary widely from person to person.
However, Dr Kok cautions that these strategies alone may not be enough for people with more severe disease.
“In moderate-to-severe AD, these strategies are supportive, and may not be sufficient on their own,” he says.
If inflammation is significant, additional medical treatments may be necessary to control the immune response driving the disease.
When Basic Management Is No Longer Enough
Despite ongoing symptoms, some patients remain reluctant to consider stronger treatments.
Fear often plays a major role.
“There’s a lot of fear around systemic medications, in both oral and injectable forms. Many patients associate them with broad immune suppression or serious side effects.” says Dr Kok.
Concerns about steroid withdrawal syndrome or long-term medication risks can also make patients hesitant.
On the other hand, some patients underestimate the severity of their condition.
“There are also some patients who feel their AD is not severe enough to justify escalation, even when their quality of life is clearly suffering.” he says.
Education and open conversations between patients and doctors are therefore of utmost importance, so that patients can understand their condition, and get the help they need.
For patients with long-standing AD, Dr Kok advises:
- When non-pharmacological strategies are no longer sufficient to manage the condition, medical treatment may be required
- For those with stable disease, review with your dermatologist every 3-6 months
- If symptoms worsen, obtain an earlier review
- This includes frequent flare-ups, persistent sleep disruption, worsening skin involvement, or symptoms of recurrent skin infections
Even after starting a new therapy, Dr Kok usually reassesses within 4-8 weeks to ensure that treatment is appropriate.
“Atopic dermatitis evolves over time, and treatment plans should evolve with it.” Dr Kok remarks.
Newer Treatments Target Symptoms More Precisely
Traditional systemic treatments, such as oral corticosteroids or immunosuppressants, act broadly on the immune system. While effective, long-term use may be limited by side effects.
Treatment options for eczema have changed significantly in recent years, with newer therapies that are much more targeted.
- Monoclonal antibodies for AD are designed specifically to block key cytokines, which are important molecules that drive inflammation and itch in AD.
- JAK inhibitors are small molecules that modify and interrupt intracellular signalling pathways involved in itch and inflammation.
Because these therapies focus on specific pathways rather than suppressing the entire immune system, they may offer more precise control of symptoms.
However, not every treatment is suitable for every patient, and a thorough evaluation by a dermatologist remains essential to determine one’s suitability for treatment.
What These Advances Mean for Patients
For individuals who have struggled with severe eczema for years, newer therapies are offering renewed possibilities. Mirroring clinical data from large studies, Dr Kok has seen meaningful improvements in many of his patients:
“The itch reduction and skin clearance are significant and can be achieved much quicker than traditional therapies. This translates into improved sleep, clearer skin, and fewer flare-ups.” he shares.
Still, realistic expectations remain important. Current treatments aim to control the disease rather than cure it. But sustained control, once difficult to achieve, is now increasingly possible for many patients who previously had limited options.
“I have seen how these newer treatments are transformative for my patients.”
Reclaiming Control Over the Itch
For those living with AD, Dr Kok encourages a shift in mindset.
“First, recognise that you do not have to live with the symptoms of AD – and for someone whose itch is unbearable, this is not something you should tolerate.” he emphasises.
Instead, patients should work with their trusted dermatologist to reassess their treatment goals and explore available options.
He recommends approaching consultations with specific questions:
- How severe is my disease right now?
- Is my current treatment appropriate for this severity?
- Am I a candidate for advanced targeted therapy?
- How will we measure success together?
Atopic dermatitis may be a chronic condition, but science has advanced, and treatment options for AD have expanded – which means that we can embrace higher expectations for control.
So if the itch is still nagging at you day and night, then it is time to consult your dermatologist and ask whether your current plan truly reflects what is possible.
Visit our Dermatology Chapter – Atopic Dermatitis for more information and resources on living with eczema and chronic itch.
