Severe Itch Related to Hard Workload Treated with Acupuncture: Unexpected Results – A Case report

The work-related stress (WRS) affects occupational health and is often associated with reduced well-being and lower productivity. Stressful experiences are multifaceted and can start a cascade of symptoms such as pain, sleep problems, chronic fatigue, and memory disturbances [1]. Those symptoms have been proven to aggravate itching, often in connection with enhanced stress with a history of atopic dermatitis (AD) [2]. When itching is an ongoing condition, a major symptom of AD, different brain networks are activated compared to healthy subjects [3]. Itching can significantly reduce a person’s quality of life [2].

Treatments for chronic pruritus and AD include anti-inflammatory therapy with topical or systemic corticosteroids, topical calcineurin antagonists, systemic antihistamines, and UVB radiation therapy [4]. Other pharmacologic therapies that have shown results are treatments for chronic pain as they seem to use the same descending modulatory system in the central nervous systems (CNS) [2]. Further treatments with positive results are cognitive-behavioral stress management, muscle relaxation, and acupuncture [2, 4, 5]. Acupuncture is a complex somatosensory stimulation and has a lot in common with prolonged physical activity, acting on local and different organ functions and modulating both the peripheral and CNS [5].

The method appears to play a positive role in physiological responses related to pain and stress, such as emotional processing [6] and cognitive effects [5, 7]. Acupuncture seems to regulate the brain reward circuit, with a positive effect on anxiety [6, 7]. This seems to enhance the sense of well-being by acting on different functions such as social bonding, learning, memory, mood, motivation, and modulating physiological arousal [5].

The method appears to modify different functions in the brain, the limbic system, the hypothalamus-pituitary-adrenal axis, and homeostatic mechanisms, including mobilizing the function of the brain’s default mode network (DMN). The effects are relaxation, pain relief, stress regulation, anti-inflammatory modulation, anti-depressive effects [5, 6, 8], and cover chronic itch through the deactivation of nuclear putamen in the brain [6, 8]. The putamen is involved in the motivation and behavior to encourage scratching [8]. Repeated treatments seem to be needed to determine the long-term effects of acupuncture, as shown in an article with a marked improvement in itching, infection, and inflamed skin caused by panitumumab-related skin toxicity [9]. These findings may open new avenues for treating itch, AD, and WRS. The underlying mechanisms of acupuncture for stress, itch, and AD are still unknown.

The patient was a 58-year-old male who was a manager of two departments in an international company. He was invited to an intervention with acupuncture treatment (AT), of well-being to avoid long-term sick leave. He was exhausted and suffered from decreased well-being, perceived stress at work, intense headaches, physical discomfort, lack of relaxation, disturbed sleep, and fatigue. For the last 8 years, the patient has suffered from severe chronic therapy-resistant itch and AD since childhood.

The skin on the face, thorax, arms, hands, and legs flamed with rash. He had itching, dry and thick skin, and chronic local lesions from scratching, with severe peaks during the day and after midnight.

The patient used topical corticosteroids (group III or IV) 2–3 times per day on hands, arms, legs, and thorax. In the face, topical corticosteroids belong to groups II or III, depending on the severity of eczema and itch. In addition, a cream with salicylic acid at 2% and UVB ultraviolet irradiation therapy were administered 2–3 times a week at a dermatology specialist clinic for 8 years. Infected wounds, which emerged 2–3 times a year, were treated with antibiotics, systemic anti-inflammatory therapy, and corticosteroids (5 mg) according to a dermatological schedule. There was no history of dysfunction of the liver or reduced renal function.

Acupuncture was given 3 times in the first week, 2 times for 4 weeks, and 3 times during 6 weeks (14 AT over 11 weeks). Each session lasted for 45 min, with a 10-min health-oriented or leadership tools conversation, followed by 30 min AT. Acupuncture was administered by a licensed nurse educated theoretically and with extensive practical experience.

Sterile disposable, single-use needles of stainless steel (HEGU needles, Shenli Medical Factory M.H.M Wujiang, China), length 15/25 mm, diameter 0.20/0.25 mm, were inserted to a depth of 5–20 mm without stimulation of Deqi, and the patient had a strong sensation. Following acupuncture points (15 points) were used for the first intervention and follow-up: LR 3, LR 8, GB 34, KI 7, LI 4, LI 11, SP 6, SP 10, ST 36, CV 17, LU 1, LU 7, PC 6, GV 20, and EX 2 (Yintang). The treatment involved the use of 7–15 needles, including bilateral points for each AT, depending on symptoms, local pain, tenderness, or discomfort at the acupuncture points. The first treatment, lasting for 15 min, was to find out how the patient copes with the method: LU 7, PC 6, GB 34, Extra 2 (Yintang), to influence the stress symptoms and stress mechanisms in the CNS. On his next AT, added LR 3, ST 36, KI 7, with the intention, to modulate the effects on the CNS, such as homeostatic effect, lower DMN, and cognitive effects to increase well-being.

Third and subsequent visits: the patient expressed a desire to reduce itching and eczema. Therefore, the intention was to modulate the immune system effects, deactivate the nuclear putamen, and maintain low-stress levels: added SP 6, SP 10, LR 8, LI 4, LI 11, LU 1, GV 20, CV 17. Needles were placed in all four extremities in the forearms, hands, lower legs, and feet, bilaterally due to the patient’s severe symptoms, to get strong sensory stimulation and enhance the effects of the CNS.

Outcome measures included questionnaires with a numerical rating scale (NRS endpoints 0 = “no work-related stress/physical discomfort/fatigue/itch/” and 100 = “maximal work-related stress/physical discomfort/fatigue/itch/”). The main outcome variables were perceived stress at work, intense headache, physical discomfort, relaxation, sleep time, fatigue, eczema, and itching. Symptom score from baseline to after 11 weeks of intervention is shown in Figure 1 and to 23-month post-intervention follow-ups is shown in Figure 2.

When entering the intervention, the patient rated vigor and energy at NRS 45, and after 11 weeks NRS 89. A positive cognitive process had started which was a more visionary approach in his leadership, more energy, more structure, more planning, and better focus. At the start, the perceived WRS estimated NRS 95 and rated 80 after 11 weeks, indicating that the overloaded working situation had not changed. The other variables changed dramatically. The scores for headache reduced after 2 weeks from NRS 70 to NRS 2. Sleep time of NRS 40, due to severe nocturnal pruritus, improved to NRS 80. Fatigue rated NRS 75 fell to NRS 45. Relaxation enhanced from NRS 18 to NRS 83.

During the first intervention, 11 weeks, the patient described an unexpected treatment effect. The intensity of the itching NRS 90, changed to NRS 60. The intensity of eczema decreased from NRS 78 to NRS 38. At that time, the company ruled out a long sick leave for recovery.

At the patient’s request, a follow-up period was initiated, divided into eight intervention sessions, including one to six AT, a total of 24 AT. Outcome measures were taken at the beginning of every intervention with NRS describing the progress of stress, fatigue, eczema, and itching (shown in Fig. 2).

At FuP 1, in September (four AT in 4 months), the patient reflected immediately that a single AT had a strong direct improvement in itch. At FuP 2, in April, 10 months later (five AT in 4 months), ratings of all variables were positive, and he had stopped the UVB-light treatments, including reducing the daily frequent use of topical corticosteroids in groups III or IV. The quality and length of sleep had extended further. When experiencing a sense of vigor and energy, the patient could keep a distance from the demanding work. At FuP 4 (one AT), all variables were stable except for a recurrence of severe itching and eczema. Together with AT, increased topical and systemic corticosteroids, and antibiotic treatment, he recovered and remained stable. At FuP 6 (three AT), a high score of severe itching NRS 85 was recorded, but a low score of eczema NRS 40. With medication and AT, a dramatic positive change started in itching, relaxation, and increased well-being. At FuP 7, a high score of WRS, NRS 50 was recorded. At FuP 8, in May (four AT in 1 month), 23 months later, he reported great feelings with keeping distance from the demanding work and positive ratings on all variables, itching NRS 10, eczema NRS 10, and fatigue NRS 5. This surprised him, as the season, since childhood, has given him severe symptoms of allergic problems such as eczema, severe itching, respiratory problems, red-itchy-watery eyes, and did not suffer from any of them. The improvement remained stable in itching and eczema through the springtime.

This retrospective case report indicates that acupuncture is of interest to explore as a complementary method for WRS symptoms. AT seemed to break the severe itching, eczema, and ongoing stress symptoms including preventing sick leave. At the last follow-up in May, the patient felt great and stayed stable on all variables with positive rates, including itchiness and eczema. AT seemed to both strengthen and improve the physiological function of the symptoms [6‒8] and reduce the severity of disease scores in itch and AD [9], but it may not affect the disease AD [10], indicating that more studies are needed.

The cognitive and emotional effects started after a few treatments in the first intervention and improved further. Then the patient’s company ruled out sick leave to recover as he was working comfortably with high work performance. The acupuncture intervention probably reduced costs for the company [11].

Different relaxation techniques and stress management have been shown to break the cycles of itch with positive results [2]. AT can act on different physiological levels to improve relaxation, lower anxiety, restore the parasympathetic nervous system, and DMN, including inactivation of the nucleus putamen, all of which enhance well-being and reduce itching [5‒8].

When entering the follow-ups, the desire was to explore if AT could further improve itch, eczema, and interrupted sleep with severe scratching to bleeding. At the second follow-up intervention, the patient had stopped the UVB light after 8 years, as well as reduced topical steroids. Sleep, in terms of length and quality, had improved, and he woke up more seldom. The two breakthroughs with severe itching and eczema were suppressed quickly with AT together with his usual medicine.

There are limitations to consider in this case. Firstly, we need to evaluate the methodological approach and the possible placebo effect, as none of them have been assessed. Secondly, the extended duration of AT may have contributed to an improvement in social bonding, which could have subsequently led to better outcomes. The case has the NRS scores and the patient’s description as the outcome; we do not have any photographs to support our observations.

It is important to conduct research on the most effective AT that includes follow-up sessions, as demonstrated by the marked improvement in itch, infection, and inflamed skin in this case and in the case of panitumumab skin toxicity [9]. This could be a reason why AT maintains its effects and even enhances them in the long term.

Surprisingly, in addition to reducing severe stress symptoms, acupuncture was superior in reducing the patient’s 8-year-old suffering from severe therapy-resistant pruritus by a total of 38 AT over 2 years and 2 months, compared to 8 years in a dermatological specialist clinic.

The results are more than what the patient, therapist, and employer expected in terms of reduction of itching, eczema, and WRS symptoms, thus long-term sick leave could be ruled out. The patient succeeded, from his perspective, with his three goals at the start of the intervention: (1) a relaxed feeling in the body; (2) to be free from eczema; (3) to have a more prearranged and planned working day. A practical point was that during working hours, there was no need to change shirts, up to 3 times a day, as before, due to bleeding wounds caused by severe itching. The quality and length of sleep had extended giving the patient more vigor and energy to handle all the demands at work. Still, the patient had an overloaded working situation and had been hesitant to try acupuncture.

We cannot draw any firm conclusions beyond speculating on the remarkable recovery of this particular patient. Formal evaluation with prospective controlled trials is needed. WRS is a large problem and costs a lot of suffering and money for society and employers. Acupuncture can be a complementary or starting treatment for itch, related to stress symptoms, as the methods are safe, cost-effective, and environmentally friendly.

No formal Ethical approval was required for this case according to the Swedish Ethical Review Authority. Written informed consent was obtained from the patient for publication of this case report and any accompanying images.

The authors have no conflicts of interest to declare.

The authors declare they received no funding for the present case.

L.D. performed the treatment, collected the data, and wrote the first draft of the manuscript. A.F. has been a supervisor, text reviewer, and made figures based on data.

All data generated and analyzed in this case are available upon request to the corresponding author.