REVIEW ARTICLE

Effects of Psychological Interventions on Itch, Scratching, and Excoriations: A Systematic Review and Meta-analysis

Christina SCHUT^1,5# , Johanna MUNZ^1# , Frederic MAAS GENANNT BERMPOHL² , Antoinette I. M. VAN LAARHOVEN³ , Jennifer SCHMIDT⁴, Andrea W. M. EVERS^3† and Jörg KUPFER¹

¹Department of Medicine, Institute of Medical Psychology, Justus-Liebig-University Giessen, Germany, ²Department of Clinical Psychology and Psychotherapy, School of Human and Social Sciences, University of Wuppertal, Germany, ³Health, Medical and Neuropsychology Unit, Faculty of Social and Behavioural Sciences, Leiden University, The Netherlands, ⁴Muenster Department of Health, FH Muenster University of Applied Sciences, Germany, and ⁵University of Applied Sciences for Public Management and Security, Faculty of Police, Wiesbaden, Germany
^#Authors contributed equally and should both be considered first authors.
^†Prof. Dr. Andrea Evers passed away on 4 August 2025.

Psychological interventions reduce itch in patients with skin diseases. However, previous systematic reviews and meta-analyses did not include patients with non-skin-related chronic itch and did not consider excoriations as outcome. This study therefore summarized randomized controlled trials investigating effects of psychological interventions on itch, scratching, and excoriations in patients with chronic itch due to all causes. A systematic literature search was conducted. A random effects model was used to aggregate between-group effect sizes. It was found that 17 of the 20 trials included patients with atopic dermatitis. Small to large post-treatment and follow-up effects were observed on self-rated itch intensity (post-treatment: k = 12, g = –0.37 [–0.60; –0.15]; follow-up: k = 6; g = –0.59 [–0.97; –0.21]), externally rated excoriations (post-treatment: k = 6, g = –0.29 [–0.49; –0.09]; follow-up: k = 6; g = –0.34 [–0.53; –0.15]), and self-rated scratching intensity (post-treatment: k = 2, g = –0.99 [–1.35; –0.63]; follow-up: k = 2; g = –0.85 [–1.22; –0.48]). Small post-treatment effects were observed on self-rated itch frequency (k = 3, g = –0.22 [–0.40; –0.04]). Thus, psychological interventions show promise in reducing not only itch and scratching, but also excoriations, with effects lasting up to 1 year.

SIGNIFICANCE

Psychological interventions like cognitive behavioural therapy or patient education programmes are effective in reducing itch. This meta-analysis summarized results from 20 randomized controlled trials investigating the effects of psychological interventions on itch, scratching, and for the first time also on excoriations in patients with chronic itch due to all causes. Small to large post-treatment and follow-up effects were observed for itch, scratching intensity, and externally rated excoriations. Despite low certainty of evidence, psychological interventions show promise in itch-related parameters, with effects lasting up to 1 year. Future high-quality randomized controlled trials are needed to confirm these findings.

Key words: chronic pruritus; itch; psychological treatment; psychotherapy; meta-analysis; systematic review.

 

 

INTRODUCTION

Chronic itch is defined by a continuous or intermittent pattern of itch that persists for at least 6 weeks and “typically differs from acute pruritus by long-term structural and functional changes of itch processing” (1; p. 6). It is a common symptom in dermatological conditions (1, 2) and non-dermatological diseases such as chronic kidney disease (4, 5), diabetes (6), and haemato-oncologic diseases (7). Chronic itch can also occur with predominant involvement of psychological factors with no clear dermatological, systemic, or neurological cause, sometimes referred to as psychogenic itch (8, 9). The biopsychosocial model of chronic itch, assumed to be particularly involved in the latter category but may also apply to other types of chronic itch, postulates that psychosocial factors can trigger physiological responses that exacerbate itch (10). In turn, itch may lead to stigma, depression, or sleeping disorders (11), creating a vicious cycle that must be addressed to help patients.

Psychological interventions like cognitive behavioural therapy (CBT), mindfulness-based interventions, habit-reversal training, or patient education programmes have shown benefits in patients with itchy skin conditions, as highlighted by previous systematic reviews and meta-analyses (12–21). Most of these studies focus on psychological variables like quality of life, anxiety and depression (14, 21), or disease severity in specific patient groups (13, 14, 17, 21). A recent meta-analysis in patients with eczema (17) found effects of psychological and educational interventions on the severity of the skin disease in general, but reductions in itch, scratching, and excoriations were not investigated separately. Some studies also directly assessed effects on itch and scratching in patients with skin diseases (13, 14, 20). Lavda et al. (14) reported medium to large effects of psychological interventions on itch and scratching (k = 6 randomized controlled trials; RCTs) in adult patients with various skin conditions, which were greater than the effects on disease severity (k = 11 RCTs) or psychosocial factors (k = 12 RCTs). Chida et al. (13) found large effects of psychological interventions on itch and scratching in adults and children with atopic dermatitis (AD), but only a moderate effect on the severity of the skin disease. A recent meta-analysis (20) found significant effects of psychological interventions in patients with AD on the severity of the skin disease and on scratching intensity, but not itch intensity. However, all these meta-analyses excluded patients with non-dermatological chronic itch (International Forum for the Study of Itch [IFSI] category II [22]) and did not assess excoriations caused by itching as an outcome.

Therefore, this systematic review and meta-analysis, conducted by members of the special interest group (SIG) “psychological factors and itch” of the IFSI, aims to investigate the effects of psychological interventions on itch and scratching in adults and children with all types of chronic itch conditions, incorporating excoriations as an additional outcome measure as well as itch and scratching.

MATERIALS AND METHODS

Protocol and registration

As recommended in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline (PRISMA) (23), the study protocol was registered on the international prospective register for systematic reviews (PROSPERO; CRD42021245916) before the literature search was conducted. All amendments were documented (Appendix S1).

Inclusion and exclusion criteria

Reports on RCTs, including parallel-group and crossover trials examining the effects of a psychological intervention on itch and scratching in humans of all ages reporting chronic itch, were included. Psychological interventions were defined as “any psychological service provided by a trained professional that primarily uses forms of communication and interaction to assess, diagnose, and treat dysfunctional emotional reactions, ways of thinking, and behavior patterns” (American Psychological Association) (24). Studies were included if interventions were carried out by at least 1 trained professional in an individual, couple, or group setting, or via (guided) self-help. Studies without control groups, comparing only the effects of a psychological intervention with another psychological intervention, were excluded. However, studies using a non-psychological active control group (e.g., dermatological education) were included. In addition, studies including healthy individuals with experimentally induced itch or participants reporting no or only acute itch were excluded. Reports had to be published in English, German, or Dutch. There was no restriction to the publication date.

Outcome measures

Outcome measures were self-rated (SR) itch intensity and frequency, SR scratching intensity, and SR and externally rated (ER) scratching frequency, as well as SR and ER excoriations. Outcomes were included for the following time points: immediately after the intervention (post-treatment; PT) and at the last available follow-up (FU) between 1 and 12 months after baseline measurement.

Literature search

A search strategy was developed by JM in close cooperation with CS and JK. Afterwards the search strategy was discussed with AE and finalized in cooperation with all authors. The final search strategy (see Appendix S2) was applied to 4 databases (Cochrane Library, PsycINFO, PubMed, and Web of Science) at 2 time points (19 May 2021; 23 August 2023). The references of eligible studies and reviews on the topic were checked for further eligible reports (citation searching). Moreover, studies were identified via other sources (e.g., conference abstracts/posters and study protocols found via database search).

Study selection

Three authors (CS, JK, and JM) independently screened all found titles and abstracts. Duplicates were excluded. Subsequently, CS performed the full-text assessment, followed by JM checking all decisions independently and documenting the decisions made in SPSS (IBM Corp, Armonk, NY, USA) (25). Dutch studies were checked by AE and AVL. The citation searching was performed by CS and JM. Any disagreements between the 2 raters were resolved by discussion or consultation with JK. If required, further information was requested from the responsible authors. If there were multiple reports to the same study, reported data were compared and, if necessary, aggregated. For each excluded record, the main reason for exclusion was documented. If full texts of papers could not be retrieved via the search databases, authors were contacted by email and/or full texts were ordered via the university library. In 6 cases we did not receive the full texts. See Fig. 1 for PRISMA flow diagram.

Fig. 1. Flow diagram illustrating the results of the literature search and exclusion criteria.

Data extraction

Twenty RCTs with parallel-group design were included in the meta-analysis. As 3 RCTs were summarized in 1 report (26), the 20 RCTs resulted from 18 reports. CS and JM independently extracted data using a standardized Excel form (Microsoft Corp, Redmond, WA, USA). Differences in assessment were resolved by discussion or by consulting a third author (JK). Besides general information, data on the methodology, participants, applied interventions, control conditions, and outcome variables were extracted (Appendix S3).

Risk of bias assessment

Risk of bias (RoB) assessment was done independently by 2 authors for all outcome variables reported in the 20 included RCTs for PT and FU separately using the revised Cochrane Risk of Bias Tool for randomized trials (RoB 2) (27). Two authors conducted the RoB assessment for the English studies (AvL, FMgB) and 2 for the German studies (FMgB, JS). Any disagreement was resolved by discussion between the 2 raters or involvement of a third rater (JS for English studies, JM for German studies).

Assessment of the quality of evidence

Quality of evidence was evaluated by CS and JM and checked by all authors using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system (28). Following the GRADE approach, each outcome variable was rated across all studies with respect to the following 5 domains: RoB, publication bias, imprecision, inconsistency, and indirectness. The quality of evidence was classified into 1 of 4 levels: high, moderate, low, or very low. In terms of inconsistency, heterogeneity of the included studies was investigated by visual inspection of forest plots and the I²-statistic. According to Higgins et al. (29), an I²-value of 25% was defined as low, 50% as moderate, and 75% as high heterogeneity. Publication bias was assessed using funnel plots (30).

Data synthesis and statistical analyses

Meta-analysis was conducted using R (Version 4.3.3; R Foundation for Statistical Computing, Vienna, Austria) (31). Statistical analyses were only conducted for studies with a parallel-group design, not for studies with a crossover design due to missing data. The effects derived from the primary reports were pooled by means of a random effects model, because the effect sizes from the studies were assumed to be naturally heterogeneous (32). We used the restricted maximum-likelihood estimator for τ². Hedge’s g with 95% confidence intervals (CI) was used as effect size (33). This is a standardized mean difference calculated as the difference between the PT or FU means (M) of the intervention group and the control group divided by the pooled PT or FU standard deviations (SD) of the intervention and control groups. Negative values of Hedge’s g indicate that the intervention group had lower itch/scratching/excoriation levels at PT or FU assessments than the control group. This was reported for all outcomes and time points (PT and/or FU) in the case of sufficient data (at least 2 studies). Where information to compute effect sizes was missing, the study authors were contacted. In this way we obtained data from 8 studies (26, 34–40). For 2 studies, we estimated the missing SD on the basis of other statistical parameters (41, 42) (Appendix S4). If studies tested the effects of more than 1 intervention and 1 comparison condition, the most active one – thus the intervention with the largest amount of psychological content – was chosen as intervention. If studies had more than 1 comparison condition, the most inactive one – thus the condition with the least amount of participant contact – was chosen as comparator. If an outcome was assessed with more than 1 instrument, the measurement that was most frequently used across studies was selected in order to increase the comparability of studies (see also Appendix S4).

For sensitivity analyses, studies identified as outliers (95% CI outside the 95% CI of the pooled effect) were excluded. Participants’ age, type of intervention, mode of delivery (guided vs self-guided), and setting (face-to-face vs internet-based interventions) were considered as potential moderators of effects. Subgroup analyses were conducted in case more than 1 study per subgroup was available.

RESULTS

Characteristics of included studies

A total of k = 20 RCTs were included in the meta-analysis (Table I). Most of the studies used patient education programmes (k = 8) or CBT (k = 5). Hypnotherapy was used in k = 3 studies, habit-reversal training in k = 2 studies, and relaxation and mindfulness and self-compassion training were each used in k = 1 study. The treatment duration ranged from 20 to 1,440 minutes (M = 576.67, SD = 386.26; k = 15). The number of treatment sessions ranged from 1 to 12 sessions (M = 5.88, SD = 3.38; k = 16). Treatment duration and number of treatment sessions were not assessable for self-help interventions (k = 5). A total of k = 17 included patients with AD, k = 1 with psoriasis, k = 1 with burns, and k = 1 with pruritus due to skin diseases not further defined. K = 9 studies included adults, k = 5 children, k = 5 patients of mixed age groups, and k = 1 reported no age-related information. Most of the included studies (k = 16) were conducted in Europe (k = 10 in Germany; k = 3 in Sweden; k = 2 in the United Kingdom; k = 1 in the Netherlands). The remaining studies were conducted in Asia (k = 2 in Japan; k = 1 in Iran; k = 1 in China). Included studies were published between 1986 and 2023 (for more information see Table I). Descriptives of outcomes for all studies are reported in Appendix S5.

Table I. Study characteristics

Study	Patient group	Age group	Conditions	n analyseda	Mode of delivery	No. of sessions	Time total(min)b	Measurement time points: PT/FU (weeksc)	Outcome measuresd
Bosecker et al., 2011 (GER) (43)	CP	NI	PEpat	91	Group	1	60	PT	Itch Int, SR (VAS 1–10)
			TAU	175	–	–	–
Ehlers et al., 1995 (GER) (44)	AD	Adults and adolescents	CBT	15	Group	12	1,080–1,440	FU (52)	Itch Int, SR (scale 0–10);Scratch Int, SR (scale 0–10);Itch Freq, SR (no. incidents); Scratch Freq, SR (no. incidents)
			DE	6	Group	12	1,080–1,440
Farahani et al., 2013 (IR) (45)	BU	Adults, adolescents and children	RELAX	55	NI	1	20	PT	Itch Int, SR (NI)
			TAU	55	–	–	–
Futamura et al., 2013 (JP) (34)	AD	Children	PEpar	28	Group	7	300	FU (24)	Exco, ER (SCORAD)
			TAU + DE	28	–	–	–
Hedman-Lagerlöf et al., 2021 (SE) (35)	AD	Adults	CBT	43–51	Self-help	Varying	Varying	PT	Itch Int, SR (VAS 0–10);Itch Freq, SR (NI)
			TAU + DE	48–51	–	–	–
Heratizadeh et al., 2017 (GER) (36)	AD	Adults	PEpat	125–141	Group	6	720	PT / FU (52)	Itch Int, SR (PO–SCORAD);Exco, SR (PO-SCORAD);Exco, ER (SCORAD)
			WL	102–113	–	–	–
Kishimoto et al., 2023 (JP) (46)	AD	Adults	MIND	54	Group	8	720–840	PT / FU (13)	Itch Int, SR (scale 0–10); Scratch Int, SR (scale 0–10)
			WL	51	–	–	–
Melin et al., 1986 (SE) (41)	AD	Adults	HR	4–7	Individual	2	NI	PT	Itch Int, SR (scale 0–6);Scratch Freq, SR (no. incidents)
			TAU	6–9	–	–	–
Niebel et al., 2000 (GER) (47)	AD	Children	PEpar	18	Group	10	1,200	PT	Exco, ER (scale 0–3)
			TAU + DE	14	–	–	–
Norén et al., 2018 (SE) (48)	AD	Children	HR	15	Individual	4	120–160	PT	Scratch Freq, ER (no. incidents);Exco, ER (SCORAD)
			TAU	17–18	–	–	–
Rotter et al., 2023 (GER) (49)	AD	Adults	HYP	4–6	Group	5	450	PT / FU (26)	Itch Int, SR (VAS 0–100)
			TAU	8–9	–	–	–
Santer et al., 2022 (UK) (37)	AD	Adults and adolescents	PEpat	130–135	Self-help	Varying	Varying	PT	Itch Int, SR (scale 0–10); Itch Freq, SR (POEM)
			TAU + DE	144–148	–	–	–
Schut et al., 2013 (GER) (38)	AD	Adults	CBT	13–14	Group	4	720	PT	Itch Int, SR (PO-SCORAD);Exco, SR (PO-SCORAD)Exco, ER (SCORAD)
			WL	14	–	–	–
Senser et al., 2004 (GER) (42)	AD	Adults	HYP	15	Individual	12	720	PT	Itch Int, SR (VAS 0–10);Scratch Int, SR (VAS 0–10)
			WL	18	–	–	–
Sokel et al., 1993 (UK) (50)	AD	Adolescents and children	HYP	12	Individual	4	120	PT / FU (20)	Exco, ER (scale 0–3)
			GD	10	Individual	4	120
Staab et al., 2006_substudy1 (GER) (26)	AD	Children	PEpar	274	Group	6	720	FU (52)	Exco, ER (SCORAD)
			WL	244	–	–	–
Staab et al., 2006_substudy2 (GER) (26)	AD	Children	PEpar/PEpat	102	Group	6	720	FU (52)	Exco, ER (SCORAD)
			WL	83	–	–	–
Staab et al., 2006_substudy3 (GER) (26)	AD	Adolescents	PEpat	69–70	Group	6	720	FU (52)	Itch Int, SR (SCORAD);Exco, ER (SCORAD)
			WL	50	–	–	–
van Beugen et al., 2016 (NL) (39)	PSO	Adults	CBT	36–45	Self-help	Varying	Varying	PT / FU (51)	Itch Int, SR (ISDL);Itch Freq, SR (ISDL)
			TAU	43–50	–	–	–
Zhai et al., 2023 (CH) (40)	AD	Adults	CBT	11	Self-help	Varying	Varying	PT	Itch Int, SR (scale 0–10);Exco, ER (EASI)
			TAU	9	–	–	–
aSummarized for PT and FU; btotal time of direct contact in minutes; cduration from baseline to last available follow-up assessment; donly for analysed data (extracted from report or provided by authors). AD: atopic dermatitis; BU: burns; CBT: cognitive behavioural therapy; CH: China; CP: chronic pruritus; DE: dermatological education/information; EASI: Eczema Area and Severity Index; ER: externally rated outcome; Exco: excoriations; f: female; FU: last available follow-up assessment; GD: patient group discussion; GER: Germany; HR: Habit Reversal Training; HYP: hypnotherapy; Itch Freq: itch frequency; Itch Int: itch intensity; IR: Iran; ISDL: Impact of Chronic Skin Disease on Daily Life; JP: Japan; m: male; MIND: Mindfulness and Self-Compassion Training; n: sample size; NI: no information; NL: The Netherlands; No.: number; NRS: Numerical Rating Scale; PEpar: parental education; PEpat: patient education; POEM: Patient-Oriented Eczema Measure; PO-SCORAD: Patient-Oriented Scoring for Atopic Dermatitis; PSO: psoriasis; PT: post-treatment assessment (immediately after intervention); RELAX: relaxation therapy; SCORAD: Scoring for Atopic Dermatitis; Scratch Freq: scratching frequency; Scratch Int: scratching intensity; SE: Sweden; SR: self-reported outcome; TAU: treatment as usual; UK: United Kingdom; VAS: visual analogue scale; WL: wait-list.

Effects on itch and scratching

Itch intensity. Twelve studies with 1,311 observations were included in the analysis of the PT effects. Nine studies included patients with AD. Results indicated that psychological interventions were significantly more effective in reducing itch intensity than control conditions (g = –0.37 [95% CI –0.60 to –0.15]; p = 0.0013). Six studies with 572 observations were included in the analysis of the FU effects. Five of them included patients with AD. The analysis revealed moderate significant effects (g = –0.59 [95% CI –0.97 to –0.21]; p = 0.0025). The FU periods varied from 13 to 52 weeks after baseline (Fig. 2).

Fig. 2. (A) Post-treatment and (B) Follow-up effects of psychological interventions on itch intensity. Nc: number of persons in the control group; Ne: number of persons in the experimental group; SMD: standardized mean difference (Hedge’s g); CI: confidence interval.

Itch frequency. Three studies with 467 observations were included in the analysis of the PT effects. Two of them included patients with AD. Results were statistically significant (g = –0.22 [95% CI –0.40 to –0.04]; p = 0.0184). Two studies with 101 observations could be included in the meta-analysis regarding the FU effects, with 1 study including patients with AD. FU periods varied between 51 and 52 weeks after baseline. Effects were small and did not reach statistical significance (g = –0.53 (95% CI –2.13 to 1.08); p = 0.521) (for forest plots, see Appendix S6a).

Scratching intensity. Two studies, with 138 (PT) and 126 (FU) observations respectively, were included in the analysis of the PT and FU effects. All of the studies included AD patients. The FU periods ranged from 13 to 52 weeks after baseline. Effects were large and significant (PT: g = –0.99 [95% CI –1.35 to –0.63]; p < 0.001); FU: g = –0.85 [95% CI –1.22 to –0.48]; p < 0.001) (for forest plots, see Appendix S6b).

As the effects of psychological interventions on SR and ER scratching frequency were investigated in k ≤ 1 studies, no statistical analyses were performed for these outcome parameters.

Effects on excoriations

Self-rated excoriations. Two studies with 281 observations were included in the analysis on PT effects, with both of them including patients with AD. Results indicated no statistical significance (g = –0.23 [95% CI –0.47 to 0.01]; p = 0.057). FU effects of psychological interventions on SR excoriations could not be determined as this outcome parameter was investigated in only 1 study (forest plots see Appendix S6c).

Externally rated excoriations. PT and FU effects on ER excoriations were investigated in 6 studies each, of which 2 investigated both PT and FU effects. All of the studies included AD patients. The analysis regarding PT effects included 386 observations in total and the analysis regarding the FU effects 1,127 observations. Results revealed small statistically significant effects in both cases (PT effects: g = –0.29 [95% CI –0.49 to –0.09]; p = 0.005; FU effects: g = –0.34 [95% CI –0.53 to –0.15]; p = 0.0005) (Fig. 3).

Fig. 3. (A) Post-treatment and (B) Follow-up effects of psychological interventions on externally rated excoriations. Abbreviations: Nc: number of persons in the control group; Ne: number of persons in the experimental group; SMD: standardized mean difference; CI: confidence interval (Hedge’s g).

Sensitivity analyses

Due to the fact that the effects of psychological interventions on itch frequency, scratching intensity, and SR excoriations were investigated in a very small number of studies (k ≤ 3), outlier analyses were conducted only for itch intensity and ER excoriations. Here, regarding itch intensity only 1 study (43) was identified as an outlier in the analysis regarding effects on itch intensity PT. Exclusion of this study did not change the results, still retaining small to moderate effects (g = –0.44 [95% CI –0.64 to –0.23]; p < 0.0001). Regarding ER excoriations, no outliers were identified.

Subgroup analyses regarding delivery mode, setting, and age

Regarding most of the outcomes (itch frequency, scratching intensity, SR excoriations) no subgroup analyses could be performed as the number of studies was too small (k ≤ 1 per subgroup). Furthermore, due to the small number of studies (k ≤ 1 per subgroup), it was not possible to conduct subgroup analyses regarding the type of intervention.

Delivery mode. Regarding delivery mode, the subgroup analyses revealed no significant PT effect on itch intensity, meaning that guided and self-guided interventions did not differ significantly (guided [k = 8]: g = –0.41 [95% CI –0.75 to –0.07]; self-guided [k = 4]: g = –0.25 [95% CI –0.48 to –0.02]; p = 0.437).

Setting. Regarding the setting, effects on itch intensity did not differ significantly between face-to-face and internet-based interventions, at either PT or FU (p ≥ 0.698).

Age. Regarding age, subgroup analyses could only be conducted for PT effects on ER excoriations. They revealed no significant effect (adults [k = 3]: g = –0.28 [95% CI –0.51 to –0.05]; children [k = 2]: g = –0.44 [95% CI –0.94 to –0.05]; p = 0.56).

DISCUSSION

This systematic review and meta-analysis revealed small to medium-sized effects of psychological interventions on itch intensity and ER excoriations in patients with chronic itch due to various conditions at PT and FU (13 to 52 weeks after baseline). Regarding scratching intensity, even large significant effects were observed at PT and FU. However, this parameter was investigated in only 2 studies at both time points. Moreover, significant small effects on itch frequency occurred at PT, while effects at FU did not reach statistical significance. SR excoriation effects were not significant at PT. Interestingly, neither the setting nor delivery mode was of particular importance for the effectiveness of the intervention. This means that, for the future, self-guided online interventions seem to be an easily accessible alternative to face-to-face interventions.

The effects on itch intensity in this study were smaller than those reported in a previous meta-analysis (14). However, psychological interventions more often had clinically meaningful effects than control conditions (see Appendix S5). The smaller effects observed in this study might be due to the inclusion of more recently published studies that found no significant effects on itch intensity (38, 39). Additionally, Lavda et al. (14) combined effects on itch and scratching and included both RCTs and non-randomized trials. Nevertheless, the effects were small to medium. The large effects on scratching intensity in our study are promising but based on only 2 studies on AD (42, 46). Thus, more RCTs assessing scratching intensity in different itchy conditions are needed.

Notably, 17 of the 20 included RCTs focused on AD. It is crucial to evaluate psychological interventions in other patient groups who experience a high psychological burden in terms of anxiety, depression, and stress due to chronic itch (e.g. 51–53). CBT including stress management, cognitive restructuring, and habit-reversal training could be helpful in all kinds of patients with chronic itch conditions.

The GRADE assessments (Appendix S7) indicate very low certainty of evidence across all assessed parameters. Thus, while psychological interventions may impact itch intensity, itch frequency, scratching intensity, and ER excoriations, the evidence remains highly uncertain (54). A key factor to this is the overall high RoB rating in most studies (also see Appendix S7c). The main reasons include the inability to blind participants and those delivering the intervention, as psychological interventions inherently prevent blinding (domain 2). Additionally, domain 3 classifies studies with more than 5% of data missing as high risk, which was common due to small sample sizes and increased attrition at longer follow-up. Given that self-report is the most valid measure of itch, we excluded domain 4 (measurement of outcomes) from our RoB rating for self-reported itch and scratching. Overall, the Cochrane RoB 2 tool may be suboptimal for assessing psychological intervention studies. Future studies should consider developing RoB tools tailored to studies on subjective symptoms.

Strengths and limitations

An advantage of this meta-analysis was the assessment of excoriations as outcome parameter and the inclusion of only RCTs. We aimed to assess the effectiveness of all kinds of psychological interventions in patients with chronic itch due to all kinds of conditions. However, this study revealed that in the clear majority of the studies, only AD patients were investigated. Moreover, it would have been interesting to compare the effects of different intervention types in subgroup analyses. However, due to the different contents of the interventions and limited number of studies, this was not possible.

Future recommendations

When planning an RCT on the effects of psychological interventions on itch and scratching, feasibility should be considered, including intervention duration and delivery mode. Short interventions (2 weeks) have shown positive effects on psychological parameters (55, 56) and online interventions offer easily accessible alternatives to face-to-face interventions (35, 39, 46). The effects of these and other innovative treatments (e.g., eye movement desensitization [57, 58]) should be tested in future RCTs with a high methodological quality also including other patient groups with chronic itch, and not only AD patients. Another aim of future research could be to additionally focus on identifying which types of psychological interventions are most beneficial for patients with chronic itch, in case more studies are conducted on this topic. Moreover, as the use of systemic treatment was mentioned explicitly in only 2 of 20 studies (39, 40), the investigation on whether psychological interventions are a beneficial add-on to new medical treatments like biologics should be another target of future studies.

Conclusion

In summary, our findings highlight the benefit of psychological interventions in improving itch and itch-related outcomes. Integrating psychological support into routine care may enhance treatment effects and, as shown previously, overall quality of life. We thus encourage clinicians to consider the recommendations of psychological interventions, especially to patients with high psychological distress.

ACKNOWLEDGEMENTS

The authors would like to thank Victoria Zoch for her help with creating figures and tables for this manuscript.

Data availability statement: The data, code, and other materials of this systematic review and meta-analysis will be made available upon reasonable request to the corresponding author.

PROSPERO number: CRD42021245916.

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