Post-burn Itch Research Articles

No indications for altered EEG oscillatory activity in patients with chronic post-burn itch compared to healthy controls

A large proportion of patients with burn injuries develop chronic itch, which impacts quality of life. The underlying pathophysiological mechanisms are poorly understood. This cross-sectional pilot study investigates whether altered cortical oscillatory processes are involved in chronic post-burn itch. Continuous electroencephalography (EEG) data were recorded during rest and stimulation of non-injured skin, inducing itch (histamine and electrical) and cold-pressor task pain for 15 adults with chronic post-burn itch and 15 matched healthy controls. Quantitative metrics comprised oscillatory power and peak frequencies in theta, alpha, and beta bands. No statistical differences between patients and healthy controls were found in oscillatory activity during rest or stimulation, with Bayesian analysis suggesting equivocal evidence. However, post-traumatic stress symptoms and duration of chronic itch may be associated with changes in oscillatory activity. A lack of differences in cortical oscillatory processing and itch levels at non-injured sites, suggests that itch symptoms have a localised character in this sample of patients with post-burn itch. For future studies, a biopsychological approach with integration of peripheral and central nervous system techniques, linear and non-linear EEG analysis, injured and non-injured stimulation sites, and incorporation of individual characteristics is recommended. Insight into pathophysiological mechanisms underlying chronic post-burn itch could improve diagnostics and treatments.

Synergic Effect of Botulinum Toxin Type A and Triamcinolone Alleviates Scar Pruritus by Modulating Epidermal Hyperinnervation: A Preliminary Report.

Patients often experience scar-related pruritus, which adversely affects quality of life. Triamcinolone acetonide (TAC) is widely used to treat pathologic scars, and botulinum toxin type A (BTX-A) reportedly improves scarring and associated discomfort. The aim of this study was to investigate the clinical efficacy of combining TAC and BTX-A to reduce scar itch; potential mechanisms were investigated via an animal model. For the clinical study, each scar on a patient was divided into 2 equal parts, with one part receiving TAC/BTX-A and the other TAC alone. Therapeutic interventions were administered over 3 sessions at 4-week intervals. Itch intensity was measured on a visual analog scale before each therapeutic intervention (V1, V2, V3) and 4 weeks after the last intervention (V4). For the animal model, rats were allocated into 5 groups: control, untreated burn, TAC, BTX-A, and TAC/BTX-A. We evaluated alloknesis in the right hind paw and analyzed possible molecular mechanisms. In humans, TAC/BTX-A significantly reduced scar itch compared with TAC alone at V4 (P = 0.04). In rats, post-burn itch was mitigated at 4 weeks after treatment with TAC, BTX-A, and TAC/BTX-A (P = 0.03, P = 0.0054, and P = 0.0053, respectively). TAC/BTX-A significantly decreased the density of intraepidermal nerve fibers post-burn relative to the untreated burn (P = 0.0008). TAC/BTX-A downregulated the expressions of nerve growth factor and protein transient receptor potential vanilloid subtype 1. TAC/BTX-A therapy exhibited enhanced and sustained clinical efficacy in relieving scar itch, possibly via modulating epidermal innervation and expression of transient receptor potential vanilloid subtype 1 .

612 Assessing the Impact of Burns on Children Aged 5–18 Years: A Narrative Review of Health Outcomes Literature

Abstract Introduction Burn injuries can have major long-term effects on the health and quality of life for children and adolescents. This study narratively reviewed the health outcomes literature focusing on the impact of burn injury for children aged 5–18. Methods Literature targeting pediatric outcomes was reviewed to identify the effects of burns on children aged 5–18 (n=16). Inclusion criteria included studies that focused on the impact of burns on health and quality of life and were age-appropriate for this population. Articles were identified via PubMed, Web of Science, and manual reference checks. Data collected included the outcomes and health domains assessed in each article and the findings of the effects of the burn injury on those specific outcomes. The Preschool LIBRE Conceptual Model served as a ‘domains framework’ to guide the identification of outcomes and health domains. Results Long-term burn-specific outcomes and broad health domains identified were physical functioning (n=9), psychological functioning (n=12), social functioning (n=4), symptoms (n=8), and family (n=7). Some studies exclusively focused on one domain whereas others assessed two domains or more. Subdomains such as upper extremity functioning and functional independence were addressed in the physical functioning domain. Psychological functioning outcomes included subdomains such as emotional health and behavioral problems. Social functioning outcomes evaluated subdomains such as problems with peers and social participation. The symptoms domain addressed post-burn pain and itch. Family outcomes subdomains such as parental satisfaction with appearance and general family functioning were identified. Conclusions Burn-specific outcomes and health domains assessing the effects of burns on children aged 5–18 were identified among 16 studies. There is a need for a comprehensive assessment tool that more precisely measures the impact of burn injury across these domains. This work will inform the development of the School-Aged Life Impact Burn Recovery Evaluation (LIBRE) Computer Adaptive Test (CAT) Profile – a new outcome metric for children and adolescents with burns. Applicability of Research to Practice This review is relevant to researchers and clinicians assessing health outcomes and measuring burn recovery in children aged 5–18.

240 A Randomized Controlled Trial of Hypnosis for Pain and Itch Following Burn Injury

Burn survivors report that pruritus (also categorized as neuropathic pain) is common for years after injury and can affect all aspects of quality of life. Pharmacological interventions have not consistently shown to be effective and often have side effects. Hypnosis has been successfully used to treat burn pain and nonburn-related pruritus. We hypothesized that hypnosis would provide greater postburn itch and pain relief than the control at 48 hours, 1, 3, 6, 12-months post-intervention. Following IRB approval, adult burn patients who had been undergoing pharmacologic therapy (gabapentin, diphendhydramine and/or cetirizine) and who scored ≥ 4 on a 0–10 Numerical Rating Scale (NRS) for itch or pain were eligible for the study. Subjects were randomly assigned to receive 4 sessions of hypnosis or treatment as usual. Both groups continued to receive pharmacologic and topical therapy. Outcome measures included NRS for pain and itch, and the 5-D Itch Scale. We conducted an intent to treat analysis of change over time for the two treatment groups on all measures. A total of 27 patients participated in the study, 62% were Caucasian and 60% were male. There were no significant differences between the groups on any outcome measure and both groups demonstrated improved pain and itch over time. There was a large effect size for Itch as measured by the NRS (intensity) and the 5D Itch Scale from baseline to 1 month. Of note, those in the hypnosis group had a larger burn size (24.1% TBSA burn vs 14.7%); however, this was not statistically significant. Our sample size was smaller than our target enrollment due to difficulties in subject recruitment. A total of 106 eligible participants were approached for the study but only 29 consented (two were lost to follow up). Top reasons for refusal included “did not believe in hypnosis” (25%), lost to follow up after screening but prior to consent (24%), and geographic distance prohibiting return to burn center (10%). Itch and pain seem to improve over time. Barriers to making hypnosis a feasible nonpharmacological option for patients who report burn pain and itch as impacting quality of life should be addressed. Our study demonstrates a need to educate the public about the potential benefits of hypnosis as a safe and efficacious nonpharmacological medical intervention. Further, future studies should validate the efficacy of hypnosis delivered via video or CD to reduce travel burden on patients returning for the intervention.

Nerve reinnervation and itch behavior in a rat burn wound model.

In this study, we investigated whether postburn itch in rats, after a full thicknessburn, is correlated to the nervous reinnervation of the burn wound area. For this purpose, we determined scratching duration (expressed as second/hour) at 24 hours, 2, 4, 8, and 12 weeks postburn and combined this with immunohistochemistry for protein gene product 9.5 (PGP9.5) to identify all nerve fibers, calcitonin gene related peptide (CGRP) to identify peptidergic fibers, tyrosine hydroxylase (TH) for sympathetic fibers, and growth-associated protein 43 (GAP-43) for regrowing fibers. We found a modest, but highly significant, increase in scratching duration of all burn wound rats from 3 to 12 weeks postburn (maximally 63 ± 9.5 second/hour compared to sham 3.1 ± 1.4 second/hour at 9 weeks). At 24 hours postburn, all nerve fibers had disappeared from the burn area. Around 4 weeks postburn PGP 9.5- and CGRP-immunoreactive nerve fibers returned to control levels. TH- and GAP-43-IR nerve fibers, which we found to be almost completely colocalized, did not regrow. No correlation was found between scratching duration and nervous reinnervation of the skin. The present results suggest that in rat, like in human, burn wound healing will induce increased scratching, which is not correlated to the appearance of nervous reinnervation.

LB1006 Mouse model of post-burn itch

The majority of the post-burn patients suffer from chronic itch, which is often resistant to antihistamine treatment. Post-burn itch involves sensitization of itch-signaling pathways, leading to ongoing itch and alloknesis (touch-evoked itch), but the underlying mechanisms behind post-burn itch are largely unknown. We have developed a novel animal model to investigate the neuronal mechanisms of post-burn itch. A scald burn injury was produced in adult C57BL/6 mice by exposing the shaved back skin to boiling water. The burn surface area was over 150 mm2 on Day 1, decreased to 30 mm2 on Day 14, and then remained at a plateau. To assess spontaneous scratching, mice were videotaped on Days 0, 1, 3, 5, 7, 10, 14, 21, and 28 after the scald burn treatment. Counts of spontaneous scratch bouts increased transiently on Days 1, 3, and Day 5 compared to Day 0, returned to the basal level by Day 10, and reincreased significantly on Days 14, 21, and 28. To test for alloknesis, a weak von Frey filament (VF; 0.7 mN) was repeatedly applied to post-burn skin on Days 0, 1, 3, 5, 7, 14, 21, and 28 after the scald burn treatment, and the presence or absence of evoked hindlimb scratch bouts was noted (VF stimulation does not elicit any response in naïve C57BL/6 mice). VF-evoked scratching increased significantly on Days 21 and 28. The histamine H1 receptor antagonist chlorpheniramine was tested on Day 22 but did not inhibit spontaneous scratching, suggesting that non-histaminergic itch pathways are involved in post-burn itch. This new animal model appears to be useful for investigations of post-burn itch and sensitization of itch-signaling pathways.

Role of Pregabalin in Management of Pruritus: A Literature Review.

Pruritus can be one of the distressing symptoms of many dermatologic, systemic, neurologic or psychiatric disorders. In each case, the origin of itch is in the skin and/or the nervous system. Involvement of the nervous system causes neurogenic, psychogenic or neuropathic itch. Itch sensation is transferred to the central nervous system via unmyelinated C-type nerve fibers, and many mediators and receptors engage in the its induction and transmission. Also it has been demonstrated that there are similarities and interactions between neurotransmitters and pathways of pain and itch sensation. Hence, effective drugs in reducing the neuropathic pain such as pregabalin have been studied and used in the management of different itchy conditions. In this narrative review we considered the available published papers dealing with the antipruritic effects of pregabalin. Results of studies conducted in uremic patients show that pregabalin is an effective option in reducing uremic pruritus especially in those who have not responded to antihistamines and topical moisturizers. Data about the effects of pregabalin on other itchy conditions are very limited; however results of the available studies show beneficial effects of this drug in burn patients with more than 5% involvement of the total body surface area, in prurigo nodularis, and in chronic and idiopathic itch. One considerable issue is that the therapeutic effects of pregabalin on uremic pruritus and post burn itch may appear more rapidly than its effects in the other conditions (1-2 weeks vs > 4 weeks). The most reported adverse effects of pregabalin are sedation, dizziness and drowsiness. Whether pregablin can be unequivocally considered as an effective and reasonable choice in the management of pruritus with different causes is a question that should be answered through large scale randomized controlled studies.

Psychophysiological Processing of Itch in Patients with Chronic Post-burn Itch: An Exploratory Study.

A substantial proportion of patients with burn injury develop chronic itch, which can severely affect their quality of life. As found in research on chronic pain, different psychophysiological processes may also play a role in chronic itch, of which central sensitization, conditioned modulation, and attentional processes have been studied most frequently. This study aimed to explore psychophysiological processes of chronic post-burn itch by comparing 15 patients with long-term itch due to burn injury with 15 matched healthy controls. Exploratory results indicated tendencies for higher itch sensitivity in patients than in controls, for mechanical stimuli and histamine, but not for electrical stimulation. Results further suggest that the efficacy of itch modulation by an itch- or pain-conditioning stimulus or directing attention towards itch stimuli do not differ between these patients and controls. Further elucidation of the processes underlying post-burn itch may improve the early identification and treatment of burn patients developing chronic itch.

Pruritus in pediatric burn survivors: defining the clinical course.

Pruritus is a frequent and severe symptom and a significant cause of distress for adult burn patients. Its effects in children are largely unstudied. The aim of this study is to characterize postburn itch in the pediatric population. This is a retrospective review from 2006 to 2013 for pediatric burn survivors who were enrolled in a longitudinal multicenter outcomes study. Demographic data, injury characteristics, associated symptoms (skin-related problems, pain, and sleep), and incidence and intensity (Numerical Rating Scale) of itch were examined. Measures were completed at hospital discharge and at 6, 12, and 24 months after injury. Spearman's correlations were used to examine the correlation between itch intensity and associated symptoms. Multivariate regression analyses examined the impact of associated symptoms on itch intensity. There were 430 pediatric burn survivors with a mean age of 7.8 years and a mean TBSA of 40.8%. Pruritus is present in most children (93%) and is of moderate intensity (5.7 ± 3.1) at discharge. The frequency and intensity of pruritus decreases over time; a majority of children continue to report symptoms at 2 years (63%). Itch was significantly correlated with associated symptoms. Regression analyses showed a correlation between itch intensity and pain at each time point. There was no association between itch intensity and burn etiology, age, gender, or burn size. Pruritus is a frequent complication that lasts for at least 2 years after injury in a majority of pediatric burn survivors. This information will enable better tracking of outcomes and will serve as a baseline for assessing interventions.

The effectiveness of moisturizers for the management of burn scars following severe burn injury: a systematic review protocol

Review question/objective The objective of this review is to identify and synthesize the best available evidence on the effectiveness of moisturizer use for the management of burn scars following severe burn injury. More specifically, the review will focus on the following question(s): What are the recommended types of moisturizers used on scar formation in patients who have sustained a burn injury? What is the effectiveness of moisturizer use on scar outcomes, including formation, breakdown, patient acceptance and water loss, following severe burn injury? Background The common mantra that patients often leave a burns unit with is "moisturize and massage". The modality of scar massage is well-recognized as an important part of burn scar management.1 Following the maturation of scar tissue after a burn injury, massage is commenced as part of the standard care offered to victims of burn injury. The premise behind massage is that it maintains joint mobility, aids softening and remodelling of scar tissue and improves scar elasticity through loosening adhering fibrous tissue, whilst also assisting with pruritus, a common side effect of healing following burn injury.1 When healing skin has gained sufficient strength to tolerate massage with the use of friction, scar massage is routinely performed with the use of lubricants,1 which commonly consist of skin moisturizers. Although existing literature provides guidance on the use of products that are fragrance free and free from other skin irritants,1 little is known in regards to recommendations on the ideal composition of moisturizers for optimal scar management. Products used should not have a negative effect on skin/scar integrity, such as breakdown of the skin. Various products have been reported for use in practice as well as in literature on scar management, include aqueous cream BP, bees wax and herbal oil creams,2 silicone based creams and paraffin/petroleum based products. Aqueous cream BP is a readily available and relatively cheap emollient that is fragrance and color free. Its formulation consists of purified water, white soft paraffin, cetearyl alcohol and sodium lauryl sulfate (SLS), liquid paraffin, and phenoxyethanol. Previously reported as the "standard treatment" for moisturization and massage in some burns units,2 aqueous Cream BP contains SLS, which has been documented as a known skin irritant.3-6 The application of aqueous cream BP in subjects with healthy skin, following the removal of increasing amounts of their stratum corneum, has also been shown to increase transepidermal water loss (TEWL) and disrupt the normal skin maturation process.7 Chronic application of aqueous cream BP was also shown in this study to increase the rate of skin turnover as well as contribute to thinning of the stratum corneum.7 This is of particular concern in burn injury as scar tissue has been shown to have increased TEWL when compared with healthy skin,8. In contrast, a comparison study between aqueous cream BP and bees wax and herbal oil cream indicated that newly healed skin in the bees wax and herbal oil group "appeared supple and moist" when compared to the aqueous BP group. Healing skin in the latter group was reported as appearing dry in contrast.2 Although the study had a small sample size, it did demonstrate that bees wax and herbal oil cream provided a greater reduction in the symptom of itch following burn injury along with a decreased use of antipruritic medications when compared to aqueous cream BP.2 The aim of this study was to compare the effectiveness of both preparations in the management of post burn itch. Anecdotal reports of alternate formulations, including silicone and petroleum based products (such as Vaseline), being used by burns units around the world are often reported at burns symposiums and forums, with their selection appearing to be based on historical practice, clinician preference, patient tolerance or beliefs in herbal medicine. Pressure garment manufacturers often also recommend the avoidance of petroleum based emollients where pressure garments are worn as they may reduce the elasticity of the pressure garment, in turn reducing its effectiveness and the life of the garment. No review on the optimal lubricant for burn scar management has been identified to date via searches of the Cochrane Database of Systematic Reviews, Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports and PubMed database, so this review aims to elucidate the best available evidence on the choice of moisturizer in the management of burn scars.

A pilot randomised trial of Medilixir cream shows some promising results, but control treatment may have been inappropriate

Aim To test the efficacy of Medilixir [cream] against the standard treatment of aqueous cream in the provision of relief from the symptoms of postburn itch. Design RCT with two parallel arms. Setting Professor Stuart Pegg Adult Burns Centre, Royal Brisbane and Women's Hospital, Brisbane, Australia. Participants Fifty-two patients aged between 18 and 80 years, admitted directly to the burns centre between 10 March and 22 July 2008, were able to provide informed consent, and had shown no allergic reaction to a patch test with the study medication, were randomised. Patients admitted from intensive care or high dependency were excluded. Main results Effect estimates and confidence intervals were not reported for any of the outcomes; only group means/proportions and P-values from hypothesis testing were provided. More patients in the intervention group reported itch reduction compared to comparison treatment (91 vs. 82%, P=0.001). Itch recurrence after cream application occurred later in the intervention group compared to the control group (P<0.001). Use of antipruritic medication was significantly greater in the control group (P=0.023). There was no difference in sleep disturbance between groups (not quantified). On average, Medilixir took longer to apply than aqueous cream (157s for Medilixir vs. 139s for aqueous cream; mean difference 17s), but authors noted that the groups did not differ significantly (CI for mean difference and P-values were not reported).

Pruritus in Adult Burn Survivors

Pruritus (itching) is a common and distressing complaint after injury. The purpose of this study was to investigate self-reported postburn pruritus in a large, multisite cohort study of adult burn survivors. Descriptive statistics, general linear regression, and mixed model repeated measures analyses were employed to test statistical significance. Two cohorts of adult burn survivors were studied. Group 1 participants (n = 637) were injured from 2006 to 2010 and were followed up prospectively for 2 years from the time of injury. Prevalence and severity of pruritus were compared across multiple subgroups. Prevalence of pruritus at discharge, 6, 12, and 24 months following injury were 93, 86, 83, and 73%, respectively. Regression results established that %TBSA-burn and %TBSA-grafted were correlated to itch intensity values. Group 2 participants (n = 336) were injured 4 to 10 years before an assessment using the validated 5-D Itch Scale. Many patients (44.4%) reported itching in the area of the burn, graft, or donor site. Within this group, 76% reported itching for <6 hours/day, and 52 and 29% considered itch intensity to be mild or moderate, respectively. This study confirms that the prevalence of burn pruritus is high, initially affecting >90% and persisting for >40% of long-term burn survivors. New predictors for postburn itch were identified to include younger age, dry skin, and raised/thick scars. Characterization of the impact of postburn pruritus on leisure, vocation, and sleep are quantified for those long-term survivors suffering from postburn pruritus.

A four arm, double blind, randomized and placebo controlled study of pregabalin in the management of post-burn pruritus

Post-burn itch is a distressing symptom in burns rehabilitation and its treatment often proves frustrating for the patient and the multidisciplinary burns team. Traditionally, the mainstay of antipruritic therapy for decades has been antihistamines and massage with emollients. With a better understanding of the neurophysiology of itch emerged a new dimension in the treatment of post-burn pruritus. Gabapentin, a centrally modulating anti-epileptic agent and α2δ ligand, proved in clinical trials to be immensely better in the treatment of post-burn pruritus. Pregabalin is a newer structural analog of gabapentin. It has a much better anxiolytic effect and pharmacokinetic profile as compared to gabapentin. The current study was initiated to specifically study the role of pregabalin in relieving post-burn itch as this has never been investigated before. This double blind, randomized and placebo controlled study had four arms and was carried out on 80 adult patients (20 each). The four arms were: pregabalin, cetirizine with pheniramine maleate, combination of pregabalin, cetirizine and pheniramine maleate, and placebo (vit. B comp.). Massage with coconut oil was integral to all groups. Drug dosage was determined by initial VAS (visual analog scale) scores. All groups matched in demographic data and initial VAS scores. VAS scores were evaluated over next 28 days (days 3, 7, 14, 21 and 28). In patients with mild itch (VAS scores 2–5) or moderate itch (VAS scores 6–8) near complete remission of itch was seen in combination group and pregabalin group where the response was comparable and close to 95%. This was significantly better response than antihistaminic combination or massage alone. However, massage alone was sufficient in decreasing mean scores in mild itch, in a large percentage of patients. Amongst the patients with severe itch (VAS scores 9–10), 3/6 and 6/7 patients dropped out of trial in the antihistaminic and placebo groups, respectively. Combination therapy and pregabalin alone had exactly similar decrease in itch scores by day 28 (78.9%). This far exceeded the response in the antihistaminic and placebo groups (23.9% and 9.2% respectively). We conclude that moderate to severe pruritus (VAS 6–10) should be treated with a systemic, centrally acting agent like pregabalin or gabapentin to eliminate itch or bring it down to tolerable limits. Patients with mild itch having VAS scores between 4 and 5 may be better served with addition of pregabalin even if massage and antihistaminics can control post-burn itch to a reasonable extent because of quicker, predictable and complete response, along with anxiolysis.

A Randomized Controlled Pilot Study Comparing Aqueous Cream With a Beeswax and Herbal Oil Cream in the Provision of Relief From Postburn Pruritis

Postburn itch is reported to affect up to 87% of the burn population. Although treatments for postburn itch are multimodal, they remain consistently ineffective. However, recent anecdotal evidence from several outpatients at a tertiary referral hospital suggests that a cream combining beeswax and several herbal oils may be effective in the minimization of postburn itch. The aim of this study was to test the efficacy of beeswax and herbal oil cream against the standard treatment of aqueous cream in the provision of relief from the symptoms of postburn itch. A randomized controlled trial compared two groups using a visual analog scale, frequency of cream application, itch recurrence after cream application, use of antipruritic medications, and sleep disturbance to determine the effect of itch severity and duration. Fifty-two participants were enrolled in the study (84% male) with a mean age of 35 years (SD = 16) and mean burn TBSA of 7.2% (SD = 7.7). Study results found that the beeswax and herbal oil cream reduce itch after application more frequently than aqueous cream (P = .001). In addition, when managed with beeswax and herbal oil cream, participants found that their itch recurred later (P ≤ .001) and their use of antipruritic medications was lower (P = .023). Findings of this study suggest beeswax and herbal oil cream to be more effective in the minimization of postburn itch than aqueous cream. Given this, a larger study examining the efficacy of beeswax and herbal oil cream appears warranted.

Assessment of Pruritus Characteristics and Impact on Burn Survivors

The goal of this cross-sectional study was to characterize and describe persistent postburn pruritus. Cause and treatment of postburn itch is elusive. It has been suggested that burn survivors with persistent pruritus should be divided into acute itch (≤6 months postinjury) and chronic itch (>6 months postinjury) because the cause of itch may be different. Cross-sectional data of itch characteristics reported here are from the baseline data of a prospective, randomized, double-blind, controlled pilot study of 23 subjects with frequent and bothersome postburn pruritus. Subjects self-completed validated scales for variables of itch sensation, affect of itch, and severity. Variables of quality of life, frequency, pain and itch intensity, skin condition, scar, and medication were also recorded. Itch frequency revealed that 87% of subjects experienced itching daily, 96% experienced three or more episodes a day, and 52% had episode durations lasting 5 to 30 minutes per incidence. Itch was reported as unbearable by 94% of subjects with chronic itch and by 86% of subjects with acute itch, whereas bothersome was 88 and 100%, respectively. Itch sensation dimension of stinging was 74% in both acute and chronic itch subjects. Crawling and burning sensations were often severe. Potential itch triggers and relief activities were identified. Differences in sensory and affective itch components were detected between acute and chronic itch subjects. Combinations of itch mechanisms probably contribute to the development of and changes in pruritus. Characterizing the sensation and affective itch dimensions in conjunction with inflammation, burn injury, recovery, scar maturation, medication, and psychological status should better elucidate postburn itch.

A prospective study on the role of gabapentin in post-burn pruritus

Gabapentin, used in the treatment of neuropathic pain, is suggested as an alternative treatment to antihistamines for post-burn itching. There is insufficient awareness about the etiopathogenesis and available treatment options for post-burn pruritus. To study the effect of gabapentin on post-burn itching, patients with post-burn pruritus not relieved with cetirizine tablet were offered gabapentin and assessed for response by the numerically graded self-report questionnaire ‘Itch Severity Scale’ for 6 months. Treatment success was determined by reduction in the itch scores, which were statistically analysed. Twenty-three patients with post-burns pruritic hypertrophic scars were studied. All patients had history of delayed burn healing (over 3 weeks). Twenty patients completed follow-up. All 20 reported a reduction in itching with gabapentin. Mean reduction in itch severity was 4.99 (statistically significant) within the first month of starting the therapy, with sustained effect seen for the duration of treatment. No serious side effects were reported. Eighty-seven per cent of patients showed good relief from itching within 1 month of starting treatment. Overall quality of life improved considerably. Gabapentin is suggested as a protocol for second-line option in post-burn pruritus. The ‘Itch Severity Scale’ is a reliable tool for pruritus measurement, including subjective parameters.

A comparative analysis of cetirizine, gabapentin and their combination in the relief of post-burn pruritus

Post-burn pruritis is a very distressing symptom having a reported incidence between 80 and 100%. The mainstay of management of post-burn itch has been with antihistaminics and emollients but the treatment is ineffective in a very large percentage of patients. With the recognition of a distinct itch specific neuronal pathway, which has a complex interaction with pain pathway, a fresh approach to itch management has surfaced with the use of gabapentin. Gabapentin is an antiepileptic drug which has been successfully used to manage neuropathic pain, and is reporting to be successful in management of all forms of itch. With a paucity of randomized trials evaluating the role of gabapentin in post-burn itch management the current study was undertaken to individually evaluate gabapentin, cetirizine and their combination in relieving itch. Twenty patients were randomly recruited in each of the three groups and administered the respective drug(s) in doses determined by initial VAS (visual analog scale) scores. There was no significant difference in all the three groups with respect to mean age, sex distribution, mean percentage of TBSA burn and mean VAS score on day 0. VAS scores were evaluated over next 28 days (days 3, 7, 14, 21 and 28), and no emollients were prescribed for the study period. The initial mean VAS score reduced 95% in gabapentin group compared to 52% for the cetirizine group, which was highly significant ( p < 0.01). There was a 94% reduction in mean VAS score in the combination group which was comparable to the relief observed with gabapentin alone ( p > 0.05). Even the onset of action with gabapentin was significantly faster than the cetirizine group as evident from the mean VAS scores on day 3, which decreased 74% in gabapentin group compared to 32% in cetirizine group ( p < 0.01). Whereas all patients receiving gabapentin (either as monotherapy or in combination with cetirizine) reached an itch free status (VAS score 0–1) by day 28 only 3/20 patients reached this level with cetirizine alone. It is quite evident from this study that gabapentin is significantly better than cetirizine as monotherapy in relieving post-burn itch and it also has a faster action. The hypothetical combination of a centrally acting drug with a peripherally acting agent did not result in any better control of post-burn itch than monotherapy with gabapentin. No side effects were reported with gabapentin administration but all patients receiving cetirizine reported sedation. There is now a need to relook at the antipruritic protocols in burn management.

Review of therapeutic agents for burns pruritus and protocols for management in adult and paediatric patients using the GRADE classification

ABSTRACTTo review the current evidence on therapeutic agents for burns pruritus and use the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) classification to propose therapeutic protocols for adult and paediatric patients. All published interventions for burns pruritus were analysed by a multidisciplinary panel of burns specialists following the GRADE classification to rate individual agents. Following the collation of results and panel discussion, consensus protocols are presented. Twenty-three studies appraising therapeutic agents in the burns literature were identified. The majority of these studies (16 out of 23) are of an observational nature, making an evidence-based approach to defining optimal therapy not feasible. Our multidisciplinary approach employing the GRADE classification recommends the use of antihistamines (cetirizine and cimetidine) and gabapentin as the first-line pharmacological agents for both adult and paediatric patients. Ondansetron and loratadine are the second-line medications in our protocols. We additionally recommend a variety of non-pharmacological adjuncts for the perusal of clinicians in order to maximise symptomatic relief in patients troubled with postburn itch. Most studies in the subject area lack sufficient statistical power to dictate a ‘gold standard’ treatment agent for burns itch. We encourage clinicians to employ the GRADE system in order to delineate the most appropriate therapeutic approach for burns pruritus until further research elucidates the most efficacious interventions. This widely adopted classification empowers burns clinicians to tailor therapeutic regimens according to current evidence, patient values, risks and resource considerations in different medical environments.

Review of therapeutic agents for burns pruritus and protocols for management in adult and paediatric patients using the GRADE classification.

To review the current evidence on therapeutic agents for burns pruritus and use the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) classification to propose therapeutic protocols for adult and paediatric patients. All published interventions for burns pruritus were analysed by a multidisciplinary panel of burns specialists following the GRADE classification to rate individual agents. Following the collation of results and panel discussion, consensus protocols are presented. Twenty-three studies appraising therapeutic agents in the burns literature were identified. The majority of these studies (16 out of 23) are of an observational nature, making an evidence-based approach to defining optimal therapy not feasible. Our multidisciplinary approach employing the GRADE classification recommends the use of antihistamines (cetirizine and cimetidine) and gabapentin as the first-line pharmacological agents for both adult and paediatric patients. Ondansetron and loratadine are the second-line medications in our protocols. We additionally recommend a variety of non-pharmacological adjuncts for the perusal of clinicians in order to maximise symptomatic relief in patients troubled with postburn itch. Most studies in the subject area lack sufficient statistical power to dictate a ‘gold standard’ treatment agent for burns itch. We encourage clinicians to employ the GRADE system in order to delineate the most appropriate therapeutic approach for burns pruritus until further research elucidates the most efficacious interventions. This widely adopted classification empowers burns clinicians to tailor therapeutic regimens according to current evidence, patient values, risks and resource considerations in different medical environments.

Can Postburn Itching be a Cause of Galactorrhea?

Can Postburn Itching be a Cause of Galactorrhea?