Post-burn Pruritus Research Articles

Effectiveness of Postburn Pruritus Treatment and Improvement of Insomnia-A Randomized Trial.

Postburn pruritus is difficult to assess and treat. Antihistamines used in its treatment provide little relief. Identification of the itch neuronal pathway has inspired new alternatives, including gabapentin, for its management. The study compared the effectiveness of cetirizine, gabapentin, and a combination of gabapentin and cetirizine in treating postburn pruritus. Burn patients were randomly assigned to treatment with Cetirizine (n = 23), Gabapentin (n = 23), or Cetirizine plus Gabapentin (n = 23). A baseline assessment of the intensity or the severity of pruritus was evaluated, after which treatment commenced with standard doses of the 3 study regimens. Quality of sleep was assessed at baseline (day 0) and repeated on day 3, day 7, and day 14. Approximately 97% of participants presented with moderate or severe itch; 69% with acute itch; and the majority (94.2%) experienced pruritus between the first and fourth weeks. Gabapentin reduced itch by 92.9% in 14 days compared to cetirizine's 61.8%. The combined effect of cetirizine and gabapentin was comparable using gabapentin alone. When the itch became protracted over 6 weeks, the effectiveness of cetirizine in controlling itch worsened. It reduced itch intensity by only 37.7%, whilst gabapentin did so at 89.4%. Itch intensity correlated positively with insomnia, and controlling itch intensity improved sleep. Gabapentin was more effective for the treatment of postburn pruritus than cetirizine. Controlling itch intensity improved sleep. In acute and moderate itch, low-dose gabapentin could be added if cetirizine is the drug intended for its treatment.

Patient-reported outcomes and their predictors 2 years after burn injury: A cross-sectional study.

This study aimed to describe patient-reported outcomes 2 years after burn injury and to comprehensively elucidate predictors that may influence these outcomes. This cross-sectional, prospective study included 352 patients who were admitted to the Department of Burn Surgery at a tertiary teaching hospital between January 2017 and December 2020. We collected demographic and disease-related data and instructed participants to complete the Readiness for Hospital Discharge Scale (RHDS) and the Burn Specific Health Scale-Brief (BSHS-B) questionnaire. The overall score of patient-reported outcomes 2 years after burn injury was 126.55 ± 33.32 points, and the dimensions with the lowest scores were "hand function" (13.96 ± 5.75), "heat sensitivity" (14.84 ± 4.90), "treatment regimens" (13.41 ± 6.77) and "work" (11.30 ± 4.97). Multiple linear regression analysis revealed that less postburn pruritus, better readiness for hospital discharge, less total body surface area (TBSA), better social participation, white-collar jobs, older age, better sleep quality and burns not caused by electricity were associated with better outcomes. Patients experienced poor patient-reported outcomes 2 years after burn injury. Integrated rehabilitative care is necessary to address patients' unique needs and improve long-term patient-reported outcomes.

Treatment of post-burn pruritus – A systematic review and meta-analysis

BackgroundPost-burn pruritus is one of the most common complaints reported by patients with limited evidence for a gold-standard treatment. ObjectiveTo review the literature and assess the efficacy of various interventions in treating post-burn pruritus. MethodsPubMed, MEDLINE, CINAHL, Web of Sciences, Ovid Databases, and ClinicalTrials.Gov were searched. The articles were scored by two assessors for inclusion with a third independent assessor resolving conflicting scores. ResultsThe present systematic review and meta-analysis synthesised findings from a total of nine studies, representing a pool of 323 patients. The standardized mean effect size for the various categories of interventions was: naltrexone at 1.47 (95 % CI of 0.75–2.20, p < 0.0000), coverings at 0.94 (95 % CI of 0.40–1.48, p = 0.006), topical ozonated oil at 2.64 (95 % CI of 1.94–3.34, p < 0.00001), lasers at 2.34 (95 % CI of 1.60–3.09, p < 0.00001), current stimulation at 1.03 (95 % CI of −0.04 to 2.10, p = 0.06), and lemon balm tea at 0.54 (95% CI of 0.12–0.96, p = 0.01). ConclusionsCurrent evidence suggests that current modalities have a statistically significant, but not clinically significant, reduction in pruritus. This review highlights the limited quality of evidence in the literature and the poor quality of reporting among excluded studies.

Pre-existing skin diseases as predictors of post-burn pruritus

BackgroundPost-burn pruritus (PBP) has been shown to adversely affect burn patients’ quality of life. However, the predictors of PBP are not known. We hypothesize a pre-existing pruritic skin diagnosis is associated with an increased risk of adverse outcomes following a burn injury. MethodsThis retrospective study utilized data from the TriNetX electronic health record. Burn patients with a history of a pruritic skin disorder were compared to patients without a diagnosed skin disorder and the occurrence of pruritus was compared between the two cohorts. ResultsPatients with pre-existing skin conditions were more likely to develop PBP. The risk of PBP was highest 1 year after injury. Stratification by percent TBSA burned, gender, race, and age showed an increased risk of PBP for females, Caucasians, older patients, and those with large burns. ConclusionA pre-existing pruritic skin diagnosis is highly associated with developing pruritus following a burn injury.

Research advances on the mechanism and treatment of post-burn pruritus

Pruritus is one of the common symptoms after burn injury, which seriously affects the wound healing and quality of life of burn patients, but its diagnosis and treatment are often neglected. The pathophysiological mechanism of post-burn pruritus has not been elucidated, and it is currently believed that post-burn pruritus is caused by the neuropathic factors. In addition, there is no consensus on the standard evaluation methods and treatment protocols for post-burn pruritus. This paper reviewed the research advances on the pathophysiological mechanism, disease evaluation, and treatment of post-burn pruritus.

Targeting the Receptor at Synapse of Keratinocyte and Peripheral Nerve Ending: A Therapeutic Hope for Post-Burn Pruritus

Chronic itch or Pruritus is an unpleasant sensation that provokes the desire to scratch. In post burn patients, it is a significant health burden with few effective treatments. Pruritus is a common distressing consequence of postburn scars which affects burn survivors’ quality of life by causing sleep disturbance, daily activity impairment, and psychological problems. The mechanism of such abnormal scars with pruritus is not yet clear. The field of pruritus research is a dynamic field which involves neural component and various receptors at skin. The receptor present at the synapse of keratinocytes and peripheral nerve ending are responsible for itching. Many recent studies have worked to define the various receptors and the itch mediations in skin. However, considering that post-burn patients mainly report itch to be localized in the burn scars, spontaneous itch might be strongly based on peripheral input. The detailed characteristic and the factors for persistence of pruritus in post burn patients have not yet been clearly understood. Experimental evidences suggest that transient receptor potential (TRP) channels in skin and their expression patterns, activation mechanisms play regulatory roles in pruritus pathogenesis. In this article author collected the pruritus related data from post burn pruritus patients, isolated keratinocytes checked the receptor expression by immunocytochemistry and discussed the complex interplay between the central and peripheral factors that causes pruritus. It would be helpful to identify novel anti-pruritic agents that target the molecular itch pathogenesis pathways and the clinical assessment for burn patients with pruritus.

Pruritus in the Pediatric Burn Population.

Postburn pruritus is a significant issue that can have a devastating impact on patient quality of life. Despite its known negative impact, few studies have focused on the pediatric population. Thus, the aim of this study was to determine the incidence of pruritus among pediatric burn patients as well as identify its predictive factors and commonly used treatments, including the novel use of laser therapy. A retrospective analysis of all burn patients treated at our pediatric burn center from 2009 to 2017 was conducted. The primary outcome measure was the presence or absence of pruritus at any point following the burn. One thousand seven hundred and eighty-three patients met the inclusion criteria for this study. The mean age at injury was 3.67 years (SD = 4.02) and the mean burn TBSA was 3.48% (SD = 4.81) with most burns resulting from scalds (66%). In total, 665 patients (37.3%) experienced pruritus. Following multivariable logistic regression, TBSA, age >5 years, burns secondary to fire/flame, and burn depth, were identified as significant predictors of pruritus (P < .05). Pruritus was treated with diphenhydramine (85.0%), hydroxyzine (37.3%), and gabapentin (4.2%) as well as massage (45.7%), pressure garments (20.0%), and laser therapy (8.6%). This study addresses the knowledge gap in the literature related to postburn pruritus among pediatric patients and includes one of the largest patient cohorts published to date. Moreover, the results further contribute to our understanding of postburn pruritus in children and may help us to predict which patients are most likely to be affected, so that treatment can be initiated as soon as possible.

Correlation Between the Warrior/Worrier Gene on Post Burn Pruritus and Scarring: A Prospective Cohort Study.

Associations between genetic variation and clinical conditions suggest that single nucleotide polymorphisms (SNPs) might correlate with postburn outcomes. COMT modulates catecholamine metabolism, and polymorphisms within the rs4680 allele result in variable enzyme activity. Catechol-amines are known to modulate the inflammatory process and may affect scar formation. The aim of this study was to determine whether variants in the rs4680 SNP of the COMT gene are associated with post-burn pruritus and scarring. Adult burn patients, admitted between 2007 and 2017, with deep partial-thickness burns or delayed healing provided blood samples for genotyp-ing and self-reported itch scores within 1 year of injury. Scarring was measured using the Vancouver Scar Scale (VSS). Itch scores ≥ 4 and VSS scores >7 were considered severe. Genomic deoxyribonucleic acid was genotyped for the rs4680 SNP using realtime polymerase chain reaction (PCR). Median itch and VSS scores were highest for GG homozygotes and lowest for AA homozygotes. This difference was statistically significant for VSS score (P < 0.0001) and approached significance for itch (P = 0.052). After accounting for confounding variables, including race/ethnicity, age, sex, and burn size, the GG homozygotes demonstrated worse scarring (odds ratio 1.88, P = 0.005) compared to AG heterozygotes whereas the AA homozygotes trended towards a protective effect against scarring (odds ratio 0.71, P = 0.10). itch did not demonstrate a statistically significant difference between rs4680 genotype. Our analysis identifies a trend between COMT genotype with scarring, with rs4680 genetic variation constituting an independent risk factor for VSS score.

Post-Burn Pruritus.

Post-burn pruritus is the pruritus that occurs after burn during the rehabilitation and healing process of burn wounds. The post-burn pruritus is a common and serious complication of burn injury, which severely lowers the quality of life of the patient. Many potential treatments are available for pruritus but there is no consensus of the best single treatment yet. The precise mechanism of post-burn pruritus has not been elucidated, but it appears to have pruritogenic and neuropathic aspects. Clinically, post-burn pruritus tends to be intractable to conventional treatment but rather responds to neuroleptic agents, such as gabapentin and pregabalin. During wound healing, various neuropeptides secreted from the nerves of the skin control epidermal and vascular proliferation and connective tissue cells. When keratinocytes are activated by an itch-inducing substance, they secrete a variety of inflammatory substances that increase the susceptibility of the itch receptor. There are two mechanisms underlying post-burn neuropathic pruritus. The first one is peripheral sensitization. The second one is the intact nociceptor hypothesis. An effective treatment for post-burn pruritus will also be effective in other neuropathic and intractable itching. In this review, we summarized the interaction and mechanism of keratinocytes, immune cells, and nerve fibers related to post-burn pruritus.

Interventions for postburn pruritus

Interventions for postburn pruritus

Predictors and Correlates of Pediatric Postburn Pruritus in Preschool Children of Ages 0 to 4.

Pruritus is a common problem following burn injuries; however, the literature to date has focused on adult survivors and/or pediatric survivors of large burns. The current study examines acute postburn pruritus in children under the age of 4 years (N = 256) with smaller burns (mean TBSA = 3.99%), which represents the most common type of patient typically treated in pediatric burn centers. Parents rated their child for pruritus, irritability, and sleep disturbances; additionally, parents completed a self-report of distress. Nearly half (47.3%) were rated by parents as displayed some level of pruritus, with the greatest proportion rated as mild. Regression analysis indicated that child minority status, greater burn TBSA, and more days elapsed since burn predicted higher levels of pruritus. In turn, pruritus was positively correlated with child irritability, delayed sleep onset, sleep disturbance, and parent distress. Thus, our results indicate that parent-rated pruritus in young pediatric burn patients is important to evaluate, as itch is significantly associated with other important clinical outcomes as early as the first month of the burn for pediatric patients and their parents.

Post-Burn Pruritus and Its Management—Current and New Avenues for Treatment

This article seeks to review the current literature on post-burn pruritus and its treatments, as well as to propose new treatments that may be of potential benefit for these patients. Post-burn pruritus has been reported to affect as many as 93% of patients after a burn injury. Pruritus is extremely distressing to these patients, yet the current state of treatment, mostly antihistamines and emollients, is still widely ineffective in providing relief of itch. Therapies that are effective in treating pruritus and that may act as superior treatment options for patients suffering from post-burn pruritus include gabapentin and pregabalin, topical ketamine-lidocaine-amitriptyline, opioid medications, neurokinin-1 inhibitors, antidepressants, anti-cytokines, PAR-2 inhibitors, and botulinum toxin among others.

242 Predictors and Correlates of Post-Burn Pruritus in Infants and Toddlers

242 Predictors and Correlates of Post-Burn Pruritus in Infants and Toddlers

Development of a Postburn Pruritus Relief Protocol

Postburn pruritus is a syndrome of stressful symptoms that is pervasive and occurs in over 90% of burn patients and continues for years after the burn has healed. Postburn pruritus is experienced by burn survivors that may require medical management and effective interventions. This article shows how to effectively relieve postburn pruritus by developing a postburn pruritus relief protocol. A descriptive literature review was conducted, and relevant empirical articles written during the years 2000-2014 were appraised to create a postburn pruritus relief protocol. Twenty-six of 79 articles were selected using preestablished inclusion criteria: any age group experiencing burn-related pruritus after second- or third-degree burns. Databases were Cochrane Central Register of Controlled Trials, CINAHL, EBSCO, PubMed, the National Guideline Clearinghouse, Google Scholar, and the American Burn Association website. This protocol included both nonpharmacological and pharmacological interventions that have been delineated for use and was developed to apply based on the healing stage: prehealing, healing, and posthealing.

36 Correlation between the Warrior/Worrier Gene on Post Burn Pruritus and Scarring

Associations between genetic variation and clinical conditions suggest that single nucleotide polymorphisms (SNPs) correlate with post-burn outcomes. One candidate gene, catechol O methyl transferase (COMT), modulates catecholamine metabolism and has been associated with stress and pain tolerance. Whereas individuals with the wild type genotype (GG) demonstrate more effective stress response, persons with an AA polymorphism break down dopamine more slowly and are vulnerable to stress. The aim of this study was to determine whether the rs4680 SNP is associated with post-burn pruritus and scarring. We examined adult burn patients, admitted between 2007 and 2017, with deep partial thickness burns or delayed healing. Subjects provided blood samples for genotyping and self-reported itch scores (0 to 10) within 1 year of injury. Scarring was measured using the Vancouver Scar Scale (VSS). Itch scores 4 and above and VSS scores over 7 were considered severe. Genomic DNA was genotyped for the rs4680 SNP using realtime PCR. Data were analyzed using ANOVA and multivariate logistic regression. Sufficient clinical data was available for 639 subjects. Our analyses corroborates previous reports that burn size ≥20% TBSA and Asian, Native American/Alaskan Indian race are significant risk factors for both severe pruritus and scarring and African American race are risk factors for itch. Severity of scarring and itch decreased with the SNP rs4680 AA variant. Mean itch and VSS scores were highest for GG homozygotes and lowest for AA homozygotes; heterozygote scores were between the two extremes. This relationship was statistically significant for VSS score (p=0.05) but not for itch (p=0.41). Multivariate logistic regression did not identify rs4680 genotype as a significant factor for either scarring or itch. Although our analysis identifies a trend between COMT genotype and both itch and scarring, rs4680 genetic variation does not appear to constitute an independent risk factor. Understanding genetic determinants of wound healing will ultimately allow clinicians to predict and potentially prevent severe pruritus and scarring.

Post burn pruritus in pediatric burn patients

BackgroundPruritus is a common problem seen in the healing process of a burn wound and gives great discomfort for the patient. Most research in this field has been done in the adult population, so evidence in the pediatric population is still lacking PurposeThe aims of this study were to assess the incidence and severity of post-burn pruritus, identify predictors for pruritus and evaluate the pharmacological treatments in a pediatric setting. MethodsPruritus was assessed in this prospective observational study using a numeric rating scale and the Itch Man Scale applied by the patients’ caregiver. The predictive values of candidate predictors for pruritus were compared using Fisher exact tests and Kruskal–Wallis tests. Results413 patients were included in this study. Pruritus was reported in 71.7% of the patients. Complete symptom relief was only achieved in 29.8% of the patients who used medication. Time since burn (p<0.001), depth of the injury (p=0.017), TBSA burned (p=0.001) and skin grafting (p=0.001) were found to be significant predictors for post-burn pruritus. ConclusionPost-burn pruritus is still a highly prevalent problem in pediatric burn care. Its intensity and frequency are higher especially in the first three months or with a deeper wound or a higher TBSA.

Effect of cold pack therapy for management of burn scar pruritus: A pilot study

PurposePruritus, a common, chronically disabling condition is often refractory to treatment. The pruritus sensation is mediated in the spinal cord and post-burn pruritus is considered a form of neuropathic pain. We investigated cold pack therapy as a treatment modality for post-burn pruritus. MethodsWe studied 23 patients with severe pruritus scoring at least 5 on the visual analogue scale (VAS) and refractory to antihistamine and gabapentin administration. Each cold pack therapy lasted more than 20min. Patients participated in more than three sessions daily for 4 consecutive weeks. The numerical rating scale (NRS), 5-D Itch Scale, Leuven Itch Scale, and perfusion units were evaluated before, within 30min after, 2, and 4 weeks cold pack therapy. ResultsIn all patients, the NRS was 9.37±1.47 pre-therapy, 3.48±2.19 at 2 weeks, and 2.78±2.13 at 4 weeks following therapy, the pre-scores being significantly different (p<0.001). Pruritus severity and consequences scores (Leuven Itch Scale) were improved after therapy compared to pre-therapy. Perfusion unit (PU) scores were statistically insignificant compared to PU scores measured before the application of cold pack therapy. Degree, direction, and disability scores (5-D Itch scale) significantly differed (p<.05). ConclusionCold pack therapy, a non-invasive, non-pharmacological treatment modality significantly reduces post-burn pruritus and could be useful in burn patients.

Laser Therapy for Pediatric Burn Scars: Focusing on a Combined Treatment Approach.

Treatment with laser therapy has the potential to greatly improve hypertrophic scarring in individuals who have sustained burn injuries. More specifically, recent research has demonstrated the success of using pulsed dye laser therapy to help reduce redness and postburn pruritus and using ablative fractional CO2 laser therapy to improve scar texture and thickness. This study describes our early experience using laser therapy in our pediatric burn program and details our specific treatment approach when using each laser individually and in combination during the same procedure. A retrospective before-after study of patients with hypertrophic burn scars who were treated with laser therapy at our pediatric institution was performed. One hundred and twenty-five patients were treated over a total of 289 laser sessions with more than 50% of patients under the age of 5 years at the first treatment. The majority of procedures were performed using both the pulsed dye and CO2 lasers in combination. Before-after Vancouver Scar Scale scores decreased from 7.37 (SD, 2.46) to 5.76 (SD, 2.29) after a single treatment. The results obtained from this study support the use of laser therapy to improve hypertrophic burn scars in the pediatric population. Rigorous randomized controlled trials are needed to confirm the effectiveness of this therapy.

TRPV3 Channel in Keratinocytes in Scars with Post-Burn Pruritus.

Post-burn pruritus is a common and distressing sequela of burn scars. Empirical antipruritic treatments usually fail to have a satisfactory outcome because of their limited selectivity and possible side effects. Therefore, novel drug targets need to be identified. Here, we aimed to investigate the possible role of protease-activated receptor 2 (PAR2) and transient receptor potential vanniloid 3 (TRPV3), along with the relation of TRPV3 to thymic stromal lymphopoietin (TSLP). Specimens from normal (unscarred) or burn-scarred (with or without pruritus) tissue were obtained from burn patients for this study. In each sample, the keratinocytes were isolated and cultured, and the intracellular Ca2+ level at the time of stimulation of each factor was quantified and the interaction was screened. PAR2 function was reduced by antagonism of TRPV3. Inhibiting protein kinase A (PKA) and protein kinase C (PKC) reduced TRPV3 function. TSLP mRNA and protein, and TSLPR protein expressions, increased in scars with post-burn pruritus, compared to scars without it or to normal tissues. In addition, TRPV1 or TRPV3 activation induced increased TSLP expression. Conclusively, TRPV3 may contribute to pruritus in burn scars through TSLP, and can be considered a potential therapeutic target for post-burn pruritus.

Long-term effects of pulsed high-intensity laser therapy in the treatment of post-burn pruritus: a double-blind, placebo-controlled, randomized study.

We assessed the long-term effects of pulsed high-intensity laser therapy (HILT) in post-burn pruritus treatment. A total of 49 adult burn patients with mean age of 31.53 ± 10.14years participated, with 24 patients randomly assigned to the active laser group (ALG) and 25 in the placebo laser group (PLG). The ALG received HILT three times per week for 6weeks, while the PLG received placebo HILT. Both groups received 10-mg cetirizine tablets twice daily and 10mg at bedtime. All patients were advised to massage their burn scars with coconut oil for 5min four times daily. The outcomes measured were the itch severity scale (ISS), impairment of pruritus-related quality of life (QoL), pain level by the visual analog scale (VAS), hand grip strength by handheld dynamometer, and daily cetirizine intake. Repeated-measures ANOVA was used to compare the baseline and post-treatment measurements and after 12weeks of follow-up. Statistical significance was set at P < 0.05. ISS decreased significantly in the ALG after 6weeks of treatment and after 12weeks of follow-up compared with the PLG. The QoL results showed a significant improvement in the ALG compared with the PLG, which continued after 12weeks. VAS results significantly decrease, hand grip strength significantly improved, and cetirizine intake significantly decreased post-treatment in the ALG relative to the PLG. HILT combined with cetirizine seems more effective in patients with post-burn pruritus than a placebo laser procedure with cetirizine.