Pruritus and Burn Wounds

Author(s): 
Robert H. Demling, MD;1 Leslie DeSanti, RN;1 Robert D. Nelson, PhD2

Guest Editor: Robert S. Kirsner, MD

Completion Time: The estimated time to completion for this activity is 1 hour.

Target Audience: This CME activity is intended for dermatologists, surgeons, internists, and physicians who treat burn wounds.

At the conclusion of this activity, the participant should be able to:
1) Recognize the problem of itching or pruritus in the healed burn wound
2) Discuss the current theories as to pathogenesis of pruritus
3) Recognize the current treatment modalities used for pruritus, including success rate and failure
4) Discuss the basis for the new modalities being pursued for
itching.

Disclosure: All faculty participating in Continuing Medical Education programs sponsored by HMP Communications, LLC, are expected to disclose to the program audience any real or apparent conflict(s) of interest related to the content of their presentation. Drs. Demling and Nelson and Ms. DeSanti disclose no financial conflicts.

Commercial Support Disclosure: This activity is financially supported through an unrestricted educational grant by Healthpoint Ltd., Ft. Worth, Texas.

Accreditation: HMP Communications, LLC, is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Designation: HMP Communications, LLC, designates this continuing medical education activity for 1 credit hour in Category 1 of the Physician’s Recognition Award of the American Medical Association. Each physician should claim only those hours he/she spent in the educational activity.

Method of Participation: Read the article, take, submit, and pass post-test by February 1, 2003.

How to obtain educational credits by reading this article: Participants must score at least 70 percent on the questions and successfully complete the entire evaluation form (found at end of article), tear anwer and evaluation form out or copy it, and send it to the correct address listed below. Certificates will be mailed to those who successfully complete the learning assessment by February 1, 2003.

Fax the completed form to: (610) 560-0501 or mail the completed form to:

Trish Levy, CME Director
HMP Communications, LLC
83 General Warren Blvd.
Suite 100
Malvern, PA 19355

This activity has been planned and produced in accordance with the ACCME Essential Areas and Policies.

Release date: February 1, 2002
Expiration date: February 1, 2003

Pruritus and Burn Wounds

Introduction

The problem of itch for the burn survivor and the need for a more effective treatment were first noted formally in 1988. At that time, Gordon wrote, “Burn-related pruritus is a serious problem that often receives little attention, even though it continues to aggravate burn patients during their post-burn course of treatment and rehabilitation.”1 Bell, et al., added, “No succinctly defined method of treatment (for pruritus in burns) is found in the literature.”2 This situation was addressed again in two Delphi studies designed to set priorities for burn nursing research.

References: 

1. Gordon M. Pruritus in burns. J Burn Care Rehabil 1988;9:305.
2. Bell L, McAdams T, Morgan R, et al. Pruritus in burns: A descriptive study. J Burn Care Rehabil 1988;9:305–11.
3. Marvin JA, Carrougher G, Bayley B, et al. Burn nursing Delphi study. J Burn Care Rehabil 1991;12:190–7.
4. Bayley EW, Carrougher G, Marvin JA, et al. Research priorities for burn nursing: Rehabilitation, discharge planning, and follow-up care. J Burn Care Rehabil 1992;13:471–6.
5. O’Donnell F. Nursing forum. J Burn Care Rehabil 2001;22:75.
6. Munster AM. Burn Care for the House Officer. Baltimore, MD: Williams and Wilkins, 1980:81.
7. Head MD. Wound and skin care. In: Fisher SV, Helm PA (eds). Comprehensive Rehabilitation of Burns. Baltimore, MD: Williams and Wilkins, 1984:148–76.
8. Blalock SJ, Bunker BJ, Moore JD, et al. The impact of burn injury: A preliminary investigation. J Burn Care Rehabil 1992;13:487–92.
9. Vitale M, Fields-Blache C, Luterman A. Severe itching in the patient with burns. J Burn Care Rehabil 1991;12:330–3.
10. Klöti J, Pochon JP. Conservative treatment using compression suits for second- and third-degree burns in children. Burns 1982;8:180–7.
11. Herndon DN, LeMaster J, Beard S, et al. The quality of life after minor thermal injury in children: An analysis of 12 survivors with >= 80% total body, 70% third-degree burns. J Trauma 1986;26:609–17.
12. Baker RAU, Zeller RA, Klein RL, et al. Burn wound itch control using H1 and H2 antagonists. J Burn Care Rehabil 2001;22:263–8.
13. Helvig E, Engrav LH, Cain VJ, et al. Patient’s report of itching post-burn injury. J Burn Care Rehabil 1999;20(part 2):S259.
14. Barone CM, Mastropieri CJ, Peebles R, Mitra A. Evaluation of the Unna boot for lower-extremity autograft burn wounds excoriated by pruritus in pediatric patients. J Burn Care Rehabil 1993;14:348–9.
15. Hartford CE. Care of out-patient burns. In: Herndon DN (ed). Total Burn Care. London: WB Saunders, 1996:71–80.
16. Smith S. Comments from Brookside Hospital Burn Center, San Pablo, California. J Burn Care Rehabil 1988;9:309–10.
17. Malenfant A, Rorget R, Papillon J, et al. Prevalance and characteristics of chronic sensory problems in burn patients. Paul 1996;67:493–500.
18. Tyack ZF, Ziviani J, Pegg S. The functional outcome of children after a burn injury: A pilot study. J Burn Care Rehabil 1999;20:367–73.
19. Lowitt MH, Bernhard JD. Pruritus. Sem Neurol 1992;12:374–84.
20. Schmelz M. A neural pathway for itch. Nat Neurosci 2001;4:9–10.
21. Andrew D, Craig AD. Spinothalamic lamina I neurons selectively sensitive to histamine: A central neural pathway for itch. Nat Neurosci 2001;4:72–7.
22. Greaves MW, Wall PD. Pathophysiology of itching. Lancet 1996;348:938–40.
23. Heyer G, Vogelgsang M, Hornstein OP. Acetylcholine is an inducer of itching in patients with atopic eczema. J Dermatol 1997;24:621–5.
24. Simone DA, Ngeow JY, Whitehouse J, et al. The magnitude and duration of itch produced by intracutaneous injections of histamine. Somatosens Res 1987;5:81–92.
25. Lee EE, Maibach HI. Treatment of urticaria. An evidence-based evaluation of antihistamines. Am J Clin Dermatol 2001;2:27–32.
26. Barnden L, Griffiths T, Littiard K, Sperring B. Burns patients and itching. Aust NZ Burn Assoc Bull 1998;22:3–5.
27. Monroe EW, Cohen SH, Kalbfleisch J, Schulz CI. Combined H1 and H2 antihistamine therapy in chronic urticaria. Arch Derm 1981;117:404–7.
28. Matheson JD, Clayton J, Muller MJ. The reduction of itch during burn wound healing. J Burn Care Rehabil 2001;22:76–81.
29. Kopecky EA, Jacobson S, Hubley P, et al. Safety and pharmacokinetics of EMLA in treatment of postburn pruritus in pediatric patients: A pilot study. J Burn Care Rehabil 2001;22:235–42.
30. Juhlin L, Evers H. EMLA: A new topical anesthetic. Adv Dermatol 1990;5:75–91.
31. Rubin JR, Alexander J, Plecha EJ, et al. Unna’s boot vs. polyurethane foam dressings for the treatment of venous ulceration. Arch Surg 1990;125:489–90.
32. Dean S, Press B. Outpatient or short-stay skin grafting with early ambulation for lower-extremity burns. Ann Plast Surg 1990;25:150–1.
33. Field T, Peck M, Hernandez-Reif M, et al. Post-burn itching, pain, and psychological symptoms are reduced with massage therapy. J Burn Care Rehabil 2000;21:189–93.
34. Field T, Peck M, Krugman S, et al. Burn injuries benefit from massage therapy. J Burn Care Rehabil 1998;19:241–4.
35. Demling RH, DeSanti L. Topical doxepin cream is effective in relieving severe pruritus caused by burn injury: A preliminary study. Wounds 2001;13(6):210–5.
36. Richelson E. Tricyclic antidepressants and neurotransmitter receptors. Psychiatr Ann 1979;19:21–5.
37. Bernstein JE, Whitney DH, Keyoumars S. Inhibition of histamine-induced pruritus by topical tricyclic antidepressants. J Am Acad Dermatol 1981;5:582–5.
38. Drake LA, Fallon JD, Sober A. Relief of pruritus in patients with atopic dermatitis after treatment with topical doxepin cream. J Am Acad Dermatol 1994;31:613–6.
39. Drake LA, Millikan LE, et al. The antipruritic effect of 5% doxepin cream in patients with eczematous dermatitis. Arch Dermatol 1995;131:1403–8.
40. Greene SL, Reed CE, Schroeter AL. Double-blind crossover comparing doxepin with diphenhydramine for the treatment of chronic urticaria. J Am Acad Dermatol 1985;12:669–75.
41. Freshefsky L, Tran-Johnson T. Pharmacokinetic factors affecting anti-depressant drug clearance and clinical effect: Evaluation of doxepin and imipramine—new data and review. Clin Chem 1988;34:863–80.
42. Richelson E. Antimuscarinic and other receptor-blocking properties of antidepressants. Mayo Clin Proc 1983;58:40–6.
43. Groene D, Martus P, Heyer G. Doxepin affects acetylcholine induced cutaneous reactions in atopic eczema. Exp Dermatol 2001;10:110–7.
44. Grandel KE, Farr RS, Wanderer AA, et al. Association of platelet-activating factor with acquired cold urticaria. N Engl J Med 1985;313:405–9.
45. Wander TJ, Nelson A, Okazaki H, Richelson E. Antagonism by antidepressants of serotonin S1 and S2 receptors of normal human brain in vitro. Eur J Pharmacol 1986;132:115–21.
46. Ritchie J, Greengard P. On the active structures of local anesthetics. J Pharmacol Exp Ther 1961;133:241–5.
47. Gibran NS, Heimbach DM. Current status of burn wound pathophysiology. Clin Plast Surg 2000;27:11–22.
48. Wang L, Hilliges M, Jernberg T, et al. Protein gene product 9.5-immunoreactive nerve fibers and cells in human skin. Cell Tissue Res 1990;261:25–33.
49. Johansson O, Virtanen M, Hilliges M. Histaminergic nerves demonstrated in the skin. A new direct mode of neurogenic inflammation? Exp Dermatol 1995;4:93–6.