The Impact of Pruritus on Patients With Burns

Pruritus is a common complaint encountered at wound centers and has been found to occur in almost 70% of patients with chronic leg ulcers compared with 13% of the general population.^1,2 Chronic pruritus, pruritus lasting longer than six weeks, accompanies many chronic conditions, including dermatologic conditions like eczema, liver or kidney dysfunction, malignancy, infections, drug reactions, diabetic autonomic neuropathy, venous stasis dermatitis, and lymphedema. The elderly population is at risk for pruritus due to several factors, including the increased prevalence of xerosis as we age,¹ polypharmacy, and comorbid conditions. There is no clear etiology in many cases of chronic pruritus, but the cause is better understood in some disease states. In pruritus associated with lymphedema, it is suspected that the degranulation of mast cells and subsequent histamine release contributes to increased itch.³ For patients with chronic wounds, the stimulation of nerve growth into the affected area, including activation of nerve growth factors, is thought to play a role in the sensation of pruritus.⁴Wound patients are also susceptible to pruritus due to various cleansing, topical, and dressing materials and the moist wound environment. This places them at risk for allergic, irritant, and contact dermatitis. Pruritus is also a common complication in burn healing and has been seen in 87% of adult burns and 100% of pediatric burns.⁵ It can occur during wound healing but can persist well after epithelialization and scar maturation. Pruritus can significantly impact the quality of life,¹ interrupt sleep, and cause skin injury leading to further complications, including wounds and cellulitis.⁶

Treatment

Treatment for pruritus may involve targeting the underlying factors, treating etiologic conditions, and medical therapy. General interventions to target underlying factors include ensuring the skin is moisturized, washing with mild cleansers, avoiding excessive or aggressive washing, providing a cooling environment, avoiding skin irritants, reducing stress, and preventing the action of scratching.⁶ The scratch-itch-scratch cycle, also known as neurodermatitis, is a phenomenon in which scratching pruritic areas exacerbates or prolongs the itch. It is thought to be caused by an interplay between the epithelial barrier, the immune system, and the peripheral nervous system.⁷ Keeping fingernails short and clean and instructing patients to avoid scratching are vital interventions. In the case of pruritus associated with xerosis, moisturization, the addition of urea or another exfoliant like glycolic acid, can be effective.

Pharmaceutical agents used to treat pruritus include multiple drug classes with various targets. Antihistamines and glucocorticoids, both over the counter and prescription, are a common treatment choice for pruritus but are mainly effective for pruritus with a histamine component etiology like eczema, urticaria, and mastocytosis.⁸ Outside of these presentations, relief received from antihistamines are mainly due to the sedative effects.⁶ Common antihistamines used include diphenhydramine and hydroxyzine. Antihistamines, along with cooling lotions, are considered first-line therapies for pruritus. Additional agents that can be added for refractory pruritus include antidepressants (tricyclic, selective serotonin reuptake inhibitors, and mirtazapine) and some anticonvulsants (gabapentin and pregabalin).⁶

First-line systemic treatment for post-burn pruritus also includes antihistamines followed by other agents such as gabapentin and hydroxyzine. Topical treatments such as Aloe vera, cocoa butter, colloidal oatmeal, silicone gel sheets, and topical glucocorticoids also may be effective.⁹

Conclusion

Pruritus is a common complaint in the chronic wound population. Clinicians educated in instigating and alleviating factors as well as evidence-based treatments to manage their pruritus have the potential to offer patients a significantly enhanced quality of life.

References

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2. Ständer S, Raap U, Weisshaar E, et al. Pathogenesis of pruritus. J Dtsch Dermatol Ges. 2011;9(6):456-463. doi:10.1111/j.1610-0387.2011.07585.x
3. Nix DP, Bryant R. Acute & Chronic Wounds: Current Management Concepts. 4th ed. St. Louis, MO: Elsevier; 2012.
4. Obreja O, Rukwied R, Nagler L, Schmidt M, Schmelz M, Namer B. Nerve growth factor locally sensitizes nociceptors in human skin. Pain. 2018;159(3):416-426. doi:10.1097/j.pain.0000000000001108
5. Goutos I, Dziewulski P, Richardson PM. Pruritus in burns: review article. J Burn Care Res. 2009;30(2):221-228. doi:10.1097/BCR.0b013e318198a2fa
6. Fazio SB, Yosipovitch G. Pruritus: Etiology and patient evaluation. UpToDate. Published September 7, 2021. Accessed September 12, 2021. https://www.uptodate.com/contents/pruritus-etiology-and-patient-evaluation.
7. Mack MR, Kim BS. The Itch-Scratch Cycle: A Neuroimmune Perspective. Trends Immunol. 2018;39(12):980-991. doi:10.1016/j.it.2018.10.001
8. Ständer S, Zeidler C, Magnolo N, et al. Clinical management of pruritus. J Dtsch Dermatol Ges. 2015;13(2):101-116. doi:10.1111/ddg.12522
9. Wiechman S, Sharar SR. Management of burn wound pain and itching. UpToDate. Published February 24, 2020. Accessed September 12, 2021. https://www.uptodate.com/contents/management-of-burn-wound-pain-and-itching/print?search=cancerpain-management-with-opioidsopttimizing-analgesia&source=search_result&selectedTitle=6~150&usage_type=default&display_rank=6.