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

Ioannis Goutos; Maria Clarke; Clara Upson; Patricia M. Richardson; Sudip J. Ghosh

doi:10.4103/0970-0358.70721

Indian Journal of Plastic Surgery, Table of Contents

CC BY-NC-ND 4.0 · Indian J Plast Surg 2010; 43(S 01): S51-S62
DOI: 10.4103/0970-0358.70721

Review Article

Association of Plastic Surgeons of India

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

Ioannis Goutos

Department of Plastic Surgery, Queen Alexandra Hospital, QUAD Building, Southwick Hill Road, Cosham, Portsmouth, PO6 3LY, United Kingdom

,

Maria Clarke

¹Departments of Occupational Therapy and Physiotherapy, Stoke Mandeville Hospital, Mandeville Road, Buckinghamshire, HP21 8AL, United Kingdom

,

Clara Upson

¹Departments of Occupational Therapy and Physiotherapy, Stoke Mandeville Hospital, Mandeville Road, Buckinghamshire, HP21 8AL, United Kingdom

,

Patricia M. Richardson

²Department of Anaesthesia, St. Andrew's Centre for Plastic Surgery and Burns, East Wing, Broomfield Hospital, Court Road, Chelmsford, CM1 7ET, United Kingdom

,

Sudip J. Ghosh

³Department of Plastic Surgery, Stoke Mandeville Hospital, Mandeville Road, Buckinghamshire, HP21 8AL, United Kingdom

› Author Affiliations

Abstract

PDF Download

ABSTRACT

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.

KEY WORDS

Pruritus - burn - itch - antihistamines - gabapentin

PDF (458 kb)

References

REFERENCES
1 Goutos I. Burns pruritus-A study of current practices in the UK. Burns 2010;36:42-8.
2 Vitale M, Fields-Blache C, Luterman A. Severe itching in the patient with burns. J Burn Care Rehabil 1991;12:330-3.
3 Malenfant A, Forget R, Papillon J, Amsel R, Frigon JY, Choinière M. Prevalence and characteristics of chronic sensory problems in burn patients. Pain 1996;67:493-500.
4 Willebrand M, Low A, Dyster-Aas J, Kildal M, Andersson G, Ekselius L, et al. Pruritus, personality traits and coping in long-term follow-up of burn injured patients. Acta Derm Venereol 2004;84:375-80.
5 Ständer S, Steinhoff M, Schmelz M, Weisshaar E, Metze D, Luger T. Neurophysiology of pruritus: Cutaneous elicitation of itch. Arch Dermatol 2003;139:1463-70.
6 Andrew D, Craig AD. Spinothalamic lamina I neurons selectively responsive to cutaneous warming in cats. J Physiol 2001;537:489-95.
7 Jinks SL, Carstens E. Superficial dorsal horn neurons identified by intracutaneous histamine: Chemonociceptive responses and modulation by morphine. J Neurophysiol 2000;84:616-27.
8 Drzezga A, Darsow U, Treede RD, Sieber H, Frisch M, Munz F. Central activation by histamine-induced itch: Analogies to pain processing: A correlational analysis of O-15H 2 O positron emission tomography studies. Pain 2001;92:295-305.
9 Brooks JP, Malic CC, Judkins KC. Scratching the surface managing the itch associated with burns: A review of current knowledge. Burns 2008;34:751-60.
10 Bell P L, Gabriel V. Evidence based review for the treatment of post-burn pruritus. J Burn Care Res 2009;30:55-61.
11 Jaeschke R, Guyatt GH, Dellinger P, Schönemann H, Levy MM, Kunz R, et al. Use of GRADE grid to reach decisions on clinical practice guidelines when consensus is elusive. BMJ 2008;337:327-30.
12 Thangaratinam S, Redman CWE. The Delphi technique. Obstetrician Gynaecologist 2005;7:120-5.
13 GRADE Working Group. Grading quality of evidence and strength of recommendations. BMJ 2004;328:1-8.
14 Guyatt GH, Oxman AD, Kunz R, Falck-Ytter Y, Vist GE, Liberati A, et al. GRADE: Going from evidence to recommendations. BMJ 2008;336:1049-51.
15 Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, et al. Surviving sepsis campaign: International guidelines for management of severe sepsis and septic shock. Crit Care Med 2008;36:296-327.
16 Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, et al. GRADE: An emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008;336:924-6.
17 University of York, NHS centre for reviews and Dissemination. Undertaking systematic reviews of research on effectiveness: CRD Guidelines for those carrying out or commissioning reviews. CRD Report Number 4 (2^nd Edition) 2001.
18 Choiniere M, Papillon J. Topical capsaicin treatment for postburn pruritus: A double blind study. In: Abstract: 9 th Congress of the International Society for Burn Injuries; 2001.
19 Hettrick H, O'Brien K, Laznick H, Sanchez J, Gorga D, Nagler W, et al. Effect of transcutaneous electrical nerve stimulation for the management of burn pruritus: A pilot study. J Burn Care Rehabil 2004;25:236-40.
20 Field T, Peck M, Hernandez-Reif M, Krugman S, Burman I, Ozment-Schenck L. Postburn itching, pain, and psychological symptoms are reduced with massage therapy. J Burn Care Rehabil 2000;21:189-93.
21 Whitaker C. The use of TENS for pruritus relief in the burns patient: an individual case report. J Burn Care Rehabil 2001;22:274-6.
22 Gaida K, Koller R, Isler C, Aytekin O, Al-Awami, Meissl G, et al. Low level laser therapy: A conservative approach to the burn scar? Burns 2004;30:362-7.
23 Roh YS, Cho H, Oh JO, Yoon CJ. Effects of skin rehabilitation massage therapy on pruritus, skin status, and depression in burn survivors. Taehan Kanho Hakhoe Chi 2007;37:221-6.
24 Gross S, Overbaugh R, Jansen R. Ondansetron for treating itch in healing burns. Internet J Pain, Symptom Control and Palliat Care; 2007.
25 Demling R, DeSanti L. Topical doxepin significantly decreases itching and erythema in the healed burn wound. Wounds 2001;13:210-5.
26 Bauling PC, McDermott T, Peterson VM. A pilot study on topical dapsone application to decrease itching in healed burn wounds. J Burn Care Rehabil 2002;23:55.
27 LaSalle L, Rachelska G, Nedelec B. Naltrexone for the management of post-burn pruritus: A preliminary report. Burns 2008;34:797-802.
28 So K, Umraw N, Scott J, Campbell K, Musgrave M, Cartotto R. Effects of enhanced patient education on compliance with silicone gel sheeting and burn scar outcome: A randomised prospective study. J Burn Care Rehabil 2003;24:411-7.
29 Mendham JE. Gabapentin for the treatment of itching produced by burns and wound healing in children; a pilot study. Burns 2004;30:851-3.
30 Kopecky EA, Jacobson S, Hubley P, Palozzi L, Clarke HM, Koren G. Safety and pharmacokinetics of EMLA in the treatment of postburn pruritus in pediatric patients: A pilot study. J Burn Care Rehabil 2001;22:235-42.
31 Barone CM, Mastropieri CJ, Peebles R, Mitra A. Evaluation of the Unna boot for lower-extremity autograft wounds excoriated by pruritus in pediatric patients. J Burn Care Rehabil 1993;14:348-9.
32 Tager K, Jenkins M, Savlors R, Warden GD. The use of Claritin to control itching in thermally injured patients. J Burn Care Rehabil 1998;19:261.
33 Baker RA, Zeller RA, Klein RL, Thornton RJ, Shuber JH, Marshall RE, et al. Burn wound itch control using H1 and H2 antagonists. J Burn Care Rehabil 2001;22:263-8.
34 Matheson JD, Clayton J, Muller MJ. The reduction of itch during burn wound healing. J Burn Care Rehabil 2001;22:76-81.
35 Brooks P, Phang KL, Moazzam A. Nanocrystalline silver (Acticoat) for itch relief in the burns patient. ANZ J Surg 2007;77:797-804.
36 Allison KP, Kiernan MN, Waters RA, Clement RM. Pulsed dye laser treatment of burn scars. Alleviation or irritation? Burns 2003;29:207-13.
37 Eldardiri MA, Ovens L, Gardiner M, Dziewulski P, Richardson PM. Pilot study into the management of itching as a complication of burn injury. Abstract, 40th Annual Meeting of the British Burn Association; 2007.
38 Goutos I, Eldardiri M, Khan AA, Dziewulski P, Richardson PM. Comparative evaluation of anti-pruritic protocols in acute burns. The emerging value of gabapentin in the treatment of burns pruritus. J Burn Care Res 2010;31:57-63.
39 Leung PC, Ng M. Pressure treatment for hypertrophic scars resulting from burns. Burns 1980;6:244-50.
40 British National Formulary. London: BMJ Group; 2009.
41 Blakeney P, Marvin J. Itch man scale. Copyrighted by Shriners Hospitals for Children; 2000.
42 Morris VE, Murphy LM, Rosenberg M, Rosenberg L, Holzer CE, Meyer III W. Itch assessment scale for the pediatric patient. J Burn Care Res; 2009.
43 Cuignet O, Pirson J, Soudon O, Zizi M. Effects of gabapentin on morphine consumption and pain in severely burned patients. Burns 2007;33:81-6.
44 Goutos I, Dziewulski P, Richardson PM. Pruritus in burns: Review article. J Burn Care Res 2009;30:221-8.
45 Goutos I. Re: Scratching the surface-managing the itch associated with burns: A review of current knowledge. Burns 2009;35:754-5.
46 Van Loey NEE, Bremer M, Faber AW, Middelkoop E, and The Research Group. Itching following burns: Epidemiology and predictors. Br J Dermatol 2008;158:95-100.