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

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.

Post-Burn Pruritus

“…Post-burn pruritus is the pruritus that occurs during the wound healing process after a burn. The onset of the pruritus may occur within a few days after burn and the prevalence of pruritus after burn is 80-100%, according to reports [1][2][3]. The prevalence of pruritus tends to decrease with time, but, in some cases, it has persisted for more than a few years and the prevalence rate has reached 40% even after 12 years [4].…”

“…Therefore, well-designed, randomized, placebo-controlled trials are still needed. Nevertheless, to tailor therapeutic regimens according to current evidence, patient values, risks, and resource considerations, the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) classification was made [1]. Twenty-three studies about therapeutic agents used on burns were analyzed by a multidisciplinary panel following the GRADE classification to rate individual agents.…”

“…This is because it softens the stratum corneum and restores its barrier function, thereby relieving itching [50]. In addition, cooling of lesions and cooling agents are widely used, but there are no well-established studies to support them [1]. However, this is an integral part of the skin care routine, and the positive clinical experience allows their inclusion.…”

Case Report of Atopic Dermatitis with Refractory Pruritus Markedly Improved with the Novel Use of Clonidine and Trimeprazine

“…Newer therapies of pruritus block the central nervous system (11); anticonvulsants, mu‐opioid receptor antagonists (MORA), and antidepressants have been found to be useful in the treatment of pruritus. The anticonvulsant and analgesic gabapentin, which structurally resembles the neurotransmitter gamma aminobutyric acid, is recognized as an effective antipruritic therapy in burn patients (12). Naloxone, a MORA, at an ultralow dose can inhibit narcotic‐induced and cholestatic pruritus by acting on opioid‐sensitive interneurons connecting itch and pain neurons (13,14).…”