University of Manchester



Wound Pruritus: Prevalence, Aetiology and Treatment TA \l "Wound Associated Pruritis: Prevalence, aetiology and treatment" \s "Wound Associated Pruritis: Prevalence, aetiology and treatment" \c 1 Professor Dominic Upton, PhD, FBPsSProfessor of Health Psychology1Dr. Clifford Richardson, BSc AUS, RGN, MSc, PG Cert (HE), PhDSenior Academic Advisor and Post-Graduate student experience lead2Miss Abbye Andrews, BSc, MBPsSResearch Assistant1Dr. Mark Rippon, PhDMedical Marketing Manager31 Institute of Health and Society, University of Worcester, Henwick Grove, St Johns, Worcester, WR2 6AJ2 School of nursing, midwifery and social work, University of Manchester, Jean MacFarlane Building, Oxford Road, Manchester, M13 9PL3 M?lnlycke Health Care, Gamlestadsv?gen 3??415 02 Gothenburg, SwedenCorresponding Author:Professor Dominic Upton: d.upton@worc.ac.uk; 01905 855517AbstractObjective: To review the literature into itching, or pruritus, in relation to burns or other types of wound, with a focus on the physiological mechanisms underlying itching and the issues associated with itching in people with wounds.Method: A search was completed using the databases PubMed and MEDLINE in addition to Google Scholar. Studies were included in the review if they addressed the implications of pruritus in relation to burns and acute or chronic wounds.Results: All types of wound may be associated with acute or chronic itching, depending on their pathology and the severity of the trauma. Burns have a very high incidence of itch and this can be an issue many years after healing in some patients. The impact of itch can be severe, leading to issues such as anxiety, depression, reduced sleep, and impaired quality of life. Furthermore, itching may lead to infection recurrence and delayed healing through exacerbating the patient’s physical and psychological condition. Conclusion: Itching is a significant issue for people with burns and other types of wound, causing a range of physical and psychological difficulties, impairing quality of life, and potentially leading to delayed healing. It is therefore essential that clear guidelines are developed in relation to treatment options for people with burns and other wounds who experience peting Interest StatementA research grant was provided by M?lnlycke Health Care.IntroductionAn itch is defined as an irritating cutaneous sensation that produces a desire to scratch.1 The term ‘pruritus’ has also been used to refer to itching, and the terms are often used interchangeably2 although it has been argued that pruritus is a condition in which itch is present without a specific cause.3Itching is often experienced in people with burns and other types of wound.4 However, there appears to be little research into wound-associated itching specifically, and furthermore, a consensus is lacking on how best to treat itching in people with wounds. The aims of this review are therefore to: identify the classification and physiological mechanisms underlying pruritus; to establish the issues associated with itching in different wound types, and; to consider current guidelines on the treatment and management of itch in people with wounds.MethodsA literature search was carried out using the following databases: PubMed, MEDLINE and Google Scholar. The search involved the terms pruritis, itching, chronic, wounds, burns for all literature up until 2012. ReviewClassification of ItchThe sensation of itch can be elicited from the skin by a variety of stimulus modalities, including thermal, mechanical, electrical and chemical stimuli. Itch can be of relatively short (acute) duration, lasting anything between seconds and up to a week,5 or it can be chronic, being present for more than six weeks.6 Itch can be classified as pruritoceptive, neurogenic , neuropathic, or mixed (see table 1). In addition to these forms, it is important to note that psychological factors can influence itch sensation. For example, itch can be reduced or eliminated through psychological techniques such as distraction, and with training, itch can be suppressed.7Table 1: Itch aetiology (adapted from Twycross et al.7ClassificationDefinitionPruritoceptive itchPruritus classified as pruritoceptive (also referred to as cutaneous,dermatological, or peripheral) includes the itch of atopic dermatitis, psoriasis, drug reactions, mites, urticaria, xerosis, and other inflammatory dermatoses1.Neurogenic itchNeurogenic itch is associated with systemic conditions, including chronic liver disease and chronic renal failure.1 Human immunodeficiency virus (HIV) often results in itch that is likely related to disruption of normal immune function resulting in systemic and cutaneous causes.8Neuropathic itchNeuropathic pruritus results from pathology along the afferent neuronal pathway as with post-herpetic pruritus, multiple sclerosis, and diabetic neuropathy.1 In these conditions, the neural pathways areaffected by the disease process, and the result is the sensation of itch.Physiological Mechanism of itchOriginally, itch was believed to follow the same physiological pathways as that of pain, although less intensely. However, a specific and distinct subgroup of C-fibres has been found to be preferentially excited by pruritic compounds that responded to histamine stimulation in parallel to the sensation9 and therefore, the specificity theory appears to apply. These specific itch-selective neurons found in humans are slow-conducting C-fibers (pruriceptors) which originate in the skin10 pass sensory information to the dorsal horn of the spinal cord and, via the spinothalamic tract, on to the thalamus in the somatosensory cortex, a pathway that is very similar to the pathway for pain (see figure 1).11, 12 7, 3 These slow-conducting C-fibers account for approximately five percent of all afferent C-fibers in human skin, they are similar to, but functionally distinct from, pain fibers. The C-fibers are responsive to histamine and other pruritogens, but are insensitive to mechanical stimuli.11 When free nerve endings of the specialized C-fibers are stimulated by pruritogens, itch is induced. Figure 1 Diagram illustrating the “selectivity hypothesis” of the neuronal mechanisms of histamine-induced itch in the spinal cord. PruritogensA number of endogenous and exogenous pruritogens (itch triggers) have been identified.These pruritogens may be found in the body of the itching person, in the wound bed, or the environment of the itching person. Individual itch response to the various pruritogens varies between individuals. Pruritogens include:Histamine is often used to elicit itch as the reaction to histamine is predictable. The reaction includes an itch which begins 30 to 45 seconds after histamine application and resolves over 10 to 15 minutes, a wheal with a surrounding flare develops alongside the itch. The wheal and flare are specifically histamine mediated.Acetylcholine is a neurotransmitter which, via muscarinic and nicotinergic receptors causes pain itch in atopic persons.7 Serotonin induces itch via 5-HT3 receptors.13 Selective serotonin reuptake inhibitors (SSRI) are known to have antipruritic effects.14 Bradykinin induces mast cell degranulation for the release of histamine and enhances histamine responses so contributes to the itch sensation.13Prostaglandins potentiate histamine-induced itch by lowering the receptor threshold to histamine and papain.13, 14Interleukins (eg. IL-2, IL-4, IL-6, and IL-31) are cytokines, which originate in t-cells and macrophages.1 Interleukins play a role in the elicitation of itch, similar to histamine, by activating the cutaneous C-fibers.13 Normal Wound Healing and itchingIn the typical wound healing process, patients have itching sensations within and around the wound site and it is thought that this itching may be due in part to regeneration of nerves within the growing wound tissue or physical interactions such as pressure within the wound environment.7 It is noteworthy that pruritogens are likely present in open wounds including histamine, which is released from granulation tissue and growth factors.7, 13, 15Itching causes a nocifensive withdrawal response to remove the offending irritant and protect the skin and integrity of the body.12 The itch-scratch cycle is described in which itch elicits a scratch response.13, 16 The scratching causes inflammation and further stimulation of nerve fibres, which results in the sensation of itch. The sensation of itch then prompts further scratching or rubbing. While scratching and rubbing can provide relief, both can also lead to lichenification (scratch marks) and further trauma.16, 17 This itch cycle can exacerbate skin conditions and cause damage and trauma that may cause wounding and infection. Chronic Wounds associated with itchBurnsBy far the greatest clinical impact of itch appears to be in burns/post-healing burns and it is largely thought that pruritus in burns stems from inflammation, dryness and changes to the surrounding skin as well as nerve damage/regeneration.18 Figure 2 demonstrates how the physiological mechanisms of itch are initiated in burns. Figure 2 Schematic diagram of the pruritic pathway. Several studies have confirmed the high prevalence of sensory dysfunction in healed burn wounds in terms of the co-presence of positive and negative sensory phenomena. In a study of 60 patients who had undergone skin grafting procedures for burns19 (mean of 27 months post-burn and 26.5 months post-grafting), 58 (97%) showed markedly diminished or absent responses to sharp, dull, cold, and light touch stimulation and 59 (98.3%) to heat application over the grafted areas. These patients had a number of sensory complaints in their wounds including tingling and burning sensations, and 25% had chronic itch. Depth of injury appeared to be the best predictor of altered sensation in this cohort of patients. In other words, itch in the late stages of rehabilitation represents a positive sensory phenomenon in wounds with otherwise decreased sensibility.The itch experienced by patients in burns is exhibited in skin where there is inflammation, dryness and other damage. The tissue injury present in a burn causes a significant increase of histamine and xanthanine oxidase concentrations and local release of bradykinins, eicosanoids, Substance P, neurokinin A, other tachykinins all of which up-regulate the C-fibre activation process. These pruritogenic mediators are constantly replenished in the burn/scar by the elevated levels of mast and inflammatory cells releasing mediators into a region of increased density of sensitised fibres.20Various authors have proposed different, but very high, rates of prevalence of itching post-burn. For example, rates of 57 – 100% have been reported in children and 25 – 87% in adults,4, 21, 22 or previously 87% of burn patients but 100% if the legs are affected.20 The problem may persist for many years. Vitale et al.23 showed that 100% of patients with leg burns and 70% of those with arm burns complained of itching, although there was no evidence for itching in facial burns.Carrougher et al.24 evaluated self-reported post-burn pruritus in a large multi-site cohort study of adult burn survivors. One group of participants (n = 637) were injured from 2006 to 2010 and followed up prospectively for 2 years from the time of injury. Prevalence rates of pruritus at discharge and at 6, 12, and 24 months following injury, were 93%, 86%, 83%, and 73%, respectively. In a second group who were injured 4 to 10 years before, many patients (44.4%) reported itching in the area of the burn, graft, or donor site and within this group, 76% reported itching for more than 6 hours per day, and 52% and 29% considered itch intensity to be mild or moderate, respectively. An evaluation was undertaken in a multicentre cohort (n=510) to examine psychological and injury characteristics in relation to itching among adults with burns at 3, 12 and 24 months post-burn.4 The reported prevalence rates of mild to severe itching were as high as 87%, 70% and 67% at the three respective points in time. Significant predictors of itching at all three time points were deep dermal injury and early post-traumatic stress symptoms. Along with these, total burned surface area and female gender were predictors at 3 months post-burn. Parnell et al.25 assessed the characteristics of pruritus and its impact on burn survivors. Measurement of itch frequency revealed that 87% of subjects experienced itching daily, 96% experienced three or more episodes a day, and 52% had episodes lasting 5 to 30 minutes per incidence. Itch was reported as unbearable by 94% of subjects with chronic itch and by 86% of subjects with acute itch, whereas 88% and 100% reported itch to be ‘bothersome.’Small burns have also been shown to have a high prevalence of pruritis, which impacts significantly on patients’ quality of life. A recent study was undertaken to identify the incidence of pruritus, the presence of predisposing factors after small burns, and their impact on daily life.26 This study was retrospective and involved interviewing all patients treated in an outpatient burn clinic during 2004. Patients were asked about aspects of the burn and the presence, intensity and impact of pruritus. The results showed that 35% of patients recalled moderate pruritus, and 14% reported severe pruritus. Impact on daily life was reported in 42% of patients suffering from moderate pruritus and 92% of patients suffering from severe pruritus. The authors concluded that recovery from small burns is associated with a high incidence of pruritus, which has a substantial impact on daily life Earlier work has demonstrated that burn-associated itching usually peaks at two to six months post-burn and often resolves with scar maturation (at 12 to 18 months).27 Bell and colleagues28 administered a questionnaire to nurses who specialized in burn care (number not specified) to determine if they viewed itching as a problem for burn patients and to determine treatment regimens to decrease discomfort from itch. Most nurses in burn care believed itching was a significant problem for their patients. Antipruritic medications and lotions were the most frequently used therapies (approximately 94% and 88%, respectively).When body tissues are damaged by a physical injury or impact, scar formation occurs as the final part of a series of interconnecting and overlapping wound healing processes. Wounds such as deep burns may result in hypertrophic scar formation; these may be itchy and painful and cause serious functional and cosmetic disability in many burn survivors. Therefore, almost all burn patients complain about their appearance and cacesthesia, such as itch or pruritus and pain. Forbes-Duchart et al.29 reported that the most common and distressful complications in burn patients were abnormal appearance (75.2%), itch (73.3%), and pain (67.6%).Itch in the hypertrophic scar, especially as a consequence of a burn injury, is a major obstacle in burn patient rehabilitation. The chronic itch may begin at wound closure, but last for many months or even years. The itch might cause psychological disturbances such as anxiety, depression and sleeplessness, impacting severely on the patient’s quality of life.30Psychosocial issues of itching in burn patientsPruritus commonly replaces pain as a source of significant anxiety and distress during the rehabilitation phase.31-35 When pruritus becomes chronic, it has been suggested that psychological factors are of increased importance.18 It may affect their ability to concentrate, and thereby their ability to function well in everyday life. It may also disrupt sleep, which is vital to recovery after a major trauma, and scratching may damage the newly developed skin.35A number of psychological studies have been undertaken to evaluate the effect of pruritis on a post burn patient. For example, the study by Parnell et al.25 demonstrated that for a large proportion of patients, itch was ‘unbearable’ (94% of those with chronic itch; 86% of those with acute itch) or at least ‘bothersome’ (88% of those with chronic itch and 100% of those with acute itch).Another study elucidated that burn patients face complex rehabilitation issues including physical, emotional, social, and vocational challenges.18 Problems with anxiety, depression, sleep, pruritis, and body image can affect the burn patient's ability to return to an acceptable quality of life. Burn patients not only require a large degree of help in the hospital setting but they also need expert care as an outpatient from vocational counselors, social workers, physical and occupational therapists, psychologists, and professionally-monitored support groups. This clearly impacts on the cost of care for patients.18The damaging impact of burns is not limited to the larger more complex burn, since small burns also have a significant impact on patients’ quality of life. This was demonstrated in a retrospective study by Casaer et al.26 as outlined earlier. Impact on daily life was reported in 42% of patients suffering from moderate pruritus and 92% of patients suffering from severe pruritus. The authors concluded that recovery from small burns is associated with a high incidence of pruritus, which has substantial impact on daily life. Additionally, it is difficult to identify patients at risk at the time of injury, since a logistic regression analysis showed baseline demographic and injury related parameters to play only a minor role. Venous UlcersLesional and peri-lesional itching has been shown to be problematic in patients with venous ulcers, paticularly when associated with eczema. Careful consideration is therefore needed when treating patients with such wounds.36 Shai and Halevy37 attempted to determine the causes of ulceration in people with venous insufficiency through reviewing the medical records of 91 patients who had a total of 110 venous ulcers. This non-experimental study involved history-taking and chart review. The authors concluded that 5.4% of the ulcers were triggered by dry skin (eczema) with subsequent scratching. Itching was also found to be an issue for people with venous ulcers by Hareendran et al.38 in their study of health-related quality of life. In a sample of 38 patients, 69.4% experienced itching. Other issues included pain, altered appearance, loss of sleep, functional limitations and disappointment with treatment, although the relationship between itching and these other factors was not explored. Similarly, in a later study, Hareendran et al.39 conducted in-depth interviews and focus groups with 36 patients who had venous leg ulcers. The issue of ‘ulcer itches’ was ranked fourth in a list of 10 symptoms which caused distress. The symptoms which were ranked higher were ‘after ulcer burns/stings’, ‘ulcer hurts’, and ‘skin irritated’.Itching in people with venous insufficiency was explored in greater depth by Eklof et al.,40 who explored itch, pain and burning sensations in terms of their characteristics, relation to the severity of venous disease, factors affecting these symptoms, and their impact on quality of life. The authors used the Clinical Signs, Etiology, Anatomic Distribution, Pathophysiologic Condition (CEAP) classification system41 to determine eligibility to participate and for grading venous disease. In a sample of 100, it was found that 66% were experiencing itch at the time of the interview. Although itch did not correlate with the severity of venous disease, there was a significant negative relationship (r=.50; p < .001) between itch intensity and quality of life, demonstrating how the presence of itch can impact negatively on people’s lives. Others have found itch to be related to symptom severity. Paul, Pieper and Templin42 conducted a pilot regarding itch and found that that itch increased significantly with an increase in severity of symptoms of chronic venous disease (r = .26, p = .025). Of the 14 participants with wounds, five (41.7%) used antibiotic ointment, and four (33.3%) used petrolatum to manage itch.The gold standard treatment for VLU is compression therapy. However, this treatment has been associated with itching. A recent study was undertaken to look at the impact of compression on patients’ quality of life, with itching as a variable.43 In this study, 200 patients who had been on compression therapy for more than 2 weeks were asked to complete questionnaires about their treatment. A total of 110 completed questionnaires were returned, giving a response rate of 55%. Analysis of these questionnaires indicated that most patients (n=105) wore their compression devices for more than six hours per day, and approximately 37% of patients had experienced an improvement in their ulcer symptoms. However, less than a third (29.1%) believed the therapy to be ‘comfortable’. The main side effects were dryness of the skin (58.5%), itching (32.7%), slipping (29.1%), and constriction of the compression device (24.5%). There were no significant differences in the side effect spectrum or the usage according to the type of compression device or the indication for the treatment (varicose surgery/ sclerotherapy). Patients with a leg ulcer and longer duration of compression therapy experienced a worse quality of life. The study concluded that patients accept the recommended compression therapy (alone or in combination with other phlebological therapies) as a necessary therapy. It is noteworthy however that patient compliance with compression therapy may be low due to patient intolerance of which itching is a component.44Pressure Ulcers. Itching is present at the site of early stage pressure ulcers or peri-lesional. In later stages, ulcers the sensation can be used as an indicator of tissue damage in patients at high risk of pressure ulcers. Spilsbury and colleagues45 interviewed 23 hospital inpatients to explore their perceptions and experiences associated with pressure ulcers. They were interested in the impact of pressure ulcers and treatment on health and quality of life. Twenty-one participants (91%) indicated that the pressure ulcer and its treatment affected their lives emotionally, mentally, physically, and socially. The researchers pointed out the difficulty that was encountered in distinguishing the impact of pressure ulcers from the impact of the participants’ multiple co-morbidities. Essex and colleagues46 conducted a study to determine the impact of pressure ulcers on health-related quality of life. Data from 218 people with pressure ulcers was compared with data from 2,289 persons without pressure ulcers who had completed the Short-Form 36 (SF-36). Age, gender, and co-morbidities were controlled. Persons with pressure ulcers had lower scores for the physical (p < .001) and mental (p = .04) component summary scores. Malignant Wounds.Maida and colleagues47 reported on the views of 67 cancer patients with malignant wounds at the time of referral for palliative care. Patients’ self-reports of up to three wound-related symptoms were studied. Of eight main symptoms, the point prevalence for pruritus was 6%. Interestingly, pruritus was reported within the wound itself as well as in the peri-wound area. Other identified symptoms included pain, mass effect, aesthetic distress, exudate, odour, bleeding, and crusting.Post-Surgical WoundsSurgical wounds are known to provoke an itch response as the healing process occurs, possibly due to the process of contraction, eliciting a mechanical stress to which the itch-sensitive nerves respond. At the same time, there are various other chemicals which get released in a healing wound, those which provoke healing in the wound (specifically histamine), but also, up-regulate the activity of these itch sensitive nerves. There is little in the literature relating to itch in post-operative wounds. However a retrospective evaluation of patients admitted to an Orthopaedic Trauma Unit over an 8-year period requiring fasciotomies, of either upper or lower limb was undertaken by Fitzgerald et al.48 The long-term morbidity was studied in 60 patients and the results showed that pain relating to the wound occurred in 6 patients (10%) and altered sensation within the margins of the wound occurred in 46 patients (77%). Examination revealed 24 patients (40%) with dry scaly skin, 20 patients (33%) with pruritus, 18 patients (30%) with discoloured wounds, 15 patients (25%) with swollen limbs, 16 patients (26%) with tethered scars, eight patients (13%) with recurrent ulceration, eight patients (13%) with muscle herniation and four patients (7%) with tethered tendons. This study therefore indicated that pruritis was a significant problem for those with post-surgical wounds.ConclusionAll wounds are capable of inducing itch to varying degrees, and this can be short-term (acute) or long lasting (chronic), being experienced for many years in some patients. This depends on the severity of the wound and its implications. Additionally patients that have suffered from burns have a very high incidence of itch (80 – 100%), mainly in appendages such as legs, yet rarely in the face. Itch has a huge impact on people’s lives, and it is considered to be one of the most severe problems, even above pain sometimes, that is suffered by patients with post-burn injury. Itch may significantly impair quality of life, causing anxiety, depression, loss of sleep and even delayed healing.It is clear then that itching in burns and other wound types is a significant issue, not only physically for patients, but also due to its psychological impact and its relation to healing. However, despite the significance of itch and the variety of treatments that exist, at present there is little agreement on which treatments to use. Further research is needed in order to explore which treatments are effective and to inform the development of guidelines into this area.References1 Ikoma, A., Steinhoff, M., Stander, S., et al. (2006). The neurobiology of itch. Neuroscience, 7, 535-547. 2 Bernhard, J. D. (Ed.). (1994). Itch: Mechanisms and Management of Pruritus. New York: McGraw-Hill, Inc.3 Waxler, B., Dadabhoy, Z. P., Stojiljkovic, L., & Rabito, S. F. (2005). Primer of postoperative pruritus for anesthesiologists. Anesthesiology, 103, 168-178. 4 Van Loey, N.E., Bremer, M., Faber, A.W., et al. (2008). Itching following burns: epidemiology and predictors. Br J Dermatol 158(1):95-100. Epub 2007 Nov 6.5 Yosipovitch , G., & Greaves, M. W. (2004). Definitions of itch. In G. Yosipovitch, M. W. Greaves, A. B. Fleischer, Jr., & F. McGlone (Eds.), Itch: Basic mechanisms and therapy (pp. 1-4), New York: Marcel Dekker, Inc.6 Stander, S., Weisshaar, E., Mettang, T., et al. (2007). Clinical classification of itch: A position paper of the International Forum for the Study of Itch, Acta Dermato-Venereologica, 87, 291-294.7 Twycross, R., Greaves, M. W., Handwerker, et al. (2003). Itch: Scratching more than the surface. Quarterly J Med, 96(1), 7-26.8 Duque, M. I., Yosipovitch, G., & Pegram, P. S. (2004). Itch in HIV-infected patients. In G. Yosipovitch, M. W. Greaves, A. B. Fleischer, Jr., & F. McGlone (Eds.), Itch: Basic mechanisms and therapy (pp. 219-229) New York: Marcel Dekker, Inc.9 Schmelz, M., Schmidt, R., Bickel, A., et al. (1997). Specific C-receptors for itch in human skin. Journal of Neuroscience, 17(20), 8003-8008.10 Stander, S., & Schmelz, M. (2006). Chronic itch and pain – similarities and differences. European Journal of Pain, 10(5), 473-478. doi: 10.106/j.ejpain.2006.03.00511 Heymann, W. R. (2006). Itch. Journal of the American academy of Dermatology, 54(4),705-706. doi: 10.1016/j.jaad.2005.12.00112 Paus, R., Schmelz, M., Biro, T., & Steinhoff, M. (2006). Frontiers in pruritus research: Scratching the brain for more effective itch therapy. Journal of Clinical Investigation, 16(5), 1174-118513 Stander, S., Steinhoff, M., Schmelz, M., et al. (2003). Neurophysiology of pruritus: Cutaneous elicitation of itch. Archives of Dermatology, 139, 1463-1470.14 Pogatzki-Zahn, E., Marziniak, M., Schneider, G., et al. (2008). Chronic pruritus: Targets, mechanisms and future therapies. Drug News Perspectives, 21(10), 541-551. 15 Baker, R. A., Zeller, R. A., Klein, R. L., et al. (2001). Burn wound itch control using H1 and H2 antagonists. J Burn Care Rehabil, 22(4), 263-268.16 Yosipovitch, G., & Hundley, J. L. (2004). Practical guidelines for relief of itch. Dermatology Nursing, 16(4), 325-238.17 Davidson, S., Zhang, X., Khasabov, S. G., et al. (2009). Relief of scratching: State-dependent inhibition of primate spinothalamic tract neurons. Nature Neuroscience, 12(5), 544-546.18 Wiechman, S.A. (2011). Psychosocial Recovery, Pain, and Itch After Burn Injuries Physical Medicine and Rehabilitation Clinics of North America, 22 (2), 327-345.19 Ward, R.S., Saffle, J.R., Schnebly, W.A., et al. (1989). Sensory loss over grafted areas in patients with burns. J Burn Care Rehabil 10 (6), 536-538.20 Brooks, J.P., Malic, C.C., Judkins, K.C. (2008). Scratching the surface--Managing the itch associated with burns: a review of current knowledge. Burns.34(6):751-60. doi: 10.1016/j.burns.2007.11.015. Epub 2008 Mar 28.21 Goutos, I., Eldardiri, M., Khan, A.A., Dziewulski, P. (2010). The emerging value of gabapentin in the treatment of burns pruritus. J Burn Care Res 31; 57-63.22 Chen,g B., Liu, H.W., Fu, X.B.(2011). Update on pruritic mechanisms of hypertrophic scars in postburn patients: the potential role of opioids and their receptors. J Burn Care Res; 32(4).23 Vitale, M., Fields-Blache, C., Luterman, A. Severe itching in the patient with burns. (1991). J Burn Care Rehabil, 12(4):330-333.24 Carrougher, G.J., Martinez, E.M., McMullen, K.S., et al. (2013). Pruritus in adult burn survivors: postburn prevalence and risk factors associated with increased intensity. J Burn Care Res, 34(1): 94-101.25 Parnell, L.K., Nedelec, B., Rachelska, G., LaSalle, L. (2012). Assessment of pruritus characteristics and impact on burn survivors. J Burn Care Res, 33(3): 407-18.26 Casaer, M., Kums, V., Wouters, P.J., et al. (2008). Pruritus in patients with small burn injuries. Burns, 34 (2): 185-91. Epub 2007 Aug 1327 Demling, R.H., DeSanti, L. (2001). Scar management strategies in wound care. Rehab Manag 14 (6): 26-30.28 Bell, L., McAdams, T., Morgan, R., et al. (1988). Pruritus in burns: A descriptive study. J Burn Care Rehabil, 9(3), 305-30929 Forbes-Duchart, L., Cooper, J., Nedelec,B., et al. (2009). Burn therapists’ opinion on the application and essential characteristics of a burn scar outcome measure. J Burn Care Res 30: 792–800.30 Yosipovitch, G., & Papoiu, A. D. P. (2008). What causes itch in atopic dermatitis? Current Allergy and Asthma Reports, 8, 306-311.31 Field, T. Peck, M., Hernandez-Reif, M., et al. (2000). Postburn itching, pain, and psychological symptoms are reduced with massage therapy. J Burn Care Rehabil 21: 189-193.32 Jaffe, S.E. & Patterson, D.R. (2004). Treating sleep problems in patients with burn injuries: Practical considerations. J Burn Care Rehabil 25: 294-305.33 Martin-Herz, S.P., Patterson, D.R., Honari, S., et al. (2003). Pediatric pain control practices of North American Burn Centers. J Burn Care Rehabil 24:26-36.34 Matheson, J.D., Clayton, J., Muller, M.J. (2001). The reduction of itch. J Burn Care Rehabil. 22(1): 7681; discussion 735 Willebrand, M., Low, A., Dyster-Aas, J., et al. (2004). Pruritus, personality traits and coping in long-term follow-up of burn-injured patients. Acta Derm Venereol 84: 375-380.36 Cameron, J. (2007). Dermatological changes associated with venous leg ulcers Wound Essentials, 2.37 Shai, A., & Halevy, S. (2005). Direct ulceration in patients with venous insufficiency. International J Dermatology, 44, 1006-1009.38 Hareendran, A., Bradbury, A., Budd, J. et al. (2005). Measuring the impact of venous leg ulcers on quality of life. J Wound Care 14(2): 53-57.39 Hareendran, A., Doll, H., Wild, D.J., et al. (2007). The venous leg ulcer quality of life (VLU-Qol)questionnaire: Development and psychometric validation. Wound Repair and Regeneration, 15, 465-473.40 Eklof, B., Rutherford, R.B., Bergan, J.J. et al. (2004). Revision of the CEAP classification for chronic venous disorders: consensus statement. J Vasc Surg, 40: 1248–1252.41 Porter, J.M., Moneta, G.L. (1995). Reporting standards in venous disease: an update. International Consensu Committee on Chronic Venous Disease. J Vasc Surg; 21: 635-45.42 Paul, J., Pieper, B., & Templin, T. (2011). Itch: Association with chronic venous disease, pain and quality of life. J Wound Ostomy and Continence Nursing, 38(1), 46-54.43 Reiche-Schupke, S., Murmann, F., Altmeyer, P. & Stücker, M. (2009). Quality of life and patients’ view of compression therapy. Int J Angiol, 28 (5), 385 – 393.44 Nelson, E.A, Bell-Syer, S.E. (2012) Compression for preventing recurrence of venous ulcers. Cochrane Database Syst Rev.15; 8. 45 Spilsbury, K., Nelson, E. A., & Cullum, C. (2007). Inpatients felt that pressure ulcers had an emotional, mental, physical, and social effects on quality of life because nurses did not adequately treat or manage their pain or discomfort. J Adv Nurs, 57, 494-504. 46 Essex, H.N., Clark, M., Sims, J., et al. (2009). Health-related quality of life in hospital in-patients with pressure ulceration: assessment using generic health-related quality of life measures. Wound Repair and Regeneration, 17, 797-805.47 Maida, V., Ennis, M., Kuzienisky, C., & Trozzolo, L. (2009). Symptoms associated with malignant wounds: A prospective case study. Journal of Pain and Symptom Management, 37(2), 206-21148 Fitzgerald, A.M., Gaston, P., Wilson, Y., et al. (2000). Long-term sequelae of fasciotomy wounds MM Br J Plast Surg 53 (8): 690-693. ................
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