Written by MICHAEL D. PECK, MD, ScD on November 2, 2019
Almost all of my patients complain of itching at one time or another. For some, itching starts right away, as soon as the burn starts to heal. For others, it may wait until one or two months have gone by. Many patients are troubled by the itching at work or school, and many others cannot sleep well at night. For an unfortunate few, itching can be so severe as to cause major disability.
If I could offer any simple solutions to this problem, my patients and I would be much less frustrated. Unfortunately the only certainty I can offer is that, first, itching is a normal response to healing and, second, it will go away with time. This latter statement is rarely received with enthusiasm, and over the years my patients and I have found a few methods that lead to temporary and partial relief. Understand first of all that itching is defined as “an uneasy sensation of the skin that inclines the person to scratch.” This is subjective, for nobody can tell you how itching feels, nor how severe your symptoms are. It is also an uncomfortable sensation that falls somewhere between a tickle on the one hand and a pain on the other. The nerve fibers responsible for the itch sensation have their endings right at the junction between the two layers of skin, the dermis and the epidermis. These nerve fibers are identical to those that conduct pain messages. So, in truth, itching is a variant of pain.
The first step in treating itching is keeping the skin moist. Dry skin, especially dry burned skin, is a common cause of itching. This problem can be easily prevented by applying skin moisturizers on a regular basis, often several times a day. We use creams that are simple in composition, avoiding those with perfumes or other additives. Lotions should also be avoided because they contain alcohol to liquefy them, and alcohol can dry the skin. Vitamin E, aloe vera, and other natural ingredients are not helpful in my experience, but neither are they harmful (although they significantly increase the price of the moisturizing cream!). Cocoa butter is one of my favorites, especially the solid stick form. Crisco shortening (in the tub, not the oil) is also very effective.
The second step is ensuring that pressure garments are applied appropriately by a professional. Many burn centers advocate pressure garments to minimize scar formation, but in addition they can also provide relief of local symptoms of discomfort in the burn scars. By squeezing the scars and reducing the amount of blood in the vessels and fluid in the tissue, pressure garments can make burn scars, especially on the extremities, easier to live with. Some of our patients continue to use their garments, particularly on the legs, long past the time when the scars are mature and no longer thickening.
Topical medications are helpful in some patients. Hydrocortisone ointment can be purchased without a prescription, as can Benadryl ointment. Unfortunately, I have had little success with either. More effective are the local anesthetics, such as Nupercainal or Preparation H. These ointments, found under the hemorrhoidal preparations in the drugstore, have local painkillers that are safe to use on the skin. Some patients have also told me that the local application of cold helps; try a bag of frozen vegetables (such as peas or corn) pressed up against the area of discomfort, particularly before going to sleep at night.
Systemic medications (taken by mouth) are the next step. Benadryl can be purchased over the counter, either as pills for adults or elixirs for children. Ataraz and Periactin are also commonly prescribed, and like Benadryl, are histamine blockers. Histamine is one of the chemical mediators released from cells in the burn scar, called mast cells that are chronically stimulated during the final maturation phase of healing. The problem with the older histamine blockers like Benadryl is that they commonly cause drowsiness. The newer generation of histamine blockers, familiar to those of us with allergies, includes such drugs as Seldane and Claritin which do not cause drowsiness in most people. Recently we have had good success with Claritin 10mg taken once a day.
More severe symptoms require the treatment supervision of a physician. Some patients require oral steroids such as prednisone for relief, but steroids have many side effects and should be used with caution. Tricyclic antidepressants such as Elavil can also be helpful. Again, these drugs are by prescription only, and should only be used with appropriate supervision.
Finally, there are many nonpharmacologic approaches to pain and itch management. Acupuncture, aromatherapy, hypnosis, meditation, and many other techniques may offer relief. We have had experience with scar massage therapy by a licensed massage therapist, and have documented in prospective studies that scar massage reduces itching discomfort.
Management of burn scar itching continues to be a challenge for health care providers. If you have stumbled upon treatment or technique that has been successful for you, please contact me in care of the Phoenix Society so I can share your findings with others.