Secondary Logo

Share this article on:

Development of a Postburn Pruritus Relief Protocol

Kim, Yeon, DNP, MSN, RN, CCRN

doi: 10.1097/rnj.0000000000000095
FEATURES

Background Postburn pruritus is a syndrome of stressful symptoms that is pervasive and occurs in over 90% of burn patients and continues for years after the burn has healed. Postburn pruritus is experienced by burn survivors that may require medical management and effective interventions.

Purpose This article shows how to effectively relieve postburn pruritus by developing a postburn pruritus relief protocol.

Design A descriptive literature review was conducted, and relevant empirical articles written during the years 2000–2014 were appraised to create a postburn pruritus relief protocol. Twenty-six of 79 articles were selected using preestablished inclusion criteria: any age group experiencing burn-related pruritus after second- or third-degree burns. Databases were Cochrane Central Register of Controlled Trials, CINAHL, EBSCO, PubMed, the National Guideline Clearinghouse, Google Scholar, and the American Burn Association website.

Conclusions This protocol included both nonpharmacological and pharmacological interventions that have been delineated for use and was developed to apply based on the healing stage: prehealing, healing, and posthealing.

Department of Nursing, California State University San Bernardino San Bernardino, CA, USA

Correspondence: Yeon Kim, Department of Nursing, California State University San Bernardino, 5500 University Parkway, San Bernardino, CA 92407, USA. E-mail: yeon.kim@csusb.edu or phoebepark2000@yahoo.com

The authors declare no conflict of interest.

Cite this article as: Kim, Y. (2018). Development of a postburn pruritus relief protocol. Rehabilitation Nursing, 43(6), 315–326. doi: 10.1097/rnj.0000000000000095

Back to Top | Article Outline

Introduction

Postburn pruritus (PBP), a severe itching sensation associated with burn injury, has been identified as one of the most debilitating symptoms postburn survivors experience (Ahuja, Gupta, Gupta, & Shrivastava, 2011 ; Carrougher et al., 2013 ; Goutos, 2010 ; Goutos, Eldardiri, Khan, Dziewulski, & Richardson, 2010 ; Otene & Onumaegbu, 2013). Pruritus appears the first 2 weeks following burn injury (Ahuja et al., 2011 ; Goutos et al., 2010). The prevalence of PBP has been noted in over 90% of burn patients and can persist in greater than 40% of patients for 4–10 years after burn injury (Carrougher et al., 2013). Several studies showed that the incidence of onset of PBP varies from 80% to 100%, with the onset during the early healing phase and sustaining for many years after injury (Ahuja & Gupta, 2013 ; Baker et al., 2001 ; Whitaker, 2001). Research findings have recurrently proposed that PBP management should be one of the top priorities for burn research (Bell & Gabriel, 2009 ; Brooks, Malic, & Judkins, 2008). Burn-associated pruritus, when persistent, can cause disabling symptoms such as sleep disturbances, anxiety, and interruption of daily activities (Goutos, Dziewulski, & Richardson, 2009).

Although pruritus in postburn patients is well recognized, there is no consensus on standardized treatment (Bell & Gabriel, 2009 ; Otene & Onumaegbu, 2013 ; Richardson, Upton, & Rippon, 2014). Single treatment may be ineffective, but most often therapies focus on either pharmacological or nonpharmacological interventions. However, pharmacological interventions have adverse effects in some populations with kidney problems, liver diseases, or allergies to specific medicines, which causes pharmacological interventions to be of limited use. Therefore, the purpose of conducting this literature review was to establish a protocol for PBP relief with the integration of evidence-based practices, primarily focused on nonpharmacological interventions.

Back to Top | Article Outline

Literature Search

A keyword search was performed to identify relevant literature via Cochrane Central Register of Controlled Trials, CINAHL, EBSCO, PubMed, the National Guideline Clearinghouse, Google Scholar, and the American Burn Association website. The key words were burn(s), itching, and pruritus. Because of limited publications, database searches were expanded to all peer-reviewed and published studies written in English during the years 2000–2014, conducted with all second- and third-degree burn populations experiencing postburn-related pruritus. As a result, 79 articles were initially listed from search engines, and 26 of 79 articles were found relevant to the purpose of this review, developing a PBP relief protocol.

Back to Top | Article Outline

Results

The process of finalizing 26 relevant articles is shown through the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram (Figure 1). All relevant articles for the treatment of PBP were summarized including the study design, setting, result, and limitation (Table 1). Treatments are categorized in pharmacological and nonpharmacological interventions.

Figure 1

Figure 1

Table 1

Table 1

Back to Top | Article Outline

Pharmacological Interventions

Thirteen of 26 articles identified pharmacological effects on PBP that included both single oral medicine use and two or three combining oral medicine. Examples of effective oral pharmacological interventions include (1) pregabalin (Lyrica) alone, (2) gabapentin (Neurontin, Gralise, Horizant, Fanatrex FusePag) alone, (3) pregabalin and two different antihistamines (histamine1 [H1] and histamine2 [H2] blockers), (4) gabapentin and one antihistamine (H1 blocker), (5) gabapentin and two different antihistamines, and (6) combination of two different antihistamines. According to the randomized controlled trial (RCT) by Ahuja and Gupta (2013), pregabalin alone or combination of two kinds of antihistamines decreased PBP, but adding more antihistamines did not decrease PBP additionally. Gabapentin alone or combination of one or two antihistamines reduced PBP in several studies (Ahuja et al., 2011 ; Goutos et al., 2010 ; Mendham, 2004). Combination of two different antihistamines also lowered PBP more than using one antihistamine (Baker et al., 2001). Two experimental studies show that naltrexone (Vivitrol, Revia, Depade) is supportive in decreasing duration and frequency of itching in patients with PBP and can be used before sleeping as a supplementary method to other antipruritic medicine (Jung et al., 2009 ; LaSalle, Rachelska, & Nedelec, 2008).

Oral medications are more effective when given as scheduled than being given as needed (Baker et al., 2001). However, oral pharmacological interventions have adverse effects. For example, antihistamines are well known for drowsiness (Vallerand, Sanoski, & Deglin, 2016). Pregabalin has withdrawal symptoms such as insomnia, headache, agitation, nausea, anxiety, diarrhea, flu-like symptoms, nervousness, major depression, pain, convulsions, hyperhidrosis, and dizziness when abruptly stopped (Vallerand et al., 2016). In addition, most pharmacological interventions are not as effective as nonpharmacological interventions once wounds begin granulating toward the healing stage when pruritus is more concerned (Goutos, 2013).

Administering topical agents in both healing and healed stages of wounds are beneficial to the population with PBP according to several researches (Campanati et al., 2013 ; Lewis et al., 2012 ; Nedelec, Rachelska, Parnell, & LaSalle, 2012; Ogawa & Hyaku-soku, 2007). Campanati et al. (2013) reported that ozonated oil and hyaluronic acid gel applied to burn-associated wounds decreased PBP. The study by Ogawa and Hyaku-soku (2008) revealed that Medilixir and mugwort lotion were effective in relieving PBP. Mugwort lotion is comprised of mugwort extract, l-menthol, absolute ethanol, and distilled water. Provase (dimethicone) cream was also reported in relieving PBP (Nedelec et al., 2012). Medilixir (a beeswax and herbal oil cream) reduced PBP when applied to burn-associated wounds (Lewis et al., 2012). Moisturizing body shampoo showed effective decrease of PBP (Ratcliff et al., 2006). Botulinum toxin (Botox) is shown to reduce PBP effectively by using a one time dose in those who failed in managing PBP with conventional therapies (Akhtar & Brooks, 2012).

Back to Top | Article Outline

Nonpharmacological Interventions

Another 13 of 26 articles reported nonpharmacological methods in relieving PBP. Examples of effective nonpharmacological interventions included massage therapy, laser therapy (either regular or low-level laser), transcutaneous electrical nerve stimulation (TENS), triamcinolone acetonide phonophoresis (TAP), muscle relaxation, silicone gel sheeting (SGS), pressure garment (Unna Boot), and nanocrystalline silver (Acticoat). Most nonpharmacological interventions showed antipruritic effects, specifically during the healed stage of burn wounds, whereas massage and Benson muscle relaxation therapy can be used regardless of the stage of healing.

The study by Parlak Gürol, Polat, and Akçay (2010), a single RCT, exhibited that massage therapy to intact skin decreased PBP among adolescent burn patients at the early phase of burn injury (prehealing stage). The experimental group’s itching level (range: 0–10) was averagely 6.1 before the message therapy and then significantly decreased to 2.5, whereas control group’s average itching level slightly decreased from 5.59 to 5.50 (Parlak Gürol et al., 2010). They also showed that this therapy significantly reduced anxiety and pain in the experimental group (Parlak Gürol et al., 2010). There are three other studies showing effective reduction in PBP with message therapy applied directly to healed burn wounds (Cho et al., 2014 ; Field et al., 2000 ; Roh, Cho, Oh, & Yoon, 2007). The study by Cho et al. (2014), an RCT, showed that massage therapy led to significant improvement in pain and itching as well as positive changes in scar characteristics. Another RCT is the study by Field et al. (2000), reporting that massage therapy resulted in the significant decrease in itching, pain, depression, and anxiety among those with PBP. Roh et al. (2007) conducted an RCT demonstrating that massage therapy improved pruritus, scar status, and depression among burn patients. The study by Farahani, Hekmatpou, and Khani (2013), a quasiexperimental study, reported that Benson muscle relaxation therapy lowered PBP in any healing stages in burn patients. The researchers supported that Benson muscle relaxation therapy was significantly effective in relieving the pain, pruritus, and vital signs of patients with burns (Farahani et al., 2013).

Gaida et al. (2004) showed that low-level laser therapy significantly decreased PBP. The study by Hultman, Edkins, Wu, Calvert, and Cairns (2013) demonstrated that regular laser therapy relieved PBP effectively as well. The experimental study by Hultman et al. (2013) was designed as pretest–posttest. The study’s control group was the intact skin of participants, and the experimental group was the participants’ burn wounds (Hultman et al., 2013).

Transcutaneous electrical nerve stimulation was proven to reduce itching in patients with PBP (Hettrick et al., 2004 ; Whitaker, 2001). The pilot RCT by Hettrick et al. (2004) stated that TENS was significantly effective in PBP reduction when TENS was provided an hour per day for 3 weeks. The case study by Whitaker (2001) revealed that receiving TENS for 9 hours a day for 2 weeks relieved pruritus, which resulted in not needing treatment for itching after 2 weeks. In detail, PBP decreased from 100% to 0% after 2 week of TENS therapy (Whitaker, 2001).

The RCT by Waked, Nagib, and Ashm (2013) reported that TAP reduced PBP as effectively as TENS did. In their study, 20 patients received TAP and another 20 students received TENS (Waked et al., 2013). The effectiveness in relieving PBP in both groups was shown to be significantly positive, but there was no difference regarding the relief of PBP between two groups (Waked et al., 2013).

A case study by Brooks, Phang, and Moazzam (2007) demonstrated that 2 weeks of applying nanocrystalline silver to unhealed wound reduced PBP in five cases with different burn-associated wound sizes. This intervention was reported to decrease the pruritus from 7.4 to 3.1 of Visual Analog Scale, which means significant reduction in PBP (Brooks et al., 2007). The researchers also reported that nanocrystalline silver improved wound healing as well as reduction in PBP (Brooks et al., 2007).

Wearing SGS was reported as the effective way in reducing PBP (Li-Tsang, Lau, Choi, Chan, & Jianan, 2006 ; Li-Tsang, Zheng, & Lau, 2010). The RCT by Li-Tsang et al. (2006) showed that the experimental group had significantly decreased itching compared to the control group. The study demonstrated that participants wearing SGS also had significant improvement in scar thickness and pliability (Li-Tsang et al., 2006). Another RCT by Li-Tsang et al. (2010) showed that wearing pressure garment significantly reduced pruritus, as well as SGS did. The study also revealed that wound was significantly improved when both pressure garment and SGS were applied together (Li-Tsang et al., 2010).

Back to Top | Article Outline

Development of the PBP Relief Protocol

The outcome of this literature review was synthesized according to the best evidence-based outcomes from both combined pharmacological and nonpharmacological interventions. Accordingly, a PBP relief protocol was developed (Figure 2). This protocol was designed according to the three different stages of wound healing: prehealing (no granulation tissue), healing (partly granulated tissue), and healed stages (scar formation) with recommended dosages and period for each intervention (Table 2). Nonpharmacological interventions were recommended before pharmacological interventions, considering established effectiveness and possible adverse effects of pharmacological interventions.

Figure 2

Figure 2

Table 2

Table 2

Back to Top | Article Outline

Utilization of the PBP Relief Protocol

Each stage of wound healing can be managed by both nonpharmacological and pharmacological interventions. Nonpharmacological interventions are less invasive and should be considered as the primary intervention. On the other hand, pharmacological interventions are more invasive and should be used only as a supplement to potentiate the therapeutic effect of nonpharmacological interventions or to minimize possible adverse effects of pharmacological interventions.

Because nonpharmacological interventions are versatile and can be combined with other nonpharmacological and pharmacological interventions, nonpharmacological interventions should be considered first. So pharmacological interventions are recommended only when nonpharmacological interventions are ineffective. In this case, only single pharmacological intervention is initially to be used with any nonpharmacological interventions (Table 2). When single pharmacological intervention is not effective, two or three different medication can be combined. For example, at prehealing stage, all nonpharmacological interventions (both massage and Benson muscle relaxation therapy) can be used with one or more pharmacological interventions (pregabalin alone, pregabalin and two antihistamines, gabapentin alone, gabapentin and one or two H1 blockers, or a combination of H1 and H2 blockers; Figure 2).

Back to Top | Article Outline

Discussion

This PBP protocol is the first evidence-based protocol that uses nonpharmacological interventions as the primary method of choice to reduce PBP. Nonpharmacological and pharmacological interventions for PBP have been identified and presented in an easily understood protocol to improve patient outcomes and clinical practice. Recommended dosage and duration of each intervention are included to clearly guide clinicians (Table 2). A rehabilitation nurse may utilize this protocol by encouraging patients to use nonpharmacological interventions as a primary intervention for PBP in collaboration with interdisciplinary team members.

This protocol was drawn from mostly RCTs, which are Level II evidence. However, each individual therapy of nonpharmacological interventions has one to three articles that support it (Table 2). Accordingly, clinicians need to validate the efficiency of this suggested protocol by conducting a pilot study for the patients with PBP. Their pilot study should demonstrate that this protocol significantly relieved PBP. The pilot study researchers can use the 5-D Itch Scale (Figure 3), the visual Analog Scale (Figure 4), and the Itch Man Scale as valid and reliable instruments for PBP (Elman, Hynan, Gabriel, & Mayo, 2010). In addition, they need to validate the efficacy of this PBP protocol by determining if the protocol: (1) relieved pruritus discomfort; (2) reduced cognitive dysfunctions such as low concentration, agitation, anxiety, and/or flat affect; and (3) increased quality of life.

Figure 3

Figure 3

Figure 4

Figure 4

Back to Top | Article Outline

Conclusion

This suggested protocol was developed to use nonpharmacological interventions primarily and pharmacological interventions as a secondary treatment. Accordingly, this protocol can be beneficial to patients by minimizing possible adverse effects of oral medications. Another benefit of this protocol is to provide a wide range of interventions with recommended treatment dosages and period. The rehabilitation nurse needs to play a key role in collaborating with the interdisciplinary team to utilize this protocol. However, the protocol needs to be verified through a pilot study ideally with an RCT design.

Back to Top | Article Outline

Key Practice Points

  • It is important to relieve post burn pruritus by using less invasive interventions among the post burn population.
  • Quality of life in post burn populations can be improved by decreasing intractable pruritus.
  • Following a post burn pruritus relief protocol can reduce severe itching related to burns.
Back to Top | Article Outline

References

Ahuja R. B., & Gupta G. K. (2013). A four arm, double blind, randomized and placebo controlled study of pregabalin in the management of post-burn pruritus. Burns, 39(1), 24–29. doi:10.1016/j.burns.2012.09.016
Ahuja R. B., Gupta R., Gupta G., & Shrivastava P. (2011). A comparative analysis of cetirizine, gabapentin and their combination in the relief of post-burn pruritus. Burns, 37(2), 203–207. doi:10.1016/j.burns.2010.06.004
Akhtar N., & Brooks P. (2012). The use of botulinum toxin in the management of burns itching: Preliminary results. Burns, 38(8), 1119–1123. doi:10.1016/j.burns.2012.05.014
Baker R. A., Zeller R. A., Klein R. L., Thornton R. J., Shuber J. H., Marshall R. E., … Latko J. A. (2001). Burn wound itch control using H1 and H2 antagonists. The Journal of Burn Care & Rehabilitation, 22(4), 263–268.
Bell P. L., & Gabriel V. (2009). Evidence based review for the treatment of post-burn pruritus. Journal of Burn Care & Research, 30(1), 55–61. doi:10.1097/BCR.0b013e318191fd95
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), 751–760. doi:10.1016/j.burns.2007.11.015
Brooks P., Phang K. L., & Moazzam A. (2007). Nanocrystalline silver (Acticoat) for itch relief in the burns patient. Australian & New Zealand Journal of Surgery, 77(9), 797–804. doi:10.1111/j.1445-2197.2007.04233.x
Campanati A., De Blasio S., Giuliano A., Ganzetti G., Giuliodori K., Pecora T., … Offidani A. (2013). Topical ozonated oil versus hyaluronic gel for the treatment of partial- to full-thickness second-degree burns: A prospective, comparative, single-blind, non-randomised, controlled clinical trial. Burns, 39(6), 1178–1183. doi:10.1016/j.burns.2013.03.002
Carrougher G. J., Martinez E. M., McMullen K. S., Fauerbach J. A., Holavanahalli R. K., Herndon D. N., … Gibran N. S. (2013). Pruritus in adult burn survivors: Postburn prevalence and risk factors associated with increased intensity. Journal of Burn Care & Research, 34(1), 94–101. doi:10.1097/BCR.0b013e3182644c25
Cho Y. S., Jeon J. H., Hong A., Yang H. T., Yim H., Cho Y. S., … Seo C. H. (2014). The effect of burn rehabilitation massage therapy on hypertrophic scar after burn: A randomized controlled trial. Burns, 40(8), 1513–1520. doi:10.1016/j.burns.2014.02.005
Elman S., Hynan L. S., Gabriel V., & Mayo M. J. (2010). The 5-D itch scale: A new measure of pruritus. British Journal of Dermatology, 162(3), 587–593. doi:10.1111/j.1365-2133.2009.09586.x
Farahani P. V., Hekmatpou D., & Khani S. S. (2013). Effectiveness of muscle relaxation on pain, pruritus and vital signs of patients with burns. Iran Journal of Critical Care Nursing, 6(2), 87–94.
Field T., Peck M., Hernandez-Reif M., Krugman S., Burman I., & Ozment-Schenck L. (2000). Postburn itching, pain, and psychological symptoms are reduced with massage therapy. The Journal of Burn Care Rehabilitation, 21(3), 189–193. doi:10.1067/mbc.2000.105087
Gaida K., Koller R., Isler C., Aytekin O., Al-Awami M., Meissl G., & Frey M. (2004). Low level laser therapy—A conservative approach to the burn scar? Burns, 30(4), 362–367. doi:10.1016/j.burns.2013.12.012
Goutos I. (2010). Burns pruritus—A study of current practices in the UK. Burns, 36(1), 42–48. doi:10.1016/j.burns.2009.06.196
Goutos I. (2013). Neuropathic mechanisms in the pathophysiology of burns pruritus: Redefining directions for therapy and research. Journal of Burn Care & Research, 34(1), 82–93. doi:10.1097/BCR.0b013e3182644c44
Goutos I., Dziewulski P., & Richardson P. M. (2009). Pruritus in burns: Review article. Journal of Burn Care & Research, 30(2), 221–228. doi:10.1097/BCR.0b013e318198a2fa
Goutos I., Eldardiri M., Khan A. A., Dziewulski P., & Richardson P. M. (2010). Comparative evaluation of antipruritic protocols in acute burns. The emerging value of gabapentin in the treatment of burns pruritus. Journal of Burn Care & Research, 31(1), 57–63. doi:10.1097/BCR.0b013e3181cb8ecf
Hettrick H. H., O’Brien K., Laznick H., Sanchez J., Gorga D., Nagler W., & Yurt R. (2004). Effect of transcutaneous electrical nerve stimulation for the management of burn pruritus: A pilot study. The Journal of Burn Care & Rehabilitation, 25(3), 236–240. doi:10.1097/01.BCR.0000124745.22170.86
Hultman C. S., Edkins R. E., Wu C., Calvert C. T., & Cairns B. A. (2013). Prospective, before–after cohort study to assess the efficacy of laser therapy on hypertrophic burn scars. Annals of Plastic Surgery, 70(5), 521–526. doi:10.1097/SAP.0b013e31827eac5e
Jung S. I., Seo C. H., Jang K., Ham B. J., Choi I. G., Kim J. H., & Lee B. C. (2009). Efficacy of naltrexone in the treatment of chronic refractory itching in burn patients: Preliminary report of an open trial. Journal of Burn Care & Research, 30(2), 257–260, discussion 261. doi:10.1097/BCR.0b013e318198a282
LaSalle L., Rachelska G., & Nedelec B. (2008). Naltrexone for the management of post-burn pruritus: A preliminary report. Burns, 34(6), 797–802. doi:10.1016/j.burns.2007.10.009
Lewis P. A., Wright K., Webster A., Steer M., Rudd M., Doubrovsky A., & Gardner G. (2012). A randomized controlled pilot study comparing aqueous cream with a beeswax and herbal oil cream in the provision of relief from postburn pruritus. Journal of Burn Care & Research, 33(4), e195–e200. doi:10.1097/BCR.0b013e31825042e2
Li-Tsang C. W., Lau J. C. M., Choi J., Chan C. C., & Jianan L. (2006). A prospective randomized clinical trial to investigate the effect of silicone gel sheeting (Cica-Care) on post-traumatic hypertrophic scar among the Chinese population. Burns, 32(6), 678–683. doi:10.1016/j.burns.2006.01.016
Li-Tsang C. W., Zheng Y. P., & Lau J. C. (2010). A randomized clinical trial to study the effect of silicone gel dressing and pressure therapy on posttraumatic hypertrophic scars. Journal of Burn Care & Research, 31(3), 448–457. doi:10.1097/BCR.0b013e3181db52a7
Mendham J. E. (2004). Gabapentin for the treatment of itching produced by burns and wound healing in children: A pilot study. Burns, 30(8), 851–853. doi:10.1016/j.burns.2004.05.009
Nedelec B., Rachelska G., Parnell L. K., & LaSalle L. (2012). Double-blind, randomized, pilot study assessing the resolution of postburn pruritus. Journal of Burn Care & Research, 33(3), 398–406. doi:10.1097/BCR.0b013e318233592e
Ogawa R., Hyakusoku H., Ogawa K., & Nakao C. (2007). Effectiveness of mugwort lotion for the treatment of post-burn hypertrophic scars. Journal of Plastic, Reconstructive & Aesthetic Surgery, 61(2), 210–236. doi:10.1016/j.bjps.2007.10.032
    Otene C. I., & Onumaegbu O. O. (2013). Post-burn pruritus: Need for standardization of care in Nigeria. Annals of Burns & Fire Disasters, 26(2), 63–67.
    Parlak Gürol A., Polat S., & Akçay M. N. (2010). Itching, pain, and anxiety levels are reduced with massage therapy in burned adolescents. Journal of Burn Care & Research, 31(3), 429–432. doi:10.1097/BCR.0b013e3181db522c
    Ratcliff S. L., Brown A., Rosenberg L., Rosenberg M., Robert R. S., Cuervo L. J., … Meyer W. J. 3rd. (2006). The effectiveness of a pain and anxiety protocol to treat the acute pediatric burn patient. Burns, 32(5), 554–562. doi:10.1016/j.burns.2005.12.006
    Richardson C., Upton D., & Rippon M. (2014). Treatment for wound pruritus following burns. Journal of Wound Care, 23(5), 227–8, 230, 232–3. doi:10.12968/jowc.2014.23.5.227
    Roh Y. S., Cho H., Oh J. O., & Yoon C. J. (2007). Effects of skin rehabilitation massage therapy on pruritus, skin status, and depression in burn survivors. Taehan Kanho Hakhoe Chi, 37(2), 221–226.
    Vallerand A. H., Sanoski C. A., & Deglin J. H. (2016). Davis’s drug guide for nurses (15th ed.). Philadelphia, PA: F. A. Davis.
    Waked I. S., Nagib S. H., & Ashm H. N. (2013). Triamcinolone acetonide phonophoresis versus transcutaneous electrical nerve stimulation in the treatment of post-burn pruritus—A randomized controlled study. Indian Journal of Physiotherapy & Occupational therapy, 7(2), 87–92. doi:10.5958/j.0973 -5674.7.2.019
    Whitaker C. (2001). The use of TENS for pruritus relief in the burns patient: An individual case report. The Journal of Burn Care & Rehabilitation, 22(4), 274–276.
    Keywords:

    Burn(s); itching; pruritus

    © 2018 Association of Rehabilitation Nurses.