Effect of transcutaneous electrical nerve stimulation for the management of burn pruritus: A pilot study

Every year it is estimated that 1.4 to 2 million burn injuries occur, requiring 70,000 hospitalizations.(1) Burns can have deleterious effects and complicated sequelae that affect patients physically, mentally, and psychosocially. One of the most reported complications as a result of burn injury is the complaint of itching (pruritus). Based upon the literature, patients with burns commonly have severe pruritus, with the reported incidence as high as 87%.(2) In addition, most complaints of severe itching arc associated with extremity burn wounds.(3) The standard treatment to manage burn pruritus is the use of oral antihistamines and topical lotions.(4) In 1988, Demling et al(5) formally noted the problem of pruritus for the burn survivor and the need for more effective treatment. Research exploring treatment options for burn pruritus has been cited as one of the top three priorities within the burn research realm, and itching has been reported to be one of the most distressing postburn issues that a burn survivor experiences.(6) Itch remains a quality-of-life issue for the burn survivor in that it interferes with sleeping, cating, working, play or leisure, and therapy routines.(5,7 8) The high incidence of postburn itching and the negative impact itching has on quality of life implores the need for a modality that can effectively and safety manage postburn itching. Transcutaneous electrical nerve stimulation (TENS) has been viewed as an effective treatment for pain management, and pruritus has been viewed as a form of pain.(5) Little research exists for the use of adjunctive therapies to help reduce burn pruritus. In 2001, Whitaker(9) published a case report discussing the use of TENS for pruritus relief in a burn patient who sustained a 70% total body surface area flame burn. The results of the case study suggested that TENS significantly reduced the patients' level of itching, demonstrating the need for more research in this area. TENS is a noninvasive, nonmedicinal modality. TENS involves the application of controlled, low-voltage electrical pulses to the nervous system by passing electricity through the skin via electrodes placed on the skin.(10) TENS is a nonaddictive analgesic technique used to modulate pain.(11) Pruritus is mediated by histamine, which is stored in mast cells and released locally during injury or inflammation. With the release of histamine, the neuronal message is conducted along the large A and small C afferent fibers to the spinal cord, where it is integrated in a complex feedback system known as the gate control. According to the gate control theory, the discharge pattern received in the brain allows for discrimination between pain and itch. Itch has an interrupted high-frequency pattern, and pain is more continuous. Pruritus is now viewed not just as a subthreshold of pain, but also as its own sensory modality.(12) The incidence of burn pruritus indicates the need for a modality that can positively reduce the pruritic response. In addition, the itching can cause patients to scratch and rub newly healed and grafted skin that can threaten its integrity, predisposing the patient to infection, increased scarring, and functional limitations.(2,12) The purpose of this study was to ascertain the role of TENS for the management of burn-related pruritus.