Presentation supported by: Exclusive distributor for:

SOZA HEALTHCARE Sdn Bhd (1001759-X)Suite 102, E111 Block E, Phileo Damansara 1, No.9, Jalan 16/11, Off Jalan Damansara, 46350 Petaling Jaya, Selangor D. E., Malaysia Tel: 03-7493 5176 Fax: 03-7493 5100 Website: www.soza.com.my

Southwest Technologies Inc. USAGLOBAL WOUND CONFERENCE 201821 - 23 September 2018 • Royale Chulan Kuala Lumpur Jalan Conlay

KUALA LUMPUR

New Effective Treatment Choicefor Post Burn PruritusKusuma Chinaroonchai, M.D., Prof. Pornprom Muangman, M.D.Division of Trauma Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand.

Figure 1: Stimulen lotion® is a glycerin base of high concentration of collagen lotion.

Table 1: Demographic Data

Table 2: Period of itching symptom and sleep quality pre and post-treatment

Sleep quality scale: 1 = Never affects sleep, 2 = Occasionally delays falling asleep, 3 = Frequently delays falling asleep, 4 = Delays falling asleep and occasionally wakes me up at night, 5 = Delays falling asleep and frequently wakes me up at night.

Table 3: Medication Pre & Post treatment

Case No.

1

2

3

4

5

Sex

Male

Male

Female

Female

Female

Age (Year)

3

40

56

66

69

Type of Burn

Scald injury

Electrical injury

Scald injury

Scald injury

Hot oil

Post injury time

5 months from injury

20 months from injury

13 months from injury

17 months from injury

12 months from injury

Case No.

1

2

3

4

5

Pre-treatment

15

15

14

17

11

Post-treatment

12

12

12

12

9

Improving hour

3

3

2

5

2

Pre-treatment

4

4

4

4

4

Post-treatment

3

3

3

3

3

Pre-treatment Post-treatment

Case No.

1

2

3

4

5

Hydroxyzine(mg/day)

30

30

30

30

30

Hydroxyzine(mg/day)

30

30

30

30

30

Gabapentin(mg/day)

100

300

Taper off

200

300

Gabapentin(mg/day)

300

900

600

700

700

Itching Hour (hour) Sleep Quality Scale

7A 7B6A 6B5A 5B

Figure 5: A 69-year female got burn injury from hot oil. 5A.The most itching skin area before treatment. 5B.The most itching skin area after 4 weeks treatment. The scarring and skin moisturizing were improved.

Figure 6: A 66-year female got burn injury from hot water. 6A.The most itching skin area before treatment. 6B.The most itching skin area after 4 weeks treatment. The scarring and skin moisturizing were improved from less whitish scale after treatment.

Figure 7: A 3-year boy got burn injury from hot syrup. 7A.The most itching skin area before treatment. 7B.The most itching skin area after 4 weeks treatment. The scarring and skin moisturizing were improved with less redness color and whitish scale after treatment.

Figure 2: The progression of VAS of itching. (VAS: visual analog score)

Figure 3: The 5-D pruritus scale

Figure 4: VSS Pre & Post treatment (VSS: Vancouver scar scale)

BackgroundFunctional and psychological impairment after severe burn injury effect quality of life inevitably. They were encouraged to resume their normal daily activity life as much as possible after their wounds healed but other factors that are not just physical aspect like wounds need to be considered. No recurrent wound in post burn victims, it does not mean they can live happily. The scar is one of the most concerns for them. Not only physical appearance in cosmetic way, but it also effects in psychological meaning. How can they gain their self-confidence and self-esteem back when their self-reflections from mirror are too scary to look. Itching is also the big problem in post burn victims and it is quite challenging in treatment successfully. Post burn itching was found more than 80% in burn patients. Age, Sex, %TBSA of injury effect its severity.1 Post burn pruritus can lead to new wound in both normal and previous injured skin that finally can get infected easily. But mostly of them occur in scarring area called unstable scar. Recent scar after injury is fragile for new wound because of its poor strength of new tissue components and hyper-inflammatory cytokine induce itching. Not only new recurrent wound is the consequence from itching, but also the poor sleep quality and disturbance of daily activity function. Post burn pruritus pathophysiology is not well understood. Multi-pathways were found to take a part. Local chemical substances like histamine are not the only cause. They were believed to be some response of central nervous pathway. The different mechanism of itching from other causes like skin disease, made the response to anti-histamine medication is quite fair. Many medications not just anti-histamine were used in combination manner to improve of the efficacy for controlling symptoms and also to decrease dose dependent side effect from single agent therapy. Most common combination medications to treat post burn itching are anti-histamine plus gabapentin. First generation of anti-histamine like hydroxyzine is proven to be more effective to relief itching when compare with others drugs in the same class.

One of the factors that affect the severity of post burn itching is the post burn scar condition. Bad scar or unstable scar made symptoms worse. Active and angry appearance scar produce more inflammatory response of surrounding skin area and also produce more histamine. So adequate post burn scar treatment is one part of the flow of post burn pruritus treatment.

Material & MethodsThis case series was conducted in burn unit, Siriraj hospital in 2017-2018. Patients that suffered from severe post burn pruritic symptoms were included in this study. The severity of itching symptom was measured and evaluated by a visual analog of itching score (VAS). Severe pruritus group was defined as VAS more than 5 and the symptom disturbed sleep quality and affect

daily activity life. All patients received standard post burn scar treatment like pressure garment, silicone gel and silicone sheath. Glycerin base of high concentration of collagen lotion, Stimulen lotion® (Southwest technologies Inc., USA; distributed by Well concept Co., Ltd. Thailand; Figure 1) was additional applied on patients skin twice a day for 4 weeks. VAS was evaluated before using Stimulen lotion® and every week for 4 weeks and the most itching skin areas were took photographs every week for 4 weeks. 5-D pruritus scale questionnaire was evaluated at pre and post-treatment of severity of itch and quality of life (QoL).2 Modified Vancouver scar scale (VSS) was used for scar evaluation at pre and post-treatment.3 Anti-itching medications were recorded at pre and post-treatment.

Results5 burns were enrolled, 1 patient with severe acute post burn itch (< 6 months onset from post injury) and the rest of them are severe chronic post burn itch (≥ 6 months from post injury) (Table 1). Mean age was 46.8 years old. The average post injury time was about 13.4 months. All patients’ VAS of itching was decreased after treatment as showed in Figure 2. Itching severity in Figure 3 from 5D pruritus scale (5D PS) of all patients decrease after treatment. The period of itching symptom is lower after treatment. The sleep quality and quality of life were better after treatment (Table 2). VSS was improved after treatment especially in pliability aspect (Figure 4). Dosage of gabapentin can be decreased after treatment as in Table 3.

DiscussionThis study is the first pilot report of glycerin base of high concentration of collagen lotion to use as adjunctive agent in severe post burn pruritus treatment. Our results showed the benefit of improvement of visual analog score of itching; suffering hours from itching and sleep quality. These results imply better QoL in treatment group from the improvement of itch severity. The scar condition as vascularity and pliability properties also improves after treatment for 4 weeks. The dosage of gabapentin per day to control the symptom is less than pre-treatment. From our result this lotion is effective to relief itch severity in both acute and chronic post burn pruritus. Through the result is interesting, but the number of sample size is too small to make precise conclusion. The clinical trial should be conducted in randomized manner to provide more information and concrete conclusion.

Conclusion:Glycerin base of high concentration of collagen lotion can be one option to improve skin moisture balance, scarring appearance, severity of pruritus symptoms and quality of life and sleep in severe post burn pruritus patient.

References: 1. Zachariah JR, Rao AL, Prabha R, Gupta AK, Paul MK, Lamba S. Post burn

pruritus--a review of current treatment options. Burns. 2012;38(5):621-9.2. Elman S, Hynan LS, Gabriel V, Mayo MJ. The 5-D itch scale: a new measure of

pruritus. Br J Dermatol. 2010;162(3):587-93. 3. Fearmonti R, Bond J, Erdmann D, Levinson H. A review of scar scales and scar

measuring devices. Eplasty. 2010;10:e43.

Presentation supported by: Exclusive distributor for:

SOZA HEALTHCARE Sdn Bhd (1001759-X)Suite 102, E111 Block E, Phileo Damansara 1, No.9, Jalan 16/11, Off Jalan Damansara, 46350 Petaling Jaya, Selangor D. E., Malaysia Tel: 03-7493 5176 Fax: 03-7493 5100 Website: www.soza.com.my

Southwest Technologies Inc. USAGLOBAL WOUND CONFERENCE 201821 - 23 September 2018 • Royale Chulan Kuala Lumpur Jalan Conlay

KUALA LUMPUR

New Effective Treatment Choicefor Post Burn PruritusKusuma Chinaroonchai, M.D., Prof. Pornprom Muangman, M.D.Division of Trauma Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand.