Management of burn wound pain and itching

INTRODUCTION — Burn wounds can be extremely painful and should be treated aggressively. Pain management, which includes pharmacologic and nonpharmacologic approaches, is a central component of the complex issues involved in treating patients with burns. Management of anxiety is also important given that high levels of anxiety can increase the perception of pain. Poor pain and anxiety management can contribute to delayed wound healing [1]. Burn pain is also among the most common causes of distress during the first year after discharge [2,3].

Inadequate burn pain management still exists during both the acute and rehabilitation phases of care [4,5]. The risks of under-medicating burn pain on long-term negative outcomes are well documented [6,7]. Unfortunately, burn pain management is frequently based upon tradition, personal bias, and/or institutional preference rather than evidence-based protocols that report reduced pain and anxiety with their use [8,9]. To address this, the American Burn Association conducted a systematic review and gathered experts in the field to establish evidence-based recommendations for the management of burn pain, which are included in this review [10].

An overview of pharmacologic and nonpharmacologic options for the management of burn pain is reviewed here. Emergency care and local management of burns and pain are discussed elsewhere. (See "Emergency care of moderate and severe thermal burns in adults" and "Moderate and severe thermal burns in children: Emergency management" and "Topical agents and dressings for local burn wound care" and "Paradigm-based treatment approaches for management of burn pain".)

CHARACTERISTICS OF BURN PAIN — Burn wounds are often painful at least initially [11]. The degree of pain varies depending upon the depth of the burn wound (figure 1). (See "Assessment and classification of burn injury".):

●Superficial partial-thickness burns result in hyperalgesia and mild-to-moderate pain. They are the most painful burns immediately following the injury. These burns damage only the outer layers of the skin.

●Moderate partial-thickness burns are associated with marked hyperalgesia and produce moderate-to-severe pain. Burns at this depth injure and/or inflame sensory receptors in the dermis.

●Deep partial-thickness to full-thickness burns are typically characterized by an absence of pain. Hyperalgesia to cutaneous stimulation is uncommon. Acute pain is typically minimal but can be variable and is universally present with respect to the transition zone between burned and unburned skin. The dermis is completely destroyed, including its sensory and vascular structures. There is little to no response to sharp stimuli, yet patients complain of a deep aching pain related to the inflammatory response.

Burn wound pain can be unpredictable due to the complex interaction of anatomic, physiologic, psychosocial, and premorbid behavior issues. Burn patients typically report pain as being severe or excruciating despite receiving opioid analgesics.

Burn wound pain varies greatly from patient to patient, also showing substantial fluctuation over the course of hospitalization. (See "Paradigm-based treatment approaches for management of burn pain", section on 'Burn pain paradigm'.)

BURN PAIN ASSESSMENT TECHNIQUES — Pain assessment tools are essential to determine the nature and severity of pain, the response to any pain management interventions, and the impact on function. Tools must be simple to use, easily reproducible (with high inter- and intrarater consistency), and simple to record. Although one-dimensional tools such as a numerical rating scale (0 to 10) are the most commonly used, an ideal pain assessment tool would be able to assess the complex, multidimensional nature of the subjective pain experience. Burn pain assessment should be done repeatedly throughout the day to account for all phases of care [10]. Pain assessment should be protocolized and documented in the electronic medical record. Most importantly, action must be taken in response to pain assessment data [12]. A variety of pain measurement tools have been used with adult and pediatric burn patients. However, there are no randomized trials that have identified an optimal assessment technique for burn patients. The key is to choose an instrument and use it consistently. The most common tools used for adults and children with burn pain include verbal adjective scales, numeric written or visual analog scales, pain assessment in dementia scales, FACES, and FLACC (Face, Legs, Activity, Cry, Consolability) [11,13-17].

Adults — A common tool for assessing postburn pain in adults is the categorical verbal rating scale, which allows a patient to describe the severity of pain in words, such as "none, mild, moderate, or severe." An alternative to the verbal description of pain is the numeric rating scale, which allows a patient to describe the pain on a scale of increasing severity, typically from 0 to 10 (figure 2) [15]. The numeric scale is administered to the patient verbally or written as a visual analog scale (figure 3). Pain assessment can be challenging in the burned and patients with dementia. The Pain Assessment in Advanced Dementia Scale, an observational scoring instrument, is a simple-to-administer, valid, and reliable instrument (table 1) [17]. The Critical-Care Pain Observation Tool is a behavioral tool that has been validated and can be used for nonresponsive patients in the intensive care unit [18]. (See "Pain control in the critically ill adult patient", section on 'Goals of pain control'.)

Children — The measurement of pain in children is more complex than it is for adults, especially for preverbal children. Typical physiologic indicators, such as heart rate, respiratory rate, and blood pressure are unreliable in measuring a child's pain since all are affected by a variety of stressors related to the burn injury [11,19]. (See "Pain in children: Approach to pain assessment and overview of management principles", section on 'Severity assessment'.)

Behavior scales have been devised to measure pain by providing standardized instructions and guidelines for observing behaviors thought to be specific to pain. Facial expression may be the most consistent infant indicator of pain. Observational scales have been developed that are multidimensional and include length of cry, facial expressions, and behavioral states [3]. These scales are easier to use and allow an observer to assess pain as either present or absent without further quantification. The FLACC (Faces, Legs, Activity, Cry, Consolability scale) is the most widely used observer rating scale in preverbal children (table 2) [13,20]. In one of the few studies to evaluate the FLACC, it was reported that nurses tended to underestimate mild and severe pain and that nurses with less experience had higher rates of accuracy [21].

Simple self-report pain scales can be used with preschool children. There is no evidence that any one of these scales is more reliable than the other; hence, it is best to select one that the evaluator prefers, and it should be used consistently. When self-report scales are used in conjunction with observational scales, a practitioner may develop a better appreciation of the intensity of the child's response to burn pain and the effectiveness of pain management. The Wong-Baker FACES Pain Scale is designed for children three years and older (figure 4) [14]. This pain scale uses drawings of faces displaying varying degrees of pain and discomfort. Each face communicates a level of pain intensity, and the child is asked to choose the face that most accurately describes their pain level.

PHARMACOLOGIC TREATMENT OPTIONS — Pharmacologic agents used to treat burn pain include opioid analgesics, nonopioid analgesics, anxiolytics, and anesthetics. The type of medication used is determined by the severity of pain, the anticipated duration of pain, and intravenous (IV) access. These medications have variable durations of action, particularly in burn patients, and should be titrated to meet the needs of the patient in each clinical setting [22]. Nonopioid agents are at least as effective as opioids for many types of acute pain [23]. However, the necessity for wound care and dressing change procedures means pharmacologic sedation and analgesia are almost essential aspects of care in burn centers in the United States, particularly in children. One survey reported high-use frequencies for opioids (100 percent), benzodiazepines (91 percent), ketamine (87 percent), propofol (57 percent), and acetaminophen (48 percent) during pediatric burn dressing change [24].

Baseline preventive management of pain from burn injury must target the constant "background pain" associated with burn wounds. Pharmacologic techniques should include near-constant plasma levels of nonopioid analgesics through regularly scheduled administration of acetaminophen and nonsteroidal anti-inflammatory agents (NSAIDs). Opioids should be initiated as immediate release, as needed, in the lowest effective dose to minimize risks [23]. Long-acting oral opioids (eg, methadone) have been used for the management of severe background burn wound pain. However, they are associated with higher risks of overdose, should only be considered in patients who have received maximal doses of immediate-release opioids daily for at least a week [23], and should only be prescribed by those familiar with their use and in a closely monitored environment. (See "Paradigm-based treatment approaches for management of burn pain", section on 'Background pain' and "Management of acute pain in opioid naïve adults in the ambulatory setting".)

Managing anxiety is an important part of pain management, as anxiety and pain act as risk factors for each other. Benzodiazepines may have a role in patients with significant procedural anxiety that contributes to their pain experience. However, benzodiazepines should be avoided in patients who are experiencing delirium. (See "Acute procedural anxiety and specific phobia of clinical procedures in adults: Treatment overview", section on 'Benzodiazepines as first-line medication'.)

Because severe burn injury results in physiologic changes that may alter the pharmacokinetic and pharmacodynamic response to drugs in inconsistent ways, deviation from the usual doses may be necessary to avoid toxicity or decreased efficacy [25]. The tables linked to this topic provide dosages of opioids and nonopioid analgesias as recommended for patients without serious pathophysiologic and metabolic changes without altered drug clearance. These dosages serve as a reference point for administering pharmacologic agents to burned patients. Medications may be more potent or less potent and have a prolonged or shortened effect in the burn patient, depending only somewhat reliably on either the drug or patient factors. Monitoring of the airway, breathing, and circulation is necessary, particularly when intravenous drugs are administered. (See "Hypermetabolic response to moderate-to-severe burn injury and management".)

Opioid analgesics — Opioid analgesics are used as a first-line treatment for moderate-to-severe acute pain and, despite a lack of evidence that they are any more effective than nonopioid analgesics [10,26], they have an important role for managing acute pain related to severe burns pain as part of a multimodal analgesic strategy. Opioid therapy also provides a dose-dependent degree of sedation important during burn wound care procedures (table 3 and table 4) [3]. A review of intravenous opioid analgesia for adults and children is discussed in detail elsewhere. (See "Pain in children: Approach to pain assessment and overview of management principles", section on 'Opioids' and "Pain control in the critically ill adult patient" and "Procedural sedation in adults in the emergency department: Medication selection, dosing, and discharge criteria", section on 'Medications' and "Management of acute pain in opioid naïve adults in the ambulatory setting".)

Opioids can be administered intravenously, orally, and transnasally depending on IV access, gastrointestinal function, and the patient's ability to cooperate. For severe pain, the optimal route of administration is IV, which provides faster pain relief and can be effectively titrated to meet the individual needs of the patient.

Patient-controlled analgesia (PCA) with IV opioids provides the burn patient a safe and efficient method of achieving more flexible analgesia, provided the patient is alert and competent enough to use the device (table 5) [27]. A common limitation of PCA use is that patients are unable to press the button to deliver a dose while asleep and may complain of waking up in pain after sleeping for more than a few hours. Some centers allow for a continuous background infusion of low-dose opioid via the PCA device, but this increases the risk of oversedation and symptomatic opioid overdose. Studies comparing PCA opioid use with other routes of administration in the burn population have shown positive, but limited, benefits [28]. (See "Use of opioids for postoperative pain control", section on 'IV opioids'.)

Oral or gastrointestinal administration of immediate-release opioids via an enteral tube provides potent pain relief with a relatively rapid onset (5 to 30 minutes depending on the drug used) and a duration of action up to several hours and requires minimal monitoring. Buccal, sublingual, or intranasal transmucosal administration can be helpful for performing burn dressing changes, particularly in children [29,30]. A systematic review reported transmucosal administration to be at least equivalent in analgesic effect to oral opioids in both adults and children [31].

Intramuscular opioid administration is not recommended for use in burn patients. The injections are painful, they need to be repeated frequently, and the absorption is variable due to compartmental fluid shifts.

Nonopioid analgesics — Nonopioid analgesics can be as effective as opioids for many types of acute pain, especially mild-to-moderate pain, and should always be used in conjunction with opioid therapy.

●NSAIDs – Oral NSAIDs and acetaminophen have a long-established safety profile and are suited to manage mild-to-moderate pain, particularly in the outpatient setting (table 6) [32]. These drugs exhibit a ceiling effect in their dose-response relationship, rendering them unsuitable as single agents for the treatment of severe burn pain. However, they are likely to have an additive effect when combined with other analgesic modalities, including opioids, to treat more severe pain. The use of NSAIDS in critically ill patients with burns is limited by potential adverse effects such as acute kidney injury, reduction in platelet activity, and gastrointestinal bleeding [33]. The mechanism of action and therapeutic use of NSAIDs is discussed in detail elsewhere. (See "NSAIDs: Therapeutic use and variability of response in adults".)

●Gabapentinoids – The gabapentinoid agents, gabapentin and pregabalin, may have a role in acute neuropathic pain, but evidence is conflicting in the burns population [33]. A randomized trial showed no reduction in the use of opioids or self-reported pain scores with the use of gabapentin versus placebo in the acute burn injury period [34]. However, another trial using pregabalin reported a significant reduction in neuropathic pain elements, such as "hot pain," "sharp pain" and itch, as well as procedural pain when used over a four-week period following burn injury of 5 percent or more [35].

●Dexmedetomidine – Dexmedetomidine is an alpha -2 adrenergic receptor agonist used to provide short-term, effective analgesia and sedation that may be helpful for limited burn debridement and/or dressing changes in adults and children. Dexmedetomidine provides sedation, anxiolysis, and analgesia for burned children, with less respiratory depression than other sedatives [36,37]. However, a meta-analysis of four studies showed better sedation but no analgesic benefit of using dexmedetomidine for procedural care in adult and pediatric burns patients [38].

●Ketamine – Ketamine is an anesthetic agent that may be useful as an adjunctive treatment for acute pain when used in subanesthetic doses in hospitalized inpatients. Its benefit is mostly seen in patients with high levels of nociception and central sensitization and in opioid-tolerant patients [39]. Ketamine has a long history of use for procedural wound care pain in burn-injured patients. Studies suggest it is both an effective and safe analgesic in adult and pediatric patients with burns [40,41]. Ketamine dosing to achieve moderate sedation in burned patients is similar to that used in other procedural pain settings and is typically limited to short procedures (5 to 15 minutes) due to its pharmacokinetics following bolus dosing. Burn care procedures that require deep sedation or general anesthesia (eg, longer procedures or those requiring absolute immobility) are better managed with either regional anesthesia or with more potent sedative/hypnotic or volatile anesthetic agents. (See "Procedural sedation in adults in the emergency department: General considerations, preparation, monitoring, and mitigating complications" and "Pediatric procedural sedation: Pharmacologic agents".)

Anxiolytics — Anxiety is a common consequence of burns, due to the need for aggressive surgical treatment and debridement of the wounds, and the persistent and repetitive qualities of background and procedural burn pain. The practice of using anxiolytic drugs in combination with opioid analgesics has become more widespread in burn centers in the past three decades [42]. This practice may be useful in premedicating patients for wound care, due to the anticipatory anxiety experienced by these patients prior to and during such procedures, but nonpharmacologic treatments for anxiety should be considered as essential first-line components to the overall approach. (See "Anesthesia for patients with acute burn injuries" and "Acute procedural anxiety in adults: Epidemiology, clinical features, assessment, and diagnosis".)

Benzodiazepine therapy improves postprocedure pain scores in certain burn patients. A trial that randomly assigned 79 burn patients to receive lorazepam or placebo in addition to their standard opioid analgesics only found a difference between groups in patients with high baseline pain in whom lorazepam significantly reduced visual analog scale pain score ratings [43]. (See "Acute procedural anxiety and specific phobia of clinical procedures in adults: Treatment overview", section on 'Benzodiazepines as first-line medication'.)

Although benzodiazepines are accepted as an efficacious tool for procedural and background anxiety, they are also associated with sedation, dependence, and addiction when used long term even at recommended doses. In 2016 the US Food and Drug Administration issued a strong warning about the use of benzodiazepines with opioids and the risk of unintentional overdose [44]. Caution should be used when prescribing these drugs, and it is not recommended to use these together in the outpatient setting.

The antihistamine agent hydroxyzine is commonly used for perioperative sedation, but evidence for its use, particularly in procedural sedation, is lacking. A recent study found the combination of hydroxyzine and clown therapy was better than placebo or clown therapy alone in reducing perioperative anxiety in children [45].

Anesthetics — A variety of anesthetic techniques can be used (eg, general anesthesia, neuraxial anesthesia, peripheral nerve block) for managing burn pain in various clinical settings. The details of administration of anesthesia are discussed elsewhere. (See "Anesthesia for patients with acute burn injuries".)

General anesthesia or deep sedation — A general anesthetic or deep sedation provides relief of relatively brief, intense pain that would be experienced during a procedure, such as extensive wound debridement or dressing changes that occur outside of the operating room. While the risks of complications following a general anesthetic are low in healthy individuals, burn patients have metabolic, physiologic, and thermoregulatory abnormalities as well as possible inhalation injuries that are associated with increased risk of complications of perioperative hypothermia, hypoxemia, and abnormal responses to some anesthetic agents and to both depolarizing and nondepolarizing muscle relaxants [46]. As an example, propofol clearance and volume of distribution are increased in patients with major burns and may require larger bolus and/or infusion doses to maintain therapeutic plasma drug concentrations [47].

Inhaled nitrous oxide is an anesthetic agent that can be safely administered and provides effective analgesia without loss of consciousness (ie, moderate sedation) for moderately painful procedures. It can be used for the treatment of burn pain, typically as a 50 percent mixture in 50 percent oxygen, and self-administered by an awake, cooperative, and spontaneously breathing patient via a mouthpiece or mask [32,48].

Full anesthetic care capabilities have been extended outside the operating room into specialized, high-volume burn center intensive care units [49,50]. Drugs, such as intravenously administered propofol or remifentanil and inhaled sevoflurane, with rapid onset and short duration of action, rapid recovery, and few side effects can facilitate burn care and pain management in the patient's hospital location without transporting the patient to the operating room. The occasional provision of brief, dense analgesia/anesthesia (eg, general anesthesia or deep sedation) should be administered in a comprehensively monitored setting by medical professionals specifically trained to provide the service. When administered in a controlled environment, general anesthesia or deep sedation is safe and efficient, both in terms of allowing wound care (eg, debridement of facial burns in children) to proceed rapidly and in terms of cost-effective use of the operating room only for true surgical burn care procedures.

Peripheral nerve block — Regional anesthesia is achieved by injecting a local anesthetic agent (eg, bupivacaine, ropivacaine) near a nerve to block the sensory stimulation from the area innervated by the nerve, with one review supporting its use in managing procedural burn pain in addition to multimodal pain treatment [51]. These are particularly useful for procedures and burn pain relief involving the extremities [52]. The most common nerve groups accessible for a nerve block include the brachial plexus (interscalene block, infraclavicular block, axillary block), the sciatic nerve, and the femoral nerve. Other nerve blocks include the fascia iliaca compartment blockade (FICB) and lateral femoral cutaneous nerve block, which can be used for lower extremity analgesia following skin graft harvesting [53-55]. A review of regional anesthesia blocks for acute burn care is available and includes illustrative graphic descriptions of regional anatomy, as well as indications, contraindications, and potential complications [56]. (See "Overview of peripheral nerve blocks".)

Neuraxial anesthesia — Neuraxial anesthesia is the administration of an anesthetic agent (eg, bupivacaine, lidocaine) and/or opioid analgesics via a spinal or epidural catheter with the goal of providing background, procedural, and postoperative pain relief. This procedure has only been anecdotally used in burn patients [57]. A major drawback to the use of neuraxial anesthesia is the potential colonization of the indwelling catheter, particularly if inserted through burned skin, and the associated risks of meningitis and epidural abscess formation [58].

TREATMENT OF PRURITUS — Severe pruritus occurs in as many as 87 percent of adult and 100 percent of pediatric burn patients during the healing process [59-61]. Pruritus tends to present early during wound healing and continues well after reepithelialization and scar maturation and can significantly impact quality of life [62,63]. Some studies have shown pruritus to persist for up to 10 years post-burn in almost one-half of burn patients [64]. An overview of the treatment of burn scar complications often causing pruritus and pruritus in general are presented elsewhere. (See "Hypertrophic scarring and keloids following burn injuries" and "Pruritus: Therapies for localized pruritus" and "Overview of lasers in burns and burn reconstruction".)

A variety of therapies, both systemic and topical, have been used for the treatment of post-burn pruritus. Proof of efficacy is primarily anecdotal as high-quality randomized trials have not been performed [59,65]. Systemic first-line treatment for post-burn pruritus consists of H1 and H2 antihistamines (eg, diphenhydramine, cetirizine, cimetidine), but none has provided complete relief. Other systemic agents that may prove helpful include cyproheptadine, hydroxyzine, gabapentin [66], and tricyclic antidepressants (eg, doxepin). Intravenous lidocaine has shown some effect in the treatment of pruritus in dermatitis [67] and treatment-resistant pruritus [68], but its potential to cause cardiac arrhythmias limits its use.

Topical treatments, which may provide relief of pruritus, include [59,65,69-71]:

●Aloe vera

●Vaseline-based creams

●Cocoa butter

●Mineral oil

●Hydrogel sheets (eg, Tegagel, Vigilon, FlexiGel)

●Topical glucocorticoids

●Colloidal oatmeal in liquid paraffin

●UNNA boot (glycerin, zinc oxide, and calamine lotion)

●EMLA, which is a mixture of local anesthetics

●Topical doxepin

●Silicone gel sheeting

●Compression garments

●Massage therapy

The role of topical glucocorticoids (eg, hydrocortisone, triamcinolone) varies importantly with the stage of the burn. These agents can be applied to reepithelialized wounds. In contrast, topical glucocorticoids are not used on unhealed burns, since they can lead to thinning of the healing skin, infection, and systemic absorption.

Topical agents high in lanolin should be avoided, since they can worsen pruritus [72].

Laser therapies have also been evaluated for the treatment of pruritus in burn patients and include pulsed dye and carbon dioxide (CO₂) laser [73-76]. Although the use of lasers had been seen as largely experimental, the body of literature is growing, and their use is becoming more widespread. A systematic review on the use of CO₂ laser for burn scar therapy concluded that it is a safe and efficacious treatment for burn scars [77]. Specifically, there was evidence that one to four sessions of laser therapy had a positive impact on both pruritus and pain. The use of lasers in burns to manage hypertrophic scarring is reviewed separately. (See "Overview of lasers in burns and burn reconstruction".)

Transcutaneous electrical nerve stimulation (TENS) remains predominantly experimental [70,78].

NONPHARMACOLOGIC TREATMENT OPTIONS — Nonpharmacologic treatments should be complementary to pharmacologic approaches when treating pain, anxiety, and pruritus in the burn patient.

Empirical evidence for the efficacy of nonpharmacologic treatments has been reported with burn pain, particularly when used as an adjunct to opioid analgesics [3]. In a systematic review that included 21 randomized trials of nonpharmacologic burn pain interventions, distraction interventions, particularly virtual reality and hypnosis, reduced pain to the greatest extent [79]. However, distraction interventions may not be effective in some patients.

In choosing an approach, the team should be guided by the manner that the patient has typically responded to prior stressful medical procedures, if possible. Such responses lie on a continuum ranging from giving up control to the health care professional and desiring little information to seeking out as much information as possible and actively participating in care [80]. The following examples illustrate the types of coping styles to burn and procedural pain:

●Avoidance – Those burn patients who wish to give up control to the health care professional have a tendency toward cognitive avoidance, or an "avoidant" style of coping mechanism. They will likely use various types of distraction techniques to avoid the painful stimuli.

●Approach – Those burn patients who seek out information about the procedure and attempt to participate and not relinquish control have an "approach" style of coping mechanism. These patients often find distraction techniques distressing as trying to ignore a procedure may serve to relinquish too much control.

It is important to note that both coping styles can be adaptive, and it is best for the burn care team to support an individual's coping style rather than try to change the natural response. Patients may also change their coping style depending on the procedure. As an example, a patient may find it is easier to use distraction techniques for short procedures such as receiving injections, whereas they are more comfortable attending to details of their long wound care sessions and participating when possible. Patients may also change their coping style as they become more familiar and comfortable with the environment.

Avoidance techniques — Avoidance interventions are designed to psychologically distract or distance the patient from the pain. The Multiple Resource Theory of Attention suggests that diverting attention toward a nonpainful stimulus may lessen the intensity of perceived pain [81]. The four interventions in the avoidance category include distraction, guided imagery, hypnotic analgesia, and virtual reality [3]. These nonpharmacologic techniques are described below in order of those more appropriate for avoidant coping styles toward those more appropriate for the approach coping styles. However, randomized trials have not been performed to determine the optimal diversion approach as an adjunct for managing pain in burn patients.

Distraction — Distraction is the most common intervention activated by patients or the provider as an adjunct for pain management in burned children [82].The types of distraction techniques available to reduce burn pain are limited only by the creativity of patients and health care professionals. Common distraction techniques used with children include bubble blowing, singing songs, reading a story, and counting. Generating distraction strategies for adults may require a bit more creativity and include engaging in enjoyable conversation during the procedure, listening to music, or playing a video game [83-86]. Gaming technology has gained more attention as evidence shows that playing an engaging, interactive video game can decrease pain during wound dressing changes, as well as physical therapy [87-89].

Guided imagery — Imagery is an integrative therapy that incorporates imagined pictures, sounds, or sensations for specific therapeutic goals, such as the reduction of burn pain. While the patient is engaged in the imagery scene, less attention is available for the painful stimuli. It is the patient who selects the imagery. A related discussion on imagery and pain control in cancer patients can be found using the following link. (See "Rehabilitative and integrative therapies for pain in patients with cancer", section on 'Relaxation training'.)

Patients using imagery simply create or recreate an image in their mind, presumably one that they find pleasant and engaging. Prior to a painful procedure, we often have the patient elicit a "safe" or "favorite" place to go. This can be a place where they have been before (eg, a favorite vacation spot) or simply a place that they imagine to be relaxing and safe. The clinician then simply cues the patient with the details that they have provided, and we encourage them to imagine this place during their subsequent wound care.

Limited evidence suggests that guided imagery is effective in reducing the sensory and emotional components of pain [90]. The Agency for Health Care Policy and Research advocates the use of imagery for reduction of pain intensity and distress for cancer pain and for the management of mild-to-severe acute pain [91].

Hypnotic analgesia — Hypnosis is an altered state of consciousness characterized by an increased receptivity to suggestion, ability to alter perceptions and sensations, and an increased capacity for dissociation [92]. It is believed that the dramatic shift in consciousness that occurs with hypnosis is the cornerstone of an individual's ability to change his/her awareness of pain [93]. Hypnotic analgesia should only be used by trained clinicians who can assess the risks and benefits of this powerful technique [92,94].

Although hypnosis involves much more than just avoidance or distraction, the end result is often similar; the patient's focus is diverted from the pain or painful procedure. Several features make hypnotic analgesia a unique method of pain control that differs markedly from imagery or relaxation. Hypnosis may or may not lead to relaxation depending on the nature of the suggestions. In turn, it is not necessary for a patient to be relaxed or even in a deep hypnotic state in order for suggestions to be useful [95]. A related discussion on hypnotic analgesia and pain control in cancer patients can be found using the following link. (See "Rehabilitative and integrative therapies for pain in patients with cancer", section on 'Clinical hypnosis'.)

Hypnosis involves several stages, including building clinician-patient rapport, enhancing relaxation through deep breathing, suggestions for deepening the hypnotic state, and narrowing the patient's attention, providing posthypnotic suggestions, and alerting stage [96]. Burn patients are good candidates for hypnotic analgesia because [97-99]:

●The intense nature and severity of burn pain motivates patients to engage in hypnosis.

●The behavioral regression that often occurs after a traumatic injury makes patients more willing to be taken care of by others.

●Patients with burn injuries often experience a dissociative response as a means of coping that may moderate hypnotizability.

●Procedures, which cause the most intense pain, can be scheduled and thus allow hypnosis to be performed in advance of the painful stimulus.

Several studies have shown the positive effect of hypnosis when used in conjunction with prescribed analgesia [99-103]. Patients with higher baseline pain levels have a greater decrease in pain after hypnosis than patients with lower baseline pain levels. However, these studies are limited by methodological differences, lack of uniform assessment of hypnotizability and severity of pain, and small series of burn patients. One trial examined the effects of hypnosis for burn wound care in children [104]. It reported that hypnosis is effective for reducing procedural anxiety and heartrate but found no benefit for pain management. More research is needed, and the authors of the trial published their protocol for replication [105].

Virtual reality — Virtual reality diverts attention away from the painful sensations by immersing patients in a computer-generated environment [3,106,107]. Burn patients can interact with the computer while painful procedures, such as dressing changes, and range-of-motion therapy are performed. Observational and small controlled studies indicate that virtual reality is effective in reducing pain and may have utility when used in conjunction with hypnosis [87,106,108-112]. It is also becoming more widely available and user friendly [113].

Approach technique — The most commonly used approach technique is information provision.

Information provision — Information provision, a technique that actively involves patient input, is an essential element of managing burn pain by providing treatment information in a timely and targeted manner. Information provision assists the patient's understanding of the issues, alternatives, and solutions. This process provides information on how his/her input will affect the end result, and sharing information can build trust and mutual understanding [114]. Furthermore, burn patients report a strong desire to receive additional pain education [115]. This helps to create a sense of control over one's environment. Caution should be taken to always follow a patient's lead in how much information is to be provided in that some patients who have an avoidant coping style would prefer less information, and too much information can increase anxiety.

Relaxation techniques — Relaxation techniques are used to lower arousal, including unnecessary muscle tension that can increase pain [3,116]. The techniques include deep breathing exercises, progressive muscle relaxation exercises, and cognitive behavioral techniques. There are no randomized trials to determine the optimal relaxation technique to be used as an adjunct for burn pain management.

Deep breathing — Deep breathing, or diaphragmatic breathing, is one of the least time-consuming techniques to employ and the easiest for adults and children to learn. When a person becomes anxious and/or experiences pain, breathing can become shallow and irregular due to the increased muscle tension in our chest wall. Such shallow breathing, known as thoracic breathing, leads to an increase in muscle tension and subsequent heightened pain [116].

Deep breathing techniques allow patients to become aware of shallow irregular breathing and leads to relaxation that may alleviate some pain. Children can be taught bubble blowing or blowing on a pinwheel to encourage deep breathing. Adults can be taught to place a hand on their stomach and to take a breath deep enough that it passes through their chest and fills their stomach (shallow breathing is more in the chest and will not cause as much hand movement on the stomach). Their hand should rise and fall with the stomach. Exhalation is the most important part of deep breathing exercises and should not be rushed. Diaphragmatic breathing is central to all forms of relaxation and is simple and time efficient.

Progressive muscle relaxation — Muscle tension increases as patients experience stress and pain; hence, the focused effort on sequentially relaxing and tensing muscles in a controlled manner diverts the attention away from the pain. Progressive muscle relaxation is a technique used to reduce anxiety associated with painful stimuli, such as burn dressing changes, by alternately tensing then relaxing muscles [117]. Muscles are sequentially tensed (10 seconds) and relaxed (20 seconds) through various parts of the body, and the technique can be performed during dressing changes. Observational studies suggest that progressive muscle relaxation can decrease recuperation time for hospitalized patients [117]. If the patient is unable to actively tense a muscle group due to pain or injury, they can still imagine each muscle becoming progressively "warm, heavy, and relaxed" or listen to a tape, a process known as autogenic training [92].

Cognitive behavioral techniques — Cognitive behavioral therapy (CBT) is used to treat multiple conditions by changing thoughts and behaviors. For treatment of burn patients, CBT includes diversion, information provision, coping skills, and relaxation techniques to modify the patient's thought process about the painful experience [3]. (See "Overview of psychotherapies", section on 'Cognitive and behavioral therapies'.)

Expectations of a bad outcome, such as intense pain, are associated with higher levels of perceived pain [118]. This is known as catastrophizing. CBT can be used adjunctively to manage these expectations and associated pain in the following manner [119]:

●Recognize that the procedure will cause pain (anticipatory pain or distress).

●Stop the thought that the procedure will cause pain by active efforts to reduce catastrophic thinking.

●Distract from the pain by diverting attention to another thought.

Mindfulness meditation — Mindful meditation is another nonpharmacologic strategy that combines attention, cognitive restructuring, and relaxation. It has gained popularity for its effectiveness for managing acute or chronic pain in adults and adolescents [120,121]. Mindfulness involves purposeful attention on the present moment in a nonjudgmental and accepting manner [122]. Meditation refers to a broad variety of practices that are aimed at clearing the mind to self-regulate the body to achieve a state of relaxation. Several mindfulness meditation practices have been developed to address acute pain [123,124]. Although none has specifically addressed burn pain, its effectiveness in mediating procedural pain for other conditions makes it a promising intervention for acute pain during burn wound care. With the help of a trained professional, mindfulness meditation can be implemented in as little as 20 minutes prior to or during a procedure.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Care of the patient with burn injury".)

SUMMARY AND RECOMMENDATIONS

●Burn pain – Pain, which is present at least initially in all burn patients, varies greatly from patient to patient, shows substantial fluctuation over the hospitalization course, and can be unpredictable due to the complex interaction of anatomic, physiologic, psychosocial, and premorbid behavior. The control of burn pain and associated anxiety, as well as itching (pruritus), is challenging and demands creativity and continued staff training on pain assessment, traditional pharmacologic analgesic approaches, and adjunctive nonpharmacologic techniques. Pharmacologic analgesics should be administered by trained and experienced staff in monitored conditions. (See 'Introduction' above and 'Characteristics of burn pain' above.)

●Burn pain assessment – Pain assessment instruments use visual and/or numeric scales to assess pain intensity, behavioral reactions, and physiologic reactions. There is no one optimal assessment technique for burn patients. The key is to choose an instrument and use it consistently. (See 'Burn pain assessment techniques' above.)

●Pharmacologic treatments – Pharmacologic agents used to treat burn pain include opioid analgesics, nonopioid analgesics, anxiolytics, and anesthetics. The type of medication used is determined by the severity of pain, the anticipated duration of pain, and intravenous (IV) access. (See 'Pharmacologic treatment options' above.)

•Opioid analgesics – Opioid analgesics (eg, morphine, fentanyl), the most common type of medication used for acute pain relief, are potent and provide a dose-dependent degree of sedation important during burn wound care procedures. (See 'Opioid analgesics' above.)

•Nonopioid analgesics – Nonopioid analgesics (eg, nonsteroidal anti-inflammatory drugs [NSAIDs], gabapentinoids, dexmedetomidine, ketamine) provide short-term, effective analgesia and sedation that may be helpful for limited burn debridement and/or dressing changes in adults and children. (See 'Nonopioid analgesics' above.)

•Anxiolytic drugs – Anxiolytic drugs (eg, benzodiazepines) are useful in premedicating patients for wound care due to the anticipatory anxiety experienced by these patients prior to and during such procedures. (See 'Anxiolytics' above.)

●Nonpharmacologic treatments – Nonpharmacologic treatments should be adjunctive to pharmacologic approaches when treating pain and anxiety in the burn patient. These approaches include cognitive distraction, information provision, relaxation, coping skills, and cognitive behavioral techniques. (See 'Nonpharmacologic treatment options' above.)

ACKNOWLEDGMENT — The editorial staff at UpToDate acknowledges Sam R Sharar, MD, who contributed to earlier versions of this topic review.