What is the next step for a patient with healed third-degree burns experiencing chronic pain?

Management of Chronic Pain in Healed Third-Degree Burns

For patients with healed third-degree burns experiencing chronic pain, the next step should be initiating a multimodal pain management approach that includes anticonvulsants (gabapentin or pregabalin) as first-line therapy, combined with topical agents and psychosocial support. 1, 2

Pharmacological Management

First-Line Medications

• Anticonvulsants are the recommended first-line treatment for neuropathic pain in healed burns:
  • Gabapentin: Start at 100-300 mg nightly, gradually increase to 900-3600 mg daily in divided doses 2-3 times daily 1
  • Pregabalin: Start at 50 mg three times daily, increase to 100 mg three times daily (more efficiently absorbed than gabapentin) 1

Topical Agents

• Apply topical agents to the painful burn site:
  • 5% lidocaine patch: Apply daily to the painful site (minimal systemic absorption) 1
  • Diclofenac gel: Apply three times daily, or diclofenac patch (180 mg) once or twice daily 1
  • Petrolatum-based ointments may provide additional relief for sensitive healed burn areas 3

Second-Line Medications

• Antidepressants can be added if anticonvulsants provide insufficient relief:
  • Secondary amines (nortriptyline, desipramine): Start at 10-25 mg nightly, increase to 50-150 mg nightly (better tolerated than tertiary amines) 1
  • SNRIs: Duloxetine (30-60 mg daily, increase to 60-120 mg daily) or venlafaxine (50-75 mg daily, increase to 75-225 mg daily) 1

Pain Assessment

• Use validated pain assessment scales to monitor treatment efficacy and guide medication titration 1
• Recognize that burn pain may have different components (neuropathic, inflammatory, psychological) requiring different treatment approaches 4, 5

Non-Pharmacological Approaches

Psychosocial Support

• Provide emotional support acknowledging the pain problem 1
• Assess impact on family and daily functioning 1
• Inform patient that chronic burn pain can be managed effectively with appropriate interventions 1

Pain Coping Skills

• Teach specific coping skills for chronic pain:
  • Relaxation techniques, guided imagery, and graded task assignments 1
  • Hypnosis to maximize function and minimize pain perception 1, 6
  • Cognitive-behavioral techniques to address psychological aspects of chronic pain 6, 7

Patient Education

• Educate that relief of pain is medically important and there is no benefit to suffering 1
• Explain that pain management is a team effort involving multiple specialists 1
• Provide written educational materials about pain management options, as this is the preferred format for many burn patients 7
• Set realistic expectations about recovery timelines and potential need for long-term pain management 7

Multidisciplinary Approach

• Consider referral to pain specialist, physiatrist, or neurologist for complex cases 1
• Involve psychologists or psychiatrists to address psychological components of chronic pain 1, 7
• Physical therapy may be beneficial for addressing functional limitations 1

Common Pitfalls to Avoid

• Undertreatment of pain is common in burn patients and can lead to psychological and functional difficulties 4, 5
• Avoid focusing solely on pharmacological management without addressing psychological aspects 7
• Do not assume that pain will resolve completely with time; chronic burn pain often requires ongoing management 5
• Recognize that patients may need education about addiction risk and medication weaning plans 7

By implementing this comprehensive approach to chronic pain management in healed burn patients, clinicians can significantly improve quality of life and functional outcomes while minimizing suffering.