Treatment for Burn Itchy Rash
For a burn-related itchy rash, apply emollients immediately and frequently, use topical hydrocortisone 2.5% for inflammation, and consider oral antihistamines (cetirizine 10 mg daily or gabapentin for severe cases) if topical therapy is insufficient. 1, 2, 3
Initial Assessment and Severity Grading
First, determine if this is simple post-burn pruritus or a severe cutaneous adverse reaction (SCAR) requiring urgent intervention:
- Rule out severe reactions: If you see blistering, skin sloughing, or mucous membrane involvement, this may be Stevens-Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN) requiring immediate burn unit admission 4
- Assess body surface area (BSA): If >10% BSA with systemic symptoms, consult dermatology urgently 4
- Standard post-burn pruritus: Most common presentation during healing phase, responds to conventional therapy 5, 6
First-Line Topical Treatment
Emollients are the foundation of therapy and must be applied liberally:
- Apply emollients at least once daily (preferably after bathing) to restore skin barrier and prevent xerosis 1, 2
- Use petrolatum-based or oil-in-water preparations; avoid alcohol-containing lotions that worsen dryness 4, 2
- Dimethicone may be offered as an alternative to petrolatum 4
Add topical corticosteroids for inflammatory component:
- Hydrocortisone 2.5% applied 3-4 times daily significantly decreases pruritus and is FDA-approved for minor skin irritations, inflammation, and rashes 2, 3
- Use the least potent preparation needed; limit high-potency steroids to short courses to avoid skin atrophy 1, 2
- For children under 2 years, consult a physician before use 3
Oral Antihistamines for Moderate-to-Severe Pruritus
When topical therapy alone is inadequate:
- Cetirizine 10 mg daily or loratadine 10 mg daily for non-sedating relief during daytime 1, 2
- Hydroxyzine 10-25 mg at bedtime if sedation is needed to break the itch-scratch cycle 1
- Note: Antihistamines provide only partial relief in 60% of burn patients and complete relief in only 20% 7
Neuromodulatory Agents for Refractory Cases
Post-burn pruritus has neuropathic components that respond better to neuroleptic agents than conventional antihistamines: 5
- Gabapentin: Reduces burn-related pruritus more effectively than cetirizine (mean difference -2.4 on VAS) with lower somnolence rates 6
- Pregabalin: Also superior to antihistamines for neuropathic itch 6
- Doxepin cream: May reduce pruritus compared to oral antihistamines (mean difference -2.6 on VAS), though somnolence is a concern 6
Physical Modalities for Adjunctive Relief
- Massage therapy: May reduce both pruritus (4.6-point reduction on VAS) and pain (3.74-point reduction) compared to standard care 6
- Extracorporeal shock wave therapy (ESWT): Reduces pruritus intensity (5.93-point reduction) in healing burns 6
- Pulsed high-intensity laser: Probably reduces pruritus (mean difference -0.51 on ISS) and pain in healed burn scars 6
Critical Avoidances
- Do not use hot showers or excessive soap – these strip natural skin lipids and worsen xerosis 1, 2
- Avoid topical antihistamines – they increase contact dermatitis risk without proven efficacy 2
- Do not use sedating antihistamines long-term in elderly patients – predisposes to dementia 4
- Avoid greasy occlusive creams – may worsen follicular obstruction 2
When to Escalate Care
Refer to dermatology or burn specialist if:
- No improvement after 2 weeks of appropriate treatment 1
- Involvement of >30% BSA or primary areas (hands, feet, face, perineum) 1
- Any mucous membrane involvement or blistering suggesting SCAR 4
- Signs of secondary infection requiring systemic antibiotics 1
Common Pitfall
The most common error is treating post-burn pruritus like allergic itch with antihistamines alone. Post-burn pruritus is predominantly neuropathic 5, which explains why 87% of discharged burn patients complain of itching despite antihistamine use 7. Consider gabapentin or pregabalin early for severe or refractory cases rather than escalating antihistamine doses indefinitely.