http://doi.org/10.33698/NRF0137- Lynette Hopper, Sukhpal Kaur, R.K.Sharma
Abstract : Split thickness skin auto grafting is the most widely used technique for covering deep burn wounds & extensive soft tissue defects. Itching in the grafted skin is a very common distressing symptom which impacts the quality of life. Donor site management is an important comfort issue for the patient. The present study was carried out to assess the effect of ‘calamine lotion’ at donor graft site itching. A total of 60 subjects were allocated to the control and the study groups, with 30 subjects in each group. Calamine lotion was applied in the study group whereas coconut oil which is a routine practice was applied in the control group. Itching scores prior to the intervention and at 2hrs and 4hrs following the intervention was assessed in both the groups. Significant improvements in itching scores were observed in both the groups. The mean itching scores prior to the intervention was 2.37± .669 in study group and 2.00±.743 in control group. Following 2 hrs of intervention there was significant reduction in itching scores i.e 0.80±.805 in study group and 0.23±.430 in the control group. At 4 hrs of intervention the mean itching scores was 1.13±.819 in study group whereas in control group it was 0.73±.640. It was concluded that although the calamine lotion has a efficacy in reducing itching, but the application of coconut oil had more sustained long lasting effect.
Key words :
Donor graft site, Itching, Calamine lotion.
Correspondence at : Lynette Hopper
HP– 33 B,Maurya Enclave Pitam Pura , Delhi
Introduction
Burn wound care involves early removal of the necrotic tissue followed by application of split thickness auto graft skin. Split thickness skin auto grafting is most widely used technique for covering deep burn wounds & extensive soft tissue defects. Donor skin is taken from the patient for grafting by means of a dermatome, which removes a thin (split thickness) layer of skin from an unburned area. This process involves the creation of a superficial wound that is the donor site.1 Itching has been reported to be one of the most distressing symptoms of healed donor grafted skin commencing as soon as wounds/ grafts start to heal2. It cause great distress in recovering patients affecting their ability to concentrate, and thereby their ability to function well in everyday life. It may also disrupt sleep, which is vital to recovery after a major trauma, and scratching may damage the newly developed skin.3 Itching during the early stages of healing is attributed to mast cell histamine release directly as part of the inflammatory response to injury and indirectly secondary to collagen formation during the proliferative stage of wound healing.4
The current management of itching relies on oral antihistamines and the use of emollients and moisturizing agents which are applied routinely to relieve itch. Emollients exert their skin softening and moisturizing effect within the stratum corneum. They help to restore the epidermal barrier and thereby prevent the penetration of environmental triggers that may cause an inflammatory reaction. Studies in acute burn in -patients has confirmed that a combination of moisturizing agents and first generation antihistamines is effective in reducing itching.5 A study explored that there exists different topical novel agents (anti-pruritic) for intractable itch including menthol l1% oatmeal based agents, calamine lotion, aloe and camphor.6 Matheson reviewed in his report representing a range of modalities including oral antihistamines, cool bathing products, local anesthetics, Unna boot, massage, and a tricyclic antidepressant in topical cream based lotion.7
Barone, has evaluated the use of Unna boot which is a boot made from gauze impregnated with glycerine, zinc oxide and calamine lotion, which improve itching in an analysis of groups of pediatric patients.8
Calamine lotion is a bland, smoothening, antipruritic lotion. Commonly used in several dermatological conditions. It combines with zinc oxide to produce a lotion that is utilized to help mitigate irritants associated with dermatitis. Calamine lotion is also used for treating sun burn since it contains zinc oxide which is used in most sunscreens, it helps to reduce redness and swelling. Its cooling and soothing effect makes it very effective for treating sunburn. Calamine lotion does not contain any harmful ingredients and is a very well tr usted medicine.9 A randomized trial by Boontangjai on cast associated pruritus prevention using calamine and talcum powder, showed that calamine lotion had a better efficacy in reducing pruritus.10
As itch remains a quality-of-life issue for the patient and that no single agent or combination of agents is entirely effective in combating the patient’s itch. There is need to find out an effective treatment modality. The present clinical study was aimed to examine the effect of calamine lotion at donor graft site itching.
Materials and Methods
The study was conducted on patients admitted / attending Out Patient Department of burns and plastic surgery unit of Post graduate institute of medical education and research (PGIMER), Chandigarh, India. A total of 60 subjects presented with persistent itching at donor graft site were recruited. Purposive sampling technique was used to assign the subjects into the control and the study groups. Subjects from the out- patient department were assigned to the study group (n=30) whereas the subjects admitted in the Plastic Ward were assigned to the control group (n=30). This was done as to avoid interference with the routine practice of applying coconut oil on the donor site of the subjects in the ward.
The various tools developed included: An interview schedule to collect patient’s identification and demographic profile, a protocol for the procedure of application of calamine lotion for the study group subjects, and an assessment sheet to record the itching scores prior to intervention, and at 2hrs and 4hrs following the intervention. The procedure of application of calamine lotion included all the steps of applying the lotion i.e. washing hands, donning gloves, exposing the area where lotion is to be applied, cleaning the area with sterile water and pat drying and applying the lotion. The content validity of all these tools was established. A pilot study was conducted to assess the feasibility of the study and relevant modifications were made.
Standardized Itchman Scale was used to assess the itching score amongst the study subjects. The score ranges from 0 to 4, with ‘0’ representing no itching and ‘4’ the worst possible itching.5,11 Assessment of itching was done prior to intervention in both the groups. In the control group researcher followed the routine practices of application of ‘coconut oil’ whereas in study group as per developed protocol ‘calamine lotion’ was applied. Using the scale again assessment of itching was done at 2hrs and 4 hrs after the intervention. The itching scores were recorded in the assessment proforma.
The study was approved by the Ethics Review Committee of the Institute. Written consent was obtained from all the patients before the study. Participants were explained that confidentiality of data will be maintained. Results of the study will be used for research purpose only and they are free to participate or withdraw from study at any time. SPSS version 16 was used to analyse the data. Mann-Whitney test was used to compare mean itching scores between the groups at different time points. Fisher test was used for categorical scores of itching.
Results
Demographic profile of the subjects
The subjects were in the range of 13 to 65 years with the mean age of 37.5 ±12.90 years in study group and 32.7 years ± 12.90 in control group. Most of the subjects (90% in study & 76.7% in control group) were male and 70% subjects from control group and 66.7% from study group were married. Educational status of 40% of the subjects in both groups were graduate and above and same number of subjects’ (40%s) occupational status in study group and 30% in control group were unskilled workers. Both the groups were homogenous as per age, sex, marital status, educational status and occupational status. (Table 1)
Table-1: Demographic profile of the subjects in both the groups N=60
| Socio-demographic profile | Control group N=30 | Study group N= 30 | Inference |
| Age (years) | n(%) | n(%) | |
| £ 20 | 6(20.0) | 2(6.8) | c2=2.857 |
| 21-30 | 11(36.7) | 10(33.3) | df =4 |
| 31-40 | 5(16.7) | 7(23.3) | p =0.582 |
| >40 | 8(26.6) | 11(36.6) | |
| Mean age (years)±SD Range | 32.73±15.31
13-65 |
37.50±12.90
16-65 |
|
| Sex | c2 =1.92 | ||
| Male | 23(76.7) | 27(90.0) | df =1 |
| Female | 7(23.2) | 3(10.0) | p =0.166 |
| Occupational status
Skilled worker |
3(10.0) |
8(26.7) |
c2 =7.076 |
| Unskilled | 9(30.0) | 12(40.0) | df =3 |
| Professional | 4(13.3) | 5(16.7) | p=0.070 |
| Not working | 14(46.7) | 5(16.7) | |
| Educational status
Illiterate |
0(0.0) |
2(6.7) |
c2 =6.222 |
| Middle | 7(23.3) | 5(16.6) | df=5 |
| Matric | 11(36.7) | 11(36.7) | p=0.285 |
| Graduate& above | 12(40.0) | 12(40.0) | |
| Marital status
Married |
21(70.0) |
20(66.7) |
c2 =0.077
df=1 |
| Unmarried | 9(30.0) | 10(33.3) | p=0.781 |
Itching scores in both the groups
Table 2 depicts mean itching scores at different intervals of time in both groups. In the study group the mean itching scores prior to the intervention was 2.37± .669. It decreased to 0.80± 0.7 at 2 hrs of intervention but at 4 hrs of intervention it again increased to 1.13±.819. In the control group the mean itching scores prior to the intervention was 2.0 ± 0.74. This decreased to 0.23 ± 0.43 at 2 hrs of intervention but at 4 hrs of intervention it increased to 0.73 ± 0.64.The findings as per the mann-whitney U test revealed that there was significant difference in the itching scores at different time interval after applying calamine lotion or coconut oil (p<0.05).
Table-2 : Mean itching scores at different intervals of time in both the groups
| Study Group | Control Group | ||||
| Itching Scores | Pre-intervention | Post – intervention (2hrs) | Post- intervention (4 hrs) | Pre- Post –
intervention intervention (2hrs) |
Post- intervention (4 hrs) |
| Mean±SD | 2.37±0 .67 | 0.80 ± 0.67 | 1.13±0.82 | 2.00±0 .74 0.23±0.43 | 0.73±0.64 |
| Median | 2.00 | 1.00 | 1.00 | 2.00 0.00 | 1.00 |
| Range | 1-4 | 0-2 | 0-3 | 1-3 0-1 | 0-2 |
| P=0.00 | P=0.00 | ||||
Table-3 : Categorical comparison of itching scores at different time points in between the groups
| Time points | Categories of itching | Control group (N=30) | Study group (N=30) |
Inference |
| n (%) | n (%) | |||
| Pre intervention | Mild | 8 (26.7) | 2(6.7) | F exact=5.045 |
| Moderate | 14(46.7) | 16(53.3) | df=3 | |
| Severe | 8(26.7) | 11(36.7) | p=0.141 | |
| Intense | 0(0.0) | 1(3.3) | ||
| After 2 hours | No | 23 (76.7) | 13 (43.3) | Fexact=10.57 |
| Mild | 7(23.3) | 10(33.3) | df=2 | |
| Moderate | 0(0.0) | 7(23.3) | p=0.0 | |
| After 4 hours | No | 11(36.7) | 7(23.3) | |
| Mild | 16(53.3) | 13(43.3) | Fexact=5.03 | |
| Moderate | 3(10.) | 9(30.0) | df=3 | |
| Severe | 0(0.0) | 1(3.3) | p=0.15 |
Categorical comparison of itching scores at different time points in between the groups
Table 3 depicts comparison of itching scores at different intervals of time. It was observed that 46.7% subjects in control group and 53.3% subjects in study group had moderate itching prior to intervention, but after 2 hrs of intervention,76.7% subjects in control group and 43.3% subjects in study group were relieved of itching & there was significant difference between both the groups(p=0.006). However at 4 hrs (53.3% in control group & 43.3% in study group) had mild itching. The difference was statistically non-significant.
Discussion
Itching represents a common presenting symptom of patients with S.T.S.G (split thickness superficial graft) donor site. It has been shown to affect the quality of life in aspects such as sleep disturbances, impairments of daily activities, and psychosocial well-being. Additionally, the urge to scratch can lead to damage to grafted skin which in turn can hamper the healing process. It is still one of the unresolved problems in burn care practice.
The present study was undertaken to assess the effect of calamine lotion at the donor graft site itching. Calamine lotion is a topical proprietary formulation. Calamine lotion has a soothing effect when applied. It is mainly used as a treatment for people suffering from dermatitis. It helps to treat the symptoms of dermatitis like itching, swelling, redness and inflammation. Calamine lotion was applied with the potential benefit to decrease the intensity of itching during the healing process. It was applied over the healed area of the donor grafted skin of the subjects in the study group, whereas in the control group the routine practice of coconut oil was done. Itching scores were assessed prior to application and then at 2 hrs and 4 hrs after the application in each group. Findings of the study revealed that there was significant decrease in itching scores, in both the groups.
Barone8 has evaluated the use of Unna boot which is a boot made form gauze impregnated with glycerin, zinc oxide and calamine lotion, which improve itch. In the present study calamine lotion as a primary medication was compared with routine practices of coconut oil and results revealed that both interventions were significantly effective in reducing itching. The extent of effect of any topical application is based on the components present in it. A randomized controlled study demonstrated that products containing emollients and humectants aid in absorption and retention of moisture, preventing dryness and itching12. The present study also demonstrated that the use of calamine which contains glycerin as a humectants and moisturizer relieves itching.
In this study, the subjects included were in the age group of 13-60 years. Mean age was 32.7± 15.3 years. The study subjects were selected from the Burns and plastic surgery out- patient department and the ward. In a similar study by Baker etal13, patients selected were adults with a mean age of 35 years attending the out – patient clinics. The relationship of gender to itch is still a controversial issue. In the present study no statistical significant relationship was found between gender and itching scores. But in an epidemiological study of itching conducted by Van Loey et al 4 it was demonstrated that the female gender developed more itching than their counterparts .The finding that women had higher itching scores cannot be explained without some speculation. One explanation could be that women are more prone to develop emotional problems than their counterpart and therefore associated with the reporting of persistent itching.
The use of any pharmacological agent demands effective mode of application modalities. In the present study a thin film of calamine lotion and coconut oil were applied on the donor grafted area and it was found that there was significant relief from itching. A similar modality of application was found beneficial in a study conducted by Maenthaisong etal14, on patients suffering with itching in which Aloe –Vera cream was applied.
It is stated that itch and pain share a peripheral group of C fibers, which carry both itch and pain stimuli to a group of dorsal horn interneuron’s and a specific pathway in the anterolateral spinal cord to the brain. Although pain and itch are now regarded as individual sensations.Clinical observations indicate that that itch and pain are separate sensations.15 Similarly in the present study these two sensations were taken as separate entities and the sensation of itch was evaluated through the assessment of how the itch interfered with the daily activities of patients.
This study reflects the fact that the time point for application of calamine on each subject was early in their treatment when itching had not yet become a significant problem. While itching was well controlled in this study, additional studies are encouraged to explain on itch control later in the graft healing process.
This study revealed that calamine lotion was effective as a primary medication to manage itch only for 2 hrs whereas coconut oil was effective for a longer time period.
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