Scratching the Surface

Welcome to this special edition of Wounds: A Compendium of Clinical Research and Practice devoted to wound pruritus (“itch”). Wound-related itch is a mysterious and understudied phenomenon. Itch is a sensation of the skin and mucous membranes, yet a wound that interrupts or penetrates the skin can be a source of itchiness. An itching wound can be unbearable. Consider how disturbing an itch can be when you are able to scratch an area for relief. Consider further the distress that an itchy chronic open wound can cause when scratching is likely to result in pain and further wound deterioration. My patients with itchy wounds have described pacing around the house and sobbing or screaming and cursing at the gods. Hospitalized patients with wounds are often confined to bed and must suffer with itching they cannot reach or address. It is often said, “It’s itching; it must be healing”; yet healing may not occur, and the itchy wound persists. The implications of itch on wound healing are not known and need much further investigation.

Itch has been described as far back as biblical times and is familiar to all. Despite its pervasiveness, insights into the physiology of itch have only been made in recent years. Scientific advances such as functional magnetic resonance imaging have enabled discovery about itch. Itch pathways and neurotransmitters are being determined. Theories of itch have been ruled on and ruled out. As more is known about itch, targets for intervention can be determined. 

The study of wounds can provide insights into understanding itch just as the study of itch can give insights into wound management. Researchers and clinicians at the 9th World Congress on Itch (October 2017, in Wroclaw, Poland) debated scientific information about itch. Dr. Gil Yosipovitch discussed the evaluation of itch on a numeric rating scale as being promoted by the Food and Drug Administration. Dr. Atilla Szollosi described itch mediators released from keratinocytes in response to toll-like receptor 3. Dr. Martin Schmelz spoke of the possibility of using diuretics to block chloride and minimize peripheral itch. At the end of the conference, researchers concluded that while much has been learned about itch, many unanswered questions remain.

Included in this special edition of Wounds are contributions from individuals from various disciplines who are clinical experts and researchers in the phenomenon of wound-related itch. Dr. Ethan Lerner, dermatologist, discusses the current understanding of itch physiology, poses thoughts on the physiology of wound-related itch, and outlines the need for further research on the topic. Dr. Julia Paul, wound care nurse practitioner, defines a group of descriptors that can be used for research and clinical assessment of wound-related itch. Dr. Bernadette Nedelec, occupational therapist, summarizes current literature on burn-related itch; acute burns can itch and continue to itch well beyond the point of healing. Ms. Laura Parnell, wound care expert consultant, reviews itch with wound healing and scar formation. Dr. Laura Bolton, author of the column Evidence Corner, reviews 2 studies concerning interventions for itch in different stages of wound healing: one in the postoperative phase of wound healing and the other for postburn hypertrophic scars.

All contributing authors hope that the content of this special edition will spark new interest in the topic of wound-related itch, enhance its priority in research initiatives, and improve clinical measures to relieve wound pruritus. In terms of understanding wound-related itch, we have only begun to scratch the surface!

Sincerely, 
Julia Paul, PhD, NP, CWS 
Oakland University, Rochester, MI