Patient-Reported Pain and Itch Scores After a Course of Laser Therapy for the Treatment of Postburn Hypertrophic Scar Are Impacted by Mental Health Status.

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Learn more: PMC Disclaimer | PMC Copyright Notice J Burn Care Res . 2025 May 31;46(6):1226–1236. doi: 10.1093/jbcr/iraf103 Patient-Reported Pain and Itch Scores After a Course of Laser Therapy for the Treatment of Postburn Hypertrophic Scar Are Impacted by Mental Health Status Lia Mandavalli 1, 2 , Casey Meretta 3 , Ishaan Nandwani 4, 5 , Taryn E Travis 6, 7, 8, 9 , Shawn Tejiram 10, 11, 12, 13 , Jeffrey W Shupp 14, 15, 16, 17, 18 , Daniel M Schneider 19, 20, 21 , Bonnie C Carney 22, 23, 24, ✉ Author information Article notes Copyright and License information 1 Firefighters’ Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC, United States 2 NSU Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, FL, United States 3 Firefighters’ Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC, United States 4 Firefighters’ Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC, United States 5 Georgetown University School of Medicine, Washington, DC, United States 6 Firefighters’ Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC, United States 7 Department of Surgery, Georgetown University School of Medicine, Washington, DC, United States 8 Department of Plastic Surgery, Georgetown University School of Medicine, Washington, DC, United States 9 Department of Surgery, The Burn Center, MedStar Washington Hospital Center, Washington, DC, United States 10 Firefighters’ Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC, United States 11 Department of Surgery, Georgetown University School of Medicine, Washington, DC, United States 12 Department of Plastic Surgery, Georgetown University School of Medicine, Washington, DC, United States 13 Department of Surgery, The Burn Center, MedStar Washington Hospital Center, Washington, DC, United States 14 Firefighters’ Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC, United States 15 Department of Surgery, Georgetown University School of Medicine, Washington, DC, United States 16 Department of Plastic Surgery, Georgetown University School of Medicine, Washington, DC, United States 17 Department of Surgery, The Burn Center, MedStar Washington Hospital Center, Washington, DC, United States 18 Department of Biochemistry and Molecular & Cellular Biology, Georgetown University School of Medicine, Washington, DC, United States 19 Department of Surgery, Georgetown University School of Medicine, Washington, DC, United States 20 Department of Surgery, The Burn Center, MedStar Washington Hospital Center, Washington, DC, United States 21 Department of Psychiatry, Georgetown University School of Medicine, Washington, DC, United States 22 Firefighters’ Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC, United States 23 Department of Surgery, Georgetown University School of Medicine, Washington, DC, United States 24 Department of Biochemistry and Molecular & Cellular Biology, Georgetown University School of Medicine, Washington, DC, United States ✉ Corresponding author: Bonnie C. Carney, ( bonnie.c.carney@medstar.net ). Roles Lia Mandavalli : DO , Conceptualization, Data curation, Formal analysis, Writing - original draft, Writing - review & editing Casey Meretta : Data curation, Formal analysis, Writing - review & editing Ishaan Nandwani : BS , Data curation, Writing - review & editing Taryn E Travis : MD , Conceptualization, Methodology, Writing - review & editing Shawn Tejiram : MD , Data curation, Methodology Jeffrey W Shupp : MD , Funding acquisition, Resources, Writing - review & editing Daniel M Schneider : Psy.D , Conceptualization, Formal analysis, Writing - review & editing Received 2025 Feb 12; Revised 2025 May 9; Accepted 2025 May 29; Collection date 2025 Nov-Dec. © The Author(s) 2025. Published by Oxford University Press on behalf of the American Burn Association. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model ( https://academic.oup.com/pages/standard-publication-reuse-rights ) PMC Copyright notice PMCID: PMC12596634  PMID: 40448279 Abstract Burn injuries are often associated with physical scarring in addition to severe psychosocial consequences, including heightened pain and pruritus (itch). These symptoms can persist long after the injury and often become recalcitrant to standard treatments, such as gabapentin and antihistamines. Fractional ablative CO 2 laser scar revision (FLSR) has gained popularity as an adjunctive therapy to address the limitations of existing treatments. However, despite this treatment, some patients continue to experience both symptoms, which negatively impacting their quality of life and daily functioning. A retrospective review of 110 patients receiving laser scar revision between 2018 and 2024 was conducted at a single institution, with patients divided into two cohorts: those with a diagnosed mental health condition and those without. Patients with a mental health diagnosis (MHD) reported a more significant reduction in pain and pruritus over the course of three laser sessions compared to those without an MHD. Despite these differences in perception, no variation was observed in the objective measures of scar healing between the cohorts. Gabapentin dosage was associated with reductions in pain perception, particularly in the MHD group. This finding suggests that mental health interventions may enhance the subjective experience of recovery, potentially through neuroplastic changes influenced by psychotherapy as compared to medications. This study underscores the need to integrate mental health care into the physical recovery of burn patients. Future research should investigate the long-term outcomes of combined mental health and scar therapy interventions to improve patient quality of life postinjury. Keywords: hypertrophic scar, patient-reported outcome metrics, pruritus, pain, psychosocial health INTRODUCTION Up to 70% of patients experience pain, pruritus, and psychosocial changes alongside hypertrophic scarring during and after burn injury recovery, placing additional strain on the healthcare system. 1–3 Even mild burn injuries can lead to cognitive changes and increased susceptibility to mental health conditions like Post Traumatic Stress Disorder (PTSD). 1–3 Furthermore, many patients report postburn pruritus, which is often associated with epidermal thickening. 4–6 This heightened pruritic perception can result from peripheral or central nervous system changes. At the periphery, the regeneration of the unmyelinated C fibers from the injured axons either increases their excitability or enhances the sensitivity of nociceptors after injury. This alteration results in an elevated release of chemical factors and inflammatory markers like Substance P and histamine, which can also cause vasodilatory effects. Centrally, the heightened response of the secondary neurons in the dorsal horn of the spinal cord activates the alpha two δ calcium channels, leading to an upregulation of the excitatory neurotransmitter glutamate. Conversely, the loss of inhibitory neurons and diminished activity of the dorsal column interneurons results in a downregulation of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA). Together, these factors contribute to increased erythema ratings and elevate the risk of complications burn patients experience, including peripheral neuropathy, exacerbated pruritus, and heightened pain perception 7–9 ( Figure 1 ). Figure 1. Open in a new tab Visualization of the Regions Involved in Pain and Pruritis. The Upper 4 Points Are Areas Involved in Further Pruritic Processing and the bottom 4 Points Are Regions Involved in Further Pain Processing Pruritic perception is processed in regions including the anterior cingulate cortex, insular cortex, motor cortex, and inferior parietal lobe, with a predominance in the left cerebral hemisphere. In contrast, the transmission of pain signals occurs in brain regions associated with the memory and affective components of pain, including the amygdala, hypothalamus, periaqueductal gray matter, and nucleus accumbens ( Figure 1 ). 4–6 Neurobiologically, some of these brain regions are associated with either structural or functional alterations in patients with certain psychiatric conditions. The amygdala, which processes positive and negative emotions, is also connected to the hippocampus, a fundamental structure for memory formation. 10 Research has demonstrated that individuals diagnosed with schizophrenia exhibit reduced amygdala volume. In contrast, patients with mood disorders, such as major depressive disorder and anxiety, may show altered patterns of amygdala activity in response to negative emotional stimuli as compared to positive emotional stimuli rather than significant structural changes. 11 , 12 The comorbid presence of mental health conditions may, therefore, contribute to a heightened state of central sensitization, leading to an exaggerated perception and experience of both pain and itch symptoms during the recovery period. 9 , 13 , 14 Increased activity in these brain regions may be due to the upregulation of glutamate and Substance P and reduced GABA and glycine. This combination of neurotransmitters promotes neuroplastic changes further reinforced by brain-derived neurotrophic factors. This change, in turn, may additionally contribute to the development of mental health conditions and symptoms, including depression, anxiety, anhedonia, cognitive problems, sleep disturbances, and suicidal thoughts, which are often inadequately managed and significantly impact the patient’s quality of life. 4 , 5 , 9 The management of acute and chronic pain in burn patients remains a significant challenge. Despite treatment with first-line medications such as gabapentin and antihistamines, many cases remain recalcitrant, resulting in chronic pain and pruritus that can persist for months or even years after the initial injury. 7 Over the past decade, fractional ablative CO 2 laser therapy has become a common adjunct to conservative treatment for hypertrophic scar; however, despite treatment, some patients continue to experience chronic postburn pain and pruritus. 15 This discomfort can significantly impact functionality and mental health. One study linked pain in burn survivors to increased depression and anxiety, which in turn negatively affects work, sexual health, and interpersonal relationships. 16 While it is known that some patients demonstrate improvement, others do not, and yet, the demographics, treatment details, and scar characteristics that could predict these outcomes have not been elucidated. The relationship between postburn mental health and burn injury recovery is a complex, multifactorial problem. Mental health emergencies are common among burn-injured patients, emphasizing the need for early psychological screening to address both physical and mental health after burn care. 17–19 Additionally, when chronic pain is associated with PTSD, there are heightened reports of pain, anxiety, depression, and opioid use. 3 , 20 The link between early acute pain scores after burn injuries and the development of long-term effects such as PTSD in soldiers underscores the need for more research into the relationship between physical pain and psychological outcomes during burn recovery. Gaps in understanding still remain as to why some postburn survivors maintain the ability to recover from stress well while others maintain high traumatic stress levels. This mental health status may further contribute to perceptions of pain and itch in the wound healing and scar remodeling processes. 21 , 22 Examining these factors on health-related quality of life can identify barriers to returning to preinjury functioning. 23 This work would bridge the gap between the need for and provision of psychological aftercare to ensure appropriate support for burn patients with and without mental health conditions. 24 This work investigates the influence of mental health on the perception of pain and itch throughout laser therapy for burn patients undergoing scar revision. It was hypothesized that patients with a diagnosed mental health history would experience heightened levels of pain and itch that do not improve throughout therapy as compared to those without a mental health diagnosis (MHD). Additionally, it was suggested that these differences may be influenced by the use of pharmacotherapy and/or cognitive behavioral therapy regimens in conjunction with laser therapy. METHODS A retrospective chart review was conducted at a single institution involving 256 patients who underwent or were currently receiving laser scar revision (FLSR) for hypertrophic scarring following burn injuries. These patients have been enrolled in the FLSR program at this institution from September 2016 to the present. Data collected included scar evaluation metrics, laser settings, date of injury, dates of FLSR intervention, location of the burn injury (sorted between Upper Extremity, Lower Extremity, Torso, Face), size of treatment area, etiology of the burn injury (sorted by: Unknown, Chemical, Cold, Flame, Electrical, Scald, Explosion), total body surface area (TBSA), length of hospitalization, number of laser sessions, and patient demographics (age, sex, ethnicity, Fitzpatrick skin types (FST) I to VI, neurological history, MHD, and number of burn psychology consults). This data was maintained and updated in an IRB-approved laser database. The inclusion criteria for this study were adult patients with hypertrophic scarring secondary to a burn etiology, with a scar area ≥100 cm², who sustained their initial burn injury after 2018 and have undergone 3 or more FLSR sessions since 2018. This timeframe was chosen because it coincided with the period when our center hired a full-time burn psychologist who participated in mental health diagnoses in the inpatient and outpatient settings. Patients must have completed both pre- and postlaser evaluations. Excluded from the study were patients who had a date of injury before 2018, had received fewer than 3 laser sessions, the etiology of scarring other than a burn (eg, Hidradenitis Suppurativa, Acne, nonburn traumatic injury, or surgical scar), had a first treatment date before 2018, a scar size <100 cm², and were diagnosed with solely an ICD code for pain which was auto-populated into the Electronic Medical Record (EMR) when specific plans were entered into the EMR. Patients were categorized into two cohorts: those without an MHD and those with an MHD. A patient was included in the latter group if they had a preexisting MHD at the time of their hospital admission for their burn injury or if they were subsequently diagnosed with a mental health condition by the burn psychology and psychiatry team. This analysis did not separate preexisting and new diagnoses due to the low number of patients. Further mental health data collected included individuals who saw the burn psychology and psychiatry team during their admission (never, saw and declined continuation of care while inpatient (<3 visits) or saw and declined care), saw consistently for multiple visits (>3 visits) and both independent and comorbid mental health diagnoses. The Burn Psychology team is embedded full-time in Burn Surgery providing behavioral health consultation, psychosocial screening and evaluation, healthcare capacity evaluations, and brief individual cognitive-behavioral therapy (CBT) interventions during the acute hospitalization. Universal screening is conducted is by the licensed Burn Psychologist and the Pain & Rehabilitation Psychology Post Doc Fellow. All inpatient burn admissions are universally administered the Injured Trauma Survivor Screen and a clinical interview by Burn Psychology to assess PTSD and Depression risk factors after 72 h from initial injury to assess the need in formulating a behavioral health care plan or follow-up. Referrals to Psychiatry Consultation-Liaison Team are discussed with the Burn Psychologist and Team in rounds. Psychiatry referrals include the stabilization of preexisting or new episodic psychosis, medication management for mood instability and multifactorial delirium, a psychiatric level of care evaluation for inpatient psychiatry and/or outpatient care plans, in addition to complex burn medical and psychiatric discharge planning. All patients who follow up in the burn clinic are counseled by the APP team on the available laser scar revision and other reconstruction and then referred to a physician for formal consultation if interested. Asymptomatic patients would likely self-select out of consultation, but all burn survivors are offered the opportunity. If after consultation with a burn surgeon the patient and surgeon would like to move forward with laser scar revision, clinical documentation is submitted to their insurer for approval. Given the logistics of the American healthcare system, those patients without a payor source would also almost always select out from participation in laser scar revision. Patients undergoing FLSR treatment initially received a preoperative consultation with an attending burn surgeon, followed by a consultation with a burn rehabilitation therapist to establish baseline scar symptoms. The first laser session utilized a Lumenis Ultrapulse FCO2 laser device with a DeepFx handpiece in the SCAAR Fx mode at a density of 1% and a pulse energy of 70 mJ. Approximately two weeks postprocedure, patients returned for scar evaluation. If well tolerated, subsequent treatments incrementally increased power and density, ranging from 70 to 120 mJ and 1%-5% density, respectively with a clinical endpoint of sporadic punctate bleeding at micro-injury sites without epidermal blistering. FLSR treatments and follow-ups continued at 4-6-week intervals until scar improvement plateaued or the patient discontinued treatment. Postlaser therapy, all patients receive topical triamcinolone (TAC) by laser-assisted drug delivery (LADD) at a dose of 40 mg in 10 mL of saline. Some patients also received LADD of 5-fluorouracil at a dose of 50 mg in 5 mL of saline concomitantly with the TAC treatment. Patient scars were analyzed using subjective metrics from baseline, pre-evaluations, and the first FLSR follow-up sessions. Subjective parameters included the Patient and Observer Scar Assessment Scale-Patient (POSAS-P) and Patient and Observer Scar Assessment Scale-Observer (POSAS-O), in which either the patient or observer scored scars compared to normal skin, assessing parameters such as vascularity, pigmentation/color, relief/thickness, pliability/stiffness, and surface area/irregularity. In the case of the POSAS-P, pain, and itch were also rated. The POSAS can be analyzed by examining each variable individually or calculating a total or average score, ranging from 1 (minimal/most minor) to 10 (maximal/most) severity. A lower score on the pain and itch scales correlates with improved scar symptoms/properties. Statistical significance between the two groups was evaluated using t -tests, two-way ANOVA, or Mann–Whitney U tests. A P -value <.05 was considered significant. Two separate analyses were conducted: one in which the mental health group was compared to the no mental health group at each session. The second analysis compared the preoperative value to the follow-up values from sessions 1, 2, and 3. Normality was assessed using the Kolmogorov–Smirnov test. Demographic variables were compared using chi-square tests for categorical variables (FST, race, sex, LADD use) and t -tests or nonparametric equivalent for continuous variables (age of patient, age of scar). Patient medications were tracked from the prelaser evaluation date until the third postlaser follow-up session. However, at our center, drug dosages are not frequently changed during follow-up sessions because patients do not see physicians at these sessions. Therefore, we could not track how medications affected their pain and itch over time, only at the presession. Medication Recommendation Tracking Form, as described by Reilly-Harrington N.A. et al. 25 ( Figure 2 ), was used to track the changes made to the patient’s medications throughout laser sessions. Specific medications were limited to prescriptions that 2 or more patients took over this period (gabapentin, pregabalin, oxycodone, combined opioid medications (ex. acetaminophen-oxycodone), hydroxyzine, cetirizine, loratadine, diphenhydramine, ibuprofen, acetaminophen, aspirin, duloxetine, sertraline, escitalopram, amitriptyline, amphetamines, prazosin) and sorted into their respective drug classes (antiepileptic, opioids, antihistamines, analgesics, SSRI/SNRIs, TCAs, amphetamines, alpha-1 blockers). Figure 2. Open in a new tab Patients Pain Perception vs Laser Sessions (A, B) Patients Itch Perception vs Laser sessions (C, D). Cohort 1 = Group With No MHD, Cohort 2 = Group With MHD Individual daily medication doses were compared by converting doses to a percentage of the maximum daily dose. This percentage was calculated by multiplying the dose by daily frequency and then dividing by the maximum daily dose for that specific medication. This allowed individual drugs within the same drug class to be compared despite differences in concentration and quantity between those medications. Statistical significance between these groups was compared using Spearman nonparametric correlation, Fisher’s exact test, and Mann–Whitney statistical tests, all with α = 0.05. RESULTS Between January 2018 and July 2024, 256 patients commenced a course of Fractional ablative CO 2 laser scar revision (FLSR). Among these, 110 patients presented with hypertrophic scars secondary to burn injuries equal to or larger than 100 cm², which had occurred post-2018. These patients underwent at least 3 treatment sessions, with corresponding pre- and postoperative evaluations. Demographics The study included 53 patients without a history of mental illness (30 males and 23 females), with a median age of 48 years (33.0, 61.0) at the time of initial treatment. The second group was comprised of 57 patients diagnosed with a mental health condition by hospital discharge (27 males and 30 females), with a median age of 45.0 years (29.0, 53.0) ( Table 1 ). Patients in both cohorts were of diverse ethnic backgrounds, including African American, White, Hispanic, Unknown, Asian, Other, and Native American, with FST ranging from I to VI. Predominantly, African American patients ( N total = 43, 78.0%) with FST V ( N total = 33, 59.8%) were represented in both cohorts. No significant differences were observed between the groups in terms of sex ( P = .3473), age ( P = .3139), ethnicity ( P = .6743), or FST ( P = .5645) ( Table 1 ). Table 1. Patients’ Demographics All Patients No MHD MHD P -value No. of patients (%) 110 (100.0) 53 (48.0) 57 (52.0) – SEX (%) .3473 Male 57 (51.8) 30 (56.6) 27 (47.4) Female 53 (48.2) 23 (43.4) 30 (52.6) ETHNICITY, no. (%) .6743 Black 43 (78.0) 18 (35.8) 24 (42.2) White 29 (63.4) 9 (28.3) 20 (35.1) Hispanic 9 (20.2) 5 (13.2) 4 (7.0) Unknown 9 (16.6) 6 (11.3) 3 (5.3) Asian 8 (14.6) 4 (7.5) 4 (7.0) Other 2 (5.5) 1(3.8) 1(1.8) Native American 1(1.8) 0 1 (1.8) Pacific Islander 0 0 0 FITZPATRICK SKIN TYPE, no. (%) .5645 5 33 (59.8) 14 (26.4) 19 (33.3) 2 33 (59.8) 14 (26.4) 19 (33.3) 3 18 (33.2) 12 (22.6) 6 (10.5) 4 18 (32.8) 9 (17.0) 9 (15.8) 6 5 (9.04) 2 (3.8) 3 (5.3) 1 3 (5.5) 2(3.8) 1(1.8) AGE, median (Q1, Q3) 46.5 48.0 (33.0, 61.0) 45.0 (29.0, 53.0) .3139 Open in a new tab Scar characteristics The etiology of burn injuries included Flame, Scald, Explosion, Electrical, Unknown, Cold, and Chemical, with the flame being the predominant cause in both cohorts ( N total = 52, 95.2%; P = .1121). Scar locations were categorized into upper extremity, lower extremity, torso, pelvis, and face, with the upper extremity being the most frequent site of injury ( N total = 56, P = .4112). Specifically, the upper arm was the most affected area in Group with no diagnosed mental health history ( n = 11, 20.4%), while the hand was the most affected in Group with diagnosed mental health conditions ( n = 10, 17.2%). However, no significant differences were observed between the 2 groups ( P = .5865) ( Table 2 ). Table 2. Patients’ Burn Characteristics. *indicates statistical significance between No MHD and MHD groups, p<0.05. All patients No MHD MHD P -value No. of patients (%) 110 (100.0) 53 (48.0) 57 (52.0) – ETIOLOGY OF BURN no. (%) .1121 Unknown 3 (5.5) 2 (3.8) 1 (1.8) Chemical 1(1.9) 1 (1.9) 0 Cold 1(1.8) 0 1 (1.8) Flame 52 (95.2) 30 (56.6) 22 (38.6) Electrical 9 (16.2) 3 (5.7) 6 (10.5) Scald 33 (59.9) 15 (28.3) 18 (31.6) Explosion 11 (19.6) 2 (3.8) 9 (15.9) LOCATION OF BURN no. (%) .5865 UE no. 56 .4112 Hand 20 (35.8) 10 (18.5) 10 (17.2) Wrist 7 (12.3) 2 (3.7) 5 (8.6) Upper arm 19 (34.2) 11(20.4) 8 (13.8) Axilla 10 (17.6) 3 (5.6) 7 (12.1) LE no. 31 Thigh 10 (18.0) 6 (11.1) 4 (6.9) Knee 4 (7.3) 3 (5.6) 1 (1.7) Calf 8 (13.9) 1 (1.9) 7 (12.1) Foot 9 (16.0) 4 (7.4) 5 (8.6) Other no. 25 Torso 14 (24.9) 6 (11.1) 8 (13.8) Pelvis 4 (7.3) 3 (5.6) 1 (1.7) Face 7 (12.7) 5 (9.3) 2 (3.4) SIZE OF TREATED SCAR (CM 2 ), median (Q1, Q3) 500 (214.5,2000.0) 600 (250.0,1900.0) .8312 TOTAL BURN SURFACE AREA, median (Q1, Q3) 9.5 (4.6,15.5) 11.5 (4.3, 27.9) .1898 LENgTH OF STAY, median (Q1, Q3) 9 (5.0, 18.0) 17.5 (8.3, 40.5) .0074* LASER THERAPY SESSIONS, median (Q1, Q3) 4.0 (3.0, 6.0) 5.0 (3.5, 7.0) .0835 Age of Scar (months), median (Q1, Q3) 6.2 (4.8,7.7) 5.7 (4.7, 7.5) .5401 Drug used during LADD no. (%) .3313 Topical Triamcinolone (TAC) 43 (39.0) 18 (33.9) 25 (43.8) Topical Triamcinolone (TAC) + 5-fluorouracil (5-FU) 67 (60.9) 35 (66.0) 32 (56.1) Open in a new tab The median scar area treatment size and TBSA were comparable between the cohorts. Group with no diagnosed mental health history had a median scar size of 500 cm² and a TBSA of 9.5%, while Group with diagnosed mental health conditions had a median scar size of 600 cm² and a TBSA of 11.5% ( Table 2 ). Additionally, the age of the scar at the time of the first laser treatment did not differ significantly between the 2 cohorts ( P = .5401), with Group with no diagnosed mental health history having a median age of 6.2 months (4.8, 7.7) and Group with diagnosed mental health conditions having a median age of 5.7 months (4.7, 7.5). There were no differences in the percentage of scars treated with either TAC or TAC+5-FU between the groups. Outcomes The only significant difference between the groups was the hospital length of stay, with a median of 8.5 days (5.0, 20.0) for Group with no diagnosed mental health history and 17.5 days (8.3, 40.5) for Group with diagnosed mental health conditions ( P = .0123) ( Table 2 ). Regarding MHD, there was a significant difference in the engagement with the Burn Psychology team. A majority of Group with no diagnosed mental health history never consulted the burn psychologist ( N = 32 (60.4%)), whereas a majority of Group with diagnosed mental health conditions had more than 3 visits ( N = 32, 56.1%) ( Table 3 ). It is also probable that the increased length of stay in the MHD group further resulted in additional burn psychology inpatient intervention. Table 3. Patients’ MHD Characteristics All patients No MHD MHD P -value No. of patients (%) 110 (100.0) 53 (48.0) 57 (52.0) - SAW BURN PSYCHOLOGY INPATIENT no. (%) <.0001 a Never 44 (40.0) 32 (60.4) 12 (21.0) <3 visits or saw and declined care 30 (27.2) 17 (32.1) 13 (22.8) >3 visits 36 (32.7) 4 (7.5) 32 (56.1) MENTAL HEALTH HISTORY no. (%) – Unknown 26 (47.3) – 2 (3.7) Anxiety – 5 (9.3) Depression – 2 (3.7) Bipolar Disorder – 1 (1.9) Adjustment Disorder – 13 (24.1) PTSD – 3 (5.6) COMORBID 29 (52.7) Anxiety/Depression – 2 (3.7) Anxiety/Pain – 1 (1.9) Anxiety/Pain/Schizophrenia – 1 (1.9) Anxiety/Depression/Substance Use Disorder – 1(1.9) Depression/Pain – 1 (1.9) Bipolar disorder/Pain – 1 (1.9) PTSD/Bipolar Disorder – 1 (1.9) PTSD/Substance use disorder – 1 (1.9) PTSD/Anxiety/Depression – 2 (3.7) Adjustment disorder/PTSD a – 3 (5.6) Adjustment disorder/ADHD – 1 (1.9) Adjustment disorder/Anxiety – 1 (1.9) Adjustment disorder/Neurocognitive disorder – 1 (1.9) Adjustment disorder/Depression – 2 (3.7) Adjustment Disorder/Pain – 2 (3.7) Adjustment disorder/Pain/Anxiety – 3 (5.6) Adjustment disorder/ PTSD / Depression a – 1 (1.9) Adjustment disorder/ Anxiety Depression – 3 (5.6) Open in a new tab a Adjustment disorder can’t be diagnosed comorbid with PTSD. These individuals were initially diagnosed with adjustment disorder and later receive a PTSD diagnosis, while still having a history of adjustment disorder present in their medical records. The MHD was further categorized into single conditions ( N = 26) including Adjustment disorder ( N = 13, 24.1%), Anxiety ( N = 5, 9.3%), PTSD ( N = 3, 5.6%), Unknown ( N = 2, 3.7%), Depression ( N = 2, 3.7%), Bipolar Disorder ( N = 1, 1.9%) and Comorbid diagnoses involving adjustment disorder/pain/anxiety, adjustment/anxiety, and adjustment/PTSD ( N = 3, 5.6%). The comorbid diagnosis combines the preexisting MHD with a new condition assessed by Burn Psychology/Psychiatry during inpatient ( Table 3 ). Subjective parameters for pain and itch were assessed using the Patient and Observer Scar Assessment Scale (POSAS-P). Intergroup comparisons between the 2 groups at each laser therapy session for pain ( Figure 2A ) and itch ( Figure 2C ) showed no significant differences. However, intragroup comparisons revealed a significant decrease in pain perception between the preoperative session and the first laser session ( P < .001) only in Group with diagnosed mental health conditions ( Figure 2B ). This trend continued with subsequent sessions, showing significant differences between preoperative scores and laser session 2 ( P < .05) and session 3 ( P < .01). There was only a significant decrease between preoperative scores and laser session 3 ( P < .01) in Group with no diagnosed mental health history ( Figure 2B ). Similarly, significant decreases in itch perceptions were noted in group with MHD, with POSAS-P scores significantly decreasing after laser session 2 ( P < .05) and session 3 ( P < .001) compared to pretreatment scores ( Figure 2D ). There were no significant changes in Group with no diagnosed mental health history ( Figure 2D ). The POSAS-O average ( Figure 3A ) and the POSAS-P average ( Figure 3B ) reflected similar statistically significant differences in both groups between preoperative scores and laser session 2 ( P < .01) and session 3 ( P < .001), where scores decreased after more sessions. Additionally, there were no statistically significant differences between the 2 groups for POSAS-O or POSAS-P in the intergroup comparisons of each session ( Figure 3C and D ). Figure 3. Open in a new tab POSAS Patient Averages vs Laser Sessions (A, C) and POSAS Observer Averages vs Laser Sessions (B, D). Cohort 1= group With No MHD, Cohort 2 = Group With MHD Regarding patient medication usage, there was a significant difference in the use of sertraline ( P = .0063, N = 0 vs N = 8 for no Mental Health vs. Mental Health). However, the remaining medications (gabapentin, pregabalin, oxycodone, combined opioid medications (ex. acetaminophen-oxycodone), hydroxyzine, cetirizine, loratadine, diphenhydramine, ibuprofen, acetaminophen, aspirin, duloxetine, escitalopram, amitriptyline, amphetamines, prazosin) showed no significant difference, when analyzed as a categorical variable (yes/no). When analyzed as a continuous variable in the unit of % of maximum dosage, there were also no significant differences between the 2 groups except for sertraline ( Table 4 ). Table 4. Medications Reported in Each Patient Group. *indicates statistical significance between No MHD and MHD groups, p<0.05. All Patients No MHD MHD P -value No. of patients (%) 110 (100.0) 53 (48.0) 57 (52.0) – Antiepileptic no. (%) 68 (62.4) 33 (63.5) 35 (61.4) .8456 Gabapentin 66 (60.6) 32 (60.4) 34 (59.6) .8474 Pregabalin 2 (1.8) 1 (1.9) 1 (1.8) >.9999 Opioids no. (%) 8 (7.3) 2 (3.8) 6 (10.5) .2748 Oxycodone 3 (2.8) 1 (1.9) 2 (3.5) >.9999 Acetaminophen/Opioid Combos (Percocet) 4 (3.7) 1 (1.9) 3 (5.3) .6196 Antihistamines no. (%) 25 (23.0) 12(22.6) 13 (22.8) >.9999 Hydroxyzine 12 (11.0) 7 (13.2) 5 (8.8) .5450 Cetirizine/Loratadine 12 (11.0) 7 (13.2) 5 (8.8) .5450 Diphenhydramine 4 (3.7) 0 4 (7.0) .1197 Analgesics no. (%) 26 (23.9) 12 (22.6) 14 (24.6) >.9999 Aspirin 3 (2.8) 0 3 (5.3) .2446 Acetaminophen 15 (13.8) 9 (17.0) 6 (10.5) .4060 Ibuprofen 16 (14.7) 6 (11.3) 10 (17.5) .4268 SSRI/SNRI no. (%) Sertraline 8 (7.3) 0 8 (14.03) .0063* Duloxetine 6 (5.5%) 3 (5.7) 3 (5.3) >.9999 Escitalopram 4 2 (3.8) 2 (3.5) >.9999 TCA no. (%) Amitriptyline 2 (1.8) 0 2 (3.5) .4964 Amphetamines no. (%) 5 (4.6) 0 5 (8.8) .0581 Open in a new tab DISCUSSION This study primarily found that patients diagnosed with a mental health condition demonstrated a decrease in pain perception compared to their prelaser session after each laser treatment that they received, indicating promising outcomes. On the other hand, patients who did not have a diagnosed mental health condition experienced a notable reduction in pain perception only by the third laser session. Regarding self-reported pruritis levels, patients diagnosed with a mental health condition exhibited the most pronounced improvements during the second and third laser sessions compared to the prelaser session, contrasting with the lack of significant improvement seen in patients without a diagnosed mental health condition. Overall, patients diagnosed with a mental health condition demonstrated a mean difference of 1.41 in self-reported pain levels and 1.65 in self-reported itch levels by the third laser session. Comparatively, patients without a diagnosed mental health condition reflected a decrement of 1.34 and 0.32, respectively. The results suggest that there may be other factors that could affect the success of laser therapy. The possibility of differences in the underlying physiological processes of scar healing, such as variation in collagen deposition, angiogenesis, and inflammatory responses, was a pertinent consideration. However, despite the variations in perceptions of itch and pain, the 2 groups had no distinction in overall scar remodeling. The mean POSAS-O scores demonstrated a similar statistically significant improvement in scar healing for both cohorts in laser sessions 2 and 3 from the preoperative scores. Additionally, no statistically significant differences were noted between this observer data and the findings derived from the POSAS-P. Given the lack of significant demographic differences between the 2 groups regarding their burn characteristics and patient demographics, alternative factors must be considered contributors to the observed improvements. Although the percentage of female patients between the groups was not statistically significantly different, there was a higher percentage of females in the MHD vs no MHD groups (53% vs 43%). This skew towards a higher percentage of female patients could partially explain why the MHD group had more improvements. In future prospectively designed trials, gender should be controlled for when randomizing patients due to the known contributor of gender toward patient-reported outcomes. The variation in pain and itch perception between the 2 cohorts may be due to differences in how their central nervous systems process pain. Differences in concomitant medications prescribed or the utilization of cognitive behavioral therapy during the postburn recovery process could contribute to the variations in pain and itch perception between the 2 cohorts. An individual’s cognitive and emotional state can influence their perception of pain and itch, particularly in patients with co-occurring mental health conditions. 26 The concurrent pharmacological therapies used by both cohorts were examined, with a focus on systemic oral medications that may impact the healing process and patient-reported outcomes. It was initially postulated that Group with diagnosed mental health conditions may have been prescribed higher dosages of medications to alleviate pain and itch. In addition, the side effect profile of psychopharmacological treatments may have played a role in the perception of pain and itch. A recent study on healthy subjects found that brain receptors have spatially organized structural connectivity that can modulate brain functions. This complex receptor distribution exhibits varying degrees of correspondence with different mental health disorders, such as attention deficit hyperactivity disorder, autism spectrum disorder, and temporal lobe epilepsy, showing stronger relationships compared to idiopathic generalized epilepsy and schizotypy. 27 Gabapentin is commonly prescribed to burn patients, both inpatient and outpatient, at this institution, as it is shown to be efficacious in reducing neuropathic pain. Gabapentin is a centrally acting antiepileptic agent that blocks the voltage-dependent calcium channels at the dorsal horn, reducing glutamate concentrations. Gabapentanoids additionally have sedating effects, improving sleep quality and contributing to the enhanced perception of pain and itch observed in Group with diagnosed mental health conditions. 28–31 Similarly, other psychiatric medications, such as Serotonin reuptake inhibitors and tricyclic antidepressants prescribed for anxiety and neuropathic conditions, hydroxyzine used for anxiety and insomnia, and second-generation antipsychotics indicated for bipolar disorders and schizophrenia, act on multiple neuroreceptors. Peripheral and central itch sensations are further attenuated by Serotonin 5-HT2 and histamine. 32 Anxiolytics and antidepressants can help address the emotional aspects of pain and itch, improving a patient’s ability to cope. The exact mechanisms by which antidepressants, antiepileptics, and antipsychotics alleviate pain and pruritus are still under investigation. However, some animal studies suggest they may modulate neuroimmune and neuroinflammatory pathways, leading to decreased sensitivity or perception of itch stimuli. 13 , 14 However, further investigation into the specific types of medications used revealed that the 2 cohorts showed no significant differences in prescription rates for pain and itch-related medications. The only medication with a large enough sample size to compare dosages was gabapentin, and it showed no significant differences in dosages between cohorts. This lack of differences in pharmacotherapy suggests that other factors contribute to these pain and itch perception variations. These findings suggest that the integration of mental health treatment and intervention may enhance the overall efficacy of laser therapy for symptomatic scar management in burn patient populations. Research shows that comprehensive care models, which strongly emphasize mental health support, yield positive outcomes for burn survivors. Studies have indicated that patients who received inpatient rehabilitation, which frequently includes psychosocial interventions, such as CBT, mindfulness-based practices, and support group sessions, can help burn survivors develop coping strategies, manage their emotional well-being and ultimately enhance their physical recovery. 33 , 34 Providing comprehensive psychosocial care, from the initial hospital admission through the rehabilitation and reintegration process, is essential for optimizing outcomes for burn survivors. Care that considers the psychological impact of burns can lead to more holistic and patient-centered treatment approaches. Burn injuries can have a profound impact on an individual’s mental health, leading to conditions such as depression, anxiety, and post-traumatic stress disorder. 17–19 , 35 This retrospective single-center study had some methodological limitations. Since the data were derived from medical records not initially intended for research purposes, there was some missing information. There were also challenges in accurately capturing medication data, including issues with patient mobility and discrepancies between pharmacy records and patient histories documented during follow-up visits. Further, substance use disorders would have been an interesting variable to include in this study. Abuse of alcohol and/or drugs may have an effect on patient perceptions of pain and itch and could have contributed to the differences that were observed between the MHD and no MHD groups. The data included in this retrospective review was from 2016 to 2024. The documentation in the EMR was not comprehensive, and we felt the information we could collect would not be strong enough to support a robust analysis surrounding substance use. Beginning in September 2025, when we overhauled some of our initial psychology-based assessments, there is a substance use history section that uses the CAGE questionnaire which is a brief screening tool for alcohol and drug use and/or abuse. While we can’t use this data in the current study, moving forward we will have this data available for retrospective analyses and will collect it for prospective analyses. Additionally, as a retrospective design, this study could only identify associations rather than establish causality. Additionally, the EMR did not help collect nuanced and quantifiable information related to behavioral health interventions, such as CBT. Our current work is to include a qualitative and quantitative framework for mental health behavioral therapy for burn survivors that can be used in research setting for future projects. Finally, a larger sample size would be beneficial in confirming whether psychopharmacological medications have any association with postburn itch and pain. Despite these limitations, this investigation provides valuable insights into the potential role of mental health interventions in burn recovery. Further prospective research is needed to understand better the nuances of how mental health interventions may influence postburn pruritus and pain. Longitudinal studies that track the long-term physical and psychosocial outcomes of burn survivors who receive comprehensive care models that prioritize mental health support would be precious. This framework could include examining the effects of CBT and laser therapy vs. CBT or laser therapy alone. Studying the impact of these factors on health-related quality of life may identify barriers to returning to preinjury functioning. 23 This study serves to identify the necessity for psychological aftercare and its significance in ensuring appropriate support for burn patients, regardless of their mental health conditions. 24 Continued research may lead to effective early interventions and support strategies to improve outcomes for those recovering from burn injuries. CONCLUSION This study highlights the potential influence of mental health conditions on the perception of pain and itch in burn patients undergoing laser therapy. Despite no significant differences in pharmacotherapy between the 2 cohorts, individuals with mental health diagnoses exhibited more pronounced improvements in self-reported pain and pruritic levels compared to those without such diagnoses. These findings suggest that the integration of mental health interventions, such as CBT and mindfulness-based practices, alongside traditional burn treatments, may enhance symptomatic outcomes for burn survivors. Future research should focus on larger cohorts and explore longitudinal effects, with a particular emphasis on how comprehensive psychosocial care models can optimize both physical and emotional recovery following burn injuries. Understanding these nuances may guide the development of more holistic treatment approaches, ultimately improving the health-related quality of life for burn patients. Contributor Information Lia Mandavalli, Firefighters’ Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC, United States; NSU Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, FL, United States. Casey Meretta, Firefighters’ Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC, United States. Ishaan Nandwani, Firefighters’ Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC, United States; Georgetown University School of Medicine, Washington, DC, United States. Taryn E Travis, Firefighters’ Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC, United States; Department of Surgery, Georgetown University School of Medicine, Washington, DC, United States; Department of Plastic Surgery, Georgetown University School of Medicine, Washington, DC, United States; Department of Surgery, The Burn Center, MedStar Washington Hospital Center, Washington, DC, United States. Shawn Tejiram, Firefighters’ Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC, United States; Department of Surgery, Georgetown University School of Medicine, Washington, DC, United States; Department of Plastic Surgery, Georgetown University School of Medicine, Washington, DC, United States; Department of Surgery, The Burn Center, MedStar Washington Hospital Center, Washington, DC, United States. Jeffrey W Shupp, Firefighters’ Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC, United States; Department of Surgery, Georgetown University School of Medicine, Washington, DC, United States; Department of Plastic Surgery, Georgetown University School of Medicine, Washington, DC, United States; Department of Surgery, The Burn Center, MedStar Washington Hospital Center, Washington, DC, United States; Department of Biochemistry and Molecular & Cellular Biology, Georgetown University School of Medicine, Washington, DC, United States. Daniel M Schneider, Department of Surgery, Georgetown University School of Medicine, Washington, DC, United States; Department of Surgery, The Burn Center, MedStar Washington Hospital Center, Washington, DC, United States; Department of Psychiatry, Georgetown University School of Medicine, Washington, DC, United States. Bonnie C Carney, Firefighters’ Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC, United States; Department of Surgery, Georgetown University School of Medicine, Washington, DC, United States; Department of Biochemistry and Molecular & Cellular Biology, Georgetown University School of Medicine, Washington, DC, United States. Author contributions Lia Mandavalli (Conceptualization [supporting], Data curation, Formal analysis, Writing—original draft [lead], Writing—review & editing [supporting]), Casey Meretta (Data curation, Formal analysis, Writing—review & editing [supporting]), Ishaan Nandwani (Data curation, Writing—review & editing [supporting]), Taryn E. Travis (Conceptualization, Methodology, Writing—review & editing [supporting]), Shawn Tejiram (Data curation, Methodology [supporting]), Jeffrey W. Shupp (Funding acquisition [equal], Resources [lead], Writing—review & editing [supporting]), Daniel M. 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