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No ice, no butter
Advice on management of burns for primary care physicians
Matthew C. Clayton, MD and Lynn D. Solem, MD
It is often difficult to determine the true extent of a burn, but most small thermal burns can be easily evaluated and managed by primary care physicians. In this article, the authors review the characteristics of different types of burns, describe those that require treatment in a burn center and discuss appropriate measures to hasten healing and promote a satisfactory cosmetic outcome.
Although about two million people in the United States are burned every year, only five percent require hospitalization.1 Most patients with burn injuries are treated as outpatients by primary care and emergency department physicians.2 Management of a burn includes identification of cause, assessment of depth and size, appropriate debridement, prophylaxis for infection, attention to pain control and diligent follow-up care. Treatment is directed to restoration of function and an acceptable cosmetic result. In some cases, referral to a surgeon or burn specialist is necessary. Associated illness or injuries and psychosocial problems may mandate temporary hospitalization.
Burns are caused by exposure to heat, electricity, chemicals or radiation.
- Thermal injuries are most common and with experience, most physicians can easily evaluate and manage small burns.
- Electrical injuries occur much less frequently than thermal burns and tend to cause deep tissue destruction beneath seemingly undamaged skin. In addition, house current can precipitate ventricular dysrhythmias.
- Chemical injuries also may be deeper and more extensive than they initially appear. For example, a burn due to exposure to low-concentration hydrofluoric acid, which is the most common cause of chemical injuries in the semiconductor industry, may be initially painless but later cause excruciating pain and severe tissue necrosis.
- Radiation injuries are extremely rare occurrences.
Many nonthermal burns require evaluation by experienced burn physicians, especially if deep tissue injury is suspected. Telephone consultation is available at regional burn centers whenever a physician is unsure whether more specialized care is needed.
An often overlooked cofactor in burn cases is drug and alcohol use. A recent study3 found that about one-quarter of patients admitted to a burn unit were intoxicated at the time of injury and 30 percent of those met the study criteria for chronic alcohol abuse. Interestingly, none of those meeting the criteria were over 60 years of age. Because alcohol abuse may adversely affect burn injury outcome, physicians should be alert for signs of chronic alcohol or other drug abuse and be prepared to initiate appropriate referral or therapy as needed.
Determining the depth of a burn is of paramount importance in planning therapy. Unfortunately, it is often quite difficult, even for a physician experienced in burn management, to predict burn depth accurately during initial evaluation. The depth may vary within the same wound, and the burn’s appearance may be misleading (as in cases of blisters over full-thickness burns). In addition, the depth may vary according to the body part affected; identical thermal exposure may cause a superficial injury on the thick palmar skin but a serious partial thickness injury on the thin skin of the abdomen or medial thigh.
Burns are classified as first, second, or third degree. Their characteristics are illustrated in Figure 1 and summarized in Table 1.4
First degree: Sunburn is a typical first-degree burn, with erythema of the skin but no blistering (Figure 2). It heals spontaneously in 3–6 days. Hospitalization is required only if fever, dehydration, or uncontrollable pain develops. First-degree burns are not included in calculations for burn size.
Second degree: These burns involve the entire epidermis and some portion of the dermis. Second-degree burns are often subclassified either as superficial partial-thickness burns or as deep partial-thickness burns.
Superficial partial-thickness burns (Figure 3a) cause blistering and are painful. Under the blister, they are red and moist. They heal within three weeks with minimal cosmetic defects, usually with only a change in pigmentation. Desiccation, infection or improper treatment may convert a superficial burn into a deeper burn.
Deep partial-thickness burns (Figure 3b) are dry and may appear ivory or pearly white. They require longer than three weeks to heal and typically produce severe deep partial-thickness burns and hypertrophic scarring.
Third degree: These burns destroy the full thickness of the epidermis and dermis. They are dry, with a dark brown or leathery appearance (Figure 4). Most third-degree burns larger than three cm in diameter are best treated with early excision, immediate skin grafting and long-term use of compression garments (BartonCarey, Jobst, Tubigrip) to minimize hypertrophic scarring.
In addition to the depth of the burn, the area of the wound must be determined. In cases of small or scattered burns, the rule of the palm is useful. This rule states that the patient’s (not the physician’s) palm, excluding fingers and thumb, represents one percent of his or her total body surface area. The rule of nines (Figure 5) is also useful but is accurate only in adults. The Lund-Browder classification (Figure 6)5 is accurate for all ages and is the “gold standard” for estimating burn area.
As the total surface area of a burn increases, morbidity and mortality also increase. Even small burns may be fatal in the elderly.6 The American Burn Association (ABA) has developed a classification based on burn surface area and patient age (table 2).7
Typically, burns managed in the outpatient setting are small, superficial thermal burns that do not affect areas of (1) critical function (i.e., hands or joints) or (2) cosmetic concern (i.e., the face). These wounds usually meet the criteria for minor burns given in Table 2. Persons with larger or deeper burns, circumferential burns of an extremity, burns complicated by an underlying medical condition or burns of the hands, joints or face are best treated as inpatients. Such wounds usually meet the criteria for major burns in Table 2 and, by ABA criteria, are best managed in a burn center. Some patients with minor burns require a short inpatient stay for pain control.
Initial outpatient management includes pain control, cleansing of the wound, debridement of blisters or bullae and application of a suitable dressing. An up-to-date tetanus immunization should be confirmed.
Table 1. Characteristics of burns, by depth
|First degree |
Superficial epidermal congestion and dilation of intradermal vessels
|UV exposure, very short flash||Red; blanches with pressure||Present||3-6 days||No|
|Second degree |
Varying depth, with blisters and bullae; sparing of dermal appendages (i.e., sweat glands, hair follicles)
|UV exposure, very short flash||Red; blanches with pressure||Present||3-6 days||No|
|Superficial||water scald, short flash||Red, weeping; blanches with pressure||Painful||7-20 days||Unusual if healed in 3 wk; pigment change Severe; risk of contracture|
|Deep||Flame, oil, grease, hot foods (e.g.,soup)||Variable color (white with red elements) wet or waxy dry; does not blanch||Pressure only||>21days||Severe; risk of contracture|
|Third degree |
Loss of all skin elements; thrombosis and coagulation of vessels
|Flame, steam, oil, grease; immersion scald; chemical, electrical||White or charred, dry, inelastic; no blanching with pressure||Deep pressure only||Never||Very severe; risk of contracture|
Pain control: An acute burn, particularly a superficial one, exposes dermal nerve endings. Any manipulation of the wound causes intense pain. Immediate cooling with water lessens pain and postburn hyperthermia and may also decrease the depth of the injury.
Narcotics are always required for adequate pain control of an acute burn and usually are needed until the wound has epithelialized. Acetaminophen with codeine may be adequate for children but is rarely sufficient for adults. Acetaminophen with oxycodone (Percocet, Tylox) is very effective pain control in adults. Aspirin is usually avoided in the presence of unhealed burns because the antiplatelet effects may exacerbate blood loss if skin grafting becomes necessary.
Cleaning and debridement: Small burns are cleansed intitially and daily with a mild soap, gently debrided and rinsed with tap water. This is done as a clean, but not sterile, procedure; sterile gloves and saline solution are not required.
Debridement of blisters and bullae is a matter of controversy, but we generally remove those larger than the diameter of a quarter and those that cross a joint. Blisters and bullae that have already drained or are leaking must be debrided, as they are otherwise a potential source of infection. Small blisters may be left intact but aspiration should not be done because it may introduce bacteria into a closed space.
Dressings: Choosing a suitable would dressing is a matter of personal preference and experience. The most widely used dressing is silver sulfadiazine (SSD, Silvadene). It is usually applied to the wound and covered with gauze. Recently, many investigators have challenged silver sulfadiazine in prospective, randomized trials done in search of the optimal dressing. Biobrane,8 DudDerm,9,10 Opsite, 11 and Inerpan12 have all recently been compared with silver sulfadiazine. Although these newer types of dressings appear to have some advantages in terms of decreased frequency of changes, slightly better compliance and marginally faster healing, none has been found clearly superior to silver sulfadiazine.
Table 2. Classification of burn severity according to patient age and burn surface area*
|Classification||Patient age (yr)||Burn surface area|
|Minor||Less than 10 or greater than 50 10-50||Less than 10 percent, Less than 20 percent|
|Major||Less than 10 or greater than 50||Greater than 10 percent, Greater than 20 percent|
*Factors mandating admission to hospital include burns of face, hands, feet, perineum or genitalia; inhalation injury; associated major trauma; concurrent major medical illness; and electrical or chemical injury.
We recommend bacitracin (Baciguent) ointment for most wounds suitable for outpatient treatment. It is an inexpensive antimicrobial agent that is very widely available, is easily applied and adheres even to exposed areas such as the face. Silver sulfadiazine is also satisfactory but is more expensive, is not proved to be more effective and may actually impede healing.13
Except for facial burns, which are treated open, gauze is applied over the bacitracin. Over time, bacitracin may sensitize the skin and cause a rash, in which case it should be discontinued.
Most burns are cleansed and dressed once each day. More frequent changes increase patient discomfort without improving the clinical rate of healing. The patient must be encouraged to remain active throughout the course of healing. Analgesia must be adequate so that the patient remains ambulatory. Affected areas, particularly the hands, should also be kept active. Splinting of burned hands causes stiffness and prolongs disability and does not speed healing. The patient should return to employment as soon as feasible.
The first few dressing changes should be done under the supervision of the physician caring for the patient. After this time, almost all patients can care for their burn at home, assisted by a family member or a visiting nurse. Weekly office examinations allow the physician to evaluate the rate of healing. Any wounds not healed within three weeks of injury in an adult or two weeks in a child are likely to form hypertrophic scarring and should be treated with early excision and grafting.
Initially after healing, the skin is dry and prone to itching. An inexpensive moisturizer such as Vaseline Intensive Care Lotion is used as soon as a wound is closed. As the skin matures and becomes more durable, other agents such as Lubriderm, Corrective Concepts or Eucerin are used. Lotions containing urea (Atrac-Tain, Lacthydrin) may help to reduce itching.
Itching is caused by dysesthesias that develop as the wound heals, as well as by dryness. Oral antihistamines such as diphenhydramine (Benadryl) and hydroxyzine (Atarax, Vistaril) are often prescribed but may or may not be beneficial; no antihistamine has been shown to be more effective than another.14 Many patients benefit from judicious application of a vibrator to the site of itching. Vibration fatigues the nerve endings and decreases itching but care needs to be taken not to injure the newly-epithelialized wound.
Patients report that newly-healed burns are sensitive to extremes of temperature and the wound should be protected if this is the case. The new skin is prone to windburn, frostbite and sunburn. Sun exposure should be avoided for a year after injury; if exposure is unavoidable, SPF 25 sunscreen should be used for protection. Repeated injury often results in permanent hyperpigmentation (Figure 7).
Hypertrophic scarring (Figure 8) can be minimized through the use of pressure garments, specially fashioned pressure splints (i.e., face masks) and intradermal corticosteroid injections.
The goals of burn treatment are (1) promotion of wound healing, (2) maintenance of patient comfort and (3) rapid return of the patient to preburn function. Most burn victims are treated as outpatients. Dressings are changed daily using bacitracin (Baciguent) or silver silvadene and pain is controlled with narcotics. The patient is encouraged to remain active during healing. Wounds that require more than three weeks (two for children) to heal should be considered for early skin grafting to reduce healing time, minimize scarring and functional outcome.
- CR Baxter CR and JF Waeckerle. Emergency treatment of burn injury. Ann Emerg Med 17(12):1305-1315, 1988
- C Hendrickson, LD Solem, B Moudry, et al. Epidemiology of outpatient burns treated in an emergency room. 23rd Annual Meeting of the American Burn Association. Baltimore, Md: American Burn Assoc, 1991:95
- JD Jones, B Barber, L Engrav, et al. Alcohol use and burn injury. J Burn Care Rehab 12(2):148-152, 1991
- WF Peate. Outpatient management of burns. Am Fam Physician 45(3):1321-1330
- CC Lund and NC Browder. The estimation of areas of burns. Surg Gynecol Obstet 79(0ct):352-358, 1944
- MC Clayton, DH Ahrenholz and LD Solem. Geriatric burn mortality. (In press)
- American Burn Association. Advanced burn life support course. National Burn Institute, Lincoln. Neb
- GL Gerding, CL Emerman ,D Effron, et al. Outpatient management of partial-thickness burns: Biobrane versus 1% silver sulfadiazine. Ann Emerg Med 13(2):121-124, 1930
- M Afilalo, J Dankoff, A Guttman, et al. DuoDERM hydroactive dressing versus silver sulphadiazine/Bactigras in the emergency treatment of partial skin thickness burns. Burns 18(4):313-316, 1992
- D Wyatt, DN McGowan, MP Najarian. Comparison of a hydrocolloid dressing and silver sulfadiazine cream in the outpatient management of second-degree burns. J Trauma 30(7):857-865, 1930
- TD Poulsen, KG Freund, P Arendrup, et al. Polyurethane film (Opsite) vs. impregnated gauze (Jelonet) in the treatment of outpatient burns: a prospective, randomized study. Burns 17(1):53-61, 1991
- J Guilbaud. European comparative clinical study of Inerpan: a new wound dressing in treatment of partial skin thickness burns. Burns 18(5):419-422, 1992
- RL McCauley, YY Li, B Poole, et al. Differential inhibition of human basal keratinocyte growth to silver sulfadiazine and mafenide acetate. J Surg Res 52(3):276-285, 1992
- M Vitae, C Fields–Blache and A Luterman. Severe itching in the patient with burns. J Burn Care Rehab 12(4):330-333, 1991