Trauma

Burn Treatment: Superficial to Partial Thickness

Initial/Prep/Goals

1. Severity Classification (assumes No high-risk areas, BSA < 5%) (View image)
   • Superficial epidermal burns (similar to sunburns)
     • Involves only epidermal layer
     • Does not blister
     • Are painful, dry, and red
     • Blanches with pressure
     • Pain and erythema subside after 2-3 days
     • Injured epithelium peels away after 4 days; heals without scarring
   • Partial thickness
     • Involves epidermis and portions of dermis
     • Superficial partial thickness: forms blisters within 24 hours between the epidermis and dermis
       • Painful, red, and weeping
       • Blanches with pressure
       • Initially appears only epidermal in depth, then seen as partial thickness after 12-24 hours
       • Can take up to 21 days to heal and may have scarring with pigment changes
       • Fibrinous exudates and necrotic debris may be present and risks bacterial colonization/delayed healing
       • No functional impairment or hypertrophic scarring usually
     • Deep partial thickness: extends into deeper dermis
       • Damages hair follicles and glandular tissue
       • Painful to pressure only, blister, can be wet or waxy dry
       • Mottled colorization (i.e., patchy white to red)
       • Does not blanch with pressure
       • High risk for infection: if infection prevented: will heal in 2-10 weeks without need for grafting
       • Hypertrophic scarring
       • Joint dysfunction can result if involves joints
       • If fails to heal in 2 weeks it is equivalent to a full-thickness burn
         • Differentiation from full-thickness burns is often difficult
2. Prehospital Care
3. Sterile gauze soaked with cool saline to burns
   • Tap water is equally safe and effective as sterile NS
4. Pain management, antibiotics
5. Be alert for burns that may be due to abuse
   • Burns with distinct shapes of objects
     • Small circular burns (i.e., cigarette or cigar tip)
     • Brands or sharp, point tips (i.e., hot poker)
     • Clothes iron burns
   • Burns on hands or feet that look suspicious for purposeful burns (especially in juveniles or infants)
     • Held over a flame, dipped in boiling water, etc.
   • Burns of waist and below (i.e., dipped in scalding water)
6. Rule of 9s (Open Calc)

Medical/Pharmaceutical

1. Cooling
   • Room temperature water (running water for < 5 minutes; do not macerate wound)
   • Avoid direct ice or iced water applications (painful)
   • Cool gauze
2. Analgesics
   • NSAIDS
   • Acetaminophen
3. Clean wounds as needed
   • If ruptured blisters, debride
   • If unruptured small blisters, leave alone
   • Blisters that last for several weeks should be referred to specialist
4. Antibiotic Ointment
   • Superficial burns and superficial partial-thickness burns rarely develop infections
     • Usually do not require topical antimicrobial agent
     • Non-perfumed moisturizing cream is recommended for superficial burns
     • May consider "first-aid" aloe vera or basic topical antibiotic (e.g., bacitracin, neosporin, etc.)
   • Partial or full thickness burns
     • Topical antibiotics
     • Silver sulfadiazine
       • May slow wound healing and increase frequency of dressing changes (can be pain with frequent re-dressings)
       • Consider newer hydrocolloid or silver impregnated dressings
5. Contraindicated
   • Systemic prophylactic antibiotics
   • Topical or systemic corticosteroids (may impair healing)

Surgical/Procedural

1. Debridement
   • Debride large bullae, loose/ruptured bullae, or bullae covering joints
     • Leave small bullae intact
   • Can be done with forceps and iris scissors or with sterile scrub
   • Consider conscious sedation for select patients/burns
2. Partial and full thickness burns are generally dressed
   • Cover with antibiotic ointment and synthetic burn dressings
     • Can also use strips of fine gauze soaked in normal saline
     • Then covered with 4x4 fluffed gauze
     • Secure with inelastic gauze dressing
   • Wash twice daily with antibiotic and dressing application
3. Superficial burns do not require dressings

Disposition

1. Admission criteria
   • Many can be discharged to home with follow-up as needed
   • Superficial burns
     • Wound recheck in 24 hours for higher risk wounds
     • Ensure adequate analgesia
   • Partial thickness burns
     • These burns should be evaluated by burn specialist if possible
       • Can be difficult to differentiate from full-thickness burns
     • Any partial thickness burn involving > 10% of BSA (in patients < 10 years old and > 50 years old)
     • Ensure early follow up
2. Consults
   • Burn specialist, dermatology as needed
3. Discharge/Follow-up instructions
   • Superficial burns can be discharged to home with instructions for skin care
     • Honey has been shown to be efficacious "home remedy" for superficial burns
     • As wound heals, may become pruritic
       • Systemic antihistamines
       • Topical lotions (AVOID lanolin)
   • Follow-up with PCP/dermatology as needed

Related Topics

• Overview
• Prehospital Care
• Major Burn Treatment

References

1. Kagan RJ, Peck MD, Ahrenholz DH, et al. Surgical Management of the Burn Wound and Use of Skin Substitutes: An Expert Panel White Paper. J Burn Care Res. Mar-Apr 2013;34(2):e60-79
2. Schaefer TJ, Szymanski KD. Burn Evaluation And Management. StatPearls [Internet]. Available at: https://www.ncbi.nlm.nih.gov/books/NBK430741/. [Accessed August 2024]
3. Jeschke MG, van Baar ME, Choudhry MA, et al. Burn injury. Nat Rev Dis Primers. Feb 13, 2020;6(11):1-25
4. Papini R. Management of burn injuries of various depths. BMJ Jul 17, 2004;329(7458):158-160
5. Stander M, Wallis LA. The emergency management and treatment of severe burns. Emerg Med Int. 2011;2011:161375
6. DuBose JA, O'Connor JV, Scalea TM. Lung, Trachea, and Esophagus. In: Mattox KL, Moore, EE, Feliciano DV; (eds). Trauma, 7th ed., McGraw-Hill, Inc, 2013;Chapter 25
7. Pham TN, Cancio LC, Gibran NS. American Burn Association Practice Guidelines: Burn Shock Resuscitation. J of Burn Care and Research Jan-Feb 2008;29(1):257-266
8. Moscati RM, Mayrose J, Reardon RF, Janicke DM, Jehle DV. A multicenter comparison of tap water versus sterile saline for wound irrigation. Academic Emerg Med. May 2007;14(5):404-409

Contributor(s)

1. Latham, Douglas E., MD

Updated/Reviewed: August 2024