Ensuring Prompt And Effective Treatment Of Burns

Jeffrey Bowman DPM MS

With barbeques, the popularity of outdoor activities and many occupations surrounding hot objects, patients commonly present with burns. Thermal injuries can come from chemicals and electricity, not just from fire or the sun.

We typically classify burns into three categories depending on severity and what the skin looks like: first degree, second degree and third degree.1-4 However, there is a fourth degree.

First-degree burns. These burns are much like your basic mild sunburn. The skin is erythematous with no blister formation. These are termed partial thickness burns, meaning the damage to the skin does not go beyond the superficial layers of the epidermis.

Treatment options include the following: aloe vera topical ointment for soothing, Benadryl (or other antihistamine) for itching and non-steroidal anti-inflammatory drugs (NSAIDs) for pain control if needed.1

Second-degree burns. These are partial thickness burns but may vary in depth of injury. Second-degree burns spare hair follicles and sweat glands, but blisters are most likely present. The blisters are a key difference between second- and first-degree burns. We can further categorize these into superficial and deep burns.

Superficial second-degree burns feature erythema with some blister formation. The area may weep and these injuries are painful.1 The burns blanch with pressure.

Deep second-degree burns do not blanch with pressure. The affected area is white with red patches. The injury may be wet or dry. Sometimes these are painless.4

Treatment consists of aloe vera and NSAIDs for pain as needed. As I have mentioned in prior blogs, leave blisters alone if not they do not rupture and cover them with a nonadherent dressing that will not irritate. If blisters have ruptured, then remove loose tissue and cover them with a dressing.

Third-degree burns. These are full-thickness burns. This means the injury has extended past the epidermis into the dermis and subcutaneous tissues. These burns destroy dermal structures such as hair follicles and sweat glands. These are usually painless due to the destruction of the cutaneous nerves. These injuries do not blanch with pressure and appear white or charred.

These are most likely to become infected.4 Clinical signs of infection following a burn include discoloration of the wound (from darkening to a green hue); erythema surrounding and spreading from the wound; spreading necrosis into adjacent areas of the injury; and breakdown of the eschar. The most common organisms found are Staph and Strep although Pseudomonas is often the most common, which would explain any green hue within the wound.

Treatment consists of cleansing the injured area and removing all loose non-viable tissue; applying a topical antibiotic or a silvadene cream with a nonadherent dressing; possible oral antibiotics for further coverage against bacterial infection; and daily wound care by a professional team.

Fourth-degree burns. These are very similar to third-degree burns except now the injury has extended past the subcutaneous tissue, destroying muscle, fat and bone.1-3 The same risks of infection are present. Treatment is the same as for third-degree burns. The risk of amputation is extremely high.

Determining How Much Of The Body Is Injured

There are other things to consider about burns besides the depth of injury.3 These factors include the percentage of body surface involved; internal injuries from inhalation of hot and toxic fumes; and promptness in managing infection, fluids and electrolyte levels.

The Rule of Nines is the classic method of determining the total surface area injured.1 Segmental body parts are in multiples of 9. Each arm is 9 percent, the head is 9 percent and each leg is 18 percent. The torso, both front and back, are each 18 percent. The palm is 1 percent and each foot is 3.5 percent. Only use this for adults. The percentages are slightly different in children.

A major burn is classified as follows:
o Covering more than 10 percent of the body in a patient under age 10 or over age 50
o Covering more than 20 percent in a patient between ages 10 and 50

A minor burn is classified as follows:
o Covering less than 10 percent of the body in a patient under age 10 or over age 50
o Covering less than 20 percent in a patient between ages 10 and 50

General Insights On Burn Treatment

We can use the five Cs to summarize burn treatment.1

Cut. Cut away clothing that is burned. Adhered clothing may need surgical removal.

Cool. Use cooled, sterile saline soaked gauze. One can use ice but should be aware of potential frostbite. The purpose of this step is to stop cellular death and decrease pain/hyperthermia.

Clean. Remove any and all loose tissue. This can occur gently with a soft towel or washcloth, mild soaps and chlorhexidine. One may use a whirlpool. Ensure complete debridement of blisters. Anesthesia may be necessary.

Chemoprophylaxis. Apply antibacterial ointments/creams such as silvadene.

Cover. Use a nonadherent, occlusive dressing followed by loose application of a gauze wrap.

Severe burns left untreated can lead to extreme disability and loss of function. Severe burns require hospitalization until the individual is stable. Further treatment involves daily wound care and the possibility of skin grafting or amputation.


1. McGlamry ED, Banks AS, Downey MS. Foot and Ankle Surgery, third edition, volume 2. Lippincott, Williams and Wilkins, Philadelphia, 2001.
2. Coughlin MJ, Mann RA, Saltzman CL (eds.) In Surgery of the Foot and Ankle, eighth edition, volume 2. Mosby, St. Louis.
3. Kumar V, Abbas AK, Aster JC, Fausto (eds.) Robbins and Cotran Pathologic Basis of Disease, eight edition. Saunders, Philadelphia, 2009.
4. Joseph W. Handbook of Lower Extremity Infections, third edition. Data Trace, Brooklandville, MD, 2009.

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