Description

  • injury with necrosis of epidermis and dermis after thermal, chemical, electrical, or radiation exposure

Types

  • first-degree (epidermis only)
  • second-degree (through epidermis and into dermis)
    • superficial
    • deep
  • third-degree (all layers of skin including subcutaneous fat)

Who is most affected

  • children and elderly patients

Possible risk factors

  • increased age
  • drug and/or alcohol abuse
  • photosensitizer medication use, including
    • amiodarone
    • chlorpromazine
    • hydrochlorothiazide
    • antibiotics (nalidixic acid, fluoroquinolone, doxycycline, tetracycline, voriconazole)naproxen
    • piroxicam
    • retinoids
  • for children < 5 years old, access to hot liquids without adult supervision

Causes

  • most common causes of superficial burns
    • sunburn
    • minor thermal injury
  • causes of thermal burns
    • scalds
      • in children
        • 70% to 80% of burns
        • hot liquid, steam, spill, or immersion
        • warm air humidifier
      • in adults
        • hot food, water and steam in patients ≥ 65 years old
        • hot bath water
    • fire (flame or flash)
      • about 50% of adult burns
      • associated with trauma or inhalation injury
    • contact with hot surfaces
  • causes of chemical burns
    • acids
    • alkalis
    • petroleum products
    • phosphorous
    • airbags
    • hair dyes
    • fabric detergents
  • causes of radiation burns
    • sunburn
    • industrial electromagnetic and particle radiation
  • electrical burn
    • may be high voltage, low voltage, or flash

History

Chief concern (CC)

  • pain

History of present illness (HPI)

  • assess risk for
    • concomitant injury
    • inhalation injury
  • if non-accidental injury suspected in a child, check for inconsistencies in histories

Medication history

Continue Reading

  • ask about use of photosensitizing drugs

Physical

Skin

  • determine depth of burn
  • first-degree burn
    • tenderness
    • dry erythema without blisters
    • brisk capillary refill with pressure
    • brisk bleeding with 21-gauge needle pin prick
  • second-degree burn
    • superficial partial-thickness (second-degree) burn
      • tenderness
      • blanching with pressure
      • wet, weeping, erythematous skin
      • clear blisters
      • usually pink but may be white
      • brisk bleeding with 21-gauge needle pin prick
    • deep partial-thickness burn

no sensitivity to touch or dull sensation

white or fixed red coloration

non-blanching with pressure

blisters

delayed bleeding with 21-gauge needle pin prick

  • third-degree (full-thickness) burn
    • no sensitivity to touch
    • dark brown, tan, or white with leathery feel
    • may be charred and dry or hard and waxy
    • no blisters
    • no blanching with pressure, capillary refill
    • no bleeding with pin prick
  • estimate body surface area (BSA) affected for second- and third-degree burns
    • Lund-Browder chart of body surface
      • most accurate
      • estimated BSA
        • neck
          • anterior 1%
          • posterior  1%
        • trunk
          • anterior 13%
          • posterior 13%
        • upper arm
          • each posterior 2%
          • each anterior 2%
        • lower arm
          • each anterior 1.5%
          • each posterior 1.5%
        • each buttock 2.5%
        • genitalia 1%
        • foot
          • each top 1.75%
          • each bottom 1.75%
        • age-based variable percentages for
          • each half of head
          • each half of 1 thigh
          • each half of lower leg
    • Wallace rule of nines
      • fast estimate of medium to large burns in adults
      • estimated total BSA in adults
        • head 9%
        • anterior trunk 18%
        • posterior trunk 18%
        • each upper extremity 9%
        • each lower extremity 18%
        • genitalia 1%
    • palmar surface measurement
      • assumes palmar surface of patient’s hand is about 0.8% of total BSA for adults and about 1% of total BSA for children
      • useful for estimation of
        • small burns (< 15% total BSA
        • small unburned areas in cases of major burn (> 85% total BSA)
      • inaccurate for medium sized burn

Making the diagnosis

  • clinical diagnosis with history of exposure and findings of injured or necrotic skin
  • criteria for minor burns
    • first-degree burns
    • second-degree burns affecting
      • 5% of total BSA in patients < 10 years old or > 50 years old
      • 10% of total BSA in patients aged 10 to 50 years
    • third-degree burns  < 1% of total BSA
    • for second- and third-degree burns
      • no involvement of face, hands, perineum, genitals, or feet
      • no crossing of a major joint
      • not circumferential
    • no concomitant injury or severe trauma
    • no comorbidity

Differential diagnosis

  • phytocontact dermatitis
    • mustard seed
    • buttercup
  • other mimics
    • leukemia cutis
    • toxic epidermal necrolysis
    • pressure necrosis

Testing overview

  • no additional testing required

Treatment overview

  • for first-degree (superficial) burns
    • moist environments
    • topical agents and dressings
    • comparative efficacy
      • studies generally of poor quality
      • insufficient evidence to determine superiority of any single burn dressing
  • for treatment of second-degree (partial-thickness) burns
    • indications for referral to burns specialist
      • unlikely to heal within 3 weeks (deep partial-thickness or full-thickness )
      • partial-thickness burns > 10% of total BSA or > 5% in children < 16 years old
      • worsening over first 72 hours (increased depth or signs of infection)
      • not healed within 2 weeks
    • consider blister management and debridement
      • no consensus and limited clinical evidence for management
      • suggestions for blister management for partial-thickness burns
        • leave intact if
          • blisters < 6 mm
          • larger blisters on palms or soles not restricting movement
        • debride if
          • blisters > 6 mm
          • prevent joint movement or likely to rupture
        • keep debrided wound moist with topical dressing
    • use occlusive dressing or topical agent
      • non-silver dressings
        • insufficient evidence to support superiority of any type for superficial and partial-thickness burns
        • associated with faster healing times compared to silver sulfadiazine
      • silver sulfadiazine in cream or dressing associated with higher rates of infections in burns compared to other dressings
  • pain control as needed,
  • tetanus booster if > first-degree burn
  • if non-accidental injury suspected in a child, immediately notify social services
  • refer to burns specialist or reconstructive surgeon if
    • significant scarring
    • any contracture

Complications

  • infection
  • hypo or hyperpigmentation
  • respiratory-related hospital admission

Prognosis

  • usual time to healing
    • superficial burn, about 3 to 10 days
    • superficial partial-thickness burn, about 2 weeks
    • deep partial-thickness burn, ≥ 3 weeks

Prevention

  • evidence-based prevention strategies
    • in infants and children
      • properly installed and maintained smoke detectors
      • water heater temperature preset to < 130° F (54.4° C)
      • clinical counseling to increase smoke detector use
    • for sunburn
      • SPF 40 sunscreen more effective than SPF 12
      • topical aloe vera cream likely not effective 

Dr. Drabkin is a senior clinical writer for DynaMed (www.ebscohost. com/dynamed), a database of comprehensive updated summaries covering more than 3,200 clinical topics, and assistant clinical professor of population medicine at Harvard Medical School.

From the July 01, 2017 Issue of Clinical Advisor

Topics:

Burns Dermatology