Partial thickness burns

Related Terms

Autograft, cardiopulmonary resuscitation, chemical burn, collagen, CPR, debride, dermis, electrical burn, electromagnetic burn, epidermis, escharotomy, eschars, first-degree burn, friction burns, full thickness burn, hyperalimentation, melanocytes, myoglobin, nasogastric tube, pain receptor, partial thickness burn, perineum, photoaging, radiation burn, radiation treatments, rhabdomyolysis, second-degree burn, skin graft, subcutaneous, subcutis, subQ, sunburn, thermal burn, third-degree burn, touch receptor, ultraviolet rays, UV rays, UVA rays, UVB rays, xenograft.

Background

Burns are a type of traumatic injury caused by thermal (heat such as fire, steam, tar, or hot liquids), electrical, radiation (UV rays or radiation treatments), chemical, or electromagnetic energy.
Burns are classified as first-degree (mild), second-degree (moderate), or third-degree (severe), depending on how deep and severe they penetrate the skin's surface.
An open flame is the leading cause of burn injury for adults, while scalding is the leading cause of burn injury for children.
Burns can cause swelling, blistering, scarring, and, in serious cases, shock and even death. Burns also can lead to infections because they damage the skin's protective barrier. After a third-degree burn, individuals need skin or synthetic grafts to cover exposed tissue and encourage new skin to grow. First- and second-degree burns usually heal without grafts.
When tissues are burned, fluid from outside the cells leaks into the tissues from the blood vessels, causing swelling and pain. In addition, damaged skin and other body surfaces are easily infected because they can no longer act as a barrier against invading organisms.
More than two million people in the United States require treatment for burns each year, and between 3,000-4,000 individuals die of severe burns. Older people and young children are particularly vulnerable.
About 20% of burns occur in children younger than age five, and most of these are scald burns from hot liquids.
About 60% of burns occur in the 18-64 year-old age group.
About 10% of burns occur in older adults, mostly scald burns from hot liquids.
Men are twice as likely to have burn injuries as women.
The skin is the body's largest organ, covering the body. In addition to serving as a protective shield against heat, light, injury, and infection, the skin also regulates body temperature. The skin also stores water and fat, is a sensory organ, prevents water loss, and prevents the entry of bacteria.
The skin has many important functions. It is composed of several layers, with each layer performing specific functions. The epidermis is the thin outer layer of the skin. The epidermis also contains melanocytes, which are cells that produce melanin (skin pigment). The dermis is the middle layer of the skin. The dermis contains blood vessels, lymph vessels, hair follicles, sweat glands, collagen bundles, fibroblasts, and nerves. The dermis is held together by a protein called collagen, made by fibroblasts. The dermis layer also contains pain and touch receptors. The subcutaneous layer, or subcutis (subQ), is the deepest layer of skin. The subcutis consists of a network of collagen and fat cells. This network helps conserve the body's heat and protects the body from injury by acting as a "shock absorber."

Signs and symptoms

First-degree burns: First-degree burns (or superficial burns) involve only the epidermis, or the outermost layer of the skin. First-degree burns are red, moist, swollen, and painful. The burned area whitens (blanches) when lightly touched but does not develop blisters. Sunburns are generally considered first degree burns.
Second-degree burns: Second-degree burns (or partial thickness burns) involve the epidermis and some portion of the dermis, the second layer of the skin. This type of burn may be broken down into superficial or deep, depending on how much of the dermis is involved. Superficial signs and symptoms include pain and redness at the burn site. This area may turn white to touch and appear discolored, blistered, and moist. Hairs may still be present. Deep signs and symptoms include: may or may not be painful, due to the fact that burns may be so deep that nerve endings have been destroyed; may be moist or dry, as sweat glands may have been destroyed; may or may not turn white when area is touched; and hairs are usually gone.
Third-degree burns: Third-degree burns (or full thickness burns) are the most severe. Third-degree burns involve all of the epidermis and dermis - the first two layers of the skin. Nerve endings, tiny blood vessels, hair follicles, and tiny sweat glands are all destroyed. If very severe, the burn may involve bone and muscle. Third degree burn areas are painless (due to damaged nerve endings). There is no sensation to touch, and they appear pearly white or charred, dry, and possibly leathery. No blisters develop. The appearance and symptoms of deep burns can worsen during the first hours or even days after the burn.

Diagnosis

If the burn is severe enough for the individual to be taken to the hospital, the doctor will take a history and perform a physical examination to determine the extent and severity of the burn. In determining the extent of the burn, the doctor may use a tool called the Rule of Nines. This tool is a formula that divides the surface area of the body into sections, each roughly 9%. Determining the amount of surface area burned helps the doctor with treatment of the burn. The doctor will determine whether the burn or burns are superficial, partial thickness, or full thickness and then begin appropriate treatment.
Special charts are used to show what percentage of the body surface various body parts comprise. For example, in an adult, the arm constitutes about 9% of the body. Separate charts are used for children, because their body proportions are different. All first-degree burns as well as second-degree burns that involve less than about 15% of the body surface usually are classified as minor, although they may seem severe to the person. A third-degree burn may be classified as minor if it involves less than 5% of the body surface, unless it involves the face, hands, feet, or genitals. Burns involving these areas or involving deeper layers of skin over larger areas of the body are classified as moderate or, more often, as severe.
In addition to the intensity, the total area of the burn is significant. This is usually measured in terms of percent of total body burnt. The skin acts as a barrier from the environment, and without it, patients are subject to infection and fluid loss. Burns that cover more than 15% of the total body surface can lead to shock and require hospitalization for intravenous fluid resuscitation and skin care.
Because the age of a burn victim and the percentage of the body's surface area that has been burned are the two most important factors affecting the prognosis of a burn injury, the American Burn Association recommends that burn patients who meet the following criteria should be treated at a specialized burn center: younger than 10 years or older than 50 years with partial- or full-thickness burns over 10% or more of the total body surface area (TBSA); age 10 years or older or age 50 years or younger with partial- or full-thickness burns over 20% or more of the TBSA; any age with full-thickness burns covering 5% or more of the TBSA; burns of the face, hands, feet, or perineum (groin, or genital area), or burns that extend all the way around a portion of the body; burns accompanied by an inhalation injury affecting the airway and/or the lungs; burn patients with existing chronic conditions such as diabetes, high blood pressure, heart disease, kidney disease, or multiple sclerosis; chemical burns; electrical injury; scald burns; grease burns; tar burns; and radiation burns.

Complications

Most minor burns are superficial and do not cause complications. However, deep second-degree and third-degree burns swell and take more time to heal. In addition, deeper burns can cause scar tissue to form. This scar tissue shrinks (contracts) as it heals. If the scarring occurs at a joint, the resulting contracture may restrict movement. Thick, crusty surfaces (eschars) are produced by deep third-degree burns. Eschars can become too tight, cutting off blood supply to healthy tissues or impairing breathing if occurring near the throat. Burns can also cause emotional problems, such as depression, nightmares, or flashbacks from the traumatizing event. The loss of a friend or family member and possessions in a fire may add grief to the emotional strain of a burn.
A severe burn (third-degree) can be a seriously devastating injury, not only physically but emotionally. A severe burn can not only affect the burn victim, but the entire family. Individuals with severe burns may be left with a loss of certain physical abilities, disfigurement, loss of a limb, loss of mobility, scarring, and infection. In addition, severe burns are capable of penetrating deep skin layers, causing muscle or tissue damage that may affect every system of the body.
Severe burns can cause serious complications due to extensive fluid loss and tissue damage. Complications from severe burns may take hours to develop. The longer the complication is present, the more severe the problems it tends to cause. Young children and older adults tend to be more seriously affected by complications than other age groups.
Dehydration eventually develops in people with widespread burns, because fluid seeps from the blood to the burned tissues. Shock develops if dehydration is severe. Shock is a life-threatening condition that occurs when the body is not getting enough blood flow. Destruction of muscle tissue (rhabdomyolysis) occurs in deep third-degree burns. The muscle tissue releases myoglobin, one of the muscle's proteins, into the blood due to muscle tissue breakdown. If present in high concentrations, myoglobin harms the kidneys. Rhabdomyolysis can be diagnosed from tests of the blood and urine.

Treatment

Burn location is very important in determining treatment. Burns of the neck or signs of burns to the nose or mouth can require emergent protection of the patient's airway, as swelling can result in life-threatening obstruction of the airway. Burned tissue shrinks and can cause damage to underlying structures. Burns that extend circumferentially around body structures require surgical release of the tissue, often referred to as escharotomy. Escharotomy usually causes some bleeding, but because the burn causing the eschar has destroyed the nerve endings in the skin, there is little pain. Escharotomy is considered a surgical procedure.
All eye burns require special attention as soon as possible. Burns to the eye may lead to clouded or lost vision if tissues, such as the cornea, are injured.
A doctor should examine a burn if it has any of the following characteristics: it is larger than the approximate size of the person's palm; contains blisters; darkens or breaks the skin; involves the face, hand, feet, genitals, or skin folds; is not completely clean; causes pain that is not relieved by acetaminophen (Tylenol?) or ibuprofen (Advil?); or causes pain that does not improve within one day after the burn was sustained.
Burn first aid: To care for a burn victim with a first- or second-degree burn, first remove the burning agent from inflicting further damage. For example, fires are extinguished and smoldering clothing that may be covered with hot tar or soaked with chemicals is immediately removed. Any constricting jewelry, such as rings are removed. It is important to distinguish that all third degree burns and complicated location burns, such as the airway and eyes, need immediate evaluation by a doctor, and burnt clothing and/or burning agents should not be removed without supervision by a healthcare provider.
It is recommended by healthcare professionals not to use butter or oils on a burn. The affected area should be dowsed with cool water as soon as possible. It can be cleansed gently with chlorhexidine (Betadine?) solution. It is recommended by healthcare professionals to not apply ice or cool to near-freezing temperatures; this can cause additional tissue injury.
A tetanus booster will be given if the individual has not had a tetanus shot or booster within the previous five years.
First degree thermal burns can be treated with local skin care such as aloe vera. Many topical antibiotics (such as Neosporin? or Bacitracin?) and antiseptics (such as chlorhexidine (Betadine?) are available over-the-counter (OTC) for minor burns.
Keeping the burned area clean is important because the damaged skin is easily infected. Cleaning may be accomplished by gently running water over the burns periodically. Wounds are cleaned and bandages changed one to three times per day. The burn can be covered with a sterile gauze bandage. The gauze should be wrapped loosely to avoid putting pressure on burned skin. Bandaging keeps air off the burned skin, reduces pain, and protects blistered skin.
Minor burns usually heal without further treatment. They may heal with pigment changes, meaning the healed area may be a different color from the surrounding skin. It is recommended by healthcare professionals to watch for signs of infection, such as increased pain, redness, fever, swelling or oozing. Seek medical help if infection develops. Avoid re-injuring or tanning if the burns are less than a year old. Tanning may cause more extensive pigmentation changes.
Sunburns: Burns caused by solar radiation may be painful and may also blister. Cool the burn. Individuals may want to put a product designed specifically for sunburn on the area; these products usually contain aloe vera and help cool the area and reduce the pain. Protect the burn by staying out of the sun. If the individual must go in the sun, it is recommended by healthcare professionals to wear a sunscreen with a sun protection factor (SPF) of at least 15 and reapply it frequently. Be sure to cover up any existing sunburn if going outside again. It is best not to apply sunscreen to already burned skin, as irritation may occur.
Severe burns: All third degree thermal burns and complicated location burns, such as the airway and eyes, need immediate evaluation by a doctor. Special topical antiseptic creams, such as silver sulfadiazine (Silvadene?) and mafenide acetate (Sulfamylon?), are used for more serious burns.
For severe burns, healthcare professionals recommend dialing 911 and calling for emergency medical assistance.
If someone is on fire, the following steps are recommended until emergency personnel arrive: tell the person to STOP, DROP, and ROLL. Wrap the person in thick material to smother the flames (a wool or cotton coat, rug, or blanket). Douse the person with water; do not remove burnt clothing. However, do make sure the victim is no longer in contact with smoldering materials or exposed to smoke or heat; do not immerse severe large burns in cold water. Doing so could cause shock; check for signs of circulation (breathing, coughing, or movement). If there is no breathing or other sign of circulation, begin cardiopulmonary resuscitation (CPR) and cover the burn area with a dry sterile bandage (if available) or clean cloth. A sheet will do if the burned area is large. Do not apply any ointments. Avoid breaking burn blisters.
Pain medications: A doctor may advise individuals with minor or moderate burns to use ibuprofen (Motrin? or Advil?) or acetaminophen (Tylenol?) if the burn is minor and the pain mild. If pain is severe, the doctor may prescribe a narcotic pain reliever, such as acetaminophen with codeine (Tylenol#3?) or hydrocodone (Lortab?). Severe burns are treated with stronger narcotic pain relievers such as morphine (MS Contin?) or meperidine (Demerol?). Side effects of narcotic pain medications include sedation, constipation, and addiction.
Dietary concerns: In severe burns, a proper diet that includes adequate amounts of calories, protein, and nutrients is important for healing. Individuals who cannot consume enough calories may drink nutritional supplements or receive them by way of a tube inserted through the nose into the stomach (a nasogastric or NG tube), or nutrition may be given intravenously (IV, or through the veins), termed hyperalimentation. Oral rehydration therapy may be given to replace lost fluids.
Depression: Because severe burns take a long time to heal, sometimes years, and can cause disfigurement, the person can become depressed. Depression often can be relieved with medications, psychotherapy, or both.
Other treatments: Some doctors may debride blisters (cut away dead tissue). Others may leave them intact. Blisters on the soles of the feet or palms of the hands will usually be left intact. Topical antibiotics (such as Neosporin? or Bacitracin?) and antiseptics (such as chlorhexidine or Betadine?) may be used to decrease the chances of infection.
Severe, life-threatening burns require immediate care. Dehydration is treated with large amounts of fluids given intravenously (IV, or into the veins). An individual who has gone into shock as a result of dehydration is also given oxygen through a face mask.
Burn center: Depending on the severity and extent of the burn, the doctor may advise or request that patient care be continued at a special Burn Center. Burns may affect so many functions and systems of the body that continued rehabilitation is critical.
Many hospitals have a specialized burn unit or center and some facilities are designated solely for the rehabilitation of burn patients. Burn patients need the highly specialized services of medical experts who work together on a multidisciplinary team, including physiatrists, plastic surgeons, internists, orthopedic surgeons, infection disease specialists, rehabilitation nurses who specialize in burn care, pharmacists, psychologists/psychiatrists, physical therapists, occupational therapists, respiratory therapists, dietitians, social workers, case managers, recreation therapists, and vocational counselors.
Burn rehabilitation begins during the acute treatment phase and may last days to months to years, depending on the extent of the burn. Rehabilitation is designed to meet each patient's specific needs; therefore, each program is different. General goals of a burn rehabilitation program include helping the patient return to the highest level of function and making independence possible, while improving the overall quality of life - physically, emotionally, and socially.
In order to help reach these goals, burn rehabilitation programs may include complex wound care, pain management, physical therapy for positioning, splinting, and exercise, occupational therapy for assistance with activities of daily living (ADLs), cosmetic reconstruction, skin grafting, counseling to deal with common emotional responses during rest, such as depression, grieving, anxiety, guilt, and insomnia, patient and family education and counseling, and nutritional counseling. Advances in the understanding and treatment of burns, state-of-the-art burn units and facilities, comprehensive burn rehabilitation services, and integrated medical care have all contributed to the increase in survival rate and recovery of burn patients.
Skin graft: A skin graft may be needed with deep minor or moderate burns or severe burns. Most skin grafts replace the burned skin. Other skin grafts help by temporarily covering and protecting the skin as it heals on its own. In a skin grafting procedure, a piece of healthy skin is taken from an unburned area of the individual's body (autograft), from another living or dead person (allograft), or from another species (xenograft, usually pigs because their skin is most similar to human skin). The skin graft is surgically sewn over the burned area after removing any dead tissue and ensuring that the wound is clean. Autografts are permanent. Allografts and xenografts, however, are rejected after 10-14 days by the individual's immune system. Medications are given to decrease the chances of skin graft rejection. Artificial skin has been developed recently and can also be used to replace the burned skin. Burned skin should be replaced within several days of the burn.
Physical and occupation therapy: Physical and occupation therapy usually are needed to prevent immobility caused by scarring around the joints from a skin graft. Stretching exercises are started within the first few days after the burn. Splints are applied to ensure that joints that are likely to be immobile rest in positions that are least likely to lead to contractures. The splints are left in place except when the joints are moved. If a skin graft has been used, however, therapy is not started for the first five to 10 days after the grafts are attached. This allows for the graft to heal undisturbed. Bulky dressings that put pressure on the burn can prevent large scars from developing.
Electrical burns: An electrical burn may appear minor or not show on the skin surface at all, but the damage can extend deep into the tissues beneath the skin. If a strong electrical current passes through the body, internal damage, such as a heart rhythm disturbance or cardiac arrest, can occur. Sometimes the jolt associated with the electrical burn can cause an individual to be thrown or to fall, resulting in fractures or other associated injuries. Healthcare professionals recommend dialing 911 or calling for emergency medical assistance if the individual who has been burned is in pain, is confused, or is experiencing changes in his or her breathing, heartbeat, or consciousness.
While helping someone with an electrical burn and waiting for medical help, following these steps are recommended by healthcare professionals: do not touch the individual - they may still be in contact with the electrical source passing the current to the one helping; the electricity source should be turned off immediately if possible; move the source away from both injured person and the helper using a non-conducting object made of cardboard, plastic, or wood; check signs of circulation (breathing, coughing, or movement) and, if absent, begin cardiopulmonary resuscitation (CPR) immediately; prevent shock by laying the individual down with the head slightly lower than the trunk and the legs elevated; and cover the affected areas. If the person is breathing, cover any burned areas with a sterile gauze bandage, if available, or a clean cloth. Do not use a blanket or towel. Loose fibers can stick to the burns.
Any significant burn resulting from electricity requires immediate physician evaluation. These burns often result in serious muscle breakdown, electrolyte (including sodium and potassium) abnormalities, and occasionally kidney failure. The actual site of damage can be internal and may not be visible on the skin surface.
Chemical burns: The first step in stopping chemical burns is to remove contaminated clothing and brush away any dry particles. Next, the area is rinsed with large amounts of water. Because chemicals can continue to inflict damage long after first contacting the skin, rinsing should continue for at least 30 minutes. In rare cases involving certain industrial chemicals (for example, metal sodium), water should not be used because it can actually worsen the burn. In addition, some chemicals have specific treatments that can further reduce skin damage.
The treatment for chemical burns is similar to thermal burns except large amounts of water should be used to irrigate the effected region. It is recommended by healthcare professionals not to attempt to neutralize the burn with another chemical, such as putting baking soda on an acid burn. This may cause a chemical reaction that could result in a thermal burn too. If are uncertain, call the local poison control center or go to the local Emergency Room (ER).

Integrative therapies

Note: Depending on the location and extent of injury, burns may be considered a medical emergency and should not be treated without guidance by a healthcare provider. All third degree burns and complicated location burns, such as the airway and eyes, need immediate evaluation by a doctor.
Unclear or conflicting scientific evidence:
Acupuncture: Acupuncture is a technique of inserting and manipulating needles into "acupuncture points" on the body with the aim of restoring health and well-being, e.g. treating pain and diseases. The practice of acupuncture originated in China 5,000 years ago. Today, it is widely used throughout the world and is one of the main pillars of Chinese medicine. Although some studies report beneficial results, there is currently not adequate available evidence to recommend for or against acupuncture in the treatment of pain associated with burns.
Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, infections, bleeding disorders or with drugs that increase the risk of bleeding (anticoagulants), medical conditions of unknown origin, neurological disorders. Avoid on areas that have received radiation therapy and during pregnancy. Use cautiously with pulmonary disease (like asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics or with history of seizures. Avoid electroacupuncture with arrhythmia (irregular heartbeat) or in patients with pacemakers.
Aloe: Aloe (including Aloe vera) gel has been used topically for thousands of years to treat wounds, skin infections, burns, and numerous other dermatologic conditions. Preliminary evidence suggests that aloe may be effective in promoting healing of mild to moderate skin burns. Further study is needed in this area.
Avoid if allergic to aloe or other plants of the Liliaceae family (garlic, onions, tulips). Avoid injecting aloe. Avoid applying to open, surgical wounds or pressure ulcers. Avoid taking by mouth with diarrhea, bowel blockage, intestinal diseases, bloody stools, hepatitis, a history of irregular heartbeat (arrhythmia), electrolyte imbalances, diabetes, heart disease or kidney disease. Avoid taking by mouth if pregnant or breastfeeding.
Arginine: Arginine, or L-arginine, is considered a semi-essential amino acid because although it is normally synthesized in sufficient amounts by the body, supplementation is sometimes required. A randomized, controlled clinical trial designed to evaluate immune function of patients suggests that arginine may help with recovery of immune function and protein function in partial-thickness burn patients. Further research is necessary in this area before a conclusion can be drawn.
Avoid if allergic to arginine, with a history of stroke, liver or kidney disease. Avoid if pregnant or breastfeeding. Use caution if taking blood-thinning drugs (like warfarin or Coumadin?) and blood pressure drugs or herbs or supplements with similar effects. Check blood potassium levels. L-arginine may worsen symptoms of sickle cell disease. Caution is advised in patients taking prescription drugs to control sugar levels.
Astragalus: Astragalus supplements are derived from the roots of Astragalus membranaceus or related species, which are native to China. Few clinical trials have been investigated in terms of astragalus and burn patients. Limited research suggests that astragalus may have positive effects on burns. Further research is required.
Avoid if allergic to astragalus, peas, or any related plants or with a history of Quillaja bark-induced asthma. Avoid with aspirin or aspirin products or herbs or supplements with similar effects. Avoid with inflammation (swelling) or fever, stroke, transplant or autoimmune diseases (like HIV/AIDS). Stop use two weeks before surgery/dental/diagnostic procedures with a risk of bleeding and avoid use immediately after these procedures. Use cautiously with bleeding disorders, diabetes, high blood pressure, lipid disorders, or kidney disorders. Use cautiously with blood-thinners, blood sugar drugs, or diuretics or herbs and supplements with similar effects. Avoid if pregnant or breastfeeding.
Beta-glucan: Beta-glucan is a soluble fiber derived from the cell walls of algae, bacteria, fungi, yeast, and plants. Beta-glucan collagen matrix, which combines the carbohydrate beta-glucan with collagen, has been used as a temporary coverage for partial thickness burns with good results. Beta-glucan collagen matrix may help reduce pain, improve healing, and lessen scar appearance. However, further study is needed to confirm these results.
Avoid if allergic or hypersensitive to beta-glucan. When taken by mouth, beta-glucan is generally considered safe. Use cautiously with AIDS or AIDS-related complex (ARC). Avoid using particulate beta-glucan. Avoid if pregnant or breastfeeding.
Bromelain: Classified as an herb, bromelain is a sulfur-containing proteolytic digestive enzyme that is extracted from the stem and the fruit of the pineapple plant (Ananas comosus, family Bromeliaceae). A bromelain-derived debriding agent, Debridase, has been studied for burn debridement on deep second degree and third degree burns with positive results. Further results are needed to confirm these results.
Avoid if allergic to bromelain, pineapple, honeybee, venom, latex, birch pollen, carrots, celery, fennel, cypress pollen, grass pollen, papain, rye flour, wheat flour, or members of the Bromeliaceaefamily. Use cautiously with a history of bleeding disorders, stomach ulcers, heart disease, liver or kidney disease. Use caution before dental or surgical procedures or while driving or operating machinery. Avoid if pregnant or breastfeeding.
Calendula: Calendula is commonly used on the skin to treat minor skin wounds. Reliable human research is necessary before a firm conclusion regarding burn healing can be drawn. Avoid if allergic to plants in the Aster/Compositae family such as ragweed, chrysanthemums, marigolds, and daisies. Use cautiously in patients taking sedatives, blood pressure medications, cholesterol medications, blood sugar-altering agents, and immunomodulators. Use cautiously with diabetes and in children. Avoid if pregnant or breastfeeding.
Danshen: Danshen (Salvia miltiorrhiza) is widely used in traditional Chinese medicine (TCM), often in combination with other herbs. Although animal studies suggest that danshen may speed burn healing and healing of wounds, there are no reliable studies in humans evaluating this claim. Danshen may increase bleeding in sensitive individuals, including in those taking blood thinning medications, such as aspirin and warfarin (Coumadin?).
Avoid if allergic or hypersensitive to danshen. Use cautiously with altered immune states, arrhythmia, compromised liver function or a history of glaucoma, stroke, or ulcers. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk, and do not use immediately after these procedures. Use cautiously if driving or operating heavy machinery. Avoid if taking blood thinners (anticoagulants), digoxin or hypotensives including ACE inhibitors such as captopri, or Sophora subprostrata root or herba serissae. Avoid with bleeding disorders, low blood pressure and following cerebal ischemia. Avoid if pregnant or breastfeeding.
Honey: Honey is a sweet, viscid fluid produced by honeybees (Apis mellifera) from the nectar of flowers. Early evidence suggests that the topical (on the skin) use of honey on burns may reduce burn-healing time. Additional study is needed.
Avoid if allergic or hypersensitive to honey, pollen, celery or bees. Honey is generally considered safe in the recommended doses. Avoid honey from the genus Rhododendron because it may cause a toxic reaction. Avoid in infants younger than 12 months of age. Use cautiously with antibiotics. Potentially harmful contaminants (like C. botulinum or grayanotoxins) can be found in some types of honey and should be used cautiously in pregnant or breastfeeding women.
Hydrotherapy: Hydrotherapy is broadly defined as the external application of water in any form or temperature (hot, cold, steam, liquid, ice) for healing purposes. It may include immersion in a bath or body of water (such as the ocean or a pool), use of water jets, douches, application of wet towels to the skin, or water birth. Hydrotherapy is widely used in hospitals and rehabilitation centers in the management of burns. Various techniques are used, with variations in methods, lengths of time, frequency, and training levels of personnel administering treatments. There is limited research at this time, and no clear conclusions can be drawn.
Avoid sudden or prolonged exposure to extreme temperatures in baths, wraps, saunas, or other forms of hydrotherapy, particularly with heart disease, lung disease, or if pregnant. Avoid with implanted medical devices like pacemakers, defibrillators, or hepatic (liver) infusion pumps. Vigorous use of water jets should be avoided with fractures, known blood clots, bleeding disorders, severe osteoporosis, open wounds, or during pregnancy. Use cautiously with Raynaud's disease, chilblains, acrocyanosis, erythrocyanosis, and impaired temperature sensitivity, such as neuropathy. Use cautiously if pregnant or breastfeeding. Hydrotherapy should not delay the time to diagnosis or treatment with more proven techniques or therapies, and should not be used as the sole approach to illnesses. Patients with known illnesses should consult their physician(s) before starting hydrotherapy.
Massage: There is some evidence from one small study involving burn and wound care suggesting that massage may reduce stress in burn patients.
Avoid with bleeding disorders, low platelet counts, or if on blood-thinning medications (such as heparin or warfarin/Coumadin?). Areas should not be massaged where there are fractures, weakened bones from osteoporosis or cancer, open/healing skin wounds, skin infections, recent surgery, or blood clots. Use cautiously with a history of physical abuse or if pregnant or breastfeeding. Massage should not be used as a substitute for more proven therapies for medical conditions. Massage should not cause pain to the client.
Pantothenic acid (Vitamin B5): Pantothenic acid (Vitamin B5) is essential to all life, and is a component of coenzyme A (CoA), a molecule that is necessary for numerous vital chemical reactions to occur in cells. Pantothenic acid is essential to the metabolism of carbohydrates, proteins, and fats, as well as for the synthesis of hormones and cholesterol. Vitamin supplementation is often recommended in individuals who have sustained severe burns, due to loss of nutrients and increased metabolic needs. It is unclear if vitamin B5 has specific beneficial effects in burn healing beyond its usual functions in the body.
Avoid if allergic or hypersensitive to pantothenic acid or dexpanthenol. Avoid with gastrointestinal blockage. Pantothenic acid is generally considered safe in pregnant and breastfeeding women when taken at recommended doses.
Phosphorus: Phosphorus is a mineral found in many foods, such as milk, cheese, dried beans, peas, colas, nuts, and peanut butter. Phosphate is the most common form of phosphorus. In the body, phosphate is the most abundant intracellular negative ion. It is critical for energy storage and metabolism, for the utilization of many B-complex vitamins, to buffer body fluids, for kidney excretion of hydrogen ions, for proper muscle and nerve function, and for maintaining calcium balance. Phosphorus is vital to the formation of bones and teeth, and healthy bones and soft tissues require calcium and phosphorus to grow and develop throughout life. Patients with serious burns may lose phosphate, and replacement may be necessary.
Avoid if allergic or hypersensitive to any ingredients in phosphorus/phosphate preparations. Use phosphorus/phosphate salts cautiously with kidney or liver disease, heart failure, unstable angina (chest pain), recent heart surgery, hyperphosphatemia (high phosphate blood level), hypocalcemia (low calcium blood level), hypokalemia (low potassium blood level), hypernatremia (high sodium blood level), Addison's disease, intestinal obstruction or ileus, bowel perforation, severe chronic constipation, acute colitis, toxic megacolon, hypomotility syndrome, hypothyroidism, scleroderma, or gastric retention. Avoid sodium phosphate enemas with congenital or abnormalities of the intestine. Excess phosphorus may cause serious or life-threatening toxicity.
Prayer, distant healing: Prayer can be defined as a "reverent petition," the act of asking for something while aiming to connect with God or another object of worship. Prayer on behalf of the ill or dying has played a prominent role throughout history and across cultures. Limited research in burn patients reports improved outcomes when prayer is used, although due to methodological problems these results cannot be considered conclusive.
Prayer is not recommended as the sole treatment approach for potentially serious medical conditions, and should not delay the time it takes to consult with a healthcare professional or receive established therapies. Sometimes religious beliefs come into conflict with standard medical approaches, and require an open dialog between patients and caregivers. Based on limited available clinical study, patients certain that they were receiving intercessory prayer had a higher incidence of complications following cardiac bypass surgery than those who did not know they were being prayed for.
Propolis: Propolis is a natural resin created by bees, used in the construction of hives. Propolis is produced from the buds of conifer and poplar trees, in combination with beeswax and other bee secretions. Preliminary research reports that propolis may have a beneficial effect on the healing of partial thickness wounds from burns.
Avoid if allergic or hypersensitive to propolis, black poplar (Populas nigra), poplar bud, bee stings, bee products, honey, and Balsam of Peru. Severe allergic reactions have been reported. Use cautiously with asthma or gastrointestinal disorders. Avoid if pregnant or breastfeeding because of the high alcohol content in some products.
Sea buckthorn: Sea buckthorn (Hippophae rhamnoides) is found throughout Europe and Asia, particularly eastern Europe and central Asia. Sea buckthorn oil is a traditional Chinese medicine (TCM) preparation derived from the fruits of sea buckthorn. In one clinical trial, application of Hippophae rhamnoides oil seemed to help with skin burns. Additional, higher quality studies are needed to confirm these results.
Avoid if allergic or hypersensitive to sea buckthorn, its constituents, or members of the Elaeagnaceae family. Use cautiously if taking angiotensin converting enzyme (ACE) inhibitors, anticoagulants and antiplatelet agents (blood thinners), antineoplastics (anticancer agents), or cyclophosphamide or farmorubicin. Avoid higher doses than food amounts if pregnant or breastfeeding.
Selenium: Selenium is a trace mineral found in soil, water, and some foods. It is an essential element in several metabolic pathways. Early study results suggest that supplementation with selenium and other trace elements (copper, zinc) may increase the rate of wound healing for burns. Additional research is necessary.
Avoid if allergic or sensitive to products containing selenium. Avoid with history of nonmelanoma skin cancer. Selenium is generally regarded as safe for pregnant or breastfeeding women. However, animal research reports that large doses of selenium may lead to birth defects.
Thymus extract: Thymus extracts for nutritional supplements are usually derived from young calves (bovine). Thymus extract is commonly used in conditions where immune function is decreased. Thymus extract may be useful for reducing infections, septicemia, and mortality. However, the evidence is mixed. More clinical trials are required regarding the use of thymus extract for burns.
Avoid if allergic or hypersensitive to thymus extracts. Use bovine thymus extract supplements cautiously due to potential for exposure to the virus that causes "mad cow disease." Avoid use with an organ transplant or other forms of allografts or xenografts. Avoid if receiving immunosuppressive therapy, with thymic tumors, myasthenia gravis (neuromuscular disorder), untreated hypothyroidism, or if taking hormonal therapy. Avoid if pregnant or breastfeeding; thymic extract increases human sperm motility and progression.
Zinc: Zinc formulations have been used since ancient Egyptian times to enhance wound healing, although the usefulness of this approach is only partially confirmed by the clinical data of today. Study results of zinc sulfate supplements given to victims of burns to increase healing rate yield mixed results. Further research is needed.
Zinc is generally considered safe when taken at the recommended dosages. Avoid zinc chloride since studies have not been done on its safety or effectiveness. Avoid with kidney disease. Use cautiously if pregnant or breastfeeding.

Prevention

More than two million Americans suffer from burn injuries each year, and about 70,000 of them require admission to the hospital. Burns are one of the leading causes of accidental injuries in childhood, and the greatest tragedy is that many of these could be prevented.
For prevention, experts recommend: when cooking, keep pot handles turned toward the rear of the stove and never leave the pans unattended; do not leave hot cups of coffee on tables or counter edges; do not carry hot liquids or food near a child or while holding a child; always test food temperatures before serving a child, especially foods or liquids heated in a microwave; keep matches and lighters out of children's reach in a locked cabinet. Use only child-resistant lighters; prevent scalding by keeping the water heater set at 120-125? Fahrenheit; test bath water before putting a child in the bathtub; cover unused electric outlets with safety caps, and replace damaged, frayed or brittle electrical cords. Keep fire extinguishers on every floor of the home, especially in the kitchen - and know how to use them. Do not put water on a grease fire - it can spread the fire. Have a working smoke detector on every floor of the home. Check batteries at least once a year. Know what to do in case clothing catches fire: stop (do not run), drop (to the floor immediately), and roll (cover the face and hands while rolling over to smother the flames).
Healthcare professionals recommend getting immediate medical attention if any of the following symptoms appear related to a burn: fever; pus or foul-smelling drainage; excessive swelling; redness of the skin; a blister filled with greenish or brownish fluid; and a burn that does not heal in 10 days to two weeks.

Author information

This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Bibliography

American Academy of Family Physicians. .
American College of Emergency Physicians. .
Centers for Disease Control and Prevention. .
Centers for Disease Control and Prevention (CDC). Sunburn prevalence among adults--United States, 1999, 2003, and 2004. MMWR Morb Mortal Wkly Rep. 2007;56(21):524-8.
Flynn MB. Nutritional support for the burn-injured patient. Crit Care Nurs Clin North Am. 2004;16(1):139-44.
Gordon MD, Gottschlich MM, Helvig EI, et al. Review of evidenced-based practice for the prevention of pressure sores in burn patients. J Burn Care Rehabil. 2004;25(5):388-410.
Namias N. Advances in burn care. Curr Opin Crit Care. 2007;13(4):405-10.
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Causes

A burn injury usually results from an energy transfer to the body. There are many types of burns caused by thermal, radiation, chemical, or electrical contact.
Thermal burns: Thermal and chemical burns usually occur because heat or chemicals contact part of the body's surface, most often the skin. Thus, the skin usually sustains most of the damage. However, severe surface burns may penetrate to deeper body structures, such as fat, muscle, or bone. Hot metals, scalding liquids, steam, and flames, when coming in contact with the skin, can cause thermal burns.
Chemical burns: Chemical burns are caused by caustic substances that contact the skin. Caustic substances are sometimes found in household products, including those containing lye (in drain cleaners and paint removers), phenols (in deodorizers, sanitizers, and disinfectants), sodium hypochlorite (in disinfectants and bleaches), and sulfuric acid (in toilet bowl cleaners). Many chemicals used in industry and during armed conflicts can cause burns. Wet cement left on the skin can cause severe burns as well.
Radiation burns: Radiation burns are burns due to prolonged exposure to ultraviolet rays (UV) of the sun or to other sources of radiation, such as x-ray or gamma radiation therapy for cancer. Radiation burns can also be caused by tanning booths and sunlamps. A sunburn is literally a burn on the skin from ultraviolet radiation. The consequence of this burn is swelling and redness of the skin. Injury can start within 30 minutes of exposure. UVA and UVB refer to different wavelengths in the light spectrum. UVB is more damaging to the skin and the main UV cause of skin cancer. Both UVA and UVB are responsible for photo aging (premature aging of the skin and wrinkles) and sunburn. UVA rays are predominately responsible for the aging process. Tanning beds produce both UVA and UVB rays.
Prior recent sun exposure and prior skin injury are risks for sunburn, even in limited exposure to the sun. Travel to the southern United States, regions close to the equator, and places at high altitudes all offer the unwary visitor an opportunity to be injured by sunburn. Certain light-skinned and fair-haired people are at greater risk of sunburn injury.
A benefit of UV radiation is the production of beneficial vitamin D in the skin.
Friction burns: Friction burns are caused by contact with any hard surface such as roads ("road rash"), carpets, or gym floor surfaces. They are usually both a scrape (abrasion) and a heat burn. Friction burns to the skin are seen in athletes who fall on floors, courts, or tracks. Motorcycle or bicycle riders who have road accidents while not wearing protective clothing might get friction burns.
Electrical burns: An electrical burn may appear minor or not show on the skin at all, but the damage can extend deep into the tissues beneath the skin. If a strong electrical current passes through the body, internal damage, such as a heart rhythm disturbance or cardiac arrest, can occur. Sometimes the jolt associated with the electrical burn can cause the individual to be thrown or to fall, resulting in fractures or other associated injuries.

Classification

Burns are classified as first-degree (mild), second-degree (moderate), or third-degree (severe), depending on how deep and severe they penetrate the skin's surface.
First-degree (superficial) burns: First-degree burns, also known as superficial burns, affect only the epidermis, or outer layer of skin. The burn site is red, painful, dry, and with no blisters. Mild sunburn is an example. Long-term tissue damage is rare and usually consists of an increase or decrease in the skin color.
Second-degree (partial thickness) burns: Second-degree burns, also known as partial thickness burns, involve the epidermis and part of the dermis layer of skin. The burn site appears red, blistered, and may be swollen and painful. If a second-degree burn is no larger than two to three inches in diameter, it is treated as a minor burn. If the burned area is larger or if the burn is on the hands, feet, face, groin, or buttocks, or over a major joint, medical attention needs to be received immediately.
Third-degree (full thickness) burns: Third-degree burns, also known as full thickness burns, destroy the epidermis and dermis. Third-degree burns may also damage the underlying bones, muscles, and tendons. When bones, muscles, or tendons are also burned, this may be referred to as a fourth-degree burn. The burn site appears white or charred. There is no sensation in the area since the nerve endings are destroyed.
Note: Babies and young children may have a more severe reaction from a burn than an adult. A burn in an adult may cause a minor loss of fluids from the body, but in a baby or young child, the same size and depth of a burn may cause a severe fluid loss.