Burns: Diagnosis and Treatment

Diagnosis

• A detailed history and physical examination is the first step. The physician will evaluate the type, duration, and timing of the burn; the burn location and severity; and associated dehydration, disfigurement, and infection. Fires in enclosed spaces should raise the suspicion for smoke–inhalation injury.
• Burns are classified based on the depth and extent of skin damage, degree of pain, and swelling:
  
• Partial Thickness Burns. First–degree burns affect only the outer skin layer (epidermis) and are characterized by redness or discoloration, mild swelling, and pain. Sun overexposure is a common cause. Injuries heal in three to six days.
  
  Second–degree burns affect the epidermis and various portions of the lower skin layer (dermis), causing a red appearance and blisters. Fluid is lost through damaged skin, and the burns are painful and tender. These injuries require one to three weeks or more to heal. Scarring is uncommon, but there can be long–term skin color changes, although most color changes fade over time.
• Full Thickness Burns. Burns that penetrate beyond the epidermis and dermis may affect fat (third–degree burn), and muscle, tendon, and bone (fourth–degree burn). Injuries may have a charred appearance and contain white, brown, or black patches. Patients may have severe pain, but the burns are often non–tender because the nerve endings are destroyed. However, partial thickness burns often surround full thickness burns and will be painful. Healing occurs only at the wound edges, and scarring is significant, unless skin grafting is done.
• Biopsy is rarely needed to verify infection.

Treatment

• Burn patients require specialized care and support. The level of care required is based on the location, depth, and percentage of total body surface area affected by the burn.  
  
• Burns should be thoroughly cleaned to prevent infection, and sterile dressings should be applied. Tetanus vaccination and pain medications should be administered as needed.
  
• Minor burns are immersed in cool water if possible, or a cool moist cloth can be applied until pain subsides. Very cold water or ice should not be used, as they may damage skin.
  
  Once a minor burn is completely cooled, a fragrance–free lotion or moisturizer can be used to prevent drying. Additional topical treatments may also be helpful, including aloe vera gel or petroleum jelly.
• Partial thickness burns may be treated with bacitracin ointment (Baciquent), collagenase ointment (Santyl), silver sulfadiazine (Silvadene cream), or surgery. Elevation of the burned area above heart level aids healing.