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BURNS
A burn is an injury to the skin or other organic tissue primarily caused by heat or due to
radiation, radioactivity, electricity, friction or contact with chemicals
Burns can be categorized by thickness according to the American Burn Criteria using those four
elements.
Partial Thickness
Superficial (first-degree) involves the epidermis of the skin only. It appears pink to red, there
are no blisters, and it is dry. It is moderately painful. Superficial burns heal without scarring
within 5 to 10 days.
Superficial partial-thickness (second-degree) involves the superficial dermis. It appears red
with blisters and is wet. The erythema blanches with pressure. The pain associated with
superficial partial-thickness is severe. Healing typically occurs within 3 weeks with minimal
scarring.
Deep partial-thickness (second-degree) involves the deeper dermis. It appears yellow or
white, is dry, and does not blanch with pressure. There is minimal pain due to a decreased
sensation. Healing occurs in 3 to 8 weeks with scarring present.
Full Thickness
Third-degree involves the full thickness of skin and subcutaneous structures. It appears white
or black/brown. With pressure, no blanching occurs. The burn is leathery and dry. There is
minimal to no pain because of decreased sensation. Full-thickness burns heal by contracture
and take greater than 8 weeks. Full-thickness burns require skin grafting.
Fourth degree shows charred skin with possible exposed bone.
Fifth degree has charred, white skin, and exposed bone.
Sixth degree has loss of skin with exposed bone.
This model helps to explain the dynamic nature of burn injuries, and how an assessment of the burn
at the time of injury can be different in terms of size and depth to an assessment of the same injury 48
hours late
If the zone of coagulation is large, it is likely that the patient will require specialist treatment and
surgery. However, good initial management, including dressings, can still prevent the burn from
getting larger and deeper while the patient awaits review or transfer.
The overall aims of any burn wound dressing, irrespective of the size and depth of the burn, include:
preventing infection
promoting moist wound healing
preventing conversion to a deeper burn
reducing pain
allowing for movement and function
assisting in decreasing swelling.
Burn dressing according to time duration
Initial burn dressings
Burn wounds are dynamic and change in appearance, particularly in the first 48 hours. Therefore, it is
the practice of the authors’ burns service to review burns after 48 hours before decisions regarding
definitive dressings or surgery are made. It follows, therefore, that the initial burn dressing should be
one that can remain intact for 48 hours and prevent infection. The microbiology and infection risk in
Australia is unique because of the very variable climate and prolonged transfer times in some rural
areas to medical attention.4 The use of antimicrobial dressings in such an environment has been
shown to improve outcomes by reducing infection.5,6 Nanocrystalline silver dressings (eg Acticoat),
slowly release silver, which is toxic to microorganisms, to the burn wound bed. It is protocol in the
authors’ burn service to dress all burns with this dressing for the first 48 hours. Practical tips for the
use of nanocrystalline dressings include:
moistening silver dressings with sterile water (not saline – the chloride ion could bind to the silver ion,
reducing the amount of silver delivered to the wound)
applying a secondary dressing on top
wet gauze, followed by dry gauze and a bandage or adhesive dressing
this outer dressing can be re-moistened, allowing the dressing to continue releasing silver ions for
several days.
Burn dressings after 48 hours
After 48 hours, the silver dressing is removed and an assessment of the burn injury is made. In the
authors’ burn service, silver dressings are not routinely continued after 48 hours. Although silver
dressings are toxic to bacteria, there is some in vitro evidence that they inhibit keratinocytes and
fibroblasts, which could potentially prolong healing times. 7,8 An exception to this would be if the burn
presented late to the clinician and appeared to be infected or critically colonised (eg green
appearance suggesting Pseudomonas). In this instance, a further 48 hours of nanocrystalline silver
would be applied.
Dressings that can be used after this time are summarised below with indications for each. Other
dressings are available and all can be sourced online or via other purchasing agreements but prices
will vary.
Hydrocolloids (eg Duoderm [15 x 15 cm thin/thick]; Granuflex)
crosslinked adhesive dressings of gelatin, pectin and carboxymethylcellulose
good for low/moderate exudating burns – contacts and holds exudate as a gel inside the
dressing
appropriate for all burn depths
water repellent and conformable
use thin hydrocolloids for paediatric dressings but thick hydrocolloids for adults
NB offensive exudate can be mistaken for infection
Foams (eg Allevyn [silver 10 x 10 cm]; Biatain [silver 10 x 10 cm]; Mepilex [silver 10 x 10 cm; plain
10 x 10 cm])
highly absorbent foam dressings suitable for highly exudating burns
available in plain and silver
absorb exudate well and therefore help to manage and prevent hypergranulation and
maceration
reduce requirement for dressing changes due to wet dressings
Alginates (eg Algisite M [10 x 10 cm]; Kaltostat)
highly absorbent, biodegradable dressings derived from seaweed and contains calcium
use on moist granulating tissue or small superficial dermal areas of burn
good for haemostasis if fragile/superficial bleeding
good for moderately-to-highly exudative sloughy wounds – becomes a gel on contact with
wound exudate
useful under a retention dressing such as Fixomull or Hypafix to secure (in the authors’
experience, direct application of retention dressings to burns can traumatise newly healed epidermis
and be difficult and uncomfortable to remove)
need to soak with water or oil to remove alginates
retention dressings can be removed using soaking with water or adhesive removal sprays such
as Niltac or Appeel
Hydrogels (eg Intrasite [8 g]; Hydrosorb [10 x 10 cm])
hydrophilic interactive dressings with very high water content
able to donate water to the burn and rehydrate dry eschar or necrotic slough and absorb
exudate also
good for dry or sloughy burns, which need some debridement
good for all burn depths but especially mid-dermal to deeper burns
no harm to granulation tissue or epithelialisation.
Post-healing dressing/wound care
All burns in the early phase of healing require moisturiser and sun protection. The newly healed
epidermis is dry and can have increased melanocyte activity if exposed to sunlight following a burn
injury,9,10 causing permanent hyperpigmentation. Current advice in the authors’ burns service is to use
sun protection factor 50 (SPF50) sun block and avoid prolonged direct sunlight for two years.
The length of time a conservatively managed burn takes to heal has an impact on scar formation.
Burns that take longer than 21 days to heal do so with exaggerated inflammation and have a high rate
of hypertrophic scarring.11 This is obviously related to the depth of the burn, as superficial burns heal
quickly and deeper burns more slowly. Additional patient factors such as pigmented skin types and
personal/family history of poor scarring may affect this risk. These patients may require referral to a
local occupational therapy service for scar management with silicone and pressure garments, or to a
burns service for consideration of scar revision by laser or surgery.
