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Chapter 94: Burns

Naveen F. Sangji; Stewart C. Wang

BURNS

Therapeutic Approach

Thermal insult can result in burn injury to:

  1. The epidermis only, classified as a first-degree burn, which appears erythematous without skin breakdown

  2. Injury encroaching into the dermis, classified as superficial or deep partial thickness or second-degree burns, with a blistered appearance

  3. Injury to the entire dermis, classified as full thickness or third-degree burns, with a pale, leathery, and ashen appearance

  4. Injury to the underlying fat, fascia, or bone, or fourth-degree burns

First-degree burns can be managed with soothing ointments, vaseline, or cocoa butter. Antimicrobial agents are not indicated. Second-degree burns can be managed with topical therapies. Wounds should be cleansed and nonviable skin debrided prior to the application of a topical antimicrobial agent. Deep second-degree burns often require surgical excision and grafting. Third-degree burns require surgical excision and grafting. Surgical donor sites are managed with topical therapies. Scars can be managed with fractional CO2 laser and Kenalog injections, as well as reconstructive surgery. See Table 94-1.

Table 94-1Burns Treatment Table
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Table 94-1 Burns Treatment Table
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TREATMENT INDICATION MECHANISM OF ACTION DOSING ADVERSE EFFECTS SUGGESTED MONITORING LEVEL OF EVIDENCE (REFERENCE)
Topical Therapy
Acticoat™ Partial and full thickness burns Silver-containing dressing; sustained release over 7 d; broad spectrum coverage; fungal coverage; stronger antimicrobial activity (compared to silver sulfadiazine) Applied as a self-adherent dressing to the wound Systemic silver uptake, skin staining (temporary) Can be left on for 3 or 7 d (depending on the dressing subtype) IB1-6
Aquacel ® Ag Partial thickness burns Silver-containing dressing; stronger antimicrobial activity (compared to silver sulfadiazine) Applied as a self-adherent dressing to the wound Systemic silver uptake, skin staining (temporary) Can be left on for 14 d and up to 3 wk IB3,4,6,7
Biobrane® Partial thickness burns Silicone-coated nylon membrane; painless dressing changes Applied as a self-adherent dressing to the wound bed with a dressing on top Infection Requires trimming as the underlying skin regenerates IB3,8-10
Bacitracina Partial thickness burns Antimicrobial; easy application 500 units/g ointment Skin hypersensitivity Daily assessment of wound and for skin reaction IV11,12

Hypochlorous acid (dilute—0.025%); Commercially available as:

  1. Dakins (0.25% and 0.125% HOCL);

  2. Vashe™; a(0.025% HOCL)

 Partial and full thickness burns Antimicrobial, antifungal 0.025% hypochlorous acid solution; applied to dressings TID-QID   Daily wound assessment IIB13
Mepilex/Mepilex transfer® Donor sites; partial thickness burns Silver-impregnated foam dressing Applied as a self-adherent dressing to the wound Contact reaction (extremely rare) Can be left on for 3-7 d; mepilex transfer can be left on for up to 2 wk IB4,5,14
Silvadenea (silver sulfadiazine) Partial and full thickness burns Broad-spectrum coverage against gram-positive and gram-negative bacteria 1% cream; apply QD; scrub clean prior to each subsequent application Self-limited leukopenia/neutropenia; contraindicated in patients with sulfur allergy

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