Burns

Signs and symptoms of burns are different depending on the severity of the burn. Your doctor will evaluate the extent of the burn (the amount of skin or body surface area that the burn covers) to assess the risk for complications, such as infection, dehydration, and disfigurement.

Infection

People who get burned are vulnerable to infection. It can be hard to tell if a minor burn is infected because the skin surrounding a burn is usually red and may become warm to the touch, both of which are also signs of infection. Any change in the appearance of a burn, or in the way that the person feels, should be brought to the attention of a doctor. Potential signs of infection include:

• Change in color of the burnt area or surrounding skin
• Purplish discoloration, particularly if swelling is also present
• Change in thickness of the burn (the burn suddenly extends deep into the skin)
• Greenish discharge or pus
• Fever

Dehydration

In severe or widespread burns, fluid is lost through the skin, and the person can become dehydrated. Dehydration can lead to life-threatening shock. A doctor will treat dehydration with intravenous (IV) fluids. Potential signs of dehydration include:

• Thirst
• Lightheadedness or dizziness, particularly when moving from a sitting or lying position to standing
• Weakness
• Dry skin
• Urinating less than usual

Burn Patterns

Burns have typical and atypical patterns. Typical patterns result from accidental burns while atypical patterns may be a sign of physical abuse. Typical burns (from spilling hot liquid, for example) tend to occur in exposed areas such as the arms, face, and neck. Atypical burns may occur in unexposed areas such as the buttocks. Burns involving entire hands and feet are also not typical, nor are third-degree burns involving a very small, focused area (resembling, for example, a cigarette).

Burns are caused by exposure to thermal (heat), electrical, radiation, or chemical sources. Thermal burns occur when hot metals, scalding liquids, steam, or flames come in contact with the skin. Exposure to electrical current causes electrical burns, and contact with caustic chemicals causes chemical burns. Prolonged exposure to the sun's ultraviolet rays, or to other sources of radiation (such as from tanning booths), can also cause burns.

The most serious burns are usually caused by scalding hot or flammable liquids, and fires. Exposure to chemicals and electrical currents also cause severe injury and damage to the skin.

Risk factors for burns may include:

• Wood stoves, exposed heating sources, or electrical cords
• Unsafe storage of flammable or caustic materials
• Careless smoking
• Child abuse
• Hot water heater set above 130°F (54.4°C)
• Heated foods and containers
• Too much exposure to the sun

These actions may reduce your risk for burns:

• Installing smoke detectors
• Teaching children about fire and burn prevention in schools
• Stopping smoking and heavy alcohol use
• Wearing flame retardant clothes (particularly children)
• Planning emergency exit routes in the home, school, and workplace
• Practicing fire drills

These steps may help reduce the severity of a burn once it occurs:

• Giving first aid immediately
• Getting prompt medical attention
• If hospitalization is necessary, being treated by a dedicated burn unit with staff specially trained in burn care

When diagnosing a burn, a doctor evaluates the depth and extent of the damage, the degree of pain, the amount of swelling, and signs of infection. Doctors classify the burn based on the depth and extent of the injury. Burns that cover a significant portion of the body, burns associated with smoke inhalation, burns from electrical injuries, and burns associated with suspected physical abuse require immediate emergency medical attention. In the emergency room, all wounds are wrapped with sterile cloths. People with burns may receive oxygen (either through a mask or tube) and fluids. People with burns are also evaluated for associated injuries (such as from physical abuse). Doctors may also conduct tests to determine whether the wound is infected.

While minor burns may be treated at home, all other burns require immediate emergency medical attention because of the risk of infection, dehydration, and other potentially serious complications.

These are first aid steps for burns:

First-degree burns:

• Run cool water on burned area for 5 to 10 minutes or cover the area with a cool compress.
• DO NOT apply oil, butter, or ice to the burn.
• Take ibuprofen or acetaminophen to relieve pain and swelling.
• Any burn to the eye requires immediate emergency help.
• DO NOT use burn care or other ointments for 24 hours to avoid sealing in the burn.

Second-degree burns:

• DO NOT break blisters.
• DO NOT remove clothing that is stuck to the skin.
• Run cool water on burned area for 5 to 10 minutes, and cleanse with mild soap. You may also cover the area with a cool compress, then carefully remove clothing that is not stuck to the skin.
• Elevate burned area above the heart.
• Take ibuprofen or acetaminophen to relieve pain and swelling.
• If not near a medical facility, apply bacitracin ointment or honey on broken blisters to prevent infection (this is the only situation in which bacitracin or honey should be applied to burned skin).
• If the burn is near the mouth, nose, or eye, seek emergency medical help immediately.

Third-degree burns:

• If the person is on fire, have them stop, drop, and roll.
• Call 9-1-1.
• Check airway, breathing, and circulation.
• DO NOT remove clothing that is stuck to the skin.
• Run cool water continuously on burned area. DO NOT immerse large burn areas in water.
• Elevate burned area above the heart.
• Cover the burned area with a sterile bandage or a clean sheet. DO NOT apply any ointments.

If you are burned seriously, you will be admitted to a hospital. There, doctors will concentrate on keeping the burned area clean and removing any dead tissue through a process called debridement. You will receive medicines to reduce pain and prevent infection. You will also get a tetanus shot if you have not had one in 5 or more years.

Burns often cause pain and anxiety, even during recovery. You may also experience emotional distress if a burn changes his or your appearance. People with massive burns require early psychological and social support. Complementary therapies that may help alleviate such pain and anxiety include:

• Massage therapy
• Hypnosis
• Therapeutic touch
• Acupuncture

Good nutrition is important during recovery. Vitamins and minerals have been shown to promote wound healing and prevent the spread of infection.

Fourth-degree burns require the same attention as third degree burns. People with serious burns should seek medical help immediately.

Medications

• Antimicrobial ointments (such as silver sulfadiazine, mafenide, silver nitrate, and povidone-iodine) are used to reduce risk of infection. Bacitracin may be used for first-degree burns. One study found that parrafin gauzes are valuable for superficial burns while silver-based dressings are preferable for deep burns.
• Antibiotics (such as oxacillin, mezlocillin, and gentamicin) are used to treat infection. Antibiotics will also probably be used if the risk of developing infection is high (for example, when the body surface area of the burn is large).
• Prescription pain medications (such as acetaminophen with codeine, morphine, or meperidine) are used for severe burns.
• Anabolic steroids, such as oxandrolone, may be used for severe burns to help decrease wound healing time.

Surgery and Other Procedures

In the case of severe burns, a doctor may perform debridement and skin grafting. Debridement is the removal of dead tissue. In skin grafting, a piece of skin is surgically sewn over the burn after dead tissue is removed. The skin can be from another part of the person's body, from a donor, or from an animal (usually a pig). Skin grafts from the person's own body are permanent. Artificial skin may also be used. Cosmetic surgery may be done to improve both the function and appearance of the burned area.

Nutrition and Dietary Supplements

Minor burns can be treated with natural products. However, severe burns always require immediate medical attention. It is especially important for people who have been seriously burned to get enough nutrients in their daily diet. Burn patients in hospitals are often given high calorie, high protein diets to speed recovery.

DO NOT try to treat a second or third degree burn by yourself. Always seek medical advice. Ask your doctor which supplements are best for you. Always tell your doctor about the herbs and supplements you are using or considering using, as some supplements may interfere with conventional treatments.

Following these tips may improve your healing and general health.

• Eat antioxidant foods, including fruits (such as blueberries, cherries, and tomatoes), and vegetables (such as squash and bell peppers). One study found that high doses of vitamin C after a burn reduced fluid requirements by 40%, reduced burn tissue water content 50%, and reduced ventilator days.
• Avoid refined foods, such as white breads, pastas, and sugar.
• Eat fewer red meats and more lean meats, cold-water fish, tofu (soy) or beans for protein.
• Use healthy cooking oils, such as olive oil or coconut oil.
• Reduce or eliminate trans-fatty acids, found in commercially baked goods, such as cookies, crackers, cakes, French fries, onion rings, donuts, processed foods, and margarine.
• Avoid caffeine and other stimulants, alcohol, and tobacco.
• Drink 6 to 8 glasses of filtered water daily.

The following supplements may also help. Be sure to ask your doctor before taking them if your burns are moderate or severe:

• A daily multivitamin, containing the antioxidant vitamins A, C, E, the B-complex vitamins and trace minerals such as magnesium, calcium, zinc, and selenium.
• Omega-3 fatty acids, such as fish oil, 1 to 2 capsules or 1 tbsp of oil, 1 to 2 times daily, to help reduce inflammation, and for healing and immunity. Cold-water fish, such as salmon or halibut, are good sources, but you may need a supplement to get a higher dose. Omega-3 fatty acids can interact with blood-thinning medications such as warfarin (Coumadin) and aspirin, and may decrease clotting time.
• Vitamin C (1,000 mg, 2 to 6 times per day) helps skin heal by enhancing new tissue growth and strength. Lower dose if diarrhea develops. You should use vitamin C only under a physician's guidance if you have cancer, certain blood iron disorders, kidney stones, diabetes, and a metabolic deficiency called "glucose 6 phosphate dehydrogenase deficiency" (G6PDD).
• Vitamin E (400 to 800 IU a day) promotes healing. May be used topically once the burn has healed and new skin has formed. Higher doses may help in healing burns. Talk to your doctor before taking vitamin E if you are scheduled to have surgery. Vitamin E can interact with certain medications, including, but not limited to antiplatelet/anticoagulant drugs. Speak with your doctor.
• Coenzyme Q10 (CoQ10), 100 to 200 mg at bedtime, for antioxidant and immune activity. CoQ10 may have a blood-clotting effect and can interact with blood-thinning medications (anticoagulant/antiplatelet drugs).
• L-glutamine, 500 to 1,000 mg, 3 times daily, for support of gastrointestinal health and immunity. Glutamine in high doses can affect mood particularly in patients with mania. There is some concern that people who are sensitive to MSG (monosodium glutamate) may also be sensitive to Glutamine. People with hepatic encephalopathy, severe liver disease with confusion, or a history of seizures, should not take Glutamine. Glutamine can interact with certain medications, so speak with your physician.
• Probiotic supplement (containing Lactobacillus acidophilus), 5 to 10 billion CFUs (colony forming units) a day. Taking antibiotics can upset the balance of bacteria in your intestines. Probiotics or "friendly" bacteria can help restore the balance, improving gastrointestinal and immune health. Some clinicians have raised concerns about giving probiotics to severely immunocompromised patients. More research is needed. Refrigerate your probiotic supplements for best results.
• Coconut oil. After a burn heals, applying coconut oil topically may be helpful for reconditioning and moisturizing the skin.

Herbs

Minor burns may be treated with herbs, but you should never take or apply any herb when you have moderate-to-severe burns. Call for emergency help first. Never apply herbs to an open wound.

Herbs are a way to strengthen and tone the body's systems. As with any therapy, you should work with your health care provider to diagnose your problem before starting treatment. You may use herbs as dried extracts (capsules, powders, or teas), glycerites (glycerine-extracts), or tinctures (alcohol extracts). Unless otherwise indicated, make teas with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups per day. You may use tinctures alone or in combination as noted.

These herbs may be applied topically (externally) to minor burns:

• Aloe (Aloe vera), as a cream or gel. Apply externally to the burned area, 3 to 4 times daily as needed, for soothing and healing.
• Calendula (Calendula officinalis), or pot marigold, as an ointment or a tea applied topically. To make tea from tincture, use 1/2 to 1 tsp. diluted in 1/4 cup water. You can also steep 1 tsp. of flowers in one cup of boiling water for 15 minutes, then strain and cool. Test skin first for any allergic reaction. Only use calendula topically.
• Gotu kola (Centella asiatica) as a cream containing 1% of the herb, may help repair skin tissue.
• Propolis, a resin created by bees to build their hives, has been used historically to treat skin wounds. One study found that people given propolis to apply to minor burns healed as well as those treated with silver sulfadiazine, a prescription ointment. However, more research is needed. If you use propolis for a minor burn, test skin first for any reaction. DO NOT use propolis if you are allergic to bee products or salicylates.

Acupuncture

Electrical Stimulation

Transcutaneous electrical nerve stimulation (TENS) uses controlled, low voltage electrical stimulation of the skin to relieve pain. Recent studies have suggested that TENS applied to acupuncture points (called electroacupuncture) on the ear (auricular acupuncture) may relieve pain for people with burns.

Massage and Physical Therapy

Massage Therapy

People with burns suffer pain, itching, and anxiety both from the burn itself and during the healing of wounds. Some studies suggest that massage may help ease these symptoms in both the emergency care and recovery phases. People receiving a massage reported significantly less itching, pain, anxiety, and depressed mood compared to those who received standard care only. Ask your doctor before using massage after a burn.

Physical Therapy

Occupational and physical therapy begins very early for people who are hospitalized for burns. Occupational and physical therapists use a number of techniques to improve movement and function of the areas affected by a burn, and to reduce scar formation. Physical therapy may include the practices listed below:

• Body and limb positioning
• Splinting
• Help with activities of daily living until normal function and ability are recovered
• Passive (physical therapist moves the person's limbs) and active exercises
• Help with walking

Homeopathy

Although few studies have examined the effectiveness of specific homeopathic therapies in the treatment of burns, professional homeopaths may consider the following measures to treat first- and second- degree burns, and to aid recovery from any burn. Before prescribing a remedy, homeopaths take into account a person's constitutional type, includes your physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate treatment for each individual.

• Place the burned area in cold water until the pain goes away (this generally takes at least a few minutes).
• Arnica Montana, taken orally immediately after the burn.
• Calendula, apply to the skin for first-degree burns and sunburns. This remedy is sometimes considered the treatment of choice for children. Calendula may also be used in the healing stages of second- and third-degree burns to stimulate regrowth of skin and to decrease scar formation.
• Hypericum perforatum, used on the skin if there are sharp, shooting pains with the burn.
• Urtica urens, taken orally for stinging pains, itching, and swelling of first-degree burns. A cream or gel may also be applied to the skin for first-degree burns and sunburns. This remedy may be used for children.
• Causticum, taken orally for burning pains with great rawness (as from an open wound) or when there are long term physical or emotional symptoms after a burn.
• Phosphorus, taken by mouth for electrical burns, especially if the individual is easily startled and excitable.

Mind-Body Medicine

Hypnosis

Several studies suggest that hypnosis may reduce pain and anxiety and enhance relaxation in people with burns.

Therapeutic Touch

Therapeutic touch (TT) is based on the theory that the body, mind, and emotions form a complex energy field. Therapists seek to correct the body's imbalances by moving their hands just over the body, what they call "the laying on of hands." This practice has been used for a number of conditions including pain and anxiety. But studies have shown conflicting results. One study of people hospitalized for severe burns suggests that TT may reduce pain and anxiety associated with burns.

Prognosis and Complications

• Infection is the most common complication of burns and is the major cause of death in burn victims. More than 10,000 Americans die every year from infections caused by burns.
• Compromised immune system
• Functional or cosmetic damage (reconstructive surgery may be necessary)
• Increased risk of developing cancer at the burn site
• Carbon monoxide poisoning (in the case of a fire)
• Heart attack which may be severe enough to cause the heart to stop (called cardiopulmonary arrest)
• Adrenal insufficiency

First-degree burns generally heal on their own in 10 to 20 days if no infection develops. In rare cases, first-degree burns spread more deeply to become second-degree (this spread is caused by infection). Deep second-degree burns may progress to third-degree. Third-degree burns may require a skin graft.

Alexander. Influence of EPA and DHA intravenous fat emulsions on nitrogen retention. Nutrition. 1999;15(2):161-162.

Antoon AY, Donovan DK. Burn Injuries. In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson Textbook of Pediatrics. 17th ed. Philadelphia, PA: W.B. Saunders Company; 2004:330-337.

Barbosa NS, Kalaaji AN. CAM use in dermatology. Is there a potential role for honey, green tea, and vitamin C? Complement Ther Clin Pract. 2014; 20(1):11-5.

Bast A, Haenen GR. Lipoic acid: a multifunctional antioxidant. Biofactors. 2003;17(1-4):207-13.

Baumann L, Spencer J. The effects of topical vitamin E on the cosmetic appearance of scars. Dermatol Surg. 1999;25:311-315.

Cabrera C, Artacho R, Gimenez R. Beneficial effects of green tea -- a review. J Am Coll Nutr. 2006;25(2):79-99.

Cummings S, Ullman D. Everybody's Guide to Homeopathic Medicines. 3^rd ed. New York, NY: Penguin Putnam; 1997:295.

Cuttle L, Kempf M, Kravchuk O, George N, Liu PY, Chang HE, Mill J, Wang XQ, Kimble RM. The efficacy of Aloe vera, tea tree oil and saliva as first aid treatment for partial thickness burn injuries. Burns. 2008 Dec;34(8):1176-1182.

D'Avignon LC, Chung KK, Saffle JR, Renz EM, Cancio LC. Prevention of infections associated with combat-related burn injuries. J Trauma. 2011; 71(2):S282-S289.

De-Souza DA, Greene LJ. Pharmacological nutrition after burn injury. J Nutr. 1998;128:797-803.

Faoagali J, George N, Leditschke JF. Does tea tree oil have a place in the topical treatment of burns? Burns. 1997;23(4):349-351.

Ferri: Ferri's Clinical Advisor 2015, 1st ed. St. Louis, MO: Elsevier Mosby; 2014.

Field T, Peck M, Hernandez-Reif M, Krugman S, Burman I, Ozment-Schenck L. Postburn itching, pain, and psychological symptoms are reduced with massage therapy. J Burn Care Rehabil. 2000;21:189-193.

Goldman: Goldman's Cecil Medicine, 24th ed. Philadelphia, PA: Elsevier Saunders; 2011.

Gravante G, Montone A. A retrospective analysis of ambulatory burn patients: focus on wound dressings and healing times. Ann R Coll Surg Engl. 2010;92(2): 118-123.

Hashmi M, Kamal R. Management of patients in a dedicated burns intensive care unit (BICU) in a developing country. Burns. 2013; 39(3):493-500.

Iqbal T, Saaiq M, Ali Z. Epidemiology and outcome of burns: early experience at the country's first national burns centre. Burns. 2013; 39(2):358-62.

Jonas WB, Jacobs J. Healing with Homeopathy: The Doctor's Guide. New York, NY: Warner Books; 1996:143-145.

Kliegman: Nelson Textbook of Pediatrics, 19th ed. Philadelphia, PA: Elsevier Saunders; 2011.

LaValle JB, Krinsky DL, Hawkins EB, et al. Natural Therapeutics Pocket Guide. Hudson, OH: LexiComp; 2000:452-454.

Liu M, Dai Y, Li Y, Luo Y, Huang F, Gong Z, Meng Q. Madecassoside isolated from Centella asiatica herbs facilitates burn wound healing in mice. Planta Med. 2008 Jun;74(8):809-815.

Lloyd EC, Rodgers BC, Michener M, Williams MS. Outpatient burns: prevention and care. Am Fam Physician. 2012; 85(1):25-32.

Marx: Rosen's Emergency Medicine, 7th ed. St. Louis, MO: Elsevier Mosby; 2009.

Rotsein OD. Oxidants and antioxidant therapy. Crit Care Clin. 2001;17(1):239-247.

Simopoulos AP. Omega-3 fatty acids in inflammation and autoimmune diseases. J Am Coll Nutr. 2002;21(6):495-505.

Somboonwong J, Jariyapongskul A, Thanamittramanee S, Patumraj S. Therapeutic effects of aloe vera on cutaneous microcirculation and wound healing in second degree burn model in rats. J Med Assoc Thai. 2000;83:417-425.

Subrahmanyan M. A prospective randomized clinical and histological study of superficial burn wound healing with honey and silver sulfadiazine. Burns. 1998;24:157-161.

Turner JG, Clark AJ, Gauthier DK, Williams M. The effect of therapeutic touch on pain and anxiety in burn patients. J Adv Nurs. 1998;28(1):10-20.

Veracruysse GA, Ingram WL, Feliciano DV. The demographics of modern burn care: should most burns be cared for by non-burn surgeons. Am J Surg. 2011; 201(1):91-96.

Visuthikosol V, Sukwanarat Y, Chowchuen B, Sriurairatana S, Boonpucknavig V. Effect of aloe vera gel to healing of burn wound a clinical and histologic study. J Med Assoc Thai. 1995:78(8):402-408.

Wang HK. The therapeutic potential of flavonoids. Expert Opin Investig Drugs. 2000;9(9):2103-2119.

Wijesinghe M, Weatherall M, Perrin K, Beasley R. Honey in the treatment of burns: a systematic review and meta-analysis of its efficacy. NZ Med J. 2009;122(1295):47-60.

Williams FN, Branski LK, Jeschke MG, Herndon DN. What, how, and how much should patients with burns be fed? Surg Clin North Am. 2011; 91(3):609-629.

Yoon JH, Baek SJ. Molecular targets of dietary polyphenols with anti-inflammatory properties. Yonsei Med J. 2005;46(5):585-596.