Burns

When the skin is exposed to excessive heat (as from fire), electricity, or corrosive chemicals, the resulting tissue damage is known as a burn. Burns are generally categorized as follows, according to the severity of tissue damage:

• First-degree burns—affect only the outer layer of the skin (epidermis), causing pain and redness
• Second-degree burns—extend to the layer below the epidermis (the dermis), causing pain, redness, and blisters that may ooze
• Third-degree burns—involve all layers of the skin and may also damage the underlying bones, muscles, and tendons. The burn site appears pale, charred, or leathery and there is generally no sensation in the area because the nerve endings are destroyed.

Between 1 and 2 million Americans seek medical attention for burns each year. Most burns occur at home, at work, or are part of an injury from a motor vehicle accident. Between 50,000 and 70,000 people are hospitalized for burns every year in the United States, 30% to 40% of whom are children younger than 15 years of age. All burns—even minor ones—may cause functional or cosmetic damage if they are not properly cared for. Skin is a natural barrier to infection, so when it is burned a person loses that protection. Because people who sustain a burn are very prone to developing infections, treatment usually involves preventing or eliminating infections.

Signs and Symptoms

In general, signs and symptoms of burns differ according to the severity of the burn (as described above). Evaluation of the extent of the burn (that is, the amount of skin or body surface area that the burn covers) is important as well because it helps a healthcare practitioner assess the risk for such complications as infection, dehydration, and/or disfigurement.

Infection

People who sustain a burn are very prone to infection. Unfortunately, knowing if an infection is present or not is often difficult because the skin surrounding a burn is usually red, and changes in body temperature (a sign of infection). This also a normal response to a large or deep burn. Any change in the appearance of the burn or in the way that the burn victim feels should be brought to the attention of a physician. 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
A burn injury can lead to loss of fluid through the skin. If dehydration is suspected, a physician who will decide whether or not intravenous fluid is necessary. Potential signs of dehydration include:

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

Burn Patterns
Burns have typical and atypical patterns—typical patterns result from unintentional 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, neither are third-degree burns involving a very small, focused area (resembling, for example, a cigarette).

Causes

Burns are caused by exposure to thermal, electrical, 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

• 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
• Heated foods and containers
• Sun overexposure

Preventive Care

The following actions have been shown to lower the incidence of burns:

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

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

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

Diagnosis

When diagnosing a burn, a healthcare practitioner will evaluate the depth and extent of the damage, the degree of pain, the amount of swelling, and signs of infection. They will classify the burn based on the depth and extent of the injury (as described in the Overview section). Burns that cover a significant portion of the body, burns associated with smoke inhalation, burns resulting from electrical injuries, and burns associated with suspected physical abuse are treated as emergencies and require hospitalization. In the emergency room, all wounds are wrapped with sterile towels and patients receive oxygen (either through a mask or tube) and fluids (some patients require intravenous fluids). Patients are also evaluated for associated injuries (such as from physical abuse). Physicians may also conduct a biopsy to determine whether infection is present in the wound.

Treatment Approach

Appropriate treatment for burns depends on the extent of the tissue damage, the cause of the burn, and whether or not infection is present. All burns (with the exception of mild, first-degree burns) require immediate medical attention because of the risk of infection, dehydration, and other potentially serious complications.

The following steps may be taken in an emergency situation:

First-degree burns:

• Run cool water on burned area for 5 to 10 minutes or cover the area with a cool compress
• Take ibuprofen or acetaminophen to relieve pain and swelling

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 or cover the area with a cool compress then carefully remove clothing
• 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)

Third-degree burns:

• Call 911
• Check airway, breathing, and circulation
• Do not remove clothing that is stuck to the skin
• Run cool water continuously on burned area
• Elevate burned area above the heart

People who have sustained serious burns will be admitted to a hospital where keeping the area clean and removing any dead tissue through a process called debridement are of the utmost importance. Medications will be used to reduce pain and prevent infection. A tetanus shot will be administered if the person has not had one in 5 or more years.

Burns are often accompanied by pain and anxiety, even during recovery. A person may also experience emotional distress if a burn alters his or her appearance. Complementary therapies that may help a person alleviate such pain and anxiety include:

• Massage therapy
• Hypnosis
• Therapeutic touch
• Acupuncture

Proper nutrition is particularly important during the recovery phase, as certain vitamins and minerals have been shown to promote wound healing and prevent the spread of infection. Many traditional cultures also use herbs to treat burns, although the safety and effectiveness of these remedies are not well understood.

Medications

• Antimicrobial ointments (such as silver sulfadiazine, mafenide, silver nitrate, and povidone-iodine) are frequently used to lower the occurrence of infection; bacitracin may be used for first-degree burns.
• Antibiotics (such as oxacillin, mezlocillin, and gentamicin) are used if infection is detected at the burn site; 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)

Surgery and Other Procedures

In the case of severe burns, removal of dead tissue, known as debridement, and skin grafting (transplanting a piece of skin from one part of the body to the damaged area) improves the recovery process. Cosmetic surgery may also be necessary to improve both the function and appearance of the burned area.

Nutrition and Dietary Supplements

It is especially important for people who have sustained serious burns to obtain adequate amounts of nutrients in their daily diet. Burn patients in hospitals are often given diets high in calories and protein to speed recovery. When skin is burned, a substantial percentage of micronutrients, such as copper, selenium, and zinc may be lost. This increases the risk for infection, slows the healing process, prolongs the hospital stay, and even increases the risk of death. Although it is unclear which micronutrients are most beneficial for people with burns, many studies suggest that a multivitamin including the following nutrients may aid in the recovery process:

• Vitamin B complex
• Vitamin C
• Vitamin A
• Arginine
• Glutamine
• Copper
• Selenium
• Zinc

In addition, vitamin K levels tend to be low following a burn. However, it is not known whether additional supplementation of this vitamin will help under these circumstances.

Antioxidants
Oxidative stress (injury to cells caused by free radicals, which are substances in the blood that result from normal metabolic processes in the body) is believed to contribute significantly to skin and soft tissue damage incurred from a burn. In addition, levels of several antioxidants (substances that protect against the cell damage of free radicals) are measurably lower in burn victims, including beta-carotene, and vitamins A, C, and E. For this reason, antioxidant therapy using, for example, vitamins C and E and carotenoids, is often part of the treatment of burns, particularly soon after the injury takes place. The precise amount and combination to use, however, is not entirely clear. While there is some evidence that vitamins C and E, both taken orally, work particularly well together in preventing sunburn, it is not clear whether this benefit would be the same for treatment of burns of any cause once they have occurred.

In addition, although it is popular during the time of recovery from a burn to use topical vitamin E to try to diminish scar formation, one study found no cosmetic benefit when using topical vitamin E for surgical wounds.

Essential Fatty Acids
Essential fatty acids (fatty acids that the body does not make and must, therefore, be obtained through the diet) have been used to reduce inflammation and promote wound healing in burn victims. Animal research indicates that omega-3 fatty acids (one class of essential fatty acids) help promote a healthy balance of proteins in the body—protein balance is critical to proper organ function and general health, particularly after sustaining a burn. Further research is necessary to determine whether essential fatty acids have similar effects on protein balance in people who have suffered a burn.

Bromelain
Bromelain, a collection of protein-digesting enzymes found in the stem of pineapple plants, has been used historically to reduce swelling following soft tissue damage. Some studies of animals indicate that bromelain (applied topically) may also be useful in removing dead tissue from third-degree burns. This has not yet been tested on humans.

Herbs

Aloe (Aloe vera)
Aloe has been used for centuries to heal skin lesions and wounds. Aloe contains glycoproteins, protein-carbohydrate compounds that speed the healing process by stopping pain and inflammation, and polysaccharides, a type of carbohydrate that stimulates skin growth and repair. In one study conducted in Thailand in 1995, 27 people admitted to a hospital for first- and second-degree burns had one half of their burn treated with aloe vera gel and the other half treated with petroleum jelly. The area treated with aloe vera healed significantly faster than the area treated with petroleum jelly, although there were some reports of discomfort and brief pain with the aloe vera gel treatments. These results seem encouraging, however, studies comparing aloe vera with standard medication may help determine whether the herb is as effective for the treatment of burns as more customary therapies.

Honey
In some traditional medical practices, honey is applied to the skin to prevent infection and heal wounds. Results from two well-designed studies conducted in India suggest that topical applications of honey may heal burns significantly faster than the antimicrobial ointment, silver sulfadiazine. Some researchers attribute this effect to nutrients in honey that promote skin growth and to antibacterial substances present in honey.

Papaya (Carica papaya)
In The Gambia, Africa, papaya is used topically to help remove dead tissue from burn wounds and prevent infection. Although the exact mechanism of action is unclear, researchers suggest that papaya contains enzymes that break down the proteins in dead tissue. In addition, papaya is believed to have antimicrobial properties.

Tea Tree Oil (Melaleuca alternifolia)
In Australia, tea tree oil was used by aborigines and early settlers to treat burns. Some reports suggest that the herb may prevent the spread of infection. Modern studies, however, have not confirmed this function for tea tree oil. In fact, a recent study suggests that substances in tea tree oil may even be destructive to skin cells and may actually slow the healing process. Therefore, until more is known about the value of tea tree oil for burns, it is best to avoid use of the herb for this purpose.

Other Herbs Although some herbs used historically have not been researched scientifically, they may be considered by an herbal specialist to treat first-degree burns. Each of the following remedies would be applied topically.

• Slippery elm (Ulmus fulva)
• St. John's wort (Hypericum perforatum )
• Roman chamomile (Chamaemelum nobile)
• Walnut leaf (Juglans reglia)
• Gotu kola (Centella asiatica)
• Horsetail (Equisetum arvense)
• Milk thistle (Silybum marianum)
• Stinging nettle (Urtica dioica)

Acupuncture

Electrical Stimulation
Transcutaneous electrical nerve stimulation (TENS) is a method of applying controlled, low-voltage electrical stimulation to the skin for the purpose of relieving pain. Recent studies have suggested that TENS applied to acupuncture points (called electroacupuncture) on the ear (auricular acupuncture) may provide pain relief for people with burns. In one study, 11 burn patients received two forms of treatment prior to wound care: auricular TENS and a placebo pill. Seven patients reported at least a 70% reduction in pain during the TENS acupuncture treatments and only two patients reported that degree of relief when receiving the placebo pill. This preliminary study suggests that further investigation into the use of auricular electroacupuncture for the relief of pain in burn patients is warranted.

Massage and Physical Therapy

Massage Therapy
People with burns suffer pain, itching, and anxiety both from the burn itself and during the healing of the wound. Some studies suggest that massage may help ease these symptoms in both the emergency-care and recovery phases. In one study, 28 burn patients were randomly assigned to receive massage therapy or standard treatment while in the hospital. Patients in the massage therapy group received a 20-minute general body massage prior to wound cleaning once a day for 1 week. Reported effects included:

• Decreased anxiety
• Decreased pulse rate (a potential sign of improved relaxation and/or diminished pain)
• Decreased levels of cortisol (a hormone that indicates stress in the body)
• Decreased pain
• Improved mood, including diminished depression and anger

In another small study, 20 burn victims were randomly assigned to receive massage and standard therapy or standard therapy only during the recovery phase of their injury (between 80 to 165 days after the injury). The massage group received a 30-minute massage twice a week for 5 weeks in addition to standard therapy (consisting of physical and occupational therapy, regular check ups by the physician, medication for symptoms of pain and itching, and application of cocoa butter to the closed wound). People who received massages reported significantly less itching, pain, anxiety, and depressed mood compared to those who received standard care only.

Physical Therapy
Occupational and physical therapy begin very early for patients who are hospitalized for burns. The techniques used by occupational and physical therapists improve movement and function and reduce scar formation. Rehabilitation with the guidance of occupational and physical therapists may include the practices listed below:

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

Homeopathy
Although very 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. A constitutional type is defined as a person's physical, emotional, and psychological makeup. An experienced homeopath assesses all of these factors when determining the most appropriate treatment for each individual.

• Immersing the burned area in cold water until the pain subsides (this generally takes at least a few minutes)
• Arnica Montana — taken orally immediately following a burn
• Calendula — applied 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 diminish scar formation
• Cantharis — for persistent pain, restlessness, and anxiety especially as a result of severe burns; oral and/or topical forms may be recommended; requires a homeopathic doctor's prescription; may be used in children
• Hypericum perforatum — used topically 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; may be used in children under the direction of a licensed homeopath, often in the case of more severe burns
• Phosphorus — taken orally 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 burn patients. In one study, 30 hospitalized burn patients received either standard wound care (including pain medications) or standard wound care plus hypnosis with a technique called rapid induction analgesia (RIA). RIA sessions were administered prior to wound care over four burn care sessions during a 48-hour period. Patients who received RIA treatment had less anxiety and pain as well as reduced consumption of pain medication over the course of the burn care sessions. Relaxation ratings also increased in the RIA group during this time. These findings suggest that RIA may be a helpful addition to standard wound care in burn patients; further research of hypnosis is certainly warranted.

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 in a practice they call "the laying on of hands." This practice has been used for a variety of ailments including the relief of pain and anxiety, but studies have shown conflicting results. A recent trial of patients hospitalized for severe burns suggests that TT may reduce pain and anxiety associated with burns. Ninety-nine patients received either TT treatments or sham TT treatments (therapists moved their hands over the body but did not attempt to alter the energy field) once a day for 5 days. Patients who received TT treatments reported a significant reduction in pain and anxiety compared with the sham group, but there was no difference between groups in amount of medication used, stress relief, or satisfaction with therapy.

Other Considerations

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)

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). Third-degree burns often require a skin graft

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