Treatment of Minor Thermal Burns

Treatment of minor thermal burns
21/09/2016, 6:39 PM
Official reprint from UpToDate

www.uptodate.com 2016 UpToDate

Authors
Arek Wiktor, MD
David Richards, MD, FACEP
Section Editor
Maria E Moreira, MD
Deputy Editor
Jonathan Grayzel, MD, FAAEM
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Aug 2016. | This topic last updated: Sep 17, 2015.
INTRODUCTION Of the more than one million burn injuries incurred annually in the United States alone, the majority
is minor and can be managed on an outpatient basis without the need for burn specialist consultation [1,2]. The severe
metabolic derangements associated with severe burns rarely occur with minor burns. However, it is important for
clinicians treating burns to be able to classify them accurately in order to ensure appropriate therapy.
The evaluation and treatment of minor thermal burns will be reviewed here. The treatment of moderate and severe
thermal burns and other injuries associated with burns are discussed separately. (See "Emergency care of moderate
and severe thermal burns in adults" and "Emergency care of moderate and severe thermal burns in children" and
"Environmental and weapon-related electrical injuries" and "Topical chemical burns" and "Inhalation injury from heat,
smoke, or chemical irritants".)
CLASSIFICATION Burns are classified according to their depth and size (size is defined as a percentage of the total
body surface area, or TBSA). Treatment and prognosis are based largely upon these two characteristics. When
assessing what appear to be minor burns, the most important aspects of classification are to distinguish superficial burns
(picture 1 and picture 2) from partial-thickness burns (picture 3 and picture 4), and to determine the overall nonsuperficial burn size (ie, the size of all partial thickness and full thickness burns). These two assessments largely
determine which patients are appropriately managed in the outpatient setting.
Accurate classification is not always possible initially and may require up to three weeks [3,4]. The classification of
burns, including burn depth and size, is discussed in detail separately. (See "Classification of burns", section on
'Classification' and "Classification of burns", section on 'Percent body surface area estimates'.)
Minor burns Minor burns are defined by the American Burn Association as (table 1):
Partial-thickness burns <10 percent TBSA in patients 10 to 50 years old
Partial-thickness burns <5 percent TBSA in patients under 10 or over 50 years old
Full-thickness burns <2 percent TBSA in any patient without other injury
To be considered minor, burns must also generally meet the following criteria:
Isolated injury (ie, no suspicion of inhalation or high-voltage injury)
May not involve face, hands, perineum, or feet
May not cross major joints
May not be circumferential
A more in-depth description of burn classification is described in the table (table 2).
Hand and foot burns are generally not considered minor because inadequate management can result in serious
disability. Most clinicians err on the side of caution when treating hand burns, and refer them to a burn center if there is
any doubt about the severity of the injury. Aggressive therapy, including early range of motion exercises, stretching, and
referral to a knowledgeable occupational therapist, may be needed. Nevertheless, many hand burns can be treated as
though they are minor, as long as there is careful follow-up looking for any signs of infection or conversion to a deeper
burn. (See 'Follow-up care' below.)
In addition, burns classified as minor but sustained by patients with comorbid illness that may increase risks of
complications, such as diabetes or peripheral vascular disease, or who are receiving immunosuppressive therapy should
be followed more closely.
TREATMENT Initial treatment of minor thermal injuries consists mainly of removing clothing and debris, cooling,
simple cleansing, appropriate skin dressing, pain management and tetanus prophylaxis. Management is described in
detail below.
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Cooling After any clothing, jewelry (eg, rings), and non-adherent debris is removed, burn wounds can be cooled with
room-temperature or cool tap water to provide some pain relief and limit tissue injury. Cool running or still water is
applied until pain diminishes but should not be applied for longer than approximately five minutes to avoid macerating
the wound. Alternatively, the wound may be covered with wet gauze or towels, which can decrease pain without
immersing the wound and may be kept on the wound for as long as 30 minutes, until dressings are applied.
Direct application of ice or iced water should be avoided as this can increase pain and burn depth. Applying water or
saline-soaked gauze, cooled to around 12C (55F), is one effective means of cooling [5]. In the clinic, this can be done
by mixing one part refrigerated saline with one part room temperature saline. Caution should be exercised and patients
carefully monitored when cooling burns that cover more than 10 percent of the total body surface area (TBSA) due to the
increased risk of hypothermia [6].
Cleaning Burn wounds should be cleaned. Although some clinicians use skin disinfectants (eg, povidone-iodine),
these cleansers can inhibit the healing process and we discourage using them. Instead, we suggest washing minor burn
wounds using only mild soap and tap water, an approach supported by a growing number of burn centers [3,4,7-9].
Patients should be instructed to wash their burns daily with mild soap and water during dressing changes.
Debridement Sloughed or necrotic skin, including ruptured blisters, should be debrided before applying a dressing
(picture 5). Necrotic blister skin remnants may increase the risk of infection and limit the contact of topical antimicrobial
agents to the burn wound. Extensive debridement is rarely necessary and may often be deferred until the initial follow-up
visit (see 'Follow-up care' below). This additional time enables the clinician to assess the full extent of the injury more
accurately and allows the patient to overcome the anxiety and pain associated with the immediate injury. Wound
debridement for minor and major burns is discussed in greater detail separately. (See "Local treatment of burns: Topical
antimicrobial agents and dressings", section on 'Cleansing and debridement'.)
Blisters Blisters may develop with superficial or deep partial-thickness burns. Ruptured blisters should be debrided,
but the management of clean, intact blisters is controversial. Needle aspiration of blisters should never be performed, as
this increases the risk of infection [7,10,11]. The management of burn blisters is reviewed separately. (See "Local
treatment of burns: Topical antimicrobial agents and dressings", section on 'Burn blisters'.)
Blisters lasting for several weeks without resorption indicate a possible underlying deep partial or full-thickness burn,
necessitating referral to a burn center or surgeon with expertise managing burns [12].
Pain management For small burn injuries, acetaminophen and nonsteroidal antiinflammatory drugs (NSAIDs), alone
or in combination with opioids, are often sufficient for analgesia [13]. Analgesia for children with significant or painful
burns is discussed in detail separately. (See "Burn pain: Principles of pharmacologic and nonpharmacologic
management".)
Initially, analgesics should be administered around the clock, giving additional "rescue" medication before dressing
changes and increased physical activity [13,14]. Elevation of foot and hand burns above the level of the heart can
reduce pain and swelling for several days following the injury.
Pain management needs usually decline markedly once wound epithelization has occurred. However, analgesia
requirements can actually increase if rescue medications are inadequate. Patients with larger or recently sustained
burns can present with significant pain, and clinicians should not hesitate to use intravenous opioids (eg, morphine) for
initial analgesia in this setting.
Chemoprophylaxis Significant burn wound surfaces are prone to rapid bacterial colonization with the potential for
invasive infection. However, minor burns (eg, sunburns) and superficial partial-thickness burns with an intact epidermis
rarely develop such infections and do not require a topical antimicrobial agent [15]. Application of non-perfumed
moisturizing cream is typically all that is required for superficial burns. A topical antibiotic should only be applied to
partial- or full-thickness burns. Systemic prophylactic antibiotics are not indicated to prevent infection in patients with
minor burns [16].
Some clinicians choose to apply aloe vera or a basic topical antibiotic such as bacitracin to superficial burns. Both are
inexpensive, and aloe vera provides some antibacterial activity, but there is no clear evidence demonstrating improved
outcomes in minor burns with such treatment. Silver sulfadiazine (SSD) is commonly used for prophylaxis against
infection but is generally not used for partial-thickness burns. Treatment with SSD may slow wound healing and
increases the frequency of dressing changes, resulting in increased pain. Modern membrane-like dressings may be
superior to SSD, while honey, an ancient wound remedy, also appears to be an effective treatment [17-19]. Topical
antibiotics are discussed in greater detail separately. (See "Local treatment of burns: Topical antimicrobial agents and
dressings", section on 'Topical antimicrobial agents'.)
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There is NO role for topical steroids in the initial treatment of minor burns, as this may increase the risk of infection and
impair healing.
Tetanus immunization should be updated, particularly for any burns deeper than superficial-thickness. Tetanus immune
globulin should be given to patients who have not received a complete primary immunization [20]. (See "Tetanusdiphtheria toxoid vaccination in adults".)
Dressings Superficial burns do not require dressings. Although partial and full-thickness burns are generally dressed,
some relatively minor burns may be treated without dressings. As an example, it is often preferable to manage smaller
burns of the face or hand (not involving fingers) without dressings; treatment consists of gentle cleansing with a mild
soap followed by the application of a topical agent. (See 'Chemoprophylaxis' above.)
This approach may improve the appearance of facial burns and helps to prevent joint stiffness with hand burns by
allowing for range of motion exercises. However, this approach is impractical for infants, children, young active adults,
and those at risk for wound contamination [21]. Burns involving fingers or toes should be dressed appropriately.
For burns requiring dressings, there are several options:
Basic dressing Particularly for emergency treatment, a basic gauze dressing provides adequate burn coverage.
It is placed after the application of topical antibiotic and consists of a first layer of nonadherent gauze (eg, Adaptic or
Xeroform) placed over the burn, a second layer of fluffed dry gauze, and an outer layer of an elastic gauze roll (eg,
Kerlix). Care should be taken to individually wrap and separate with fluffed gauze all toes or fingers to prevent
adherence and maceration. The following video clips show a basic burn dressing being applied in the operating room
(movie 1). In patients with less severe burns that are dressed in an outpatient setting, and who are not being treated with
IV analgesics, cleaning is performed more gently and splints are generally not needed.
Some patients with minor burns may need to be transferred to a burn center for reevaluation and treatment. In such
cases, all burns should be dressed in dry gauze only. Moist gauze dressings increase the likelihood of hypothermia,
macerate wounds, and subsequently increase burn depth. Topical agents applied to wounds delay transport time and
are tedious to remove upon arrival to the burn unit when the wounds are inspected. The key in transferring a burn
patient is to keep their body warm and prevent unnecessary delays.
Biologic and synthetic dressings Although generally not used in the emergency department or primary care
clinic, biologic and synthetic dressings can be used to treat partial-thickness burns. Their use in both adults and children
reduces the frequency of dressing changes and may reduce pain, help prevent infection, and promote healing [22-24].
The different types and use of biologic and synthetic dressings are discussed separately. (See "Local treatment of burns:
Topical antimicrobial agents and dressings", section on 'Dressings'.)
Dressing changes Recommended frequencies for dressing changes depend on the type of dressing used, and
range from twice daily to weekly [12]; no firm recommendations can be made due to the paucity of literature on this
subject. However, typical antibiotic ointment and non-adherent gauze dressings should be changed once daily. A small
study in a pediatric burn unit reported that once-daily dressing changes resulted in less need for pain medication with no
increase in morbidity [25]. It appears best to change dressings whenever they become soaked with excessive exudate
or other fluids [4]. Topical antibiotics and desiccated fluid should be removed gently during dressing changes; scrubbing
and sharp debridement are not necessary and may hinder healing [4].
Once epithelialization occurs, a nonperfumed moisturizing cream (eg, Vaseline Intensive Care, Eucerin, Nivea, mineral
oil, or cocoa butter) should be applied to the wound until natural lubricating mechanisms return [12]. Avoid cosmetic
preparations with lanolin as well as thick waxes and ointments as these can irritate the skin [4]. Hypoallergenic lanolin
preparations appear to be an acceptable option [26].
Pruritus Itching is a common problem during the healing process. The causes of pruritus are multifactorial. It is often
triggered or worsened by environmental extremes (especially heat), physical activity, and stress. Pruritus usually
diminishes gradually and stops after complete wound healing. Until then, a variety of approaches can control itching.
Systemic antihistamines (eg, oral diphenhydramine) are standard first-line therapy, but a number of topical agents,
including bicarbonate of soda baths and moisturizing lotions, can also be used. Many patients prefer loose, soft cotton
clothing. The management of burn-related pruritus is discussed in detail separately. (See "Local treatment of burns:
Topical antimicrobial agents and dressings", section on 'Local treatment of pruritus'.)
Oral burns Oral burns may occur from ingesting very hot liquids or solids, by inhalation of hot vapors or liquids, or by
holding flammable/corrosive objects in the mouth (picture 6). Food heated in a microwave or nearly boiling liquids are
often implicated, with tea, cheese, potatoes, and noodles among the most common sources. While little has been
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published regarding the management of patients affected by oral burns, proper management should include cooling with
water and monitoring for evidence of airway compromise. Treatment for minor burns along the lips and oral commissure
includes topical antibiotic ointment and intermittent application of Vaseline to keep the lips from drying out. Minor oral
mucosal burns typically require no specific treatment other than saline rinses and basic oral hygiene. Alcohol-based
mouth rinses should be avoided as they can irritate wounds and increase pain.
Several case reports describe epiglottitis caused by thermal injury after an oral scald burn [27-32]. Closer attention
should be paid to young children with oral scald burns as their airway structures are narrower and are more prone to
obstruction with smaller degrees of inflammation. If there is any concern for airway compromise or about the extent of
injury, the patient is best evaluated in the emergency department.
Disposition Minor burns are generally treated on an outpatient basis, but there are exceptions. As an example, a
partial-thickness burn involving the entire circumference of an arm (<10 percent TBSA) can pose a significant care
challenge for some patients depending on their resources and social circumstances. Some patients may not tolerate
debridement in an outpatient clinic and require admission to a burn unit for wound care and pain management. A
clinician may elect to treat as an inpatient a patient with burns that meet all the minor burn criteria listed above if there
are concerns about the patient's ability to tolerate dressing changes or debridement, or such issues as physical abuse,
reliability, adequate follow-up, or comorbid disease (eg, diabetes). Ultimately, clinician judgment is the most important
arbiter of patient disposition. (See 'Classification' above.)
FOLLOW-UP CARE Follow-up care involves surveying for signs of infection, increasing depth of the burn, and
scarring. Patients with an infected wound should be hospitalized to minimize the risk of sepsis or extension of the burn.
Scarring and contracture can result in long-term disfigurement and disability, both of which are indications for specialized
care. Any questionable or complex burn wounds should be referred to a local burn center for further evaluation.
Timing of visits The clinician should examine the patient the day after injury to adjust pain medications and to
assess the patient's competence performing dressing changes. Subsequent follow-up can then be done on a weekly
basis until wound epithelialization occurs. If the clinician harbors any concern that pain control may be insufficient or the
patient or their family may not be able to provide adequate care, then it is best to perform daily assessments of the
wound until epithelialization is complete [3,12]. More frequent follow-up, particularly during the first week after the injury,
is usually necessary if biologic or synthetic dressings are used.
After epithelialization, follow-up visits are conducted every four to six weeks to look for any evidence of hypertrophic scar
formation and to monitor the patient's overall well-being. (See "Local treatment of burns: Topical antimicrobial agents
and dressings", section on 'Local treatment of burn scars'.)
Diagnosis and management of infection Diagnosing infection in burn patients is challenging. Fortunately, the
incidence of infections among ambulatory patients with partial-thickness or superficial burns is low [33]. Burns
themselves elicit inflammation, resulting in mild erythema, edema, pain, and tenderness. Typically, a rim of hyperemia is
present on all burn wounds (picture 7); however, if this rim extends more than 2 cm beyond the border of the burn,
cellulitis is likely (picture 8). In addition, burn wound hyperemia normally follows the exact borders of the wound,
whereas cellulitis is more confluent, with less distinct borders. Infection should also be suspected if these signs occur in
association with increased pain, lymphangitis, fever, or malaise and anorexia [12].
Infection can extend the depth and extent of a burn, converting a superficial partial-thickness burn into a deep partialthickness burn or even a full-thickness burn. In addition, burn infections are more susceptible to blood invasion and
sepsis. Because of these risks, all infections of suspected partial or full-thickness burns warrant aggressive management
including hospital admission and parenteral antibiotics [7].
Superficial cultures of the burn wound do not differentiate colonization from invasive infection, leading some authors to
recommend a full-thickness skin biopsy for all possible burn infections to confirm infection and identify the aggravating
organism [34]. Full-thickness skin biopsy is generally performed if treatments are failing and if there is concern for
invasive or resistant microorganisms. (See "Burn wound infection and sepsis" and "Pseudomonas aeruginosa skin, soft
tissue, and bone infections", section on 'Burn infections'.)
Referral Patients with minor burns should be referred to a surgeon with expertise in burn care if wound
epithelialization has not begun after one week or if subsequent evaluations reveal a full-thickness burn greater than 2 cm
(picture 9) [3,7,12]. All full-thickness wounds that might benefit from skin grafting should be referred. Skin grafting
performed less than 72 hours after injury is beneficial and is indicated for non-scald full-thickness burns in children and
in adults younger than 30 years of age. Wound complications, such as infection or the development of necrotic tissue or
a hypertrophic scar, are additional grounds for referral.
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It is best to wait two weeks before assessing the need for surgery in children with hot water scald burns, as overly
aggressive excision and grafting in this group has resulted in worse outcomes, according to a small randomized trial
[35]. More extensive excisions were performed in patients treated early whereas those in whom treatment was delayed
needed less extensive excisions or sometimes none at all. A full-thickness burn less than 2 cm wide can be allowed to
heal by contracture as long as it is in a nonfunctional, noncosmetic area, and the skin is not thin [9].
The presence of necrotic tissue in deep burn wounds can cause progressive tissue injury, which suggests that excision
of this tissue enhances healing. In addition, excision of necrotic tissue from burn wounds followed by skin grafting
restores the skin barrier and appears to improve immunologic functioning, thereby reducing the risk of infection. Early
excision of necrotic tissue and skin grafting generally results in improved outcomes. The principles, techniques, and
indications for this approach are reviewed separately. (See "Principles of burn reconstruction: Overview of surgical
procedures".)
Scarring Hypertrophic scarring is thought to be inevitable in any case where epithelialization takes longer than two
weeks in blacks and young children, and three weeks in all others [36]. Scar contractures result in disfigurement and
disability. Early application of pressure dressings reduces the risk for hypertrophic scarring, although the optimal
pressure has not yet been determined in controlled trials [37].
Patients should be referred to a burn center promptly at the first sign of hypertrophic scarring or if the wound misses the
following epithelialization milestones:
10 to 14 days in blacks and young children
14 to 21 days in all ages, other races
Epithelialization consists of tiny opalescent islands of epithelium throughout the wound (picture 10). Complete healing
usually follows in 7 to 10 days [12]. A deep partial-thickness burn at different stages of healing, including
epithelialization, is shown in the following photographs (picture 11).
While pressure does little to remodel existing hypertrophic scars, silicone has significantly reduced established scars as
late as 12 years after injury. Splinting, surgical excision, or reconstruction may be needed to treat some scars. (See
"Principles of burn reconstruction: Overview of surgical procedures" and "Keloids and hypertrophic scars", section on
'Silicone gel sheets'.)
INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, "The Basics" and "Beyond
the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and
they answer the four or five key questions a patient might have about a given condition. These articles are best for
patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient
education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade
reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to
your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and
the keyword(s) of interest.)
Basics topic (see "Patient education: Skin burns (The Basics)")
Beyond the Basics topic (see "Patient education: Skin burns (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS Most minor burns heal well with minimal intervention and can be managed
appropriately in an outpatient setting. To insure proper care, however, it is crucial for clinicians to be able to classify
burns accurately. Listed below are recommendations for the treatment of minor burns.
Burns are classified according to their depth and size. Treatment and prognosis are based largely upon these
characteristics. Most important is to distinguish superficial burns from partial-thickness burns, and to assess
accurately the overall nonsuperficial burn size. These two assessments largely determine which patients are
appropriately managed in the outpatient setting. (See 'Classification' above.)
Initial treatment of minor thermal injuries consists mainly of cooling (with room temperature tap water or cooled,
saline-soaked gauze; not with ice), simple gentle cleansing with mild soap and water, and appropriate dressing.
Pain management and tetanus prophylaxis are important. Early extensive debridement is generally not necessary
and may be deferred until the initial follow-up visit. (See 'Treatment' above.)
A topical antibiotic should be applied to any nonsuperficial burn to prevent infection. (See 'Treatment' above.)
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Superficial burns generally do not require dressings; partial and full-thickness burns often do. Particularly in the
emergency setting, a basic gauze dressing provides good burn coverage. It is placed after the application of topical
antibiotic and consists of a first layer of nonadherent gauze (eg, Adaptic or Xeroform) placed over the burn, a
second layer of fluffed dry gauze, and an outer layer of elastic gauze roll (eg, Kerlix). Individually wrap and
separate with fluffed gauze all toes or fingers to prevent adherence and maceration. (See 'Dressings' above.)
Follow-up care involves surveying for signs of infection, increasing burn depth, and contracture, and ensuring
adequate analgesia. Patients should be seen the day after injury to adjust pain medications, assess dressing
change competence, and possibly to debride the wound. Subsequent follow-up can then be done on a weekly
basis until wound epithelialization occurs. More frequent follow-up is needed if there are concerns about the
wound, patient comorbidities, patient compliance, or other issues. (See 'Follow-up care' above.)
All infections of suspected partial or full-thickness burns warrant aggressive management including admission and
parenteral antibiotics. In addition to causing sepsis, burn infections can extend the depth and extent of a burn,
converting a superficial partial-thickness burn into a deep partial-thickness or full-thickness burn. (See 'Diagnosis
and management of infection' above.)
Patients with minor burns should be referred to a surgeon with expertise in burn care if wound epithelialization has
not begun after one week or if subsequent evaluations reveal a full-thickness burn greater than 2 cm. Superficial
minor burns to functional areas (eg, joints, hands, or feet), thin skin (eg, very young or very old patients, perineum),
or cosmetic areas (eg, face) need to be followed closely and referred if any signs of full-thickness burns develop.
Additional indications for referral include complications, such as infection or the development of necrotic tissue.
(See 'Referral' above.)
When transfer to a burn center is necessary, burn wounds should be dressed in dry gauze only. Topical agents or
moist dressings should not be applied. The patient should be kept warm and transport should be expedited. (See
'Dressings' above.)
ACKNOWLEDGMENT The editorial staff at UpToDate would like to acknowledge Eric Morgan, MD and William
Miser, MD, who contributed to an earlier version of this topic review.
Use of UpToDate is subject to the Subscription and License Agreement.
Topic 349 Version 19.0
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GRAPHICS
Superficial burn
Red burns that blanch are typical of superficial burns.

Courtesy of Eric D Morgan and William F Miser, MD.
Graphic 55928 Version 3.0
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Superficial burn of the forearm
Superficial, or epidermal, burns involve only the epidermal layer of

skin. They do not blister but are painful, dry, red, and blanch with
pressure. Note the absence of hair and areas of redness in the exposed
portion of the forearm.
Courtesy of Simon G Talbot, MD.
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Superficial partial-thickness burn
Blistering burns that blanch with pressure characterize superficial

partial-thickness burns. They are also typically moist and weep.
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Deep partial-thickness burn
Easily unroofed blisters that do not blanch with pressure and have a
waxy appearance typify deep partial-thickness burns.
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Burn center referral criteria*

Partial-thickness burns greater than 10% of TBSA
Burns that involve the face, hands, feet, genitalia, perineum, or major joints
Third-degree burns in any age group
Electrical burns, including lightening injury
Chemical burns
Inhalation injury
Burn injury in patients with preexisting medical disorders that could complicate management, prolong
recovery, or affect mortality
Any patient with burns and concomitant trauma (such as fractures) in which the burn injury poses the
greatest risk for morbidity or mortality. In such cases, if the trauma poses the greater immediate risk,
the patient may be stabilized initially in a trauma center before being transferred to a burn unit.
Physician judgment will be necessary in such situations and should be in concert with the regional
medical control plan and triage protocols.
Burned children in hospitals without qualified personnel or equipment for the care of children
Burn injury in patients who will require special social, emotional, or rehabilitative intervention
TBSA: total body surface area.
* A burn center may treat adults, children, or both. Burn injuries that should be referred to a burn center
include any of the criteria listed.
Copyright American Burn Association. Advanced Burn Life Support Provider Manual. Chicago. 2011. 2527. Print.
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Burn depth
Depth
Superficial
Cause
Ultraviolet
exposure
Appearance
Dry, red
Sensation
Healing time
Painful
3 to 6 days
Painful to
temperature
and air
7 to 20 days
Perceptive of
pressure only
>21 days
Deep pressure
only
Never (if >2% total

body surface area)
Blanches with pressure
Very short
flash
Superficial
partialthickness
Scald (spill
or splash)
Blisters
Short flash
Blanches with pressure
Deep partialthickness
Scald (spill)
Blisters (easily unroofed)
Flame
Wet or waxy dry
Oil
Variable color (patchy to

cheesy white to red)
Grease
Moist, red, weeping
Does not blanch with

pressure
Full-thickness
Scald
(immersion)
Waxy white to leathery

gray to charred and black
Flame
Dry and inelastic
Steam
No blanching with pressure
Oil
Grease
Chemical
Electrical
Adapted from:
1. Mertens DM, Jenkins ME, Warden GD. Out patient burn management. Nurs Clin North Am 1997;
32:343.
2. Peate WF. Outpatient management of burns. Am Fam Physician 1992; 45:1321.
3. Clayton MC, Solem LD. No ice, no butter. Advice on management of burns for primary care
physicians. Postgrad Med 1995; 97:151.
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Undebrided and debrided partial thickness thermal

burn
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The photographs above show a partial thickness thermal burn before

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and after basic debridement. Topical antibiotic ointment and an

appropriate dressing with a non-adherent first layer are applied
following debridement.
Courtesy of Arek Wiktor, MD.
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Thermal burns of tongue
Oral burn due to exploded lithium ion battery from flashlight held in mouth.
Laceration of base of tongue (arrow). Pale areas of full thickness mucosal burn on
anterior surface of tongue (arrowheads). All areas subsequently healed without
surgical intervention.
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Hyperemia associated with dermal burns
The photograph to the left shows deep partial- and full-thickness flame burns on the patient's back. Note the
exactly follows the wound border. This rim is hyperemia, not cellulitis. The photograph to the right shows full
the lower extremities. Note the rim of erythema that exactly follows the wound border, which again is hypere
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Cellulitis associated with dermal burn
This photograph shows deep partial-thickness flame burn to middle finger. Note the erythema extending prox
arm, which is cellulitis.
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Full-thickness burn
Burn areas that are waxy white or leathery gray and insensate
characterize full-thickness burns.
Courtesy of Eric D Morgan, MD and William F Miser, MD.
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Early epithelialization of deep partial thickness thermal burn
Tiny opalescent "islands" of epithelium (skin buds) are apparent in this photograph of a deep partial thicknes
burn of the arm in the early stages of epithelialization.
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Healing deep partial thickness burn
These photographs show a deep, partial thickness burn of the proximal

leg at different stages of healing. The top image was taken at one
week, the middle image at four weeks, and bottom image at 10
months after the initial injury was sustained.
Courtesy of Simon G Talbot, MD.
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Contributor Disclosures
Arek Wiktor, MD Nothing to disclose. David Richards, MD, FACEP Nothing to disclose. Maria E Moreira, MD Nothing
to disclose. Jonathan Grayzel, MD, FAAEM Nothing to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by
vetting through a multi-level review process, and through requirements for references to be provided to support the
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