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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 non-superficial 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 burn injury", section on 'Classification by depth' and "Classification of burn injury", section on 'Extent of burn injury'.)
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.
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 12°C (55°F), is one effective means of cooling . 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 .
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' and "Treatment of superficial burn wounds requiring hospital admission", 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 .
Pain management — For small burn injuries, acetaminophen and nonsteroidal antiinflammatory drugs (NSAIDs), alone or in combination with opioids, are often sufficient for analgesia . Analgesia for children with significant or painful burns is discussed in detail separately. (See "Management of burn wound pain and itching".)
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 . 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 .
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'.)
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 . (See "Tetanus-diphtheria 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 . 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 ; 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 . It appears best to change dressings whenever they become soaked with excessive exudate or other fluids . Topical antibiotics and desiccated fluid should be removed gently during dressing changes; scrubbing and sharp debridement are not necessary and may hinder healing .
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 . Avoid cosmetic preparations with lanolin as well as thick waxes and ointments as these can irritate the skin . Hypoallergenic lanolin preparations appear to be an acceptable option .
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 "Management of burn wound pain and itching".)
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 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 "Management of keloid and hypertrophic scars following burn injuries".)
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 . 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 .
Infection can extend the depth and extent of a burn, converting a superficial partial-thickness burn into a deep partial-thickness 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 .
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 . 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 and soft tissue 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.
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 . 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 .
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 . 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 .
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 . 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.)
●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.
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