A burn is a type of injury to skin, or other tissues, caused by heat, cold, electricity, chemicals, friction, or radiation. Most burns are due to heat from hot liquids, solids, or fire. Females in many areas of the world have a higher risk related to the more frequent use of open cooking fires or unsafe cook stoves. Alcoholism and smoking are other risk factors. Burns can also occur as a result of self harm or violence between people.
Burns that affect only the superficial skin layers are known as superficial or first-degree burns. They appear red without blisters and pain typically lasts around three days. When the injury extends into some of the underlying skin layer, it is a partial-thickness or second-degree burn. Blisters are frequently present and they are often very painful. Healing can require up to eight weeks and scarring may occur. In a full-thickness or third-degree burn, the injury extends to all layers of the skin. Often there is no pain and the burn area is stiff. Healing typically does not occur on its own. A fourth-degree burn additionally involves injury to deeper tissues, such as muscle, tendons, or bone. The burn is often black and frequently leads to loss of the burned part.
Burns are generally preventable. Treatment depends on the severity of the burn. Superficial burns may be managed with little more than simple pain medication, while major burns may require prolonged treatment in specialized burn centers. Cooling with tap water may help pain and decrease damage; however, prolonged cooling may result in low body temperature. Partial-thickness burns may require cleaning with soap and water, followed by dressings. It is not clear how to manage blisters, but it is probably reasonable to leave them intact if small and drain them if large. Full-thickness burns usually require surgical treatments, such as skin grafting. Extensive burns often require large amounts of intravenous fluid, due to capillary fluid leakage and tissue swelling. The most common complications of burns involve infection. Tetanus toxoid should be given if not up to date.
In 2013, fire and heat resulted in 35 million injuries. This resulted in about 2.9 million hospitalizations and 238,000 deaths. Most deaths due to burns occur in the developing world, particularly in Southeast Asia. While large burns can be fatal, treatments developed since 1960 have improved outcomes, especially in children and young adults. In the United States, approximately 96% of those admitted to a burn center survive their injuries. Burns occur at similar frequencies in men and women. The long-term outcome is related to the size of burn and the age of the person affected.
Many things can cause burns, including:
- Hot liquid or steam
- Hot metal, glass or other objects
- Electrical currents
- Radiation from X-rays or radiation therapy to treat cancer
- Sunlight or ultraviolet light from a sunlamp or tanning bed
- Chemicals such as strong acids, lye, paint thinner or gasoline
There are certain risk factors that make it more likely that a person is burned. Risk factors for burns include:
Age – Children under 4 who are poorly supervised are at risk of burns. Additionally, children who live with abusive parents are at increased risk of burns.
Drug use – Use of alcohol and illegal drugs increases risk of burns.
Gender – Men are more than twice more likely to suffer burn injuries than women.
Seasonal – Burns occur more often during holidays celebrated with fireworks and school breaks.
Smoking – Careless smoking puts you at risk of burns.
Socio-economic status – People living in substandard or older housing, as well as those in low income neighbourhoods are more likely to experience burns.
Sun exposure – Too much exposure to the sun puts you at risk of burn injury.
Unsafe heating practices – Use of heated foods and containers, hot water heaters set above 130 °F, and unsafe storage of flammable or caustic materials put you at higher risk of burns. Also, the use of wood stoves and exposure to heating sources or electrical cords puts you at risk of burns.
Burns occurs when the skin comes into contact with electricity, radiation, chemicals or heat. During a severe burn case, nerve damage and extreme scarring can occur. But how can you be sure that you are experiencing a minor burn, or not? Learn to identify the symptoms of burns by reading about types of burns, including second degree burns here.
Burns don’t affect the skin uniformly, so a single injury can reach varying depths. Distinguishing a minor burn from a more serious burn involves determining the extent of tissue damage.
The following are three classifications of burns:
- First-degree burn. This minor burn affects only the outer layer of the skin (epidermis). It may cause redness, swelling and pain. It usually heals with first-aid measures within several days to a week. Sunburn is a classic example.
- Second-degree burn. This type of burn affects both the epidermis and the second layer of skin (dermis). It may cause red, white or splotchy skin, pain, and swelling. And the wound often looks wet or moist. Blisters may develop, and pain can be severe. Deep second-degree burns can cause scarring.
- Third-degree burn. This burn reaches into the fat layer beneath the skin. Burned areas may be charred black or white. The skin may look waxy or leathery. Third-degree burns can destroy nerves, causing numbness. A person with this type of burn may also have difficulty breathing or experience smoke inhalation or carbon monoxide poisoning.
When to see a doctor
Seek emergency medical assistance for:
- Burns that cover the hands, feet, face, groin, buttocks, a major joint or a large area of the body
- Deep burns, which means burns affecting all layers of the skin and even other tissues
- Burns caused by chemicals or electricity
- Difficulty breathing or burns to the airway
Minor burns can be cared for at home, but call your doctor if you experience:
- Large blisters
- Signs of infection, such as oozing from the wound, increased pain, redness and swelling
- A burn or blister that doesn’t heal in several weeks
- New, unexplained symptoms
- Significant scarring
During the physical exam, your doctor will examine your burned skin and determine what percentage of your total body surface area is involved. In general, an area of skin roughly equal to the size of your palm equals 1 percent of your total body surface area. For people ages 10 to 40, the American Burn Association defines a severe burn as one that involves 25 percent total body surface area or any burn involving the eyes, ears, face, hands, feet or groin.
You’ll also be examined for other injuries and to determine whether the burn has affected the rest of your body. You may need lab tests, X-rays or other diagnostic procedures.
Resuscitation begins with the assessment and stabilization of the person’s airway, breathing and circulation. If inhalation injury is suspected, early intubation may be required. This is followed by care of the burn wound itself. People with extensive burns may be wrapped in clean sheets until they arrive at a hospital. As burn wounds are prone to infection, a tetanus booster shot should be given if an individual has not been immunized within the last five years. In the United States, 95% of burns that present to the emergency department are treated and discharged; 5% require hospital admission. With major burns, early feeding is important. Hyperbaric oxygenation may be useful in addition to traditional treatments.
In those with poor tissue perfusion, boluses of isotonic crystalloid solution should be given. In children with more than 10-20% TBSA burns, and adults with more than 15% TBSA burns, formal fluid resuscitation and monitoring should follow. This should be begun pre-hospital if possible in those with burns greater than 25% TBSA. The Parkland formula can help determine the volume of intravenous fluids required over the first 24 hours. The formula is based on the affected individual’s TBSA and weight. Half of the fluid is administered over the first 8 hours, and the remainder over the following 16 hours. The time is calculated from when the burn occurred, and not from the time that fluid resuscitation began. Children require additional maintenance fluid that includes glucose. Additionally, those with inhalation injuries require more fluid. While inadequate fluid resuscitation may cause problems, over-resuscitation can also be detrimental. The formulas are only a guide, with infusions ideally tailored to a urinary output of >30 mL/h in adults or >1mL/kg in children and mean arterial pressure greater than 60 mmHg.
While lactated Ringer’s solution is often used, there is no evidence that it is superior to normal saline. Crystalloid fluids appear just as good as colloid fluids, and as colloids are more expensive they are not recommended. Blood transfusions are rarely required. They are typically only recommended when the hemoglobin level falls below 60-80 g/L (6-8 g/dL) due to the associated risk of complications. Intravenous catheters may be placed through burned skin if needed or intraosseous infusions may be used.
Early cooling (within 30 minutes of the burn) reduces burn depth and pain, but care must be taken as over-cooling can result in hypothermia. It should be performed with cool water 10–25 °C (50.0–77.0 °F) and not ice water as the latter can cause further injury. Chemical burns may require extensive irrigation. Cleaning with soap and water, removal of dead tissue, and application of dressings are important aspects of wound care. If intact blisters are present, it is not clear what should be done with them. Some tentative evidence supports leaving them intact. Second-degree burns should be re-evaluated after two days.
In the management of first and second-degree burns, little quality evidence exists to determine which dressing type to use. It is reasonable to manage first-degree burns without dressings. While topical antibiotics are often recommended, there is little evidence to support their use. Silver sulfadiazine (a type of antibiotic) is not recommended as it potentially prolongs healing time. There is insufficient evidence to support the use of dressings containing silver or negative-pressure wound therapy.
Burns can be very painful and a number of different options may be used for pain management. These include simple analgesics (such as ibuprofen and acetaminophen) and opioids such as morphine. Benzodiazepines may be used in addition to analgesics to help with anxiety. During the healing process, antihistamines, massage, or transcutaneous nerve stimulation may be used to aid with itching. Antihistamines, however, are only effective for this purpose in 20% of people. There is tentative evidence supporting the use of gabapentin and its use may be reasonable in those who do not improve with antihistamines. Intravenous lidocaine requires more study before it can be recommended for pain.
Intravenous antibiotics are recommended before surgery for those with extensive burns (>60% TBSA). As of 2008, guidelines do not recommend their general use due to concerns regarding antibiotic resistance and the increased risk of fungal infections. Tentative evidence, however, shows that they may improve survival rates in those with large and severe burns. Erythropoietin has not been found effective to prevent or treat anemia in burn cases. In burns caused by hydrofluoric acid, calcium gluconate is a specific antidote and may be used intravenously and/or topically. Recombinant human growth hormone (rhGH) in those with burns that involve more than 40% of their body appears to speed healing without affecting the risk of death.
Wounds requiring surgical closure with skin grafts or flaps (typically anything more than a small full thickness burn) should be dealt with as early as possible. Circumferential burns of the limbs or chest may need urgent surgical release of the skin, known as an escharotomy. This is done to treat or prevent problems with distal circulation, or ventilation. It is uncertain if it is useful for neck or digit burns. Fasciotomies may be required for electrical burns.
Honey has been used since ancient times to aid wound healing and may be beneficial in first- and second-degree burns. There is tentative evidence that honey helps heal partial thickness burns. The evidence for aloe vera is of poor quality. While it might be beneficial in reducing pain, and a review from 2007 found tentative evidence of improved healing times, a subsequent review from 2012 did not find improved healing over silver sulfadiazine. There were only three randomized controlled trials for the use of plants for burns, two for aloe vera and one for oatmeal.
There is little evidence that vitamin E helps with keloids or scarring. Butter is not recommended. In low income countries, burns are treated up to one-third of the time with traditional medicine, which may include applications of eggs, mud, leaves or cow dung. Surgical management is limited in some cases due to insufficient financial resources and availability. There are a number of other methods that may be used in addition to medications to reduce procedural pain and anxiety including: virtual reality therapy, hypnosis, and behavioral approaches such as distraction techniques.
The obvious best way to fight burns is to prevent them from happening. Certain jobs put you at a greater risk for burns, but the fact is that most burns happen at home. Infants and young children are the most vulnerable to burns. Preventive measures you can take at home include:
- Keep children out of the kitchen while cooking.
- Turn pot handles toward the back of the stove.
- Place a fire extinguisher in or near the kitchen.
- Test smoke detectors once a month.
- Replace smoke detectors every 10 years.
- Keep water heater temperature under 120 degrees Fahrenheit.
- Measure bath water temperature before use.
- Lock up matches and lighters.
- Install electrical outlet covers.
- Check and discard electrical cords with exposed wires.
- Keep chemicals out of reach, and wear gloves during chemical use.
- Wear sunscreen every day, and avoid peak sunlight.
- Ensure all smoking products are stubbed out completely.
- Clean out dryer lint traps regularly.
It’s also important to have a fire escape plan and to practice it with your family once a month. In the event of a fire, make sure to crawl underneath smoke. This will minimize the risk of passing out and becoming trapped in a fire.
For minor burns:
- Cool the burn to help soothe the pain. Hold the burned area under cool (not cold) running water for 10 to 15 minutes or until the pain eases. Or apply a clean towel dampened with cool tap water.
- Remove rings or other tight items from the burned area. Try to do this quickly and gently, before the area swells.
- Don’t break small blisters (no bigger than your little fingernail). If blisters break, gently clean the area with mild soap and water, apply an antibiotic ointment, and cover it with a nonstick gauze bandage.
- Apply moisturizer or aloe vera lotion or gel, which may provide relief in some cases.
- If needed, take an over-the-counter pain reliever, such as ibuprofen (Advil, Motrin IB, others), naproxen sodium (Aleve) or acetaminophen (Tylenol, others).
- Consider a tetanus shot. Make sure that your tetanus booster is up to date. Doctors recommend people get a tetanus shot at least every 10 years.
See your doctor if you develop large blisters. Large blisters are best removed, as they rarely will remain intact on their own. Also seek medical help if the burn covers a large area of the body or if you notice signs of infection, such as oozing from the wound and increased pain, redness and swelling.
Call 911 or emergency medical help for major burns. Until an emergency unit arrives, take these actions:
- Protect the burned person from further harm. If you can do so safely, make sure the person you’re helping is not in contact with smoldering materials or exposed to smoke or heat. But don’t remove burned clothing stuck to the skin.
- Check for signs of circulation. Look for breathing, coughing or movement. Begin CPR if needed.
- Remove jewelry, belts and other restrictive items, especially from around burned areas and the neck. Burned areas swell rapidly.
- Don’t immerse large severe burns in cold water. Doing so could cause a serious loss of body heat (hypothermia) or a drop in blood pressure and decreased blood flow (shock).
- Elevate the burned area. Raise the wound above heart level, if possible.
- Cover the area of the burn. Use a cool, moist, bandage or a clean cloth.
When properly and quickly treated, the outlook for first- and second-degree burns is good. These burns rarely scar but can result in a change in pigment of the skin that was burned. The key is to minimize further damage and infection. Extensive damage from severe second-degree and third-degree burns can lead to problems in deep skin tissues, bones, and organs. Patients may require:
- physical therapy
- lifelong assisted care
It’s important to gain adequate physical treatment for burns, but don’t forget to find help for your emotional needs. There are support groups available for people who have experienced severe burns, as well as certified counselors. Go online or talk to your doctor to find support groups in your area. You can also use other resources such as Burn Survivor Assistance and the Children’s Burn Foundation.
Deep or widespread burns can lead to many complications, including:
- Infection. Burns can leave skin vulnerable to bacterial infection and increase your risk of sepsis. Sepsis is a life-threatening infection that travels through the bloodstream and affects your whole body. It progresses rapidly and can cause shock and organ failure.
- Low blood volume. Burns can damage blood vessels and cause fluid loss. This may result in low blood volume (hypovolemia). Severe blood and fluid loss prevents the heart from pumping enough blood to the body.
- Dangerously low body temperature. The skin helps control the body’s temperature, so when a large portion of the skin is injured, you lose body heat. This increases your risk of a dangerously low body temperature (hypothermia). Hypothermia is a condition in which the body loses heat faster than it can produce heat.
- Breathing problems. Breathing hot air or smoke can burn airways and cause breathing (respiratory) difficulties. Smoke inhalation damages the lungs and can cause respiratory failure.
- Scarring. Burns can cause scars and ridged areas caused by an overgrowth of scar tissue (keloids).
- Bone and joint problems. Deep burns can limit movement of the bones and joints. Scar tissue can form and cause shortening and tightening of skin, muscles or tendons (contractures). This condition may permanently pull joints out of position.