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Burns

• Signs and Symptoms
• Causes
• Risk Factors
• Preventive Care
• Diagnosis
• Treatment
• Other Considerations
• Supporting Research

When the skin is exposed to excessive heat (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 - 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 - 70,000 people are hospitalized for burns every year in the United States, 30 - 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 health care practitioner assess the risk for such complications as infection, dehydration, and disfigurement.

Infection

People who get burned 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 may become warm to the touch -- both of which are also signs of infection. Redness and temperature increase are normal responses to a deep burn, but these symptoms may occur in any degree or type of burn. Bring any change in the appearance of the burn or in the way that the burn victim feels to the attention of a doctor. Potential signs of infection include:

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

Dehydration

A burn injury can lead to loss of fluid through the skin. If dehydration is suspected, a doctor who will decide whether or not fluid injected into the veins 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, nor 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
• Stopping 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 doctor evaluates the depth and extent of the damage, the degree of pain, the amount of swelling, and signs of infection. They 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). Doctors may also conduct tests to determine whether the wound is infected.

Treatment

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 - 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 - 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 are burned seriously 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 often cause 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 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

Minor burns can be treated effectively with the use of natural products. 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, it may lose a substantial percentage of micronutrients, such as copper, selenium, and zinc. This increases the risk for infection, slows the healing process, prolongs the hospital stay, and even increases the risk of death.

Do not try to treat a second- or third-degree burn without seeking medical advice. Discuss with your health care provider which supplements may be important for you. Always tell your health care provider about the herbs and supplements you are using or considering using, as some supplements may interfere with conventional treatments.

Following these nutritional tips may improve your healing and general health.

• Eat antioxidant foods, including fruits (such as blueberries, cherries, and tomatoes), and vegetables (such as squash and bell peppers).
• Avoid refined foods, such as white breads, pastas, and sugar.
• Eat fewer red meats and more lean meats, cold-water fish, tofu (soy) or beans for protein.
• Use healthy cooking oils, such as olive oil or vegetable oil.
• Reduce or eliminate trans-fatty acids, found in commercially baked goods such as cookies, crackers, cakes, French fries, onion rings, donuts, processed foods, and margarine.
• Avoid coffee and other stimulants, alcohol, and tobacco.
• Drink 6 - 8 glasses of filtered water daily.
• Exercise at least 30 minutes daily, 5 days a week.

You may address nutritional deficiencies with the following supplements:

• A daily multivitamin, containing the antioxidant vitamins A, C, E, the B-complex vitamins and trace minerals such as magnesium, calcium, zinc, and selenium.
• Omega-3 fatty acids, such as fish oil, 1 - 2 capsules or 1 tablespoonful oil, one to two times daily, to help decrease inflammation, and for healing and immunity. Cold-water fish, such as salmon or halibut, are good sources, but taking the supplement is recommended.
• Vitamin C, 500 - 1,000 mg, one to three times daily, as an antioxidant and for healing.
• Coenzyme Q10, 100 - 200 mg at bedtime, for antioxidant and immune activity.
• L-glutamine, 500 - 1,000 mg three times daily, for support of gastrointestinal health and immunity.
• Probiotic supplement (containing Lactobacillus acidophilus ), 5 - 10 billion CFUs (colony forming units) a day, when needed for maintenance of gastrointestinal and immune health. You should refrigerate your probiotic supplements for best results.
• Grapefruit seed extract ( Citrus paradisi ), 100 mg capsule or 5 - 10 drops (in favorite beverage) three times daily when needed, for antibacterial, antifungal, and antiviral activity, and for immunity.
• Astaxanthin, 2 - 6 mg daily, for immune and antioxidant support.
• Alpha-lipoic acid, 50 - 100 mg twice daily, for antioxidant support.
• Whey protein, 10 - 20 grams daily mixed in favorite beverage or as a smoothie (use soy or rice milk), twice daily, for support of immunity and weight gain.

Herbs

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

• Green tea ( Camellia sinensis ) standardized extract, 250 - 500 mg daily, for antioxidant, anticancer, and immune effects. Use caffeine-free products. You may also prepare teas from the leaf of this herb.
• Turmeric ( Curcuma longa ) standardized extract, 300 mg three times a day, for pain and inflammation.
• Milk thistle ( Silybum marianum ) seed standardized extract, 80 - 160 mg two to three times daily, for detoxification support.
• Panax ginseng ( Panax ginseng ) standardized extract, 100 - 200 mg twice daily, for general health support. You can also prepare teas from this herb.
• Holy basil ( Ocimum sanctum ) standardized extract, 400 mg daily, for burn protection. You can also prepare teas from the plant.
• Aloe vera ( Aloe barbadensis ) gel, apply externally to the burned area, 3 - 4 times daily as needed, for soothing and healing.
• Tea tree oil ( Melaleuca alternifolia ) topical preparations, dilute with water and apply externally to burned area(s) 2 - 3 times a day. Tea tree oil may be found in a cream or salve combined with calendula ( Calendula officinalis ) flowers extract.

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.

Massage and Physical Therapy

Massage Therapy

People with burns suffer pain, itching, and anxiety both from the burn itself and during the healing of wounds. Some studies suggest that massage may help ease these symptoms in both the emergency-care and recovery phases. Patients receiving a massage 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 firs-t and second-degree burns and to aid recovery from any burn. Before prescribing a remedy, homeopaths take into account a person’s constitutional type -- your physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate treatment for each individual.

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

Mind-Body Medicine

Hypnosis

Several studies suggest that hypnosis may reduce pain and anxiety and enhance relaxation in burn patients.

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.

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 - 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 may require a skin graft.

Supporting Research

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

Antoon AY, Donovan DK. Burn Injuries. In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson Textbook of Pediatrics . Philadelphia, Pa: W.B. Saunders Company; 2000:287-294.

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

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

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

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

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

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

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

Gilboa D, Boenstein A, Seidman DS, Tsur H. Burn patients' use of autohypnosis: making a painful experience bearable. Burns . 1990;16(6):441-444.

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

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

Lewis SM, Clelland JA, Knowles CJ, Jackson JR, Dimick AR. Effects of auricular acupuncture-like transcutaneous electric nerve stimulation on pain levels following wound care in patients with burns: a pilot study. J Burn Care Rehabil . 1990;11:322-329.

Meyer NA, Muller MJ, Herndon DN. Nutrient support of the healing wound. New Horizons . 1994;2(2):202-214.

Rotsein OD. Oxidants and antioxidant therapy. Crit Care Clin . 2001;17(1):239-47.

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

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

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

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

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

Wang HK. The therapeutic potential of flavonoids. Expert Opin Investig Drugs . 2000;9(9):2103-19.

Yoon JH, Baek SJ. Molecular targets of dietary polyphenols with anti-inflammatory properties. Yonsei Med J . 2005;46(5):585-96.

• Review Date: 10/16/2006
• Reviewed By: Ernest B. Hawkins, MS, BSPharm, RPh, Health Education Resources; and Steven D. Ehrlich, N.M.D., private practice specializing in complementary and alternative medicine, Phoenix, AZ. Review provided by VeriMed Healthcare Network.

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