When the skin is exposed to excessive heat (as from fire), electricity, or
corrosive chemicals, the resulting tissue damage is known as a burn. Burns are
generally categorized as follows, according to the severity of tissue damage:
- First-degree burns—affect only the outer
layer of the skin (epidermis), causing pain and redness
- Second-degree burns—extend to the layer below
the epidermis (the dermis), causing pain, redness, and blisters that may ooze
- Third-degree burns—involve all layers of the
skin and may also damage the underlying bones, muscles, and tendons. The burn
site appears pale, charred, or leathery and there is generally no sensation in
the area because the nerve endings are destroyed.
Between 1 and 2 million Americans seek medical attention for burns each year.
Most burns occur at home, at work, or are part of an injury from a motor vehicle
accident. Between 50,000 and 70,000 people are hospitalized for burns every year
in the United States, 30% to 40% of whom are children younger than 15 years of
age. All burns—even minor
ones—may cause functional or cosmetic damage if they
are not properly cared for. Skin is a natural barrier to infection, so when it
is burned a person loses that protection. Because people who sustain a burn are
very prone to developing infections, treatment usually involves preventing or
|Signs and Symptoms|
In general, signs and symptoms of burns differ according to the severity of
the burn (as described above). Evaluation of the extent of the burn (that is,
the amount of skin or body surface area that the burn covers) is important as
well because it helps a healthcare practitioner assess the risk for such
complications as infection, dehydration, and/or disfigurement.
People who sustain a burn are very prone to infection. Unfortunately, knowing
if an infection is present or not is often difficult because the skin
surrounding a burn is usually red, and changes in body temperature (a sign of
infection). This also a normal response to a large or deep burn. Any change in
the appearance of the burn or in the way that the burn victim feels should be
brought to the attention of a physician. Potential signs of infection
- 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
- Greenish discharge or pus
A burn injury can lead to loss of fluid through the skin. If dehydration is
suspected, a physician who will decide whether or not intravenous fluid is
necessary. Potential signs of dehydration include:
- Lightheadedness or dizziness, particularly when moving from sitting or
lying position to standing
- Dry skin
- Urinating less often than usual
Burns have typical and atypical patterns—typical
patterns result from unintentional burns while atypical patterns may be a sign
of physical abuse. Typical burns (from spilling hot liquid, for example) tend to
occur in exposed areas such as the arms, face, and neck. Atypical burns may
occur in unexposed areas such as the buttocks. Burns involving entire hands and
feet are also not typical, neither are third-degree burns involving a very
small, focused area (resembling, for example, a cigarette).
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.
- 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
The following actions have been shown to lower the incidence of
- Installing smoke detectors
- Educating children about fire and burn prevention in
- Abstaining from smoking and heavy alcohol use
- Wearing flame-retardant clothes (particularly children)
- Planning emergency exit routes in the home, school, and
- Fire drills
The following steps may help reduce the severity of a burn once it
- 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
When diagnosing a burn, a healthcare practitioner will evaluate the depth and
extent of the damage, the degree of pain, the amount of swelling, and signs of
infection. They will classify the burn based on the depth and extent of the
injury (as described in the Overview section). Burns that cover a significant
portion of the body, burns associated with smoke inhalation, burns resulting
from electrical injuries, and burns associated with suspected physical abuse are
treated as emergencies and require hospitalization. In the emergency room, all
wounds are wrapped with sterile towels and patients receive oxygen (either
through a mask or tube) and fluids (some patients require intravenous fluids).
Patients are also evaluated for associated injuries (such as from physical
abuse). Physicians may also conduct a biopsy to determine whether infection is
present in the wound.
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
The following steps may be taken in an emergency situation:
- Run cool water on burned area for 5 to 10 minutes or cover the area
with a cool compress
- Take ibuprofen or acetaminophen to relieve pain and
- Do not break blisters
- Do not remove clothing that is stuck to the skin
- Run cool water on burned area for 5 to 10 minutes or cover the area
with a cool compress then carefully remove clothing
- Elevate burned area above the heart
- Take ibuprofen or acetaminophen to relieve pain and
- 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
- Call 911
- Check airway, breathing, and circulation
- Do not remove clothing that is stuck to the skin
- Run cool water continuously on burned area
- Elevate burned area above the heart
People who have sustained serious burns will be admitted to a hospital where
keeping the area clean and removing any dead tissue through a process called
debridement are of the utmost importance.
Medications will be used to reduce pain
and prevent infection. A tetanus shot will be administered if the person has not
had one in 5 or more years.
Burns are often accompanied by pain and anxiety, even during recovery. A
person may also experience emotional distress if a burn alters his or her
appearance. Complementary therapies that may help a person alleviate such pain
and anxiety include:
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.
- Antimicrobial ointments (such as silver sulfadiazine, mafenide, silver
nitrate, and povidone-iodine) are frequently used to lower the occurrence of
infection; bacitracin may be used for first-degree burns.
- Antibiotics (such as oxacillin, mezlocillin, and gentamicin) are used
if infection is detected at the burn site; antibiotics will also probably be
used if the risk of developing infection is high (for example, when the body
surface area of the burn is large)
|Surgery and Other Procedures|
In the case of severe burns, removal of dead tissue, known as debridement,
and skin grafting (transplanting a piece of skin from one part of the body to
the damaged area) improves the recovery process. Cosmetic surgery may also be
necessary to improve both the function and appearance of the burned area.
|Nutrition and Dietary Supplements|
It is especially important for people who have sustained serious burns to
obtain adequate amounts of nutrients in their daily diet. Burn patients in
hospitals are often given diets high in calories and protein to speed recovery.
When skin is burned, a substantial percentage of micronutrients, such as copper,
selenium, and zinc may be lost. This increases the risk for infection, slows the
healing process, prolongs the hospital stay, and even increases the risk of
death. Although it is unclear which micronutrients are most beneficial for
people with burns, many studies suggest that a multivitamin including the
following nutrients may aid in the recovery process:
- Vitamin B complex
- Vitamin C
- Vitamin A
In addition, vitamin K levels tend to be low following a burn. However, it is
not known whether additional supplementation of this vitamin will help under
Oxidative stress (injury to cells caused by free radicals, which are
substances in the blood that result from normal metabolic processes in the body)
is believed to contribute significantly to skin and soft tissue damage incurred
from a burn. In addition, levels of several antioxidants (substances that
protect against the cell damage of free radicals) are measurably lower in burn
victims, including beta-carotene, and vitamins A, C, and E. For this reason,
antioxidant therapy using, for example, vitamins C and E and carotenoids, is
often part of the treatment of burns, particularly soon after the injury takes
place. The precise amount and combination to use, however, is not entirely
clear. While there is some evidence that vitamins C and E, both taken orally,
work particularly well together in preventing sunburn, it is not clear whether
this benefit would be the same for treatment of burns of any cause once they
In addition, although it is popular during the time of recovery from a burn
to use topical vitamin E to try to diminish scar formation, one study found no
cosmetic benefit when using topical vitamin E for surgical wounds.
Essential Fatty Acids
Essential fatty acids (fatty acids that the body does not make and must,
therefore, be obtained through the diet) have been used to reduce inflammation
and promote wound healing in burn victims. Animal research indicates that
omega-3 fatty acids (one class of essential fatty acids) help promote a healthy
balance of proteins in the body—protein balance is
critical to proper organ function and general health, particularly after
sustaining a burn. Further research is necessary to determine whether essential
fatty acids have similar effects on protein balance in people who have suffered
Bromelain, a collection of protein-digesting enzymes found in the stem of
pineapple plants, has been used historically to reduce swelling following soft
tissue damage. Some studies of animals indicate that bromelain (applied
topically) may also be useful in removing dead tissue from third-degree burns.
This has not yet been tested on humans.
Aloe (Aloe vera)
Aloe has been used for centuries to heal skin lesions and wounds. Aloe
contains glycoproteins, protein-carbohydrate compounds that speed the healing
process by stopping pain and inflammation, and polysaccharides, a type of
carbohydrate that stimulates skin growth and repair. In one study conducted in
Thailand in 1995, 27 people admitted to a hospital for first- and second-degree
burns had one half of their burn treated with aloe vera gel and the other half
treated with petroleum jelly. The area treated with aloe vera healed
significantly faster than the area treated with petroleum jelly, although there
were some reports of discomfort and brief pain with the aloe vera gel
treatments. These results seem encouraging, however, studies comparing aloe vera
medication may help determine whether
the herb is as effective for the treatment of burns as more customary
In some traditional medical practices, honey is applied to the skin to
prevent infection and heal wounds. Results from two well-designed studies
conducted in India suggest that topical applications of honey may heal burns
significantly faster than the antimicrobial ointment, silver sulfadiazine. Some
researchers attribute this effect to nutrients in honey that promote skin growth
and to antibacterial substances present in honey.
Papaya (Carica papaya)
In The Gambia, Africa, papaya is used topically to help remove dead tissue
from burn wounds and prevent infection. Although the exact mechanism of action
is unclear, researchers suggest that papaya contains enzymes that break down the
proteins in dead tissue. In addition, papaya is believed to have antimicrobial
Tea Tree Oil (Melaleuca alternifolia)
In Australia, tea tree oil was used by aborigines and early settlers to treat
burns. Some reports suggest that the herb may prevent the spread of infection.
Modern studies, however, have not confirmed this function for tea tree oil. In
fact, a recent study suggests that substances in tea tree oil may even be
destructive to skin cells and may actually slow the healing process. Therefore,
until more is known about the value of tea tree oil for burns, it is best to
avoid use of the herb for this purpose.
Although some herbs used historically have not been researched
scientifically, they may be considered by an herbal specialist to treat
first-degree burns. Each of the following remedies would be applied topically.
- Slippery elm (Ulmus fulva)
- St. John's wort (Hypericum perforatum )
- Roman chamomile (Chamaemelum nobile)
- Walnut leaf (Juglans reglia)
- Gotu kola (Centella asiatica)
- Horsetail (Equisetum arvense)
- Milk thistle (Silybum marianum)
- Stinging nettle (Urtica
Transcutaneous electrical nerve stimulation (TENS) is a method of applying
controlled, low-voltage electrical stimulation to the skin for the purpose of
relieving pain. Recent studies have suggested that TENS applied to acupuncture
points (called electroacupuncture) on the ear (auricular acupuncture) may
provide pain relief for people with burns. In one study, 11 burn patients
received two forms of treatment prior to wound care: auricular TENS and a
placebo pill. Seven patients reported at least a 70% reduction in pain during
the TENS acupuncture treatments and only two patients reported that degree of
relief when receiving the placebo pill. This preliminary study suggests that
further investigation into the use of auricular electroacupuncture for the
relief of pain in burn patients is warranted.
|Massage and Physical Therapy|
People with burns suffer pain, itching, and anxiety both from the burn itself
and during the healing of the wound. Some studies suggest that massage may help
ease these symptoms in both the emergency-care and recovery phases. In one
study, 28 burn patients were randomly assigned to receive massage therapy or
standard treatment while in the hospital. Patients in the massage therapy group
received a 20-minute general body massage prior to wound cleaning once a day for
1 week. Reported effects included:
- Decreased anxiety
- Decreased pulse rate (a potential sign of improved relaxation and/or
- Decreased levels of cortisol (a hormone that indicates stress in the
- Decreased pain
- Improved mood, including diminished depression and
In another small study, 20 burn victims were randomly assigned to receive
massage and standard therapy or standard therapy only during the recovery phase
of their injury (between 80 to 165 days after the injury). The massage group
received a 30-minute massage twice a week for 5 weeks in addition to standard
therapy (consisting of physical and occupational therapy, regular check ups by
the physician, medication for symptoms of pain and itching, and application of
cocoa butter to the closed wound). People who received massages reported
significantly less itching, pain, anxiety, and depressed mood compared to those
who received standard care only.
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
- Assistance with activities of daily living until normal function and
ability are recovered
- Passive (physical therapist moves the patient's limbs) and active
- Assistance with walking
Although very few studies have examined the effectiveness of specific
homeopathic therapies in the treatment of burns, professional homeopaths may
consider the following measures to treat first and second degree burns and to
aid recovery from any burn. Before prescribing a remedy, homeopaths take into
account a person's constitutional type. A constitutional type is defined as a
person's physical, emotional, and psychological makeup. An experienced homeopath
assesses all of these factors when determining the most appropriate treatment
for each individual.
- Immersing the burned area in cold water until the pain subsides (this
generally takes at least a few minutes)
- Arnica Montana -- taken orally immediately following a burn
- Calendula -- applied to the skin for first-degree burns and
sunburns; this remedy is sometimes considered the treatment of choice for
children; calendula may also be used in the healing stages of second- and
third-degree burns to stimulate regrowth of skin and to diminish scar formation
- Cantharis -- for persistent pain, restlessness, and anxiety
especially as a result of severe burns; oral and/or topical forms may be
recommended; requires a homeopathic doctor's prescription; may be used in
- Hypericum perforatum -- used topically if there are sharp,
shooting pains with the burn
- Urtica urens -- taken orally for stinging pains, itching, and
swelling of first-degree burns; a cream or gel may also be applied to the skin
for first-degree burns and sunburns; this remedy may be used for children
- Causticum -- taken orally for burning pains with great rawness
(as from an open wound) or when there are long-term physical or emotional
symptoms after a burn; may be used in children under the direction of a licensed
homeopath, often in the case of more severe burns
- Phosphorus -- taken orally for electrical burns, especially if
the individual is easily startled and
Several studies suggest that hypnosis may reduce pain and anxiety and enhance
relaxation in burn patients. In one study, 30 hospitalized burn patients
received either standard wound care (including pain medications) or standard
wound care plus hypnosis with a technique called rapid induction analgesia
(RIA). RIA sessions were administered prior to wound care over four burn care
sessions during a 48-hour period. Patients who received RIA treatment had less
anxiety and pain as well as reduced consumption of pain medication over the
course of the burn care sessions. Relaxation ratings also increased in the RIA
group during this time. These findings suggest that RIA may be a helpful
addition to standard wound care in burn patients; further research of hypnosis
is certainly warranted.
Therapeutic touch (TT) is based on the theory that the body, mind, and
emotions form a complex energy field. Therapists seek to correct the body's
imbalances by moving their hands just over the body in a practice they call
"the laying on of hands." This practice has been used for a variety of ailments
including the relief of pain and anxiety, but studies have shown conflicting
results. A recent trial of patients hospitalized for severe burns suggests that
TT may reduce pain and anxiety associated with burns. Ninety-nine patients
received either TT treatments or sham TT treatments (therapists moved their
hands over the body but did not attempt to alter the energy field) once a day
for 5 days. Patients who received TT treatments reported a significant reduction
in pain and anxiety compared with the sham group, but there was no difference
between groups in amount of medication used, stress relief, or satisfaction with
|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
- Increased risk of developing cancer at the burn site
- Carbon monoxide poisoning (in the case of a fire)
- Heart attack which may be severe enough to cause the heart to stop
(called cardiopulmonary arrest)
First-degree burns generally heal on their own in 10 to 20 days if no
infection develops. In rare cases, first-degree burns spread more deeply to
become second degree (this spread is caused by infection). Third-degree burns
often require a skin graft.
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|Review Date: June 2001|
|Reviewed By: Participants in the review process include: John Balletto, LMT, NCTMB, Center
for Muscular Therapy, President, Providence, RI; Ruth Debusk, RD, PhD,
Editor, Nutrition in Complementary Care, Tallahassee, FL; Richard
Glickman-Simon, MD, Department of Family Medicine, New England Medical Center,
Tufts University, Boston, MA; Jacqueline A. Hart, MD, Department of Internal
Medicine, Newton-Wellesley Hospital, Harvard University and Senior Medical
Editor Integrative Medicine, Boston, MA; Jane Hart, MD, Clinical Instructor,
Case Western Reserve University School of Medicine and Director for Preventive
Medicine Consultations and Medical Director for the Institute for Total Health
at the Cleveland YMCA, Cleveland, OH; R. Lynn Shumake, PD, Director, Alternative
Medicine Apothecary, Blue Mountain Apothecary & Healing Arts, University of
Maryland Medical Center, Glenwood, MD; Devorah Steinberg, LICSW, licensed
clinical social worker, certified hypnotherapist, private practice, Jamaica
Plain, MA; Dana Ullman, MPH, Homeopathic Educational Services, Berkeley, CA; Ira
Zunin, MD, MPH, MBA, President and Chairman, Hawaii State Consortium for
Integrative Medicine, Honolulu, HI.|
Copyright © 2004 A.D.A.M., Inc
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