Treatment of superficial burns requiring hospital admission

INTRODUCTION — Superficial injuries to the skin, most commonly thermal injuries, can often be managed in an outpatient setting. When large areas of skin are affected, specialized anatomic sites are involved, or when the patient's comorbidities complicate management, inpatient management, often at a burn center, is recommended.

Superficial burns are managed by maintaining a clean and moist wound healing environment and protecting the wound from shear, tearing, and further injury while promoting re-epithelialization. Dressings are chosen to help to manage wound drainage and are changed according to the manufacturer's recommendations (eg, daily, or every second or third day) [1].

Superficial skin loss from other types of injury, such as chemical burns, or skin loss from toxic epidermal necrolysis (TEN) is managed using similar principles. However, there are several differences. As an example, superficial skin loss from TEN is characterized by wounds that are not often challenged by problems of exudate management but may suffer from complicated superinfection. In addition to wound care, the underlying pathophysiologic cause needs to be specifically addressed. Chemical burns may require additional therapies to neutralize deleterious local or systemic effects. (See "Stevens-Johnson syndrome and toxic epidermal necrolysis: Management, prognosis, and long-term sequelae" and "Topical chemical burns: Initial evaluation and management".)

The management of patients with superficial skin loss requiring hospitalization (predominantly thermal burns), the management of potential complications, and follow-up care are reviewed here.

Treatment of minor burns (not requiring hospital admission) and treatment of deep partial-thickness and full-thickness burns are reviewed separately. (See "Treatment of minor thermal burns" and "Treatment of deep burns".)

SUPERFICIAL BURNS — Burns are classified and treated according to the depth of tissue injury (ie, superficial [epidermal], superficial partial-thickness, deep partial-thickness, full-thickness, and deeper burns) (table 1). (See "Assessment and classification of burn injury" and "Assessment and classification of burn injury", section on 'Classification by depth'.)

Superficial (epidermal) burns involve only the epidermal layer of skin. These do not blister but are painful, dry, red, and blanch with pressure (picture 1). This process is commonly seen with sunburns. Over two to three days the pain and erythema subside, and by approximately day 4, the injured epithelium peels away from the newly healed epidermis. Such injuries are generally healed in six days with conservative care without scarring. It is important to realize that burns that initially appear to be only epidermal in depth may be determined to be partial thickness (deeper) 12 to 24 hours later. Patients with extensive epidermal burns may require admission to manage significant pain, dehydration, or other associated challenges or social issues and comorbidities such as drug or alcohol use and neglect. Patients with sunburns are counseled as to prevention strategies, the potential for sun damage, detrimental actinic changes, and skin cancer concerns.

Partial-thickness burns, by definition, involve the epidermis and portions of the dermis. Partial-thickness burns can be superficial or deep, each of which require different therapy. It is often difficult to distinguish between superficial partial-thickness and deep partial-thickness burns immediately following the burn injury presentation. As a result, these burns must be reevaluated frequently during the first 72 hours.

●Superficial partial-thickness burns characteristically form blisters within 24 hours between the epidermis and dermis. They are painful, red, and weeping and blanch with pressure (picture 2). These burns generally heal in 7 to 21 days, and, though scarring is unusual, pigment changes can occur. Treatment of superficial partial-thickness burns generally consists of debridement, topical antimicrobial applications, and dressing changes.

●Deeper burns (deep partial-thickness and deep burns) generally require excision and skin grafting. Failure to identify which wounds require operative management can result in scar formation and contractures that may be debilitating [2,3]. The treatment of deep burn wounds is reviewed separately. (See "Treatment of deep burns".)

ASSESSMENT FOR INPATIENT CARE — An accurate assessment of burn depth and extent of total body surface area (TBSA) burned is an essential determinant of the decision as to whether or not inpatient care is required. Only minor burns, as defined by the American Burn Association and American College of Surgeons, should be treated on an outpatient basis [4,5]. (See "Treatment of minor thermal burns".)

Inpatient hospital care, ideally at a burn center (table 2), is mandated for any patient with any burn who has at least one of the following:

●Comorbid illness

●Questionable patient reliability

●Noncompliance

●Suspected or known abuse

Inpatient treatment is also indicated for patients who do not meet criteria for a minor burn (ie, >10 percent TBSA burn [teens and adults]; >5 percent TBSA burn [children and older adults]; associated with multiple trauma; involvement of the face, hands, perineum, or feet; crosses a major joint; or circumferential burn). (See "Treatment of minor thermal burns", section on 'Criteria for minor burns and specialty referral' and 'Special anatomic sites' below.).

The treatment of superficial burns (epidermal or superficial partial-thickness) must address a number of issues, particularly local treatment of the burn, which may vary with the anatomic site of the burn, as well as systemic therapies to prevent complications.

INITIAL CARE — Systemic therapies include tetanus immunization, pain management, and, in selected patients, systemic antibiotics.

Tetanus immunization should be updated, and tetanus immunoglobulin should be given to patients who have not received complete primary immunization. (See "Treatment of minor thermal burns", section on 'Chemoprophylaxis' and "Tetanus-diphtheria toxoid vaccination in adults".)

Pain management — The wound care and physical therapy regimens associated with the treatment of superficial and intermediate-depth burns can be extremely painful.

Smaller burn wounds can be treated with maintenance doses of acetaminophen and nonsteroidal anti-inflammatory drugs, alone or in combination with oral opioids [6-9]. For breakthrough pain during dressing changes or physical therapy, additional opioids and anxiolytics may be used. Patients treated with multidrug regimens should be monitored for adverse interactions and respiratory compromise. Topically applied or locally injected anaesthetics are not recommended because of increased toxicity and variable absorption. (See "Approach to the management of acute pain in adults".)

Severe pain associated with larger total body surface area (TBSA) burns typically requires intravenous opioids. Patient-controlled analgesia can be used for patients who are awake, alert, and have the dexterity necessary to safely and effectively use these devices. Supplemental analgesia and sedation are often required during interventions. (See "Management of burn wound pain and itching", section on 'Pharmacologic treatment options'.)

Inpatient dressing changes and manipulations often require intravenous combination strategies for sedation and analgesia. Medications like ketamine, fentanyl, and propofol are commonly employed. These medications require close monitoring with pulse oximetry. (See "Paradigm-based treatment approaches for management of burn pain", section on 'Paradigm-based management'.)

Longer-acting pain medications (eg, fentanyl patches and methadone) are reserved for the management of chronic rather than acute pain. For difficult-to-control post-burn chronic pain, consultation with a pain management service is advised. (See "Approach to the management of chronic non-cancer pain in adults".)

Parenteral antibiotics — Prophylactic systemic antibiotics are not recommended for patients with small-to-moderate-percent TBSA superficial partial-thickness burns [10,11]. For superficial partial-thickness burns that involve more than 40 percent TBSA, it is unclear if there is any benefit to antimicrobial prophylaxis [11].

The treatment of burn wound infection requires systemic antimicrobial therapy and is reviewed separately. (See 'Assessing for burn wound infection' below and "Burn wound infection and sepsis".)

LOCAL BURN CARE — Burn wound healing is a dynamic process, and local management must address the evolving clinical picture. Acute burn wounds should, if available, be evaluated and treated by an experienced burn care provider. Conservative, nonoperative therapies include cleansing, debridement, and dressing changes using any of a number of topical antimicrobial agents and wound coverings.

Our approach — After the initial assessment and cleansing, superficial burn wounds without signs of infection can be covered with dressing materials that aid with skin healing and reepithelialization. There is no consensus on which topical agent or dressing is best suited for these burn wounds. A review of 26 randomized trials (most with methodologic shortcomings) did not identify an optimal dressing type [12,13].

In general, superficial (epidermal) burns do not require antimicrobial therapy, but for extensive superficial (epidermal or superficial partial-thickness) burns, topical antimicrobials may be used to prevent colonization while maintaining a moist wound healing environment. Furthermore, because superficial partial-thickness burns may not always be easily distinguished from deeper injuries, topical antimicrobial agents are often used. For superficial burns, we suggest starting with a combination antibiotic ointment or creme (eg, Polysporin) covered with a nonadherent dressing (eg, Xeroform or Adaptic). When in close proximity to the eyes, we use an ophthalmic ointment without steroids.

Clean and still moist wounds, particularly when they occur in the pediatric patient population, or in functional and aesthetic regions such as the face, hands, feet, and chest, are often definitively managed using biologic or biosynthetic dressings. (See 'Burn wound dressings and topical therapy' below.)

Cleansing and debridement — Cleansing and debridement removes loose, devitalized, and necrotic tissue (eg, blister, foreign material, and debris). Debrided wounds have a greater tendency to heal in a timely fashion as compared with nondebrided wounds [1]. After judicious debridement, the wound site may be treated with a topical antimicrobial agent or nonadherent dressing regimen.

Initially, burn wounds are gently and carefully cleansed and then reevaluated. Cleansing can be performed using skin disinfectants or mild soap and water. An additional debridement is generally performed using gentle mechanical techniques (eg, brushing, scraping, curetting, and cutting). In our practice, we generally prefer to begin with well-moistened soft gauze or cotton laparotomy pads. When more aggressive debridement is required, we will often use well-moistened chlorhexidine surgical scrub brushes.

A variety of proteolytic enzymes (eg, collagenase, bromelain) have been selectively used to debride burn wounds without damage to the normal tissue [14,15]. These products may be beneficial when removing eschar and pseudoeschar. (See "Basic principles of wound management", section on 'Enzymatic'.)

Proteolytic agents should not be used in infected sites or in areas where there is a risk of ocular contamination. In addition, some patients develop allergic reactions. While treatment of burns with enzymatic debridement is safe [16], results are highly variable [15,17].

Burn blisters — The management of burn blisters depends, in part, upon whether the blister has ruptured. Ruptured blisters should be debrided. The best treatment for an intact burn blister remains a matter of debate [18]. There is no universal standard of practice regarding intact burn blisters, and, in the absence of good data, experts may come to differing conclusions. As an example, some feel that there is an increased risk of infection in intact blisters, while others feel that the blister acts as a barrier to infection.

Potential reasons to rupture intact blisters include:

●Large and expanding blisters may exert pressure onto the underlying wound surface.

●Large blisters can impair range of motion or movement (eg, hand, fingers, foot, toe).

●Intact blisters can hinder the accurate assessment of burn depth.

●The risk of infection is increased in intact blisters.

●Components of blister fluid are harmful to wound healing.

Potential reasons for preserving a burn blister include:

●Blisters form a natural barrier against infection.

●Blister fluid provides wound healing benefits.

●A wound may become desiccated in the absence of adequate dressings and topical antimicrobial agents.

Burn wound dressings and topical therapy — After the initial assessment and cleansing, superficial partial-thickness burn wounds can be covered using a variety of dressing materials that aid with skin healing and re-epithelialization. There is no consensus on which topical agent or dressing is best suited for burn wound management [12,13]. Dressing changes should be frequent enough to control exudate but not so frequent as to interfere with wound re-epithelialization. Re-epithelialization can be disturbed by very frequent dressing changes. A delicate balance must be achieved between a clean wound and delayed wound healing.

Commonly used topical agents for partial-thickness burns include bacitracin, polymyxin, neomycin, silver-containing agents, chlorhexidine, povidone-iodine, mafenide, and petroleum-impregnated gauze [10,12]. These agents have variable degrees of local or systemic adverse effects and can impede wound healing (table 3) [1,19]. (See "Topical agents and dressings for local burn wound care", section on 'Antimicrobial agents'.)

Other forms of burn wound coverage can be used for superficial partial-thickness burns. Hydrocolloid dressings, silicone-coated polyurethane dressings, cellulose, or silk are advocated for the treatment of superficial and partial-thickness burns that comprise a limited body surface area. Hydrocolloid dressings, which provide a moist environment, may be more beneficial in the later phase of reepithelialization. For antimicrobial activity, some materials contain silver. Silver dressings (eg, Acticoat) can also be used as a primary dressing. The mechanism of action and efficacy of these agents are reviewed separately. (See "Topical agents and dressings for local burn wound care", section on 'Dressings'.)

Biologic dressing such as placental-derived products (eg, AmnioExcel, Amnioburn, EpiBurn) or biosynthetic dressings (eg, Suprathel, PermeaDerm) are skin substitutes that are used as temporary dressings. These may improve comfort of the burn patient by reducing the number of dressing changes [20,21]. The type of skin substitute to use depends on the appearance of the wound, desired outcome, cost efficacy, availability, and the clinician's experience, as well as cultural preferences. In a review of 20 prospective trials, for the treatment of partial-thickness burns, skin substitutes were at least as efficacious as topical agents/wound dressings or allografts [22]. (See "Topical agents and dressings for local burn wound care", section on 'Biologic grafts' and "Topical agents and dressings for local burn wound care", section on 'Semibiologic skin substitutes' and "Skin substitutes".)

An autologous cell harvesting device can prepare an epidermal suspension (ie, ReCell), which is directly applied to acute partial-thickness burn wounds or applied in combination with meshed autografts [23]. While this preparation has been used in combination with other dressing (eg, Suprathel) with reports of improved healing, the evidence for this over dressings alone is lacking but will likely be addressed in future trials [24]. ReCell has been approved for use by the US Food and Drug Administration for direct application to acute partial-thickness thermal burn wounds in patients 18 years and older.

Special anatomic sites — Superficial partial-thickness burns to the face, hands, perineum, genitalia, and feet require special attention and should be carefully evaluated for nonoperative management. Patients with burns in these areas should be cared for at a burn center.

Face — Superficial partial-thickness burns to the face are best managed by daily gentle washes, followed by the application of a topical cytoprotective or moisturizing agent. Excessive drying or desiccation of the wound should be avoided. A gentle debridement and/or the adjunctive use of an enzymatic debriding agent removes accumulated proteinaceous material or pseudoeschar and promotes re-epithelialization. Skin substitutes can be used in facial burns, especially intermediate partial-thickness wounds [25,26]. Burn wounds that do not heal within 14 to 21 days require surgical or chemical treatment. (See "Principles of burn reconstruction: Face, scalp, and neck".)

Ears — There is little protection or insulation of the cartilage from injury because the ear lacks a subcutaneous layer. Chondritis, a painful and destructive process of the cartilage, occurs in 5 to 25 percent of all burned ears and is the most common complication [27]. Burns to the ear are managed conservatively with shaving the hair around the ear, daily cleansing, and application of a topical ointment [27]. Topical antimicrobial ointments, such as mafenide acetate, are advocated to prevent the conversion of superficial partial-thickness burns to a deeper burn [28]. External pressure to the ear should be avoided, and operative intervention should be judiciously used. (See "Principles of burn reconstruction: Face, scalp, and neck", section on 'Ear'.)

Ocular area — Burns to the eyelid, periorbital region, sclera, conjunctiva, and cornea are considered ocular burns and should always be assessed in facial burns. Ocular burn severity is directly correlated to duration of exposure and causative agent [29]. Ocular burns represent 7 to 18 percent of all ocular traumas [30]. For burns that result from a chemical injury, the eyes should be immediately and copiously irrigated with sterile saline solution. A topical anesthetic can be inserted into the eye to facilitate irrigation. Ocular burns should be treated with non-steroid-containing topical antimicrobial ointments to the eye and eyelid if burned. Cool saline compresses can be applied to the eyelids, and burned eyelashes and eschar may need to be removed. An eye patch may be needed in the case of a thermal injury or lid retraction from a splash injury. Artificial tears are needed if the lacrimal ducts are burned. Pain relief should be addressed, and an ophthalmologic consultation should be obtained. (See "Principles of burn reconstruction: Face, scalp, and neck", section on 'Ocular'.)

Hands — Burns to the hand, like those involving all critical aesthetic and functional areas, require special attention [31-33]. Due to the unique anatomy of the palmar skin, most burns to the palmar surface in adults and children can be managed conservatively. A retrospective review of 168 pediatric patients with palm burns found that 87 percent healed with conservative, nonoperative management and only four of those palms (2.4 percent) required late reconstruction [34]. However, the skin overlying the dorsum of the hand is much thinner. The underlying and more superficially positioned joints and tendons require early excision and coverage with either skin grafts or a tissue flap. (See "Primary operative management of hand burns".)

Feet — Burns to the feet may require special attention because of difficulties in self-management of the wound. As in the case of palmar hand burns, superficial burns to the thick and heavily keratinized sole will, in most instances, heal well when treated conservatively with daily cleansing, followed by gauze-based, nonadherent, or antimicrobial dressings. (See "Principles of burn reconstruction: Extremities and regional nodal basins", section on 'Foot and toes'.)

Perineum — Burns to the perineum will also necessitate special attention with daily cleansing and antimicrobial dressings [35]. Catheter drainage systems are generally not required for most superficial burns; however, pain on voiding due to periurethral involvement or the necessity for monitoring the adequacy of resuscitation or urinary output might require catheter placement. (See "Principles of burn reconstruction: Perineum and genitalia".)

Reassessment of burn wounds

Burn wound depth — Wound depth may evolve from superficial to deep; hence, early reassessment over the ensuing 72 hours is important. Assessment should continue over 7 to 14 days, as needed. Deep burn wounds will require a different treatment. (See "Treatment of deep burns" and "Overview of surgical procedures used in the management of burn injuries", section on 'Skin grafting'.)

Laser Doppler imaging has been used for evaluation of depth of injury in burn wounds and may be able to predict healing by discriminating various depths of injury [36,37].

Assessing for burn wound infection — Immediately following a burn injury, the surface of the burn wound is free of microorganisms. Over the subsequent days following the burn, the wound is colonized from various sources [2,11]. (See "Burn wound infection and sepsis", section on 'Pathogenesis' and "Burn wound infection and sepsis", section on 'Microbiology'.)

Clinical correlation and expertise are required to distinguish between bacterial colonization of the burn wound, which is frequent, and an invasive infection, which requires systemic treatment. The clinical features of noninvasive burn wound infection and invasive burn wound infection are reviewed separately. (See "Burn wound infection and sepsis", section on 'Burn wound appearance'.)

In summary:

●Noninvasive burn wound infection is present when there are typical clinical features of infection without systemic signs and the bacterial count is >10⁵ bacteria per gram of tissue (or recovery of mold or yeast by culture) obtained from a burn wound or eschar with no invasive component (ie, no microbial invasion into unburned tissue) as identified by tissue histopathology.

●Invasive burn wound infection is present when there are typical clinical features consistent with burn wound infection associated with systemic signs and bacterial count is >10⁵ bacteria per gram of tissue obtained from a burn wound or eschar with an invasive component (ie, microbial or fungal invasion into unburned tissue) identified by tissue histopathology.

Systemic antimicrobial therapy is required to treat a burn wound infection and is based on quantitative wound cultures and microbial sensitivity. Aggressive surgical management of the local wound requires thorough cleansing and debridement, and dressing coverage. (See "Burn wound infection and sepsis", section on 'Treatment'.)

OUTPATIENT FOLLOW-UP MANAGEMENT — Patients with superficial burns may be discharged with wounds that have not completely re-epithelialized. These patients must be closely monitored and followed in the outpatient clinic to:

●Assess the adequacy of pain control and manage pruritus

●Reassess the depth of the burn wound and address the evolving state of the wound

●Assess the appropriateness of the wound care regimen

●Evaluate patient compliance

Similarly, for superficial burns treated in the emergency department or as an outpatient, we suggest reexamination by a surgical burn specialist as soon as feasible.

Burn wound pruritus — Pruritus is often reported by the burn survivor. Pruritus tends to present early during wound healing process and continues well after re-epithelialization and scar maturation. It usually diminishes over time and rarely persists beyond 18 months.

First-line treatment includes oral antihistamines such as diphenhydramine hydrochloride. Other agents that may be helpful include H1 and H2 blockers, cyproheptadine, hydroxyzine, and tricyclic antidepressants (doxepin) as well as various topical agents [38]. Preparations high in lanolin should be avoided, as they can worsen the problem. (See "Management of burn wound pain and itching", section on 'Treatment of pruritus'.)

There are some inherent risks with the topical application of steroids to burn wounds, including thinning of the healing skin, infection, and systemic absorption. Use of hydrocortisone is limited in many burn centers. Do not exceed recommended dosing, and limit the surface area treated.

Restoring form and function — Restoration of form and function, as well as return to home, work, and activities of daily living, are important goals and determinants for adequacy of treatment.

The follow-up plan should include:

●Restoring range of motion and strength of a burned extremity.

●Maintaining durability of the repaired burn wound.

●Local skin care.

●Scar modification, if needed.

●Desensitization strategies to assist the burn victim in coping with the trauma. The importance of psychosocial support cannot be overemphasized.

It is very common for small trauma, sheer stresses, and local injuries to cause traumatic blisters and wounds in the recently re-epithelialized wounds. Bonding of the epidermis and dermis is fragile and will gain strength over time. Ruptured blisters can be managed with a nonadherent gauze dressing, a topically applied antimicrobial dressing, or a hydrocolloid dressing.

Burn patients should be referred to a surgeon with expertise in burn care if complete or near-complete reepithelialization takes longer than three to four weeks, as well as at the first sign of hypertrophic scarring. The development of hypertrophic scarring occurs in wounds that require more than 21 days to heal. The application of pressure garments is often advocated for our patients, as are massage and moisturization [39]. For established hypertrophic scars, silicone sheeting is also often recommended. Patients who develop functional or disfiguring scarring should be treated by a surgeon experienced in burn care. (See "Hypertrophic scarring and keloids following burn injuries".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Care of the patient with burn injury".)

SUMMARY AND RECOMMENDATIONS

●Superficial burns – It is important to distinguish between superficial (ie, superficial [epidermal], superficial partial-thickness) burns from deeper burns (table 1). Superficial burns are treated conservatively with debridement, topical agents, and dressing changes while deeper burns require excision and skin grafting. Wound depth can evolve from superficial to deep; thus, reassessment is important. (See 'Reassessment of burn wounds' above and "Treatment of deep burns".)

●Criteria for inpatient management – Patients with extensive superficial burns, particularly those with comorbid illness, or with questionable patient reliability, noncompliance, suspected or known abuse, or involvement of special anatomic sites, require inpatient evaluation and treatment. (See 'Assessment for inpatient care' above.)

●Management

•Topical agents – There is no consensus on which topical agent or dressing is best suited for burn wound management. In the absence of high-quality data comparing agents, the choice can be made based on burn wound characteristics, phase of burn wound healing, frequency of dressing changes, provider familiarity, local availability, and cost.

-In general, superficial (epidermal) burns do not require antimicrobial therapy, but for extensive superficial (epidermal or superficial partial-thickness) burns, topical antimicrobials may be used to prevent colonization while maintaining a moist wound healing environment. Furthermore, because superficial partial-thickness burns may not always be easily distinguished from deeper injuries, topical antimicrobial agents are often used.

-For superficial burns, we suggest starting with a combination antibiotic ointment or creme (eg, Polysporin) covered with a nonadherent dressing (eg, Xeroform or Adaptic) (Grade 2C). When in proximity to the eyes, we use an ophthalmic ointment without steroids. (See "Topical agents and dressings for local burn wound care", section on 'Antimicrobial agents'.)

•Dressings – Dressing changes should be frequent enough to control exudate but not so frequent as to interfere with wound reepithelialization. It appears best to change dressings whenever they become soaked with excessive exudate or other fluids or if there are signs of infection. (See 'Burn wound dressings and topical therapy' above.)

•Pain and itching – A variety of oral medications are used to treat burn wound pain and post-burn pruritus. Topical agents are also available to treat pruritus. (See 'Burn wound pruritus' above and "Management of burn wound pain and itching", section on 'Treatment of pruritus'.)

●Patient referral – For patients with superficial burns not initially managed at a burn center, referral to a surgeon with expertise in burn care should be made if complete or near complete re-epithelialization takes longer than three to four weeks, as this is a risk factor for hypertrophic scarring. (See 'Restoring form and function' above and "Hypertrophic scarring and keloids following burn injuries".)