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Burns

Introduction

What should I know about Burns?

Burns have a number of causes, including thermal agents, ultraviolet light radiation, chemicals, and electricity. Burn damage in the skin causes cellular death, capillary injury, and coagulation of protein. Capillary injury is manifested by increased capillary permeability, resulting in a wet or weepy appearance of second and third degree burns.

About two million burns occur yearly in the United States. (1) Fully 500,000 are seen in the emergency room, 100,000 result in hospitalization, and 20,000 are of sufficient severity to necessitate care in a burn center. (2) Burns are the fourth most frequent cause of death from unintentional injury. Over 80 percent of minor burns occur in the home, usually being caused by scalds, contact burns, and fabric burns. (3) Most of these burns do not require medical assistance, and may be managed by the patient with appropriate care and nonprescription products.

Of the minor burns that occur outside the home, sunburn is the most common. Sunburn has been underrated in most burn surveys because the public does not consider sunburn in the same context as thermal burns. (4) Sunburn is different from thermal burns in that it does not result from an abrupt temperature increase in tissue, but rather is produced gradually from the ionizing radiation of the sun or other ultraviolet light source. It is also the only burn that is considered preventable and generally results from a willful choice of prolonged exposure to sunlight.

Thermal burns can be caused by flames, flaming liquids such as food or drinks made with high-proof alcohol and set afire, hot liquids such as water or oil, hot objects such as curling irons, burners, irons, and even hot pavement, and hot gasses such as steam burns, or gasses released during airbag deployment.

Scalds represent about 30 percent of burn injuries and generally occur from common household accidents. Sources include boiling water, hot coffee, soup, or other hot beverages, and even hot water from a faucet. Because a child’s skin is much thinner than an adult’s, it is easy to cause scalding even in hot tub water. For this reason, it is recommended that all hot water heaters be adjusted to no more than 120-130°F.

Chemical burns result from exposure to caustic chemicals such as acids and alkalis. Battery acid, hydrochloric acid, and sulfuric acid are a few examples, as well as drain cleaners, caustic lime, oven cleaners, and cement. Chemical burns can also result from garlic applied to the skin as a natural remedy. (5)

Electrical burns usually result from touching a source of electricity. In the pediatric population, this can occur when children bite through cords or place objects into outlets. In evaluating electrical burns, both the entrance and exit site must be evaluated.

Electrical burns are usually considered quite serious, and depending upon the voltage exposure, may cause full thickness injuries affecting muscle and even bone. Complications from electrical burns include bone and soft tissue destruction, renal tubular damage, cardiac dysrhythmias, and cardiovascular collapse.

Burns have long been classified in degrees. This classification system is used to describe all types of burns, whether thermal, electrical, chemical, or sunburn and progresses from the least severe (first degree) to the most severe (fourth degree).

Burn assessment is difficult, even for professionals. The American Burn Association has developed an injury severity grading system:

Minor burns generally may be treated on an outpatient basis. Very young patients may need hospitalization.

    Less than 15 percent of the body surface area (BSA) in adults or 10 percent in children and the elderly if a partial thickness burn; Less than 2 percent of the BSA is a full thickness burn; Must not present functional or cosmetic risk to areas of specialized function (face, eyes, ears, hands, feet, and perineum).

Moderate burns may be treated in the hospital; they do not require treatment in a burn facility.

    15-25 percent body surface area in adults or 10-20 percent in children and elderly if a partial-thickness burn; 2-10 percent of the BSA if a full thickness burn; Must not present functional or cosmetic risk to areas of specialized function.

Major burns require emergency treatment at a local hospital followed by transport to a regional burn facility for specialized definitive care.

    More than 25 percent of the BSA in adults and more than 20 percent in children and the elderly if a partial thickness burn; More than 10 percent of BSA if a full thickness burn; All burns involving the face, eyes, ears, hands, feet, or perineum that may result in functional or cosmetic impairment; Burns due to caustic chemical agents; High voltage electrical injury; Burns complicated by inhalation injury, major trauma, or poor risk patients.

Infection secondary to burns can be dangerous and difficult to treat because the burned skin provides an excellent growth medium for bacteria. Also, the burned tissue hampers the effective delivery of systemic antibiotics.

Additional complications may occur if the patient has another medical condition that compromises healing, causes reduced circulation, or a decreased ability to resist infection.

The risk of complications increases as the severity of the burn increases. The more deeply the skin layers are damaged, the greater the body’s natural defense mechanisms are compromised, increasing the possibilities of skin infection, systemic infection, fluid and electrolyte loss, and shock, which can cause death.

Statistic

World Health Organization, 2007

  • Globally, fire-related burns were responsible for nearly 322,000 deaths in 2002.
  • Globally, fire-related burns are one of the 15 leading causes of death and burden of disease among children and young adults, ages 5-29 years.
  • Over 90% of fatal fire-related burns occur in low- and middle-income countries.

World Health Organization, 2006.

  • India accounting for 35,000 burn-related deaths.

World Health Organization, 2002.

  • Burns contributed for nearly 1 per cent of total deaths in Sri Lanka.

National Institute of General Medical Sciences, 2000.

    Each year in the United States, 1.25 million burn injuries require medical attention. Approximately 50,000 of these require hospitalization, and roughly half of those burn patients are admitted to a specialized burn unit. Up to 10,000 people in the United States die every year of burn-related infections; pneumonia is the most common infectious complication among hospitalized burn patients.

Signs and Symptoms

The following list does not insure the presence of this health condition. Please see the text and your healthcare professional for more information.

Burn symptoms vary, depending on the burn severity. In appearance, burns range from the red of sunburn to the charred appearance of a fourth degree burn. Superficial burns are very painful due to tissue damage; however, deep burns are much less painful because nerve destruction has occurred. While superficial burns appear red, and slightly more severe burns develop blisters (second degree burns), very severe burns (third and fourth degree) eliminate the layers of skin that cause blistering.

As a minor burn wound heals, severe itching may develop. Signs of infection include erythema, edema in the tissue surrounding the burn, increasing pain, odor, drainage, and necrosis or darkening tissue color. Immediately after a moderate to severe burn, there is cessation of blood flow to the area, caused primarily by thrombosis. This may continue for three to four weeks in full thickness burns. In partial thickness burns, arterial and venous circulation is restored in 48-72 hours.

The classic method of categorizing burns is by degrees. The appearance and symptoms of each include the following:

First degree burns

  • Involves top layer of skin and hair
  • Redness
  • Swelling
  • Pain
  • Area turns pale when pressure is applied, red color returns quickly
  • May peel
  • Generally heals in 3-5 days
  • No scarring
  • May cause itching while healing

Second degree burns

  • Involves skin and hair, plus deeper skin layer called the dermis, sweat glands, and hair follicles
  • Blistering
  • Redness
  • May have pus draining from blistered skin
  • Area turns pale when pressure is applied, red color returns slowly
  • Mild for

Third degree burns

  • Involves all thickness of outer skin including fatty layer
  • Looks dry or leathery, may be charred
  • Little or no pain (nerve endings have been damaged)
  • Greater possibility of infection, since blood supply to area is damaged
  • Long process fo

Fourth degree burns

  • Involves all thickness of skin plus muscle and sometimes bone
  • Looks charred or blackened
  • No pain (nerve endings damaged)
  • Very great risk of infection (blood supply to tissues damaged)
  • Very long healing process
  • Skin grafting usually nec

Treatment Options

Conventional

Treatment approaches depend upon the extent and severity of the burn. Only first-degree and minor second-degree burns are considered self-treatable. Also to be considered is the source of the burn, with sunburn and thermal burns being self-treatable, while chemical and electrical burns should be referred to a hospital for treatment.

Immediate treatment from minor thermal burns consists of prompt cold applications (ice water) that are continued until pain does not return upon stopping them. If no effort is made to cool the tissues, the elevated temperature may continue to produce injury for several minutes. (6)

For mild (first degree burns), topical corticosteroids and oral analgesics or NSAIDs can be helpful. Small second-degree burns may be treated with a topical anti-infective ointment to minimize bacterial growth and to keep the lesion moist while healing occurs. (7)

FDA labeling of over-the-counter hydrocortisone has restricted its official indications to use as a topical agent. It has no specific indications for uses in minor burns or sunburn. Topical local anesthetics, which act to inhibit conduction of nerve impulses from sensory nerves, are often used to treat minor burns, as are topical antihistamines, which act to depress pain and itch receptors.

Severe burns, which should be managed in the hospital, are treated with prescription antimicrobial agents to prevent bacterial colonization from developing into cellulitis or septicemia. The most widely used agent is silver sulfadiazine. Others include silver nitrate aqueous solution, mafenide, and chlorhexidine. (8) Collagen is a prevalent fibrous insoluble protein found in connective tissue, including skin, bone, ligaments, and cartilage. Unique properties of the skin are the result of collagen and elastin networks that form a protective and supportive "scaffold" within the cellular tissues (as plants have cellulose). Collagen consists of amino acids and is especially high in glycine and proline and low in histidine, tryptophan, and cystine. (9) Collagen also contains two amino acids not found in other proteins, hydroxyproline and hydroxylysine.

Type 1, hydrolyzed collagen is smaller peptide fragments of collagen that can migrate to wound sites more efficiently. It has been reported to be useful in wound healing in a variety of situations. (10) , (11) , (12)

Type 1, hydrolyzed collagen may provide an advantage over other forms by being degradable in the wound site. It does not have to be removed with dressing changes, which is an advantage over other wound care agents. As hydrolyzed collagen is left in the site, it continues to have the ability to absorb, be interactive with the wound site, and provide needed mechanical protection against physical and bacterial insult.

Nutritional Suplementation


Omega-3 Fatty Acids

In experimental work with animals, researchers were able to show that the omega-3 fatty acids had an important influence on outcome variables following severe burn injury. Dietary fatty acids alter the composition of cell membranes and the quantity and types of prostaglandins that are synthesized. Improving the ratio of omega-3 to omega-6 fatty acids enhances immune function and reduces inflammation. (13)


L-Glutamine

Sever injury, such as burns, cause plasma glutamine levels to decline substantially. In one study, patients with major burn injuries, the plasma glutamine concentration was 58% lower than that in normal controls and it remained low for at least 21 days after the injury. These findings indicate that the decrease in plasma glutamine concentration may contribute to the injury-induced impairment of immune function occurring after major burn injury. (14)


Arginine

Studies have reported success in treating burn patients with arginine. (15)


Vitamin C

Thirty-seven patients with burns over more than 30% of their total body surface area, hospitalized within 2 hours after injury, were randomly divided into ascorbic acid and control groups. Administration of high-dose ascorbic acid during the first 24 hours after thermal injury significantly reduced resuscitation fluid volume requirements, body weight gain, and wound edema. A reduction in the severity of respiratory dysfunction was also apparent in these patients. (16)


Zinc

Zinc has a long history as an agent used to promote wound healing. It was used topically as calamine lotion as far back as 1500 BC by the Egyptians. There are over 200 zinc requiring enzymes in the body. For example, DNA polymerase is required for cellular proliferation during healing, and zinc-containing superoxide dismutase is an important anti-oxidant enzyme. During an infection, leukocytes produce free radicals to kill bacteria. Zn-SOD is an important part of our immune system, which protects our body from damage while free radicals are being produced to fight an infection. (17)

Stress from events such as burns, surgery, or other accidental injury, causes serum zinc levels to decline. (18) One explanation for the fall in serum zinc levels during wound healing is because zinc is mobilized to the trauma site. Zinc concentrates in wounds during the period of collagen synthesis and affects the strength of new tissue. It is thought that this is why topical administration of zinc improves wound healing, even in patients who are not zinc deficient. (19)

Herbal Suplementation


Aloe Vera

Aloe, a genus with over 150 species, is mostly native to East and South Africa. Aloe is a succulent plant that has been used medicinally for centuries. Records of its use date back to 1750 BC. Aloe vera (a synonym for Aloe species) leaf gel has been used for centuries as a topical wound healing agent for traumatic wounds (from mechanical, traumatic, or thermal injury, including contusions, abrasions, punctures, fractures, sunburn, burns, and frost bite), and chronic wounds (including pressure and diabetic ulcers). (20) Aloe vera has been reported for years to be effective in treating various types of burns. (21) , (22) A recent study supported these findings, where aloe vera gel was reported to increase microcirculation to the burn area, causing vasodilation and increased post-capillary venular permeability. (23) There has been a report of aloe hindering the wound healing process, causing a thickness of granulation tissue with a decreased amount of hair follicles as compared to 1% silver sulfadiazine cream. (24)


Calendula

Calendula extracts have been used topically to promote wound healing, with several studies reporting a measurable effect. In a laboratory study, an ointment containing a 5% fractionated extract of calendula flowers markedly stimulated the physiological regeneration of wound tissue, reported to be due to more intensive metabolism of glycoproteins, nucleoproteins, and collagen proteins during the regenerative period in the tissues. (25) Calendula extracts have also been reported to be anti-inflammatory, which also aids in wound repair and healing. (26) , (27)


Gotu Kola

Gotu kola is reported to have a positive effect on tissues, specifically skin, connective tissue, lymph and mucous membranes. (28) , (29) , (30) It does not contain any caffeine and is not related in any way to kola nut. Gotu kola has been used primarily for venous insufficiency, soft tissue inflammation and infection, and for postsurgical wound healing. (31) , (32)

References

  1. View Abstract: Parsons L. Office management of minor burns. Lipencotts Primary Care Practice. 1997;1(40):1997.
  2. View Abstract: Griglak MJ. Thermal injury. Emerg Med Clin North Am. 1992;10:369.
  3. U.S. Preventive Services Task Force, Guidelines from Guide to Clinical Preventive Services. Second Edition. Williams & Wilkins; 1996.
  4. Bond CA. Burn and sunburn products. Handbook of Nonprescription Drugs, 9th ed. Washington, DC: APhA; 1990:889-902.
  5. Farrell AM, Staughton RCD. Garlic burns mimicking herpes zoster. Lancet. 1996;347:1195.
  6. Pray WS. Burns. In: Nonprescription Product Therapeutics. Baltimore MD: Lippincott, Williams & Wilkns; 1999:502.
  7. Covington TR, ed. Burns. In: Nonprescription Drug Therapy Guiding patient self-care. Facts and Comparisons. St Louis, MO. 2000;89-100.
  8. Covington TR, ed. Burns. In: Nonprescription Drug Therapy Guiding patient self-care. Facts and Comparisons. St Louis, MO. 2000;89-100.
  9. Rogers R. Monograph on Collagens. NTIS No. PB-289599. Prepared by Informaitons, Inc. Rockville, MD. Contract No. FDA. 1978;223:76-2001.
  10. View Abstract: Swaim SF. Effects of a hydrolyzed collagen dressing on the healing of open wounds in dogs. Am J Vet Res. Dec2000;61(12):1574-8.
  11. View Abstract: Van Swol RL, et al. Collagen Membrane Barrier Therapy to Guided Regeneration in Class II Furnications in Humans. J Periodontol. 1993;64:622-629.
  12. View Abstract: Haney JM, et al. Periodontal repair in dogs: expanded polytetrafluoroethylene barrier membranes support wound stabilization and enhance bone regeneration. J Periodontol. 1993;64(9):883-890.
  13. View Abstract: Alexander JW. Immunonutrition: The Role of Omega-3 Fatty Acids. Nutrition. 1998;14(7-8):627-633.
  14. View Abstract: Parry-Billings M, et al. Does glutamine contribute to immunosuppression after major burns? Lancet. Sep1990;336(8714):523-5.
  15. View Abstract: Lu SL. Effect of arginine supplementation on T-lymphocyte function in burn patients. Chung Hua Cheng Hsing Shao Shang Wai Ko Tsa Chih. Sep1993;9(5):368-71, 398.
  16. View Abstract: Tanaka H, et al. Reduction of resuscitation fluid volumes in severely burned patients using ascorbic acid administration: a randomized, prospective study. Arch Surg. Mar2000;135(3):326-31.
  17. View Abstract: Okada A, et al. Zinc in clinical surgery: a research review. Japanese Journal of Surgery. 1990;20:635.
  18. Werbach MR. Nutritional Influences on Illness. Tarzana, CA: Third Line Press; 1996:618.
  19. View Abstract: Prasad AS. Zinc and growth in development and the spectrum of human zinc deficiency. J Am Coll Nutr. 1988;7:377.
  20. Salcido R. Complementary and alternative medicine in wound healing. Adv Wound Care. Nov1999;12(9):438.
  21. View Abstract: Visuthikosol V, et al. Effect of aloe vera gel to healing of burn wound a clinical and histologic study. J Med Assoc Thai. Aug1995;78(8):403-9.
  22. View Abstract: Rodriquez-Bigas M, et al. Comparative evaluation of aloe vera in the management of burn wounds in guinea pigs. Plast Reconstr Surg. Mar1988;81(3):386-9.
  23. View Abstract: Somboonwong J, et al. Therapeutic effects of Aloe vera on cutaneous microcirculation and wound healing in second degree burn model in rats. J Med Assoc Thai. Apr2000;83(4):417-25.
  24. View Abstract: Kaufman T, et al. Aloe vera gel hindered wound healing of experimental second-degree burns: a quantitative controlled study. J Burn Care Rehabil. Mar1988;9(2):156-9.
  25. View Abstract: Klouchek-Popova E, et al. Influence of the physiological regeneration and epithelialization using fractions isolated from Calendula officinalis. Acta Physiol Pharmacol Bulg. 1982;8(4):63-7.
  26. View Abstract: Akihisa T, et al. Triterpene alcohols from the flowers of compositae and their anti-inflammatory effects. Phytochemistry. Dec1996;43(6):1255-60.
  27. Bezakova L, et al. Inhibitory activity of isorhamnetin glycosides from Calendula officinalis L. on the activity of lipoxygenase. Pharmazie. Feb1996;51(2):126-7.
  28. View Abstract: Suguna L, et al. Effects of Centella asiatica Extract on Dermal Wound Healing in Rats. Indian J Exp Biol. 1996;34(12):1208-11.
  29. View Abstract: Hausen BM. Centella asiatica (Indian Pennywort), an Effective Therapeutic But a Weak Sensitizer. Contact Dermatitis. 1993;29(4):175-79.
  30. View Abstract: Tenni R, et al. Effect of the Triterpenoid Fraction of Centella asiatica on Macromolecules of the Connective Matrix in Human Skin Fibroblast Cultures. Ital J Biochem. 1988;37(2):69-77.
  31. View Abstract: Maquart FX, et al. Stimulation of Collagen Synthesis in Fibroblast Cultures by a Triterpene Extracted from Centella asiatica. Connect Tissue Res. 1990;24(2):107-20.
  32. View Abstract: Cesarone MR, et al. The Microcirculatory Activity of Centella asiatica in Venous Insufficiency. A Double-blind Study. Minerva Cardioangiol. 1994;42(6):299-304.