Articles

Burns

Introduction

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) On average 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 the 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 from myoglobulinuria, 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 avascular, 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.

Not available

World Health Organization, 2006, India

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

World Health Organization, 2002, Sri Lanka

  • 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

[span class=alert]The following list does not insure the presence of this health condition. Please see the text and your healthcare professional for more information.[/span]

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 (2nd degree burns), very severe burns (3rd and 4th 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, 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 are reviewed:

First degree

    Affects epidermis and hair Localized edema Redness Pain Blanch when pressure is applied, quick refill Healing generally occurs within 3-5 days No associated scarring Peeling may occur Itching while healing

Second degree

    Affects epidermis, dermis sebaceous glands, sweat glands, and hair follicles Redness Pain Blisters Loss of proteinaceous fluid Blanch when pressure is applied, refill slowly Mild forms heal in 7-10 days More severe burns may take up to 8-12

Third degree

    Affects the epidermis, dermis, subcutaneous layer and associated structures Leathery, dry, inelastic or charred appearance Little or no pain Healing is a lengthy process Scarring Danger of secondary infection Grafting may be necessary

Fourth degree

    Affects epidermis, dermis, subcutaneous layers, muscle and possibly bone Charred appearance Generally not painful Danger of deep infection Loss of circulation to affected area Grafting necessary Severe scarring

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. Heat destroys tissues through denaturation of native protein and disruption of cell membranes. However, protein that has undergone heat-induced denaturation can refold into its original configuration if cooled rapidly enough. (6) If no effort is made to cool the tissues, the elevated temperature may continue to produce injury for several minutes. (7)

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 reepithelialization occurs. (8)

FDA labeling of OTC hydrocortisone has restricted its official indications to use as a topical antipruritic. 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 cutaneous 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. (9) Agents that are collagen based have been introduced to assist in stimulating granulation.

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. (10) Collagen also contains two amino acids not found in other proteins, hydroxyproline and hydroxylysine. The most abundant structural protein in the body, collagen, contains 14 different types of collagen, with Types I, III, and V being the most common in the skin. Type I collagen, however, is the most prevalent collagen in the body at approximately 90 percent.

Collagen has medical applications with characteristics including: (1) hemostatic; (11) (2) low antigenicity; (12) (3) chemotactic properties. (13) Other reasons why collagen is used medically is: high tensile strength; orientation of fibers; semipermeability of membranes; and general positive effects on wound healing rates. Upon placement in a wound, the exogenous collagen adheres well and helps activate the inflammatory phase of wound healing. (14) Collagen's primary structure represents attachment sites for fibroblasts that act as a template for new tissue growth. (15)

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, including: (16) , (17) , (18)

    May prevent postoperative fibrous adhesions and scarring. Suture replacement. Dental agent following treatments involving the mucosa, gingival, and periodontal ligament (oral mucosa is predominantly Type 1 collagen); used in clot formation and stabilization; neovascularization; and epithelial cell rejuvenation following periodontal and gingival therapy. Hemostatic agent. Anti-inflammatory at wound site. Absorbent - decreases exudate and removes bacteria from wound site; can actually absorb up to 30 times its own weight in wound exudate due to its hydrophilicity. May regenerate tissues. Aids in debridement of the wound by attracting bacteria, exudate, and debris through osmotic forces in the wound area. Forms an occlusive gel at wound site; aids in protection, remodeling, and scarring of wound. May aid in diminishing pain in the wound by protection of nerve endings. May be used in treatment of first and second degree burns (gel form preferred). Deodorizing agent.

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 wound exudate, be interactive with the wound site and provide needed mechanical protection against physical and bacterial insult.

Type 1, hydrolyzed collagen may be used topically in the management of chronic wounds and dermal ulcers, including pressure ulcers (Stages I-IV), venous stasis ulcers, diabetic ulcers, ulcers resulting from arterial insufficiency, surgical wounds, wounds from the long-term effects of radiation or medication, traumatic wounds, and all superficial wounds, including minor cuts, scrapes, abrasions, and burns (first degree and some second degree).

Nutritional Supplementation

Honey
Honey dressings are reported to be an effective treatment for burns. Honey’s high viscosity enables it to form a physical barrier, which prevents bacterial colonization and reduces the incidence of infections in wounds. The antibacterial effects are reportedly due to hydrogen peroxide, which is produced due to the action of the enzyme glucose oxidase secreted by the bees. The viscous barrier formed by honey creates a moist environment, which helps quicken wound healing. Nutrients in honey, such as levulose and fructose, improve the local nutrition and promote epithelialization. (19)


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 phospholipid 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. (20)


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. (21) Glutamine increases nitrogen retention, helps preserve skeletal muscle mass, reduces the incidence of wound and general infections, and shortens hospital stays in patients suffering from burns. (22)


Arginine

Results from animal studies indicate that arginine supplementation decreases the mRNA expression of inflammatory cytokines in organs and improves the survival rate after thermal injury. (23)

The recoveries of burn patients receiving 2% of energy supplied by arginine were compared to similar burn patients who did not receive arginine. Arginine was found to significantly enhance the T lymphocyte response to phytohemagglutinin, CD4 phenotype expression, CD4/CD8 ratio, IL-2 production and IL-2 receptor expression, as compared with the control group. These improvements prompted researchers to suggest that arginine should become one of the most important nutrients supplied to burn patients. (24)


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. The results of this prospective, randomized study were significantly reduced resuscitation fluid volume requirements, body weight gain, and wound edema after adjuvant administration of high-dose ascorbic acid (66 mg/kg per hour) during the first 24 hours following thermal injury. There was also a reduction in the severity of respiratory dysfunction in these patients. (25)

Ascorbic acid has also been used topically in combination with other substances as a safe and effective method of improving repair and controlling infection of wounds. The protocol consists of daily debridement and a topically, balanced solution consisting of salts, amino acids, a high-molecular weight D-glucose polysaccharide, and ascorbic acid. Wounds treated with this solution were second- and third-degree thermal burns, diabetic lesions, decubitus, varicose and stasis ulcers. The majority of cases responded quickly and local infection was controlled early. In 4 to 8 weeks, small- and medium-sized lesions were healed. (26)


Vitamin E

The bodies of patients who have been severely burned undergo a substantial increase in oxidative free radical damage. In one study, serum vitamin E levels decreased most significantly from days 6 to 8 postburn in burn patients, while serum lipid peroxides increased significantly. In burn patients who received vitamin E, serum vitamin E levels increased and lipid peroxides decreased to the levels of healthy people. These results suggest that providing burn patients with supplemental vitamin E may provide substantial benefit. (27) However, several studies report that topical application of vitamin E to burns is ineffective and in some cases may actually be detrimental. (28) , (29)


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. (30)

Stress from events such as burns, surgery, or other accidental injury, causes serum zinc levels to decline. (31) 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. (32) Topical administration of zinc chloride (spray or ointment) reduces the size of the wound and shortens healing time. (33)

In zinc deficiency, there is delayed closure of wounds and ulcers and the collagen produced during zinc deficiency has weaker tensile strength. (34) Zinc deficiency also compromises the immune system in several ways. It causes a decrease in the number of lymphocytes and natural killer T-cells, and a decrease in the size of the thymus, resulting in an increased susceptibility to recurring infections and poor wound healing. (35)

Herbal Supplementation


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). (36) In one study, it was observed that aloe increased the collagen content of granulation tissue as well as cross-linking as seen by increased aldehyde content and decreased acid solubility. (37) The type I/ type III collagen ratio of treated groups was lower than that of the untreated controls, indicating enhanced levels of type III collagen.

The influence of aloe on the glycosaminoglycan (GAG) components of the matrix in a healing wound has also been reported as a mechanism in wound healing. The early stage of wound healing is characterized by the deposit of a provisional matrix, followed by the formation of granulation tissue and synthesis of collagen and elastin. A recent study reported the influence of aloe vera on the content of GAG and its types in the granulation tissue of healing wounds. (38) The amount of ground substance synthesized was found to be higher in wounds treated with aloe vera gel, with the levels of reported glycohydrolases (hyaluronic acid and dermatan sulfate) being elevated, indicating increased turnover of the matrix. Both topical and oral treatments with aloe vera were found to have a positive influence on the synthesis of GAGs and contribute to wound healing. An amorphous hydrogel dressing derived from the aloe plant containing acemannan is approved by the FDA for the management of stages I through IV pressure ulcers. (39)

Aloe contains vitamins and minerals (including vitamin C, E, and zinc) reported to be beneficial in wound healing. (40) , (41)

Aloe vera has been reported for years to be effective in treating various types of burns. (42) , (43) 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. (44) 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. (45)

Aloe vera gel also reportedly aids in wound healing topically due its anti-inflammatory activity. (46) Aloe constituents with anti-inflammatory activity include: mannose-6-phosphate; (47) , (48) the glycoproteins aloctin A and alprogen; (49) , (50) a C-glucosyl chromone; (51) the anthraquinones; (52) and gibberellin. (53)


St. John's Wort

St. John’s wort has gained a great deal of attention for its use in minor depression. St. John's wort also has traditional uses in the topical treatment of superficial wounds, burns and dermatitis. In a study, an ointment containing an extract of hypericum was compared with untreated skin in inflammatory conditions of the skin such as wounds and burns. (54) Treatment with the hypericum ointment resulted in a significant suppression of the mixed epidermal cell lymphocyte reaction MECLR and also of the proliferation of T lymphocytes. These results may provide a rationale for the traditional treatment of inflammatory skin disorders with topical hypericum extracts.

Another study evaluated the wound healing potential of a hypericum ointment applied to wounds of laboratory animals. (55) The effect produced by the extract ointment, in terms of wound contracting ability, wound closure time, regeneration of tissues at wound site, tensile strength of the wound and histopathological characteristics were comparable to those of nitrofurazone ointment.


Calendula

Used since ancient times as a healing agent, calendula is mentioned in herbal books that date back to 1373. The name calendula refers to the plant’s tendency to bloom in accordance with the calendar – every month in some regions of the Mediterranean, or during the new moon. Used historically as “poor man’s saffron", calendula was used both as a culinary herb and spice as well as a medicinal agent. Extracts of calendula flowers are popular in Europe where they are employed in various first aid creams and cosmetics. Calendula is a very popular homeopathic remedy also, used topically for skin problems including diaper rash and other conditions in children and infants. (56) Calendula is listed in the German Commission E Monographs for use as a mouthwash for the oral and pharyngeal mucosa as well as topically for the skin. (57)

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 and epithelialization of wound tissue, reported to be due to more intensive metabolism of glycoproteins, nucleoproteins and collagen proteins during the regenerative period in the tissues. (58) Another later study reported immune activation by calendula extracts using in vitro granulocyte tests and in vivo carbon clearance tests, both laboratory determinants of immune activation. (59) Calendula extracts have also been reported to be anti-inflammatory, which also aids in wound repair and healing. (60) , (61) The anti-inflammatory effect has been reported to be due to the triterpenoids (specifically faradiol) found in calendula. (62) Various case reports of calendula preparations healing wounds, including traumatic wounds and chronic wounds (including pressure sores and diabetic ulcers). (63)


Gotu Kola

Gotu kola is reported to have a positive effect on tissues, specifically skin, connective tissue, lymph and mucous membranes. (64) , (65) , (66) 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. (67) , (68) Asiaticosides are reported to exert a preferential stimulation of collagen synthesis, in addition to stimulating glycosaminoglycan synthesis. (69) Also, gotu kola’s affects the connective tissue by strengthening weakened veins. (70) Gotu kola may assist in the maintenance of connective tissue. In the treatment of scleroderma, gotu kola may also assist in stabilizing connective tissue growth, reducing its formation. (71) It reportedly stimulates the formation of hyaluronidase and chondroitin sulfate, as well as exerting a balancing effect on the connective tissue. (72) It is believed to have an effect on keratinization, which aids in thickening skin in areas of infection. (73) Gotu kola is used topically and internally for skin conditions including psoriasis and eczema. (74)

Homeopathic

Apis mellifica

Typical Dosage: 6X or 6C, 30X or 30CMinor burns with pinkish swelling

Belladonna

Typical Dosage: 6X or 6C, 30X or 30CMinor burns with red swelling

Calendula officinalis(topical)

Typical Dosage: N/AUsed topically for minor burns; Relieves pain; Protects the wound

Cantharis

Typical Dosage: 6X or 6C, 30X or 30CMinor burns with large painful blister

Hypericum perforatum

Typical Dosage: 6X or 6C, 30X or 30CMinor burns with nerve pain

Rhus toxicodendron

Typical Dosage: 6X or 6C, 30X or 30CMinor burns with small blister

Urtica urens

Typical Dosage: 6X or 6C, 30X or 30CMinor burns with burning, stinging pain

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