Burn Wounds

The incidence of burn injury in the United States is approximately 1.25 million cases per year. The American Burn Association, in conjunction with the American College of Surgeons, has established suggested criteria for transferring patients with major burn injuries to a recognized burn center for treatment. The number of patients meeting these criteria is far smaller than the number of people who are burned each year, however, which means that most people who experience less-- serious burns will seek treatment at other facilities, including private practices.

One criterion for burn center referral is burn depth. For the purpose of this article, burn depth is divided into 2 categories: superficial and deep.3 Deep burns are categorized as deep partial-thickness (extending into the reticular layer of the dermis) and full-thickness (destroying the entire thickness of the skin). Patients with deep burns will generally be treated in a burn center.

Superficial burns can be further separated into 2 types: a superficial burn that solely involves the epidermis and a superficial partial-thickness burn that extends down into the more superficial, papillary layer of the dermis. The most common type of isolated superficial burn is caused by overexposure to ultraviolet rays (sunburn).4-8 These bums are red in color with intact skin.3 They can become painful, which is a primary reason people seek treatment from a health care provider. Management generally consists of applying a moisturizing cream to rehydrate the skin and strong cautioning for the patient to avoid further exposure to the sun. These types of burns generally heal in about 5 to 7 days following exposure.

If extensive, however, superficial burns can be lifethreatening.6 Clinicians should be aware of the adverse interaction of suntan-enhancing agents (such as from the psoralen family) and extended exposure to sunlight, which can cause an extensive body surface area burn (Table 1).5-8

A hallmark of a superficial partial-thickness burn is the appearance of blisters on the skin that remain intact at the site of heat exposure. The clinical concern surrounding blisters is how to manage them. There are 2 thoughts for treatment: leave the blister intact or remove the blister and its fluid content. Some investigators state that blister fluid contains substances that are deleterious to wound healing,9-18 while other authors report that blister fluid provides an environment that contributes to wound healing.19-22

Proponents of removing blisters focus their arguments on 3 primary concerns:

* the presence of vasoactive substances that can decrease circulation to an already compromised wound and, possibly, convert a superficial bum to a deeper injury13-15,17

* a decrease in the antibacterial capacity of burn blister fluid9,12

* unwanted wound healing effects, such as an increase in the inflammatory response,18 a decrease in reepithelialization,16 a suggested decrease in the antioxidative capacity of burn blister fluid,10 and an increase in the contractility of fibroblasts.11

Those who advocate leaving blisters intact cite the following studies:

* Ono et al,19 who indicated a wound healing stimulatory effect due to the presence of various growth factors and cytokines identified in blister fluid

* Uchinuma et al21 and Wilson et al,21 who both reported that blister fluid facilitates fibroblast growth and an increase in mitogenic activity of fibroblasts and keratinocytes

* Reagan et al,22 who demonstrated that there is no strong evidence related to keratinocyte proliferation or differentiation to support the removal of blisters.

However, the noted results of Uchinuma et al20 and Wilson et al21 may not promote the best patient outcome when viewed against the suggestion of Wilson et al that an increase in fibroblast activity may be implicated in poorer patient outcomes. When these reports are viewed collectively, the evidence weighs in favor of evacuating blister fluid. Logically, a blister is an abnormal eruption of the skin that eventually goes away. It makes clinical sense to remove the blister early.

Treatment

Suggested treatment for small, intact blisters is to remove the blister contents by needle aspiration or to lance the blister at its base but leave a pedicle of attachment. A bland antibiotic ointment, such as bacitracin or polymixin and bacitracin (Polysporin), is applied to the underside of the blister flap that has been created. Applying ointment directly to the denuded skin surface will be extremely painful for the patient because of exposed cutaneous sensory nerve endings. The blister flap, which essentially remains as a biologic dressing, should be gently replaced over the exposed wound surface.

Blisters that are already disrupted are generally debrided. Further treatment depends on wound appearance. If the wound is pink, blanches, and is sensate, then a moist barrier dressing may be applied. If the wound is deep, leaving blister flaps only serves to make it difficult for topical antibiotics to reach the wound. The primary location that is amenable to leave blisters intact is the fingertips and palm of the hand. Prematurely disrupting blisters in these areas usually leads to increased pain for the patient. The glabrous skin on the palm of the hand rarely heals with any visible scar; therapy for superficial partialthickness burns here should be directed toward pain control.

 

Burn Wounds

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