Burns

Types of Burns

Burns are divided into 3 different types:

First degree or superficial burns:

It is commonly seen with a sunburn. It is usually red and blanches (becomes white) on pressure. It occurs due to damage to only the top (epidermis) layer of the skin. It heals by itself in 3-6 days and generally does not require hospitalization.

Partial thickness burns or second degree burn:

• Superficial partial-thickness burns: They are painful and associated with blisters. They heal within 3 weeks without any visible scars. There may be some pigment changes.

• Deep partial-thickness burns: They are dry white in color. They may cause scarring and take longer to heal. Skin grafting is usually required for healing.

Full thickness burns:

They involve the entire epidermis and dermis. They are dry and leathery in appearance. They cause scarring and require immediate skin grafting and the use of compression garments.

Burns

Burns are death and necrosis of a tissue due to heat. Burns may occur due to dry heat, (in form of fire) wet heat (in form of scalds), or electrical burns.

Burns - Pathophysiology

Heat damages the cells of the skin releasing chemicals that stimulate nerves and cause pain. Burn heals when a new layer of skin grows in from the edges of the burn. However, if the burn is very large or very deep, bacteria may invade and cause infection. Also due to the evaporation of fluids from the open wound, the patients may get dehydrated. Hence the 2 major short term complications of burns are infection and dehydration. Long-term, during healing, the wound may start shrinking or becoming smaller leading to contractures. Contracted tissue may lead to a loss of normal motion if present in the limbs and can also cause a distorted appearance due to pulling on the surrounding healthy tissue. In a burn patient, sensations of hot, cold, wetness, dryness, touch, and pain may change even permanently. A patient post-burn will not to be able to sweat properly due to damaged sweat glands. Hence appropriate clothing as per the season is required (cotton in summer and warm clothing in winter)

Skin color is determined by the melanin and carotene pigments in the epidermis. Melanin protects the skin from sunburn. After a burn, the burnt skin may not be able to produce melanin, hence leading to sunburn. Also, the skin may become lighter(depigmented or hypopigmented) as compared to the normal skin or darker (hyperpigmented).

Treatment

First degree or superficial burns heal naturally. Deep second degree and full-thickness burns require skin grafting for rapid healing and minimum scarring and generally require hospital care. In addition, supportive therapy like fluids, blood infusion, and pain medication is required. In some patients, the burn may lead to intolerable and excruciating pain for which even lV morphine may be required. For first degree burns and open wounds, topical creams like silver sulfadiazine and bacitracin may be applied. Often dressings may be applied.

Treatment of Skin Discoloration that Occurs with Healing

UV protection is required for 12-18 months post-burn and these patients should apply sunscreen lotion when going out in the sun. Camouflage cosmetics to cover the burns can be used. Hair coloring products can be used 6 weeks after healing is completed. Permanent products can be used 3 months after healing.

Skin Grafting

Skin grafting consists of excision or removal of burnt devitalized tissue, removal of healthy skin from a donor site to cover the cleaned burnt area. An instrument (dermatome) gently shaves a piece of skin about 1/100 of an inch thick from the healthy skin and that skin is grafted over the burnt area. Skin can also be used by dead people (cadavers).To help the graft become secure, the area of the graft is immobilized for at least 5 days and later normal daily activity is started. Skin grafting is usually done under anesthesia.

There are other types of artificial skin grafts available which can temporarily cover the wounds:

• Xenograft or Heterograft: Skin is taken from animals

• Collagen

Meshing is a process by which the donor skin is enlarged to cover a large burnt area when there is not enough healthy skin available. The disadvantage is that it is a less durable graft and leads to more scarring. However, it helps by allowing the blood and body fluids to drain under the graft and thus preventing graft loss and it allows the donor skin to cover a great burnt area.

Grafts are held in place with surgical staples or stitches. Once the graft usually becomes stable within 4-5 days, the staple/stitches are removed.

What Happens to the Donor Site from where the Skin Is Removed?

Although the skin taken from the donor site is very thin, it can cause scarring and pigmentary changes at the donor site.

How Does Exercise Help A Burn Patient?

Exercise helps the body heal better. It helps a burn patient to regain independence.

How Do You Prevent Contractures?

Contractures usually occur due to the extension of burns over a joint limiting movement. Skin tightness may be the first sign of contracture and anti contracture positioning may be required for 24 hours a day. Exercises to stretch or elongate the skin are recommended. Sometimes surgical procedures like the release of the band area (z-plasty) may be required. Before surgery, the casting of the limb may be required as a constant stretch is applied by the cast to elongate the skin.

How Do You Prevent Ugly Scars (hypertrophic Scars) From Developing?

Compression garments are worn over the burnt area. Compression can also be given by splints, orthoses, and casts. Compression garments help the burn heal with a minimum amount of scarring by pressing and flattening the scars. Compression is given for 22-23 hours a day. It is required until almost 12-18 months post- burn or till the burn completely heals (matures).