Self-Treatment of Burns

Self-Treatment of Burns

W. Steven Pray, Ph.D., R.Ph.

US Pharmacist 27(4), 2002. © 2002 Jobson Publishing

Introduction

The local pharmacy is often where people first seek assistance with minor injuries. One of these is the burn injury. The pharmacist should be prepared to conduct a burn assessment, and to understand with certainty which types of burns can be self-treated, and which require triage to another medical practitioner.

Causes of Burns

Several types of injuries may be broadly referred to as burns. They include thermal burns and sunburn as well as exposure to chemicals or contact with an electrically live object. In the case of chemical burns, first aid consists of flushing the affected area with copious amounts of water for a minimum of 15 minutes to remove the offending agent.^[1] If clothing is saturated, it must be removed to minimize further skin contact. Beyond these initial steps, chemical burns are not appropriate for self-care; physician referral is mandatory. Electrical burns also require immediate referral to a physician or emergency room. The patient may appear outwardly to be healthy, with one small burn at the point of electrical current contact and another at the spot where the patient was grounded. However, the patient can have severe internal damage, which necessitates referral.

The most common burn presented to the pharmacist is the thermal burn, although the sunburn is also a frequent problem, especially during the summer months. Both may be self-treated, depending on severity.

Assessment of Burns

Whether or not a thermal burn is self-treatable depends on such variables as the extent and depth of the burn, the presenting symptoms, the age of the patient, the burn location, and any underlying medical conditions the patient may have.

Depth

One of the most critical burn criteria is depth, which depends on the thermal source that caused the burn and the length of time the patient was in contact with it. The first-degree burn is the most minor form of burn. Examples of first-degree burns include a serious sunburn, a burn resulting from low-intensity heat, or short duration of exposure to a more intense source of heat (e.g., an explosion).^[2,3] Affecting only the epidermis, this type of burn is also referred to as a superficial partial-thickness burn.^[4] First-degree burns develop a pink color, and are painful.^[5] Depending on the amount of time since the injury occurred, they may be accompanied by minor edema.^[6] The skin is soft, and blisters are usually absent. Infection is not a concern, since the skin usually remains unbroken.^[7] The burned area may undergo superficial exfoliation, but the skin is usually normal within 3 to 5 days. First-degree burns heal without any residual scarring.

The second-degree (deep partial-thickness) burn might be caused by brief exposure to spilled hot liquids, a flash of flame that bathes the skin, or instantaneous reactions such as grabbing a falling curling iron by the heated end. It affects the epidermis and the underlying dermis. Superficial second-degree burns are confined to the upper dermis and range in color from pink to bright-red. A second-degree burn that penetrates to deep dermal areas, by contrast, appears dark red to mottled yellow-white.^[6] Either may blister, though the superficial second-degree burn causes blisters that are variable in size. Upon rupture, the blisters yield large amounts of exudate. The deep dermal second-degree burn produces smaller blisters, and the skin is only slightly moist. The superficial second-degree burn causes pain since all superficial nerve endings are still intact. The area may be so sensitive that even a current of air causes exquisite pain.^[5] The skin may thicken temporarily due to edematous effusion into the area, though it will retain full pliability.^[6] Healing proceeds to completion in 5 to 21 days. With the deep dermal second-degree burn, the patient exhibits decreased skin sensation to pinprick, though deep pressure sensations that arise from subdermal stimulation will still be present. Moderate edema decreases skin elasticity, and healing is usually completed within 3 weeks, though it may take up to 6 weeks. Unless proper care is obtained for second-degree burns, the patient may experience scarring, with a possibility of restricted joint movements.^[3] Grafting may be required.^[5] Even when grafting is unnecessary, the burned area may retain a residual hyperpigmentation for one month or more.

The third-degree (full-thickness) burn is caused by accidents such as extended contact with steam or fire, or being immersed in scalding water. Wound penetration proceeds to the subcutaneous tissues underlying the dermis. Surface discoloration is variously described as pearly, translucent, or parchment-like to overtly charred. Blistering is not an issue since tissues that would respond by blistering are destroyed. Deadened epidermis and dermis (eschar) adheres to the wound in various degrees, with thrombosed veins visible throughout the devitalized, escharotic mass. Pain is typically not present, since destruction of nerves renders the area numb.^[8] The patient may only be able to perceive deep pressure. The skin is inelastic and leathery due to destruction of collagen and elastic fibers. Healing will not occur without grafting, since the tissue layers that normally allow post-injury regeneration are also absent.^[3] Some amount of scarring is inevitable and cannot be prevented, since even grafted areas will remain visible.

Some burn taxon-omies also include the fourth-degree burn, a devastating injury resulting from such accidents as incineration exposure or sustained electrical contact. In either case, muscle, fascia periostium and bone are affected. Patients with these burns often die.^[2]

Surface Area

The percentage of body surface area (BSA) burned is very useful to know in the clinical setting, but it is of less importance in retail pharmacy assessment and triage. The "Rule of Nines" is popular, relying on a simple, fairly accurate generalization.^[6] In an adult, each leg is 18% of the BSA each arm is 9%, the torso is 18% (front) and 18% (back), the head is 9%, and the genital area of males is 1% (all figures are approximations).^[3,5] If the patient is a pregnant female, her abdominal area will occupy a slightly larger BSA. The shortcomings of this rule are that burned areas must be cleared of debris before an accurate visual assessment can be made, and, because of their comparatively larger head to body ratio, it is not applicable to infants. Further, it is rare for people to suffer burns in discrete body sections, as assumed by the Rule of Nines. Rather, burns tend to be scattered over the body in a mottled pattern. For this reason, researchers also suggest use of the "Rule of Palms," in which the patient's own palm (exclusive of fingers) is approximately 1% of the total BSA.^[5]

Pharmacist Burn Assessment

Burn assessment is difficult, even for trained professionals, as proven by the complicated algorithms and tables developed by such groups as the American Burn Association. They take into account additional variables, such as location, associated trauma, and concomitant disease conditions. (In other words, sophisticated burn assessment is beyond the capabilities of the typical retail pharmacy.) The FDA OTC review panel responsible for determination of which burns safely allow self-treatment simplified the pharmacist's triage decision by focusing solely on the degree of the burn, rather than BSA and other variables. The ruling of the panel, confirmed by the FDA, was that self-treatment is only appropriate for first-degree and minor second-degree burns due to thermal exposure or sunburn (electrical and chemical burns are inappropriate for self-therapy).^[9] Thus, the pharmacist may use the recognition parameters outlined above to make a rapid assessment. Since some patients request help over the phone, it is prudent to request that they visit the pharmacy so valuable visual input may be obtained. For example, the patient who does not report blistering may have a first-degree burn or a third-degree burn, which could immediately be differentiated from each other by a visual inspection. A prudent rule to follow in advising self-treatment is to note the color of the wound and the sensitivity, as these differ markedly in the superficial and deep second-degree burn. If there is any doubt as to severity, a physician referral is the wisest choice.

Treatment of Minor Burns

There are several types of products the pharmacist can recommend for patients with first-degree or minor second-degree burns. However, the pharmacist must caution the patient that a burn that worsens or fails to improve within 7 days of the injury should be seen by a physician to rule out infection. If the patient's burn occurred more than 7 days before the patient initially speaks to a pharmacist, he or she is already outside of the realm of self-care and should be referred. Further, children under 2 years old who suffer burns should always be seen by a physician. Finally, burns of the hands, feet, face, and perineum should always be referred. The hands may suffer severe functional problems with even minor burn scarring, foot burns heal slowly and are prone to infection, facial burns may be disfiguring, and it is difficult to apply dressings to the perineum, where wounds are easily damaged due to urine/fecal contact.

Relief of pain and itching may be effected with local anesthetics, counterirritants, and antipruritics. Since application of solid products may stimulate further pain, aerosols are an effective alternative (e.g., Americaine Aerosol, Dermoplast, Solarcaine). If the skin has been broken, an antibacterial should be applied to prevent infection. Due to the possibility of allergy and contact sensitization, neomycin should be avoided. Antibacterials without neomycin include Polysporin, Betadine First Aid, hydrogen peroxide, and Betadine.

References

Winfree J, Barillo DJ. Nonthermal injuries. Nurs Clin North Am 1997;32(2):275-296.
Rose DD, Jordan EB. Perioperative management of burns. AORN J 1999;69(6):1211-1230.
Lim J, Rehmar SG, Elmore P. Rapid response: Care of burn victims. AAOHN J 1998;46(4):169-180.
Polko LE, McMahon MJ. Obstet Gynecol Surv 1998;53(1):50-56.
Barillo DJ, Goodwin CW. Dermatologists and the burn center. Dermatol Clin 1999;17(1):61-75.
Smith MA, Munster AM, Spence RJ. Burns of the hand and upper limb--a review. Burns 1998;24(6):493-505.
Judson R. Minor burns. Aust Fam Physician. 1997;26(9):1023-1026.
Leikin JB, Aks SE, Andrews S, Auerbach PS, et al. Environmental injuries. Dis Mon 1997;43(12):809-916.
Fed Reg. 1978;43:34628-34648.
Morison WL. Sunlight: An environmental toxin for humans. Md Med J 1997;46(5):227-230.

Sidebar: Sunburn

Sunburn is the only completely preventable type of burn injury, since it results from prolonged overexposure to the sun. Whether exposure is voluntary (e.g., recreational tanning) or "forced" (e.g., outdoor manual labor, military service), the individual must understand that adequate application of sunscreen coupled with the use of protective clothing and headgear can keep the skin healthy.^[10] Some patients who approach the pharmacist are sunburned severely enough to have massive blistering over a large part of the body. These burns may be more serious second-degree burns and should be referred. If the sunburn is minor, however, self-treatment may proceed as outlined in the article, with the use of skin protectants, lubricants, local anesthetics, and antibacterial/antibiotics to prevent infection.

Sidebar: Patient Information

What to Do When You Have Been Burned

Appropriate first aid for a burn depends on the cause. Burns may arise as a result of electrical contact or exposure to dangerous chemicals. You should remove the patient from the electrical source and seek immediate emergency room care for electrical burns. For chemical burns, you should remove any clothing containing chemical and flush the skin for at least 15 minutes with large amounts of water before seeking emergency care.

Thermal Burns. Burns due to hot objects are the most common type. First aid suggests running lukewarm or cool water over the burned area until it is free of pain, both when in the water and when out of the water. Sunburn is another type of burn, and may be treated with any of several nonprescription products, like the thermal burn.

If your burn is a thermal burn or sunburn, it can be self-treated only if it is not too severe. Your pharmacist may be able to help you decide whether self-care is appropriate, which is generally only the case for burns known as first-degree or minor second-degree in severity.

Is the Burn Painful?. A general rule to remember is that self-treatable burns are painful. If the burn looks dark-red, yellowish-white, or pearly, and is not painful, it may be the more severe second-degree or third-degree burn that requires a physician or emergency room visit. Lack of pain does not mean that the burn is minor. Instead, it does not hurt because the nerves have been burned away. Thus, you cannot use the absence of pain as a basis for deciding whether or not to seek immediate care.

Burn Self-Treatment. Self-care is not appropriate for those under the age of 2 years. It is also wise to seek care if the burn is on the hand, foot, face, or genital area. However, if the burn is not severe enough to require physician care, there are several things you can do to treat it. You may choose a skin protectant to cover the burn and a lubricant to help the burn feel less dry. Protectant/lubricants include cocoa butter, glycerin, and petrolatum. You may apply either freely as often as needed.

You may also wish to deaden the pain and itching associated with the burn. Many products advertise an ability to do this, including those with ingredients such as benzocaine, dyclonine, pramoxine, benzyl alcohol, and menthol. Aerosol sprays are convenient in allowing you to place a product on the burn without having to rub it on and produce further pain. Examples of products include Dermoplast Spray, Solarcaine Aerosol and Americaine Aerosol.

If the skin was broken, you may wish to apply a product to prevent infection. These products include Polysporin Ointment, Betadine Ointment, hydrogen peroxide, and Betadine First Aid Antibiotic Ointment.

Observe the Burn Closely

If your burn looks or feels worse, or doesn't improve after 7 days have passed, you may have a wound infection, and should discontinue self-care to seek a physician appointment.

W. Steven Pray, Ph.D., R.Ph., Professor of Nonprescription Products and Devices, School of Pharmacy, Southwestern Oklahoma State University, Weatherford, OK