The pharmacy is often regarded as a first resource for emergency care. Pharmacists see injuries ranging from trivial to serious, and few are harder to assess than the burn injury. Making the correct decision about self-treatment or referral can help the patient avoid infection and lifelong complications.1
Causes of Burns and Immediate First Aid
A burn is a lesion caused by heat or some other agent.2,3 When patients ask pharmacists for assistance in treating burns, it is critical to clarify exactly what has happened, as first aid advice is often critical. For instance, if the patient has sustained contact with a noxious chemical, the pharmacist should suggest immediately flushing the skin with copious amounts of water for at least 20 minutes.4-6 However, the water should be sterile; flushing damaged skin with contaminated water can lead to invasive and necrotizing infection.7 Patients should also remove any clothing that has the chemical on it. The patient should visit an emergency room immediately. If the patient has sustained contact with a live electrical source, an immediate referral is mandatory, even if the patient has little or no outward appearance of damage, as internal injury may be severe.4 Patients may even refer to irritant dermatitis (e.g., caused by hair styling procedures) as “burns.”8
The major source of burns is contact with an external source of heat.1,4 This is the well-known
thermal burn, the most common type of burn. It is often accidental, as spilling a hot liquid on the hands, contacting a hot stove, or stepping into a bath where the water is too hot. Thermal burns are also self-induced, as when someone lies out in the sun for sustained periods or fails to use adequate sunscreen. Self-induced burns also result when misguided individuals attempt to decorate their bodies by pressing heated objects (e.g., coat hangers) into the epidermis, dermis, and underlying tissues to produce a distinctive scar.
First aid for minor thermal burns involves immediately placing the burned area under a steady flow of cool water (not cold or iced water).9 The damaged area should be free of discomfort when under the water and also when removed from the water, perhaps 15 to 20 minutes or longer. If the patient does this properly for minor thermal burns, the burn may not blister.
The pharmacist should immediately refer all chemical and electrical burns. Thermal burns may be self-treatable, and pharmacists should be familiar with the criteria for deciding whether the burn can be treated at home or whether the patient should seek the care of a physician.
Assessing Thermal 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, patient age, burn location, and any underlying medical conditions the patient might have.1
Depth: One of the most critical factors in distinguishing a minor burn from a serious burn is the depth to which tissues have been damaged.9-11 The depth of damage depends on the cause of the burn, its temperature, and the length of time the patient was in contact with it.
The first-degree burn (superficial partial-thickness burn) is the most minor and common burn. Many people have experienced it as a minor sunburn. It can also occur from exposure to low intensity heat or a short exposure to a more intense heat (e.g., an explosion).1 As the most shallow burn, its damage is limited to the epidermis, the skin’s outermost layer. The burn is pink to red and most are painful.9-11 There may be a moderate amount of edema. However, if the patient does not seek help until a short time has passed, the edema may have abated somewhat. The burned area remains soft and unbroken, since this type of burn does not produce sufficient damage to create blisters. Since the skin is not broken, there is little risk of infection. Skin can exfoliate (“peel”), but it usually returns to normal in 3 to 6 days without causing residual scarring.9
Second-degree burns are also referred to as deep partial-thickness burns. They could be produced by such incidents as a short exposure to a hot liquid that is spilled on the hands, a flash of flame that touches the skin when grilling food, or absentmindedly trying to catch a falling curling iron by the hot end. Damage extends through the full depth of the epidermis and into the dermis that lies beneath.
It is critical in pharmacist triage to determine whether the second-degree burn is superficial or deep, as only superficial second-degree burns are self-treatable. A superficial second-degree burn damages only the upper dermis, and is colored pink to bright red.9-11 The patient complains of severe pain since all superficial nerve endings are intact. The area may be so sensitive that even a current of air causes exquisite pain. The skin may thicken temporarily due to edematous effusion into the area, although it retains full pliability. Healing is normally complete in 5 to 21 days.
If the second-degree burn extends down into the deep dermis, the skin appears dark red to mottled yellow-white. The patient exhibits decreased skin sensation to pinprick, although deep pressure sensations that arise from subdermal stimulation are still present. Moderate edema is present, decreasing skin elasticity, and healing may take 3 to 6 weeks.
Both superficial and deep second-degree burns may blister, although blisters are variable in size in the superficial second-degree burn.1,9-11 When they rupture, the blisters yield large amounts of exudate. Blisters are smaller in deep dermal second-degree burns, and the skin is only slightly moist. Unless proper care is obtained for the second-degree burn, the patient may undergo scarring, with a possibility of restricted joint movements, and a need for grafting. Even when grafting is unnecessary, the burned area may retain a residual hyperpigmentation for 1 to 2 months or longer.
Third-degree burns (full-thickness) are caused by extended contact with flames (e.g., clothing that has caught on fire), steam, or immersion in scalding water, among other accidents. Damage involves the subcutaneous tissues beneath the dermis. The burn site is described as pearly, translucent, parchment-like, or overtly charred.9-11 Deadened epidermis and dermis (eschar) adheres to the wound in various degrees, with thrombosed veins visible throughout the devitalized, escharotic mass. The skin is inelastic and leathery due to destruction of collagen and elastic fibers.
The skin does not blister in a third-degree burn, as the damage utterly obliterates the tissues that would respond by blistering. Similarly, there is little or no pain with these burns, as the nerves are also destroyed. The patient may only be able to perceive deep pressure. Third-degree burns can even extend down into muscle and bone. Following debridement of necrotic tissue, grafting is mandatory with third-degree burns, since the tissue layers that normally allow postinjury regeneration are also absent. Scarring cannot be prevented, so the damaged area remains fully visible.
Surface Area: The percentage of body surface area (BSA) burned is also useful in the clinical setting, although it is of less importance in retail pharmacy assessment and triage.1 The “Rule of Nines” is popular, relying on a simple, fairly accurate generalization. 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). If the patient is a pregnant female, the distended abdominal area occupies a slightly larger BSA. Shortcomings of this rule are that burned areas must be cleared of debris before an accurate visual assessment can be made, and that it is not applicable to infants because of their comparatively larger head-to-body ratio. 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 about 1% of the BSA.
Pharmacist Burn Assessment
Burn assessment is difficult, even for trained professionals, as demonstrated by complicated algorithms that take into account such variables as location, associated trauma, and concomitant medical conditions. Sophisticated burn assessment is beyond the capabilities of the typical retail pharmacy in any case.12 The FDA OTC review panel responsible for determination of which burns would be safe enough for self-treatment simplified the pharmacist’s triage decision by focusing solely on the degree of the burn, rather than body surface area and other variables.1 The ruling of the panel, confirmed by the FDA, is 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).1 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 denies blistering may have a first-degree or a third-degree burn, both of which would be immediately differentiated by a visual confirmation. A prudent rule to follow in advising self-treatment is 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.1 Thus, if the 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. Children under the age of 2 years who suffer burns should be checked by a physician. Finally, burns of the hands, feet, face, and perineum should be referred. The hands may suffer severe functional problems with even minor burn scarring. Foot burns heal slowly and are prone to infection, and facial burns may be disfiguring. It is difficult to apply dressings to the perineum, and the wound is easily irritated due to urine and fecal contact.
When the pharmacist is asked to help choose self-care products for burn treatment, pain and itch control may be attained with local anesthetics, counterirritants, and antipruritics. Since application of solid products may stimulate further pain, aerosols serve nicely, including such products as Americaine Aerosol (benzocaine), Dermoplast (benzocaine), and Itch-X (hydrocortisone).1 If the skin has been broken, it is also wise to apply an antibacterial to prevent infection in the injury.13,14 Due to the possibility of allergy and contact sensitization, neomycin should be avoided. Neomycin-free antibacterials include Polysporin (bacitracin zinc, polymyxin B sulfate) and hydrogen peroxide.
PATIENT INFORMATION
Thermal Burns and Other Causes
Exposure to a source of heat is the most common cause of burns. If the burn is a minor one, you can soak it in cool water for 15 to 20 minutes. You should continue soaking it until it is free of pain when in and out of the water. First aid for a minor sunburn consists of applying a topical nonprescription pain reliever.
Thermal burns and sunburns should only be self-treated if they are minor. If they are severe, you will need to visit a physician. Your pharmacist can help you determine whether the burn needs medical care. Generally, you will need to seek physician care for deep second-degree and third-degree burns.
If the burn was caused by electricity, you should remove the individual from the electrical source by using a nonconducting object such as a broomstick. While you are making sure the person is safe, have a bystander call 911.
Exposure to a dangerous acid or alkali can also cause skin damage that is referred to as a burn. For these chemical burns, remove any clothing containing the chemical and flush the skin for at least 15 minutes with large amounts of clean tap water before seeking emergency care.
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 type 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 in your decision as to 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 your 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. Protectants/lubricants include cocoa butter, glycerin, and petrolatum (Vaseline). You may apply any of these freely as often as needed. Aloe vera has no proven therapeutic value and should be avoided, since it may cause allergies.
You may also wish to deaden the pain and itching associated with the burn. Choose products with ingredients such as benzocaine, dyclonine, pramoxine, and benzyl alcohol. Aerosol sprays are convenient and allow you to place a product on the burn without having to rub it on and produce further pain. Examples include Itch-X Spray, Dermoplast Spray, and Americaine Aerosol.
If the skin was broken, you may wish to apply an antibacterial product to prevent infection. These products include Polysporin Ointment and hydrogen peroxide.
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. You should stop self-care and seek an appointment with a physician.
REFERENCES
1. Pray WS. Nonprescription Product Therapeutics. 2nd ed. Baltimore, MD: Lippincott Williams & Wilkins; 2006.
2. Burns. MedlinePlus Medical Encyclopedia.
www.nlm.nih.gov/medlineplus/
3. Burns. Mayo Clinic.
www.mayoclinic.com/health/
4. Choi M, Armstrong MB, Panthaki ZJ. Pediatric hand burns: thermal, electrical, chemical. J Craniofac Surg. 2009;20:1045-1048.
5. Chiang YC, Lin TS, Yeh MC. Povidone-iodine-related burn under the tourniquet of a child—a case report and literature review. J Plast Reconstructive Aesthetic Surg. 2011;64:412-415.
6. Chemical burns: first aid. Mayo Clinic.
www.mayoclinic.com/health/
7. Ribeiro NF, Heath CH, Kierath J, et al. Burn wounds infected by contaminated water: case reports, review of the literature and recommendations for treatment. Burns. 2010;36:9-22.
8. Chan HP, Maibach HI. Hair highlights and severe acute irritant dermatitis (“burn”) of the scalp. Cutaneous Ocular Tox. 2010;29:229-233.
9. Burns: first aid. Mayo Clinic.
www.mayoclinic.com/health/
10. Burns. MedlinePlus.
www.nlm.nih.gov/medlineplus/
11. First aid: burns. FamilyDoctor.org.
http://familydoctor.org/
12. Sharma VP, O’Boyle CP, Jeffery SL. Man or machine? The clinimetric properties of laser Doppler imaging in burn depth assessment. J Burn Care Res. 2011;32:143-149.
13. Dai T, Huang YY, Sharma SK, et al. Topical antimicrobials for burn wound infections. Recent Pat Antiinfect Drug Discov. 2010;5:124-151.
14. Ravat F, Le-Floch R, Vinsonneau C, et al. Antibiotics and the burn patient. Burns. 2011;37:16-26.
To comment on this article, contact rdavidson@uspharmacist.com.
