Illustrated: Commonly presented burns

Contributed by Dr Jean Watkins, a retired GP in Hampshire

Sunburn – epidermal (superficial partial thickness) burn
In spite of the repeated warnings of the risk of malignant melanoma it is still common for patients to present in the surgery with sunburn. This woman had fallen asleep on the beach and was subsequently complaining of painful burns.

On examination, the skin was grossly inflamed, painful, sore and there was brisk capillary refill after pressure on the skin, which suggested a superficial, partial thickness burn involving the epidermis only.

She was offered analgesics to ease the pain and advised that a cool shower or bath and the application of emollients might help to ease her symptoms. She could expect resolution within a week, but warned that there might well be some peeling of the skin later.

Sunburn – superficial dermal burn

This man had forgotten to use sunscreen on his feet. After a day out walking in open sandals, he was left with this very painful area of inflamed, weeping skin with small blisters. Once again, there was brisk capillary refill suggesting that the damage affected only the upper part of the dermis.

The area was cleansed with a water-based disinfectant, and any remaining blisters left intact, covered with a non-adherent dressing (paraffin gauze, silicone coated nylon dressing, polyurethane film or hydrocolloid dressing) and protected by a loosely fitting covering bandage.

He was warned that it might take two to three weeks to heal, that he might be left with some slight scarring and to be aware of secondary infection. 

Deep dermal, partial thickness burns

Deep dermal, partial thickness burns involve deeper parts of the dermis. They may appear either moist or dry, tend to be red and blotchy and may be associated with pain, however, some cases are painless. Blistering can occur and some of these blisters may be large.

In general, it is better to leave the blisters intact as this reduces the possibility of secondary infection, but if the blisters are large, or in awkward positions, such as the perineum or in flexures, they may be aspirated. Healing of a deeper burn such as this may take longer, sometimes as long as two months.  

Infected burn  

This girl had sustained a scald when she spilt boiling water on her foot. The area affected was small and she had not bothered to cover it, but three days later, she attended the surgery with increasing pain, swelling, inflammation and offensive exudate emanating from the wound. 

A swab was taken for culture and sensitivities and the wound was then cleansed with a weak saline solution. She was prescribed a seven-day course of flucloxacillin and recommended to take paracetamol or ibuprofen to ease the pain.

As she was fully covered by her previous tetanus immunisations and had not come into contact with soil or garden waste, a further booster seemed unnecessary. Routine prophylactic antibiotics are not recommended in cases such as these. 

Extensive burns of the arms and trunk

Many of the burns that we see in the surgery can easily be treated on the spot, and care continued at home or with follow up in the clinic. However, more serious burns will require admission to hospital. Apart from checking on the patient’s general condition, one important factor in making this assessment is the extent of the burn.

Referral is recommended in those adults with burns on more than 10% of the body surface and in children with more than 5% burns. The ‘rule of nines’ is a simple guide when making the calculations. In adults, the head and upper limb are each considered to be 9%, a lower limb, front of chest and back of trunk 18% each, and the head 1%. For children it is different, under one year – the head is 18% and a leg is 14%. This changes as the child grows.

This man made the great mistake of pouring petrol on a bonfire. With both arms and the whole of the front of his trunk involved, he needed hospital care.

Non-accidental injury

When taking a history it is important to understand how the burn or scald occurred and try to exclude the possibility that the event was not accidental. This child, with a bad burn on her hand, was said to have grabbed hold of the hot iron while her mother was out of the room.

She was then brought to the surgery four days later by her grandmother rather than her mother. It was therefore felt that it was necessary to involve social services. 

There are said to be certain criteria that should alert us to the possibility of non-accidental injury: if the injury does not fit the story or findings on examination; where a child cannot get around on its own and delay in seeking help. Some injuries would seem to be more likely to have been inflicted by others, for example, scalds on the buttocks, perineum and lower limb, especially if symmetrical and in a glove and stocking distribution or where there may be signs of restraint on the arms or other signs of physical abuse.

Scarred for life

This 40-year-old woman suffered burns when her nightdress caught fire when she was five years old. With serious burns to her chest and arm, she was rushed into hospital where for 10 weeks she suffered repeated painful dressings and skin grafts of her wounds.

Still, she cannot fully extend her right arm where movement is limited by the scar. Apart from the embarrassment of her disfigured breast, it also caused her problems when she wished to breast feed her children.

Smoke inhalation

Smoke inhalation can lead to respiratory distress with bronchospasm, pulmonary and laryngeal oedema. This may be obvious immediately but sometimes develops 24 hours later. Consequently, it is important to understand the circumstances of the burn and/or any fire.

As in the case of this man who received these facial burns in a chip pan fire, an inhalation injury is a possibility. Although apparently well at the time and with relatively superficial burns restricted to the face, he was referred to the hospital.

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