The total area of the body affected by a burn is a critical factor in determining its severity and impact. Burn size is often estimated as a percentage of the total body surface area (TBSA). For adults, the “rule of nines” is a common method for this estimation:

• Head: 9%
• Front of Torso (Chest and Abdomen): 18%
• Back of Torso (Upper Back, Lower Back, and Buttocks): 18%
• Each Arm: 9%
• Each Leg: 18% (9% front, 9% back)
• Genital Area: 1%
• Palm of Hand (excluding fingers): Approximately 1%

Only second-degree and deeper burns are included when calculating the TBSA percentage for assessing severity. Although painful, first-degree burns do not compromise the skin’s integrity or its role in fluid and temperature regulation.

Significant fluid loss can occur with burns involving more than 15%-20% of the TBSA, potentially leading to shock if adequate intravenous fluids are not administered. The risk of mortality increases with the percentage of TBSA burned. While individuals with burns affecting less than 20% of their body generally have a good prognosis, those with burns exceeding 50% face a considerably higher risk of death, influenced by factors like age and pre-existing health conditions.

The Importance of Burn Location

The location of a burn can significantly impact its potential complications:

• Burns to the face, neck, or airway area carry a risk of inhalation injury and swelling that can obstruct breathing.
• Circumferential burns around the chest can restrict chest wall movement, impairing adequate respiration.
• Circumferential burns on limbs, fingers, or toes can compromise blood flow, potentially endangering the viability of the affected extremity.
• Burns in areas with skin creases, such as joints, the face, or the groin, require specialized care due to the risk of contractures (scarring that shortens and tightens the skin), which can limit range of motion.

Appearance of Burn Injuries

The appearance of a burn can change over time, sometimes becoming deeper than it initially appears:

• First-Degree Burns: Appear red, dry, and painful, blanching with pressure. They typically heal within a few days without scarring.
• Second-Degree Burns: Are red and moist, often blistered, and very painful, even to air currents. They blanch with pressure and usually heal within one to three weeks, though the skin color in the affected area may change permanently. Scarring is typically not a major issue unless complications arise.
• Third-Degree Burns: May be white, leathery, or charred, with a dry appearance. They do not blanch with pressure and are often less painful to light touch due to nerve damage, though deep pressure may still cause pain. Healing takes longer than three weeks and typically results in significant scarring.
• Fourth-Degree Burns: Appear waxy white, leathery gray, or charred black and feel dry. They do not blanch with pressure and are typically painless due to complete nerve destruction. These burns cannot heal without surgical intervention and result in severe scarring.

Treating Burn Injuries

Burn treatment varies depending on the severity and type:

• For Minor Burns (First-degree or small Second-degree):
  
  • Gently clean the burn with lukewarm water. Avoid using cold water, as this can cause hypothermia.
  • Do not apply butter or other home remedies.
  • Remove any jewelry or constricting items before swelling occurs.
  • Apply a thin layer of antibiotic ointment (such as Bacitracin or Neosporin) or a burn-specific cream like silver sulfadiazine if available and appropriate.
  • Cover the burn with a clean bandage.
  • Ensure tetanus immunization is up to date.
  • Seek medical attention if there is concern the burn is deeper or involves a significant area.
• For Major Burns (Large Second-degree or Third/Fourth-degree):
  
  • Prioritize safety by removing the individual from the burn source without endangering the rescuer.
  • Remove any burning materials from the person.
  • Call emergency services immediately (e.g., 911).
  • Keep the person warm and still. Cover the burned areas with a clean sheet if possible. Avoid using cold water.
  • Burns on the face, hands, or feet should always be considered serious and require medical evaluation.
• For Electrical Burns: Always seek medical evaluation due to the potential for significant internal damage.
• For Chemical Burns:
  
  • Remove the chemical from contact with the skin.
  • Identify the chemical involved.
  • Contact a poison control center or local emergency department for guidance.
  • Flush the affected area with copious amounts of water, as directed by poison control or medical professionals.
  • Seek immediate emergency care for chemical burns to the eyes or any chemical burn causing severe or extensive damage.

Prognosis and Complications

Minor burns generally heal without lasting issues, although they can be quite painful and may leave temporary pigmentation changes. Medical attention is necessary for larger or more severe burns, or if the affected person is an infant or elderly. Second-degree burns typically heal within a few weeks, with recovery time potentially extended by complications. Major burns require urgent medical intervention. Untreated burns, particularly deeper ones covering a large area, can lead to serious complications, including severe infections, dehydration, shock, and potentially death.

Burn Scar Formation

Scarring is a natural part of the body’s healing process following burns that cause significant tissue destruction. When skin cells are damaged, the body produces collagen to repair the wound. This can result in the formation of thickened, discolored areas known as scars. Scarring is less common in first-degree burns but typically occurs in second-degree and deeper burns where substantial tissue damage has taken place.

Different types of burn scars exist:

• Hypertrophic Scars: Raised and often reddish-purple, staying within the boundaries of the original burn wound.
• Contracture Scars: These scars tighten and shorten the skin, and potentially underlying muscles and tendons, restricting movement, especially if located near joints.
• Keloid Scars: Abnormal scar tissue growth that extends beyond the original wound margins, appearing as raised, shiny, often hairless bumps.

While pigmentation changes can occur with first-degree burns, significant scar tissue formation is generally seen with burns that penetrate deeper into the skin.

Preventing Burn Injuries and Scars

Many burn injuries are preventable through implementing safety measures:

• Lowering hot water heater temperature to a safe level (e.g., 120°F or 49°C).
• Using and reapplying sunscreen to prevent sunburn.
• Using caution in the kitchen, such as placing pots on back burners and turning handles inward.
• Ensuring electrical safety with grounded outlets and unplugging unused appliances.
• Installing and maintaining smoke detectors and having a fire extinguisher readily available.
• Having electrical wiring inspected periodically.

Appropriate and prompt care of first- and second-degree burns can help minimize significant scar formation. Preventing a scar from forming is the most effective approach, as treating established scars can be challenging. While preventing scarring from severe third- and fourth-degree burns is often difficult and usually requires specialized burn care and surgical interventions like skin grafting, proper initial wound care for less severe burns can aid in faster healing and potentially reduce scarring. This includes cooling the burn with cool water (avoiding ice), applying antibiotic ointment as recommended, and keeping the area covered with a clean dressing. For blisters, it is generally advised to let them break on their own and protect the area from sun exposure to reduce pigmentation changes.