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How do you manage second degree burns? I mean you specifically. Do you have a favorite antibiotic ointment, a favorite dressing? Are you a blister popper, a blister leaver? Do you think silver sulfadiazine is the greatest thing ever or simply horrible? Burn surgeon Chuck Yowler gives his answers to these controversies (and more!)
Second Degree Burns
Jessica Mason MD and Chuck Yowler MD
Take Home Points
Total body surface area of the burn is estimated using the amount of second or third degree burns.
The management of third degree burns is Silvadene (silver sulfadiazine) and transfer to a burn center for definitive care.
Silvadene should not be used in second degree burns as it delays wound healing.
Diabetic patients with burns to the feet should follow-up every day for 3-4 days to make sure there is no infection
First degree burns have erythema and pain but the skin is intact. These burns just need lotion and pain medication. These are like a bad sunburn.
Second degree burns have loss of skin with either raw skin or blisters.
Third degree burns are white or black hard wounds with no capillary refill. These are insensate.
Second degree burns should be pink. Bright red burns are third degree burns; the heat causes rupture of the red blood cells in the capillaries and distributes hemoglobin through the tissue. These are insensate.
Second degree (partial thickness) burns are divided into two types; superficial partial thickness and deep partial thickness burns.
Superficial partial thickness burns involve the most superficial layers of the dermis. They are red, blistered and usually heal without much scarring because the deeper structures of the dermis, including the hair follicles which contain stem cells, are spared.This can create new epidermis.
Deep partial thickness burns involve the deeper layer of the dermis. They are blistered and pale to yellow. The hair follicles and glands are damaged. Scarring is worse and some may require grafting.
This distinction is most important to the burn surgeon because it has implications for healing and grafting. Burns that heal after 21 days uniformly look better with a skin graft. A deep partial thickness burn will require grafting. An intermediate partial thickness burn will scar. A superficial second degree burn will heal without scarring.
How do you estimate the total body surface area of a burn?
You use the area of second degree burn. Red doesn’t count. A patient who presents with sunburn (first degree burn) over 80% of their body has no burn. All of the formulas are for second or third degree burns. Overestimation of burn size is a problem.
The rule of 9s. 9% for the head and each arm. 18% for each leg. 18% for the front and 18% for the back of the torso.
Another way to estimate is to take the size of the palm of hand including the fingers as 1%. This doesn’t work as well in morbidly obese patients.
First degree burns do not require any intervention. These will heal within a week.
The management of third degree burns is Silvadene (silver sulfadiazine) and transfer to a burn center for definitive care. Silver sulfadiazine has a good spectrum of antibiotic killing and minimal side effects. This is usually the antibiotic of choice in third degree burns. However, it inhibits keratinocyte replication which is problematic for second degree burns as it inhibits healing. Silver sulfadiazine has clearly been shown to inhibit healing and increase scarring of second degree burns.
The management of second degree burns has changed in the last 10-15 years.
Should you pop blisters? Blister fluid has the highest concentration of inflammatory cytokines of any tissue in the body. However, it also has the highest concentration of growth factors which are good for you. Management of blisters is controversial and burn surgeons do not agree on one approach.
A reasonable approach is to debride thin walled blisters as these are likely to rupture at home in an uncontrolled setting and dress them.
You can aspirate the fluid from thick-walled blisters. This will provide a natural dressing and then apply dressing with bacitracin and non-adherent dressing like Xeroform. These dressings need to be changed daily.
How do you debride the blister? Take a pair of sterile scissors, puncture the blister and trim the skin. Clean the wound with a mild antibiotic soap product like chlorhexidine. There are multiple options. Choose an ointment and dressing that makes sense for your patient’s circumstances.
Yowler uses a silver impregnated dressing for intermediate burns. These are antibiotics and don’t inhibit wound healing. These usually require changing only 3-7 days.
A Cochrane review compared hydrocolloid, biosynthetics and silicone coated dressings to silver sulfadiazine. Each dressing outperformed silver sulfadiazine. They found the burns with hydrogel dressings healed more quickly than those with usual care.
Wasiak, J et al. Dressings for superficial and partial thickness burns. Cochrane Database Syst Rev. 2013 Mar 28;3:CD002106. PMID: 23543513
There are multiple options for dressing burns.
Biosynthetics such as Biobrane. This is a silicone membrane with a nylon mesh.
Alginates are carbohydrates derived from algae and good at absorbing exudates.
Hydrogels are gels with a liquid component that is mostly water.
Foam pads like Optifoam serve as barriers and help protect the wound.
Hydrocolloid dressings such as DuoDERM form a gel in the presence of moisture and help absorb exudates.
Burns at risk for MRSA. Yowling uses mupirocin for facial burns around the nose such a flash burn due to home oxygen. Bacitracin and neosporin do not treat MRSA well.
Which patients are at risk for a wound infection? Diabetics, especially with burns to the feet which have a rate of infection of 15%. Diabetic foot infections may be limb threatening. Yowling recommends diabetic patients with burns to the feet follow-up every day for 3-4 days to make sure there is no infection. If the patient is unable to return, they are admitted and monitored for 3-4 days.
What should you do for weight bearing areas? They occasionally put hydrocolloid dressings such as DuoDERM on a weight bearing area. They don’t do this for a few days as the dressing prevents visualization of the wound to rule out infection.
There is no role for oral antibiotics in the treatment of second degree burns. There is no decrease in infection in burns treated with cephalexin versus no antibiotics. There is no antibiotic on the surface of your skin when you take an oral antibiotic. Burns need topical antibiotics on the surface. If the patient develops cellulitis where infection enters the tissue, systemic antibiotics are indicated.
Tyler S. - April 14, 2016 9:49 PM
So mentioned the not applying Silvadene to 2nd degree burns to my attending the other day, and he acted like this was standard practice for all burns centers. How controversial is this practice exactly?
Jess Mason - April 18, 2016 11:18 AM
Takes time for the culture to change. The Cochrane Review was published in 2008: Wasiak, et al. Dressings for superficial and partial thickness burns. Cochrane Database Syst Rev.2008Oct;4