Burns
In dermatology, a burn is acute structural damage to the skin caused by intense heat, corrosive chemicals, electric current or ionizing radiation. How much harm is done depends directly on the strength of the agent and how long the skin is exposed.
Once skin temperature rises above 44°C, normal cell function starts to break down, proteins denature and cells begin to die.
Jackson's Burn Wound Model
A burn is made up of three concentric zones, each with its own pathology:
- Zone of coagulation (center): the point of greatest heat, where proteins coagulate completely and the tissue undergoes irreversible cell death.
- Zone of stasis (surrounding area): blood flow drops sharply and small vessels become blocked by clots. This zone can go on to die if perfusion is not restored promptly in the first 24–48 hours.
- Zone of hyperemia (outer rim): cells are only mildly injured and vessels dilate in response; the tissue recovers fully within a few days unless it becomes infected.
Histopathology
- Superficial burns (first and second degree): plasma leakage separates the epidermis from the dermis, forming a fluid-filled space beneath the epidermis (a subepidermal blister). Keratinocyte nuclei shrink and condense (pyknosis) and the cytoplasm becomes strongly eosinophilic.
- Deep burns (third degree): the entire thickness of the epidermis and dermis dies (full-thickness necrosis). The skin appendages (sweat glands, hair follicles, sebaceous glands) are completely destroyed, so the skin can no longer regrow from within; the wound either needs a skin graft or heals with dense scarring.
Burn care in dermatology does not end with emergency wound treatment. It continues through the extracellular matrix (ECM) remodeling phase, with the aim of controlling hypertrophic scars and keloids, the biggest challenge in restorative aesthetic dermatology.
Burn Classification and Estimating Burn Size
Classification by Depth
- First degree (superficial or epidermal burn): damage to the keratinocyte and basal layers of the epidermis. The skin is bright red, dry and very painful, with no blisters. It heals on its own in 3–7 days as the damaged layer peels away, leaving no scar.
- Second degree (partial-thickness burn):
- Superficial second degree: damage extends into the papillary dermis. Tense blisters filled with clear fluid form over a moist pink wound bed that is extremely sensitive to pain. Heals on its own in 1–2 weeks.
- Deep second degree: damage reaches the reticular dermis. The wound bed is pale white or mottled light pink, with reduced pain sensation. Healing takes longer (more than 3 weeks) and leaves fibrotic, hypertrophic scars.
- Third and fourth degree (full-thickness or deep burn): the entire epidermis and dermis are destroyed. The wound is opaque white, ash gray or charred black (eschar). There is no pain at all because the nerve endings have been destroyed. Surgical skin grafting is required.
Estimating Burn Size (Rule of Nines)
Used to quickly estimate the percentage of body surface area burned (% BSA) in adults:
- Head and neck: 9% (4.5% front, 4.5% back).
- Each arm: 9% (4.5% front, 4.5% back).
- Front of the trunk: 18%.
- Back of the trunk: 18%.
- Each leg: 18% (9% front, 9% back).
- Genitals / perineum: 1%.
Emergency Care, Resuscitation and Recovery Treatment at Haute-Derma
At Haute-Derma, acute burns and burn scars are managed with a multimodal emergency and skin regeneration program (the Haute-Derma Burn Recovery Protocol):
Immediate First Aid at the Scene
- Cool it right away: immediately immerse the burn in, or run it under, clean water at 15–20°C for at least 20 minutes. Cool water brings down the temperature deep in the tissue and stops necrosis from spreading into Jackson's zone of stasis.
- Things you must never do: do NOT apply toothpaste, python fat, medicated balm oil, fish sauce or leaves to a burn (they cause infection, including tetanus, and seal in heat); do NOT put ice directly on the skin (it adds a cold injury on top of the burn); do NOT pop large blisters yourself without sterile technique.
- Protect the wound: cover it loosely with moist sterile gauze or a clean lint-free cloth, and go straight to a specialist medical facility if the burn covers more than 10% of the body or involves the face, hands, feet or genitals.
Fluid Resuscitation and Wound Care (Acute Phase)
- Parkland formula: used for burns over 15–20% BSA. The total volume of lactated Ringer's solution for the first 24 hours is: fluid volume (ml) = 4 ml × body weight (kg) × burned area (% BSA). (Note: give half of the total in the first 8 hours from the time of the burn and the remaining half over the next 16 hours.)
- Local wound care: the wound is cleaned with a mild antiseptic (chlorhexidine gluconate 0.05%), then covered with silver sulfadiazine 1% cream or a biosynthetic dressing to protect it and prevent water loss through the damaged skin.
Early Scar Treatment and Recovery at Haute-Derma (Chronic Phase)
- Pressure garments and silicone: medical-grade silicone gel sheets combined with high-pressure garments (24–30 mmHg) are started as soon as the wound has fully re-epithelialized, to curb excessive fibroblast proliferation.
- Intralesional corticosteroid injections: triamcinolone acetonide (10–40 mg/ml) is injected in small amounts directly into newly forming hypertrophic scars every 4–6 weeks to flatten and soften the hard fibrous tissue.
- Fractional CO2 and Pico Laser Technology:
- Fractional CO2 laser (10,600 nm): creates columns of micro-thermal injury deep in the scarred dermis, prompting the disorganized bundles of type I and III collagen to realign and smoothing raised or depressed scar surfaces.
- LED light therapy (830 nm): stimulates fibroblasts to produce ATP, reduces inflammation and speeds up recovery of the small blood vessels in the injured skin.
