Abstract
Introduction
Superficial burns that affect the epidermis and upper dermis only are characterised by redness of the skin that blanches on pressure, pain, and hypersensitivity. The skin blisters within hours and usually heals with minimal scarring within 2 to 3 weeks if no infection is present. Most minor burns occur in the home, with less than 5% requiring hospital treatment.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical question: What are the effects of treatments for minor thermal burns? We searched: Medline, Embase, The Cochrane Library, and other important databases up to October 2008 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found eight systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review, we present information relating to the effectiveness and safety of the following interventions: alginate dressing; antibiotics; chlorhexidine-impregnated paraffin gauze dressing; foam dressing; hydrocolloid dressing; hydrogel dressing; paraffin gauze dressing; polyurethane film; silicone-coated nylon dressing; and silver sulfadiazine cream.
Key Points
Superficial burns that affect the epidermis and upper dermis only are characterised by redness of the skin that blanches on pressure, pain, and hypersensitivity. The skin blisters within hours and usually heals with minimal scarring within 2 to 3 weeks if no infection is present.
Most minor burns occur in the home, with less than 5% requiring hospital treatment.
Cooling the burn for 20 to 30 minutes with cold tap water within 3 hours of the injury reduces pain and wound oedema, but prolonged cooling or use of iced water may worsen tissue damage or cause hypothermia.
We don't know whether alginate dressings, antibiotics, chlorhexidine-impregnated paraffin gauze dressing, foam dressing, hydrocolloid dressing, hydrogel dressing, paraffin gauze dressing, polyurethane film, or silicone-coated nylon dressing are effective in treating minor burns.
Topical antibacterial substances, such as chlorhexidine, may be toxic to regenerating epithelial cells, and their use may delay healing in wounds that are not infected.
Silver sulfadiazine cream may prolong healing times and increase pain compared with other treatments.
About this condition
Definition
Burn depth is classified as erythema (first degree) involving the epidermis only, superficial partial thickness (second degree) involving the epidermis and upper dermis, deep partial thickness (second degree) involving the epidermis and dermis, and full thickness burns (third degree) involving the epidermis, dermis, and damage to appendages. This review deals with minor thermal burns — that is, superficial partial-thickness burns that do not involve the hands or face. Superficial partial-thickness burns are caused by exposure to heat sufficient to cause damage to the epidermis and papillary dermis of the skin. They are characterised by pain and hypersensitivity. The skin seems moist and pink or red, and is perfused, as demonstrated by blanching on pressure. This type of injury will blister within hours and heal within 2 to 3 weeks with minimal scarring if no infection is present. The severity of a superficial partial-thickness burn is usually judged by the percentage of total body surface area involved: less than 15% total body surface area for adults and 10% total body surface area for children.
Incidence/ Prevalence
The incidence of minor thermal burns is difficult to estimate. Generally, less than 5% of all burn injuries requiring treatment will necessitate admission to hospital. Worldwide estimates surrounding all thermal burn injuries suggest that about 2 million people are burned, up to 80,000 are hospitalised, and 6500 die of burn wounds every year.
Aetiology/ Risk factors
The pattern of injury varies among different age groups. Males aged 18 to 25 years seem more susceptible to injury owing to a variety of causes — mainly flame, electrical, and, to a lesser extent, chemicals. Many burn injuries in this age group are due to the inappropriate use of flammable agents, such as petrol. However, most burns occur in the home. Thermal burns, in particular scalds, are common among children as well as older adults. The kitchen is reported to be the most common place of injury for children, as is the bathroom for older people. Those with concomitant conditions or complicating factors such as motor or neurological impairment are at greater risk.
Prognosis
Superficial partial-thickness burns will heal spontaneously, with minimal hypertrophic scarring, within 2 to 3 weeks if the wound remains free of infection. The capacity to heal is also dependent on the health and age of the individual, with older people and those with concomitant medical conditions prone to delayed healing. Cooling the burn, as part of the initial emergency treatment, significantly reduces pain and wound oedema if started within 3 hours of injury. The optimal time to cool a wound may vary from 20 to 30 minutes, using tap water (at a temperature of 5–25°C). Use of iced water or prolonged periods of cooling can deepen tissue injury and induce hypothermia, and are best avoided. Cleaning solutions and dressings aim to prevent wound infection. The ideal dressing will establish an optimum microenvironment for wound healing. It will maintain the wound temperature and moisture level, permit respiration, allow epithelial migration, and exclude environmental bacteria.
Aims of intervention
To promote wound healing; to prevent infection, with minimal adverse effects and discomfort.
Outcomes
Healing: time to healing; quality of healing with regard to scarring, re-epithelialisation, repigmentation, and cosmetic results; prevention of wound infection; requirement for antibiotic treatment; number and frequency of dressing changes; quality of life during treatment regimen. Symptom severity: pain; ease of dressing application and removal. Investigator/participant preference and satisfaction. Adverse effects of treatment.
Methods
Clinical Evidence search and appraisal October 2008. The following databases were used to identify studies for this systematic review: Medline 1966 to October 2008, Embase 1980 to October 2008, and The Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Clinical Trials, 2008, Issue 4. Additional searches were carried out using these websites: NHS Centre for Reviews and Dissemination (CRD) — for Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment (HTA), and NICE. We also searched for retractions of studies included in the review. Abstracts of the studies retrieved from the initial search were assessed by an information specialist. Selected studies were then sent to the author for additional assessment, using pre-determined criteria to identify relevant studies. Study design criteria for inclusion in this review were: published systematic reviews and RCTs in any language, at least single blinded, and containing more than 20 individuals of whom more than 80% were followed up. There was no minimum length of follow-up required to include studies. We excluded all studies described as “open”, “open label”, or not blinded unless blinding was impossible. In addition, we use a regular surveillance protocol to capture harms alerts from organisations such as the FDA and the UK Medicines and Healthcare products Regulatory Agency (MHRA), which are added to the reviews as required. To aid readability of the numerical data in our reviews, we round many percentages to the nearest whole number. Readers should be aware of this when relating percentages to summary statistics such as relative risks (RRs) and odds ratios (ORs). We have performed a GRADE evaluation of the quality of evidence for interventions included in this review (see table). The categorisation of the quality of the evidence (high, moderate, low, or very low) reflects the quality of evidence available for our chosen outcomes in our defined populations of interest. These categorisations are not necessarily a reflection of the overall methodological quality of any individual study, because the Clinical Evidence population and outcome of choice may represent only a small subset of the total outcomes reported, and population included, in any individual trial. For further details of how we perform the GRADE evaluation and the scoring system we use, please see our website (www.clinicalevidence.com).
Table.
GRADE Evaluation of interventions for Burns (minor thermal).
| Important outcomes | Healing, Investigator/participant satisfaction , Symptom severity | ||||||||
| Studies (Participants) | Outcome | Comparison | Type of evidence | Quality | Consistency | Directness | Effect size | GRADE | Comment |
| What are the effects of treatments for minor thermal burns? | |||||||||
| 1 (34) | Healing | Chlorhexidine-impregnated paraffin gauze dressing versus hydrocolloid dressing plus silver sulfadiazine cream | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, weak methods (randomisation/allocation), and no statistical analysis between groups |
| 1 (34) | Healing | Hydrocolloid dressing versus chlorhexidine-impregnated paraffin gauze dressing | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, incomplete reporting of results, and weak methods (randomisation/allocation) |
| 1 (42) | Healing | Hydrocolloid dressing versus silver sulfadiazine cream | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, incomplete reporting of results, and weak methods (randomisation/allocation) |
| 1 (42) | Symptom severity | Hydrocolloid dressing versus silver sulfadiazine cream | 4 | –2 | 0 | –1 | 0 | Very low | Quality points deducted for sparse data and weak methods (randomisation/allocation). Directness point deducted for unclear outcome |
| 1 (42) | Investigator/participant satisfaction | Hydrocolloid dressing versus silver sulfadiazine cream | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, incomplete reporting of results, and weak methods (randomisation/allocation) |
| 1 (47) | Healing | Hydrogel dressing versus silver sulfadiazine cream | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, lack of blinding, and incomplete reporting of results |
| 1 (47) | Symptom severity | Hydrogel dressing versus silver sulfadiazine cream | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, lack of blinding, and incomplete reporting of results |
| 1 (55) | Healing | Polyurethane film versus paraffin gauze dressing | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 1 (55) | Symptom severity | Polyurethane film versus paraffin gauze dressing | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 1 (55) | Investigator/participant satisfaction | Polyurethane film versus paraffin gauze dressing | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 1 (51) | Healing | Polyurethane film versus chlorhexidine-impregnated paraffin gauze dressing | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, incomplete reporting of results, and weak methods (randomisation/allocation) |
| 1 (51) | Symptom severity | Polyurethane film versus chlorhexidine-impregnated paraffin gauze dressing | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, incomplete reporting of results, and weak methods (randomisation/allocation) |
| 2 (139) | Healing | Silicone-coated nylon dressing versus silver sulfadiazine | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and weak methods (randomisation/allocation) |
| 1 (63) | Symptom severity | Silicone-coated nylon dressing versus silver sulfadiazine | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and weak methods (randomisation/allocation) |
| 1 (32) | Healing | Silver sulfadiazine cream plus hydrocolloid dressing versus hydrocolloid dressing alone | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, incomplete reporting of results, and weak methods (randomisation/allocation) |
We initially allocate 4 points to evidence from RCTs, and 2 points to evidence from observational studies. To attain the final GRADE score for a given comparison, points are deducted or added from this initial score based on preset criteria relating to the categories of quality, directness, consistency, and effect size. Quality: based on issues affecting methodological rigour (e.g., incomplete reporting of results, quasi-randomisation, sparse data [<200 people in the analysis]). Consistency: based on similarity of results across studies. Directness: based on generalisability of population or outcomes. Effect size: based on magnitude of effect as measured by statistics such as relative risk, odds ratio, or hazard ratio.
Glossary
- Low-quality evidence
Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
- Polyurethane film dressing
such as Opsite or Tegaderm serves as a barrier to bacteria and water. The dressing can be left in place for several days. Film dressing is suitable for lightly exuding wounds and as secondary dressing because fluid from moderate to heavily exudating wounds may leak from this type of dressing, increasing the risk of wound contamination.
- Very low-quality evidence
Any estimate of effect is very uncertain.
Disclaimer
The information contained in this publication is intended for medical professionals. Categories presented in Clinical Evidence indicate a judgement about the strength of the evidence available to our contributors prior to publication and the relevant importance of benefit and harms. We rely on our contributors to confirm the accuracy of the information presented and to adhere to describe accepted practices. Readers should be aware that professionals in the field may have different opinions. Because of this and regular advances in medical research we strongly recommend that readers' independently verify specified treatments and drugs including manufacturers' guidance. Also, the categories do not indicate whether a particular treatment is generally appropriate or whether it is suitable for a particular individual. Ultimately it is the readers' responsibility to make their own professional judgements, so to appropriately advise and treat their patients. To the fullest extent permitted by law, BMJ Publishing Group Limited and its editors are not responsible for any losses, injury or damage caused to any person or property (including under contract, by negligence, products liability or otherwise) whether they be direct or indirect, special, incidental or consequential, resulting from the application of the information in this publication.
Contributor Information
Jason Wasiak, Victorian Adult Burns Service, The Alfred Hospital, Melbourne, Australia.
Dr Heather Cleland, Victorian Adult Burns Service, The Alfred Hospital, Melbourne, Australia.
References
- 1.Brigham PA, McLoughlin E. Burn incidence and medical care use in the United States: estimates, trends and data sources. J Burn Care Rehabil 1996;17:95–107. [DOI] [PubMed] [Google Scholar]
- 2.Haertsch PA. Burn injuries. Aust Doct. 2003;8:37–44. [Google Scholar]
- 3.Deitch EA, Wheelahan TM, Rose MP. Hypertrophic burns scars: analysis of variables. J Trauma 1983;3:895–898. [PubMed] [Google Scholar]
- 4.McCormick RA, La Hei ER, Martin HCO. First-aid management of minor burns in children: a prospective study of children presenting to the Children's Hospital at Westmead, Sydney. Med J Aust 2003;178:31–33. [DOI] [PubMed] [Google Scholar]
- 5.Hayward PG, Morrsion WA. Current concepts in wound dressings. Australian Prescriber 1996;19:11–13. [Google Scholar]
- 6.Wasiak J, Cleland H, Campbell F. Dressings for superficial and partial thickness burns. In: The Cochrane Library, Issue 4, 2008. Chichester, UK: John Wiley & Sons, Ltd. Search date 2008. 18843629 [Google Scholar]
- 7.Wise R, Hart T, Cars O, et al. Antimicrobial resistance is a major threat to public health. BMJ 1998;317:609–610. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Brown AP, Khan K, Sinclair S. Bacterial toxicosis/toxic shock syndrome as a contributor to morbidity in children with burn injuries. Burns 2003;29:733–738. [DOI] [PubMed] [Google Scholar]
- 9.Thomas SS, Lawrence, JC, Thomas A. Evaluation of hydrocolloids and topical medication in minor burns. J Wound Care 1995;4:218–220. [DOI] [PubMed] [Google Scholar]
- 10.Wright A, MacKechnie DW, Paskins JR. Management of partial thickness burns with Granuflex ‘E' dressings. Burns 1993;19:128–130. [DOI] [PubMed] [Google Scholar]
- 11.Phipps A, Lawrence JB. Comparison of hydrocolloid dressings and medicated tulle-gras in the treatment of outpatient burns. In: Ryan TJ editor(s). Beyond Occlusion: Wound Care Proceedings, Royal Society of Medicine Services International Congress and Symposium Series No. 136. London: RSM Services Ltd, 1988. [Google Scholar]
- 12.Wyatt D, McGowan DN, Najarian, MP. Comparison of a hydrocolloid dressing and silver sulfadiazine cream in the outpatient management of second-degree burns. J Trauma 1990;30:857–865. [DOI] [PubMed] [Google Scholar]
- 13.Homann H, Rosbach O, Moll W, et al. A liposome hydrogel with polyvinyl-pyrrolidone iodine in the local treatment of partial-thickness burn wounds. Ann Plast Surg 2007;59:423–427. [DOI] [PubMed] [Google Scholar]
- 14.Hauser J, Rossbach O, Langer S, et al. Local therapy of grade IIa burns: efficacy and tolerability of a new hydrosome wound gel for the local treatment of grade IIa burns as compared with silver sulfadiazine ointment. Unfallchirurg 2007;110:988–994. [DOI] [PubMed] [Google Scholar]
- 15.Chen J, Han CM, Lin XW, et al. Effect of silver nanoparticle dressing on second degree burn wound. Zhonghua Wai Ke Za Zhi 2006;44:50–52. [In Chinese] [PubMed] [Google Scholar]
- 16.Poulsen TD, Freund KG, Arendrup K, et al. Polyurethane film (Opsite) vs. impregnated gauze (Jelonet) in the treatment of outpatient burns: a prospective, randomized study. Burns 1991;17:59–61. [DOI] [PubMed] [Google Scholar]
- 17.Neal DE, Whalley PC, Flowers MW, et al. The effects of an adherent polyurethane film and conventional absorbent dressing in patients with small partial thickness burns. Br J Clin Pract 1981;35:254–257. [PubMed] [Google Scholar]
- 18.Bugmann PH, Taylor S, Gyger D, et al. A silicone-coated nylon dressing reduces healing time in burned paediatric patients in comparison with standard sulfadiazine treatment: a prospective randomized trial. Burns 1998;24:609–612. [DOI] [PubMed] [Google Scholar]
- 19.Gotschall CS, Morrison MI, Eichelberger MR. Prospective, randomized study of the efficacy of Mepitel on children with partial-thickness scalds. J Burn Care Rehabil 1998;19:279–283. [DOI] [PubMed] [Google Scholar]