A general overview of burn care

Abstract

The majority of burn victims do not need to be treated in a burn centre. Adequate care can be given by non specialised medical personnel, provided that proper guidelines are followed. The article outlines and reviews these guidelines.

Introduction

Although no reliable statistics are available about burn patients outside burn centres, it is likely that burns are among the most common types of trauma occurring in any society. Most burns are relatively small and consequently not life threatening, but large burns, even partial thickness ones, still pose a major threat when not treated properly.

Even smaller burns may cause major morbidity, because the injury is very painful and may lead to disfiguring scar formatting, primarily hypertrophic scarring (1).

This article provides a basic overview of burn care, particularly aimed at the non specialised hospital and the non specialised health care worker.

Types of burns

Burns (thermal) injuries can be categorised as follows:

• • Scalds: the injury is caused by contact with a hot fluid (i.e. hot tea, soup and coffee). In most cases, these injuries, when cooled quickly, are partial thickness.
• • Flame: the injury is caused by exposure to flames (i.e. a house fire or a barbecue explosion with clothing catching fire). These burns are usually full thickness.
• • Flash: the injury is caused by very short exposure to a burning gas or vapour (i.e. a barbecue explosion without clothing catching fire). The injury is usually partial thickness.
• • A contact burn: the injury is caused by contact with a hot surface. In many cases, these burns are not deep. However, particularly the combination of pressure and prolonged exposure to the heat source may lead to major injuries, as is the case in patients who, after a seizure, remain in contact with a hot surface for a prolonged period (2, 3). Similarly, burns caused by contact with molten metals, hot coals or other high‐temperature agents are usually very deep.
• • Electrical burns are, in fact, thermal injuries. This type of burn is caused by contact with or strike through of an electrical current: the electricity is converted to heat which causes coagulation and cell walls to explode. The amount of heat is in direct proportion to the amperage and electrical resistance of the tissues through which the electricity passes (4) and may lead to extensive and deep tissue necrosis. This, in turn, may lead to acidosis or myoglobinuria, which are life‐threatening complications. Thus, early exploratory surgery is necessary. Sometimes, the extent of the injury may not be immediately apparent, particularly when most of the damage done is on the subcutaneous or deeper levels.
• • Radiation: the injury is caused by exposure to heat radiation. The typical example of this type of burn is the sun burn. The injury is usually first degree.

Other types or injuries are commonly treated in burn centres but have a different aetiology:

• • Radiation burns as caused by radiotherapy are, in the opinion of the author, not real burns but ulcers, as this type of injury is not caused by thermal energy and will react differently to ‘standard’ therapy because of the radiation damage to the underlying tissues.
• • Chemical burns: as with therapeutic radiation, the mechanism of injury is different, but, again, because of the skin injury and possible consequence of the agent being absorbed through the skin, patients with chemical injuries usually end up in a burn centre (5).
• • Frostbite: when occurring over large surfaces, major tissue damage may be the result, requiring care similar to that provided to burn patient (6). Frostbite areas may very well need skin grafting.
• • Dermatological diseases such as Stevens Johnson syndrome, epidermolysis bullosa and toxic epidermal necrolysis 7, 8, 9, 10, 11): the results of these diseases may be major skin loss, thus leading to a level of morbidity that is similar to that of patients with major burns.
• • Other skin diseases accompanied by major skin loss, such as necrotising fasciitis (12, 13), and unusual infections such as phaeohyphomycosis (14).

This article primarily will discuss the treatment of true thermal injuries.

Depth of burns

The depth of a burn is very important as it determines how (surgically or not) the lesions should be treated.

The depth classification is related to the anatomy of the skin. The upper layer, the epidermis, is separated from the dermis, the underlying layer, by the basal membrane. The dermis contains epidermal structures such as the hair follicles, the sweat glands and sebaceous glands. If some of these structures are still intact, the epidermis can, in principle, heal spontaneously ‘from its deep roots’. If the epidermis and dermis are completely destroyed, as is the case in a full thickness lesion, reepithelialisation can only occur from the wound edges. This type of healing will take considerably longer, and in large burns, it will not be successful.

The thickness of the skin varies over the body: in very thin skin (the eyelids and the dorsum of the hand), a given heat insult will result in more damage than in very thick skin (i.e. the lower areas of the back). Consequently, a burn of the dorsum of the hand becomes deep more quickly than a burn of the lower back.

First degree

The typical first‐degree burn is the sun burn. The skin is painful, but there is no breach of the epidermis. The skin looks red and dry and there are no blisters.

Superficial partial thickness (superficial second degree)

In this type of burn, the epidermis is destroyed, thus exposing the underlying more superficial parts of the dermis. Blisters may or may not occur. The skin (underneath the blisters) is moist, pink in colour and hypersensitive to the touch (Figure 1). Blanching with pressure is positive, and capillary refill is virtually immediate.

Figure 1.

Typical partial thickness burn.

Deep partial thickness (deep second degree)

Here, the superficial parts of the dermis also have been destroyed, thus exposing the deep dermis. The exact depth of this type of burn may be very difficult to determine, as it may mimic a superficial one (with pain, pink surface, etc.), but it may also look like a full thickness one (see below). Capillary refill is slow or may not occur at all.

Full thickness burns (Third degree)

In this type of burn, the entire epidermis and dermis are destroyed. Initially, these burns are not or hardly painful (the nerve endings, residing in the dermis, have been destroyed as well). The aspect depends on the mode of injury and may be anywhere from white (a deep scald) to dark grey or black (a flame burn). The wound surface is usually dry and leather like to the touch (Figure 2).

Figure 2.

Typical full thickness burn.

Fourth‐degree burns

In fourth‐degree burns, the entire skin is destroyed, and substantial thermal damage also has been done to subcutaneous and deeper tissues (i.e. muscle).

Depth diagnosis

Establishing a correct depth diagnosis is largely based on the patient history (e.g., having been in a car fire virtually always results in a full thickness burn) as well as on judging the physical aspects of the burn. The pin prick tests may be helpful to determine the pain level: the burn is very gently touched with the sharp tip of a needle, and the patient is asked about the level of pain that is experienced. The level of blanching of the skin may also help establishing a proper depth diagnosis.

Dyes have been used in the past, particularly in experimental burns, in an attempt to distinguish between dead and vital tissues, but are not used in the clinical situation. Fluorescein has been tested quite extensively (15), based on the same principles but, again, is not used clinically. Ultrasound has been used as well but was shown not to be better than clinical judgement with respect to determining burn depth (16).

Laser Doppler Flowmetry seems to be promising. In clinical research, the technique was proven to be reliable (17, 18). Recently, devices have become available that make the technique practical in the day‐to‐day setting, making accurate and rapid diagnoses over large surfaces possible within a short time frame 18, 19, 20, 21).

Physiology of a burn wound

Burns are dynamic wounds which means that overtime they may change, particularly with respect to their depth: this phenomenon is known as conversion or secondary deepening 22, 23, 24). Burns that were initially diagnosed as superficial partial thickness may actually turn out to be (or have become) deeper after a few days. While the physiological mechanisms of conversion are beyond the scope of this article, it is important to recognise that desiccation of the wound bed, as well as infection, may contribute to or lead to wound conversion. Consequently, the dressing choice in partial thickness burns plays an important role in the prevention of conversion (25).

However, in spite of the use of proper dressings and techniques, some burns may convert anyway. It also has been recognised that even experienced burn physicians and burn nurses sometimes misjudge the initial depth of a burn.

Size of the burn, inhalation injury and burn disease

Morbidity and mortality in burn care is largely defined by the size of the burn, the depth and whether or not an inhalation injury and/or other concomitant or pre‐existing diseases exist (26) (Table 1). Even superficial but very large burns, particularly in elderly and young children, are still associated with a high level of morbidity and mortality.

Table 1.

Severity of burns

Minor burn

<15% TBSA in adults

<10% TBSA in children or elderly

<2% TBSA full thickness in children or adults without cosmetic or functional at risk areas

Moderate burn

15–25% TBSA in adults, <10% full thickness

10–20% TBSA partial thickness in children

<10 years and adults >40 years with <10% full thickness TBSA

<10% TBSA full thickness in children or adults without cosmetic or functional at risk areas

Major Burn

>25% TBSA

>20% TBSA in children <10 years and adults >40 years

>10% TBSA full thickness burns

All burns involving eyes, ears, face, hand, feet and/or perineum that are likely to result in functional or cosmetic impairment

All high‐voltage electrical burns

All burn injuries complicated by major other trauma and/or inhalation injury

All poor‐risk patients with a burn injury

TBSA, total body surface area.

Burn size is expressed as a percentage of the total body surface area (TBSA) and may be determined by the rule of nines (27): the body is divided in areas of nine or multiples of nine percent. The head and arms each count for nine percent, each side of the trunk and each leg count for 18 percent, and the remaining one percent is reserved for the genitalia and the perineum (Figure 3).

Figure 3.

Rule of nines.

For children, these percentages are different: for example, in a very young child the head counts for 18 percent. Burn centres use much more specific charts for determining the exact size of a burn.

The amount of necrotic tissue, heat and protein loss is directly related to the size of the burn injury and will cause major systemic problems in large burns. Because of these secondary effects of the skin injury, a large burn is much more than just a skin injury: the systemic effects cause the ‘burn disease’ which is associated with multiorgan responses.

The immediate threat of a larger burn is shock, due to a major change in capillary permeability which is associated with massive fluid transport out of the circulation into the interstitium.

Longer term complications are the risk of sepsis and organ system responses to shock and to the ‘burn toxins’ (28, 29) that are released from the coagulation necrosis of the skin.

A specific, very serious complication which quite often accompanies flame burns is inhalation injury, damage to the tracheal and pulmonary system caused by inhaling hot and/or toxic gasses and fumes (30). Often, this condition needs artificial ventilation. It is still associated with a high level of morbidity and mortality (31, 32).

Better management of these complications, in combination with better topical therapies and more aggressive surgical approaches, has led to a significantly lower mortality over the last decades, and, nowadays, survival of patients with full thickness burns of more that 95% TBSA is reported in the literature (33, 34).

First aid and guidelines for referral

Guidelines for referral are fairly straightforward (Table 2).

Table 2.

Indications for referral to a burn centre

Patients with:

Partial thickness burns greater than 10% TBSA.

Full thickness burns

Burns that involve the face, hands, feet, genitalia, perineum and/or major joints

Chemical injuries

Electrical burn (including lightning injuries)

Any burn with concomitant trauma, where burn injury poses the greatest (acute) risk

Inhalation injuries

Pre‐existing medical conditions that could complicate management, prolong recovery or affect mortality

Furthermore:

The non presence of a hospital with qualified personnel and/or equipment for the care of critically burnt children.

With respect to simple measures (i.e. cooling and cleaning of the wound, IV administration of fluids), initial care essentially is identical and independent of whether or not a patient is referred.

• • Dissipating the heat is the first objective as tissue temperatures above 45°C continue to cause local injury (35). Cooling with running tap water for 10 minutes is essential as this removes as much heat as possible, helps reducing the initial pain 36, 37, 38) and decreases oedema in the wound (39). Particularly in young children, the risk of under cooling, with associated dangerous drops in core temperature exists: thus, burn patients should not be emerged in a bath with ice cold water.
• • Rings on fingers and toes have to be removed: these will serve as a tourniquet when oedema starts to occur.
• • Wounds may be gently cleaned with a bland soap. Chlorhexidine gluconate soap is preferred by some because of its activity against regular skin flora (40).
• • Tar and asphalt burns should be cooled first. The causing agents will stick to the skin: physically peeling these materials off may do further harm to the skin and the wound. Thus, it is better to use a solvent (41).
• • Many chemical lesions may benefit from rinsing with water as well as this at least dilutes the agent. However, in many cases, more specific measures are necessary 42, 43, 44, 45, 46, 47, 48). Therefore, it is always important to identify the chemical agent that caused the injury. Neutralising an alkaline burn with acid and vice‐versa should not be done: proper titration is impossible and the chemical reaction is exothermic, thus producing heat and, potentially, additional injury.
• • Prior to transportation, clothing may be removed, but this has to be done carefully as it may be stuck to the wound. A neutral dressing may be used to cover the burnt areas. Silver sulphadiazine should not be used if the patient is referred, as painful removal of the cream upon arrival in the burn centre will have to take place to assess wound aspect and size.
• • In larger burns, administration of IV fluids may be indicated prior to transporting the patient to a burn centre, if transportation is expected to take longer than 60 minutes. Ringers lactate should be infused at 2–4 ml/kg/percentage TBSA (49). IV lines should be introduced into larger veins (central lines are preferable) and, if possible, should not penetrate through burnt skin.
• • Narcotics may be used as pain medication but may only be given intravenously: other ways of administration should be avoided as the pattern of uptake is unpredictable.
• • If an inhalation injury is suspected, 100% humidified oxygen should be provided during transportation. However, given the possible acute onset of oedema, it is wise to consult with the burn centre to which the patient will be transported about possible intubation prior to putting the patient in the ambulance or helicopter.
• • Similarly, guidelines from a burn centre are advisable when one is considering escharotomies (50, 51): these are release excisions that may need to be made in patients with circumferential deep burns that may restrict respiratory excursion of the chest, circulation into the limbs and/or post‐burn intraabdominal hypertension (52).

Before transporting a patient to a burn centre, it is, in fact, always wise to call the centre about general and specific measures they would like to be taken before the patient is sent off.

Principles of wound management in burn care

Management of the burn wounds depends largely on the depth of the burn but should fulfil the following objectives: reduction of pain, prevention of infection, desiccation and conversion, rapid healing, and, for the long term, minimisation of the change of scarring problems, particularly hypertrophic scarring and contractures.

First‐degree burns

These burns do not require any dressings. A soothing, moisturising cream in combination with an anti‐inflammatory pain killer usually provides sufficient patient comfort.

Superficial partial thickness burns

These lesions potentially heal on their own within approximately 2 weeks, without the necessity of skin grafting and without significant scarring. An appropriate dressing should be used, particularly to reduce pain and to help prevent infection. It needs to be realised that superficial partial thickness may convert and becomes deeper (23, 24). Thus, even when the initial diagnosis established a superficial burn, healing times longer than 2 weeks are a reason to check for conversion: virtually always secondary tangential excision (see below) will be necessary.

Some advocate the use of collagenase to remove the thin layer of necrosis that exists in partial thickness burns, although this is not standard practice in most burn centres (53, 54).

Blister formation is very common in patients with superficial partial thickness burns. The literature is contradictory with respect to whether or not blister should be removed. Some state that the blister roof acts as a biological occlusive dressing and that blister fluid is beneficial to wound healing and has antimicrobial properties. Other research indicates the opposite, particularly with respect to the fluid being detrimental to fibroblasts (22, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65).

With the availability of synthetic occlusive dressings and realising that large blisters will probably break anyway, an option for small blister would be to carefully evacuate the fluid with a syringe after the blister roof has been painted with povidone iodine or chlorhexidine, and, after evacuation, to support the blister with a polyurethane film or thin hydrocolloid dressing. For large blisters that will probably break anyway, the blister and blister fluid may be removed and replaced with a synthetic occlusive or moisture retentive dressings.

Deep partial thickness burns

These wounds may heal spontaneously as well but, because fewer epithelial remnants are left in the wound, will take more time than superficial partial thickness burns. In fact, many deep partial thickness burns will take more than 2–3 weeks and consequently will result in significant scarring.

It is therefore that many burn centres are more aggressive with these types of burns and perform tangential excision 66, 67, 68). With this technique, using a specially designed dermatome, thin layers of necrosis are excised until a viable wound bed (as proven by punctate bleeding) is reached. Depending on the depth of the wound bed, subsequent grafting (for the deeper burns) may be performed, but the more superficial burns may be treated with a dressing: different centres take different approaches here.

When the depth of a burn is difficult to determine, tangential excision also is used as a diagnostic tool: again, the depth of the burn is judged from the wound bed left after excision.

Mixed partial thickness burns

In this type of burn, superficial and deeper areas cannot be easily distinguished or are confluent with each other in a mosaic‐like fashion. Again, tangential excision is used as a diagnostic tool, and deeper excised areas may be grafted while the superficial ones are left to heal spontaneously, with the help of an appropriate dressing.

Timing of the procedure depends on the burn centre but most will perform tangential excision within the first few days after the injury.

Full thickness burns

The preferential treatment for full thickness burns is excision and grafting, unless the lesions are so small that they can be expected to heal spontaneously within a few weeks. Enzymes that may replace surgical excision are being tested at the moment (69, 70) but are not the standard treatment at this moment.

Spontaneous desloughing will occur but will take considerable time and the wound may infect in the mean time, with sepsis as a possible consequence. If spontaneous debridement does occur, the resulting wound bed will certainly be contaminated and it is usually of poor quality: reepithelialisation may start but will not succeed over large, exposed surfaces. Contraction will also occur and will result in contractures: the edges of the wound will be drawn towards each other as a consequence of cellular changes in the wound bed as well as changes in the extracellular matrix. If this happens over a joint, flexing of the joint will occur, and the rigidity of the wound bed and its skin will prevent extension of the joint.

The lack of spontaneous healing and the scarring problems that result are the main reasons why excision is, in fact, the only real option for the treatment of full thickness burns, and it needs to occur as soon as possible (66, 71, 72). Early excision has been shown to reduce morbidity and mortality significantly (73).

Excision will result in an open‐wound bed that needs to be covered as soon as possible. Preferentially, this needs to be done with autografts. Full sheet autografting offers the best results but, in major burns, is usually only reserved for cosmetically and functionally important areas such as the face, the neck and the hands, when not enough donor sites are available to cover all excised wounds with full sheets.

When large areas have been excised, alternative options are available. Among them, meshing the grafts is a good option. Different techniques are available, but they all use small incisions in the graft so that it can be expanded 74, 75, 76, 77, 78, 79, 80): ratios of expansion depend on equipment used, personal preference of the surgeon and, again, the total amount of grafts available. Thorough fixation of the graft is necessary and can be done with staples or sutures, different types of synthetic glue (81), fibrin glue (82), specially designed fixation materials 83, 84, 85) and techniques (86). More recently, the use of a vacuum‐creating wound care device (87) has been advocated by some.

Cultured epithelium may also be used to cover excised areas. As soon as possible, biopsies are taken from undamaged skin of the burn victim. The different cell layers of the biopsy are separated and keratinocytes put in culture. After 10–14 days, cultured confluent sheets of the patients own epidermis are ready for application. Although this technique is not new (88, 89), several disadvantages (biochemical and physical fragility, odd aspects of the grafted areas, the lack of dermis and economical factors) still have to be overcome to make it widely used, although its life‐saving properties have been described as well 90, 91, 92, 93, 94).

An alternative technique depends on the use of temporary coverage materials: these are used to cover the wound until donor sites (see below) have healed and can be reused (reharvested) again which, depending on the depth and location of the donor site, the age of the patient and some other factors, may take anywhere from 7 days to 3 weeks.

A number of different temporary cover materials is available: the most common ones are allografts (cadaver skin from a skin bank, amnion membrane) 95, 96, 97, 98, 99, 100, 101, 102, 103, 104, 105), xenografts [primarily porcine skin (106, 107), less commonly used nowadays] or (semi) synthetic materials. One of the semisynthetic materials is bilayered and designed in such a way that the wound bed grows into the wound side layer of the material: it thus becomes a ‘neodermis’108, 109, 110, 111). The outer layer of the dressing is a thin silicone sheet which protects the underlying material and wound from desiccation and infection. This sheet can be peeled of and replaced with autografts once the donor sites can be reharvested.

Donor sites

Donor sites, from which the skin grafts are taken, can be virtually anywhere in the body.

In big burns, the scalp is often used as the site reepithelialises rapidly (thus can be reharvested quickly and often) (112). Alopecia is usually not a problem because there are so many, deep‐seated, hair follicles.

Donor sites themselves can cause considerable morbidity, primarily because they are very painful 113, 114, 115, 116, 117). In large burns and, particularly, in elderly patients with frail skin, donor sites may also be difficult to heal (118).

Dressings for donor sites require the same set of properties as those for burns (see below). A major distinction, though, is that donor site may bleed heavily during the first hours to days after they have been made. Among haemostatic materials used to deal with this bleeding, pharmacological agents such as thrombin‐ and adrenaline‐soaked gauze bandages (119) are used, as well as special dressings such as alginates (120).

Dressing materials and techniques

Partial thickness burns, unless they are so deep that they have to be excised, can be managed well with dressings, and a plethora of different materials is available. For burns that will be excised within a short period after admission, it does not make a great deal of difference what type of preoperative material is used.

The most commonly used material for treating partial thickness burns is silver sulfadiazine 1% cream (121). This material has a reasonable antimicrobial profile, but it also has significant side effects such as the need for frequent dressing changes, pain associated with these dressing changes and discoloration of the wound bed [pseudo eschar (122)] which makes judging the wound difficult once the material has been applied a number of times 123, 124, 125, 126). Some contribute initial leucopoenia to the material, but others consider transient leucopoenia a normal consequence of the burn injury 127, 128, 129, 130, 131, 132).

Also, commonly used are different types of impregnated gauze. However, most of these materials adhere to the wound, and often tissue starts to grow into the gauze mesh, causing significant pain and damage to the wound bed upon dressing removal. Therefore, these materials should be avoided as dressing for burn care and wound care in general.

A large number of newer dressings have become available, most of them based on the principles of moist wound healing (116, 117, 133, 134, 135, 136) which prevents the wound from desiccation and prevents gauze‐type adherence and tissue ingrowth. Some modern gauze‐based dressings have been shown not to be adherent (137, 138) and, therefore, might be indicated as well. Most moisture retentive, non adherent dressings also help reducing pain (139).

In a simplified way, a number of dressing categories can be defined: synthetic materials, biological materials, biosynthetic materials and skin substitutes (for different materials different terminologies are used, which makes classification confusing).

The group of synthetic materials is by far the largest and includes hydrocolloids, foams, hydrofibres, alginates, film dressings, silicon‐based materials and many others (113, 120, 133, 140, 141). Some of these dressings have antimicrobial agents [nowadays primarily silver (115, 140)] incorporated in them.

The most appropriate dressing combines a number of properties. The material must

• • be able to handle large amounts of exudate
• • not be painful upon application or removal and help minimising pain in the period in between
• • be cost effective and easy to use
• • provide a moist wound environment
• • be an off the shelf, or otherwise readily available, product
• • have no (serious) side effects
• • not allow for tissue ingrowth
• • be antimicrobial, passively (by creating a moist wound environment) or actively (by having an active compound incorporated)
• • be non toxic
• • be non allergenic

With respect to dressings with an antimicrobial compound, the recently developed silver dressings are very promising as some of them combine the good antimicrobial properties of silver with good dressing properties of the material in which the silver is embedded (115, 140, 142, 143).

It is important to realise that many of ‘ideal dressing’ properties are claimed for many materials. It is beyond the scope of this article to discuss properties and claims for all materials individually. However, claims made must have been proven in clinical trials and published in peer‐reviewed journals, and it is the task of the health care provider to base his/her decision on materials to be used on these articles, rather than on non substantiated claims or on just a series of case studies.

Along the same lines, it is also very important to realise that all materials within one group (i.e. all alginates, films, hydrocolloids and silver dressings) may actually not have the same properties. However, manufacturers quite often tend to extrapolate their claims from other materials in the same group. Thus, a critical approach is necessary.

Biological materials are usually either allografts or xenografts (100, 104, 105, 107) although other, non mammal‐derived (144) materials are being used as well. Xenografts [primarily porcine skin (106, 107)] are commercially available as are some forms of allografts.

Biological materials have in common that the skin structure of the graft acts as a biological occlusive dressing. These grafts usually become temporarily adherent to the wound bed, to be rejected or slough off over time.

They all tend to generate an immune response at some level although this depends on the species from which the graft is obtained and the way the graft is preserved.

Allografts are considered, by many, the theoretical gold standard for burn dressings, but for religious, commercial, economical and infrastructural reasons, their availability differs greatly from country to country. Theoretically, allografts (and xenografts) can transfer a donor disease to the graft recipient, but careful screening of the donor and the graft itself, as well as certain types of preservation (145), in practice reduce this risk to a virtually negligible level.

Biosynthetic materials combine a biological source (quite often collagen or other compounds of the extracellular matrix) with a synthetic matrix or top layer. These materials aim to use the advantages of a biological matrix, with or without the advantage of different top layers. Their in vivo performance largely depends on the purpose for which the material is designed and, consequently, the physical and biochemical structure of the compounds. Some perform well as temporary dressings while others are designed to be incorporated (al least partially) into the wound bed.

A number of skin substitutes are currently available or in the process of being developed. Many of them use a biological matrix (collagen and/or other molecules found in the extracellular matrix) which is seeded with live cells, such as fibroblast and/or keratinocytes 146, 147, 148, 149, 150, 151, 152). The purpose of these materials is not only to provide a good dressing but also to bathe the wound in growth factors and other cytokines delivered into the wound milieu by the living cells in the dressing.

The possible advantage of this approach over ‘simply’ applying one or two growth factors from a delivery system is that the living cells are supposed to ‘sense’ what type of growth factor is needed in the wound, at what time and in which amounts.

Non living growth factor and cytokine delivery systems (i.e. a cream with one or two growth factors in it) do not play a major role in burn care and are beyond the scope of this article.

Long‐term results

After reepithelialisation is complete, the wound‐healing process continues into the remodelling phase. During this phase, deposited collagen is broken down and replaced with new and reorganised collagen. However, in many burns, the remodelling phase goes awry both with respect to the type of collagen and its orientation: macroscopically, this results in hypertrophic scarring. Hypertrophic scars are raised above the skin level and very inflamed in the beginning. They can be very debilitating and will interfere negatively with the quality of life, as they may limit movement, can be painful and virtually always are very pruritic. The psychological aspects of ‘being ugly’ are extremely important in this context as well.

Hypertrophic scarring is virtually certain to occur in burns that have taken a long time to heal spontaneously (153). However, also rapidly healing burns may result in serious scar formation, as scarring is largely genetically determined: dark‐skinned patients have a significantly higher risk of serious scarring (1, 154). Scarring also depends on other factors, such as the location of the wound (a sternotomy incision, e.g., virtually always results in a hypertrophic scar). During the reepithelialisation process, not much can be done to prevent hypertrophic scarring. However, because the change of hypertrophic scar formation is to a certain degree linked to the length of reepithelialisation, using dressings and techniques that are proven to reduce time to healing may contribute indirectly to reducing the incidence of hypertrophic scarring (153).

In patients who are prone to scarring (based on the results of previous injury and wound‐healing time), preventative measures may be taken after reepithelialisation is complete. These measures include the use of customised pressure garments 155, 156, 157, 158), with or without silicon sheeting as a contact layer on the wound 159, 160, 161). Corticosteroid injections are also used (162, 163), and other therapies are being developed as well, among them the use of different types of laser (164, 165) and, possibly, the use of pharmacological agents (166).

The results of hypertrophy prevention are often not truly satisfactory, and a visible scar may remain, although in the long time, hypertrophic scars will become flatter and less inflamed. However, surgical scar revision is often necessary, particularly when scar formation leads to contractures 167, 168, 169).

Keloid formation is different from hypertrophic scarring, both physiologically and macroscopically: a typical keloid extends beyond the borders of the original wound and has a cauliflower‐type aspect 170, 171, 172). Prevention and treatment of keloid are even more difficult than that of hypertrophic scarring 173, 174, 175, 176, 177) and lies beyond the scope of this article.

Conclusion

The treatment of large burns and burns in functional areas should be done in a burn centre. In these centres, an entire team (physicians, nurses, OTs, PTs dieticians, psychologists, etc.) is dedicated to burn care, and their treatment options often lead to impressive results.

However, the large majority of burn victims suffers from lesions that do not need this high level of care and that are small enough to be treated outside a burn centre, in a general hospital or an outpatient clinic, provided that wound management is done in line with burn care guidelines and modern wound care research.

This article attempts to give an overview of the principles of burn care, both for small and large burns. For the smaller ones, the principles of burn wound care (as opposed to burn disease care) should be used as a guideline. Because the number of materials, available for the treatment of partial thickness burns, is so extensive, it is the task of the physician and health care worker to become familiar with dressings that provide good burn care and to use evidence‐based medicine for the choice of dressings to be allowed into their clinics.