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Burn Injury

Typical recovery: Healing depends mainly on burn depth, size, location and patient factors. Superficial burns commonly heal within several days without scarring. Superficial partial-thickness burns often re-epithelialise within about two weeks when uncomplicated. Deep partial-thickness burns may take longer than three weeks and carry a greater risk of hypertrophic scarring and contracture; selected wounds benefit from specialist assessment for excision and grafting. Full-thickness burns do not regenerate normal full-thickness skin across substantial defects and usually require specialist surgical management. Scar maturation can continue for many months after wound closure.

Key points

  • The first priority is to stop the burning process and move the patient away from the heat, electrical or chemical source safely.
  • Cool thermal burns with cool running water for about 20 minutes as soon as possible; cooling can still be beneficial when started within several hours of injury.
  • Cool the burn rather than the whole patient, particularly in children and larger burns, because hypothermia can be harmful.
  • Remove rings, watches, belts and loose clothing early because swelling can make them constrictive.
  • Do not forcibly remove clothing or material that is stuck to the burned skin.
  • Do not apply ice directly to a burn because extreme cold can worsen tissue injury.
  • Do not apply toothpaste, butter, cooking oil, powders or unprescribed creams to an acute burn.
  • After cooling, cover the wound loosely with a clean non-adherent material or appropriate temporary covering while arranging assessment.
  • Burn depth can evolve during the first 24 to 72 hours, so an initially uncertain burn may need reassessment.
  • Superficial erythema such as uncomplicated sunburn is not included in total body surface area calculations used for burn severity.
  • Partial-thickness and full-thickness burns are included in TBSA assessment.
  • The adult Rule of Nines is a rapid estimate; the Lund-Browder chart is more accurate in children because body proportions differ with age.
  • For small irregular burns, the patient's palmar surface can be used as an approximate reference for about 1% TBSA, but local protocols vary in whether fingers are included.
  • Current American Burn Association referral guidance recommends immediate burn-center consultation with consideration of transfer for full-thickness burns, partial-thickness burns involving 10% or more TBSA, and deep partial- or full-thickness burns involving the face, hands, genitalia, feet, perineum or major joints.
  • Suspected inhalation injury requires urgent specialist assessment even if the external skin burn appears limited.
  • All chemical burns and high-voltage electrical burns require specialist consultation; low-voltage electrical injuries may also need specialist follow-up because deeper or delayed complications can occur.
  • Children with burns may benefit from burn-center referral because pain control, dressing changes, rehabilitation and safeguarding needs differ from adults.
  • A circumferential deep burn can impair limb circulation or chest expansion as oedema develops and requires urgent assessment.
  • Routine prophylactic systemic antibiotics are not recommended simply because a burn wound is open.
  • Antibiotics are used when there is clinical infection, sepsis or another specific indication.
  • Tetanus immunisation status should be checked and updated when indicated.
  • Deep partial-thickness burns and full-thickness burns often need specialist surgical assessment because spontaneous healing can be prolonged, incomplete or associated with significant scarring.
  • Early rehabilitation, movement and positioning are important for burns across joints to reduce stiffness and contracture.
  • Once healed, burned skin requires sun protection because pigment changes and photosensitivity can persist for a prolonged period.

Overview

A burn is tissue injury caused by heat, hot liquids or steam, chemicals, electricity, radiation or other energy sources. Severity is determined not only by how the wound looks but also by burn depth, percentage of total body surface area involved, anatomical location, age, associated injuries and medical conditions. Superficial burns affect only the epidermis and are red and painful without true blistering. Partial-thickness burns extend into the dermis and may blister; superficial partial-thickness burns are usually moist, red, blanching and very painful, while deep partial-thickness burns are paler or drier, may blanch poorly and can be less sensitive. Full-thickness burns destroy the full thickness of skin and can appear white, brown, black or leathery with reduced sensation. Immediate first aid is important: stop the burning process, remove jewellery and non-adherent clothing, cool the affected area with cool running water for about 20 minutes as soon as possible, keep the rest of the patient warm, and cover the cooled wound loosely with a clean non-adherent material. Ice, toothpaste, butter, oils and unprescribed creams should not be applied. Clinical assessment includes depth, total body surface area, airway and inhalation risk, circulation, pain and associated trauma. Partial-thickness and full-thickness burns are counted when estimating burn surface area; superficial erythema such as sunburn is not. Small uncomplicated superficial or superficial partial-thickness burns may be managed as outpatient wounds, while deeper, larger, electrical, chemical, inhalational or anatomically critical burns require specialist assessment. Treatment can include analgesia, wound cleansing, blister and devitalised-tissue management, suitable dressings, tetanus prophylaxis, rehabilitation and scar management. Routine systemic antibiotics are not given simply because a burn is present; they are used when clinical infection or another specific indication develops. Deep partial-thickness and full-thickness burns that are unlikely to heal promptly may require excision and skin grafting. Burn care therefore ranges from simple outpatient wound management to specialised multidisciplinary treatment depending on severity.

Signs & symptoms

  • Redness and pain after heat or scald exposure.
  • Blistering of the skin in partial-thickness burns.
  • A moist, pink or red and very painful wound in superficial partial-thickness injury.
  • A pale, mottled, drier or less blanching wound in a deeper partial-thickness burn.
  • White, brown, black or leathery skin with reduced sensation in full-thickness injury.
  • Swelling around the burned area.
  • Severe pain, although very deep burns can paradoxically be less painful because nerve endings have been destroyed.
  • Facial burns, soot, hoarseness, coughing, wheeze or breathing difficulty after smoke exposure suggesting possible inhalation injury.
  • Circumferential burns around a limb or chest, which can become dangerous as swelling increases.
  • Electrical burns with deceptively small skin wounds despite deeper tissue injury.
  • Chemical burns in which tissue injury can continue until the chemical is removed or sufficiently irrigated.

How assessment and treatment are planned

  1. 1

    Ensure scene safety and stop the burning process before approaching or treating the patient.

  2. 2

    Remove the patient from the heat, flame, electrical or chemical source and address immediately life-threatening trauma.

  3. 3

    Assess airway, breathing and circulation, especially after enclosed-space fire, facial burns, smoke exposure, major trauma or high-voltage electrical injury.

  4. 4

    Remove jewellery and non-adherent clothing near the burn, but leave material that is firmly stuck to the wound.

  5. 5

    For thermal burns, cool the affected area with cool running water for about 20 minutes while preventing hypothermia.

  6. 6

    For chemical exposure, remove contaminated clothing and dry chemical material when appropriate, then irrigate with copious water unless a specific chemical requires a different protocol.

  7. 7

    Cover the cooled wound loosely with a clean non-adherent material for transfer or early assessment.

  8. 8

    Provide appropriate analgesia.

  9. 9

    Assess burn depth and estimate total body surface area using an appropriate method.

  10. 10

    Examine the face, airway, chest and extremities for signs requiring urgent intervention or specialist referral.

  11. 11

    Assess distal circulation and sensation when a limb burn is deep or circumferential.

  12. 12

    Clean the wound and remove loose contaminants using appropriate wound-care technique.

  13. 13

    Manage blisters selectively according to size, location, contamination, likelihood of rupture and the need to assess the wound bed; there is no requirement to deroof every intact blister automatically.

  14. 14

    Apply an appropriate non-adherent or modern burn dressing according to depth, exudate and local practice.

  15. 15

    Check tetanus immunisation status and provide prophylaxis when indicated.

  16. 16

    Arrange burn-specialist consultation or transfer when referral criteria are met.

  17. 17

    For larger burns, initiate monitored resuscitation and fluid therapy according to burn severity and specialist protocol rather than giving indiscriminate fluid boluses.

  18. 18

    Reassess depth, perfusion, pain, infection and healing trajectory during follow-up because burns can evolve.

  19. 19

    Refer deep partial-thickness or full-thickness wounds unlikely to heal satisfactorily for consideration of excision and skin grafting.

  20. 20

    Begin range-of-motion, positioning, splinting or rehabilitation early when burns involve joints, hands or other functionally important areas.

Preparation

  • Note the time of injury and the exact mechanism—flame, scald, contact, chemical, electrical or other cause.
  • For chemical burns, identify the chemical or bring its container or safety information if this can be done safely.
  • For electrical injury, note the voltage if known, contact points, loss of consciousness, fall or associated trauma.
  • Tell the clinician whether the injury occurred in an enclosed space or involved significant smoke exposure.
  • Bring details of first aid already given, including duration of cooling and any substances applied to the wound.
  • Bring a current medication list and details of allergies.
  • Tell the clinician about diabetes, vascular disease, kidney disease, immunosuppression or other conditions that can complicate healing.
  • Check or bring vaccination records if tetanus status is known.
  • Do not intentionally burst blisters or apply home remedies before assessment.
  • Do not eat or drink if a major burn may require urgent anaesthesia or surgery unless the treating team advises otherwise.

Recovery and aftercare

  • Keep the dressing clean, dry and in place for the interval advised by the treating team.
  • Take prescribed or recommended analgesia according to instructions, especially before dressing changes when needed.
  • Move unaffected joints normally and perform prescribed range-of-motion exercises when a burn crosses or approaches a joint.
  • Elevate a burned limb when advised to reduce swelling.
  • Do not apply unprescribed creams, antiseptics or home remedies to an open burn wound.
  • Return earlier if pain increases after initial improvement, redness spreads, the wound develops purulent discharge, fever appears or you feel systemically unwell.
  • Attend reassessment if the burn is not healing as expected because depth can declare itself over time.
  • Once the wound has fully healed, moisturise the healed skin as advised and protect it from sun exposure with clothing and high-SPF sunscreen.
  • Use scar-management measures such as silicone, pressure therapy, massage or specialist rehabilitation only when recommended for the wound and scar type.
  • Seek review for persistent itching, hypertrophic scarring, contracture, weakness or restricted joint movement.

Risks and possible complications

  • Dehydration and shock in major burns.
  • Airway swelling and inhalation injury.
  • Carbon monoxide or other toxic smoke exposure in enclosed-space fires.
  • Wound infection and cellulitis.
  • Sepsis in severe burns.
  • Progression of burn depth during the first days after injury.
  • Delayed healing.
  • Hypertrophic scar formation.
  • Contracture and restricted movement, particularly across joints.
  • Altered pigmentation and long-term sun sensitivity.
  • Chronic itching, pain or altered sensation.
  • Need for debridement, excision or skin grafting.
  • Compartment-like vascular compromise from a deep circumferential limb burn.
  • Restricted chest expansion from a deep circumferential chest burn.
  • Deep muscle, nerve or cardiac injury after significant electrical burns despite limited external skin injury.
  • Psychological distress after significant burns or visible scarring.

When to seek medical care

  • URGENT: Any full-thickness burn.
  • URGENT: Partial-thickness burns involving about 10% or more of total body surface area.
  • URGENT: Deep partial-thickness or full-thickness burns of the face, hands, feet, genitalia, perineum or over major joints.
  • URGENT: Burns associated with breathing difficulty, hoarseness, soot around the mouth or nose, facial flash burns, singed facial hair or significant smoke exposure.
  • URGENT: Chemical burns.
  • URGENT: High-voltage electrical burns or lightning injury.
  • URGENT: Circumferential deep burns around a limb, chest, neck or digit.
  • URGENT: Burns associated with major trauma, loss of consciousness or significant comorbidity.
  • URGENT: Poorly controlled pain despite appropriate analgesia.
  • SOON: Any potentially deep burn even when the surface area is small.
  • SOON: A burn in a child, particularly when dressing, pain-control, rehabilitation or safeguarding needs are significant.
  • SOON: Increasing redness, swelling, purulent discharge, fever or increasing pain after initial improvement.
  • SOON: A burn that has not substantially re-epithelialised within about two weeks or is clearly deeper than initially thought.
  • SOON: Persistent stiffness or reduced movement across a joint after a burn.
  • EMERGENCY: Rapidly worsening breathing difficulty, stridor, confusion, shock or extensive burns.

Myth vs fact

Frequently asked questions

Sources

Medically reviewed by Dr. Shams Alam Mohammed Tahir, MBBS, MS (General Surgery). Last reviewed 2026-09-20.

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