Burn Wounds

• 1 st degree
  There will only be seen redness and a little swelling (oedema) of the skin.
  The wound will be closed, feel supple but very painful.
  
• 2 nd degree:
  There will be blistering and the wounds are painful.Dependent on the depth of the colour the skin beneath the blister will be intense red (superficial) to light pink ( deep). The sensibility is not disturbed and the wound feels supple.
  
• 3 rd degree:
  These wounds aren't painful and feel leather-like. The burnt skin looks white or beige. All layers of the skin are damaged and spontaneously cure isn't possible anymore.
  
• 4 th degree:
  These wounds can look as 3 rd degree burns, but often the colour is black by carbonization. Not only the skin is burnt but the underlying tissues as well.

An intermediary burn, 2 nd degree deep, forms an exception to the management of this wound. This skin has been burnt subtotally, and has the possibility of spontaneously healing. The slow curing and great chance to scar-hypertrophy enhances the surgeon treatment.

The clinical judgement of the depth of the degree is often difficult, especially with intermediary burns. Only three days after the burn, a proper treatment can be given.

Eventually this allows us to start the right treatment and a quick healing. Burns can also evolve to a higher degree if not treated effectively. Dehydration, infections and mechanical damaging have to be avoided. Extensively washing with lukewarm water and the right bandage care can avoid this. At 2 nd degree burns not only the closure of the sink defect is important but also the prevention of scar-hypertrophy . The sooner the wound will be closed, the faster the beginning with the pressure-therapy and the better the final result of the scar. Especially children are notorious to develop hypertrophical scars.

Forms of conservative wound treatment

1. Occlusive wound treatment

This bandage aims at impermeability to microbes, creates an environment in which the growth of microbes can be restrained and offers protection to the grown epithelium. This bandage can be used in the follwing ways.

• Blistering
  As long as the blister is intact no infection can appear. Once punctured the blister needs to be treated to prevent woundcontamination and infection. A daily disinfection and a jelonet greasy bandage can be used for this. After five or seven days the blister can be removed, washed and treated with flammazine.
  
• Polyurethane foil
  This foil is limitedly permeable to air and water and impermeable to microbes. Because there isn't any anti-bacterial effect, it can only be used on small superficial burns that aren't infected (eg. Tegaderm, Opsite)
  
• Hydrocolloid bandages
  These bandages lay an artifial blister on the wound. The outside exists of a polyuethane foil and the inside, a hydrocolloid, sticks to the healthy skin and resorbs the fluid of the wound. In combination with the fluid of the wound hydrocolloid forms a jelly with a sour PH which has an anti-bacterial effect. These membrane bandages are comfortable, adhesive and allow taking a short shower. (eg. Duoderm, Allevyn)
  
• Donor skin
  Humane donor skin is reserved to the 2nd degree warm water burns with children. It relieves pain, is applied once and gives, comparing to flammazine bandage, less cause to scar-hypertrophy. Donor skin is a temporary replacement of the own skin. It forms a new thin layer which will get loose once the own skin is healing again. After 14 days a new layer of donor skin is replaced and this procedure will be repeated as long as necessary.

2. Half-open bandage

Locating, depth, extension of the burn just as infection can render a burn for a closed wound treatment.A flammazine bandage through a half-open treatment will be the gold standard. The following bandages will be applied once daily. It are all greasy bandages which have a stimulating effect at the healing.

•  Flammazine cream:
Flammazine cream (silversulfadiazine) has a broad anti-bacterial spectrum and is active against negative micro-organisms which frequently colonize burns. Extended open wounds and infected wounds form an excellent indication.The cream will ease the pain as well.

•  Cerium-flammazine cream:
Is only used for extended deep burns and often to prepare an operation. The cerium-flammazine forms a dry crust on the wound that prevents a bacterial invasion and cause spontaneous epithelisation. This cream isn't used for the face and the hairy scalp and only applied in burn centres.

•  Flamigel:
Flamigel, a hydrocolloid in jelly, can be used for 1 st degree burns. This jelly consists of polymers which have a inhibitory function on the growth of microbes. It consists no antiseptic or antibiotic. At 2 nd degree burns is can be used in a closed form of bandage or as half-open bandage with daily disinfection of the wound. The jelly relieves the pain.

•  Flaminalg:
A hydrocolloid in jelly enriched with alginate polymers, especially indicated to 2 nd degree burns where more wound-excudates are seen. Unlike flamigel it inhibates the growth of microbes by its enzymatical working. This can also be combined with a daily disinfection of the burns. An advantage compared to flammazine cream is that it doesn't form a crust on the wound so it won't hinder the judgement of the depth. It also gives better results in combination with polarized light (see later on). Here too a reasonable ease of pain has been observed.

•  Furacine:
Furacine (Nitrofurazon) has as soluble dressing (cream) a place at the treatment of 2 nd degree burns. This cream has a smaller anti-bacterial spectrum than Flammazine cream, but is also very active against Staphylococcus Aureus. Furacine soluble dressing is often used at facial burns and in variation with flammazine used long-lasting. Combining these two products a local therapy with a broad spectrum is gained, which can be supplied for a long term without a chance of insensible micro-organisms.

•  Betadine-cream, Fucidin, Bactroban skin cream
and other products aren't suitable to primary treatment of burns. They will be applied in a secondary stage after a treatment before with one of the membranic wound-coverers or Flammazine cream. The result of the wound culture is determined to the choice of the local therapy.

•  Jelonet greasy bandage:
Is a good bandage to the treatment of small granulating rest defects which are often seen in healing burns.

The following bandages are only used after indication. For the sake of completeness they are mentioned below.

•  Acetic acid
Wound infections with Pseudomonas Aeruginosa are treated succesfully with acetic acid bandages. Wound cultures have to be taken regularly to detect infections with other germs and to adapt the bandage treatment. (Flamiclens)

•  Silvernitrate
Hypergranulate tissue can be dabbed with AgNO3. At very extended zones the use of a corticosteroid cream can be necessary.

This form of treatment is seldom being used nowadays. The wound is being exposed to the air and a crust will form under which the healing takes place. A facial burn and very small burns form the only exceptions. Eg. An open bandage with Furacine soluble dressing for a facial burn.

The use of polarized light

Recent investigations show us that polarized light has a stimulating effect on the healing of the wound. The bio-stimulating effect of this therapy results in a accelerated epitheliation and a higher quality of the forming of scars. The use of polarized light is applied once daily during 6-10 minutes per area (180 cm/2) and can be combined with a half-open bandage. Flamigel and Flaminalg are eligible best.

The conservative wound treatment towards
extensiveness and depth of the burn

•  1 st DEGREE I: A hydrating cream and a “total sunblock” protecting cream

•  2 nd DEGREE II: = 20%

•  Membrane wound coverers like donor skin/Opsite/Duoderm
•  Flammazine cream 1x/d
•  Flaminalg + Bioptron lamptherapy 1x/d

•  Flammazine cream 1x/d
•  Flammanalg + Bioptronlamp 1x/d

•  Cerium-Flammazine

•  3 rd DEGREE III:

•  Cerium-Flammazine

•  DONORSITE:

•  Membrane wound coverers like Opsite/Duoderm

•  Alginate bandage like Kaltostat
•  Flammazine cream