**11. Local treatment of burn wounds**

Knowing the mechanisms involved in wound healing is very important for effective treatment of burn wounds. The treatment strategy for the burn wound varies according to the extent and depth of injury [1–3].

#### **11.1. Burn wound care at first step and emergency department**

Interventions that should be done at first step may differ according to the severity and mechanism of the burn. For minor burns, burned area should be put under running tap water for 20 min. Clothing that are soaked in hot liquid or contaminated with chemicals should be removed. For chemical burns, neutralizing agents should not be applied (neutralization reaction may cause further heat). Dry chemicals should be brushed away first and then irrigated with tap water. Before transfer to the designated facility, wounds should be wrapped with clean cloth but not covered with topical drugs. Topical silver sulfadiazine can be applied initially at the emergency department except for facial burns. Topical anesthetics are not recommended. Adherent dressings should not be used. Irrigation should be done with caution in order to avoid hypothermia due to cold water exposure [12]. As mentioned above, depending on the severity of burn, wound care in a multidisciplinary burn center may be required [11, 12, 15].

#### **11.2. Topics to be covered in burn wound treatment**

As previously mentioned, prolonged and exaggerated inflammatory response in deep burns results in intensified edema which further delays wound repair and is associated with scarring. Although the anti-inflammatory treatments such as prostaglandin inhibitors and glucocorticoids carry the risk of impaired wound healing, it seems reasonable to diminish excess inflammation and edema in burn injury [2, 19]. Indeed, treatment with topical or low dose systemic glucocorticoids in the early phase of burns has been suggested to prevent aberrant inflammation [11, 20]. For deep burns, early excision and grafting are crucial to remove the foci of inflammation and infection. Anti-inflammatory drugs including cytokine inhibitors, corticosteroids, interferons α and β, and methotrexate have also been used to prevent scar formation [1].

As the infection risk is increased in burn patients due to immunosuppression and the wounds can be rapidly contaminated by the organisms, prevention of infection should be the primary strategy in burn wound care [3, 11, 12]. Disinfectants can be used without inhibiting wound healing, and wounds should be cleaned with tap water, saline, and non-irritant soaps [11, 12]. Early covering of burn wound with topical antimicrobial agents may prevent the invasion or contamination of wound [3]. In deep burns, microorganisms may colonize the tissue below the eschar producing a source for infection. As the standard topical antimicrobials cannot penetrate the eschar tissue, early excision of the eschar is important in prevention of infection. Furthermore, early detection of infection is crucial especially in patients with deep and extensive burns [1–3]. Prophylactic antibiotics are not recommended for burn wounds unless there is high probability of infection. In case of wound contamination and in immunocompromised patients (pediatric, perioperative, and diabetic patients), prophylactic antibiotics can be considered [11, 12].

As the burn injury results in a profound hypermetabolic state, nutritional support is recommended in order to enhance wound healing [2, 3, 21]. Although the periodical clinical examination of the wound by the specialist stays the primary way of tracking wound healing, simple measurement tools, sophisticated techniques, and various serum parameters can be used to predict the likelihood of healing and for the follow-up of improvement in healing [2, 22, 23].

#### **11.3. Burn wound coverage and grafting**

#### *11.3.1. For the first-degree burn wounds*

complicates the interventional procedures [12, 18]. Burn patients may suffer from different types of pain including background and procedural pain. In severe burns, moderate to potent opioids (fentanyl, morphine, ketamine, and others) are preferred, and non-steroidal antiinflammatory drugs (NSAIDs) may be added to reduce the overall dose of opioids. NSAIDs may be sufficient to relieve pain in patients with mild to moderate burns. As they reduce the perception of pain, anxiolytics such as benzodiazepines may also be used. Although mild anesthetics are adequate for simple procedures, deeper anesthesia (with tramadol, ketamine, etc.) is required for the patients with severe burns during excision and grafting. Antidepressants and anticonvulsants are used as first-line therapies for neuropathic pain that may be seen in burn patients. Psychological therapies have also been reported with various successes for

Knowing the mechanisms involved in wound healing is very important for effective treatment of burn wounds. The treatment strategy for the burn wound varies according to the

Interventions that should be done at first step may differ according to the severity and mechanism of the burn. For minor burns, burned area should be put under running tap water for 20 min. Clothing that are soaked in hot liquid or contaminated with chemicals should be removed. For chemical burns, neutralizing agents should not be applied (neutralization reaction may cause further heat). Dry chemicals should be brushed away first and then irrigated with tap water. Before transfer to the designated facility, wounds should be wrapped with clean cloth but not covered with topical drugs. Topical silver sulfadiazine can be applied initially at the emergency department except for facial burns. Topical anesthetics are not recommended. Adherent dressings should not be used. Irrigation should be done with caution in order to avoid hypothermia due to cold water exposure [12]. As mentioned above, depending on the severity of burn, wound care in a multidisciplinary burn center may be required [11, 12, 15].

As previously mentioned, prolonged and exaggerated inflammatory response in deep burns results in intensified edema which further delays wound repair and is associated with scarring. Although the anti-inflammatory treatments such as prostaglandin inhibitors and glucocorticoids carry the risk of impaired wound healing, it seems reasonable to diminish excess inflammation and edema in burn injury [2, 19]. Indeed, treatment with topical or low dose systemic glucocorticoids in the early phase of burns has been suggested to prevent aberrant inflammation [11, 20]. For deep burns, early excision and grafting are crucial to remove the foci of inflammation and infection. Anti-inflammatory drugs including cytokine inhibitors, corticosteroids, interferons α

and β, and methotrexate have also been used to prevent scar formation [1].

management of pain [12, 18].

8 Hot Topics in Burn Injuries

extent and depth of injury [1–3].

**11. Local treatment of burn wounds**

**11.1. Burn wound care at first step and emergency department**

**11.2. Topics to be covered in burn wound treatment**

For the first-degree wounds, topical antibiotics are not necessary. Moisturizing agents are sufficient, and topical anesthetics may be given depending on the patient's condition [12].

#### *11.3.2. For superficial second-degree burn wounds*

Although the burn wounds are sterile at the beginning of injury, the wound begins to be invaded by the organisms from the patient's flora or from the environment. Therefore, topical antimicrobials are recommended for superficial second-degree burn wounds. As silver sulfadiazine delays epithelialization, it can be used only for the first days to prevent infection. Wounds should be covered with non-adherent dressings including paraffin-impregnated gauze or ointments containing 0.2% nitrofurazone, zinc oxide, or dimethyl isopropylazulene. Several alternative topical agents have also been suggested to be effective [12]. Various types of dressing materials are available for the local care of burn wounds. Wound dressing selection should be tailored according to the amount of wound exudate, the presence of fibrin or necrotic tissue, and the depth of the wound. Hydrocolloids, hydrogels, chitin, polyurethane foams, alginates, and hydrofibers all have been recommended as treatment options for the local care of second-degree burn wounds [11]. Blisters that may be seen in superficial seconddegree burns may serve as an excellent environment for the growth of microorganisms and increase the risk of infection. Small blisters may be left intact; however, large blisters should be removed, and the wound should be dressed [3, 12].

#### *11.3.3. For deep second-degree, third-degree, and fourth-degree burns*

The removal of the necrotic tissue, prevention of infection, and the maintenance of a moist environment are the primary goals to facilitate the wound healing in deep burns [11].

the maturation of scar [26]. Experimental studies showed promising results in the wound healing with platelet-rich plasma (PRP) treatment; however, its routine use in burn wounds and scars requires further evaluation [27]. Various types of lasers including pulse dye laser (PDL) and fractional ablative laser may offer better results when used in combination with surgery [28]. Pressure garments and massage therapy are also used to minimize scar contraction. Burn rehabilitation, splintage, and physiotherapy are very important to prevent contractures and to improve functional outcome. Additionally, as burn survivors may experience significant psy-

Introductory Chapter: An Introduction to Burn Injuries http://dx.doi.org/10.5772/intechopen.71973 11

Marjolin's ulcer is a rare cutaneous malignancy which may develop in burn scar. It occurs approximately two to three decades after the burn and is commonly seen on lower extremities as verrucous lesions. The squamous cell carcinoma is the most common form. The prevention of scar carcinoma by the early and effective treatment of scar formation is of primary importance to reduce the associated morbidity and mortality. Additionally, regular follow-up of patients with burn scars and early detection and evaluation of the non-healing ulcers are

1 Dermatology Department, Diskapi Yildirim Beyazit Training and Research Hospital,

[1] Oryan A, Alemzadeh E, Moshiri A.Burn wound healing: Present concepts, treatment strategies and future directions. Journal of Wound Care. 2017;**26**:5-19. DOI: 10.12968/jowc.2

[2] Rowan MP, Cancio LC, Elster EA, Burmeister DM, Rose LF, Natesan S, Chan RK, Christy RJ, Chung KK. Burn wound healing and treatment: Review and advancements. Critical Care.

[3] Tiwari VK. Burn wound: How it differs from other wounds? Indian Journal of Plastic

and Dilek Bayramgurler<sup>3</sup>

chosocial problems, proper specialists should be consulted as soon as possible [3].

**12. Malignancy on burn scars**

important considerations [29, 30].

\*, Cemile Tuğba Altunel<sup>2</sup>

2 Dermatology Department, Private Natomed Hospital, Ankara, Turkey

3 Dermatology Department, Kocaeli University, Ankara, Turkey

2015;**19**:243. DOI: 10.1186/s13054-015-0961-2

Surgery. 2012;**45**:364-373. DOI: 10.4103/0970-0358.101319

\*Address all correspondence to: pelin@dr.com

University of Health Sciences, Ankara, Turkey

**Author details**

Selda Pelin Kartal<sup>1</sup>

**References**

017.26.1.5

Eschar is the tough, leathery necrotic tissue seen in full-thickness burns. Circumferential eschar tissue may compromise circulation on extremities or restrict breathing over the chest. Escharotomy may be indicated in these patients. In the case of compartment syndrome, fasciotomy should be performed [3, 12]. Eschar tissue does not break down spontaneously, except in the case of infection [12]. Although the necrotic tissue of small deep burns may be treated by topical necrolytic agents, surgical debridement is needed in extensive burns [11]. As spontaneous healing is not expected and the scar formation is the final outcome of deep seconddegree and third-degree burns, early excision of the eschar and grafting are the preferred treatments for these wounds. After the excision of eschar, temporary wound covering for the first days by topical antimicrobials (silver sulfadiazine) or wound dressings prevents infection and maintains moisture before surgery [1, 2, 11].

As the formation of scar can be prevented by the early and appropriate management of burn wound, excision should be done as soon as the patient is stabilized [3, 12]. Although the splitthickness autografts are the gold standard method in deep burns, they have many disadvantages. Allografts and xenografts may serve a good option for larger burns until the allografts are incorporated; however, they have also many limitations [1, 2]. Tissue engineering has provided a new era in the wound care field. Skin tissue regeneration by tissue-engineered products showed promising results in wound healing. Tissue scaffolds, healing-promoting factors (growth factors), stem cells, and gene therapy are the current solutions provided by bioengineering. Tissue scaffolds consist of epidermal, dermal, or composite substitutes which can provide a three-dimensional tissue for the optimal proliferation of cells and tissue regrowth. Several growth factors may be used as healing-promoting factors. Although the experimental studies with either embryonic or adult stem cells demonstrate the potential use of stem cells in the treatment of chronic wounds, further research is required to investigate their long-term effects on wound healing process. Gene therapy is a promising approach for the future treatment of burn wounds. It involves the transfer of genes into cells that encode growth factors required for enhancing wound repair. However, its use in burn wounds is limited by technical challenges. In conclusion, further trials are required to explore the long-term effects and safety of tissue engineering methods in burn wound treatment [1, 2, 24].

Fourth-degree burns are associated with significant functional impairments which require complicated and repeated surgeries. They often lead to amputations. Whereas local flaps may be used for the reconstruction of mild to moderate cases, burns with extensive damage need tissue transfers [1].

The common goal of all therapeutic tools abovementioned is to optimize wound healing, prevent scar formation, and minimize the functional disability. There are more other treatments that have been used for these purposes with varying success. Hyperbaric oxygen therapy has been suggested as a safe and effective treatment for burn wounds and can be used in conjunction with other modalities for burn patients [2, 25]. Silicone gels have been suggested to be useful in burns which carry high risk of hypertrophic scarring. They are recommended to be used before the maturation of scar [26]. Experimental studies showed promising results in the wound healing with platelet-rich plasma (PRP) treatment; however, its routine use in burn wounds and scars requires further evaluation [27]. Various types of lasers including pulse dye laser (PDL) and fractional ablative laser may offer better results when used in combination with surgery [28]. Pressure garments and massage therapy are also used to minimize scar contraction. Burn rehabilitation, splintage, and physiotherapy are very important to prevent contractures and to improve functional outcome. Additionally, as burn survivors may experience significant psychosocial problems, proper specialists should be consulted as soon as possible [3].
