Should burn dressings be kept moist or dry to prevent scarring?

Burn Dressings Should Be Kept Moist to Prevent Scarring

After initial cooling, burn wounds should be covered with moist dressings (such as petrolatum-based ointments, honey, or aloe vera with nonadherent dressings) rather than dry dressings to reduce scarring and accelerate healing. 1

Initial Cooling Phase

Before applying any dressing, the burn must be cooled immediately:

• Cool thermal burns with clean running water (15-25°C) for 5-20 minutes as soon as possible after injury 1, 2
• This cooling step limits burn depth, reduces pain, and should precede any dressing application 1, 2
• Monitor children closely during cooling for hypothermia, especially with burns >10% total body surface area (TBSA) 1, 3
• Avoid cooling large burns (>20% TBSA in adults, >10% in children) for prolonged periods due to hypothermia risk 2

Moist vs. Dry Dressing Evidence

The evidence strongly favors moist wound healing for preventing scars:

Why Moist Dressings Are Superior

Moist wound environments reduce scarring by facilitating autolytic debridement, activating collagen synthesis, promoting keratinocyte migration, and reducing hypertrophic scar formation. 4

• Research demonstrates that moist dressings significantly reduce complications including hypertrophic scarring compared to dry silver sulfadiazine dressings (RR 0.13; 95% CI 0.03-0.52) 1
• Moist dressings accelerate healing time by an average of 2.9 days compared to dry dressings (mean healing time 10.9 vs 13.8 days, P<0.01) 5
• Faster healing correlates with reduced scarring, as prolonged healing time increases scar formation risk 4

Guideline Recommendations for Dressing Application

After cooling, the 2024 American Heart Association guidelines recommend:

• For small partial-thickness burns managed at home: apply petrolatum, petrolatum-based antibiotic ointment, honey, or aloe vera with a clean nonadherent dressing 1
• For burns with intact skin or intact blisters awaiting professional evaluation: loosely cover with a clean cloth or nonadherent dry dressing 1
• The distinction is critical: open burn wounds (including unroofed blisters) benefit from moist dressings, while intact blisters can be covered with dry dressings temporarily 1

Practical Application Algorithm

For Open Partial-Thickness Burns (Most Common Scenario)

1. Cool with running water for 5-20 minutes 1
2. Clean with tap water, isotonic saline, or antiseptic solution 2
3. Apply a moist dressing:
   • Petrolatum or petrolatum-based antibiotic ointment, OR
   • Medical-grade honey, OR
   • Aloe vera 1
4. Cover with nonadherent dressing (such as Mepitel or similar) 5
5. Change dressing based on wound appearance and exudate level 2

For Burns with Intact Blisters

• Do not break blisters (increases infection risk) 3
• Cover loosely with clean, nonadherent dry dressing while awaiting medical evaluation 1
• Once blisters open or are debrided by healthcare professionals, transition to moist dressing protocol 1

Important Caveats and Pitfalls

What NOT to Do

• Never apply ice directly to burns - causes tissue ischemia and worsens outcomes 2, 3
• Avoid butter, oil, or home remedies - increase infection risk and delay healing 3
• Do not use topical antibiotics routinely on uninfected wounds - reserve for infected wounds only to prevent antimicrobial resistance 2, 3
• Avoid prolonged use of silver sulfadiazine on superficial burns - may delay healing 2

Contradictory Evidence Addressed

The 2015 International Consensus stated "no recommendation" for wet vs. dry dressings due to insufficient prehospital evidence 1. However, this reflects the limited quality of studies available at that time, not a finding that moist dressings are ineffective. The 2024 American Heart Association guidelines supersede this by making a clear recommendation for moist dressings (petrolatum-based products, honey, aloe) for open burns 1. Additionally, one study showed higher infection rates with occlusive dressings 6, but this used specific occlusive techniques that may have created overly moist environments; the key is maintaining optimal moisture balance, not excessive wetness 4, 7.

Optimal Moisture Balance

• Moist does not mean wet - the goal is maintaining a moist wound surface without maceration 4, 7
• Dressings should have appropriate water vapor transmission rates to prevent both desiccation and overhydration 4, 7
• Change dressings when saturated or when exudate soaks through to maintain optimal moisture levels 7

When to Seek Specialized Care

Refer to burn center or emergency department for:

• Burns involving face, hands, feet, or genitals 1, 2, 3
• Burns >10% TBSA in adults or >5% in children 1, 2, 3
• All full-thickness burns 1, 3
• Signs of inhalation injury (soot around nose/mouth, difficulty breathing) 1
• Signs of infection (increasing pain, redness, swelling, purulent discharge) 2, 8