What is the first line ointment for a partial-thickness (2nd-degree) burn that is still open?

First-Line Ointment for Open Partial-Thickness Burns

For open partial-thickness (2nd-degree) burns, apply petrolatum or petrolatum-based antibiotic ointment (such as triple-antibiotic ointment containing bacitracin, neomycin, and polymyxin B) after cooling, covered with a clean nonadherent dressing. 1

Recommended Topical Agents (in order of preference)

Primary Options

• Petrolatum-based antibiotic ointment (triple-antibiotic ointment with bacitracin, neomicin, and polymyxin B) is the preferred first-line treatment 2

  • Research demonstrates faster reepithelialization compared to silver-containing dressings (complete healing by day 21 vs. 55% healing) 3
  • Results in less scar depth (4.3mm vs. 5.1mm) and reduced scar contraction (25% vs. 39%) compared to silver-based dressings 3
  • Maintains moist wound environment essential for optimal healing 3

• Plain petrolatum is equally effective and more cost-efficient 1

  • Studies show comparable or faster healing than silver sulfadiazine (mean 6.2 days vs. 7.8 days to re-epithelialization) 4
  • No increased infection risk compared to antimicrobial agents 4

Alternative Options (if primary unavailable)

• Honey shows benefit for infection resolution and reduced hypertrophic scarring 1

  • Decreased mean healing time by 7.8 days compared to silver sulfadiazine 1
  • Reduced hypertrophic scar formation (RR 0.13; 95% CI 0.03-0.52) 1, 5

• Aloe vera may be reasonable for small burns being managed at home 1

Application Protocol

Before Applying Ointment

1. Cool immediately with clean running water for 5-20 minutes 1, 6
2. Remove jewelry before swelling occurs to prevent vascular compromise 1, 6
3. Clean the wound with tap water, isotonic saline, or antiseptic solution 2
4. Administer over-the-counter analgesics (acetaminophen or NSAIDs) for pain control 1, 6

Ointment Application

• Apply a thin layer of petrolatum or petrolatum-based antibiotic ointment to the open burn wound 1, 2
• Cover with a clean, nonadherent dressing 1
• Change dressing daily or as needed 2
• If blisters are present with detached epidermis, leave the epidermis in place as a biological dressing 2

Critical Pitfalls to Avoid

What NOT to Use

• Avoid silver sulfadiazine as first-line therapy - despite historical popularity, it delays healing compared to petrolatum-based treatments 4, 3

  • Forms overlying slough making wound assessment difficult 7
  • Prolonged use may delay healing and worsen scarring 5
  • More expensive without superior outcomes 8

• Never apply ice directly to burns - causes additional tissue damage 6, 2

• Never apply butter, oil, or home remedies 6, 2

• Never break intact blisters - significantly increases infection risk 6, 5

When to Seek Immediate Specialized Care

All partial-thickness burns involving the face, hands, feet, or genitals require evaluation at a specialized burn center regardless of size due to high risk of functional disability and cosmetic deformity. 1, 6, 2

Additional urgent referral criteria: 1, 6

• Signs of inhalation injury (soot around nose/mouth, difficulty breathing, singed nasal hairs)
• Burns >10% total body surface area in adults (>5% in children)
• Circumferential burns
• Blue, purple, or pale extremities indicating vascular compromise

Evidence Quality Considerations

The 2024 American Heart Association/Red Cross guidelines provide the most current recommendations (Class 2, Level C-EO evidence), acknowledging that petrolatum, petrolatum-based antibiotic ointment, honey, and aloe vera all show benefit for open partial-thickness burns. 1 While the evidence quality is moderate, the consistency across multiple studies and the 2024 guideline update support petrolatum-based products as first-line therapy over traditional silver sulfadiazine. 4, 3