What is the recommended treatment for a diabetic patient with burns?

Burn Treatment in Diabetic Patients

Diabetic patients with burns require aggressive wound care with sharp debridement, antiseptic cleansing, and non-adherent dressings, while avoiding routine systemic antibiotic prophylaxis unless infection is clinically evident. 1

Initial Wound Management

Clean wounds with tap water, isotonic saline, or antiseptic solution (such as chlorhexidine 1:5000) before applying dressings. 1 This should be performed in a clean environment with adequate analgesia or general anesthesia. 1

Debridement Protocol

• Perform sharp debridement to remove necrotic tissue, debris, eschar, and surrounding callus. 1 This is the standard of care and should be done at a frequency determined by clinical need. 1
• Sharp debridement is generally superior to mechanical, autolytic, or enzymatic methods. 1
• Avoid surgical debridement when sharp debridement can be performed outside a sterile environment. 1

Dressing Selection

Apply non-adherent dressings to denuded dermis, avoiding topical antibiotics as first-line treatment. 1 Suitable options include:

• Non-adherent interface dressings (such as Mepitel or Telfa) as primary layer. 1
• Secondary foam or burn dressing to collect exudate. 1
• Do NOT use silver sulfadiazine for prolonged periods on superficial burns, as it is associated with delayed healing. 1
• Do NOT use topical antiseptic or antimicrobial dressings routinely for wound healing purposes. 1, 2

Antibiotic Management

Systemic antibiotic prophylaxis should NOT be administered routinely to burn patients. 1 The evidence shows:

• Routine prophylaxis does not reduce infection risk and promotes multidrug-resistant bacteria. 1
• Administer systemic antibiotics ONLY when clinical signs of infection are present (erythema, warmth, swelling, tenderness, purulent discharge). 1, 3
• For infected wounds, initiate empiric antibiotics targeting Staphylococcus aureus and streptococci. 3

Infection Surveillance

• Take swabs for bacterial and candidal culture from three areas of lesional skin on alternate days throughout the acute phase. 1
• Apply topical antimicrobial agents only to sloughy or infected areas, guided by local microbiological advice. 1

Critical Considerations for Diabetic Burn Patients

Higher Risk Profile

Diabetic patients with burns face significantly increased morbidity compared to non-diabetic burn patients:

• Longer hospital length of stay (5.65 days per 1% TBSA versus typical rates). 4
• Higher rates of surgical interventions, including amputations. 4, 5, 6
• Increased infection rates with different colonizing microorganisms than immunocompetent individuals. 5
• Mortality rates are significantly increased despite equivalent burn surface area. 6, 7

Lower Extremity Burns

Lower extremity burns in diabetics require heightened vigilance, as they frequently result from peripheral neuropathy and lead to major complications despite small burn size. 4, 5

• Mean burn size of only 4.2% TBSA can result in mean hospital stay of 15.2 days. 4
• Common mechanisms include walking on hot surfaces, soaking feet in hot water, or warming feet near heaters due to insensate feet. 4, 5
• Amputation rates are substantial (below-knee, transmetatarsal, and toe amputations common). 4

Metabolic Optimization

Aggressively correct hyperglycemia with insulin therapy, as hyperglycemia delays wound healing through osmotic diuresis, decreased oxygenation, and impaired neutrophil function. 3 Most diabetic burn patients present with poor glycemic control (mean glucose 215.8 mg/dL, mean HbA1c 9.08%). 4

Nutritional Support

Start enteral nutrition within 12 hours after burn injury, preferably via oral or enteral routes rather than parenteral. 1 This attenuates the neuro-hormonal stress response and hypermetabolic response. 1

• Provide 20-25 kcal/kg daily during the early catabolic phase. 1
• Increase to 25-30 kcal/kg daily during the anabolic recovery phase. 1
• Supplement with copper, zinc, selenium, and vitamins B, C, D, and E. 1

Thromboprophylaxis

Routinely prescribe thromboprophylaxis for severe burn patients in the initial phase. 1

Monitoring and Follow-up

• Re-evaluate dressings daily, ideally. 1
• Monitor distal perfusion when applying circular dressings to prevent tourniquet effect. 1
• Arrange close outpatient follow-up within 1-2 weeks after initial treatment. 3
• Schedule follow-up every 1-3 months for high-risk patients, noting that recurrence rate is 40% within one year. 3

Common Pitfalls to Avoid

• Do NOT delay wound care for prolonged cooling - external cooling devices should not be used for extended periods due to hypothermia risk. 1
• Do NOT use honey, collagen, or alginate dressings - these are not recommended for diabetic wound healing. 1, 3
• Do NOT underestimate small burns in diabetics - even burns <5% TBSA can lead to prolonged hospitalization, multiple operations, and amputations. 4, 5
• Do NOT fail to assess for osteomyelitis in deep or chronic wounds, especially those overlying bony prominences. 1

Prevention Education

Implement aggressive prevention programs for diabetic patients, emphasizing never walking barefoot, avoiding heat therapies on insensate feet, daily foot inspection, and immediate reporting of new lesions. 3, 4, 5 The majority of diabetic lower extremity burns result from intentional exposure to heat sources without recognition of burn risk due to peripheral neuropathy. 4, 5