What is the appropriate treatment for a patient with a second-degree burn?

Treatment of Second-Degree Burns

Immediately cool the burn with clean running water for 5-20 minutes, then apply petrolatum-based triple-antibiotic ointment covered with a clean non-adherent dressing, and provide adequate analgesia. 1, 2, 3

Immediate First Aid (Within Minutes of Injury)

• Cool the burn with clean running water (15-25°C) for 5-20 minutes to limit tissue damage and reduce pain 1, 2, 3
• Monitor for hypothermia during cooling, particularly in preadolescent children, though this is less concerning with isolated burns 1, 2
• Remove all jewelry from the affected area before swelling occurs to prevent vascular compromise 1, 3
• Never apply ice directly, butter, oil, or other home remedies as these cause further tissue damage or increase infection risk 1, 2, 3

Wound Cleaning and Preparation

• Clean the wound with tap water, isotonic saline, or antiseptic solution before applying any dressing 3
• Do not break or pop intact blisters as this significantly increases infection risk 1, 2

Topical Treatment Selection

Apply petrolatum-based triple-antibiotic ointment (containing bacitracin, neomycin sulfate, and polymyxin B) as the preferred topical agent. 1, 2, 4 This recommendation is based on preclinical evidence showing triple-antibiotic ointment results in faster reepithelialization (100% vs 55% at day 21) and reduced scar depth compared to silver-containing dressings 4.

Alternative: Paraffin Gauze

• Paraffin gauze can be applied directly as a primary dressing, creating a non-adherent barrier that protects the wound while allowing exudate drainage 3
• May be used in conjunction with greasy emollients (50% white soft paraffin with 50% liquid paraffin) 3

Silver Sulfadiazine: Use With Caution

While FDA-approved for second-degree burns 5, avoid prolonged use of silver sulfadiazine on superficial burns as it may delay healing 1, 2, 3. If used, apply once to twice daily at approximately 1/16 inch thickness 5.

Dressing Application

• Cover with a clean, non-adherent dressing (such as paraffin gauze) after applying topical agent 1, 2, 3
• Change dressings every 1-2 days based on wound condition 3
• Reassess the wound at each dressing change to monitor healing and check for infection 3
• Reapply topical agent immediately after hydrotherapy or if removed by patient activity 5

Pain Management Algorithm

Start with over-the-counter analgesics (acetaminophen or NSAIDs), escalating to short-acting opioids for moderate-to-severe pain. 6, 1, 2

For severe pain or during dressing changes:

• Titrated intravenous ketamine combined with other analgesics 6, 2
• Inhaled nitrous oxide, especially when IV access unavailable 6, 2
• General anesthesia for highly painful procedures 6
• Consider multimodal analgesia using validated comfort assessment scales 6

Non-Pharmacological Adjuncts

• Virtual reality or hypnosis techniques may reduce pain intensity and anxiety in stable patients 6
• Cooling limited burned surfaces and covering with fatty substances (e.g., Vaseline) may improve pain control 6

Antibiotic Considerations

Do NOT routinely prescribe systemic prophylactic antibiotics. 2 Reserve topical antibiotics for infected wounds only, not prophylactically on clean burns 2.

Monitor for Infection Signs:

• Increased pain beyond expected trajectory 3
• Redness extending beyond burn margins 3
• Swelling or purulent discharge 3
• Systemic antibiotics should be reserved for clinically evident infections 3

Mandatory Burn Center Referral Criteria

Refer immediately to a specialized burn center for: 1, 2

• Burns involving face, hands, feet, or genitalia (regardless of size) 1, 2
• Burns covering >10% body surface area in adults (>5% in children) 1, 2
• Signs of inhalation injury (soot around nose/mouth, difficulty breathing) 1

The American Burn Association mandates burn center referral for burns of the feet, hands, face, or genitalia due to high risk of functional impairment and potential need for surgical intervention 2.

Special Considerations for Oxygen Therapy

• Avoid oil-based emollients on or near nostrils when oxygen is in use due to combustion risk in oxygen-enriched environments 1
• Petrolatum-based antibiotic ointments are safe on facial burns in patients receiving oxygen 1
• Ensure hands are dried after using alcohol-based sanitizers before applying topical agents 1

Critical Pitfalls Summary

The most common errors include applying ice (causes tissue damage), breaking blisters (increases infection), using home remedies, delaying medical attention for burns in sensitive areas, and discharging patients with foot/hand/face burns without burn center consultation 1, 2, 3.