What are the guidelines for outpatient management of a patient with minor to moderate burns, less than 10% of total body surface area?

Outpatient Burn Management

Immediate Assessment and Triage

For burns less than 10% TBSA in adults (or <10% in children) without deep burns >5%, function-sensitive area involvement, or inhalation injury, outpatient management is appropriate with proper wound care, pain control, and close follow-up. 1, 2

Criteria Requiring Burn Center Referral (NOT Outpatient Candidates)

• Adults: TBSA >10%, deep burns >5%, burns to face/hands/feet/perineum/flexures, age >75 with comorbidities, electrical or chemical burns 1
• Children: TBSA >10%, deep burns >5%, age <1 year, burns to function-sensitive areas, any electrical/chemical burns 1
• Any partial-thickness or full-thickness hand burns require immediate specialist referral regardless of size 3

Initial Wound Care Protocol

Cooling Phase

• Cool burns with clean running water for 5-20 minutes immediately after injury to limit tissue damage and reduce pain 1, 3
• Only cool burns <20% TBSA in adults or <10% TBSA in children, as larger burns risk hypothermia 1, 2
• Never apply ice directly, as this causes additional tissue damage 4

Wound Cleansing

• Clean wounds with tap water, isotonic saline, or antiseptic solution in a clean environment 1, 2
• Gently debride loose tissue and address blisters per clinical judgment 1
• Perform wound care only after addressing pain adequately 1, 2

Dressing Selection and Application

Primary Dressing Options (Listed by Evidence Quality)

Modern occlusive dressings are superior to silver sulfadiazine for outpatient partial-thickness burns, providing faster healing, less pain, and better cost-effectiveness. 5, 6, 7

First-Line: Hydrofiber with Silver (Aquacel Ag)

• Apply and change every 3 days 6
• Heals partial-thickness burns in 10±3 days versus 13.7±4 days with silver sulfadiazine 6
• Significantly reduces pain scores (4.1 vs 6.1 on day 1, p<0.02) 6
• Lower total treatment cost ($52 vs $93) 6
• Reduces dressing change frequency, improving compliance 6

Second-Line: Hydrocolloid with SSD (Urgotul SSD)

• Change every few days based on exudate 8
• Heals in 10±4 days versus 12±6 days with standard silver sulfadiazine 8
• Dramatically reduces pain (score 3±1 vs 6±2, p<0.05) 8
• Comparable infection rates and costs 8

Third-Line: Biosynthetic Dressing (Biobrane)

• For properly selected superficial partial-thickness burns 7
• Heals in 10.6±0.8 days versus 15.0±1.2 days with silver sulfadiazine 7
• Lower pain at 24 hours (1.6±0.8 vs 3.6±1.3, p<0.001) 7
• Improved compliance (88.6% vs 63.2% attendance) 7

Traditional Option: Silver Sulfadiazine 1%

• Avoid prolonged use on superficial burns, as it delays healing and increases infection risk 1, 2, 9
• Apply once to twice daily to thickness of 1/16 inch 9
• Reapply after any removal from patient activity 9
• Reserve for large or contaminated burns where antiseptic properties outweigh healing delay 1, 2

Dressing Technique

• Apply chosen dressing to cover entire burn surface 9
• Cover with non-adherent secondary dressing (Xeroform, Mepitel, or clean cloth) 2, 3, 4
• Dressings optional with silver sulfadiazine but recommended for patient comfort 9

Pain Management Protocol

Acute Pain Control

• Administer oral acetaminophen or NSAIDs for mild-moderate pain 3, 4
• For severe pain during initial dressing: consider short-acting opioids or ketamine if available 1
• Titrate analgesics carefully due to burn-induced inflammation and capillary leakage 1

Ongoing Pain Management

• Pre-medicate 30-60 minutes before dressing changes 1
• Modern occlusive dressings dramatically reduce pain compared to daily silver sulfadiazine changes 8, 6, 7
• Non-pharmacological: cooling (initial phase only), covering with fatty substances like petrolatum 1, 4

Follow-Up Schedule and Monitoring

Frequency of Reassessment

• Reevaluate within 24-48 hours initially, then every 3-7 days depending on dressing type 5
• Daily visits required only for silver sulfadiazine (major disadvantage) 6, 7
• Every 3-day visits adequate for hydrofiber or hydrocolloid dressings 8, 6

Signs Requiring Immediate Medical Attention

• Increased redness, warmth, purulent drainage, or fever (infection) 4, 5
• Increasing pain rather than improvement 4
• No healing progress after 1-2 weeks of treatment 4, 5
• Wound conversion to deeper appearance 5

Critical Pitfalls to Avoid

• Never use topical antibiotics as first-line prophylaxis; reserve only for infected wounds 2
• Do not apply butter, oil, or other home remedies 4
• Avoid prolonged silver sulfadiazine on superficial burns (delays healing) 1, 2
• Do not cool burns >20% TBSA in adults or >10% in children (hypothermia risk) 1, 2
• Never delay specialist referral for function-sensitive area burns to attempt outpatient management 3

Expected Healing Timeline

• Superficial partial-thickness burns: 10-14 days with modern dressings 8, 6, 7
• Deeper partial-thickness burns: 14-21 days, may require specialist evaluation 5
• If not healing by 2 weeks, refer to burn specialist for possible grafting 9, 5

Post-Healing Management

For healed burns with hypopigmentation, dryness, or itching:

• Apply petrolatum-based ointment with hydrocortisone 1% cream 4
• Continue daily until symptoms resolve 4
• Avoid prolonged potent steroids (cause further hypopigmentation) 4
• Repigmentation depends on burn depth; superficial burns repigment better 4