What is the best course of treatment for a patient with second or third-degree burns on the hands and palms, specifically involving the first three fingers on the left hand, two fingers on the right hand, and a portion of the lateral side of the palms, who has developed multiple blisters?

Management of Second-Degree Burns with Multiple Blisters on Bilateral Hands and Palms

Immediate Cooling and Pain Control

Cool the burn wounds immediately with cold tap water (15-25°C) for 5-20 minutes to limit burn depth, reduce pain, and improve healing outcomes. 1, 2, 3

• Cooling is effective for up to 3 hours after injury and significantly reduces the need for skin grafting when performed for 20-40 minutes. 3
• Do not apply ice directly to the burns, as this causes tissue ischemia and additional damage. 1, 2, 4
• Provide adequate pain control with over-the-counter analgesics (acetaminophen or NSAIDs) before wound care. 2

Blister Management

Leave intact blisters in place and pierce only the largest blisters with a sterile needle, draining the fluid while leaving the blister roof intact as a natural biological dressing. 1, 2

• The overlying epidermis acts as a natural biological dressing that protects the wound, reduces pain, and decreases infection risk. 2
• For blisters that have already ruptured, leave the overlying skin in place rather than completely removing it. 2
• If blisters are particularly large or interfere with hand function, pierce them with a sterile needle to release fluid but preserve the blister roof. 1

Wound Cleaning

Clean all burn wounds thoroughly with warmed tap water, normal saline, or dilute antiseptic solution in a clean environment after adequate pain control is established. 1, 2, 3

• Thorough irrigation removes foreign matter and debris, which is essential for preventing infection. 1, 2
• Gentle cleaning with warmed sterile water or saline is preferred to avoid driving bacteria deeper into tissues. 2

Wound Dressing Application

Apply a greasy emollient such as 50% white soft paraffin with 50% liquid paraffin over the entire burn surface, including intact blisters, then cover with a non-adherent dressing such as Mepitel or Telfa. 2

• Moist dressings significantly reduce complications including hypertrophic scarring compared to dry dressings. 2, 3
• Apply petrolatum-based ointment or antibiotic ointment with a clean nonadherent dressing as an alternative. 2, 3
• Cover with a secondary foam or burn dressing to collect exudate and protect from contamination. 2

Antimicrobial Management

Reserve topical antibiotics for infected wounds only; do not apply them routinely to all burn wounds. 1, 2, 3, 4

• Silver sulfadiazine should be applied to a thickness of approximately 1/16 inch once to twice daily if infection develops, but avoid prolonged use on superficial burns as it may delay healing. 1, 3, 5
• Topical antimicrobial agents should be guided by local microbiological advice and reserved only for sloughy or obviously infected areas. 2
• Do not administer systemic antibiotic prophylaxis routinely. 1, 3

Monitoring for Infection

Monitor closely for signs of infection including increasing pain, redness, swelling, purulent discharge, fever, or systemic signs of sepsis. 2, 4

• Re-evaluate dressings daily if possible. 1
• Bacterial colonization typically begins with Gram-positive bacteria from endogenous skin flora, followed by Gram-negative bacteria within a week. 4

Mandatory Burn Center Referral

Refer this patient immediately to a burn center because bilateral hand involvement with second-degree burns mandates specialist evaluation regardless of total body surface area. 2, 3, 4

• Burns involving the hands require specialized burn center treatment due to high risk of functional impairment. 2, 3, 4
• Contact a burn specialist immediately to determine severity, guide management, and arrange transfer, as specialist management is associated with better survival, reduced complications, shorter hospital stays, and lower costs. 3, 4
• All full-thickness burns, bilateral hand involvement, and burns to high-risk anatomic locations mandate specialist evaluation even if burns appear minor. 2

Critical Pitfalls to Avoid

• Never completely unroof blisters, as this significantly increases infection risk. 2
• Never apply butter, oil, or home remedies to burns, as this increases infection risk and delays healing. 2
• Never use routine topical antibiotics on uninfected wounds, as this promotes antimicrobial resistance. 1, 2, 3, 4
• Never delay specialist referral for bilateral hand burns, as hands are high-risk anatomic locations requiring specialized care. 2, 3, 4
• Never apply ice directly to burns, as it causes additional tissue damage. 1, 2, 4