What is the recommended treatment for a patient with a 2nd degree burn?

Treatment of Second-Degree Burns

Immediately cool the burn with clean running water for 5-20 minutes, then apply petrolatum-based antibiotic ointment (such as triple antibiotic ointment containing bacitracin, neomycin, and polymyxin B) and cover with a non-adherent dressing. 1, 2

Initial Management

Immediate Cooling

• Cool the burn with clean running water for 5-20 minutes to limit tissue damage and reduce pain 1, 2
• Monitor preadolescent children for hypothermia during cooling 1
• Remove jewelry from the affected area before swelling occurs to prevent vascular compromise 1, 2

Pain Control

• Administer acetaminophen or NSAIDs for pain management 1, 3
• For severe burn-induced pain requiring hospitalization, use multimodal analgesia with titrated medications based on validated assessment scales 4
• Titrated intravenous ketamine can be combined with other analgesics for severe pain 4

Wound Cleaning and Preparation

• Clean the wound with tap water, isotonic saline solution, or antiseptic solution before applying any dressing 2

Topical Treatment Options

First-Line Recommendation

Apply petrolatum-based antibiotic ointment (triple antibiotic containing bacitracin, neomycin sulfate, and polymyxin B) as the primary topical agent 1, 2

Alternative Options

• Paraffin gauze can be applied directly to the burn wound as a primary dressing, optionally combined with 50% white soft paraffin and 50% liquid paraffin 2
• Aloe vera has demonstrated faster healing than silver sulfadiazine (15.9 vs 18.7 days) and can be considered 5
• Honey is an acceptable alternative topical agent 3

Silver Sulfadiazine: Important Caveat

• While FDA-approved for second-degree burns 6, avoid silver sulfadiazine for prolonged use on superficial burns as it may delay healing 1, 2, 3
• If used, consider combining with hyaluronic acid (0.2% HA + 1% SSD), which showed 4.5 days faster healing compared to SSD alone 7

Dressing Application

• Cover with a clean, non-adherent dressing after applying topical agent 1, 2
• Change dressings every 1-2 days based on wound condition 2
• Reassess the wound during each dressing change to monitor healing progress and check for infection 2

Blister Management

Preserve intact blisters as a biological dressing to help with pain management and promote healing 3

• Loosely cover intact blisters with a clean cloth or non-adherent dry dressing 3
• If drainage is necessary, pierce the blister at the base with a sterile needle (bevel facing up) while preserving the blister roof 3
• After drainage, apply petrolatum-based antibiotic ointment and a clean non-adherent dressing 3

When to Seek Specialized Care

Mandatory Referral Criteria

• Burns involving the face, hands, feet, or genitalia require specialized care regardless of size 1, 2, 3
• Burns covering >10% body surface area in adults (>5% in children) should be treated in a specialized burn center 1, 2, 3
• Signs of inhalation injury (soot around nose/mouth, difficulty breathing) require immediate medical attention 1

Infection Monitoring and Treatment

• Monitor for increased pain, redness extending beyond burn margin, swelling, or purulent discharge 2
• Do not use systemic antibiotics prophylactically—reserve them only for clinically evident infections 2
• Topical antimicrobials can be combined with paraffin gauze when necessary for contaminated wounds 2

Critical Pitfalls to Avoid

• Never apply ice directly to burns—this causes further tissue damage 1, 2, 3
• Never apply butter, oil, or other home remedies 1
• Never break or pop blisters unnecessarily—this significantly increases infection risk 1
• Avoid oil-based emollients near nostrils in patients on oxygen therapy due to combustion risk 1
• Do not delay seeking medical attention for burns in sensitive areas or covering large surface areas 1

Special Considerations for Oxygen Therapy

• Petrolatum-based antibiotic ointments are safe to use on facial burns in patients receiving oxygen therapy 1
• The primary fire hazard relates to oil-based products applied directly to oxygen delivery sites (nostrils) 1
• Ensure hands are adequately dried after using alcohol-based hand sanitizers before applying topical agents 1