Could the thickened, gray‑ish, non‑wet patch with an excoriation‑like surface on a chest tattoo represent a contusion or a burn wound?

Clinical Assessment of a Thickened, Grayish, Non-Wet Patch with Excoriation on a Tattooed Area

Based on the clinical description—thickened, grayish, dry skin with an excoriation-like surface overlying a tattoo—this presentation is most consistent with a superficial burn injury (likely second-degree) rather than a simple contusion, and requires immediate cooling and appropriate wound care to prevent progression and infection.

Distinguishing Features Between Burn and Contusion

Burns Present With:

• Gray or white discoloration indicating deeper dermal injury with compromised blood flow 1
• Thickened, leathery texture from coagulated proteins in thermal injury 1
• Dry surface in full-thickness or deep partial-thickness burns where capillary perfusion is lost 1
• Excoriation or denuded appearance from epidermal loss, which exposes the raw dermis 1

Contusions Present With:

• Red, purple, or blue-black discoloration from subcutaneous hemorrhage, not gray 2
• Soft, boggy texture from blood accumulation in tissues 2
• Intact epidermis unless there is associated abrasion 2
• Gradual color evolution over days (red→purple→green→yellow) as hemoglobin breaks down 2

The grayish color and thickened, dry texture strongly favor a burn injury over contusion. 1

Immediate Management Algorithm

Step 1: Cool the Burn Immediately

• Apply clean running water for 5-20 minutes until pain is relieved, which reduces tissue damage, edema, and depth of injury 1, 3
• Never apply ice directly, as this causes additional tissue ischemia and damage 1
• Monitor for hypothermia during prolonged cooling, especially in children 4

Step 2: Assess Burn Depth and Extent

• Grayish color with dry surface suggests deep partial-thickness (deep second-degree) or full-thickness burn requiring specialist evaluation 1
• Measure total body surface area involved using the rule of nines or palm method 3
• Document location on the tattooed chest area 2

Step 3: Wound Care Protocol

• Leave any overlying loose skin in place as a biological dressing to reduce pain and infection risk 1
• Gently irrigate with warmed sterile water or saline to remove debris without driving bacteria deeper 1
• Apply greasy emollient (50% white soft paraffin with 50% liquid paraffin) over the entire burn surface, which significantly reduces hypertrophic scarring 1
• Cover with non-adherent dressing (Mepitel or Telfa) directly over the emollient, then apply secondary foam dressing to collect exudate 1

Step 4: Pain Management

• Provide adequate analgesia with over-the-counter acetaminophen or NSAIDs before and during wound care 1, 3
• Consider short-acting opioids for severe pain during dressing changes 1

Step 5: Infection Prevention

• Do NOT apply topical antibiotics routinely to uninfected burns, as this promotes antimicrobial resistance without proven benefit 1, 4
• Reserve topical antimicrobials (such as silver sulfadiazine) only for sloughy or obviously infected areas, guided by local microbiological advice 1, 3
• Monitor for infection signs at each dressing change: increasing pain, redness, swelling, purulent discharge, fever, or systemic signs 1

Mandatory Specialist Referral Criteria

Refer immediately to a burn center if ANY of the following apply: 1, 3

• Burns involving face, hands, feet, or genitals (this chest tattoo location may not require referral based on location alone)
• Burns covering >10% body surface area in adults or >5% in children
• Full-thickness burns (suggested by gray color and dry texture)
• Signs of infection developing despite appropriate care
• Bilateral involvement of any anatomic area
• Any signs of inhalation injury (facial burns, difficulty breathing, soot around nose/mouth)

Critical Pitfalls to Avoid

• Never apply butter, oil, or home remedies, as this increases infection risk and delays healing 1
• Never completely unroof blisters, as this significantly increases infection risk 1
• Never use routine topical antibiotics on uninfected wounds, as silver sulfadiazine was associated with increased infection (OR 1.87) and longer hospital stays (mean 2.11 days longer) 4
• Never delay cooling the burn—immediate cooling for 5-20 minutes reduces need for surgical excision and grafting 1
• Never ignore the gray color and dry texture, as these indicate deeper injury requiring specialist evaluation 1

Tattoo-Specific Considerations

• Tattoo pigment does not prevent burn assessment, though it may obscure color changes 5, 6
• Inflammatory tattoo reactions (allergic or foreign body reactions) typically present as papulonodular elevations, plaques, or excessive hyperkeratosis, not as acute grayish excoriated patches 6, 7
• The acute presentation with excoriation favors thermal injury over chronic tattoo complications 6

Follow-Up Monitoring

• Re-epithelialization timing depends on burn depth: superficial partial-thickness heals in 7-14 days, deep partial-thickness in 14-21 days 1
• Change dressings every 2-3 days or when strike-through occurs, monitoring for infection signs 1
• Assess for hypertrophic scarring during healing, which is reduced by greasy emollient application 1