How should I manage a skin burn in an adult, including initial first aid, outpatient treatment for a superficial partial‑thickness burn covering less than 10 % total body surface area, and criteria for transfer to a specialized burn center with fluid resuscitation?

Skin Burn Management

Immediate First Aid

Immediately cool the burn with clean running water for 20 minutes to limit tissue damage, reduce pain, and improve healing outcomes. 1

• Remove all jewelry and tight clothing from the affected area before swelling occurs to prevent vascular compromise 2, 3
• Use running tap water at approximately 15°C (cool tap water temperature) rather than ice or very cold water 4
• Do not apply ice directly to burns as this causes additional tissue damage 3, 5, 4
• Do not apply butter, oil, toothpaste, or other home remedies as these impair healing and increase infection risk 3, 5, 6
• Monitor young children (<4 years) during cooling for signs of hypothermia (shivering, visible coldness), especially if cooling large body surface areas 1
• Only cool burns <20% TBSA in adults or <10% TBSA in children to avoid hypothermia risk 5

Wound Care for Superficial Partial-Thickness Burns (<10% TBSA)

After cooling, proceed with systematic wound preparation:

• Clean the wound with tap water, isotonic saline, or antiseptic solution (such as chlorhexidine 1/5000) 1, 2, 5
• Do not break or pop blisters as this significantly increases infection risk 2, 3
• If blisters are tense, decompress by piercing and expressing fluid while leaving the blister roof intact as a biological dressing 1
• Apply petrolatum-based ointment (50% white soft paraffin with 50% liquid paraffin) over the entire burn surface 1, 2
• Cover with non-adherent dressing such as Mepitel, Telfa, or Xeroform 1, 2, 3
• Apply secondary foam or absorbent dressing to collect exudate 1
• Change dressings daily for optimal monitoring 3

Critical Dressing Pitfall

Avoid prolonged use of silver sulfadiazine on superficial partial-thickness burns as it is associated with delayed healing and potentially increased infection risk 3, 5

Pain Management

• Administer oral acetaminophen or NSAIDs for mild-to-moderate pain control 2, 3, 5
• Pre-medicate 30-60 minutes before dressing changes 5
• For severe pain during initial dressing, consider short-acting opioids if available 5
• Cooling and covering with fatty substances like petrolatum also reduce pain 5

Criteria for Burn Center Transfer

Transfer to a specialized burn center is mandatory for:

Adults (American Burn Association criteria) 5:

• Partial-thickness burns >10% TBSA
• Full-thickness burns >5% TBSA
• Burns involving face, hands, feet, genitalia, perineum, or major joints (regardless of size) 3, 5
• Electrical burns (including lightning injury)
• Chemical burns
• Inhalation injury
• Circumferential burns of extremities or chest
• Age >75 years with comorbidities and any significant burn 5

Children (American Academy of Pediatrics criteria) 5:

• Partial-thickness burns >10% TBSA
• Full-thickness burns >5% TBSA
• Age <1 year with any significant burn
• Burns to function-sensitive areas (face, hands, feet, perineum, flexures)
• Any electrical or chemical burns

Special Considerations:

• All partial-thickness facial burns require burn center evaluation regardless of size due to high risk of functional and cosmetic disability 3
• Burns on toes require specialist consultation as these are function-sensitive areas with higher risk of impairment 2
• Any partial-thickness or full-thickness hand burns require immediate specialist referral regardless of size 5

Fluid Resuscitation (For Burns Requiring Transfer)

• Initiate fluid resuscitation in adults when burns involve ≥15% TBSA 1
• Use modified Parkland formula for SJS/TEN and extensive burns: body weight (kg) × % BSA epidermal detachment = mL/hour over first 24 hours 1
• Avoid overaggressive fluid resuscitation as this may cause pulmonary, cutaneous, and intestinal edema 1
• Requirements for thermal burns are typically lower than standard Parkland formula predictions 1

Outpatient Management Criteria

Burns appropriate for outpatient management with proper wound care, pain control, and close follow-up 5:

• Adults: <10% TBSA, no deep burns >5%, no function-sensitive area involvement, no inhalation injury
• Children: <10% TBSA, no deep burns >5%, age >1 year, no function-sensitive area involvement

Red Flags Requiring Immediate Medical Attention

• Signs of infection: increasing redness, warmth, purulent drainage, fever 3, 5
• Increasing pain not controlled by over-the-counter medications 3
• Difficulty breathing or swallowing 3
• Evidence of clinical deterioration, extension of epidermal detachment, or delayed healing 1
• Subepidermal pus or local sepsis 1

Follow-Up Care

• Monitor for signs of infection during healing 2
• Keep burn area clean and dry, changing dressings as recommended 2
• Continue pain management as needed 2
• For healed burns with hypopigmentation, dryness, or itching, apply petrolatum-based ointment with hydrocortisone 1% cream until symptoms resolve 5
• Avoid prolonged potent steroids as they can cause further hypopigmentation 5