What is the appropriate initial management of a second-degree (partial-thickness) burn?

Initial Management of Second-Degree Burns

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

Immediate First Aid (First 20 Minutes)

Active Cooling

• Cool the burn with clean running water for 5-20 minutes to limit tissue damage and reduce pain 3, 1, 2
• Do NOT apply ice directly to burns, as this causes further tissue damage 1
• Monitor preadolescent children for signs of hypothermia during the cooling process 1
• The American Heart Association strongly recommends active cooling despite low-quality evidence, prioritizing decreased burn depth over potential risks of infection or hypothermia 3

Remove Constricting Items

• Remove all jewelry from the affected area immediately before swelling occurs to prevent vascular compromise and ischemia 1, 2

Pain Management

• Administer over-the-counter acetaminophen or NSAIDs for pain control 1, 2

Wound Care After Cooling

Topical Treatment

• Apply petrolatum-based antibiotic ointment (triple antibiotic ointment with bacitracin, neomycin sulfate, and polymyxin B) after cooling 1
• Avoid prolonged use of silver sulfadiazine cream (Silvadene) on superficial burns, as the American Burn Association notes it may delay healing 1
• Silver sulfadiazine should only be applied to sloughy (non-viable) areas of second-degree burns, guided by local microbiological assessment 1

Dressing Application

• Cover with a clean, non-adherent dressing after applying petrolatum-based antibiotic ointment 1, 2
• If silver sulfadiazine is used (for deeper burns with non-viable tissue), apply once to twice daily to a thickness of approximately one-sixteenth of an inch, and reapply after hydrotherapy 4

Criteria for Immediate Burn Center Referral

Mandatory Referral Situations

• Burns covering >10% body surface area in adults (>5% in children) require specialized burn center treatment 1, 2, 5
• All deep partial-thickness burns require burn center referral 5
• Second-degree burns involving the face, hands, feet, or genitalia require specialized care regardless of size 1
• Signs of inhalation injury (soot around nose/mouth, singed nasal hairs, difficulty breathing) mandate immediate emergency medical services activation 1, 2

Infection Management

Antibiotic Use

• Do NOT use prophylactic systemic antibiotics for second-degree burns 1
• Initiate antibiotics only when clinical signs of infection appear (increased pain, erythema, swelling, or purulent discharge) 1
• For patients under specialist care, obtain bacterial and candidal cultures from burn lesions on alternate days throughout the acute phase 1

Critical Pitfalls to Avoid

• Never break or pop blisters, as this significantly increases infection risk 1
• Never apply butter, oil, or other home remedies to burns 1
• Avoid oil-based emollients on or near the nostrils when oxygen is in use due to combustion risk in oxygen-enriched environments 1
• Do not delay seeking medical attention for burns in sensitive areas (face, hands, feet, genitalia) or those covering large surface areas 1
• Inadequate cooling immediately after injury may lead to progression of burn depth 5

Special Considerations

Patients with Diabetes

• Consider early referral to a burn center, as these patients are at increased risk of complications and infection 6

Ongoing Wound Care

• Continue treatment until satisfactory healing occurs or the burn site is ready for grafting 4
• Superficial partial-thickness burns may take up to three weeks to heal 6