Burn disease: stages and treatment

Burn disease is a combination of local and systemic reactions to thermal, chemical, electrical, or radiation damage to the skin and underlying tissues. With significant surface area and depth of injury, the process extends far beyond the skin wound: burn shock develops with significant plasma loss, microcirculation and respiratory dysfunction, followed by a protracted hypermetabolic and inflammatory phase. It is these systemic disturbances that determine the severity of the disease, the need for intensive care, and the risk of death. [1]

Even with moderate burns, dehydration, infections, pain, thermoregulatory disorders, and psychoemotional consequences are often complicated. Severe burns are characterized by a persistent hypermetabolic response, insulin resistance, catabolism, and muscle loss, requiring early nutritional and rehabilitative support. The sooner proper care is initiated, the lower the risk of complications and disability. [2]

Understanding the depth and extent of damage is critical even at the first contact with the victim: this determines the choice of treatment site, the volume of infusion therapy, the indications for surgery, and the prognosis. To assess the extent of damage, the rule of nines is used in adults and a special Lund-Browder diagram is used in children, and the depth is determined based on clinical signs, taking into account the possibility of progression within the first 24 hours. [3]

Today, standards of care are based on the clinical guidelines of the American Burn Association and international consensuses: they emphasize the priority of early airway assessment, controlled fluid therapy, careful wound care, timely surgery, adequate pain relief, and nutritional support. The leading approach is multidisciplinary, with the early involvement of intensivists, burn surgeons, pain specialists, nutritionists, and rehabilitation specialists. [4]

Code according to ICD-10 and ICD-11

In the International Classification of Diseases, Tenth Revision, thermal and chemical burns are coded in sections T20-T32, which specify the body regions and depth of injury. A separate entry, T31, indicates the percentage of body surface area affected by the burn, which is used for medical statistics, treatment planning, and prognosis. External causes are recorded in sections X10-X19, including contact with hot liquids and fire. [5]

In the eleventh revision, the classification groups diseases into sections for skin injuries from temperature, chemicals, and other sources, including multiple sites of injury. The codes represent a continuous range, allowing for more precise specification of anatomical sites and the type of agent. The physician selects a code based on the mechanism of injury, depth, and distribution across body parts. [6]

Table 1. Codes according to ICD-10 and ICD-11

System	Code range	What do they mean?	Note
ICD-10	T20-T25	Burns of the head, neck, torso, upper and lower extremities	By localization and depth
ICD-10	T31	Percentage of body surface area affected by burns	Used for total gravity
ICD-10	X10-X19	External causes of burns	Mechanism of injury
ICD-11	ND90-NE2Z	Thermal and chemical burns by region	Detailed blocks
ICD-11	Multiple area codes	Burns to multiple areas of the body	For combined lesions

Epidemiology

The World Health Organization estimates that approximately 180,000 people die from burns annually worldwide, with the majority of deaths occurring in low- and middle-income countries. Children and women are at increased risk in the home, particularly when using open flames and unsafe stoves. Even if they survive, a high proportion of victims suffer long-term functional limitations and significant scarring. [7]

In the United States, hundreds of thousands of people with burns seek medical care each year, and specialized centers record tens of thousands of hospitalizations. Mortality rates at certified burn centers remain relatively low due to standardized care. These data illustrate the role of service organization and protocols in reducing mortality. [8]

In Europe, burn rates vary by country, but there is a general trend toward a reduction in severe cases thanks to prevention, smoke detectors, water temperature regulation, and workplace safety. However, older age, underlying medical conditions, and inhalation injury remain key predictors of poor outcomes. [9]

Global registries and reviews highlight the heterogeneity of the distribution of causes. In the home, burns from hot liquids in children and flame burns in adults predominate, while in the workplace, thermal and chemical injuries, including electrical injuries, predominate. Epidemiological data are important for targeted prevention and healthcare resource planning. [10]

Table 2. Epidemiological characteristics

Indicator	Globally	Comment
Annual mortality	≈ 180,000 people	A large proportion is in low-income countries
Main household reasons	Hot liquids in children, flames in adults	Depends on the region
Risk reduction factors	Smoke detectors, water temperature control, safe stoves	Effective at the population level
Key predictors of death	Age, area of damage, inhalation injury	Used in prognostic scales

Reasons

Thermal burns occur when exposed to flames, hot liquids, hot surfaces, or steam. Common burns include spills of boiling water in children and clothing fires in adults, and contact with hot metal and steam in the workplace. The depth and severity of the burn depend on the temperature of the agent and the time of contact. [11]

Chemical burns are caused by acids and alkalis, as well as oxidizing agents. They can penetrate deeper than initially apparent and continue to damage tissue until the agent is completely neutralized and removed. Early and prolonged rinsing with running water and knowledge of the specific substance are essential for toxicological assessment. [12]

Electrical burns are often associated with damage to muscles, blood vessels, and nerves along the current path, and visible entry and exit points do not reflect the extent of the deep injury. Arrhythmias, rhabdomyolysis, and acute renal failure are possible, requiring cardiac monitoring and muscle damage assessment. [13]

Radiation burns are less common and are associated with medical procedures, industrial accidents, or solar radiation. Damage can progress slowly due to the interaction of ionizing radiation with tissue, so long-term monitoring with the participation of related specialists is necessary. [14]

Risk factors

An increased risk of severe disease is observed in young children and the elderly due to thin skin, lower immune reserves, and underlying medical conditions. Even relatively moderate lesions in these groups can lead to significant systemic impairment and the need for intensive care. [15]

Inhalation injury during a fire significantly worsens the prognosis: damage to the respiratory tract by combustion products increases the risk of respiratory failure, pneumonia, and death. The outcome is also affected by concomitant trauma, including traumatic brain injury and associated injuries. [16]

Social and household factors are important for primary prevention: lack of smoke detectors, use of open flames at home, overheating of hot water systems, and inadequate supervision of children. Working with hot surfaces and aggressive chemicals without protective equipment increases the risk of injury in adults. [17]

Medical risk factors for complications include diabetes, cardiovascular disease, chronic infections, smoking, and alcohol abuse. These conditions impair healing, increase the risk of infection, and complicate infusion therapy and rehabilitation. [18]

Table 3. Risk factors for severe course of the disease

Category	Specific factors	Why is it dangerous?
Age	Children and the elderly	Thin skin, small reserves
Mechanism	Flame, smoke inhalation, electricity	Deep and combined lesions
Social	No smoke detectors, open fire	High probability of late detection
Medical	Diabetes mellitus, heart failure	Slow healing, infections

Pathogenesis

In the first hours after a major burn, burn shock develops: massive plasma leakage through damaged capillaries leads to a decrease in circulating blood volume, reduced cardiac output, and tissue hypoperfusion. This condition requires timely infusion therapy to restore perfusion and prevent multiple organ failure. [19]

A persistent hypermetabolic response then develops, with hormonal and immune shifts: increased energy and protein requirements, insulin resistance, and increased lipolysis and proteolysis, leading to muscle loss and functional deficits. These changes can persist for months, requiring tailored nutritional and medicinal support. [20]

Inhalation trauma and systemic inflammation exacerbate lung damage, impairing gas exchange and predisposing to infection. Added to this are the toxic effects of carbon monoxide and cyanide, necessitating early oxygenation, carboxyhemoglobin monitoring, and the use of antidotes when indicated. [21]

At the immune level, a complex combination of hyperinflammation and secondary immunodeficiency is observed, predisposing to sepsis and chronic inflammation in scars. Modern models of volume regulation and renal function after burns help better understand the dynamics of the response and optimize infusion therapy algorithms. [22]

Symptoms

Local manifestations depend on the depth: superficial burns cause severe pain and redness, superficial partial-thickness burns are accompanied by blisters and a moist surface, and deep partial-thickness and full-thickness burns appear pale, waxy, or charred and may be slightly painful due to the destruction of nerve endings. Assessment is based on color, capillary reaction, sensitivity, and the presence of blisters. [23]

Systemic manifestations of extensive burns include weakness, thirst, chills, decreased urine output, tachycardia, and signs of microcirculatory impairment. In severe cases, confusion, shortness of breath, and hypotension rapidly develop, requiring emergency care and monitoring in an intensive care unit. [24]

Signs of inhalation injury include facial burns, singed nasal hair, hoarseness, a sooty cough, shortness of breath, airway spasms, and decreased blood oxygen saturation. These symptoms are especially concerning after a fire in a confined space and require early intubation and bronchoscopy. [25]

In children and the elderly, any symptoms may progress more rapidly than in middle-aged adults due to their lower physiological reserves. Even with a small lesion, severe pain, dehydration, and impaired thermoregulation may develop, necessitating a low level of suspicion and early medical attention. [26]

Classification, forms and stages

Burn depth is classified as superficial, partial, or full-thickness. Superficial partial-thickness burns typically heal within approximately 14 days, deep partial-thickness burns take longer and often require surgical closure, and full-thickness burns always require surgical intervention. [27]

The affected area is expressed as a percentage of body surface area. For adults, the rule of nines is often used, while for children, the Lund-Browder diagram is used, which takes into account age-related proportions. For a rough estimate, the area of the victim's palm can be used as one percent. [28]

The clinical dynamics are divided into an early phase of shock with intravascular volume deficiency, a phase of hypermetabolism and inflammation with the risk of infection and multiple organ dysfunction, and a phase of healing and rehabilitation, where the key objectives are restoration of function, prevention of contractures, and correction of cicatricial changes. This phased approach sets guidelines for treatment tactics. [29]

Prognostic scales are used to standardize severity. The recalculated Bowe index, which combines age and body surface area percentage and includes an adjustment for inhalation injury, is widely used. This helps rank risk and plan the intensity of therapy and the extent of surgery. [30]

Table 4. Depth and indicative features

Depth	Clinical signs	Expected healing
Surface	Redness, pain, no blisters	On your own, usually quickly
Partial superficial	Blisters, wet pink surface, pain	Up to approximately 14 days
Partial deep	Pale or mottled surface, decreased pain	Surgery is often required
Full-layer	Dry, waxy or charred surface, no pain	Mandatory surgical closure

Complications and consequences

Wound infections, pneumonia, and sepsis remain the leading causes of deterioration and death in extensive burns. Early surgical debridement, proper dressing management, and antibacterial vigilance reduce this risk, but routine prophylaxis with systemic antibiotics is not recommended due to low evidence of efficacy and the risk of resistance. [31]

Multiple organ dysfunction can affect the respiratory system, kidneys, and cardiovascular system. Electrical injuries and compartment syndrome increase the risk of rhabdomyolysis and acute renal failure, requiring monitoring of urine output and laboratory parameters. Acute respiratory failure is common with inhalation trauma. [32]

Chronic sequelae include hypertrophic scars, contractures, itching, cold or heat intolerance, chronic pain, and psychological distress. Early rehabilitation, proper scar management, and long-term monitoring by a multidisciplinary team are essential for their prevention and correction. [33]

Of particular importance are the nutritional and endocrine consequences: a prolonged hypermetabolic reaction leads to muscle loss, osteopenia, and a reduced quality of life. The role of targeted nutritional support, physical rehabilitation, and, in carefully selected patients, the use of drugs that reduce hypermetabolism has been proven. [34]

When to see a doctor

Immediate assistance is required for signs of respiratory damage, burns to the face, neck, or mouth, after a fire in a confined space, difficulty breathing, or hoarseness. These conditions can progress rapidly and be life-threatening. [35]

Burns of any depth on the hands, feet, face, perineum, or large joints, as well as any full-thickness burns or partial-thickness burns covering approximately 10 percent of the body surface area in adults, are considered severe. These cases require consultation or transfer to a specialized burn center. [36]

Chemical and electrical burns, signs of circulatory compression of the limb due to circumferential lesions, severe pain, pallor, or loss of pulse distal to the burn warrant emergency evaluation. In such situations, urgent release surgery may be required to preserve function. [37]

Even minor superficial burns require evaluation if there is severe pain, signs of infection, prolonged healing, or in patients with severe underlying medical conditions. A low threshold for seeking medical attention is especially important for children and the elderly. [38]

Diagnostics

The initial assessment follows the principles of casualty care: first, the airway, breathing, and circulation, followed by a full examination of the entire body surface. The depth and extent of the injury, the presence of inhalation trauma, and associated injuries are determined. If respiratory damage is suspected, early intubation is preferred. [39]

Clinical assessment of depth includes analysis of color, capillary response, tenderness, and sensitivity. In adults, the area is estimated using the rule of nines; in children, using the Lund-Browder diagram, which improves accuracy. For a rough estimate, the victim's palm can be used as one percent of the body surface area. [40]

Laboratory tests include complete blood counts, biochemistry profiles, coagulation parameters, arterial blood gas analysis, carboxyhemoglobin determination if carbon monoxide is suspected, and lactate determination when assessing perfusion. If cyanide poisoning is suspected, measurement of the relevant parameters and administration of an antidote are considered. [41]

Instrumental diagnostics, as indicated, include bronchoscopy to confirm inhalation injury, ultrasound or invasive monitoring during complex infusion therapy, and Doppler ultrasonography to assess blood flow distal to circumferential lesions. Radiography and computed tomography of the lungs are used in the development of respiratory complications. [42]

Table 5.

Step	What to do	For what
Airway and breathing	Oxygenation, intubation if necessary	Prevention of respiratory failure
Circulation	Access to the vein, start of infusion	Shock relief
Burn assessment	Depth and area, photographic recording	Treatment plan and prognosis
Laboratory tests	Gas composition, lactate, carboxyhemoglobin	Perfusion and inhalation assessment
Instrumental methods	Bronchoscopy, Doppler ultrasound	Confirmation of complications

Differential diagnosis

Some dermatological emergencies mimic burns in their appearance of epidermal detachment and mucosal damage. These include Stevens-Johnson syndrome and toxic epidermal necrolysis, which are characterized by drug-induced reactions, rapid epidermal necrosis, and systemic manifestations. Verification is based on medication history, clinical examination, and, if necessary, biopsy. [43]

Deep-seated infections of the skin and soft tissues, such as necrotizing fasciitis, require prompt recognition and surgical treatment. Characteristic features include rapid spread, severe pain out of proportion to the clinical picture, and signs of systemic toxicity. [44]

Phototoxic reactions such as phytophotodermatitis, chemical dermatitis, and contact dermatitis may resemble a thermal burn with blisters and erythema. Information about exposure to plant photosensitizers, cosmetics, irritants, and ultraviolet radiation, as well as the characteristic geometry of the rash, are important. [45]

The list of "burn-like" dermatoses includes rare deficiency states and hypersensitivity reactions. In controversial cases, a joint evaluation by a dermatologist and burn surgeon is required, with targeted biopsy and exclusion of drug-induced forms. [46]

Treatment

The first goal is to stabilize vital functions: ensuring airway patency, oxygenation, and monitoring breathing and circulation. If inhalation injury is suspected, early intubation is indicated; in cases of combustion product poisoning, high-flow oxygen is administered; and if signs of cyanide intoxication are present, hydroxocobalamin is administered as indicated. Warming, pain relief, and careful wound assessment are initiated simultaneously. [47]

Fluid therapy is individualized based on clinical goals, the most important of which is maintaining a urine output of approximately fifty milliliters per hour in an average-weight adult, or approximately half a milliliter per kilogram per hour. Current recommendations suggest starting with two milliliters per kilogram of body weight for each percent of body surface area affected by the burn, using Ringer's lactate solution and titrating the rate according to the response to avoid excessive fluid administration. In some cases of large lesions, the addition of albumin solutions is considered to reduce the total volume. [48]

First aid for wounds includes prolonged cooling with running water for fresh thermal injury, gentle cleansing and removal of exfoliated epidermis for superficial lesions, and application of modern atraumatic dressings. Data on topical silver preparations is conflicting, and the evidence base indicates no clear advantages of traditional silver sulfadiazine in healing speed and infection prevention compared to alternatives. Dressing selection is determined by the depth, location, and need for exudate control. [49]

Pain management is based on a multimodal approach, combining non-narcotic analgesics, opioids when indicated, adjuvant agents, and regional techniques. Low-dose ketamine is increasingly used for dressings and procedures as it offers a predictable analgesic effect and stable hemodynamics. Regional blocks are used for appropriate anatomy, reducing opioid requirements and improving procedural tolerability. [50]

Antibiotics are not prescribed prophylactically for uncomplicated burns due to the lack of proven benefit and the risk of antibiotic resistance. Exceptions include preoperative prophylaxis for skin grafting and certain situations involving mechanical ventilation, where the decision is made on an individual basis. The key to infection prevention is early wound closure, appropriate dressing selection, isolation, and regular microbiological evaluation if infection is suspected. [51]

Surgical tactics rely on early necrectomy with closure of defects with autologous skin grafts where healing is not expected within a reasonable timeframe. For circular, full-thickness lesions of the extremities and chest, releasing incisions are indicated to restore blood flow and ventilation. The timing and extent of interventions depend on hemodynamic stabilization, the area of the lesion, and the readiness of the recipient sites. [52]

Modern coverings and technologies accelerate healing and reduce pain. For superficial to moderately severe partial lesions, synthetic and biosynthetic coverings are used, reducing the frequency of dressing changes and the time to epithelialization. For extensive or deeply severe partial lesions, autologous sprayed skin cell technologies approved by regulatory agencies are used in select situations, including in combination with mesh autografts. [53]

Nutritional support begins early, preferably enterally. A high protein intake is recommended, ranging from one point five to two grams per kilogram of body weight per day in adults, with adjustments based on clinical dynamics. In some centers, beta-blockers are used in carefully selected patients to control hypermetabolism, and oxandrolone is used for anabolic support, with a benefit-risk assessment. [54]

Rehabilitation begins early and includes positioning, splints to prevent contractures, stretching and strengthening exercises, gait training, swelling management, and daily living skills training. Silicone gels and sheets, as well as compression garments, are used for scar prevention and correction, although the evidence base for the effectiveness of compression remains limited and contradictory. The decision is made on an individual basis, taking into account the patient's tolerance and preferences. [55]

Finally, tetanus prophylaxis is performed according to standard algorithms with assessment of vaccination status and administration of immunoglobulin in unvaccinated individuals or those with an unknown history of contaminated wounds. Routine use of antibiotics for tetanus prophylaxis is not indicated. [56]

Table 6. Key decisions in the first day

Direction	Basic goal	A guideline for practice
Respiratory tract	Prevention of obstruction and hypoxia	Early intubation if signs of damage are present
Infusions	Restore perfusion, avoid overload	Start with two milliliters per kilogram per percent, then titrate by diuresis
Wound	Reduce pain and bioburden	Cooling, cleaning, atraumatic coatings
Pain	Control of background and procedural pain	Multimodal analgesia, ketamine for procedures
Surgery	Remove necrosis and close the defect	Early necrectomy and skin grafting as indicated

Prevention

At the household level, smoke detectors, hot water temperature limits, safe stoves and ovens, and spill-proofing of hot drinks and soups are effective. Teaching children and adults how to safely handle fire and hot liquids reduces the risk of injury. [57]

In industry, personal protective equipment, control of procedures for handling chemicals and electrical installations, and evacuation and fire safety training remain crucial. Regular workplace audits and a safety culture reduce the frequency of serious incidents. [58]

At the healthcare level, educational programs, standardized hospitalization routes to burn centers, and registries that help set prevention priorities are in place. The benefits of safe stoves and improved home ventilation have been proven in vulnerable communities. [59]

On an individual basis, technical solutions can be helpful: thermostatic faucets, tip-resistant kettles, burner locks, and fire-resistant clothing and bedding materials. These measures are especially important for families with small children and the elderly. [60]

Forecast

The prognosis depends primarily on age, the area and depth of the lesion, and the presence of inhalation injury. For rapid risk assessment, the recalculated Bowe index is widely used, which combines age and the percentage of lesion area with a fixed value for inhalation injury. The higher the final score, the higher the risk of death and complications. [61]

Even in high-risk patients, outcomes are improved with early specialized care: controlled fluid therapy, timely surgery, and early nutritional support reduce the incidence of complications and length of hospital stay. A burn center referral system plays a significant role. [62]

Long-term outcomes depend on the quality of scar management, early rehabilitation, and psychological support. With the right strategy, many patients return to their normal activities, although some require long-term monitoring and reconstructive interventions. [63]

Prognostic models continue to evolve, incorporating laboratory parameters such as lactate levels and clinical factors in addition to age and area. This allows for more precise planning of treatment intensity and resources without replacing clinical judgment. [64]

Table 7. What influences the outcome the most?

Factor	Influence	Note
Age and area	The more, the higher the risk	Basis of prognostic scales
Inhalation injury	Significantly worsens the prognosis	Added to the risk index
Timeliness of assistance	Reduces complications and mortality	Routing is important
Rehabilitation	Improves functional results	Early activation is important

Frequently Asked Questions

Can you cool a burn with ice? No. Ice can worsen tissue damage. Long-term cooling with cool running water is recommended as soon as possible after the injury, followed by a clean, dry bandage and evaluation by a doctor if indicated. [65]

Are antibiotics necessary "just in case" for a burn? No. Prophylactic use of systemic antibiotics for uncomplicated burns has not shown convincing benefit and increases the risk of antibiotic resistance. Antibiotics are prescribed based on signs of infection or as preoperative prophylaxis. [66]

How much fluid should be administered for a large burn? The volume is adjusted based on clinical goals, focusing on maintaining adequate diuresis. Current recommendations suggest starting with two milliliters per kilogram of body weight for each percent of the affected area and then titrating according to the response, avoiding fluid overload. [67]

Do special scar dressings and gels help? Silicone gels and sheets are often used and may improve certain scar parameters in some patients, but the evidence is mixed. Compression garments are used selectively, taking into account tolerance and preference. The decision is made by the physician in consultation with the patient. [68]

Table 8. True and false ideas about first aid

Statement	Truth or myth	Brief explanation
You need to apply ice	Myth	Cool water is recommended
Everyone needs antibiotics	Myth	Prescribed according to indications
The timing of dressing changes is important	Is it true	Minimize pain and infection
Early nutrition helps	Is it true	Reduces complications and catabolism

Additional reference tables

Table 9. Guidelines for transfer to a burn center

Criterion	Explanation
Partial burns of approximately 10 percent area in adults	Especially when localized in functionally significant areas
Any full-thickness lesions	Need surgery
Burns of the face, hands, feet, perineum, large joints	High risk of functional impairment
Electrical, chemical burns, inhalation injury	Require specialized assistance

Table 10. Key elements of multimodal analgesia

Component	Role	Comment
Non-narcotic analgesics	Basic background	Reduce the need for opioids
Opioids according to indications	Relief of severe pain	Short-term, under monitoring
Low dose ketamine	Procedural pain	Predictable effect when changing dressings
Regional blockades	Donor and wound areas	Reduce system load