About 80% of thermal injuries (burns) occur in the home, and 5% (one million per year) require hospitalization. Included among thermal injuries are sunburns (most common), direct heat, scalding (a moist burn), electrical burns, and chemical burns. The severity of the burn, based on depth, duration of exposure, and extent, determines appropriate management.

Fires, hot water or steam, sun overexposure, electricity, and certain chemicals produce burns.

• Hot water heater set above 120^oF
• Careless smoking
• Unsafe storage of flammable or caustic materials
• Microwaved foods/containers
• Wood stoves or exposed heating sources or electrical cords
• Sun overexposure, especially for older and fair-skinned people

• Superficial partial-thickness burns (first degree)—epidermis only; red, painful but intact; no blisters
• Deep partial-thickness burns (second degree)—epidermis only; red, painful, blisters, oozing
• Full-thickness burns (third degree)—all layers of dermis and epidermis plus deeper layers; skin charred, pale, or brownish yellow and leathery, often without pain or blisters; also injuries that involve the face, neck, shoulders, elbows, hands, perineum, popliteal fossa, ankles, or feet (where skin is thin). Requires specialist in burn care

Infections or drug reactions causing toxic epidermal necrolysis (scalded skin syndrome)

Evaluate depth and extent of injury using the rule of nines (Lund-Browder chart): surface area estimated as each arm 9%, each leg 18%, front of torso 18%, back of trunk 18%, head 9%, and groin 1%. For infants and small children, as above but head is 18% and legs 13.5%. Determine the cause to see if smoke inhalation is a possibility. Check for localized edema impeding circulation.

For thermal injuries:

• Cool the area with cold water.
• Gently debride and cleanse the wound.
• Give oral analgesics for pain; IV medications for major burns.
• Open blisters and excise dead skin.
• Cover with bacteriostatic cream and apply soft bulky dressing, which should be changed and medication reapplied twice a day.
• Review status of tetanus prophylaxis and update.
• Do not give systemic antibiotics.
• Fluid resuscitation.

For chemical burns:

• Remove patient's clothing.
• Irrigate area copiously with water, especially if the eyes are involved.

For electrical burns:

• Damage depends on resistance, type of current, amperage, voltage, duration of exposure, and pathway. Areas most affected are neurovascular bundles and muscles.
• Because cardiorespiratory arrest is common, patient may require CPR and advanced cardiac life support.
• Characteristic lesions are most intense at port of entry and exit.
• Evaluate for other injuries.
• May need early decompressive fasciotomies and debridement to assess the extent of damage; the incidence of major amputation with electrical burns is 33%.
• Transfer to a specialized center after patient's condition is stabilized.
• ECG monitoring for 24 hours.

Hospitalization required for: second-degree burns over 10% of body; third-degree burns; burns on hands, feet, face, or genitals; electrical/chemical burns; smoke inhalation.

Burn center required for: second- or third-degree burns over 10% of body in patients under 10 years or over 50 years; second- or third-degree burns over 20% of body.

• Silver sulfadiazine (Silvadene). Topical antibiotic applied to burned area, effective against most Pseudomonas, fairly good eschar penetration. Some microorganisms are resistant. Side effects are leukopenia or fever and delay in epithelialization.
• Mafenide. Penetrates eschar better than silver sulfadiazine, more effective against Pseudomonas; recommended for burns over cartilage and deep burns. Side effects are (in 10% solution) carbonic anhydrase inhibition, causing metabolic acidosis, delay in epithelialization, pain; can be lessened in 5% solution. Limit use to no more than 10% of total body surface.
• Povidone-iodine (Betadine). Especially useful against Candida and gram-positive and gram-negative microorganisms, but poor eschar penetration. Side effects are desiccation of wound surface, pain, high blood iodine levels.

Herbal support, both internally and externally, can facilitate wound healing, reduce the risk for infection by stimulating the immune system, and may help prevent scarring. Homeopathic remedies can provide excellent pain relief and reduction of symptoms.

• Hydration is of primary importance in managing moderate to severe burns. Fresh vegetable and fruit juices, water, and electrolyte replacement drinks should be used liberally.
• Vitamin C (1,000 to 1,500 mg tid), zinc (30 to 50 mg/day), and beta-carotene (100,000 IU/day) supports immune function and enhances dermal healing.
• Vitamin E (1,200 IU d-alpha tocopherols tid) is a strong antioxidant and reduces scarring.
• Bromelain (250 to 500 mg qid between meals) is a proteolytic enzyme that decreases inflammation. Use with turmeric (Curcuma longa, 500 mg qid) to potentiate effects.
• L-glutamine (3 to 10 g tid) provides amino acids to the gut that may be necessary to prevent damage secondary to severe burns.

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, it is important to ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as noted.

• To mobilize the immune system and minimize risk of infection during the acute phase, combine equal parts of tinctures of coneflower (Echinacea purpurea) and goldenseal (Hydrastis canadensis). Take 30 to 60 drops every three to four hours.
• Gotu kola (Centella asiatica) has been used in patients with second- to third-degree burns with great success. Daily topical application prevented or limited shrinking and swelling of the skin, inhibited scar formation, increased healing, and decreased fibrosis.
• Herbs that enhance circulation to the skin can facilitate the delivery of nutrients and elimination of metabolic waste. Combine equal parts of the following in a tea (1 cup four to six times/day) or tincture (30 to 60 drops tid to qid). Yarrow (Achillea millefolium), cleavers (Gallium aparine), prickly ash bark (Xanthoxyllum clava-herculis), marigold (Calendula officinalis), plantain (Plantago major), and ginger root (Zingiber officinale).
• For acute pain relief combine equal parts of tincture of Jamaica dogwood (Piscidia piscipula), valerian (Valeriana officinalis), St. John's wort (Hypericum perforatum), and California poppy (Escholizia californica) with one-half part of gelsemium (Gelsemium sempervirens). Take 10 to 15 drops every 15 minutes up to eight doses, acutely. For general pain relief, take 30 drops tid to qid.
• Aloe vera: Cut a fresh leaf and apply the gel to skin, or peel leaf, blend pulp, then apply to skin.
• Comfrey leaf (Symphytum officinale): Make a strong tea with 1 heaping tsp. herb/cup. Use as a wash. Do not use internally for prolonged periods due to potential for liver damage.
• Combine powders of slippery elm (Ulmus fulva), marshmallow root (Althaea officinalis), goldenseal, and comfrey root. Apply to burns to speed healing and reduce risk for infection.

An experienced homeopath should assess individual constitutional types and severity of disease to select the correct remedy and potency. For acute prescribing, use 3 to 5 pellets of a 12X to 30C remedy every one to four hours until acute symptoms resolve.

• Cantharis for burns and scalds with cutting, burning, or smarting pains that are relieved with cold applications. Specifically for extensive burns causing renal involvement.
• Carbolic acid for rapid prostration following a burn, with coldness of the skin and rapidly progressing to shock and collapse.
• Carbo vegetabilis for burns with great prostration and sluggishness of circulation. Patient has air hunger and wishes to be fanned even though they are chilly.

Topical homeopathic preparations for burns may provide acute pain relief. Do not apply over broken skin.

Patient should return 72 hours after injury, then every five to seven days until the wound is healed.

• If excessive swelling: Assess circulation and instruct patient to keep injured area elevated to avoid developing a compartment syndrome, wherein the injury progresses to full-thickness burn.
• If superficial infection: Do wound culture and sensitivity.
• If systemic signs of sepsis (fever, leukocytosis, extensive erythema): Manage aggressively with systemic antibiotics.
• If moderate swelling and erythema: Use elevation and warm moist dressings.
• For itching: Use moisturizing cream.
• To prevent functional disability, refer to physical therapist or reconstructive surgeon.

• Safety inspection of home by fire department.
• Plan fire/emergency escape route.
• Keep hot water heater set at maximum of 120Þ F.

• Local edema: maintain adequate circulation
• Functional or cosmetic defects (risk greater with partial-thickness burns)
• Burn sepsis
• Carcinoma developing in burn site

Partial-thickness burns generally heal in three to five weeks. Third-degree burns require skin graft.

Topical applications and homeopathic remedies may provide excellent support in pregnancy.

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