Outpatient Burn Care: Prevention and Treatment


Am Fam Physician. 2020 Apr 15;101(8):463-470.

  Patient information: See related handout on burn injuries, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Most patients with burn injuries are treated as outpatients. Two key determinants of the need for referral to a burn center are burn depth and percentage of total body surface area involved. All burn injuries are considered trauma, prompting immediate evaluation for concomitant injuries. Initial treatment is directed at stopping the burn process. Superficial (first-degree) burns involve only the epidermal layer and require simple first-aid techniques with over-the-counter pain relievers. Partial-thickness (second-degree) burns are subdivided into two categories: superficial and deep. Superficial partial-thickness burns extend into the dermis, may take up to three weeks to heal, and require advanced dressings to protect the wound and promote a moist environment. Deep partial-thickness burns require immediate referral to a burn surgeon for possible early tangential excision. Full-thickness (third-degree) burns involve the entire dermal layer, and patients with these burns should automatically be referred to a burn center. Prophylactic antibiotics are not indicated for outpatient management and may increase bacterial resistance. People with diabetes mellitus are at increased risk of complications and infection, and early referral to a burn center should be considered. Pruritus, hypertrophic scarring, and permanent hyperpigmentation are long-term complications of partial-thickness burns. Burn injuries are more likely to occur in children and older people. Patient education during primary care visits may be an effective prevention strategy.

Approximately 500,000 patients seek medical care for burns every year in the United States, and roughly 92% are treated as outpatients.1,2 Even small-appearing burns can cause significant morbidity because of pain, secondary infection, and scarring if not treated properly.1 The mechanism of burn injury can be categorized as thermal (caused by contact with flames, steam, or hot surfaces), electrical, chemical, and radiation.1,3 Thermal burns are the most common type among all ages.2,3

 Enlarge     Print


Clinical recommendationEvidence ratingComments

Burn patients who meet American Burn Association referral criteria should be promptly transferred to a burn center.10,11


Expert opinion

The burn surface should be cooled with running tap water for at least 20 minutes within three hours of the burn injury.19,20


Cohort studies and animal models

Patients with partial- or full-thickness burns who have unknown or inadequate tetanus immunization status should be vaccinated and given tetanus immune globulin.13,14,37


Consensus guidelines

Burn patients with diabetes mellitus who develop complications, such as cellulitis, should be referred to a burn center for further treatment.38


Expert opinion

Patients with burns expected to take longer than 14 days to heal should be referred to a burn center because of the risk of hypertrophic scarring.15


Expert opinion

In children, burns to the feet, buttocks, or posterior legs and hands; a history incongruent with injury; and the presence of burns with other unrelated injuries may be indicators of abuse.1,24


Case series, expert opinion

Targeted education initiatives may be effective in increasing patient and caregiver fire safety knowledge.52,53


Longitudinal interventional trials

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

The Authors

show all author info

JASON S. LANHAM, MD, MA, FAAFP, is program director of the Family Medicine Residency Program at Eisenhower Army Medical Center, Fort Gordon, Ga., and is assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences, Bethesda, Md....

NICOLE K. NELSON, DO, is a faculty member in the Family Medicine Residency Program at Eisenhower Army Medical Center and is assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences.

BRYAN HENDREN, MD, FACS, is the trauma medical director at Eisenhower Army Medical Center and an assistant professor in the Department of Surgery at the Uniformed Services University of the Health Sciences.

TENEISHA S. JORDAN, MD, is a resident in the Family Medicine Residency Program at Eisenhower Army Medical Center.

Address correspondence to Jason S. Lanham, MD, MA, FAAFP, 300 Hospital Rd., Fort Gordon, GA 30905 (email: jason.s.lanham.mil@mail.mil). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


show all references

1. Hermans MHE. An introduction to burn care. Adv Skin Wound Care. 2019;32(1):9–18....

2. American Burn Association. Burn incidence fact sheet. Burn incidence and treatment in the United States: 2016. Accessed May 27, 2019. http://ameriburn.org/who-we-are/media/burn-incidence-fact-sheet

3. Yin S. Chemical and common burns in children. Clin Pediatr (Phila). 2017;56(5 suppl):8S–12S.

4. Vandergiff TW. Anatomy and physiology. In: Bolognia JL, Cerroni L, Schaffer JV, eds. Dermatology. 4th ed. Elsevier; 2018:44–55.

5. Martin NA, Falder S. A review of the evidence for threshold of burn injury. Burns. 2017;43(8):1624–1639.

6. American Burn Association white paper. Surgical management of the burn wound and use of skin substitutes. 2009. Accessed September 15, 2019. http://www.figeducation.com/nlcp/resources/section-5/ABA%20White%20Paper.PDF

7. Morgan ED, Bledsoe SC, Barker J. Ambulatory management of burns. Am Fam Physician. 2000;62(9):2015–2026. Accessed December 2, 2019. https://www.aafp.org/afp/2000/1101/p2015.html

8. Lloyd EC, Rodgers BC, Michener M, et al. Outpatient burns: prevention and care [published correction appears in Am Fam Physician. 2012; 85(12):1127]. Am Fam Physician. 2012;85(1):25–32. Accessed December 2, 2019. https://www.aafp.org/afp/2012/0101/p25.html

9. Rossiter ND, Chapman P, Haywood IA. How big is a hand? Burns. 1996;22(3):230–231.

10. Herndon DN, ed. Total Burn Care. 5th ed. Elsevier; 2018.

11. American Burn Association. Burn center referral criteria. Accessed May 27, 2019. http://ameriburn.org/wp-content/uploads/2017/05/burncenterreferralcriteria.pdf

12. Gee Kee E, Stockton K, Kimble RM, et al. Cost-effectiveness of silver dressings for paediatric partial thickness burns: an economic evaluation from a randomized controlled trial. Burns. 2017;43(4):724–732.

13. ISBI Practice Guidelines Committee; Steering Subcommittee; Advisory Subcommittee. ISBI practice guidelines for burn care. Burns. 2016;42(5):953–1021.

14. Agency for Clinical Innovation. Clinical guidelines: burn patient management. Accessed May 27, 2019. https://bit.ly/2szlyeM

15. Murphy F, Amblum J. Treatment for burn blisters: debride or leave intact? Emerg Nurse. 2014;22(2):24–27.

16. Lau EY, Tam YY, Chiu TW. Importance of clothing removal in scalds. Hong Kong Med J. 2016;22(2):152–157.

17. Gnaneswaran N, Perera E, Perera M, et al. Cutaneous chemical burns: assessment and early management. Aust Fam Physician. 2015;44(3):135–139.

18. Toussaint J, Singer AJ. The evaluation and management of thermal injuries: 2014 update. Clin Exp Emerg Med. 2014;1(1):8–18.

19. Harish V, Tiwari N, Fisher OM, et al. First aid improves clinical outcomes in burn injuries: evidence from a cohort study of 4918 patients. Burns. 2019;45(2):433–439.

20. Wood FM, Phillips M, Jovic T, et al.; Steering Committee of the Burn Registry of Australia and New Zealand (BRANZ). Water first aid is beneficial in humans post-burn: evidence from a bi-national cohort study. PLoS One. 2016;11(1):e0147259.

21. Huang CY, Choong MY. Comparison of wounds' infection rate between tap water and normal saline cleansing: a meta-analysis of randomised control trials. Int Wound J. 2019;16(1):300–301.

22. Fernandez R, Griffiths R. Water for wound cleansing. Cochrane Database Syst Rev. 2012;(2):CD003861.

23. Norman G, Christie J, Liu Z, et al. Antiseptics for burns. Cochrane Database Syst Rev. 2017;(7):CD011821.

24. Strobel AM, Fey R. Emergency care of pediatric burns. Emerg Med Clin North Am. 2018;36(2):441–458.

25. Maenthaisong R, Chaiyakunapruk N, Niruntraporn S, et al. The efficacy of aloe vera used for burn wound healing: a systematic review. Burns. 2007;33(6):713–718.

26. Shahzad MN, Ahmed N. Effectiveness of aloe vera gel compared with 1% silver sulphadiazine cream as burn wound dressing in second degree burns. J Pak Med Assoc. 2013;63(2):225–230.

27. Douglas HE, Wood F. Burns dressings. Aust Fam Physician. 2017;46(3):94–97.

28. Ro HS, Shin JY, Sabbagh MD, et al. Effectiveness of aspiration or deroofing for blister management in patients with burns: a prospective randomized controlled trial. Medicine (Baltimore). 2018;97(17):e0563.

29. Chaganti P, Gordon I, Chao JH, et al. A systematic review of foam dressings for partial thickness burns. Am J Emerg Med. 2019;37(6):1184–1190.

30. Heyneman A, Hoeksema H, Vandekerckhove D, et al. The role of silver sulphadiazine in the conservative treatment of partial thickness burn wounds: a systematic review. Burns. 2016;42(7):1377–1386.

31. Barajas-Nava LA, López-Alcalde J, Roqué i Figuls M, et al. Antibiotic prophylaxis for preventing burn wound infection. Cochrane Database Syst Rev. 2013;(6):CD008738.

32. Warner PM, Coffee TL, Yowler CJ. Outpatient burn management. Surg Clin North Am. 2014;94(4):879–892.

33. Jull AB, Cullum N, Dumville JC, et al. Honey as a topical treatment for wounds. Cochrane Database Syst Rev. 2015;(3):CD005083.

34. Panahi Y, Beiraghdar F, Akbari H, et al. A herbal cream consisting of aloe vera, Lavandula stoechas, and Pelargonium roseum as an alternative for silver sulfadiazine in burn management. Asian Biomed. 2017;6(2):273–278.

35. Morgan M, Deuis JR, Frøsig-Jørgensen M, et al. Burn pain. Pain Med. 2018;19(4):708–734.

36. Jones LM, Uribe AA, Coffey R, et al. Pregabalin in the reduction of pain and opioid consumption after burn injuries. Medicine (Baltimore). 2019;98(18):e15343.

37. Centers for Disease Control and Prevention. Tetanus. Accessed September 16, 2019. https://www.cdc.gov/tetanus/clinicians.html

38. Goutos I, Nicholas RS, Pandya AA, et al. Diabetes mellitus and burns. Int JBurns Trauma. 2015;5(1):13–21.

39. Barsun A, Sen S, Palmieri TL, et al. A ten-year review of lower extremity burns in diabetics. J Burn Care Res. 2013;34(2):255–260.

40. Tu Y, Lineaweaver WC, Zheng X, et al. Burn-related peripheral neuropathy: a systematic review. Burns. 2017;43(4):693–699.

41. Thombs BD. Patient and injury characteristics, mortality risk, and length of stay related to child abuse by burning. Ann Surg. 2008;247(3):519–523.

42. American Burn Association. Burn injury fact sheet. Accessed December 2019. http://ameriburn.org/wp-content/uploads/2017/12/nbaw-factsheet_121417-1.pdf

43. Guy GP Jr, Holman DM, Watson M. The important role of schools in the prevention of skin cancer. JAMA Dermatol. 2016;152(10):1083–1084.

44. Centers for Disease Control and Prevention. Traveler's health. Environmental hazards and other noninfectious health risks. Accessed June 1, 2019. https://wwwnc.cdc.gov/travel/yellowbook/2018/the-pre-travel-consultation/sun-exposure

45. Baggott K, Rabbitts A, Leahy NE, et al. Pediatric sink-bathing: a risk for scald burns. J Burn Care Res. 2013;34(6):639–643.

46. Safe Kids Worldwide. Burns and scalds prevention tips. Accessed June 1, 2019. https://www.safekids.org/tip/burns-and-scalds-prevention-tips

47. Saint Barnabas Medical Center. Burn prevention and fire safety tips. Accessed December 18, 2019. https://www.rwjbh.org/saint-barnabas-medical-center/treatment-care/the-burn-center/community-outreach/burn-prevention-and-fire-safety-tips/

48. Jeschke MG, Peck MD. Burn care of the elderly. J Burn Care Res. 2017;38(3):e625–e628.

49. Maxwell D, Rhee P, Drake M, et al. Development of the Burn Frailty Index: a prognostication index for elderly patients sustaining burn injuries. Am J Surg. 2019;218(1):87–94.

50. Leahy NE, Sessler KA, Baggott K, et al. Engaging older adults in burn prevention education: results of a community-based urban initiative. J Burn Care Res. 2012;33(3):e141–e146.

51. New York-Presbyterian Weill Cornell Medical Center. Burn safety and prevention for older adults. Accessed December 18, 2019. https://www.nyp.org/pdf/burn_center/Burn_Safety_Prevention_Older_Adults_englishWEB.pdf

52. Lehna C, Coty MB, Fahey E, et al. Intervention study for changes in home fire safety knowledge in urban older adults. Burns. 2015;41(6):1205–1211.

53. Lehna C, Fahey E, Janes EG, et al. Home fire safety education for parents of newborns. Burns. 2015;41(6):1199–1204.



Copyright © 2020 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

More in AFP

Related Content

More in Pubmed


Jan 2022

Access the latest issue of American Family Physician

Read the Issue

Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article