Part I (.pdf 958 kb), Part II(.pdf 1165 kb), Part III(.pdf 456 kb), Part IV(.pdf 171 kb).
Table of contents
Section I: Skin (Biological Properties)
Section II: Pathogenesis of Burn Injury (Initial and Delayed)
Section III: Burn Wound Assessment
Section IV: Initial Wound Management
Section V: Daily Wound Care
Section VI: Care of Burns to High Risk Areas
Section VII: Surgical Management
Section VIII: Use of Skin Substitutes
Section IX: Scar Formation and Management
Section X: The Rehabilitation Process
Section XI: Long Term Wound Problems (itch, drying, breakdown, T° regulation)

Burn treatments
Immediate Care

While it is ideal to prevent burn injuries from ever happening, unexpected circumstances will always exist. Effective burn treatments help to minimize damage and complications while promoting healing and recovery. All burn injuries are potentially dangerous; that's why healthcare professionals check for immediate injury as well as monitor for delayed complications. If a burn injury is severe, it often requires emergency treatment to prevent shock and infection.
Some burn injuries can be treated on an outpatient basis; others may require hospital admission; and still others may require advanced treatment at special burn units or care centers. Children and elderly patients present special challenges to immediate care procedures and often require advanced treatment.

Burn Assessment

Proper burn assessment is important for administering appropriate treatment. However, burns are difficult to diagnose within 24 hours of an actual injury as the full extent of burn damage can develop over time. For this reason, it is important to know the burning agent and the length of time that agent has had contact with the skin. Other factors such as the look, texture and sensitivity of skin; the size and location of the burn; and the age and health of the injured person can provide healthcare professionals valuable clues for accurately assessing a burn injury.
You will often hear a burn injury described by the percentage of the body burned, such as third degree burns over 45% of the body. This percentage is determined using standard evaluation tools. Percentage estimation is an important step in administering proper treatment.
The most common method for determining burn percentage is called the "Rule of Nines." This method divides the body surface into areas representing nine percent of total body surface area (TBSA). In infants and small children, the percentages are adjusted because the surface area of the head and neck is proportionately greater than that of adults. Adding up the injured areas provides quick assessment of burn percentage.
Burn Assessment Illustration

Debridement and Excision

Debridement and excision are both methods of cleansing or preparing a burn wound for proper assessment, classification and treatment. Healthcare professionals perform these procedures for two important reasons-to remove damaged tissue and promote healing.
Debridement removes dead tissue and blisters to expose the true depth and severity of a wound. In some burn injuries, dead tissue naturally falls off as part of the healing process. However, in most cases, a healthcare professional will need to assist in the removal of the damaged skin. Debridement is often an extremely painful procedure. However, it is necessary for protection from bacteria and other complications.
There are four primary methods of debridement. They include:
Skin Healing - Burn Treatments
Skin Healing - Burn Treatments
Autolytic-allowing the body to naturally rid itself of dead tissue
Skin Healing - Burn Treatments
Skin Healing - Burn Treatments
Enzymatic-using chemical enzymes to free dead tissue
Skin Healing - Burn Treatments
Skin Healing - Burn Treatments
Mechanical-removing dead tissue through the use of hydrotherapy (water)
Skin Healing - Burn Treatments
Skin Healing - Burn Treatments
Surgical-using sharp instruments or lasers for debridement
Skin Healing - Burn Treatments
Excision is usually an option for burn wounds determined to be deep second degree or full thickness third degree. This process surgically removes dead tissue in order to prepare a wound for a skin graft or other skin replacement procedure. Using specialized instruments, a surgeon will remove thin layers of burned skin until living tissue is exposed. The wound is then cleansed and prepared for grafting.

Dressing and Bandaging

Burn dressings and bandages serve three purposes:
1. Protect against infection 2. Reduce heat loss 3. Provide comfort
Functionally, dressings are applied to absorb drainage and isolate the wound from the environment. Sometimes, healthcare professionals use antimicrobial agents (topical ointments) before applying a dressing to prevent bacteria contamination and infection.
Dressings come in various forms (from cotton gauze to synthetic bandages) depending on the nature of the burn wound. Joints are bandaged to facilitate range of motion and extremities, such as arms, legs, fingers and toes, are often bandaged separately to isolate specific injuries. The frequency of dressing change can range from twice daily to once a week. These routine changes enable healthcare professionals to check for infection and monitor the healing process.

Skin Grafts and Flaps

Treatment of severe burns often requires skin grafting. Skin grafts involve taking skin (both the epidermis and dermis) from unburned sites on the body (known as donor sites) and grafting that skin onto the burn wound. The grafted skin attaches to the underlying tissue and effectively closes the wound.
A graft "takes" or is successful when new blood vessels and tissue form in the injured area. Sometimes, skin grafts do not take because of complications such as infection (the most common cause of graft failure) or shearing (pressure causing a graft to detach from the skin). While grafting is a proven and effective treatment, it is important to understand that all grafts leave some scarring at both the donor and recipient sites.
By using a patient's own skin to cover a burn wound, the risk of tissue rejection is eliminated. However, skin grafts are often a challenge for patients with severe burns across large portions of their body. In these instances there may not be sufficient donor site skin to immediately cover all of the individual's wounds.
Skin flaps are a complex type of skin graft that attach donor skin and underlying tissue by surgically connecting blood supply from the wound to the transferred skin. Skin flaps and other skin replacement methods are sometimes used in situations where standard skin grafts are not possible or where alternative methods are preferred.

Split-Thickness Grafts

Split-thickness skin grafts (STSGs) are grafts that include the epidermal and part of the dermal skin layers. Grafts up to four inches wide and 10-12 inches long can be removed from flat body surfaces such as the abdomen, thigh or back. These grafts are sewn or stapled into place and covered with compression dressings (tightly wrapped elastic bandages) to provide firm contact. Occasionally, graft sites are left open to air.
Split-thickness grafts are generally not used for weight-bearing parts of the body or for areas subject to friction such as hands or feet. Generally, STSGs are applied as intact sheets or, if there is too little donor skin available, meshed and expanded to maximize graft coverage area. (Meshing involves cutting tiny holes in the donor skin so it can be stretched to cover more surface area.) The advantages of STSGs include less tissue use, an improved chance of graft survival and minimized donor site damage. However, one disadvantage is that STSGs tend to contract more than full-thickness skin grafts.

Full-Thickness Grafts

Full-thickness skin grafts (FTSGs) consist of both the epidermal and complete dermal skin layers. This type of graft is used instead of a split-thickness skin graft when cosmetic outcome is essential and a skin flap is not available. The thicker the graft, the less the potential for contraction. Other advantages include increased resistance to trauma over thin grafts and less distortion functionally and cosmetically.

Comparison of Split-Thickness and Full-Thickness Skin Grafts

Composition Epidermis + part of the dermis Epidermis + dermis + various amounts of fat
Graft Survival Greater chance of graft survival Less chance of graft survival
Resistance to Trauma Less resistant More resistant
Cosmetic Appearance Poor cosmetic appearance owing to poor color and texture match. Does not prevent contraction. Superior cosmetic appearance. It is thicker, preventing wound contraction or distortion.
When Used Temporarily or permanently after excision of a burn injury when there is adequate blood supply. When aesthetic outcome is essential (e.g., facial defects).
Donor Site Tissue Thigh, buttock, abdomen, inner or outer arm, inner forearm. Nearby site, with similar color or texture to skin surrounding the defect.
Disadvantages Poor cosmetic appearance, greater chance of distortion or contraction. Greater risk of graft failure. Donor site wound requires prolonged healing time and has a greater risk of distortion and hypertrophic scar formation.

Skin Flaps

Sometimes, the area requiring reconstruction lacks the blood supply needed to support a skin graft. The tissues used to reconstruct these wounds must carry their own blood supply. Skin flaps, an advanced form of skin grafting, is a complex procedure in which skin, along with underlying fat, blood vessels and sometimes muscle, is moved from a healthy part of the body to the injured site. In skin flaps located adjacent to the wound site, blood supply may remain attached at the donor site. In instances where the skin flap needs to be attached to a wound elsewhere on the body, surgeons will reattach blood vessels in the flap at the new site through microvascular surgery.
Cosmetically, skin flaps generally produce better results than typical skin grafts because they are often taken from the skin surrounding the injury. This provides the graft superior color and texture match.

Donor Sites

When performing a skin graft, special care must be taken to prevent the creation of another difficult-to-heal wound or scar at the donor site. Thick split-thickness and full-thickness skin grafts result in deeper donor site wounds which require longer healing time and may result in contraction and hypertrophic scarring.
With deep split-thickness and full-thickness skin grafts, dermal tissue may be permanently lost at the donor site. The dermal layer cannot grow back by itself and most often results in scar formation. Healing time for most split-thickness skin grafts is approximately 10 to 20 days. Most full-thickness skin grafts require a longer 21 to 90 day period. As a result, medium-thickness split grafts are frequently used as a compromise to provide improved graft survival and durability with minimized donor site complications.

Skin Replacement

The lack of sufficient donor sites on many burn patients and certain safety concerns over traditional skin grafts prompted the search for more widely available skin substitutes. As such, certain skin alternatives have recently been developed and approved by the US Food and Drug Administration (FDA) that have the structural and functional properties of natural skin. In certain procedures, these alternative products can be used to replace damaged skin on a temporary or permanent basis.
Temporary skin substitutes help heal partial-thickness burns and close the excised wounds until a patient is able to receive a skin graft or other permanent skin covering. Permanent skin substitutes replace lost epidermis and/or dermis skin layers and may provide better long-term results than skin grafts. This section highlights some of the latest options in both temporary and permanent skin substitutes.

Temporary Wound Covering

The purpose of a temporary wound covering is to promote wound healing and prevent infection while a permanent skin replacement is prepared. Two common instances when this procedure applies are when burn survivors need time to regenerate enough donor skin for a graft, or when a person may not be healthy enough to undergo a reconstructive surgery.
Temporary coverings are also used occasionally as 'test' grafts for questionable skin graft sites or for additional protective covering on skin grafts that have been widely meshed and stretched for maximum coverage.
A xenograft refers to tissue that has been grafted from one species to another. This process is not new. In fact, the use of frog, lizard, rooster, rabbit and pig skin to help heal severe wounds dates back hundreds of years. Today however, pig skin is the xenograft most commonly used. It possesses properties that are similar to human skin and can effectively close a wound while a permanent option is determined.
The primary advantage of using xenografts on burn injuries is the wide availability of animal skin. The disadvantages include its risks of rejection and infection.
Allografts became a standard procedure in the 1950s and still remain a popular option for temporary wound coverings. This process uses cadaver, or organ donor, skin to cover deep partial or full thickness burn wounds. The advantage of using allografts centers on its ability to enable blood supply to regenerate. Disadvantages to the procedure include the risk of disease and the limited supply of donor skin.
Synthetic Skin Coverings
The evolution of synthetic skin began with the recognition that burn wounds require outer barrier protection to prevent infection and dehydration, as well as an inner layer framework for blood supply and cell regeneration. Recent innovations are now combining synthetic membranes that protect wounds from the outside environment with natural substance layers that encourage skin regeneration and minimize tissue rejection.

Permanent Skin Replacement

Permanent skin replacement or regeneration is naturally more complex than temporary wound covering. To be an effective and acceptable replacement for full-thickness skin loss, skin covering material must provide adequate protection against infection and heat loss. It must also enable the regeneration of blood supply and dermal skin cells while resisting rejection. But most importantly, a permanent replacement needs to grow with natural skin in order to prevent scarring and contractures.
INTEGRAŽ Dermal Regeneration Template
An innovative replacement product that actually regenerates dermal skin is INTEGRA Dermal Regeneration Template. INTEGRA Template is composed of two layers-a silicone outer layer that acts as a person's epidermis and a porous matrix that replaces the dermis. When applied to an excised wound, the dermal component acts as "scaffolding" and promotes skin regeneration, while the silicone layer protects the wound from infection and heat loss.
Once the dermal cells have grown back through the template, the silicone layer is removed and a thin epidermal skin graft is applied to the surface. INTEGRA Template slowly biodegrades, leaving the patient with flexible, pliable and growing skin.
The FDA first approved INTEGRA Template for the treatment of burns in 1996. Since then it has been used successfully on nearly 10,000 patients. In April 2002, it was approved as the first skin replacement treatment for the reconstruction of scar contractures resulting from prior burn injuries. In addition, INTEGRA Template is the only treatment proven to regenerate functional dermal tissue (the inner layer of skin).
Explore the chart below to see how the INTEGRA Template compares to traditional skin grafting treatment. For more information about INTEGRA Template visit the About INTEGRA section of this site.
Skin Graft and INTEGRA Template Comparison
Traditional Skin Graft: INTEGRAŽ Dermal Regeneration Template:
Skin graft from the patient applied to wound. Two-layer template composed of a porous matrix inner layer and a silicone outer layer applied to the wound.
Grafted dermis does not regenerate, resulting in scars that contract Dermis is regenerated and grows as the patient grows
Larger donor sites are needed to compensate for graft shrinkage Regenerated dermis maintains shape and strength
Harvested donor sites are painful, itchy and red Thin epidermal graft does not create lasting donor site wound
Scaled, rough, dry appearance in skin at wound site More smooth, evenly healed site
Stiffness of graft area Pliable skin
Acellular Matrices
Other permanent skin replacement treatments aim to regenerate dermal tissue by applying chemically treated cadaver skin to excised wounds. While the human skin has been cleansed of all living material, it still possesses the cellular framework that enables dermal skin to regenerate.
Acellular matrices are often used in conjunction with split-thickness skin grafts. Dermal tissue begins to populate the underlying matrix with living cells as the skin graft effectively closes the wound. Eventually, the wound site will maintain attributes of a growing and flexible skin. However, because these matrices are derived from cadaver skin, concerns about contamination and availability remain.
Cultured Epidermal Autograft
An autograft is a skin graft using the patient's own tissues. However, when there is insufficient donor skin, surgeons can perform a cultured skin autograft using cells grown in a laboratory. Initially used in 1981 to treat severely burned patients, cultured epidermal autografts (CEAs) have been commercially available since 1988. However, the process is hampered by the need to grow a sufficient quantity of epidermal skin for wound coverage. CEAs are difficult to handle in fragile sheets, have short-term stability and lack a dermal layer.


Severe burn scars can dramatically hinder a person's daily activities. To restore and maintain functional ability, physical and occupational therapists are often consulted as part of a patient's initial burn treatment. Short and long term goals are developed to reduce the incidence of contractures and ensure an acceptable range of motion. Ultimately, the aim of burn rehabilitation is to return a person back to independent living without or with minimal loss of functional activity.
Immobilization, stiffness, scarring and contracture all can be possible challenges to burn rehabilitation. Treatment is often a long process and success depends largely on patient and family education, understanding and involvement. Depending on the extent of a person's injury, there are many possible components to burn rehabilitation. Here are some of the most common.

Pressure Therapy

When skin is damaged by a partial or full-thickness burn, the normal pressure of the epidermis exerted on the dermal, or underlying, layer of skin is removed. The lack of pressure causes scar tissue to rapidly generate in irregular patterns. This uncontrolled scarring can persist for months following a burn injury and worsen over time.
To minimize the scarring response to a burn, pressure is often applied to a healing wound in the form of pressure therapy. This involves the careful application of tight-fitting or restricting garments and bandages to an area where a burn injury has occurred. These garments are worn day and night until the wounds mature to prevent excessive scarring from taking place.
In areas where pressure garments can not provide adequate compression, a therapist may use specially designed inserts. These custom plates are designed to tightly conform to different parts of the body in order to provide more uniform pressure. They can be made from a variety of materials, from soft foams to hard plastics, and are worn under a person's pressure garments.
Pressure Garments
Healthcare professionals use specially designed pressure garments or elastic bandages to provide continual and equal pressure over healing burns. The constricting nature of the garments mimics the pressure of healthy skin and reduces the development of irregular scarring common methods include:
  • Elastic bandage wraps
  • Tubular, sock-type pressure bandages
  • Custom-made elastic garments

Scar Massage

Once scars are mature enough to resist shearing (pulling away from undamaged tissue), scar massage can be incorporated into rehabilitation treatment. Frequent massage helps maintain softer, more pliable tissue and can help prevent scar contractures. In addition, it can also alleviate itching and desensitize pain-both troublesome symptoms that affect many burn survivors. Scar massage is generally performed two or more times a day and is occasionally combined with heat and lotion to increase tissue flexibility.

Exercise Therapy

Exercise is an integral part of burn rehabilitation. Participating in regular physical activity as instructed by a therapist can help improve functionality and maintain body strength. As a person's rehabilitation progresses, advanced exercises can be introduced to increase strength, motion and mobility. For many burn survivors, learning to walk again is the primary goal of their exercise program.
Walking, perhaps more than any other recovery milestone, can help return a person to an active and independent lifestyle. Not only does walking enable an individual to move place to place, but it also helps prevent muscles from weakening and contracting. Other benefits of exercise therapy include:
  • Reduced swelling in arms and legs
  • Improved joint motion and muscle strength
  • Increased flexibility
  • Decreased likelihood of blood clots
  • Increased bone density

Reconstruction options

Complications of a major burn injury often require multiple treatment procedures and can take several years of recovery. Even with aggressive treatment, scarring from a burn injury can leave you with visual disfigurement and functional limitations. Reconstruction is the ongoing effort to repair scars and persistent damage to help improve a burn survivor's quality of life. In addition to surgery, reconstruction treatments often involve psychological support, exercise and physical therapy.
Generally, it is best to postpone reconstruction until your wounds have matured. But sometimes, it's not possible to wait due to certain functional limitations. Regardless of when your reconstruction treatments begin, it's important to set realistic goals to make sure you have a clear understanding of the procedure outcomes.