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Injuries Skin and nail

Burns and scalds

Last revised in May 2026

A burn is an injury caused by exposure to thermal (heat), chemical, electrical, or radiation energy.

Burns and scalds: Summary

A burn is an injury caused by exposure to thermal (heat), electrical, chemical, or radiation energy.
A scald is a burn caused by contact with a hot liquid or steam.
Complex burns include:
- All electrical and chemical burns.
- Any thermal burn injury affecting a critical area (defined as burns to the face, hands, feet, perineum, or genitalia; burns crossing joints; and circumferential burns).
- Any thermal burn covering more than 15% of the total body surface area (TBSA) in adults or more than 10% in children (more than 5% in children younger than one year of age).
Non-complex burns include:
- Any partial-thickness thermal burn covering up to 15% of the TBSA in adults or up to 10% in children (up to 5% in children younger than one year of age) that does not affect a critical area.
- A deep partial-thickness burn covering up to 1% of the body.
Immediate first aid should be given to all people with burns.
- Personal injury should be avoided by checking the area is safe and wearing personal protective equipment, if necessary.
- The type and extent of first aid needed will depend on the cause of the injury but should include (where safe to do so) removing the person from the source of the burn and assessing their airway, breathing, and circulation.
The severity of a burn injury is determined by its location, extent, and depth; the person's age; and the presence of other injuries or comorbidities.
Most burns are non-complex and can be managed in primary care.
Immediate admission to A&E should be arranged for:
- All complex burn injuries.
- All full-thickness burns.
- Deep dermal burns affecting more than 5% of TBSA in adults.
- All deep dermal burns in children.
- Circumferential deep dermal burns.
- Any high-pressure steam injury.
- Any burn associated with suspected non-accidental injury.
- Burns affecting the face, hands, feet, genitalia, perineum, or any flexural surface.
- Burns associated with suspected inhalation injury or sepsis.
- People with significant comorbidities that may affect wound healing or increase the risk of complications, or those clinically judged to be at risk of complications.
- People with other significant injuries or trauma, such as crush injuries, fractures, head injuries, or penetrating injuries.
Primary care management of a burn will depend on the cause of injury and should include:
- Appropriate wound management.
- Advising on simple analgesia for pain relief.
- Giving skin care advice, such as taking a cool bath or shower, applying cold compresses, massaging the area with an emollient (such as emulsifying ointment) to relieve itching and dryness, and protecting the skin from direct sunlight.
- Considering the need for tetanus prophylaxis.
- Assessing for (and managing) infected wounds.
- Providing additional sources of information and support.

Have I got the right topic?

From age 1 month onwards.

This CKS topic covers the primary care management of burns and scalds.

This CKS topic does not cover the assessment or management of radiation burns. It also does not cover the assessment or management of extreme cold burns (for example, due to frostbite).

There are separate CKS topics on Cellulitis - acute and Child maltreatment - recognition and management.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

May 2026 — minor update. First aid advice made consistent with BBA recommendations.

Previous changes

January 2023 — reviewed. A literature search was conducted in November 2022 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. No changes to clinical recommendations have been made.

September 2020 — minor update. The URL link to the Lund and Browder chart has been updated.

October 2019 — minor update. The advice to arrange immediate referral for all adults aged over 49 years has been changed to 'adults with significant co-morbidities or clinically adjudged to be at risk of complications'.

November to December 2017 — reviewed. A literature search was conducted in November 2017 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials (RCTs) published since the last revision of the topic. The topic has undergone significant restructuring. A node on Assessment has been created in the Diagnosis section. The Scenarios on Referral and infected minor burns and scalds have been removed and incorporated into other Scenarios. An additional node on Wound management has been created in the section on Superficial dermal burns. The Prescribing information section has been removed, and a link created to the CKS topic on Cellulitis - acute. The recommendations on the assessment, management, and referral criteria for burns and scalds have been amended in line with current evidence.

July 2015 — minor update. The sections on Erythromycin and Clarithromycin in Prescribing Information have been clarified.

April 2015 — minor update. A link has been inserted to the CKS topic on Analgesia - mild-to-moderate pain.

May 2013 — two minor updates to the text. The recommendation to use aqueous cream has been removed to reflect advice issued by the Medicines and Healthcare products Regulatory Agency (MHRA) publication Aqueous cream: may cause skin irritation, particularly in children with eczema, possibly due to sodium lauryl sulfate content (2013). The text has been updated to reflect referral guidelines published by the National Network for Burn Care publication National burn care referral guidance (2012).

February 2013 — minor update. The 2013 QIPP options for local implementation have been added to this topic.

October 2012 — minor update. The 2012 QIPP options for local implementation have been added to this topic.

April 2012 — reviewed. A literature search was conducted in March 2012 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. Minor changes to clinical recommendations have been made in line with the New Zealand Guidelines Group guideline Management of Burns and Scalds (2007).

July 2011 — minor update. More exact paracetamol dosing for children has been introduced by the Medicines and Healthcare products Regulatory Agency (MHRA). Prescriptions have been updated to reflect the revised dosing.

June 2011 — minor update. The 2010/2011 QIPP options for local implementation have been added to this topic. Text amended regarding the need for additional contraception during or after a course of antibiotics — additional contraception is no longer required when using antibiotics that are not enzyme inducers with combined hormonal methods for durations of 3 weeks or less.

March 2011 — topic structure revised to ensure consistency across CKS topics. No changes to clinical recommendations have been made.

August 2009 — minor update. Advice from the National Institute for Health and Care Excellence (NICE) clinical guideline When to suspect child maltreatment has been added to this topic.

August 2007 — converted from CKS guidance to CKS topic structure. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence. No major changes were made to the recommendations. Information has been added regarding the management of an infected minor burn.

October 2006 — minor update. Analgesia prescriptions updated because new doses of ibuprofen for children are recommended by the British National Formulary (BNF).

November 2005 — minor technical update.

November 2004 — updated to include new read codes for Mefilm^®and Mepitel^®dressings.

September 2004 — updated to include the new combined tetanus vaccines Pediacel^®, Repevax^®, and Revaxis^®.

March 2004 — reviewed. Validated in May 2004 and issued in July 2004.

June 2001 — reviewed. Validated in July 2001 and issued in October 2001.

September 1998 — written, replacing the guidance on Burn of lower limb, Burn — trunk, Burn — upper arm, Burn — wrist/hand, and Burn — unspecified.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 November 2022.

HTAs (Health Technology Assessments)

No new HTAs since 1 November 2022.

Economic appraisals

No new economic appraisals relevant to England since 1 November 2022.

Systematic reviews and meta-analyses

No new systematic reviews or meta-analysis which reach the CKS threshold for inclusion since 1 November 2022.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 November 2022.

New policies

No new national policies or guidelines since 1 November 2022.

New safety alerts

No new safety alerts since 1 November 2022.

Changes in product availability

No changes in product availability since 1 November 2022.

Goals and outcome measures

Goals

To support primary healthcare professionals to:

Ensure appropriate referral of people with major burns and scalds.
Provide advice on symptom relief.
Be aware of when to consider or suspect child maltreatment.
Manage and promote wound healing.
Prevent complications, such as infection and scarring, where possible.
Provide tetanus prophylaxis, where appropriate.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP were found during the review of this topic.

NICE quality standards

No NICE quality standards were found during the review of this topic.

Background information

What is it?

A burn is an injury caused by exposure to thermal (heat), electrical, chemical, or radiation energy [NICE, 2016]. It usually affects the skin but may also affect the airways, lungs, muscles, bones, or other internal organs [Lloyd, 2012; Stylianou, 2015].
- A scald is a burn caused by contact with a hot liquid or steam. For the purposes of this topic, the term 'burn' will be used to include scalds.
Burns are categorized as complex or non-complex [Wounds International, 2014]:
- Complex burns (previously described as 'major burns') include:
  - All electrical and chemical burns.
  - Any thermal burn injury affecting a critical area (defined as burns to the face, hands, feet, perineum, or genitalia; burns crossing joints; and circumferential burns).
  - Any thermal burn covering more than 15% of the total body surface area (BSA) in adults or more than 10% in children (more than 5% in children younger than one year of age).
- Non-complex burns (previously described as 'minor burns') include:
  - Any partial-thickness thermal burn covering up to 15% of the total BSA in adults or up to 10% in children (up to 5% in children younger than one year of age) that does not affect a critical area (defined as burns to the face, hands, feet, perineum, or genitalia; burns crossing joints; and circumferential burns).
  - A deep partial-thickness burn covering up to 1% of the body.

How do burns occur?

Thermal burns include scalds, flame injuries, and contact burns.
- Scalds are caused by contact with a hot liquid or steam, for example spilling of hot drinks or immersion in a hot bath or shower. They tend to cause superficial epidermal or superficial dermal burns, and may involve a large area of skin.
- Flame injuries are caused by direct or indirect exposure to a flame source. They tend to be of any depth (partial or full thickness) and are often a mixture of depths.
- Contact burns occur when the skin touches an extremely hot object (often seen in industrial accidents) or a less hot object (such as an iron, oven door, or radiator) for a prolonged period of time. They usually cause deep dermal or full-thickness burns.
Electrical burns occur when electricity flows through the body from an entry point to an exit point. Heat energy from the electric current damages tissue along its path of flow. The extent of tissue damage is determined by the voltage of the current.
- Low-voltage burns (domestic current) typically cause small, deep contact burns at the entry and exit points.
- High-voltage burns (currents of more than 1,000 volts) cause extensive deep tissue damage and even limb loss. Currents of more than 70,000 volts are usually fatal.
- Flash burns (high voltage) occur when a person is exposed to an arc of high-voltage current, but the current does not actually enter the body. They typically cause superficial burns to the face, neck, hands, and upper limbs. Ignited clothing may cause deeper burns.
Chemical burns result from contact with corrosive agents, such as acids, alkalis (in household cleaning agents, bleaches, and cement), and organic products (such as bitumen). They tend to cause deep dermal or full-thickness burns because the tissues continue to be damaged until the chemical is completely removed (for example, by copious irrigation with water).

[Wounds International, 2014]

How common is it?

Burns are the fourth most common type of trauma worldwide, after road traffic accidents, falls, and interpersonal violence [Agbenorku, 2013].
The exact prevalence of burn injuries is unknown as some people will self-treat and do not seek medical attention [BMJ Best Practice, 2022].
- The World Health Organization (WHO) estimates that 180,000 deaths every year are caused by burns, the vast majority in low- and middle-income countries [WHO, 2018].
- In the UK, it is estimated that [National Burn Care Review Committee, 2001]:
  - 250,000 people receive burn injuries each year.
  - 175,000 people with burns attend A&E departments.
  - 16,000 people are admitted to hospital for specialist burns care.
About 90% of burn injuries in the UK are non-complex burns [Wounds International, 2014].
Children account for almost 50% of the population with severe burn injury, and children under five years of age account for 50–80% of all childhood burns [Agbenorku, 2013; Wounds International, 2014].
- Burns are the eleventh most common cause of death in children aged 1–9 years.
- Burns are the fifth most common cause of non-fatal childhood injuries.
- Boys are more likely to be affected than girls.
The risk of burn injury is also increased in [Wounds International, 2014]:
- Elderly people.
- People with reduced mental capacity, such as those with dementia or learning difficulties, and those who may not recognize or react to a dangerous situation.
- People with reduced mobility.
- People with sensory impairment, which may prevent a quick response to injury.

What are the complications?

Complications from burns may present soon after the injury or during the healing process.
- Early complications of burns include:
  - Respiratory distress from smoke inhalation or a circumferential chest burn — smoke inhalation may cause bronchospasm, and pulmonary and laryngeal oedema.
  - Poisoning from inhalation of noxious gases released by burning (for example, cyanide poisoning due to smouldering plastics).
  - Fluid loss, hypotension, and hypovolaemic shock (severe burns).
  - Hypothermia — epidermal damage may lead to problems with thermoregulation.
  - Wound infection and sepsis.
  - Toxic shock syndrome — a rare, potentially life-threatening complication of small burns in children caused by strains of Staphylococcus aureus. It typically presents with fever, rash, diarrhoea, irritability, poor feeding, tachycardia, and tachypnoea, and may present 2–4 days post-injury.
  - Cardiac arrhythmias — electrical burns may cause ventricular fibrillation and chemical burns may cause electrolyte disturbances, which may precipitate arrhythmias.
  - Vascular insufficiency, distal ischaemia, or compartment syndrome from a circumferential burn of a limb or digit.
  - Acute kidney injury (AKI) — early burn AKI occurs up to 3 days after the injury and is typically due to reduced cardiac output, mainly caused by hypovolemia. This is usually caused by delayed or inadequate fluid resuscitation, but may also result from substantial muscle breakdown (resulting in myoglobinuria) or haemolysis (resulting in haemoglobinuria) [Emara, 2013; Clark, 2017].
  - Limb loss — high-voltage burns (more than 1000 volts) may cause extensive deep tissue damage and limb loss.
  - Death — may result from severe, extensive burns or electric shock. Currents of more than 70,000 volts may cause cardiac arrhythmias and paralysis of respiratory muscles, and are usually fatal.
- Late complications of burns include:
  - Wound infection.
  - AKI — late burn AKI occurs 4–14 days after the injury and is often due to sepsis, multi-organ failure, and the use of nephrotoxic drugs [Emara, 2013; Clark, 2017].
  - Chronic neuropathic pain and itch.
  - Contractures — shortening of the scar and underlying tissues after the wound has closed.
  - Scarring — burns that take more than 2–3 weeks to heal are more likely to result in hypertrophic scarring (raised, rigid, red scarring which may have altered sensation and pigmentation).
  - Psychosocial impact, such as depression, anxiety, post-traumatic stress disorder, changes in body image, stigma, and social isolation following scarring.
  - Sleep disorders, such as insomnia, hypersomnia, and nightmares.

[Lloyd, 2012; Culleiton, 2013; Wounds International, 2014; Gnaneswaran, 2015]

What is the prognosis?

The prognosis and healing time of a burn injury depend on factors such as [Cleland, 2012; Stylianou, 2015]:
- The location and extent of the burn.
- The depth of the burn.
- The person's age.
- Associated co-morbidities.
In relation to the depth of the burn [Lloyd, 2012; Wounds International, 2014; Douglas, 2017]:
- Superficial epidermal burns typically heal within 7 days with conservative management, and do not result in scarring.
- Superficial dermal burns typically heal within 14 days with conservative management, and do not result in scarring.
- Deep dermal burns may need surgical intervention to heal, and may result in some contraction and scarring.
- Complex, full-thickness burns usually need surgical intervention to heal, and result in considerable contraction and scarring.

Diagnosis of burns and scalds

How should I assess a person with a burn?

After giving immediate first aid, assess the person to determine whether immediate admission to A&E is needed, or whether the person can be managed in primary care.

Take a detailed history. Ask about:
- The timing and exact cause of the injury.
- Past medical history, including conditions that could impair wound healing and/or increase the risk of complications, such as:
  - Cardiac, respiratory, or hepatic disease.
  - Diabetes mellitus.
  - Pregnancy.
  - Immunocompromized state or use of immunosuppressive drugs (such as corticosteroids or chemotherapy).
  - Poor nutritional status.
  - Cognitive impairment.
- Predisposing factors which may require further investigation or management, for example, a burn resulting from a fit, fall, blackout, or alcohol and/or drug misuse.
- Immunization status, specifically the tetanus vaccine history.
- Allergies, specifically to latex, anaesthetics, or antibiotics.
Assess for:
- Complications, such as infection, hypotension, and possible inhalation injury (suggested, for example, by singed eyebrows or nasal hairs, sore throat, black carbon in the sputum, hoarse voice, stridor, wheeze, or signs of carbon in the oropharynx).
- Other significant injuries or trauma, such as crush injuries, fractures, head injuries, or penetrating injuries.
Assess the burn severity. Document:
- The location and size of the burn.
- The extent of the burn.
  - This is expressed as total burn surface area (TBSA) and can be estimated in different ways, for example by using the Lund and Browder chart.
  - Do not include simple erythema when estimating TBSA.
- The depth of the burn.
  - Examine the skin for colour change, presence of blisters, capillary refill time, and pain. For more information, see the section on Classification of burn depth.
  - Burn depth may increase with time, so reassessment after 24–72 hours is essential.
  - Be aware that most burns are a mixture of different depths.
Consider the possibility of a non-accidental inury and any child or adult safeguarding issues.
- Assess for the presence of red flags for non-accidental injury.

What are the red flags for non-accidental injury?

Suspect non-accidental injury if a child or adult has a burn or scald with any of the following:
- Explanation for the injury is absent or unsuitable.
- The person is not independently mobile.
- The injury is on any soft tissue area that would not be expected to come into contact with a hot object in an accident (for example, the backs of hands, soles of feet, buttocks, or back).
- The injury is in the shape of an implement (for example, a cigarette or iron from a contact burn).
- The injury indicates forced immersion, for example, scalds:
  - To the buttocks, perineum, and lower limbs.
  - To limbs in a glove or stocking distribution.
  - To limbs with a symmetrical distribution.
  - With sharply delineated borders.
Consider the possibility of non-accidental injury if there is:
- Delayed presentation in seeking medical attention. Note that this may be due to effective first aid measures masking the severity of the injury.
- An unrelated adult presenting the child to healthcare services.
- Evasive or changing history.
- A trigger event such as soiling, enuresis, or minor misbehaviour by the person.
- History inconsistent with assessed development.
- A lack of parental or carer concern.
- A lack of appropriate supervision of a vulnerable person (may indicate neglect).
- Failure to engage with healthcare appointments or health promotion programmes (may indicate neglect).
Consider the possibility of non-accidental injury if on examination:
- The history given is incompatible with examination findings.
- There are no splash marks in scald injuries (a fall into the bath will usually produce splash marks).
- There are signs of restraint on upper limbs.
- There is sparing of the flexion creases (suggests the child was in the fetal position when burnt).
- There is central sparing of the buttocks (the 'doughnut sign'), may be found in submersion injuries if a person has been forcibly held down.
- There are associated unrelated injuries (such as bruises of various ages).

[NICE, 2017; Gray, 2019; RCPCH, 2022]

How should I assess the extent of the burn?

The extent of a burn is a measure of burn severity. It is expressed as the total burn surface area (TBSA), which is the percentage of the body surface area (BSA) affected.
There are three main methods for estimating TBSA: the Lund and Browder method, Wallace's Rule of Nines, and the Rule of Palm.
- The Lund and Browder method is a chart with an outline of a person divided into several regions, each represented by a number.
  - The chart is shaded to show the burned area, and the TBSA is calculated by adding the numbers for each affected region.
  - In babies and children, the head and legs make up different proportions of the BSA, so the chart includes age‑related numbers for these areas.
- Wallace's Rule of Nines estimates an adult's affected BSA using multiples of 9 representing different areas of the body.
  - Head and neck represent 9%.
  - Each lower extremity is 18%.
  - Each upper extremity is 9%.
  - Anterior and posterior torso are 18% each.
  - For scattered or irregular burns, the palmar surface of the person's hand represents approximately 1%.
  - Different calculations are used for children and infants.
- The Rule of Palm assumes that the palm (including the fingers) of the person who is burned is about 1% of the body. This can be used to calculate the BSA burned. It can be used as a guide for small or scattered burns, or for assessing the amount of unburnt skin in very extensive burns.
- Note that all three methods are reported to provide inaccurate estimates of TBSA.

[NICE, 2016; BMJ Best Practice, 2022]

Classification of burn depth

Burn injuries are classified into two groups according to the amount of tissue damage.

Superficial partial thickness burns (also known as first-and second-degree burns) do not extend through all the layers of skin.
- They may be further classified into three groups:
  - Superficial epidermal burns (or superficial first-degree burns).
  - Superficial dermal burns (or superficial partial-thickness burns).
  - Deep dermal burns (or deep partial-thickness burns).
- See Table 1 for more information.
Full-thickness burns (also known as third-degree burns) extend through all layers of the skin and into the subcutaneous tissues. Severe full-thickness burns (also known as fourth-degree burns) extend into muscle and bone.
- See Table 1 for more information.

Table 1. Classification of the depth of burn.

Depth of burn	Layers of skin affected	Skin examination
Superficial epidermal (for example, sunburn)	The epidermis is affected, but the dermis is intact.	The skin is red and painful, but not blistered. Capillary refill* blanches then rapidly refills.
Superficial dermal (partial thickness)	The epidermis and upper layers of dermis are involved.	The skin is red or pale pink and painful with blistering. Capillary refill* blanches but regains its colour slowly.
Deep dermal (partial thickness)	The epidermis and the upper and deeper layers of the dermis are involved, but not underlying subcutaneous tissues.	The skin appears dry, blotchy or mottled, red, and typically painful (due to exposed superficial nerves). There may be blisters. Capillary refill* does not blanch.
Full thickness	The burn extends through all the layers of skin to subcutaneous tissues. If severe, it extends into muscle and bone.	The skin is white, brown, or black (charred) in colour, with no blisters. It may appear dry, leathery, or waxy and is painless. Capillary refill* does not blanch.
*Assess capillary refill by pressing with a sterile cotton bud (such as a bacteriology swab). Note: assessment should take into account the person's skin pigmentation. In white skin, full thickness burns may be mistaken for unburnt skin. In pigmented skin, a superficial epidermal or dermal burn may not appear red.
Data from: [Lloyd, 2012; Wounds International, 2014; Douglas, 2017]

Basis for recommendation

These recommendations are largely based on the International Best Practice Guideline Effective skin and wound management of non-complex burns [Wounds International, 2014], the International Society for Burn Injuries (ISBI) Practice Guidelines for Burn Care [ISBI, 2016], the National Institute for Health and Care Excellence (NICE) clinical guideline Mersey Burns for calculating fluid resuscitation volume when managing burns [NICE, 2016], the NICE guideline When to suspect child maltreatment [NICE, 2017], the NHS Scotland publication Care of Burns in Scotland: National Managed Clinical Network [Gray, 2019], the Royal College of Paediatrics and Child Health (RCPCH) publication Child protection evidence: Systematic review on burns [RCPCH, 2022], and on expert opinion in review articles on burns [Lloyd, 2012; Culleiton, 2013; Gnaneswaran, 2015; Giretzlehner, 2021; BMJ Best Practice, 2022].

Rapid initial assessment

Rapid initial assessment allows complex wounds to be transferred for immediate specialist care, which may involve surgical intervention [Wounds International, 2014].

Assessment for non-accidental injury

This recommendation is based on the fact that the prevalence of abusive burns is estimated to be 5.3–14% of children admitted to burns units, highest for those aged 0 – 1 years [RCPCH, 2022].

Assessment of burn extent and depth

Appropriate burn injury assessment and management is critical to ensure the best outcomes for the person with a burn. The severity of a burn injury is determined by its location, extent, and depth, the person's age, and the presence of other injuries or comorbidities [NICE, 2016].
It is important to exclude erythema in the percentage total body surface area (TBSA) calculation to avoid an inaccurate estimations of the burn extent, which could lead to over resuscitation and over treatment [Giretzlehner, 2021].
An accurate and efficient estimation of burn size is crucial because larger burns require increased resuscitation due to systemic effects [ISBI, 2016].
People with burns have improved outcomes if treated in a facility capable of providing an advanced level of burn care. Therefore, it is important to accurately identify those people with burns severe enough to merit transfer so that outcome is optimized [ISBI, 2016].

What else might it be?

Conditions that may present similarly to burns and scalds include:
- Blistering skin diseases, such as Stevens-Johnson syndrome, staphylococcal scalded skin syndrome, toxic epidermal necrolysis, or bullous impetigo. See the CKS topic on Impetigo for more information.
- Cellulitis. See the CKS topic on Cellulitis - acute for more information.
- Eczema. See the CKS topic on Eczema - atopic for more information.
- Hypersensitivity reactions, for example, to detergents, shampoo, or laxatives (such as senna perineal burns).
- Intentional burns without malicious intent, for example, from traditional remedies, moxibustion, or cupping.
- Photodermatitis — sun exposure following chemical contact with, for example, perfume or plant oils such as citrus or wild parsnip. May present as initial skin erythema leading to blistering lesions that follow the pattern of contact with the chemical in sun-exposed areas of skin.
- Skin necrosis, for example, caused by pressure.
- Congenital curvilinear palpable hyperpigmentation (rare) — occurs spontaneously from one month after birth; presents as symmetrical, loop-like raised areas of skin on the posterior calves.

Basis for recommendation

The information on differential diagnosis is based on the expert opinion of the National Burn Care Review Committee [National Burn Care Review Committee, 2001], the Royal College of Paediatrics and Child Health (RCPCH) publication Child protection evidence: Systematic review on burns [RCPCH, 2022], the NHS Scotland publication Care of Burns in Scotland: National Managed Clinical Network [Gray, 2019], and in a review article [BMJ Best Practice, 2022].

Management

Scenario: First aid and initial management

From age 1 month onwards.

What immediate first aid should be given to a person with a burn?

When giving immediate first aid to a person with a burn:
- Avoid personal injury by checking the area is safe and wearing personal protective equipment, if necessary (for example, when treating chemical burns).
- Assess the person's airway, breathing, and circulation.
- Assess for other significant injuries or trauma that may be life-threatening and require emergency treatment, such as crush injuries, fractures, head injuries, or penetrating injuries.
For thermal burns:
- Stop the burning process (for example, extinguish flames using 'drop and roll' or smother them with a blanket).
- Remove non-adherent clothing and potentially restricting jewellery.
  - Do not attempt to remove tar stuck to the skin.
- Within 3 hours of the injury, irrigate the burn with cool running water for 20 minutes.
  - Do not use ice or very cold water as it may cause vasoconstriction and may deepen the wound.
  - If water is not available, use wet towels or compresses.
  - Ensure the person is kept warm with coats, sheets, or blankets to avoid hypothermia, especially if cooling large areas of skin in children and the elderly.
- Immediately after cooling, cover the burn using cling film.
  - The layers of cling film should be laid over the burn rather than wrapped circumferentially, to avoid the possibility of constriction.
  - If cling film is not available, use a clean, cotton sheet. Consider using a clean, clear plastic bag for burns to the hand.
  - Do not apply topical creams at this stage, as they will hinder later assessment of the wound.
- Elevate the affected area if possible, to reduce the risk of oedema.
- Offer pain relief, such as paracetamol or ibuprofen, for mild-to-moderate pain. Consider adding codeine for more severe pain. See the CKS topics on Analgesia - mild-to-moderate pain and NSAIDs - prescribing issues.
- Take a history and assess burn severity to determine whether immediate admission to A&E is needed, or whether the person can be managed in primary care.
For electrical burns
- Do not approach a person connected to a high-voltage source (1000 volts or more).
- If the person has been injured by a low-voltage source (for example, domestic electricity supply [220–240 volts]):
  - Switch off the power supply if it is safe to do so, or remove the person from the electrical source using a non-conductive material (such as a wooden stick or wooden chair).
- Arrange immediate admission to A&E.
- If possible, take a history and assess burn severity to help guide subsequent management.
For chemical burns
- Determine the causative chemical, where possible.
- Remove affected clothing. Brush the chemical off the skin if it is in a dry form.
- Irrigate the burn with copious amounts of water for about an hour.
- Do not attempt to neutralize chemicals as additional heat will be generated, which may increase tissue damage.
- Arrange immediate admission to A&E.
- If possible, take a history and assess burn severity to help guide subsequent management.

Basis for recommendation

Immediate first aid

Rapid and efficient first aid and initial management of burn injuries can impact on the rate of wound healing, the level of pain and distress, and the cosmetic and functional outcomes for the person in the longer term [Lloyd, 2012; Wounds International, 2014].
The recommendations on assessing airway, breathing, and circulation are largely based on the ISBI guideline [ISBI, 2016] and the RCH guideline [RCH, 2022].
- Respiratory failure is immediately life-threatening; therefore, the initial assessment of a person with a burn should include an evaluation of the airway and breathing [ISBI, 2016].
- Assessment and monitoring of airway patency and breathing should be carefully observed as people at risk of inhalation burns can deteriorate up to 72 hours post-burn injury [RCH, 2022].
- Children who sustain burns injuries are at increased risk of circulatory compromise due to significant fluid loss and fluid shifts. Therefore, they must be closely monitored for signs and symptoms of hypovolemia and hypothermia [RCH, 2022].

First aid for thermal burns

The recommendation to cool the burn for 20 minutes with cool running water within 3 hours of injury is taken from the British Burn Association Clinical practice guidelines [British Burn Association, 2018].
Non-adherent clothing should be removed as soon as possible because it may retain heat and worsen the burn injury. Immediate cooling of the burn wound removes the heat, prevents progression of thermal injury, and limits tissue damage. It may also reduce pain, clean the wound, and minimize oedema formation [Wounds International, 2014].
The recommendation to avoid ice or very cold water is based on the fact this may lead to further tissue injury, necrosis, and hypothermia [Kim, 2012; Lloyd, 2012].
Elevating the injury to reduce the risk of oedema is important because oedema can affect mobilization, cause joint stiffness, and may delay healing [Cleland, 2012].
Covering the burn with cling film after cooling may help to prevent bacterial colonization, prevent wound desiccation, and relieve pain from exposed nerve endings. It also allows for immediate visualization of the wound on subsequent assessment [Wounds International, 2014].
The recommendation to avoid topical antimicrobial creams is based on the fact that there is limited evidence for their efficacy, and they may affect later wound assessment [Wounds International, 2014].

First aid for electrical burns

The extent of tissue damage in electrical burns is determined by the voltage of the current. Injuries associated with high-voltage burns may be life threatening and require immediate specialist management [Wounds International, 2014].
If a person is connected to a high-voltage source, there is a risk that the electrical current will arc to an approaching first aider [Wounds International, 2014].
In high-voltage electrical injuries, urgent surgery may be life-saving, and is necessary to allow the highest chance for limb salvage [ISBI, 2016].

First aid for chemical burns

Chemical burns tend to cause deep dermal or full thickness wounds because tissue damage continues until the chemical is completely removed, for example, by copious irrigation with water [Wounds International, 2014].
Prolonged, early irrigation dilutes the chemical concentration on the affected skin, reducing the risk of subsequent tissue injury [Gnaneswaran, 2015].

When should I admit or refer a person with a burn or scald?

Arrange immediate admission to A&E in the following situations, depending on clinical judgement and local referral pathways. Transfer to a regional burns unit may be arranged in A&E if necessary:
- All complex burn injuries.
- All full-thickness burns.
- Deep dermal burns affecting more than 5% of total body surface area (TBSA) in adults.
- All deep dermal burns in children.
- All circumferential deep dermal burns.
- Any high-pressure steam injury.
- Any burn associated with suspected non-accidental injury, regardless of the complexity of the burn.
- Burns associated with sepsis.
- Burns affecting the face, hands, feet, genitalia, or perineum, or any flexural surface, such as the neck, axilla, elbow, or knee.
- Burns associated with suspected inhalation injury (suggested, for example, by singed eyebrows or nasal hairs, sore throat, black carbon in the sputum, hoarse voice, stridor, wheeze, or signs of carbon in the oropharynx).
- People with significant comorbidities that may affect wound healing or increase the risk of complications, or those clinically judged to be at risk of complications.
- People with other significant injuries or trauma, such as crush injuries, fractures, head injuries, or penetrating injuries.
Arrange referral to a specialist burns unit or seek specialist advice if:
- There is any uncertainty as to whether referral is needed or appropriate.
- The person is deemed to require special social, emotional, or rehabilitative intervention.
- There is inadequate pain control, or dressings are difficult to manage, in primary care.
- A burn wound is not healing as expected or has not healed within two weeks of initial injury, depending on clinical judgement.
For people with superficial epidermal burns (such as sunburn), consider immediate admission to A&E:
- If there are signs or symptoms of heat exhaustion or heat stroke, such as fatigue, dizziness, nausea, vomiting, headache, muscle cramps, irritability, confusion, disorientation, hallucinations, fever, and/or tachycardia.
- For very young children with greater than 10% BSA coverage.
- For adults with greater than 15–25% BSA blistering.
For people with superficial dermal burns, arrange referral to:
- A physiotherapist and/or occupational therapist if the person has hypertrophic scars or contractures that need support with maintaining movement and function.
- A skin camouflage service, if needed.

Basis for recommendation

These recommendations are based on the National Network for Burn Care document National Burn Care Referral Guidance [NNBC, 2012], the International Best Practice Guideline Effective skin and wound management of non-complex burns [Wounds International, 2014], the International Society for Burn Injuries (ISBI) Practice Guidelines for Burn Care [ISBI, 2016], and on expert opinion in review articles [Cleland, 2012; Lloyd, 2012; Culleiton, 2013; BMJ Best Practice, 2021; BMJ Best Practice, 2022].

Full-thickness burns may require specialist surgical excision and grafting [Lloyd, 2012].
People with burns to the face and neck are at increased risk of airway oedema and inhalation injury, and facial burns may need specialist surgical management and can have a significant psychological impact on the person [Lloyd, 2012].
Burns extending over a joint or flexure may need physiotherapy or occupational therapy during wound healing to minimize joint stiffness, weakness, and loss of function [Lloyd, 2012].
Circumferential burns to limbs and extremities can lead to vascular compromise and increased risk of compartment syndrome [Lloyd, 2012], and circumferential burns to the thorax may affect chest wall expansion and cause respiratory compromise [Culleiton, 2013].
People with suspected inhalation injuries may need emergency bronchoscopy, intubation, ventilatory support, and management of carboxyhaemoglobin levels [Culleiton, 2013].
Very young children with greater than 10% body surface area (BSA) coverage, adults with greater than 15–25% BSA blistering, and those with systemic symptoms should be considered for hospitalization for intravenous fluids and supportive care [BMJ Best Practice, 2021].
If a burn wound has not healed after 2–3 weeks, the burn may be deeper than thought at initial assessment and may need specialist management. Burns with prolonged healing times have an increased risk of hypertrophic scarring, and surgical intervention, such as excision and grafting, may be needed [Cleland, 2012; Wounds International, 2014].
Inadequate initial management of a superficial burn may allow it to progress to a deeper, more complex wound [Wounds International, 2014].

Scenario: Managing non-complex burns

From birth onwards.

How should I manage a person with a superficial epidermal burn?

If a person presents with a superficial epidermal burn, ensure that appropriate immediate first aid has been given and that the wound has been fully assessed. If hospital admission is not indicated:

Advise the person on measures to provide symptom relief, such as:
- Taking a cool bath or shower, or applying cold compresses.
- Massaging the area with an emollient, such as emulsifying ointment, to relieve itching and dryness.
- Using simple analgesia, such as paracetamol or ibuprofen, if needed. See the CKS topics on Analgesia - mild-to-moderate pain and NSAIDs - prescribing issues for more information.
Advise the person to:
- Maintain adequate hydration to aid wound healing and reduce the risk of complications.
- Arrange an urgent review if blisters develop, as this may suggest progressive dermal injury. See the section on Management of superficial dermal burns for more information.
- To arrange an urgent review if they develop signs or symptoms of infection (such as increased pain, odour, excessive exudate, fever, or erythema). See the section on Managing wound infection for more information.
- Protect their skin from the sun by using sunscreen, wearing protective clothing, and not being outdoors in direct sunlight for too long, particularly during peak hours from 10 am to 4 pm.
Give sources of information and support, such as:
- The NHS information leaflets on Sunburn and Heat exhaustion and heatstroke.
- The British Burn Association — a charity concerned with all aspects of burn care, which has information on burn clubs and camps, and links to other support organizations.
Arrange referral to a specialist burns unit or seek specialist advice for any wound that is not improving as expected, or that has not healed within two weeks of the initial injury, depending on clinical judgement.

Basis for recommendation

How should I manage a person with a superficial dermal burn?

If a person presents with a superficial dermal burn, ensure that appropriate immediate first aid has been given and that the wound has been fully assessed. If hospital admission is not indicated:

Arrange for the wound to be managed by a professional with appropriate expertise and training (such as a practice nurse, district nurse, or tissue viability nurse).
- Initially, the wound should be cleaned and dressed.
- Then, the wound should be reassessed:
  - After 48 hours — for a dressing change and to check for signs and symptoms of infection (such as increased pain, odour, excessive exudate, fever, or erythema).
  - Every 3–5 days until the wound is healed — for dressing changes (depending on the type of dressing, amount of exudate, and rate of healing).
- Note that excessive exudate may be a normal clinical finding in the first 72 hours after a burn injury.
Assess the need for tetanus prophylaxis.
Advise the person:
- On the use of analgesics to alleviate discomfort and systemic symptoms. See the CKS topics on Analgesia - mild-to-moderate pain and NSAIDs - prescribing issues for more information.
- To maintain adequate hydration to aid wound healing and reduce the risk of complications.
- To arrange an urgent review if they develop signs and symptoms of infection. See the section on Managing wound infection for more information.
- That after the wound has healed, they should:
  - Massage the area daily with an emollient, such as emulsifying ointment, until the burn is no longer dry or itchy (usually around 3–6 months), to reduce the risk of hypertrophic scarring.
  - Use high-factor sunblock (sun protection factor 30–50) or clothing over the affected skin for 1–2 years, to prevent irregular pigmentation or hyperpigmentation.
Give sources of information and support, such as:
- The NHS information leaflet on Burns and scalds.
- The British Burn Association — a charity concerned with all aspects of burn care, which has information on burn clubs and camps, and links to other support organizations.
- Changing Faces — a national charity that supports people living with a scar, mark, or condition on their face or body.
Arrange referral to:
- A specialist burns unit or seek specialist advice for any wound that is not improving as expected, or that has not healed within two weeks of the initial injury, depending on clinical judgement.
- A physiotherapist and/or occupational therapist if the person has hypertrophic scars or contractures that need support with maintaining movement and function.
- A skin camouflage service, if needed.

Wound management

These recommendations are intended as a brief guide as burn wounds should be managed by a professional with appropriate experience and expertise (such as a practice nurse, district nurse, or tissue viability nurse), to optimize wound healing and reduce the risk of infection.

Wound cleaning
- Cleansing is useful for removing foreign bodies, soluble debris, excess slough, or necrotic tissue, which may become a focus for infection.
  - If a clean technique is being used, use lukewarm tap water.
  - If a sterile technique is required, use 0.9% normal saline.
  - Ideally, the cleansing fluid should be at body temperature. If this is not possible, the fluid should be warmed to room temperature before use.
- Gentle wound irrigation is recommended.
  - Do not clean wounds by scrubbing, as this causes pain and local tissue oedema. Irrigation is more protective of fragile tissue.
  - Do not use topical antiseptics, due to reported pain, tissue damage, wound drying, and delayed healing.
- Wound debridement describes the removal of necrotic, devitalized, sloughy, or infected tissue. This allows visualization of the wound bed and may encourage epithelialization.
  - Natural (autolytic) debridement may be promoted by the use of specialist dressings, such as hydrogels.
  - Specialist surgical debridement may be appropriate, following referral.
- Blisters should be left intact wherever possible, to reduce the risk of infection.
  - Consider de-roofing large blisters (for example, greater than 1 cm²), blisters that are likely to rupture, or those over a joint, using an aseptic technique.
Wound dressing
- The choice of dressing will depend on the site, size, and depth of the wound; level of exudate; infection risk; and local formulary availability.
- The British National Formulary (BNF) has suggestions on choices of dressings for different types of wounds. As a general guide:
  - An appropriate size and type of dressing should be selected to avoid stretching or applying dressings under tension.
  - The wound should be covered with a non-adherent dressing, such as paraffin gauze, silicone-coated nylon dressing, polyurethane film, or hydrocolloid dressing.
  - A secondary, non-fibrous, absorbent dressing, such as a dressing pad, should then be applied and secured well with a lightweight conforming bandage or tubular gauze bandage.
- Dressings should be changed regularly to encourage wound healing. Once burn depth is accurately estimated, the frequency of dressing change may be reduced to minimize the risk of bacterial contamination and trauma to the wound. If appropriate, the person or a carer can be supported to change their own dressings.
- Appropriate analgesia should be taken by the person before dressing changes. See the CKS topics on Analgesia - mild-to-moderate pain and NSAIDs - prescribing issues for more information.
- Due to limited and conflicting evidence, the following treatments should not be routinely used:
  - Systemic or topical prophylactic antibiotics.
  - Antimicrobial-impregnated dressings.
  - Antimicrobial creams, such as silver sulfadiazine.
  - Other topical preparations.

[Kim, 2012; Lloyd, 2012; White, 2012; Barajas-Nava, 2013; Wounds International, 2014; Douglas, 2017]

Basis for recommendation

These recommendations are based on the International Best Practice Guideline Effective skin and wound management of non-complex burns [Wounds International, 2014]; the International Society for Burn Injuries (ISBI) Practice guidelines for burn care [ISBI, 2016]; the Cochrane systematic reviews Antibiotic prophylaxis for preventing burn wound infection (Review) [Barajas-Nava, 2013], Dressings for superficial and partial thickness burns (Review) [Wasiak, 2013], and Antiseptics for burns (Review) [Norman, 2017]; and expert opinion in review articles [Cleland, 2012; Lloyd, 2012; White, 2012; Culleiton, 2013; Gnaneswaran, 2015; Douglas, 2017].

Appropriate wound management

The aim of good wound management is to provide a moist environment to promote re-epithelialization and prevent wound progression, dehydration, and infection [Lloyd, 2012; Douglas, 2017].

Topical antimicrobial treatments

Expert opinion in the international best practice guideline recommends considering their use for local wound infection [Wounds International, 2014]. However, the ISBI practice guideline does not recommend the use of systemic prophylactic antibiotics for acute burns [ISBI, 2016].
Expert opinion in a review article is that deep dermal burns should be treated with a topical antimicrobial preparation, such as silver sulfadiazine (SSD), to reduce pain, promote healing, and prevent wound desiccation. However, it notes that newer occlusive dressings may be more clinically- and cost-effective [Lloyd, 2012].
There is limited and conflicting evidence in the literature on the use of topical antimicrobial treatments for burn injuries:
- A Cochrane systematic review (search date: November 2012) assessed the effects of burn wound dressings on superficial and partial thickness burns [Wasiak, 2013]:
  - Poor-quality evidence from 30 randomized controlled trials (RCTs) showed that SSD was consistently associated with poorer healing outcomes compared with newer occlusive dressings, such as biosynthetic (skin substitute) dressings, silver-containing, and silicon-coated dressings.
- A Cochrane systematic review (search date: January 2013) assessed the effects of antibiotic prophylaxis on rates of burn wound infection [Barajas-Nava, 2013].
  - Eleven RCTs (n = 645) evaluated topical prophylaxis with SSD were pooled in a meta-analysis.
  - There was a statistically significant increase in burn wound infection associated with SSD compared with dressings/skin substitutes. These trials were at high, or unclear, risk of bias.
  - SSD was also associated with significantly longer length of hospital stay compared with dressings/skin substitute.
- A subsequent Cochrane systematic review (search date: September 2016) assessed the effects and safety of antiseptics for the treatment of burns in any care setting [Norman, 2017]:
  - Fifty-six RCTs (n = 5807) were included in the systematic review.
  - Most of the studies compared antiseptic treatments with a topical antibiotic, primarily SSD; other studies compared antiseptic with a non‐antibacterial treatment or another antiseptic.
  - There was no clear difference in the likelihood of healing between topical antiseptics and antibiotics.
  - Very low-quality evidence that antiseptics were of unknown effectiveness in their ability to reduce the risk of infection compared with topical antibiotics or non-antimicrobial agents.
  - Most of the included studies had poorly reported methodology, meaning that it was unclear whether they were at high risk of bias.

Arranging regular review until wound healing

The burn depth and complexity of injuries may increase within the first few days of a burn injury, due to progression of thermal injury, so frequent re-evaluation is necessary to identify wounds that are at increased risk of complications or which need specialist assessment [Lloyd, 2012; Wounds International, 2014].
Burn extent and depth may be more clearly demarcated after 72 hours following initial injury [Culleiton, 2013].
Superficial burns may produce a significant amount of exudate in the first 24–72 hours after injury due to increased capillary permeability, and this does not necessarily indicate wound infection [Butcher, 2012; Wounds International, 2014].
- Increased levels of exudate should be managed with appropriate dressings, as this provides a portal for bacterial contamination if allowed to soak through dressings.
- Following this initial time period, it may be necessary to reassess the optimal dressing choice as levels of exudate reduce.

Advice on skin care

The recommendation on the use of massage and emollient application is based on the fact that symptoms such as itch typically peak at 2–6 months after injury. It may also reduce the risk of hypertrophic scarring, which may occur 4–6 weeks after injury to the deep dermis [Cleland, 2012; Wounds International, 2014].
The recommendation on the use of high factor sunblock is based on the fact that newly healed epidermis may have increased melanocyte activity if exposed to sunlight following a burn injury, causing permanent hyperpigmentation [Douglas, 2017].

Arranging referral or seeking specialist advice

If a burn wound has not healed after 2–3 weeks, the burn may be deeper than thought at initial assessment and may need specialist management. Burns with prolonged healing times have an increased risk of hypertrophic scarring, and surgical intervention such as excision and grafting may be needed [Cleland, 2012; Wounds International, 2014].
Inadequate initial management of a superficial burn may allow it to progress to a deeper, more complex wound [Wounds International, 2014].

When should I offer tetanus prophylaxis to a person with a burn?

Check the person's tetanus immunization status. A fully immunized person will have had a primary course of three tetanus vaccines, followed by two boosters spaced 10 years apart. For further details, see the CKS topic on Immunizations - childhood.
- For children under 5 years who have received an adequate priming course of tetanus vaccine (at least 3 doses):
  - A tetanus vaccine is not required.
  - Continue with the recommended vaccination schedule, to ensure future immunity.
- For children aged 5–10 years who have received an adequate priming course of tetanus vaccine (at least 3 doses) and preschool booster:
  - A tetanus vaccine is not required.
  - Continue with the recommended vaccination schedule, to ensure future immunity.
- For children aged 5–10 years who have received an adequate priming course of tetanus vaccine (at least 3 doses) but no preschool booster:
  - For a clean wound, a tetanus vaccine is not required.
  - For a tetanus-prone wound, administer an immediate reinforcing dose of the tetanus vaccine.
  - For a high-risk tetanus-prone wound, administer an immediate reinforcing dose of the tetanus vaccine plus one dose of human tetanus immunoglobulin (HTIG) in a different site. If HTIG is not available in primary care, refer the person to the A&E department. Human normal immunoglobulin (HNIG) may be used as an alternative to HTIG.
  - Continue with the recommended vaccination schedule, to ensure future immunity.
- For people aged 11 years and over who have received an adequate priming course of tetanus vaccine (at least 3 doses) with the last dose within 10 years:
  - A tetanus vaccine is not required.
  - Continue with the recommended vaccination schedule, to ensure future immunity.
- For people aged 11 years and over who have received an adequate priming course of tetanus vaccine (at least 3 doses) but the last dose was more than 10 years ago:
  - For a clean wound, a tetanus vaccine is not required.
  - For a tetanus-prone wound, administer an immediate reinforcing dose of the tetanus vaccine.
  - For a high-risk tetanus-prone wound, administer an immediate reinforcing dose of the tetanus vaccine plus one dose of HTIG in a different site. If HTIG is not available in primary care, refer the person to the A&E department. HNIG may be used as an alternative to HTIG.
  - Continue with the recommended vaccination schedule, to ensure future immunity.
- For people who have not received an adequate priming course of tetanus vaccine (at least 3 doses):
  - For a clean wound, administer an immediate reinforcing dose of the tetanus vaccine.
  - For a tetanus-prone wound or a high-risk tetanus-prone wound, administer an immediate reinforcing dose of the tetanus vaccine plus one dose of HTIG in a different site. If HTIG is not available in primary care, refer the person to the A&E department. HNIG may be used as an alternative to HTIG.
  - Continue with the recommended vaccination schedule, to ensure future immunity.
- If the person is not immunized or their immunization status is unknown or uncertain:
  - For a clean wound, administer an immediate reinforcing dose of the tetanus vaccine.
  - For a tetanus-prone wound or a high-risk tetanus-prone wound, administer an immediate reinforcing dose of the tetanus vaccine plus one dose of HTIG in a different site. If HTIG is not available in primary care, refer the person to the A&E department. HNIG may be used as an alternative to HTIG.
  - A full course of tetanus immunization is likely to be required.
- If the person is fully immunized but is severely immunosuppressed:
  - Consider the need for additional boosting and/or immunoglobulin as they may not be adequately protected against tetanus, despite having been fully immunized.

Tetanus infection

Tetanus is an acute disease caused by the action of tetanus toxin, released following infection by the bacterium Clostridium tetani.
- C. tetani spores are present in soil or manure, and may be introduced into the body through a laceration, puncture wound, burn, or scratch.
- The incubation period of the disease is usually between 3–21 days, although it may range from one day to several months, depending on the character, extent, and localization of the wound.
- Tetanus is not spread from person to person.
Tetanus infection can present as generalized (the most common presentation), localized, or cephalic.
- Generalized tetanus is characterized by trismus (lockjaw), tonic contractions, and spasms. Tonic contractions and spasms may lead to dysphagia, opisthotonus, and a rigid abdomen. In severe cases, they may cause respiratory difficulties. Autonomic instability is typical. Consciousness is not affected.
- Localized tetanus is characterized by rigidity and spasms confined to the area around the site of the infection, and may be more common in partially immunized people. Localized symptoms can continue for weeks or may develop into generalized tetanus.
- Cephalic tetanus is localized tetanus after a head or neck injury, primarily involving the musculature supplied by the cranial nerves.
Any wound can give rise to tetanus. However, clean wounds (defined as wounds less than 6 hours old, non-penetrating with negligible tissue damage) are considered to have a low likelihood of harbouring C. tetani spores and of developing the anaerobic and acidic conditions that promote spore germination.
- Tetanus-prone wounds include:
  - Puncture-type injuries acquired in a contaminated environment, such as gardening injuries.
  - Wounds containing foreign bodies.
  - Compound fractures.
  - Wounds or burns with systemic sepsis.
  - Certain animal bites and scratches. Smaller bites from domestic pets are generally puncture injuries. Animal saliva should not contain C. tetani spores unless the animal has been rooting in soil or lives in an agricultural setting.
- High-risk tetanus-prone wounds include any of the above with one or more of the following:
  - Heavy contamination with material likely to contain C. tetani spores, for example, soil or manure.
  - Wounds or burns that show extensive devitalized tissue.
  - Wounds or burns that require surgical intervention that is delayed for more than 6 hours are high risk even if the contamination was not initially heavy.
- Clinical judgement and individual risk assessment are required when considering the risk of infection. For example, a wound from discarded needle found in a park may be a tetanus-prone injury but a needle stick injury in a medical environment is not.
Tetanus (local and generalized) is a notifiable disease.
- Doctors have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team (HPT) of suspected cases.
- Further information is available form the GOV.UK website (www.gov.uk).

[PHE, 2019; PHE, 2022]

Basis for recommendation

These recommendations are based on the Public Health England (PHE) publication Immunisation against infectious disease (The Green Book) Chapter 30: Tetanus [PHE, 2022].

According to the Green Book:
- People who have received an adequate priming course of tetanus vaccine (defined as at least 3 doses) would be expected to retain antibody levels above the protective threshold for between 5–10 years (depending on the age at which they received their last dose). These people would be expected to have adequate protection following a tetanus-prone injury and will therefore not require any immediate treatment. Further doses of vaccine may be required to complete the recommended schedule for future immunity.
- People who have received an adequate priming course but are more than 5–10 years since the last dose (depending on the age of the final dose) would be expected to make a rapid response to a booster dose of vaccine and so all people in this group are recommended a booster dose of vaccine for immediate protection. This is likely to be sufficient except in situations of heavy contamination; therefore, only people who have sustained a high-risk injury require human tetanus immunoglobulin (HTIG) in addition to a reinforcing dose of vaccine. Further doses of vaccine may be required to complete the recommended schedule for future immunity.
- For people who have not received an adequate priming course, any tetanus prone injury should receive both HTIG and a reinforcing dose of vaccine. This should include people with an uncertain immunization status and /or those born before routine immunization in 1961. Further doses of vaccine may be required to complete the recommended schedule for future immunity.

How should I manage a person with an infected burn wound?

If there are signs or symptoms of infection (such as increased pain, odour, excessive exudate, fever, or erythema):
- Prescribe empirical oral antibiotics. See the section on Management of acute cellulitis in the CKS topic on Cellulitis - acute for more information.
  - Take a swab of the wound before starting antibiotic treatment.
- Arrange to review the person, the time interval depending on clinical judgement.
  - If symptoms are improving but have not fully resolved after 7 days of the first-line antibiotic, consider prescribing another course of the treatment.
  - If there is little or no clinical response to the first-line antibiotic, review the swab results, change the antibiotics if indicated, and arrange a further review.
Do not prescribe antibiotic treatment if there are no signs or symptoms of infection.

Basis for recommendation

These recommendations are based on the International Society for Burn Injuries (ISBI) Practice guidelines for burn care, Part 2 [ISBI, 2018] and on expert opinion in review articles [White, 2012; BMJ Best Practice, 2022].

The most common wound infection in small outpatient burns is cellulitis, usually caused by Staphylococcus aureus. [BMJ Best Practice, 2022].
The recommendation to take a bacteriological swab before starting antibiotic treatment is based on the fact that this allows the identification of causative micro-organisms and specific antibiotic sensitivities that can guide management [White, 2012].
The use of prophylactic systemic antibiotics has not been shown to reduce infections or sepsis, but will increase the incidence of multiply resistant organisms [ISBI, 2018].

Supporting evidence

This CKS topic is largely based on the International Best Practice Guideline Effective skin and wound management of non-complex burns [Wounds International, 2014], the International Society for Burn Injuries (ISBI) Practice guidelines for burn care [ISBI, 2016], the National Network for Burn Care document National Burn Care Referral Guidance [NNBC, 2012], evidence from Cochrane systematic reviews [Barajas-Nava, 2013; Wasiak, 2013; Norman, 2017], and on expert opinion in several review articles on burns.

The rationale for the individual recommendations is discussed in the relevant basis for recommendation sections.

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

Scope of search

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of burns and scalds.

Search dates

November 2017 - November 2022

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

exp Burns/, (burn or burns).tw., (scald or scalds).tw., (sunburn* or sun-burn*).tw.

Sources of guidelines

Sources of systematic reviews and meta-analyses

The Cochrane Library:
- Systematic reviews
- Protocols
- Database of Abstracts of Reviews of Effects
Medline (with systematic review filter)
EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

NIHR Health Technology Assessment programme
The Cochrane Library:
- NHS Economic Evaluations
- Health Technology Assessments
Canadian Agency for Drugs and Technologies in Health
International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

The Cochrane Library:
- Central Register of Controlled Trials
Medline (with randomized controlled trial filter)
EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Department of Health
Health Management Information Consortium (HMIC)

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

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Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

Animal studies
Original research is not written in English

Possible exclusions for reviewed literature:

Sample size too small or study underpowered
Bias evident or promotional literature
Population not relevant
Intervention/treatment not relevant
Outcomes not relevant
Outcomes have no clear evidence of clinical effectiveness
Setting not relevant
Not relevant to UK
Incorrect study type
Review article
Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

Feasibility
- Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
Organizational and Financial Impact Analysis
Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
- Eligible population
- Current interventions
- Likely uptake of new intervention or recommendation
- Cost of the current or new intervention mix
- Impact on other costs
- Condition-related costs
- In-direct costs and service impacts
- Time dependencies
Cost-effectiveness or cost-benefit analysis studies are identified where available.

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

Personal financial interests
Personal family interest
Personal non-financial interest
Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

References

Agbenorku, P., Agbenorku, M. and Fiifi-Yankson, P.K. (2013) Pediatric burns mortality risk factors in a developing country's tertiary burns intensive care unit. International Journal of Burns and Trauma 3(3), 151-158. [Abstract] [Free Full-text]
Barajas-Nava, L.A., Lopez-Alcalde, J., Roque i Fuguls, M., et al. (2013) Antibiotic prophylaxis for preventing burn wound infection (Cochrane Review). Issue 6. John Wiley & Sons, Ltd. http://www.cochranelibrary.com [Free Full-text]
BMJ Best Practice (2021) Sunburn. BMJ Best Practice. http://bestpractice.bmj.com
BMJ Best Practice (2022) Cutaneous burns. BMJ Best Practice. http://bestpractice.bmj.com
British Burn Association (2018) First Aid Clinical Practice Guideline. British Burn Association. https://www.britishburnassociation.org [Free Full-text]
Butcher, M. and Swales, B. (2012) Assessment and management of patients with burns. Nursing Standard 27(2), 50-56.
Clark, A., Neyra, J. A., Madni, T., et al. (2017) Acute kidney injury after burn. Burns: Journal of the International Society for Burn Injuries 43(5), 898-908. [Abstract]
Cleland, H. (2012) Thermal burns. Assessment and acute management in the general practice setting. Australian Family Physician 41(6), 372-375. [Abstract]
Culleiton, A.L. and Simko, L.M. (2013) Caring for patients with burn injuries. Nursing Critical Care 8(1), 15. [Abstract]
Douglas, H.E. and Wood, F. (2017) Burns dressings. Australian Family Physician 46(3), 94-97. [Abstract]
Emara, S.S. and Alzaylai, A.A (2013) Renal failure in burn patients: a review. Annals of Burns and Fire Disasters 26(1), 12-15. [Abstract] [Free Full-text]
Giretzlehner, M., Ganitzer, I. and Haller, H (2021) Technical and Medical Aspects of Burn Size Assessment and Documentation. Medicina 57(3), 242. [Free Full-text]
Gnaneswaran, N., Perera, E., Perera, M. and Sawhney R. (2015) Cutaneous chemical burns: assessment and early management. Australian Family Physician 44(3), 135-139. [Abstract]
Gray, A (2019) Care of Burns in Scotland: National Managed Clinical Network. NHS Scotland. http://www.cobis.scot.nhs.uk [Free Full-text]
International Society for Burn Injuries (2016) ISBI Practice guidelines for burn care. Burns 42(5), 953-1021. [Abstract]
International Society for Burn Injuries (2018) ISBI Practice Guidelines for Burn Care, Part 2. Burns 44(7), 1617-1706. [Abstract]
Kim, L.K.P., Martin, H.C.O. and and Holland, A.J.A. (2012) Medical management of paediatric burn injuries: Best practice. Journal of Paediatrics and Child Health 48(4), 290-295. [Abstract]
Lloyd, E.C.O., Rodgers, B.C., Michener, M. and Williams, M.S. (2012) Outpatient burns: prevention and care. 85(1), 25-32. [Abstract]
National Burn Care Review Committee (2001) National burn care review. British Association of Plastic Surgeons. http://www.bapras.org.uk [Free Full-text]
NICE (2016) Mersey Burns for calculating fluid resuscitation volume when managing burns. National Institute for Health and Care Excellence. http://www.nice.org.uk [Free Full-text]
NICE (2017) Child maltreatment: when to suspect maltreatment in under 18s. National Institute of Health and Care Excellence. http://www.nice.org.uk [Free Full-text]
NNBC (2012) National burn care referral guidance. NHS Specialised Services. https://www.britishburnassociation.org [Free Full-text]
Norman, G., Christie, J., Liu, Z., et al. (2017) Antiseptics for burns (Cochrane Review). Issue 7. John Wiley & Sons, Ltd. http://www.cochranelibrary.com [Free Full-text]
PHE (2019) Tetanus: Guidance on the management of suspected tetanus cases and on the assessment and management of tetanus-prone wounds. Public Health England. http://www.gov.uk [Free Full-text]
PHE (2022) Immunisation against infectious disease (The Green Book) Chapter 30: Tetanus. Public Health England. http://www.gov.uk [Free Full-text]
RCH (2022) Nursing management of burn injuries. Royal Children's Hospital Melbourne. http://www.rch.org.au [Free Full-text]
RCPCH (2022) Child Protection Evidence - Systematic review on Burns. Royal College of Paediatrics and Child Health. http://www.rcpch.ac.uk [Free Full-text]
Stylianou, N., Buchan, I. and Dunn, K.W. (2015) A review of the international Burn Injury Database (iBID) for England and Wales: descriptive analysis of burn injuries 2003–2011. British Medical Journal 5(2), 1-10. [Abstract]
Wasiak, J., Cleland, H., Campbell, R. and Spinks, A. (2013) Dressings for superficial and partial thickness burns (Cochrane Review). Issue 3. John Wiley & Sons, Ltd. http://www.cochranelibrary.com [Free Full-text]
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Wounds International (2014) Effective skin and wound management of non-complex burns. Wounds International. http://www.woundsinternational.com [Free Full-text]

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Burns and scalds: Summary

Have I got the right topic?

How up-to-date is this topic?

Changes

Previous changes

Update

New evidence

Evidence-based guidelines

HTAs (Health Technology Assessments)

Economic appraisals

Systematic reviews and meta-analyses

Primary evidence

New policies

New safety alerts

Changes in product availability

Goals and outcome measures

Goals

Outcome measures

Audit criteria

QOF indicators

QIPP - Options for local implementation

NICE quality standards

Background information

What is it?

How do burns occur?

How common is it?

What are the complications?

What is the prognosis?

Diagnosis of burns and scalds

How should I assess a person with a burn?

What are the red flags for non-accidental injury?

How should I assess the extent of the burn?

Classification of burn depth

Basis for recommendation

Rapid initial assessment

Assessment for non-accidental injury

Assessment of burn extent and depth

What else might it be?

Basis for recommendation

Management

Scenario: First aid and initial management

What immediate first aid should be given to a person with a burn?

Basis for recommendation

Immediate first aid

First aid for thermal burns

First aid for electrical burns

First aid for chemical burns

When should I admit or refer a person with a burn or scald?

Basis for recommendation

Scenario: Managing non-complex burns

How should I manage a person with a superficial epidermal burn?

Basis for recommendation