Management of Minor Burns and Sunburn; Pharmacist Role
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Learning outcomes Learn about different type of skin burn Learn
how to provide a quick pharmaceutical advice when patient seeking
your advice in such situation Learn about the cases you should
refer for medical attention Learn about the products available in
the pharmacy
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Ambulatory management of burns is divided into: Acute treatment
Follow-up care. Acute management includes: Measures to minimize
further damage to patients Identifying patients requiring
hospitalization Implementing measures to promote healing Prevent
infection and relieve pain. Follow-up care The focus shifts to
limiting disfigurement from scarring and dysfunction from
contractures. Although most patients with burns can be managed by
family physicians, some require surgical referral for skin grafting
and scar rehabilitation. 4
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First aid advice for burn: Immediately get the person away from
the heat source to stop the burning. Cool the burn with cool water
for 10-30 minutes. Do not use ice, iced water or any creams or
greasy substances, such as butter. Remove any clothing or jewellery
that is near the burnt area of skin, but do not move anything that
is stuck to the skin.
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Make sure the person keeps warm for example by using a blanket
but take care not to rub it against the burnt area. Cover the burn
by placing a layer of cling film over it. Use painkillers, such as
paracetamol or ibuprofen, to treat any pain.paracetamol
ibuprofen
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When to get medical attention Depending on how serious a burn
is, it may be possible to treat it at home. For minor burns, keep
the burn clean and do not burst any blisters that form. More
serious burns will require professional medical attention. Tell
patient to get to a hospital A&E department for: All chemical
and electrical burns Large or deep burns any burn bigger than your
hand Full thickness burns of all sizes these burns cause white or
charred skin Partial thickness burns on the face, hands, arms,
feet, legs or genitals these are burns that cause blisters
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The skin Skin is the largest organ. It has many functions,
including acting as a barrier between you and the environment and
regulating your temperature. The skin is made up of three layers:
The epidermis (the outer layer of your skin) is 0.5-1.5mm thick. It
has five layers of cells that work their way up to the surface of
your skin, where dead cells are shed approximately every two weeks.
The dermis (the underlying layer of fibrous tissue) is 0.3- 3mm
thick and is made up of a mix of three types of tissue. The dermis
contains your hair follicles and sweat glands, as well as small
blood vessels and nerves. The subcutaneous fat or subcutis (the
final layer of fat and tissue) varies in thickness from person to
person. It contains your larger blood vessels and nerves, and
regulates the temperature of your skin and body.
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DEPTH OF A BURN The traditional classification of burns as
first, second or third degree is being replaced by the designations
of superficial, superficial partial thickness, deep partial
thickness and full thickness. 9
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Superficial epidermal burns Superficial epidermal burns are
where the epidermis is damaged. Skin will be red, slightly swollen
and painful but not blistered. Superficial dermal burns Superficial
dermal burns are where the epidermis and part of the dermis are
damaged. Skin will be pale pink, painful and there may be small
blisters. Deep dermal or partial thickness burns Deep dermal or
partial thickness burns are where the epidermis and the dermis are
damaged. This type of burn makes skin turn red and blotchy. Skin
may also be dry or moist, become swollen and blistered, and it may
be very painful or painless.
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Full thickness burns Full thickness burns are where all three
layers of skin (the epidermis, dermis and subcutis) are damaged. In
this type of burn, the skin is often burnt away and the tissue
underneath may appear pale or blackened. The remaining skin will be
dry and white, brown or black with no blisters. The texture of the
skin may also be leathery or waxy.
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13 Superficial burns on the trunk and right arm of a young
child. Typically, these are red burns that blanch with
pressure.
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14 Superficial partial-thickness burn on a man's right knee.
Blistering wounds that blanch with pressure are characteristic of
superficial partial-thickness burns. These wounds are also
typically moist and weeping.
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15 Deep partial-thickness burns on the trunk and extremities of
a young child. These burns are typified by easily unroofed blisters
that have a waxy appearance and do not blanch with pressure.
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16 Full-thickness burn on a woman's left flank. Burn areas of
this type are characteristically insensate and waxy white or
leathery gray in color.
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ClassificationCause Characteristics AppearanceSensationHealing
timeScarring Superficial burn Ultraviolet light, very short flash
(flame exposure) Dry and red; blanches with pressure Painful3 to 6
daysNone Superficial partial- thickness burn Scald (spill or
splash), short flash Blisters; moist, red and weeping; blanches
with pressure Painful to air and temperature 7 to 20 days Unusual;
potential pigmentary changes Deep partial- thickness burn Scald
(spill), flame, oil, grease Blisters (easily unroofed); wet or waxy
dry; variable color (patchy to cheesy white to red); does not
blanch with pressure Perceptive of pressure only More than 21 days
Severe (hypertrophic) risk of contracture Full-thickness burn Scald
(immersion), flame, steam, oil, grease, chemical, high-voltage
electricity Waxy white to leathery gray to charred and black; dry
and inelastic; does not blanch with pressure Deep pressure only
Never (if the burn affects more than 2 percent of the total surface
area of the body) Very severe risk of contracture 17 Classification
of Burns Based on Depth
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When to refer All chemical and electrical burns large or deep
burns any burn bigger than the affected persons hand Full thickness
burns of all sizes these burns cause white or charred skin Partial
thickness burns on the face, hands, arms, feet, legs or genitals
these are burns that cause blistersblisters Also get medical help
straight away if the person with the burn: Has other injuries that
need treating or is going into shock (signs include cold, clammy
skin, sweating, rapid, shallow breathing and weakness or dizziness)
If pregnant If over 60 years of age If under five years of age Has
A medical condition such as heart, lung or liver disease, or
diabetes (A long-term condition caused by too much glucose in the
blood)diabetes Has A weakened immune system (the bodys defence
system), for example because of HIV or AIDS or because they're
having chemotherapy for cancerHIV or AIDS chemotherapy
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Chemical burns Chemical burns can be very damaging and require
immediate medical attention at an A&E department. If possible,
find out what chemical caused the burn and tell the healthcare
professionals the emergency department. If you are helping someone
else, wear appropriate protective clothing, then: Remove any
clothing that has the chemical on it from the person who has been
burnt If the chemical is dry, brush it off their skin Use running
water to remove any traces of the chemical from the burnt area
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Sunburns In cases of sunburn, advice the patient: If you notice
any signs of sunburn, such as hot, red and painful skin, move into
the shade or preferably inside. Take a cool bath or shower to cool
down the burnt area of skin. Apply after-sun lotion to the affected
area to moisturise, cool and soothe it. Do not use greasy or oily
products. If you have any pain, paracetamol or ibuprofen should
help relieve it. Always read the manufacturers instructions and do
not give aspirin to children under 16 years of age. Stay hydrated
by drinking plenty of water. Watch out for signs of heat exhaustion
or heatstroke, when the temperature inside your body rises to 3740C
(98.6104F) or above. Symptoms include dizziness, a rapid pulse or
vomiting.
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If the eye is involved, the eyelid should be pulled back and
the eye irrigated with tap water for at least 15-30 min from the
nasal side to the outside corner. No attempts should be made to
neutralise any chemical burns; this might cause further
damage.
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Treatment of minor burns and sunburns Most patients with
superficial burns complain of pain. Therapeutic options include
topical cold compresses, skin protectant, external anaesthetics,
topical corticosteroids and OTC analgesics. The inflammatory
response to burns evolves over the first 24 to 48 hours.
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Moisturisers that contain aloe vera will also help soothe skin.
Calamine lotion can relieve any itching or soreness. Cleanse the
burn before applying the dressing. Dont use alcohol containg
products Non-adherant hypo-allergic dressing should be used New
dressing would include the option of exudate absorption and
conclusiveness; if remain dry and intact could be left 10 days
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Pharmacological therapy Skin protectant They can make the burn
area less painful Protect from mechanical irritation Re-hydrating
helps healing They only provide symptomatic relief Bismuth
subnitrate and boric acid are not considered safe for burned skin
(FDA) Live Yeast cell derivative has not accepted by FDA to be safe
and effective in accelerating healing Skin protectant can be
applied as often needed, if not improved within 7 days (refer)
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Pharmacological therapy Systematic analgesics Recommend short
term analgesics preferably with anti inflammatory effect (NSAID)
NSAID are of benefit to mild sunburn, esp. with the first 24 hours
(reduce inflammation caused by UV radiation) For who can tolerate
NSAID; use acetaminophen (no prostaglandin effect though)
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Pharmacological therapy Topical anaesthetics Can inhibit pain
signals transmission Short relief 15-45 min Benzocaine (5-20%),
lidocaine (.5-4%) The higher concentration are recommended for
intact skin while lower when skin is not intact. Should be applied
to small area to avoid systematic toxicity No more than 3-4 times
daily
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Pharmacological therapy Topical Hydrocortisones Not FDA
approved in minor burn However, often used 1% in first aid products
Should be used with caution in broken skin (allow infection to
develop) High potency corticosteroids might may delay
reepithelialisation
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Pharmacological therapy Antimicrobials Silver Sulfadiazine have
been the gold standard agent Recent studies showed lack of
superiority comparing to honey and membrane like dressing However,
in minor burns antibiotics and antiseptics are limited value, esp
for intact skin
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Pharmacological therapy Vitamins The benefit is not well known
Deficiency of Vit C and A will impair healing No scientific
evidence that vit dosage above RDA would accelerate healing
However, Vit C play a role in collagen synthesis, because it is not
stored in the body it is reasonable to recommend up to 2 grams
daily from the injury until healing is complete.
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Vit A is shown to improve healing and deficiency may be
associated with increase infection However, Vit A stored in the
liver and long term supplements are not recommended. In minor burn,
oral supplement might not of benefit but topical product might be
advised Deficiency of Vit B may retard healing and should be
supplemented if nutritional status is poor. Vit E might delay wound
healing and not recommended for burns
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In summary, burned patient with good nutritional status not
benefit from Vit supplements and assuring of adequate vit C intake
is recommend. Counterirritants Such as camphore, menthol FDA still
evaluating this but generally should not be used They increase
blood flow and might cause further edema
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Product selection (Tip for the pharmacist) Ointment helps with
a protective layer that prevent evaporation and skin drying but
might promote bacterial growth Ointment are more appropriate in
intact skin minor burn Lotions that produce powder layer are not
recommended Generally, minor burn treatment is empirical
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Dressing A sterile, non-adherent, fine-mesh gauz impregnated
with hydrophilic petrolatum should be placed over wound (non-intact
skin) A second layer of absorbent gauze should be used as a
protective layer Should not be constricting and replaced every 48
hours (inspect for sign of infection)