Burns: Minor to Severe

Burns are among the most painful injuries a person can sustain, and they are also among the most mismanaged in first aid settings. Incorrect treatment — particularly putting butter, toothpaste, or oil on burns; using ice or very cold water; or bursting blisters — can significantly worsen outcomes by increasing infection risk, deepening the injury, or causing hypothermia. Burns kill approximately 180,000 people annually worldwide, and many more suffer lasting disability. Most domestic burns are preventable, and most first-aid errors are avoidable with basic knowledge.

This guide covers burn classification, correct cooling treatment, what to do with blisters and dressings, chemical and electrical burns (which require different approaches), and when a burn requires emergency care.

Burn Classification

Burns are classified by depth of tissue damage:

First-Degree (Superficial) Burns

• Depth: Affects only the outermost layer of skin (epidermis)
• Appearance: Red, dry, no blistering; resembles a sunburn
• Pain: Painful to touch and exposure to air
• Healing: 3–5 days; no scarring expected
• Examples: Mild sunburn, brief contact with a hot surface

Second-Degree (Partial Thickness) Burns

• Depth: Through the epidermis into the dermis
• Appearance: Blistering, wet, weeping surface; intense redness or blotchy appearance
• Pain: Extremely painful — the dermis contains many nerve endings
• Healing: 2–3 weeks for superficial partial thickness; longer for deep partial thickness
• Scarring: Possible, particularly for deeper partial thickness burns
• Examples: Scalds from hot liquid, flash burns, prolonged contact with hot surfaces

Third-Degree (Full Thickness) Burns

• Depth: Through all layers of skin; may involve subcutaneous tissue, muscle, or bone
• Appearance: White, brown, or black; leathery, waxy, or charred; dry
• Pain: Paradoxically may be less painful than second-degree because nerve endings are destroyed
• Healing: Cannot heal on their own without grafting; significant scarring inevitable
• Examples: Fire, prolonged contact with hot objects, severe electrical burns

⚠️ Burns that appear less painful may actually be deeper and more serious. A white or charred burn that "doesn't hurt much" may be a full-thickness burn with nerve destruction — not a minor one. Seek immediate medical care.

Immediate Treatment — Thermal Burns

Step 1: Remove the Heat Source

Move the casualty away from flame. Remove burning or very hot clothing and jewellery from the burn area, unless they are stuck to the skin.

⚠️ Do not attempt to remove clothing that is adhered to burned skin — you will cause further tissue damage. Cut around it.

Step 2: Cool with Lukewarm Running Water

This is the single most important first-aid action for burns:

• Use cool running water — ideally 15–25°C (not ice cold; not warm)
• Cool for 20 minutes
• Start cooling as soon as possible — cooling begun within 3 hours of the burn continues to have benefit
• A shower, tap, or even poured bottles of water are all acceptable

⚠️ Do not use ice or ice-cold water. Ice causes vasoconstriction and can deepen the burn; it also causes hypothermia risk with large burns. Do not use cold water — it can cause systemic hypothermia, particularly in children and elderly people.

Step 3: Prevent Hypothermia

For large burns (more than approximately 10% of body surface area in adults), cooling the burn also cools the body. After the 20-minute cooling period:

• Cover the casualty with a blanket (not over the burn itself)
• Move them out of cold or wind
• Children and elderly people are at significantly higher risk of hypothermia from burn cooling

Step 4: Cover the Burn

After cooling:

• Cover loosely with a clean, non-fluffy dressing or cling film
• Cling film is ideal — it is sterile (inner layers), does not stick to the wound, and allows clinicians to assess the burn without removing it
• Do not wrap cling film circumferentially around a limb — it can act as a tourniquet as swelling develops; lay it across the burn instead
• If no cling film: a clean plastic bag over a hand burn; a clean sterile dressing for other areas

Step 5: Seek Medical Care

Criteria for emergency care:

Criterion	Seek Emergency Care
Size	Burns larger than the casualty's palm (approximately 1% body surface) on face, hands, feet, genitals, or major joints
Any full-thickness burn	All third-degree burns require hospital care
Circumferential burns	Burns going all the way around a limb — can restrict circulation
Burns in children under 5 or adults over 60	Any burn beyond minor requires medical evaluation
Inhalation injury	Singed nasal hairs, soot in mouth/nose, hoarse voice, stridor — call emergency services
Chemical burns	Any significant chemical exposure
Electrical burns	Any burn from electrical current

What Not to Put on Burns

Many traditional home remedies cause significant harm:

Substance	Why It Is Harmful
Butter / margarine	Traps heat, increases infection risk
Toothpaste	Cooling is brief; increases infection risk
Aloe vera (fresh)	Some evidence supports soothing; however, infected wounds have been associated with fresh application — use commercial sterile preparations
Flour	Traps heat; attracts infection
Oil (cooking, coconut)	Traps heat; infection risk
Ice	Deepens burn; hypothermia risk
Egg whites	Infection risk (Salmonella)
Adhesive bandages directly on burn	Stick and damage skin on removal
Fluffy materials (cotton wool)	Fibres shed and contaminate wound

The correct answer is: cool water for 20 minutes, then cover with cling film or a clean dressing.

Blisters

Blisters are a natural protective response — the fluid cushions and protects the healing dermis underneath.

• Do not burst blisters — the blister roof is a sterile barrier against infection
• If a blister bursts naturally, cover with a sterile non-adherent dressing
• If a blister is very large and in a location likely to burst anyway (palm, sole), medical teams may drain it under sterile conditions — this should not be done in a field setting

Chemical Burns

Chemical burns continue to damage tissue as long as the chemical is in contact. The priority is removal of the chemical — not waiting to identify it.

Treatment

1. Brush off any dry chemical (powder) before applying water — some dry chemicals react with water
2. Flush with large quantities of running water for at least 20 minutes — in some chemical burns (hydrofluoric acid, alkali), the recommendation is 60 minutes or more
3. Remove contaminated clothing while flushing (protect yourself — wear gloves or use water to dilute as you remove clothing)
4. Call emergency services / Poison Control for guidance on the specific chemical
5. Do not attempt to neutralise the chemical with an acid or alkali — you risk a neutralisation reaction producing heat and worsening the burn

⚠️ Alkali burns (cement, oven cleaner, drain cleaner) are often more serious than acid burns because alkalis continue to penetrate deeper tissue for longer. Prolonged irrigation is critical.

Eye Burns

Chemical burns to the eye are emergencies. Irrigate with running clean water or saline for a minimum of 20 minutes, holding the eyelids open. Remove contact lenses if present. Seek immediate ophthalmological care.

Electrical Burns

Electrical burns have two distinct injury patterns:

1. Entry and exit wounds — where current entered and exited the body; may appear small on the surface
2. Internal burns — the current passes through the body along the path of least resistance (blood vessels, nerves, muscle); internal damage is almost always more extensive than surface wounds suggest

Treatment

1. Do not touch the casualty until the power source is confirmed off
2. Isolate the power before approaching
3. Assess for cardiac arrest — cardiac arrhythmias are common after electrical injury; begin CPR if needed
4. All electrical burns require hospital evaluation regardless of surface appearance — internal injuries, delayed cardiac arrhythmias, and rhabdomyolysis (muscle breakdown) all need medical management

Inhalation Injury

Smoke and hot gas inhalation is the leading cause of fire death. Signs of inhalation injury:

• Facial burns
• Singed nasal hair or eyebrows
• Soot in mouth or nostrils
• Hoarse voice
• Coughing or stridor (high-pitched breathing sound)

Any suspected inhalation injury is a medical emergency. The airway can swell closed over minutes to hours after injury. Call emergency services immediately and keep the casualty upright if conscious.

Quick Reference

Burn Type	Immediate Action
Minor thermal burn	Cool water 20 min; cover with cling film
Large/serious burn	Cool water 20 min; cover; prevent hypothermia; emergency services
Chemical burn	Remove dry chemical; flush 20–60 min water; emergency services
Electrical burn	Isolate power; CPR if needed; hospital for all electrical burns
Eye burn	Irrigate 20+ min; ophthalmology urgently
Inhalation suspected	Upright; emergency services immediately
Do NOT apply	Ice, butter, toothpaste, oil, flour, egg white
Blisters	Do not burst; cover if broken

This guide provides general first-aid information for burns. All burns beyond minor first-degree burns should receive medical evaluation. Chemical and electrical burns are medical emergencies. Follow local emergency service guidelines for major burns.