Burns

The skin is made up of several layers: the epidermis, the outer layer that provides the barrier against the environment; the dermis, which contains blood vessels, nerve endings, hair follicles and glands; and the hypodermis, the layer of fatty tissue beneath the skin. A burn destroys these layers from the surface downwards. The higher the temperature and the longer the contact, the deeper the injury goes. The structures within the dermis — hair follicles and glands — supply the cells needed to rebuild the epidermis; when they are destroyed, the skin can no longer repair itself and scar tissue forms instead.

Degrees of burn. The usual classification describes the depth of the injury:

• First-degree burn (superficial). Only the epidermis is affected. The skin is red, dry and painful, with no blisters. Sunburn is the common example. It usually settles within a few days, with peeling and without scarring.
• Second-degree burn (partial thickness). The epidermis and part of the dermis are affected. Blisters with clear fluid appear, and the skin is red, moist and very painful. Superficial forms heal in two to three weeks; those reaching deep into the dermis heal more slowly and may leave colour changes or scars.
• Third-degree burn (full thickness). The epidermis and dermis are completely destroyed. The area looks white, brown or charred, dry and leathery, and local pain may be absent because the nerve endings have been destroyed. Spontaneous healing is possible only over very small areas.
• Fourth-degree burn. The injury extends beyond the skin into fat, muscle or bone.

Who is affected. Burns can happen at any age, but small children and older adults are the most exposed, both because their skin is thinner and because of household accidents involving hot liquids, ovens, stoves and hot objects. Chemical and electrical burns occur more often in the workplace.

What the patient sees and how it evolves. In the first hours the burned area becomes red and swollen; in second-degree burns blisters appear, sometimes several hours after the accident. The wound then goes through three overlapping stages: the inflammatory phase, in which the body clears the area; the proliferative phase, in which new granulation tissue forms and epithelium advances from the edges; and the remodelling phase, which may last months or even years and during which the scar flattens and gradually loses its redness.

Wound care. The generally accepted principles are immediate cooling of the area with room-temperature running water for several minutes (not with ice), removal of rings and of clothing that is not stuck to the skin, covering with a clean dressing, and avoiding improvised remedies applied to the wound. Keeping the wound clean and protected reduces the risk of bacterial superinfection, which is the main complication of burns and the main factor that worsens the resulting scar. Extensive burns, third-degree burns, circumferential burns, burns of the face, hands, joints or genital area, as well as chemical and electrical burns, require urgent medical assessment.

Scarring. A burn scar matures slowly. In the first months it may be red, thickened and itchy; some people develop hypertrophic or keloid scars, more often on the chest, shoulders and in areas under mechanical tension. Scars crossing a joint may contract and restrict movement. Scarred skin remains sensitive to the sun for a long time and pigments unevenly, which is why sun protection is recommended throughout the maturation period.

What can make the course worse:

• Breaking blisters and removing them in an uncontrolled way.
• Applying butter, toothpaste, alcohol or other irritating substances to the wound.
• Wound superinfection and dressings that are dirty or changed too rarely.
• Sun exposure of an area that is still healing.
• Smoking, poorly controlled diabetes and circulatory disorders, which slow healing.
• Rubbing of the area against rough or tight clothing.

In our practice, burns and post-burn scars are addressed through the Kozak Method — internal and external treatment, individually tailored, following a consultation. Results differ from patient to patient.