Some Burns are considered major burns because of location, and the risk of significant morbidity. These areas which include face, hands, feet and perineum require special care preferably in a burn center. Function is so important in hands and feet that optimum care is required. Facial burns are at high risk for major cosmetic deformity if not managed correctly. Perineal burns are difficult to manage and at high risk for infection.

Burn depth is defined based on the depth of coagulation necrosis into epidermis and dermis (recognizing that the anatomical depth may change with wound conversion).

B. Eyes

Burns to the eyes must always be considered with a facial burn. Superficial corneal burns should be managed like any corneal abrasion. Ophthalmic antibiotic ointment applied three to four times daily is indicated. An eye patch is then applied. Artificial tears every several hours will be required if the tear ducts are involved. Burns to the eyelids are managed in a similar fashion. As the lids retract with healing, a patch is often required at night along with the lubricant to avoid corneal drying. Tarsorrhaphy may be required with deep burns.

C. Ears

Superficial burns to the ears can be managed like those to the face. However, external pressure should not be applied to the injured helix. The cartilage is already poorly vascularized and any compression will potentate further injury. No pillows or any external pressure are allowed. In addition, the topical agent, silver sulfadiazine) or mafenide, must be applied multiple times a day, especially if any cartilage is exposed. Mafenide is the agent of choice for deep burns with a thick eschar. Chondritis is a major complication that requires an extensive (several weeks) course of systemic antibodies. Chondritis invariably leads to loss of cartilage and permanent deformity. Pseudomonas is the most common pathogen.

D. Hands

Escharotomies on the hand and fingers must be considered with deep circumferential burn. Superficial burns of the hands can be effectively managed using Xeroform gauze with a thin layer of bacitracin followed by a soft gauze dressing. Temporary skin substitutes are also ideal and markedly decrease pain and improve motion. Topical antibiotics are necessary for deeper burns. Fingers should be wrapped separately to avoid any impairment. Hands must be elevated for the first 24 to 48 hours to minimize edema. Hand splints to maintain position of function are advantageous for all burns, especially if pain is limiting motion. Motion, however, must be strongly encouraged. For deeper second and third degree burns, hand splints are absolutely necessary to avoid permanent loss of tendon function and development of flexion contractures. However, active and passive range of motion exercises should begin as soon as possible after injury, during which time splints are removed.


Fitted hand splint	Early scar in web of thumb: needs continued hand therapy

E. Feet

Burned feet must also be elevated initially. A compression wrap over a bulky dressing can be used when walking. Blood supply to the feet is not as good as that to face and hands, and therefore, better topical antibiotic coverage, e.g. silver antibiotic, is usually needed except in the superficial burn. At least once a day cleaning and reapplication of the topical agent is needed with a deep burn. Because of the difficulty of function and of self-cleaning, foot burns of any significance should be admitted at least for the initial 24 to 48 hours until home care can be arranged.

F. Perineum

Superficial burns can be managed open with an antibiotic grease-based ointment that has a broad-spectrum coverage, such as Neosporin. Hospitalization is usually necessary, at least initially, for observation of urinary obstruction secondary to edema. Deeper burns by definition require admission with two to three times daily application of topical antibiotic cream, usually silver sulfadiazine. Open technique or closed dressing, with a loose diaper dressing, can be used.