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Scenario

Miranda Janus walks into the pharmacy, practically dragging her husband Andy behind her. “Tell him he needs to get this seen to,” she implores pharmacy technician Vicky. “Look!”

Miranda pushes Andy round and Vicky sees a large crescent-shaped burn on the side of his lower leg. “Ooh, that looks nasty. What on earth happened?” asks Vicky, coming round to the other side of the counter and noticing that the skin is blistered and looks wet and greasy.

“I was getting the last bits of shopping out of the boot of the car when I caught my leg on the exhaust,” says Andy. “It’s painful – who knew exhaust pipes get that hot? But I’m sure it’ll settle down in time. Perhaps you can give me a dressing or some cream to put on it? I’m sure there is something better than butter, which is what Miranda slapped on. I swear it has made it worse.”

Answer

Andy needs to go to accident and emergency because his skin is blistering from the burn. This indicates that the burn is ‘second degree’ – i.e. it involves the entire epidermis and some of the dermis. By comparison, a ‘first degree’ burn involves only the epidermis and, while the skin is usually red and undoubtedly painful, it will usually heal within a few days. The size of the burn is also of concern, as is the fact that it has had butter on it, which will have trapped the heat in rather than cooling it down.

Andy needs to run the affected area under cool water for 15 minutes or longer in order to take the heat out of his skin. He may want to take a simple analgesic such as ibuprofen or paracetamol before seeking medical help so that it can be properly assessed in case he needs antibiotics, stronger pain relief, the blister draining or a sterile dressing. He will need to sit with his leg up as much as is feasible for the next few days, otherwise fluid will collect in the wound.

Miranda should be made aware of the signs of shock, as it is possible for this to develop after a serious burn. Symptoms include pale, cold or clammy skin, a rapid pulse, fast, shallow breathing, yawning and loss of consciousness. If this occurs, it is a medical emergency.

The bigger picture

Once Andy has sought medical attention, he needs to be aware of the signs that his burn has become infected, which is more likely as his skin has blistered. These include an unanticipated increase in the level of discomfort, pain or smelliness at the site, a temperature of 38°C or higher, and signs of cellulitis (the skin will become red, hot, swollen and tender). Occasionally, an infected burn can lead to sepsis (blood poisoning) or toxic shock syndrome, which can be fatal, so Andy should seek urgent medical advice if he develops a high fever or experiences unexplained vomiting or dizziness.

In the longer term, Andy may have concerns about scarring. He can minimise this – once the wound has healed – by applying an emollient to the affected area a few times a day, and making sure he uses sun cream with a high sun protection factor when he goes outside.

Extend your learning

• You may have come across the term ‘third degree burn’. Do you know what this means? Find out here 
• Are you aware of the ‘rule of nines’ with regard to burns? Read the definition and look at the diagram
• The rule of nines does not work for children, who have differently proportioned bodies to adults. Find out about how body surface percentage is calculated in children at GP Notebook.
• A skin graft is sometimes needed after a severe burn. Click here to read about what happens during this procedure.