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Skin burns are very common. When caused by direct contact with heated objects or flames. they are labeled as combustions. When caused by contact with hot liquids or gasses, usually hot water or steam, they are called scald burns or ambustions. The healing process and level of damage to the burned skin depend on several factors.

Pathophysiology Of Scald Burns

When hot liquids or gasses come into contact with skin, they can cause both local effects and a systemic response

Locally, there are three zones of the affected part of the skin, depending on the contact with harmful agent:

  • The zone of coagulation is a central zone that came into direct contact with hot liquid or steam and has the most pronounced changes. Usually, cells in this zone are dead and nothing can be done to preserve their function. 
  • The zone of stasis is the surrounding, less damaged zone in which the blood vessels and nerve endings usually experience most damage. If appropriate measures are taken, cells in this zone can be saved. 
  • The third zone is the zone of hyperemia (redness of the skin), and it is usually completely recoverable.

A systemic response is reflected within the whole body and it is a result of chemicals (cytokines and other inflammatory mediators) released from the damaged skin into the bloodstream. A systemic response does not appear if the burns affect less than 30 percent of the skin's surface. Through damaged skin, proteins from the bloodstream are lost, which starts a cascade of body fluid redistribution and causes cardiovascular problems. A drop in blood pressure (hypotension) and lack of blood supply to organs are the most common consequences. Some of the mediators released from the scalded skin can cause bronchoconstriction (narrowing of airways) and severe breathing difficulties. Other immunological and metabolic changes also occur as a part of the systemic response.

Scald Burn Degrees

Unlike dry burns, which have four degrees, scald burns are usually limited to first or second degree, depending on the depth of the damage. Third degree scald burns can occur if there is a prolonged contact with a damaging agent. First degree scald burns affect only the superficial layer of the skin (epidermis), and they manifest as redness of the skin (hyperemia), pain, and irritation. They usually heal spontaneously within five to10 days, leaving no permanent damage. 

Second degree scald burns have two sub-stages (2a and 2b) which are very different in terms of outcome. The superficial part of the dermis (the layer of the skin right beneath the epidermis) is affected in 2a degree scald burns. These burns are very painful and manifested with blisters and local hyperemia. The surface of the skin is usually moist, in contrast to first degree burns where it is usually dry. Spontaneous healing typically occurs in two to three weeks. 

In 2b degree scald burns, deep dermal structures are affected, and the affected area looks yellowish or white, dry, and with less blisters. It is usually less painful than 2a degree and the patient may feel irritation and discomfort. This might seem illogical, but in fact, nerve endings are damaged, so the sensation of pain is also impaired. These burns take at least three to eight weeks to heal.

Unlike 2a degree burns which heal with no permanent damage, 2b degree burns produce permanent damage in the form of scarring, which is the main difference between these two stages.

Differentiating between 2a and 2b degree burns is not easy, but it is important because of the different final outcomes.

Third degree scald burns affect the full thickness of the skin. They look white or brown and they are painless (complete damage of nerve endings). Recovery may take months and is usually incomplete, leaving scars and contractures. Sometimes even amputations of dead tissue are required.

First Aid And Treatment Options

First of all, the damaging agent should be immediately removed. Within 20 minutes of the injury, it is helpful to ally some kind of cooling the affected skin. Immersion in cold water can be applied.  This will stop the progression of the damage and partially eliminate chemicals produced by damaged skin cells. Analgesics, usually non-steroidal anti-inflammatory drugs (NSAIDs) are useful for pain relief. Some available dressing should be lightly applied to the wound to protect and prevent infection of the damaged area of the skin.

Both scald and dry burns should be reported to your health care provider as soon as possible. This is particularly important even for minor burns of the face and hands, because of the possibility of nerve damage and for asthetic reasons.

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