Management of Minor Burns and Sunburn Pharmacist Role

Management of Minor Burns and Sunburn; Pharmacist Role

� Learning � Learn outcomes about different type of skin burn how to provide a quick pharmaceutical advice when patient seeking your advice in such situation � Learn about the cases you should refer for medical attention � Learn about the products available in the pharmacy

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Ambulatory management of burns is divided into: � Acute treatment � Follow-up care. � Acute management includes: ◦ Measures to minimize further damage to patients ◦ Identifying patients requiring hospitalization ◦ Implementing measures to promote healing ◦ Prevent infection and relieve pain. • Follow-up care ◦ The focus shifts to limiting disfigurement from scarring and dysfunction from contractures. ◦Although most patients with burns can be managed by family physicians, some require surgical referral for skin grafting and scar rehabilitation. 4

First aid advice for burn: �Immediately get the person away from the heat source to stop the burning. �Cool the burn with cool water for 10 -30 minutes. Do not use ice, iced water or any creams or greasy substances, such as butter. �Remove any clothing or jewellery that is near the burnt area of skin, but do not move anything that is stuck to the skin.

�Make sure the person keeps warm – for example by using a blanket – but take care not to rub it against the burnt area. �Cover the burn by placing a layer of cling film over it. �Use painkillers, such as paracetamol or ibuprofen, to treat any pain.

� When to get medical attention � Depending on how serious a burn is, it may be possible to treat it at home. For minor burns, keep the burn clean and do not burst any blisters that form. � More serious burns will require professional medical attention. Tell patient to get to a hospital A&E department for: � All chemical and electrical burns � Large or deep burns – any burn bigger than your hand � Full thickness burns of all sizes – these burns cause white or charred skin � Partial thickness burns on the face, hands, arms, feet, legs or genitals – these are burns that cause blisters

The skin � Skin is the largest organ. It has many functions, including acting as a barrier between you and the environment and regulating your temperature. The skin is made up of three layers: � The epidermis (the outer layer of your skin) is 0. 5 -1. 5 mm thick. It has five layers of cells that work their way up to the surface of your skin, where dead cells are shed approximately every two weeks. � The dermis (the underlying layer of fibrous tissue) is 0. 33 mm thick and is made up of a mix of three types of tissue. The dermis contains your hair follicles and sweat glands, as well as small blood vessels and nerves. � The subcutaneous fat or subcutis (the final layer of fat and tissue) varies in thickness from person to person. It contains your larger blood vessels and nerves, and regulates the temperature of your skin and body.

DEPTH OF A BURN The traditional classification of burns as first, second or third degree is being replaced by the designations of superficial, superficial partial thickness, deep partial thickness and full thickness. 9

� Superficial epidermal burns are where the epidermis is damaged. Skin will be red, slightly swollen and painful but not blistered. � Superficial dermal burns are where the epidermis and part of the dermis are damaged. Skin will be pale pink, painful and there may be small blisters. � Deep dermal or partial thickness burns are where the epidermis and the dermis are damaged. This type of burn makes skin turn red and blotchy. Skin may also be dry or moist, become swollen and blistered, and it may be very painful or painless.

� Full thickness burns are where all three layers of skin (the epidermis, dermis and subcutis) are damaged. In this type of burn, the skin is often burnt away and the tissue underneath may appear pale or blackened. The remaining skin will be dry and white, brown or black with no blisters. The texture of the skin may also be leathery or waxy.

Superficial burns on the trunk and right arm of a young child. Typically, these are red burns that blanch with pressure. 13

Superficial partial-thickness burn on a man's right knee. Blistering wounds that blanch with pressure are characteristic of superficial partial-thickness burns. These wounds are also typically moist and weeping. 14

Deep partial-thickness burns on the trunk and extremities of a young child. These burns are typified by easily unroofed blisters that have a waxy appearance and do not blanch with 15 pressure.

Full-thickness burn on a woman's left flank. Burn areas of this type are characteristically insensate and waxy white or leathery gray in color. 16

Classification of Burns Based on Depth Classification Cause Characteristics Appearance Sensation Healing time Scarring 3 to 6 days None Superficial Ultraviolet light, Dry and red; burn very short flash blanches with (flame exposure) pressure Superficial Scald (spill or Blisters; moist, partial- splash), short red and weeping; temperature pigmentary flash blanches with changes thickness Painful to air and 7 to 20 days Unusual; potential pressure burn Deep partial- Scald (spill), thickness Painful Blisters (easily Perceptive of flame, oil, grease unroofed); wet or pressure only More than 21 Severe days (hypertrophic) waxy dry; burn risk of contracture variable color (patchy to cheesy white to red); does not blanch with pressure Full-thickness Scald burn (immersion), Waxy white to Deep pressure Never (if the burn Very severe risk leathery gray to only affects more than of contracture flame, steam, oil, charred and 2 percent of the grease, chemical, black; dry and total surface area high-voltage inelastic; does not of the body) electricity blanch with 17

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When to refer All chemical and electrical burns large or deep burns – any burn bigger than the affected person’s hand � Full thickness burns of all sizes – these burns cause white or charred skin � Partial thickness burns on the face, hands, arms, feet, legs or genitals – these are burns that cause blisters � � � � Also get medical help straight away if the person with the burn: Has other injuries that need treating or is going into shock (signs include cold, clammy skin, sweating, rapid, shallow breathing and weakness or dizziness) If pregnant If over 60 years of age If under five years of age Has A medical condition such as heart, lung or liver disease, or diabetes (A long-term condition caused by too much glucose in the blood) Has A weakened immune system (the body’s defence system), for example because of HIV or AIDS or because they're having chemotherapy for cancer

Chemical burns � Chemical burns can be very damaging and require immediate medical attention at an A&E department. � If possible, find out what chemical caused the burn and tell the healthcare professionals the emergency department. � If you are helping someone else, wear appropriate protective clothing, then: � Remove any clothing that has the chemical on it from the person who has been burnt � If the chemical is dry, brush it off their skin � Use running water to remove any traces of the chemical from the burnt area

Sunburns � In cases of sunburn, advice the patient: � If you notice any signs of sunburn, such as hot, red and painful skin, move into the shade or preferably inside. Take a cool bath or shower to cool down the burnt area of skin. Apply after-sun lotion to the affected area to moisturise, cool and soothe it. � Do not use greasy or oily products. � � � If you have any pain, paracetamol or ibuprofen should help relieve it. Always read the manufacturer’s instructions and do not give aspirin to children under 16 years of age. � Stay hydrated by drinking plenty of water. � Watch out for signs of heat exhaustion or heatstroke, when the temperature inside your body rises to 37– 40°C (98. 6– 104°F) or above. Symptoms include dizziness, a rapid pulse or vomiting.

�If the eye is involved, the eyelid should be pulled back and the eye irrigated with tap water for at least 15 -30 min from the nasal side to the outside corner. �No attempts should be made to neutralise any chemical burns; this might cause further damage.

Treatment of minor burns and sunburns � Most patients with superficial burns complain of pain. Therapeutic options include topical cold compresses, skin protectant, external anaesthetics, topical corticosteroids and OTC analgesics. � The inflammatory response to burns evolves over the first 24 to 48 hours.

� Moisturisers that contain aloe vera will also help soothe skin. Calamine lotion can relieve any itching or soreness. � Cleanse the burn before applying the dressing. Don’t use alcohol containg products � Non-adherant hypo-allergic dressing should be used � New dressing would include the option of exudate absorption and conclusiveness; if remain dry and intact could be left 10 days

�Skin protectant ◦ They can make the burn area less painful ◦ Protect from mechanical irritation ◦ Re-hydrating helps healing ◦ They only provide symptomatic relief ◦ Bismuth subnitrate and boric acid are not considered safe for burned skin (FDA) ◦ Live Yeast cell derivative has not accepted by FDA to be safe and effective in accelerating healing ◦ Skin protectant can be applied as often needed, if not improved within 7 days (refer) Pharmacological therapy

�Systematic analgesics ◦ Recommend short term analgesics preferably with anti inflammatory effect (NSAID) ◦ NSAID are of benefit to mild sunburn, esp. with the first 24 hours (reduce inflammation caused by UV radiation) ◦ For who can tolerate NSAID; use acetaminophen (no prostaglandin effect though) Pharmacological therapy

�Topical anaesthetics ◦ Can inhibit pain signals transmission ◦ Short relief 15 -45 min ◦ Benzocaine (5 -20%), lidocaine (. 5 -4%) ◦ The higher concentration are recommended for intact skin while lower when skin is not intact. ◦ Should be applied to small area to avoid systematic toxicity ◦ No more than 3 -4 times daily Pharmacological therapy

�Topical Hydrocortisones ◦ Not FDA approved in minor burn ◦ However, often used 1% in first aid products ◦ Should be used with caution in broken skin (allow infection to develop) ◦ High potency corticosteroids might may delay reepithelialisation Pharmacological therapy

�Antimicrobials ◦ Silver Sulfadiazine have been the gold standard agent ◦ Recent studies showed lack of superiority comparing to honey and membrane like dressing ◦ However, in minor burns antibiotics and antiseptics are limited value, esp for intact skin Pharmacological therapy

�Vitamins ◦ The benefit is not well known ◦ Deficiency of Vit C and A will impair healing ◦ No scientific evidence that vit dosage above RDA would accelerate healing ◦ However, Vit C play a role in collagen synthesis, because it is not stored in the body it is reasonable to recommend up to 2 grams daily from the injury until healing is complete. Pharmacological therapy

◦ Vit A is shown to improve healing and deficiency may be associated with increase infection ◦ However, Vit A stored in the liver and long term supplements are not recommended. ◦ In minor burn, oral supplement might not of benefit but topical product might be advised ◦ Deficiency of Vit B may retard healing and should be supplemented if nutritional status is poor. ◦ Vit E might delay wound healing and not recommended for burns

◦ In summary, burned patient with good nutritional status not benefit from Vit supplements and assuring of adequate vit C intake is recommend. �Counterirritants ◦ Such as camphore, menthol ◦ FDA still evaluating this but generally should not be used ◦ They increase blood flow and might cause further edema

�Product selection (Tip for the pharmacist) ◦ Ointment helps with a protective layer that prevent evaporation and skin drying but might promote bacterial growth ◦ Ointment are more appropriate in intact skin minor burn ◦ Lotions that produce powder layer are not recommended ◦ Generally, minor burn treatment is empirical

�A sterile, non-adherent, fine-mesh gauz impregnated with hydrophilic petrolatum should be placed over wound (non-intact skin) �A second layer of absorbent gauze should be used as a protective layer ◦ Should not be constricting and replaced every 48 hours (inspect for sign of infection) Dressing