Burns
Last Update 1st September 2026
Burns
Burns affect at least 1% of Australians each year, and most minor injuries are never reported. Scalds from hot liquids, contact with hot objects and flame account for the majority.
First aid
For all thermal burns, run cold water over the burn for 20 minutes. Water at 2–15 °C reduces both the area and the depth of the burn, and consequently the area that needs grafting. It is ideally applied within an hour but still works up to three hours after injury, and has an analgesic effect in its own right. Twenty minutes is the dose — a brief rinse is not equivalent.
Ice is never appropriate. It deepens the injury and causes hypothermia.
Remove clothing, nappies and jewellery, which continue to burn and store heat. If clothing is firmly stuck to skin, cut around it and leave the adherent cloth in place for removal in hospital.
Cooling itself causes hypothermia, particularly in large burns, young children and older people. Keep unaffected areas covered while the burn is being cooled.
Chemical burns are decontaminated with copious cold running water. Hydrogel dressings give some analgesia and are a reasonable temporary cover, but they do not replace 20 minutes of cold running water and carry the same hypothermia risk.
Assessing depth
Depth is a clinical judgement made on colour, blistering and capillary refill. Capillary refill is the most useful single sign: brisk refill means superficial, sluggish or absent refill means deep.
| Depth | Appearance | Expected healing |
|---|---|---|
| Epidermal (erythema) | Skin intact, no blisters, red, brisk refill | 3–7 days, spontaneously |
| Superficial dermal | Pink, blisters present or absent, brisk refill under the blister | 7–10 days |
| Mid dermal | Dark pink to red, sluggish refill | ~14 days; deeper areas may need surgery |
| Deep dermal | Blotchy red/white, very sluggish or absent refill | Generally needs surgery — refer |
| Full thickness | White, waxy, brown, black or yellow; no refill | Generally needs surgery — refer |
Burn depth is dynamic. Re-evaluate at 3–5 days, because a burn that looked superficial on day one is often deeper than first appreciated.
Assessing area
Use the rule of nines. In anyone at least 10 years old, the head is 9%, each upper limb 9%, the anterior trunk 18%, the posterior trunk 18% and each lower limb 18%. Children under 10 have proportionally larger heads, so the rule varies. For scattered burns at any age, the patient’s own palm and fingers approximate 1% of total body surface area.
Epidermal (superficial) burns are not counted in the TBSA figure.
Non-accidental injury
Consider it in children and in older people, and look at the pattern rather than the story alone. Cigarette burns, well-demarcated immersion burns that spare the skin folds — the “stocking-and-glove” pattern of a child plunged into scalding water — and burns shaped like household objects are the concerning patterns.
Lip commissure burns in a toddler who has bitten an electrical cord are not themselves suspicious, but they carry a specific hazard: they rarely bleed at presentation and can bleed heavily from the labial artery when the eschar separates at 1–2 weeks. Warn the parents explicitly, teach direct pressure, and arrange burn-unit follow-up.
Referral to a burn unit
ANZBA burn-unit referral criteria:
- Burns >10% total body surface area
- Full-thickness burns >5% TBSA
- Paediatric burns >5% TBSA
- Burns to the face, hands, feet, genitalia, perineum and major joints
- Chemical burns
- Electrical burns, including lightning injuries
- Burns with associated trauma
- Burns with inhalation injury
- Circumferential burns of the limbs or chest
- Burns in patients with pre-existing medical conditions
- Burns with suspected non-accidental injury, assault or self-harm
- Burns during pregnancy
- Burns at the extremes of age — infants and the elderly
Add infected burns to that list. They are not a formal ANZBA criterion but warrant referral, since early debridement and IV antibiotics may be needed.
More than 10% TBSA in a child or 20% in an adult is severe: these patients need emergency management and fluid resuscitation. Between 5–10% in children and 10–20% in adults, referral is still required, often for pain management alone. Any burn crossing a joint is referred regardless of size, because of scar contracture. Circumferential burns threatening circulation or chest expansion go immediately, for consideration of escharotomy.
Electrical injuries can look trivial and still need cardiac monitoring for arrhythmia. Chemical burns are often much deeper than they appear and may need specific decontamination or urgent debridement.
Burn units take phone consultations and accept photographs for advice and for monitoring healing — use this rather than guessing, including for burns that do not meet a referral criterion.
Practical rule of thumb: any burn larger than a 20-cent piece, or a smaller deep burn, should be seen by a doctor.
Community management
Small superficial burns not meeting referral criteria.
Cleaning and debridement. Clean with 0.1% aqueous chlorhexidine or normal saline. Remove foreign material and loose, non-viable skin. Debride blisters larger than 5 cm or overlying joints. Shave hair in and around the wound to a 2 cm radius. Ruptured blisters are debrided; needle aspiration of intact blisters is discouraged.
Analgesia first. Adequate analgesia is needed to assess and dress the burn properly, and it is what makes ongoing dressing changes tolerable. Poor analgesia is associated with higher rates of anxiety and depression after burns. Paracetamol and an NSAID are often sufficient for a minor burn; larger or deeper burns commonly need an oral opioid in addition.
Tetanus. Burns are tetanus-prone wounds. Check immunisation status and give a booster, with tetanus immunoglobulin where indicated.
Dressings. The principle is a clean, moist wound. Match the dressing to depth:
- Epidermal — no dressing needed; a simple moisturiser.
- Superficial dermal — paraffin gauze or a silicone dressing; silver products if contaminated.
- Mid dermal and deeper — silver or other antimicrobial dressings, plus a silicone dressing.
Dermal burns exude heavily for the first 72 hours, so add an absorbent secondary layer (gauze or foam) and hold it with a tubular or crepe bandage. Change frequency runs from daily to weekly depending on the product and the exudate — fewer changes means less procedural pain, which is worth paying more for.
Silver sulfadiazine is no longer a routine burns dressing. It needs daily changes and produces a pseudo-eschar that makes depth assessment harder and may slow re-epithelialisation. Its remaining role is the infected burn — and that burn is being referred anyway.
Do not prescribe prophylactic oral antibiotics. Antimicrobial dressings keep colonisation down. Antibiotics are for clinical infection only, and routine prophylaxis drives multi-resistant S. aureus and Pseudomonas.
Follow-up and safety-netting
Review dermal burns at 24–48 hours, then according to healing. Refer early to a surgeon if excision and grafting might be needed for a mid dermal, deep dermal or full-thickness burn.
Time to healing predicts scarring, and drives the referral decision as much as the initial assessment does:
- Not healed by 10 days — discuss with a burn unit.
- Not healed by 14 days — likely to scar; refer.
- Not healed by 21 days — will very likely scar.
Refer any burn that becomes infected or is slow to heal.
Tell the patient to return for spreading redness, increasing pain, fever, discharge or any wound that looks worse rather than better.
Aftercare once healed. Sun protection is essential — pigmentation change is common in the first 12 months and burned skin carries a higher long-term malignancy risk, so protective clothing is more reliable than cream on new skin. Dryness and itch can persist for months: a water-based sorbolene cream regularly, and avoid soaps for up to 12 months. Aqueous cream containing sodium lauryl sulfate can worsen dryness and should not be used. Antihistamines help resistant itch; oils are avoided in the first months, particularly in children, as they interfere with pressure garments.