Burns and Wounds


Burns are a type of painful wound caused by thermal, electrical, chemical, or electromagnetic energy. Smoking and open flame are the leading causes of burn injury for older adults. Scalding is the leading cause of burn injury for children. Both infants and the older adults are at the greatest risk for burn injury.

What are the different types of burns?

Anatomy of  the skin

There are many types of burns caused by thermal, radiation, chemical, or electrical contact.

  • Thermal burns. These burns are due to heat sources which raise the temperature of the skin and tissues and cause tissue cell death or charring. Hot metals, scalding liquids, steam, and flames, when coming into contact with the skin, can cause thermal burns.

  • Radiation burns. These burns are due to prolonged exposure to ultraviolet rays of the sun, or to other sources of radiation such as X-ray.

  • Chemical burns. These burns are due to strong acids, alkalies, detergents, or solvents coming into contact with the skin or eyes.

  • Electrical burns. These burns are from electrical current, either alternating current (AC) or direct current (DC).

The skin and its functions

The skin is the largest organ of the body and has many important functions. It is made up of several layers, with each layer having a specific functions:




The epidermis is the thin, outer layer of the skin with many layers including:

  • Stratum corneum (horny layer)
    This layer is made up of cells containing the protein keratin. it keeps body fluid in while keeping external substances out. As the outermost layer, it continuously flakes off.

  • Keratinocytes (squamous cells)
    This layer is made up of living cells that are maturing and moving toward the surface to become the stratum corneum.

  • Basal layer
    This layer is where new skin cells divide to replace the old cells that are shed at the surface.

The epidermis also contains melanocytes, which are cells that produce melanin (skin pigment).


The dermis is the middle layer of the skin. The dermis contains the following:

  • Blood vessels

  • Lymph vessels

  • Hair follicles

  • Sweat glands

  • Collagen bundles

  • Fibroblasts

  • Nerves

The dermis is held together by a protein called collagen, made by fibroblasts. This layer also contains nerve endings that conduct pain and touch signals.




The subcutis is the deepest layer of skin. The subcutis, consisting of a network of collagen and fat cells, helps conserve the body's heat and protects the body from injury by acting as a "shock absorber."

In addition to serving as a protective shield against heat, light, injury, and infection, the skin also:

  • Regulates body temperature

  • Stores water and fat

  • Is a sensory organ

  • Prevents water loss

  • Prevents entry of bacteria

What are the classifications of burns?

Burns are classified as first-, second-, or third-degree, depending on how deep and severely they penetrate the skin's surface.

  • First-degree (superficial) burns
    First-degree burns affect only the epidermis, or outer layer of skin. The burn site is red, painful, dry, and with no blisters. Mild sunburn is an example. Long-term tissue damage is rare and usually involves an increase or decrease in the skin color.

  • Second-degree (partial thickness) burns
    Second-degree burns involve the epidermis and part of the dermis layer of skin. The burn site appears red, blistered, and may be swollen and painful.

  • Third-degree (full thickness) burns
    Third-degree burns destroy the epidermis and dermis. Third-degree burns may also damage the underlying bones, muscles, and tendons. When bones, muscles, or tendons are also burned, this may be referred to as a fourth-degree burn. The burn site appears white or charred. There is no feeling in the area since the nerve endings are destroyed.

Burns that are more severe and extensive need specialized treatment. Because the age of a burn victim and the percentage of the body's surface area that has been burned are the most important factors affecting the outlook of a burn injury, the American Burn Association recommends that burn patients who meet the following criteria should be treated at a specialized burn center:

  • Individuals with partial-thickness burns over 10% or more of the total body surface area (TBSA)

  • Any age with full-thickness burns

  • Burns of the face, hands, feet, or groin, or genital area, or burns that extend all the way around a portion of the body

  • Burns accompanied by an inhalation injury affecting the airway or the lungs

  • Burn patients with existing chronic conditions such as diabetes, high blood pressure, heart disease, kidney disease, or multiple sclerosis

  • Suspected child or elder abuse

  • Chemical burn

  • Electrical injury 

The effects of burns

A severe burn can be a seriously devastating injury -- not only physically but emotionally. It can affect not only the burn victim, but the entire family. Persons with severe burns may be left with a loss of certain physical abilities, including loss of limb(s), disfigurement, loss of mobility, scarring, and recurrent infections because the burned skin has decreased ability to fight infection. In addition, severe burns can penetrate deep skin layers, causing muscle or tissue damage that may affect every system of the body.

Burns can also cause emotional problems such as depression, nightmares, or flashbacks from the traumatizing event. The loss of a friend or family member and possessions in the fire may add grief to the emotional impact of a burn.

The burn rehabilitation team

Because so many functions and systems of the body can be affected by severe burns, the need for rehabilitation becomes even more crucial.

Many hospitals have a specialized burn unit or center and some facilities are designated solely for the rehabilitation of burn patients. Burn patients need the highly specialized services of medical professionals who work together on a multidisciplinary team, including the following:

  • Physiatrists

  • Plastic surgeons

  • Internists

  • Orthopedic surgeons

  • Infectious disease specialists

  • Rehabilitation nurses who specialize in burn care

  • Psychologists/psychiatrists

  • Physical therapists

  • Occupational therapists

  • Respiratory therapists

  • Dietitians

  • Social workers

  • Case managers

  • Recreation therapists

  • Vocational counselors

The burn rehabilitation program

Burn rehabilitation starts during the acute treatment phase and may last days to months to years, depending on the extent of the burn. Rehabilitation is designed to meet each patient's specific needs; therefore, each program is different. The goals of a burn rehabilitation program include helping the patient return to the highest level of function and independence possible, while improving the overall quality of life -- physically, emotionally, and socially.

To help reach these goals, burn rehabilitation programs may include the following:

  • Complex wound care

  • Pain management

  • Physical therapy for positioning, splinting, and exercise

  • Occupational therapy for assistance with activities of daily living (ADLs)

  • Cosmetic reconstruction

  • Skin grafting

  • Counseling to deal with common emotional responses during convalescence, such as depression, grieving, anxiety, guilt, and insomnia

  • Patient and family education and counseling

  • Nutritional counseling

Advances in the understanding and treatment of burns, state-of-the-art burn units and facilities, comprehensive burn rehabilitation services, and integrated medical care have all contributed to the increase in the survival rate and recovery of burn patients.


Laser Treatments for Burn Scars: Startish’s Story

Scar revision patient Startish Rivers

When Startish Rivers was burned by an assailant, laser scar revision treatment at Johns Hopkins Bayview helped lessen the visual reminders of the attack, and helped her heal.