What is the characteristics of a deep burn?

A burn takes place when the skin comes into contact with a heat source.[1] Burns can occur from many different sources. The most common sources that cause burns are fire/flame, scalds, hot objects, electrical, and chemical agents, respectively.[2] Injuries related to a burn are highly variable, as is their severity. Morbidity and mortality tend to increase as the surface area of the burn increases.[3] It is vital to classify a burn accurately, as it can help determine the outcome, as well as guide initial management.[2] The skin location, the degree of temperature, and duration are contributing factors to the severity of the burn. There is a synergistic effect between the temperature and duration of exposure.[4] Skin exposure to 140 degrees Fahrenheit (60 degrees Celsius) for 10 seconds can cause a full-thickness burn.[1]

The basis of burn classification is depth. When examining a burn, there are four components needed to assess depth: appearance, blanching to pressure, pain, and sensation.[2] Burns can be categorized by thickness according to the American Burn Criteria using those four elements. Burn injuries tend to be a dynamic process. Some burns, especially partial-thickness, may progress over 2 to 4 days, peaking at day 3.[4]

Partial Thickness

Superficial (first-degree) involves the epidermis of the skin only. It appears pink to red, there are no blisters, and it is dry. It is moderately painful. Superficial burns heal without scarring within 5 to 10 days.[1][4]

Superficial partial-thickness (second-degree) involves the superficial dermis. It appears red with blisters and is wet. The erythema blanches with pressure. The pain associated with superficial partial-thickness is severe. Healing typically occurs within 3 weeks with minimal scarring.[1][4]

Deep partial-thickness (second-degree) involves the deeper dermis. It appears yellow or white, is dry, and does not blanch with pressure. There is minimal pain due to a decreased sensation. Healing occurs in 3 to 8 weeks with scarring present.[1][4]

Full Thickness

Third-degree involves the full thickness of skin and subcutaneous structures. It appears white or black/brown. With pressure, no blanching occurs. The burn is leathery and dry. There is minimal to no pain because of decreased sensation. Full-thickness burns heal by contracture and take greater than 8 weeks. Full-thickness burns require skin grafting.[1][4]

Fourth degree shows charred skin with possible exposed bone.

Fifth degree has charred, white skin, and exposed bone.

Sixth degree has loss of skin with exposed bone.

Burns are a common injury seen in emergency departments around the world.[3] Even as emergency management improves, burns continue to have significant morbidity and mortality. Burn treatments, such as intravenous fluids and surgical options, are based upon the classification of the burn. It is essential to accurately classify burns to optimize treatment and provide an accurate prognosis.[5][6]

Review Questions

1.

Tolles J. Emergency department management of patients with thermal burns. Emerg Med Pract. 2018 Feb;20(2):1-24. [PubMed: 29369586]

2.

Toussaint J, Singer AJ. The evaluation and management of thermal injuries: 2014 update. Clin Exp Emerg Med. 2014 Sep;1(1):8-18. [PMC free article: PMC5052819] [PubMed: 27752547]

3.

Vivó C, Galeiras R, del Caz MD. Initial evaluation and management of the critical burn patient. Med Intensiva. 2016 Jan-Feb;40(1):49-59. [PubMed: 26724246]

4.

Evers LH, Bhavsar D, Mailänder P. The biology of burn injury. Exp Dermatol. 2010 Sep;19(9):777-83. [PubMed: 20629737]

5.

Hautier A. [Minor burn outpatient management]. Rev Prat. 2018 Dec;68(10):1083-1086. [PubMed: 30869212]

6.

Nicolas C, Maréchal O. [Severe burned patient rehabilitation]. Rev Prat. 2018 Dec;68(10):1092-1095. [PubMed: 30869214]

Deep dermal burns are characterised by the early (within hours) development of extensive blisters, which usually rupture early to expose deep damaged dermis. The exposed reticular dermis may be pale in colour due to damage to dermal blood vessels, or red due to extravasation of red blood cells from damaged vessels.

The hallmark of these types of burns is greatly diminished capillary return, with no or sluggish blanching when pressure is applied to the wound bed. This is a result of the extensive destruction of the dermal vascular plexus. The dermal nerve endings are also damaged and so sensation is reduced. These deeper burns tend to be dry, with diminished fluid exudates compared with more superficial burns.

Following first aid and cleansing, deep dermal burns should be covered with an appropriate silver or antibacterial dressing and referred to a surgeon for surgical management.

Deep dermal burns can also be pale in colour due to the damage to dermal blood vessels 
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Redness in deep dermal burns is caused by the extravasation of red blood cells
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A burn can be classified as superficial, partial thickness, or full-thickness. This article details the assessment of burns with charts, tables, and illustrations.

5 Key Points on Burn Depth Assessment

1. Burn depth is classified into superficial, partial, and full-thickness.

2. Assessment focuses on colour, pain, blanching, blisters, sensation.
3. Superficial burns are like sunburn - hot, red, painful, no blisters.
4. Partial-thickness burns have blisters as the dermis is now involved.
5. Full-thickness burns can be charred, leathery, and insensate.

Burn Depth

Burn Depth Classification

The following chart and table outline the assessment and characteristics for each burn depth. 

Burn depth and total body surface area of a burn are two key aspects of a burn assessment. The assessment of burn depth, and as such, the estimation of whether a burn wound is expected to heal on its own within 21 days, is one of the most important roles of the burn surgeon4.

Currently, the determination of burn depth based on clinical examination is only 70% accurate1. It can be difficult to effectively stratify burn wounds.

A burn is a dynamic process for the first few days and a burn that appears shallow on day 1 may appear deep by day 32. A deeper burn may require more fluid resuscitation.  

Burn Depth Classification Chart

Despite the plethora of technological advances, the most common technique for diagnosing burn depth remains the clinical assessment of an experienced burn surgeon.  A clue is often in the history - type of burn and immediate first aid.

You can download this burn depth chart with the link below.

Burn Depth Classification

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Tip: it's very rare for a burn to be one specific depth. The majority of burns are "mixed thickness" with one depth more present than the others. 

Superficial Burn Depth (1st Degree Burns)

A superficial burn is similar to a "sunburn" - red, painful, and generally resolves over a few days.

A superficial burn (1st degree) has the following characteristics:

• Involve the epidermis
• Warm, painful, red/erythematous, soft, and blanching.
• No blistering.
• A typical example is a sunburn.
• Healing by rapid re-epithelialization3

Superficial Burn

Partial Thickness Burn Depth (2nd Degree Burns)

A partial-thickness burn has 3 subclassifications: superficial-dermal, mid-dermal, and deep-dermal

Superficial dermal partial thickness

A superficial partial-thickness burn (2nd degree) has the following characteristics:

• Involves epidermis and into the papillary dermis
• Painful, red, blistered, moist, soft, and blanching when touched.
• When blistered are deroofed, the skin is moist, red, and hypersensitive.

Superficial-Partial Thickness Burn 

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Tip: Blisters are a collection of fluid between the interface of the epidermis and dermis. If there are blisters, it means the burn cannot be superficial.

Mid dermal partial thickness

Mid-Partial Burn

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Tip: Burns that heal within 3 weeks generally do so without hypertrophic scarring or functional impairment, although long term pigmentary changes are common

Deep dermal partial thickness

A deep partial-thickness burn (2nd degree) has the following characteristics:

• Involves epidermis and into the reticular dermis
• It can also blister but is less likely than a superficial dermal burn.
• The wound surface is usually a mottled pink immediately following the injury and overtime may progress to a whiter and drier wound.
• Blanching is minimal or non-existent (due to capillary damage)  
• Reduced sensation and less pain.

Deep-Partial Burn

Full Thickness Burn Depth (3rd Degree Burns)

A full-thickness burn is an insensate, non-blanching, painless burn that can have an overlying black eschar or feel like leather. 

A full-thickness burn (3rd degree) has the following characteristics:

• Involve epidermis, dermis, and into the subcutaneous fat or deeper.
• Minimal or no pain
• Colour can be white, brown, or charred
• Feel firm and leathery with no blanching.

Full Thickness Burn

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Tip: Superficial Burns and Full Thickness burns don't have blisters!

Flashcards on Burn Depth

Test your knowledge with the largest online flashcard database!

References on Burn Depth

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Thank you to Abdulrahman Abdulaziz Alghamdi for his contribution to this article. 

1. Bezuhly, Michael F.R.C.S.C.; Fish, Joel S. F.R.C.S.C. Acute Burn Care, Plastic and Reconstructive Surgery: August 2012 - Volume 130 - Issue 2 - p 349e-358e doi: 10.1097/PRS.0b013e318258d530
2. Heimbach D, Engrav L, Grube B, Marvin J. Burn depth: a review. World J Surg. 1992 Jan-Feb;16(1):10-5. doi: 10.1007/BF02067108. PMID: 1290249.
3. Monstrey S, Hoeksema H, Verbelen J, Pirayesh A, Blondeel P. Assessment of burn depth and burn wound healing potential. Burns. 2008 Sep;34(6):761-9. doi: 10.1016/j.burns.2008.01.009. Epub 2008 Jun 3. PMID: 18511202.
4. Amín D. Jaskille, MD, Jeffrey W. Shupp, MD, Marion H. Jordan, MD, James C. Jeng, MD, Critical Review of Burn Depth Assessment Techniques: Part I. Historical Review, Journal of Burn Care & Research, Volume 30, Issue 6, November-December 2009, Pages 937–947, //doi.org/10.1097/BCR.0b013e3181c07f21