If the patient has a dense overlying haircoat, severity and extent of injury may be difficult to interpret until thick adherent crusts become evident or a necrotic odor is noticed. Toxic epidermal necrolysis is one of the main differential diagnoses; other common differential diagnoses include erythema multiforme, epidermal and subepidermal autoimmune blistering diseases (eg, pemphigus vulgaris, bullous pemphigoid), ischemic dermatopathies, and pressure necrosis.5 Burn wound biopsy can be helpful in determining the cause of injury and extent of microbial infection, establishing anatomic depth of the injury, and evaluating the adequacy of surgical excision17,18; it also has medical, legal, and forensic value.
Histologically, thermal and chemical burns are described as coagulation necrosis of the epidermis and deeper tissue. Electrical burns may display keratinocytes with stretched nuclei and fringed, elongated degenerated cytoplasm.2,5
Initial assessment of burn patients should include identification of superficial, partial, and full-thickness burn wounds and assessment of the total body surface area affected. If the patient is a victim of severe burn injury and/or smoke inhalation, emergency care should be performed according to the Advanced Trauma Life Support guidelines (airway, breathing, and circulation; see Suggested Reading) and requires identification of respiratory distress, cardiovascular derangements, and shock.11
The Table summarizes classification, clinical signs, and healing characteristics of burn wounds.