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Burn Surgery

Assessment of burn degrees

Authors: Rami Mossad Ibrahim, MD, Elisabeth Lauritzen, MD, Frederik Gulmark Hansen med.stud., Magnus Balslev Avnstorp, MD and Rikke Holmgaard, Consultant, Burns Specialist, MD, PhD

Figure 1 | Burn degrees: 1st, 2nd, 3rd degree.

Epidermal burns (1st  degree)

The burn presents itself as a red (erythema), but there are no bullae. Cell destruction only extends only into the epidermis (1). A sunburn is a typical epidermal burn. The skin is red but intact. The epidermal burns do not require treatment beside sun cream and painkillers. 1st degree burns should not be taken into account when calculating the area of the burn (TBSA%) in regard to fluid resuscitation and hospital admission.

Dermal burns (2nd degree)

Presents with blisters/bullae filled with serous fluid, deep redness, pain and swelling. When the blisters are removed a shiny/wet surface appear. 2nd degree (dermal burns) are categorized into superficial 2nd degree burns and deep 2nd degree burns which included the more profound part of the dermis.

Superficial 2nd degree burns will retain a normal capillary response when pressure is applied. Deeper burns will not display a normal capillary response.

The sub-dermal parts of the skin with hair follicles, sebaceous- and sweat glands are intact in 2dn degree burns (Fig. 6) (1).

Swelling (oedema) occurs approximately 15 min – 1 hour after the burn, reaching its maximum after approximately 24 hours.

If the dermal burn remains non-infected it heals conservatively. The superficial dermal burn will heal approximately in 10-14 days, usually without scarring. The deep dermal burns heal after more than 3 weeks and can leave significant scarring.

Subdermal burns (3rd degree)

Presents with a brown or black form an inelastic crust. There are no bullae. The lesion is without pain as the cutaneous nerves are damaged. All dermal cells are affected, and the damage has reached the subcutaneous part of the skin (1). Only cells from connective tissue remain intact. A subdermal burn will therefore not heal conservatively from the epithelial cells of the woundbed. The lesion must either be excised and grafted or heal by shrinkage and epithelial growth from the rim. 


  1. Orgill DP, Solari MG, Barlow MS, O’Connor NE. A finite-element model predicts thermal damage in cutaneous contact burns. J Burn Care Rehabil [Internet]. [cited 2018 Mar 25];19(3):203–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9622462


Illustrations: Emma Tubæk, med.stud.

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