After resuscitation, management focuses on wound care to limit microbial proliferation, which can convert a partial-thickness into a full-thickness burn, and to prevent invasive infection of underlying tissue. Initial care includes gentle cleansing with a surgical detergent disinfectant, debriding nonviable tissue, and shaving hair from the area. A topical agent such as mafenide acetate cream or solution, silver sulfadiazine cream, 0.5% silver nitrate solution, or newer nanocrystalline silver preparations is applied. Silver nitrate solution is bacteriostatic against gram-negative bacteria including some against Pseudomonas, but does not penetrate eschar and has limited antifungal activity. It has the potential to cause electrolyte imbalance because it binds chlorine ions, discolors the wound bed, making visual inspection difficult, and is difficult to apply and maintain, so it is rarely used. Silver sulfadiazine is bactericidal against gram-negative bacilli and sometimes against Pseudomonas with minimal toxicity but does not penetrate eschar. Mafenide acetate (Sulfamylon) (10% cream or 5% solution) has broad gram-negative coverage including Pseudomonas as well as Clostridium species but is ineffective against fungi so concomitant antifungal therapy is needed. The cream is applied to the surface and the wound is left exposed; the solution is applied and soaked in; both formulations penetrate eschar. The solution has been shown to have less pain with application and less inhibition of carbonic anhydrase (leading to metabolic acidosis). Nanocrystalline silver preparations exist in multiple commercial forms; they have broad-spectrum activity, including against Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus, and vancomycin-resistant enterococci. They can be left in place for days at a time if the wound does not have significant exudates and are becoming a popular alternative. Mupirocin is used in centers where methicillin-resistant S. aureus is problematic. Nystatin is used as an antifungal agent in conjunction with antibacterial therapy to treat both superficial and deep burn wound infections.

None of the available topical agents sterilizes the burn wound; therefore, protection from invasive infection is not complete. During daily wound care when the topical agent has been removed, the wound must be examined to identify local signs of infection. Common color changes that signal infection are focal, multifocal, or generalized dark brown, black, or violet discoloration. The most reliable sign of invasive infection is the conversion of an area of partial-thickness burn to full-thickness necrosis. Other local signs include hemorrhagic discoloration of subeschar tissue; unexpectedly rapid separation of the eschar (most commonly due to fungal infection); green pigment visible in the subcutaneous fat; edema or violet discoloration, or both, of unburned skin at the margin of the wound; and rapidly expanding ischemic necrosis.

Because noninfectious factors such as minor local trauma can induce similar local changes in the burn wound, assessment of the microbial status of the wound is needed. A 500-mg lenticular biopsy sample is harvested from the area of most marked changes and must include the eschar and underlying unburned tissue so that the nonviable-viable tissue interface is where invasive infection begins. One half of the specimen is cultured, and the other half is sent for histologic examination.

On detection of microorganisms in unburned tissue, local and systemic therapy is begun. Treatment comprises application of mafenide acetate burn cream if other topical agents have been used; subeschar injection of a broad-spectrum penicillin solution into infected areas, followed by surgical excision of the infected tissue; and systemic antibiotics.

The goal is to promote an environment prone to healing or amenable to definitive coverage. A newer approach called “moist wound healing” has been advantageous in superficial burn wounds, meshed skin grafts, and excised burn wounds. The goal is to maintain a moist environment about the surface that stimulates growth factors, increases proteolytic enzymes to clear devitalized tissue, enhances oxygen delivery and immune response, promotes angiogenesis and fibroblast proliferation, has improved epithelialization, and has less pain associated with moisture retaining dressings. Although topical creams cause desiccation due to their hyperosmolar properties, they are still the standard of care for deep burn wounds.