key milestones that need to be achieved by dermatology residents; however, there is no data on the nature and the amount of wound care training during residency.15 Moreover, once in practice, continuing education is paramount to ensuring high quality wound and burn care.16,17 The lack of education in these two areas is a harbinger of a wider dearth of academic focus on burns in dermatology. A recent review of dermatology literature revealed a paucity of clinically oriented coverage of topics pertaining to therapeutic management of burn patients. Upon review of the American Academy of Dermatology Annual Meeting Archives from 2009 to 2014, only 2 educational sessions were identified within the realm of burn care and management. Furthermore, there was a lack of clinically oriented literature pertaining to thermal burn care in several high impact factor dermatological journals (Journal of Investigative Dermatology, JAMA Dermatology, Journal of Dermatological Science, Acta Dermato-Venereologica, Clinics in Dermatology). Taken together, these findings suggest the necessity for further education about burn care within the field of dermatology in order to provide more competent and confident dermatological care for burn patients.
The therapeutic approach to burn care has its own challenges. The American Burn Association provides guidelines for
deciding which patients can be treated in an outpatient setting versus those that should be referred to burn centers.18 Deep partial, and full thickness burns usually require excision in a surgical setting; however, patients with more superficial burns and burns at a later stage of healing may be managed in an outpatient setting.19,20 Assessing burn depth may be challenging even for an experienced clinician.21 Selection of treatment depends not only on burn etiology but also on the body part affected, the depth of the injury, and the body surface area (BSA) involved. Interestingly, silver sulfadiazine (SSD) was the most prescribed treatment by the providers in our study. SSD has been a treatment of choice for burns for decades mainly due to its antimicrobial properties. However, several clinical studies have found that SSD actually delays burn wound healing.22,23 Notably, a study that reviewed 30 randomized clinical trials showed that SSD was consistently associated with delayed wound healing compared to other products.24 These studies, together with our findings, suggest that lack of focus on burns in dermatologic training results in a disconnect between evidence and clinical practice.25
Our study was limited by its retrospective design and the lack of a standardized burn registry. Additionally, the data on total BSA, an important characteristic in judging burn severity, was not available. It is also important to note that several factors could potentially influence the frequency of burn patients seen in a particular dermatology clinic such as appointment availability, geographic location and socioeconomic factors. Several socioeconomic factors such as low income, low level of education and large family size have been associated with an increased risk of burn injuries.26 Our study was conducted in the Bronx, a community engulfed with many socioeconomic disparities affecting health outcomes that may also influence burn injury incidence.27
With most burns seen in an outpatient setting, burn care may represent a niche not fully explored by dermatologists. Here, we set the stage for further discussion and address likely barriers. A shortage of dermatologists and the resulting long wait times for an appointment are likely impediments to the patient, accounting for lower incidence of burns seen by dermatologists. Furthermore, a lack of focus on burn care in residency, continuing medical education and dermatology literature impedes dermatologists from taking on a more active role in this field. Our study underscores the merits of a larger scale, multi-center epidemiological evaluation to fully elucidate the role of dermatologists in outpatient burn care.
CONCLUSION
Our study demonstrates that burns are not frequently seen by dermatologists. We hypothesize that longer wait times in specialty practices, the lack of burn-specific training and the complexities of burn care prevent dermatologists from
