1 Introduction

Burn injuries result from exposure to thermal, chemical, electrical, or radiation sources. Burn depth is a critical determinant of clinical management, particularly the need for surgical intervention. Superficial (first-degree) burns, limited to the epidermis, are typically painful but heal without scarring and rarely require surgery. Partial-thickness (second-degree) burns extend into the dermis and are characterized by blister formation, with severity ranging from superficial (moist, hyperemic, blanching) to deep (dry, insensate, nonblanching). In contrast, full-thickness (third-degree) and fourth-degree burns, which involve deeper tissues (e.g., muscle or bone), often appear necrotic and insensate, necessitating surgical intervention and frequently resulting in significant scarring [1].

Burn management encompasses acute resuscitation, wound assessment, surgical excision, grafting, and long-term scar rehabilitation. Key challenges include infection control, fluid balance, pain management, and specialized care for high-risk populations (e.g., children and the elderly) [2-4]. Conventional treatments such as debridement, skin grafting, and biological dressings have limitations, including cost, infection risk, and scar formation. Traditional Chinese medicine (TCM) has shown promise in wound healing due to its anti-inflammatory, antioxidant, and fibroblast-stimulating properties [5, 6].

Pathologic scarring arises from dysregulated wound healing, involving prolonged inflammation, excessive proliferation, and aberrant remodeling [7]. Clinically, this manifests as pain, pruritus, functional impairment, and disfigurement. Fractional laser therapy has emerged as an effective scar treatment, utilizing controlled microthermal damage to stimulate tissue regeneration and remodeling [8].

2 Case History/Examination

A male patient was admitted with a 1% total body surface area (TBSA) deep burn affecting the right face and ear, due to the hot crush injury. Physical examination identified a 12 cm × 6 cm fourth-degree burn involving underlying muscle and auricular cartilage, with focal necrosis and tissue loss (Figure 1A).

3 Differential Diagnosis, Investigations and Treatment

Given the clear etiology, no differential diagnosis was required. Admission blood tests revealed inflammatory markers. The patient had no significant comorbidities (e.g., diabetes or immunodeficiency) and maintained good nutritional status.

We implemented a standardized clinical protocol for this patient, consistent with our institutional approach for small-area deep burns (< 10% TBSA). The treatment was divided into three distinct phases based on wound healing pathophysiology.

4 Outcome and Follow-Up

After 1 month of treatment, new skin tissue had formed at the edges of the wound; however, a significant amount of necrotic tissue remained attached to the burned area in the center (Figure 1A–C). After 3 months of treatment, the burn wound had nearly healed (Figure 1D–F). Throughout the entire wound management process, antibiotics were never administered, and the patient did not experience any systemic infection. Subsequently, we discontinued wound treatment and proceeded with the first session of laser therapy. After 13 laser therapy sessions, the wound exhibited substantial epithelialization (Figure 1G–J) with marked improvement in scar assessment parameters (Table S1,S3). Following a follow-up period of one and a half years, the treated area showed no signs of contracture, hypertrophic scarring, or subcutaneous adhesions (Figure 1K and Video S1).

5 Discussion

Burn injuries result in long-term physiological and functional alterations that persist beyond wound closure, necessitating comprehensive management to optimize patient outcomes and quality of life [1, 9]. Achieving high-quality wound healing with minimal scar formation remains a critical therapeutic goal.

Current standard therapies include silver sulfadiazine, the first-line antimicrobial agent for burn infections, which exhibits broad-spectrum activity against Gram-positive, Gram-negative, and fungal pathogens [10]. Enzymatic debridement with bromelain-based agents (e.g., NexoBrid) has emerged as an effective adjunct for mixed-depth dermal burns, primarily through selective removal of necrotic tissue rather than direct antimicrobial effects [11, 12]. TCM conceptualizes burn wounds as “ulcers” attributed to tissue “decay.” The principle of “removing decay and promoting regeneration” aligns with modern debridement strategies [13]. TCM formulations enhance phagocytic activity of neutrophils and macrophages, facilitating necrotic tissue clearance and inflammatory resolution [14]. This mechanism complements conventional approaches by modulating the wound microenvironment during critical healing phases.

The primary advantage of TCM lies in its multicomponent nature, allowing for simultaneous targeting of multiple pathways and producing synergistic effects [15]. Traditional hemostatic drugs, such as DanShen (Radix Salviae Miltiorrhizae), SanQi (Radix Notoginseng), and JiangHuang (Curcumae Longae), have been extensively utilized in wound healing [16]. KuShen (Radix Sophora Flavescens), traditionally used to treat damp-heat syndromes [17], contains over 200 bioactive compounds, primarily flavonoids and alkaloids. Studies demonstrate its extracts exhibit broad pharmacological effects including anti-inflammatory, antimicrobial, and antipyretic activities [18]. The therapeutic mechanisms involve modulation of critical signaling pathways, particularly the NF-κB-mediated inflammatory response and Nrf2-ARE antioxidant pathway, as demonstrated by extracts of Chrysanthemum zawadskii and Glycyrrhiza uralensis [19]. Other components like carboxymethylated polysaccharides from YeJuHua (Chrysanthemum indicum) contribute antimicrobial and hemostatic properties [20], while RenDongTeng (Lonicerae Japonicae Caulis) shows protective effects against cell injury through MAPK pathway inhibition [21]. Several TCM herbs including HuangQi (Radix Astragali Seu Hedysari), DangShen (Radix Codonopsis Pilosulae), BaiZhu (Rhizoma Atractylodis Macrocephalae), DangGui (Radix Angelicae Sinensis), and BaiZhi (Radix Angelicae Dahuricae) exhibit antitumor and immunomodulatory effects through cell cycle regulation and apoptosis induction [22, 23]. These compounds modulate key signaling pathways including Wnt, PI3K/Akt, NF-κB, TGF-β/Smad, to promote diabetic wound healing by balancing inflammatory responses and oxidative stress [24]. Recent studies further demonstrate their ability to enhance neural stem cell proliferation and migration [25]. The oil-based vehicles in TCM preparations provide additional benefits by maintaining optimal wound moisture. However, despite promising clinical applications in various wound types [26], further research is needed to standardize formulations and evaluate long-term safety profiles. TCM treatments may lead to adverse wound healing effects, such as local irritation and allergic reactions. The integration of TCM's multitarget approach with conventional therapies represents a promising treatment strategy that warrants rigorous clinical investigation.

Our protocol recommends initiating combined laser and Kushen ointment therapy immediately after wound closure, continuing until scar stabilization. Adjunctive therapies including scar massage, pressure therapy, and silicone gel sheet application should be incorporated. Treatment endpoints include: normalized skin color without erythema/hyperpigmentation, soft pliable texture without induration, stable scar thickness, and absence of pruritus or pain. This combined approach achieved excellent esthetic and functional outcomes in our patient without wound contracture or pathological scarring.

While our nonsurgical protocol requires longer treatment duration than operative approaches, it avoids the need for repeated debridement, autografting, or expensive biological dressings, reducing hospitalization costs by approximately 50% (~$4000). The favorable safety profile and patient tolerance further enhance its clinical utility. However, treatment efficacy may be limited in patients with extensive burns (> 20% TBSA) or significant comorbidities, as seen in our healthy patient with optimal outcomes.

This case demonstrates that simply achieving wound closure without addressing the pathological wound microenvironment (“decay”) may be insufficient. Although time-intensive, our approach effectively minimizes late scar complications. While promising for small-area deep burns, limitations include prolonged treatment courses and compliance demands. Further evidence-based evaluation is needed to optimize TCM integration into burn care.

Author Contributions

Yating Yin: data curation, investigation, supervision, writing – original draft, writing – review and editing. Shun Xu: funding acquisition, investigation, methodology, resources, supervision, visualization, writing – review and editing.

Ethics Statement

Ethical approval for the study was granted by the ethics committee of the Seventh People's Hospital Affiliated to Shanghai University of Traditional Chinese Medicine (2023-7th-HIRB-040). A written informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy.

Conflicts of Interest

The authors declare no conflicts of interest.