Beyond Skin Loss: Immune Dysregulation, Infectious Complications, and Early Reconstructive Strategies in Extensive Burn Injuries

Extensive burn injuries represent a major challenge in contemporary medicine because of their complex interactions with systemic inflammation, immune dysfunction, infectious complications, and reconstructive requirements. Severe thermal injury disrupts skin barrier integrity and initiates profound immunological alterations involving innate and adaptive immune responses, creating conditions that may increase susceptibility to wound infection and systemic deterioration. This narrative review examines the immunopathological mechanisms associated with extensive burns, the microbiological characteristics of burn wound infections, and the clinical relevance of early surgical excision and reconstructive coverage. Scientific literature addressing burn pathophysiology, microbial colonization, invasive infection, antimicrobial resistance, skin grafting, and dermal substitutes was critically examined, incorporating international evidence and contributions from Latin America. The findings demonstrate that postburn immune dysfunction involves the coexistence of inflammatory activation and impaired antimicrobial defense, complicating the differentiation between sterile inflammation and infectious deterioration. Microorganisms such as Pseudomonas aeruginosa, Staphylococcus aureus, Acinetobacter species, and Enterobacterales remain clinically relevant, although their distribution varies according to institutional and geographical characteristics. Early excision of devitalized tissue and appropriate reconstructive coverage are fundamental components of burn management, particularly in patients with extensive tissue loss and limited donor-site availability. Nevertheless, differences in burn severity, surgical timing, and reported outcomes restrict direct comparisons between reconstructive techniques. The available evidence supports an integrated multidisciplinary approach combining immunological assessment, infection surveillance, antimicrobial stewardship, and individualized surgical management. Further multicenter investigations incorporating standardized clinical definitions, longitudinal immune monitoring, and consistent reconstructive outcomes are needed to optimize treatment strategies and improve survival, functional recovery, and long-term quality of life.