Assessing Burn Depth by Indocyanine Green Angiography: A Systematic Review and Algorithm for Clinical Use

Experienced burn surgeons correctly assess burn depth in only 60-75% of cases. Various strategies are available to define the degree of burn, ranging from clinical observation (the most common) to biopsy and subsequent histological analysis. Among these, indocyanine green angiography (ICG) is gaining popularity for its potential to improve diagnostic accuracy. This study aims to explore the utility of ICG as a tool for evaluating the extent and severity of burns, thereby enhancing diagnostic accuracy and treatment outcomes in burn care. A systematic review of the literature was conducted using PubMed, Scopus, Embase and the Cochrane Library through February 2025 using the search terms [ICG OR indocyanine green] AND [burn]. Article selection was performed following the PRISMA guidelines. The initial search yielded 201 results, of which 10 articles met inclusion criteria (3 on animal models, 7 on human subjects, involving 122 patients overall). Preclinical studies demonstrated ICG's ability to distinguish between partial- and full-thickness burns with 100% accuracy when compared to histopathology. Clinical studies confirmed improved diagnostic performance over clinical assessment alone. Optimal imaging was reported at five minutes post-injection, with evaluation recommended between days two and three post-injury. Quantitative and qualitative fluorescence analysis enabled discrimination of superficial burns, where dermal vascularization is preserved, from deep burns. This method could reduce waiting times and support early surgical decision-making. A structured clinical algorithm integrating timing, dosing, and interpretation was proposed based on literature. ICG video-angiography has shown to be an effective technique that deserves consideration in the assessment of burn patients. Further studies are needed to increase knowledge and guide its optimal clinical use.