White Phosphorus Burns: A Comprehensive Review over a Century of Evidence from "Willie Peter" to Modern Clinical Management.

White phosphorus (WP) is a highly reactive incendiary agent capable of causing severe injuries through combined thermal combustion and chemical tissue damage, with potential systemic toxicity disproportionate to burn size. Although traditionally associated with warfare, accidental civilian exposures continue to occur, including in coastal environments where historical military residues may persist. This narrative review synthesizes over a century of evidence on WP burns, integrating findings from experimental studies, clinical reports, military experiences, environmental investigations, and toxicological analyses. A contemporary civilian case of accidental coastal exposure is included to illustrate ongoing non-combat relevance. Available evidence consistently identifies hypocalcemia, hyperphosphatemia, cardiac arrhythmias, renal injury, and hepatocellular damage as major systemic complications of WP exposure. Clinical reports show that retained particles may continue to oxidize and reignite upon oxygen exposure, requiring prompt decontamination, mechanical removal, metabolic monitoring, and repeated evaluation for residual material. Current evidence supports copious irrigation, oxygen exclusion with moist dressings, careful debridement, and avoidance of copper sulfate because of its systemic toxicity. The presented case highlights that even limited exposure may result in full-thickness, burns requiring close observation despite minimal TBSA involvement. Despite over a century of reported experience, evidence guiding WP burn management remains fragmented and largely based on case reports and observational studies. The findings underscore the need for standardized clinical protocols, improved preventive strategies, and collaborative civilian-military approaches to advance recognition and management of this uncommon but potentially life-threatening injury.