Acute chemical skin injuries in the United States: a review

Abstract

The objective was to perform a thorough review of published and other available data to elucidate the extent of chemical skin injuries in the US. Chemical skin injuries differ significantly from skin lesions produced by other injury mechanisms, so this review was restricted to the former. Retrieval of relevant published data was performed in PubMed and Google. Other data were retrieved from the American College of Surgeons National Trauma Databank, American Burn Association National Burn Repository, US Department of Labor Bureau of Labor Statistics, websites of all 50 US States Departments of Health, and the National Poison Data System of the American Association of Poison Control Centers. Two areas of significance in disfiguring skin burn injuries and particularly of chemical skin injuries, psychosocial issues and the associated financial burden, have been briefly reviewed. Because of the paucity of published data, international as well as US data have been included. A brief description of an active flushing fluid as an alternative to potable water, Diphoterine^® solution, has also been included. Chemical skin injuries generally comprise approximately 2–5% of all skin burns, but sometimes higher percentages have been reported. Data analysis shows that while there are various sources regarding the epidemiology of chemical skin injuries, the total annual number cannot be determined because there is no centralized US national reporting mechanism. Literature and clinical experience demonstrate the importance of chemical skin injuries in USA. Dermal exposures to chemicals can result in mortality and morbidity. Chemical skin injuries can be avoided or ameliorated and preventive advanced measures should be taken to reduce or ameliorate them.

Keywords:

• Burns
• skin burns
• dermal burns
• chemical burns
• chemical skin injury

Introduction

At least 25,000 chemical products can cause chemical skin injury (Liao and Rossignol 2000), such as acids, bases, oxidizers, reducing agents, alkylating agents, etc. Chemical skin injuries are different from thermal and other types of burns in terms of mechanisms. Jelenko (1974), Maibach and Hall (2014), and Tovar and Leikin (2015) listed mechanisms by which chemicals splashed on the skin can cause dermal injury: oxidation reactions, reduction reactions, metabolic competition or inhibition, desiccation, and vesicant action with resultant ischemia (Jelenko 1974; Hall and Maibach 2014; Tovar and Leikin 2015).

The US Occupational Safety and Health Administration’s (OSHA’s) definition of an irritant toxic substance is one which can cause reversible skin injury following dermal test substance application for up to 4 h. A corrosive agent is one which can cause irreversible skin injury (visible necrosis) following test substance dermal application for up to 4 h. Irritant substances can result in inflammation at concentrations much lower than those needed to cause corrosive effects. Corrosive injuries can cause either coagulative necrosis (i.e. acid injuries) or liquefaction necrosis (i.e. alkaline injuries) (Tovar and Leikin 2015).

Methods

The PubMed database of the US National Library of Medicine and Google were searched for relevant data using search terms of ”burns,” ”dermal burns,” ”skin burns,” ”dermal injury,” ”chemical burns,” and ”chemical skin injury.”

The following organizations' websites were searched:

• American College of Surgeons National Trauma Databank

• American Burn Association National Burn Repository

• US Department of Labor, Bureau of Labor Statistics

• Websites of all 50 US States Departments of Health

Websites of all 50 US States Health Departments were accessed from Google searches using the search term “(State Name) State Health Department.” These websites are not listed in the References section. When the State Health Department had a searchable interface, search terms ”burns,” ”burn statistics,” and ”chemical injuries” were used. When there was only an alphabetical list of topics, the entire list was perused for any potentially relevant data.

Hard-copy printouts of the American Association of Poison Control Centers (AAPCC) National Poison Data System (NPDS) for the 10-year period of 2006–2015 were reviewed.

Two areas of significance in disfiguring skin burn injuries and particularly of chemical skin injuries are psychosocial issues and the associated financial burden, which have been briefly reviewed. Because of the paucity of published data, international as well as US data have been included. A brief description of an active flushing fluid as an alternative to potable water, Diphoterine^® solution (Laboratoire Prevor, Valmondois, France), has also been included.

In the Results section, each data source has been rated according to Evidence-Based Medicine criteria, as follows:

Levels of Evidence (US Preventive Services Task Force, 1989):

• Level I: Evidence obtained from at least one well-designed randomized controlled trial

• Level II-1: Evidence obtained from well-designed controlled trials without randomization

• Level II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group

• Level II-3: Evidence obtained from multiple time series designs with or without interventions. Dramatic results in uncontrolled trials might also be regarded as this type of evidence

• Level III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees

Results

Data limitations and scope of the problem

It is difficult to accurately define the scope of the problem of chemical skin injuries in the US, as there are no comprehensive reporting systems or structures. Some data sources such as the National Trauma Data Bank of the American College of Surgeons group together into one category ”Fire/Burn” and do not separate out other types of burns from chemical skin injuries specifically (American College of Surgeons 2005).

Various organizations have collected data which allow some conclusions about the annual incidence of chemical skin injuries. Chemical skin injuries are a relatively small proportion of all skin burn injuries. However, chemical skin injuries can be serious in many cases and some are fatal.

Some relevant incidence data come from the American Burn Association (ABA) with reporting from 125 US hospitals having specialized burn treatment centers/units and which therefore may be presumed to care for the most severely injured patients. From 2003 to 2012, chemical skin injuries represented about 3% of all cases, or in 2012 approximately 291/10,732 cases. Some data resources allowing an approximation of the scope of the problem are described below.

American Association of Poison Control Centers National Poison Data System

The American Association of Poison Control Centers (AAPCC) has operated the National Poison Data System (NPDS; formerly the Toxic Exposure Surveillance System – TESS) since 1983. The NPDS collects information on poison exposures self-reported by telephone callers to Poison Centers serving the United States and its territories (Bronstein et al. 2009). Telephone inquiries to US Poison Centers come from the general public as well as health care providers. Published data from the NPDS for the 10-year period, 2006 through 2015, are reviewed below.

Table 1 shows the total number of human poison exposures (a ”poison exposure” means that someone telephoned a US Poison Center not just for information purposes, whether or not illness or injury occurred) and shows, for each year, the number and percent of all types of dermal exposures, and the number of fatal dermal exposure cases (Bronstein et al. 2007, 2008, 2009, 2010, 2011, 2012; Mowry et al. 2013, 2014, 2015, 2016).

Table 1. AAPCC NPDS data 2006–2015* Total Human Poison Exposure vs. Total Dermal Poison Exposure and %; Fatal Dermal Poison Exposures.

Year	Total Human Poison Exposures	Total Dermal Poison Exposures	% Dermal Poison Exposures	Fatal Dermal Poison Exposures
2006	2,403,537	188,848	7.50	21
2007	2,482,041	191,298	7.30	14
2008	2,491,049	188,930	7.22	22
2009	2,479,355	179,832	6.90	12
2010	2,384,825	172,318	7.23	18
2011	2,334,004	162,638	6.97	16
2012	2,275,141	159,513	7.01	17
2013	2,188,013	152,028	6.95	11
2014	2,165,142	151,796	7.01	8
2015	2,168,371	150,866	6.96	8
Totals	23,371,444	1,698.067	7.27	147

*(Bronstein et al. 2007, 2008, 2009, 2010, 2011, 2012; Mowry et al. 2013, 2014, 2015, 2016).

(For Evidence-Based Medicine, this would be Level II-3.)

The AAPCC NPDS database is thought by the data collecting organization to capture approximately 25% of all poison exposures that actually occur in the United States. Because data are acquired from telephone calls from the general public as well as health care providers, it tends to over-represent asymptomatic and mildly symptomatic poison exposure cases, and tends to under-represent workplace poison exposures and fatal cases, as there is no requirement or mechanism for coroners and medical examiners to report all fatal poisoning cases to the NPDS. There is no way to separate out exposures in industrial facilities from exposures to the general public.

The NPDS does not differentiate in its summaries of the total numbers of cases between exposures resulting in no symptoms and symptomatic exposures, especially by exposure route. It cannot be determined how many clinically symptomatic dermal exposures occurred during the 10-year period. Also lacking are detailed descriptions for most individual cases and important information such as the amount and concentration of substances involved in dermal exposures, delay to and type of decontamination measures utilized, and pertinent clinical outcomes (lost work time, requirement for additional medical or surgical treatment, sequelae). It is not possible from the published NPDS data to differentiate the number of dermal exposures resulting in chemical skin injuries from those which did not.

US bureau of labor statistics data

The United States Department of Labor's Bureau of Labor Statistics (BLS) collects annual data on non-fatal and fatal occupational injuries and illnesses. The most recent available data are from 2015 (BLS 2017a, 2017b, 2017c). These data are nonspecific and cannot be easily related to the scope of the problem of chemical skin injuries. However, they do allow some insights. The data reviewed below refer to occupational injuries and illnesses in private industry unless noted otherwise.

(For Evidence-Based Medicine, this would be Level II-3.)

There were 2.9 million non-fatal workplace injuries and illnesses reported by employers to the BLS in 2015 (BLS 2017a). About 2.8 million of these (95.2%) were injuries, and approximately 2.1 million (75%) occurred in service-providing as opposed to goods-producing industries, where 25% of total injuries occurred (BLS 2017a). More than one-half of the total 2015 cases resulted in days-away-from-work, job transfer, or restricted duty (BLS 2017a).

Chemical manufacturing is a sector where chemical skin injuries may be reasonably predicted to occur. Overall rates of 2015 non-fatal occupational injuries and illness for private industry were 3.0 per 100 full-time workers (BLS 2017a). The total rate of days-away-from-work, job transfer, or duty restriction for private industry was 1.6 per 100 full-time workers. For the chemical manufacturing sector, the overall rate was 2.1 per 100 full-time workers and the total rate of days-away-from-work, job transfer, or duty restriction was 1.2 per 100 full-time workers (BLS 2017a).

In 2015 actual reported numbers, for private industry there were 2,905,900 reported cases with a total number of days-away-from-work, job transfer, or duty restriction of 1,571,900. For the chemical manufacturing sector, there were 170,000 total reported cases with a number of days-away-from-work, job transfer, or duty restriction of 101,000 (BLS 2017a).

The overall rate of days-away-from-work (for recuperation from occupational injuries and illnesses) was 104.0 per 10,000 full-time workers in 2015 (BLS 2017b). This equates to 1,153,490 days-away-from-work (which included private industry as well as state and local government workers) (BLS 2017b). In the private industry sector, the median number of days-away-from-work to recuperate (one measure of the severity of the injury or illness) was 8 in 2015; the incidence rate was 93.9 per 10,000 full-time workers (BLS 2017b).

In 2015, under the category of chemical burns and corrosions, there were 3490 cases with days-away-from-work in the combined private industry sector and the state and local governments sectors (BLS 2017b). In the private industry sector, there were 3300 cases with days-away-from-work in 2015 (BLS 2017b).

There were 4836 fatal occupational injuries reported in 2015, for an overall rate of 3.38 per 100,000 full-time employee equivalents (BLS 2017c). Ages of fatally-injured workers are shown in Table 2 (BLS 2017c).

Table 2. Ages, numbers, and rates of fatally-injured workers. Adapted from BLS (2017a).

Age (years)	Number of fatal injuries	Fatal injury rates*
<16	12	N/A
16–17	12	N/A
18–19	50	2.1
20–24	329	2.7
25–34	758	2.3
35–44	864	2.7
45–54	1,130	3.5
55–64	1,031	4.3
65 and over	650	9.4

* Rates per 100,000 full-time worker equivalents.

American Burn Association National Burn Repository Data

The American Burn Association (ABA) collects data on burn cases reported by member hospitals in its National Burn Repository (ABA 2013). A Report of Data from 1999 to 2013 lists patients treated by contributing hospitals. Over these years, chemical burn injuries accounted for approximately 3% of all burn injuries.

(For Evidence-Based Medicine, this would be Level II-3.)

The 2013 report described that new cases in that year involved 10,722 patients with burn injuries, of which 291 (2.9%) had a chemical exposure etiology. Work-related chemical skin injuries were more common (49%) than non-work-related injuries (42%). Of those exposure settings that were reported (not all were reported), chemical skin injuries occurred in the home in 39.8% of patients and in industrial settings in 39.2% of patients. As the Total Body Surface Area (TBSA) of chemical skin injuries increased, survivals decreased and fatalities increased (ABA 2013).

Mean peak ages of chemical skin injuries had a frequency distribution between 20 and 60 years. This corresponds to the general demographics of persons in the workforce (ABA 2013).

Chemical skin injury can result in more or less severe complications. The top 10 complications in such cases from the 2013 report are listed in Table 3 (ABA 2013). By age group, complications occurred in 5–7% of patients aged <20 years, in 7–10% of patients aged 20–60 years, and in 14–16% in patients aged >60 years. The top 10 procedures performed among patients with chemical skin injuries are shown in Table 4 (ABA 2013).

Table 3. ABA data, top 10 chemical skin injury complications (ABA, 2013).

Complication	Number	% of total complications	% of patients with this complication
Cellulitis	131	16.1	2.6
Pneumonia	64	7.8	1.3
Wound infection	56	6.9	1.1
Urinary tract infection	53	6.5	1.1
Respiratory failure	52	6.4	1.0
Septicemia	42	5.1	0.8
Renal failure	26	3.2	0.5
Other blood/Systemic infection	24	2.9	0.5
Dysrhythmias	22	2.7	0.4
Other hematological complications	20	2.5	0.4

Table 4. ABA data top 10 performed procedures among chemical skin injury patients (ABA, 2013).

Procedure	Number	Percentage of total procedures (%)
Excisional debridement	2137	18.8
Other skin graft to other sites	1510	13.3
Application of other Wound dressing	798	7.0
- Skin homografting	677	6.0
- Skin heterografting	399	3.5
Venous catheterization	387	3.4
Dermal regeneration grafting	287	2.5
Fiberoptic bronchoscopy	189	1.7
Packed red blood cell transfusion	181	1.6

50 US States Health Departments websites data

Available data from a search of the websites of all 50 US states Health Departments are shown in Table 5. US state Health Department websites with no relevant data found were Alabama, Florida, Hawaii, Idaho, Illinois, Indiana, Maine, New Mexico, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Washington (state), West Virginia, Wisconsin, and Wyoming.

Table 5. Data from the 50 US States Health Departments where data were available.

State	Time period covered	Number of cases	Available descriptive information
Alaska	2012–2013	7 (with 1 fatality)	• Non-fatal injury hospitalization in infants: Burns (not further categorized) = 10.7% • Ammonia release, Sitka, AK, 06/24/2002: 7 victims (10–82 years old; median 38 years old); 3/7 with chemical skin injuries + respiratory tract effects; 1 fatality • 2012: 32 Releases of extremely hazardous substances; those that could have resulted in chemical skin injuries:   ^ Anhydrous ammonia: 23 releases (72%); 21,382 pounds   ^ Sulfuric acid: 3 releases (9%); 608 pounds   ^ Hydrofluoric acid: 1 release (3%); 40 pounds   ^ Hydrochloric acid: 1 release (3%); 4 pounds
Arizona	2008 2013	187 (Children) 63 (EMS burn cases)	• Unintentional burn and scald injuries in children aged 0–17 years   ^ 2242 total (with 4 deaths)   ^ Caustic or corrosive substances =187 cases (8%)  • EMS June Quarterly Report: AZ-PIERS, Q3 & Q4, 2012   ^ Total patients: 12,833   ^ Burns (not further classified): 63 (0.49%)
Arkansas	2000–2007 2000–2009	549 1042	• Deaths from unintentional fires/burns (burns not further characterized)   ^ 549 total cases?  • Hospitalizations from unintentional fires/burns (burns not further characterized)   ^ 1042 total cases   ^ 2007: 303 cases   ^ 2008: 305 cases   ^ 2009: 434 cases
California	2011	168	• Unintentional burn, fire/flame deaths (burns not further characterized)   ^ Total: 168 cases
Colorado	1995–2012 2001–2007	3434/ 3157 276	• Hospitalizations for fire/burns – scalds/caustic substances/hot objects (not further characterized)   ^ Crude rate = 3.9 per 100,000 population  • Hospitalizations for work-related burns (not further characterized)   ^ 2001: 44/crude rate 2.0   ^ 2002: 39/crude rate 1.7   ^ 2003: 34/crude rate 1.5   ^ 2004: 28/crude rate 1.2   ^ 2005: 54/crude rate 2.2   ^ 2006: 42/crude rate 1.7   ^ 2007: 35/crude rate 1.4   ^ Average: 39.4/crude rate 1.7  • See also below for additional 2003 data
Connecticut	1990–1998 2003–2008	148 297	• Total burns =777   ^ Chemical burns: 19% (148 cases)  • Total workplace burn injuries: 1649  • Chemical burns =18% (297 cases)
Delaware	1979–1998 1996–2005 2001 2004 2005–2009 2009	69 30 Not reported 63 Not reported 36	• Leading causes of childhood injury deaths: fire/burn (not further characterized   ^ 69 cases (6.8%)  • Leading causes of childhood injury deaths: fire/burn (not further characterized   ^ 30 cases (6.5%)  • Childhood injury report – leading causes of injury deaths: fire/burn (not further characterized   ^ 10.4%  • Trauma system registry – fire/burn/explosion/electrical (not further characterized)   ^ 63 cases (1.4%)  • Unintentional injury, suicide, and homicide mortality: fire/burn unintentional injury (not further characterized)   ^ 2.8%  • Hospital discharges: burn (not further characterized)   ^ 36 cases (0.4%)   ^ Mean length of stay: 5.6 days
Georgia	2006–2009	684	• Occupational health surveillance report: hospitalizations for work-related burns (not further characterized)   ^ 2006: 185 cases   ^ 2007: 186 cases   ^ 2008: 165 cases   ^ 2009: 149 cases   ^ Total: 684 cases
Iowa	2006 2011	Not reported 113	• Hazardous Substances Emergency Events Surveillance (Released chemicals that could have caused chemical skin injuries)   ^ Acids    ▪ Fixed facility: 26 events (10%)    ▪ Transportation: 6 events (8%)    ▪ Total: 35 events: (8%)   ^ Ammonia    ▪ Fixed facility: 108 events (39%)    ▪ Transportation: 17 events (22%)    ▪ Total: 125 events (35%)   ^ Bases    ▪ Fixed facility: 11 events (4%)    ▪ Transportation: 2 events (3%)    ▪ Total: 13 events (4%)   ^ Chemical burns    ▪ Fixed facility: 27 injuries (14.5%)    ▪ Transportation: 0 injuries    ▪ Total: 27 injuries (13.7%)   ^ Skin irritation    ▪ Fixed facility: 26 cases (14.0%)    ▪ Transportation: 3 cases (27.3%)    ▪ Total: 29 cases (14.7 %)  • Trauma service statistics summary report: burn/thermal injury (not further classified)   ^ Survivors: 111 cases   ^ Deaths: 2 cases   ^ Total cases: 113  • See below for 1999 Burn Center Data
Kansas	1995–2003 2005–2009	4,184 326	• Health statistics report: burn hospitalizations (not further characterized)   ^ Total: 4184 cases   ^ Hospitalization rates were greatest for young children and the elderly  • Unintentional injury hospital discharges: fire/burn (not further characterized)   ^ <1 y.o.: 43 cases (10%)   ^ 1–4 y.o.: 184 cases (12%)   ^ 0–14 y.o.: 326 cases (8%)  • Report on unintentional injuries in children: age-specific top 5 causes of unintentional injury emergency department visits   ^ Fire/burn (not further characterized): < 1 y.o.: 116 cases (6%)
Kentucky	1998–2000	69	• Epidemiological notes & reports: Occupational Burn Surveillance   ^ Total occupational burn cases: 430   ^ Hospitalized (of total): 32 cases (7%)   ^ Fatalities (of total): 3 cases (1 %)   ^ Chemical skin injuries: 16% (69 cases)   ^ Acid skin injuries: 17 cases (4%)
Louisiana	1998–2007 2002 2001–2007	463 732 events Not Reported	• Work-related hospitalizations: review of hospital inpatient discharge data   ^ Total burns (not further characterized): 463   ^ Deaths from burns (not further characterized): 9 cases (16.1%)  • Hazardous Substances Emergency Events Surveillance: HSEES-related injuries, fatalities, and evacuations   ^ 732 total events: 630 (88.3%) at fixed facilities; 124 (16%) during transportation   ^ 20 events with victims (65%) had only 1 victim; 95% of events had either 1 or 2 victims   ^ At fixed facilities, the most common adverse effects were chemical burns (38.9%)   ^ Acids    ▪ Total releases: 47 (39%)    ▪ Releases with victims: 4 (20%)   ^ Ammonia    ▪ Total releases: 33(2.7%)    ▪ Releases with victims: 2 (10%)   ^ Bases    ▪ Total releases: 22 (1.8%)    ▪ Releases with victims: 2 (10%)  • Hazardous Substances Emergency Events Surveillance (HSEES) system: summary report – injuries to responders during HSEES events   ^ Fixed facility: 0 cases   ^ Transportation: Chemical burns – 1 case (12.5%)   ^ Total chemical burns: 1 (2.4%)   ^ 15 events where responders were injured (with the potential for chemical skin injuries)    ▪ Ammonia: 1 event, 3 cases    ▪ Acid NOS*: 1 event, 4 cases    ▪ Phenol: 1 event, 1 case
Michigan	2006–2011 2011 2012	661 127 events 197 events	• Unintentional fatal injuries; burn, fire/flame (not further characterized)   ^ 2006: 96 cases   ^ 2007: 122 cases   ^ 2008: 119 cases   ^ 2009: 130 cases   ^ 2010: 95 cases   ^ 2011: 99 cases   ^ Total: 661 cases  • HSEES (Hazardous Substance Emergency Event Surveillance)   ^ 127 events   ^ 44 events resulted in an injury in 68 victims   ^ 10 fatalities   ^ Most frequently reported injuries were burns and trauma   ^ Fixed facilities: 115 events (90.6%)   ^ Transportation: 12 events (9%)   ^ Substances involved with the potential to cause chemical skin injuries:    ▪ Ammonia: 10 events    ▪ Hydrochloric acid: 2 events   ^ Events with 1 victim:    ▪ Fixed facility: 29 (65.9%)    ▪ Transportation: 2 (4.5%)    ▪ Total: 31 (70.4%)   ^ Events with 2 victims:    ▪ Fixed facility: 6 (13.6%)    ▪ Transportation: 2 (4.5%)    ▪ Total: 8 (18.2%)   ^ Events with 3 victims:    ▪ Fixed facility: 2 (4.5%)    ▪ Transportation: 0 (0%)    ▪ Total: 2 (4.5%)   ^ Events with >/= 4 victims:    ▪ Fixed facilities: 3 (6.8%)    ▪ Transportation: 0 (0%)    ▪ Total: 3 (6.8%)   ^ Total events/victims:    ▪ Fixed facility: 40 events; 62 victims    ▪ Transportation: 4 events; 6 victims    ▪ Total: 44 events; 68 victims   ^ Victims by population group:   ^ General population: 44.65%   ^ Employees: 27.3%   ^ Firefighters: 2.3%   ^ 10 victims died (none from chemical skin injuries)   ^ Burns (not further characterized) accounted for 26 injuries (43.3%)   ^ Chemical substances involved with the potential to cause chemical skin injuries:    ▪ Ammonia: 10 events (7.9%)    ▪ Hydrochloric acid: 2 events (1.6%)    ▪ Nitric acid: 1 event (0.8%)    ▪ Sulfuric acid: 1 event (0.8%)  • HSEES (Hazardous Substance Emergency Event Surveillance)   ^ 197 events   ^ Most frequently reported injuries were burns and trauma   ^ 164 events occurred in fixed facilities (83.2%)   ^ Substances releases in more than 1 event with the potential to cause chemical skin injuries:    ▪ Ammonia: 7 releases    ▪ Sodium hydroxide: 3 releases    ▪ Sulfuric acid: 2 releases   ^ Released substances with the potential to cause chemical skin injuries:    ▪ Ammonia: 7 releases (3.6%)    ▪ Sodium hydroxide: 3 releases (1.5%)    ▪ Sulfuric acid: 2 releases (0.5%)    ▪ Hydrochloric acid: 1 release (0.5%)    ▪ Potassium hydroxide: 1 release (0.5%)   ^ Events with 1 victim:    ▪ Fixed facility: 38 events (58.4%); 38 victims    ▪ Transportation: 5 events (7%); 5 victims    ▪ Total: 43 events (66.2%); 43 victims   ^ Events with 2 victims:    ▪ Fixed facility: 8 events (12.3%); 16 victims    ▪ Transportation: 2 events (3.1%); 4 victims    ▪ Total: 6 events (9.2%); 20 victims   ^ Events with 3 victims:    ▪ Fixed facility: 4 events (6.2%); 12 victims    ▪ Transportation: 0 events (0%); 0 victims    ▪ Total: 4 events (6.2%); 12 victims   ^ Events with >/= 4 victims:    ▪ Fixed facility: 8 events (12.3%); 45 victims    ▪ Transportation: 0 events (0%); 0 victims   ^ Total: 65 events; 120 total victims   ^ Victims by population group:    ▪ General population: 83.69%    ▪ Employees: 28.23%    ▪ Firefighters: 6.5%    ▪ Police: 3.3%   ^ 10 (8.3%) fatalities (none due to chemical skin injuries)   ^ Most common injuries were Burns (not further characterized) (47 victims; 43.5%) and trauma (27 victims; 25.0%)
Minnesota	1995–2005 2000–2010	136 560	• Environmental health information; an overview of accidental anhydrous ammonia releases   ^ Accidentally released: 459 times (∼14.4% of all HSEES releases)   ^ 25% of these events resulted in evacuations, injuries, or both (chemical burns not specifically listed)   ^ 136 persons injured during 47 releases (16.8% of all HSEES events)   ^ 391 (85%) of releases occurred at fixed facilities  • Work-related burn injuries (not further characterized)/rates (rate per 100,000 employed persons >/= 16 years of age)   ^ 2000: 76; 2.5   ^ 2001: 65; 2.4   ^ 2002: 75; 2.7   ^ 2003: 61; 2.2   ^ 2004: 61; 2.2   ^ 2005: 61; 2.2   ^ 2006: 51; 1.8   ^ 2007: 35; 1.3   ^ 2008: 38; 1.4   ^ 2009: 22; 0.8   ^ 2010: 24; 0.9   ^ Total: 560   ^ ∼ 92% were males
Missouri	2003–2009	439	• Annual number of work-related burn (not further characterized) Hospitalizations for persons age 16 and older   ^ 2003: 74   ^ 2004: 58   ^ 2005: 71   ^ 2006: 84   ^ 2007: 57   ^ 2008: 45   ^ 2009: 50   ^ Total: 439
Nebraska	2008–2009	42	• 2012 occupational health indicators report – hospitalizations for work-related burns (not further characterized); employed persons age 16 and older   ^ 2008: 34   ^ 2009: 8   ^ Total: 42
Nevada	2009 2010 2001	4 6 12	• Annual hospitals report; sentinel events   ^ Burns (not further characterized): 4  • Annual sentinel events summary report   ^ Burns (not further characterized): 6 (1.4%) Annual sentinel events summary report   ^ Burns (not further characterized): 12 (1/1%)
New Hampshire	2000–2007	5874 (ED† discharges) 98 (Inpatient hospital – IH‡ – Discharges)	• Annual number of employees hospitalized for burns (not further characterized)  • 2000   ^ ED: 942   ^ IH: 8  • 2001   ^ ED: 882   ^ IH: 9  • 2002   ^ ED: 863   ^ IH: 16  • 2003   ^ ED: 673   ^ IH: 16  • 2004   ^ ED: 710   ^ IH: 8  • 2005   ^ ED: 595   ^ IH: 9  • 2006   ^ ED: 619   ^ IH: 20  • 2007   ^ ED: 590   ^ IH: 12  • Total   ^ ED: 5,874   ^ IH: 98
New Jersey	2004	5; 7	• Work-related fatalities   ^ 5 (50%) of incidents due to harmful substances or environments were associated with caustic, noxious, or allergenic substances   ^ Burns (not further characterized): 7 (5%) of 129 fatal injuries
New York	1992–1997 1992–2000	6 3%	• Injuries following reported hydrochloric acid events; HSEES   ^ Chemical burns    ▪ Employees: 3    ▪ General public: 2    ▪ Responder: 1    ▪ Total: 6  • Census of fatal occupational injuries; percent distribution of fatal occupational injuries by nature   ^ Burns (not further characterized): 3%
North Carolina	2006 2007 2007 2007 2008	964 996 9433 141 112	• Number and rates per 100,000 population, hospitalizations, unintended injuries   ^ Fire/burn (not further characterized): 964 Cases; Hospitalization rate: 10.9  • Number and rates per 100,000 population, hospitalizations, unintended injuries   ^ Fire/burn (not further characterized): 996 cases; Hospitalization rate: 11.0  • Number and rates per 100,000 population, ED visits, total   ^ Fire/burn (not further characterized): 9,433 cases; ed visit rate: 104.1  • Unintentional injury-related deaths and death rates per 100,000 population   ^ Fire/burn (not further characterized): 141 cases; death rate: 1.6  • Unintentional injury-related deaths and death rates per 100,000 population   ^ Fire/burn (not further characterized): 112 cases; death rate: 1.2
North Dakota	2008 2009–2010 2011	57 120 69	• Trauma data report   ^ Burn (not further characterized): 57 cases; % mortality: 1.754  • Trauma data report   ^ 2009: burn (not further characterized): 51 cases   ^ 2010: burn (not further characterized): 69 cases   ^ Total: burn (not further characterized): 120 cases  • Trauma data report   ^ Burn (not further characterized): 69 cases
Ohio	2013 2002–2005 2004 2006	22 44 27 37	• Child fatality review, 2011 deaths   ^ Fire/burn (not further characterized): 22 cases  • MCH fact sheet, school-aged children, adolescents and young adults, injuries   ^ Age 5–24 years; death by intent; fire/burn (not further characterized): 44 cases  • Child fatality review   ^ Fire/burn (not further characterized): 27 cases (2%)  • Child fatality review   ^ Fire/burn (not further characterized): 37 cases (8%)
Oklahoma	1988–2004 1999–2008 2003–2008	197 49 340	• Summary of reportable injuries; burn and smoke inhalation injuries   ^ Chemical skin injuries: 197 cases (2%)   ^ Fatalities: 3 cases   ^ Case fatality rate: 2%  • Chemical burns; occupational safety and health surveillance program   ^ 463 persons were hospitalized in burn centers and 125 died as a result of work-related burns   ^ Chemical skin injuries: 49 cases (8% of Total Burn Injuries)   ^ 1 fatality from chemical skin injury   ^ Chemical skin injuries were severe and resulted in high numbers of lost work days   ^ 75% of chemical skin injuries involved <10% TBSA; but 2 victims had >20% TBSA and 17% had >/=10 days of hospitalization  • Occupational health indicators; hospitalizations for work-related burns (not further characterized)   ^ 2003: 42 cases; hospitalization rate per 100,000 population: 2.6   ^ 2004: 51 cases; hospitalization rate per 100,000 population: 3.1   ^ 2005: 60 cases; hospitalization rate per 100,000 population: 3.6   ^ 2006: 57 cases; hospitalization rate per 100,000 population: 3.4   ^ 2007: 63 cases; hospitalization rate per 100,000 population: 3.8   ^ 2008: 67 cases; hospitalization rate per 100,000 population: 4.0   ^ Total: 340 cases
Oregon	2005–2007	–	• Top 10 acute chemical releases captured by the Hazardous Substances Emergency Event Surveillance (HSEES) program   ^ Frequency of releases (substances with the potential to cause chemical skin injuries)    ▪ Ammonia: 45 releases (6.3%)    ▪ Sodium hydroxide: 45 releases (6.3%)    ▪ Sulfuric acid: 24 releases (3.4%)    ▪ Hydrochloric acid: 19 releases (2.7%)   ^ Percent of Victims Reporting Symptoms in the Top 10 Chemical Incidents    ▪ Burns: 1%
Utah	1956–2001 1998 2009	– 62 –	• Unintentional injury deaths by cause of injury   ^ Fire and burns (not further characterized): 3%  • Work-Related Burns Surveillance   ^ Total work-related burns: 270   ^ Chemical source: 23% (62 Cases)  • Hazardous Substances Emergency Event Surveillance (HSEES)   ^ Total events: 252   ^ 62 events (24.6%) resulted in 108 symptomatic victims with 8 fatalities   ^ Released substances with the potential to cause chemical skin injuries:    ▪ Sodium hydroxide: 32 events (6.3%)    ▪ Corrosive liquid basic inorganic NOS: 15 events (4.1%)    ▪ Hydrochloric acid: 9 events (2.5%)  • Burn injuries (not further characterized)    ▪ Total: 8 (4.6%)    ▪ Fixed facility: 7 (4.7%)    ▪ Transportation: 1 (4.0%)
Vermont	1990–2000	–	• Unintentional injury deaths   ^ Fire/burn (not further characterized): 5%
Virginia	1994–1997	95, 582	• Childhood injury: A report on injury-related deaths and hospitalization among children and adolescents ages 0––19   ^ Fire and burn (not further characterized) deaths: 95 cases (7%)   ^ Fire and burn (not further characterized) hospitalizations: 582

* NOS: Not Otherwise Specified.

† ED: Emergency Department/Emergency Department Discharges.

‡ IH: Inpatient Hospital Discharges.

As seen in Table 5, data gleaned from US State Health Departments vary widely in scope. In many cases, such data are not specific for etiology of skin injuries, particularly as regards dermal chemical exposures.

No relevant data were found for 22 states (44%). Sixteen US states (32%) had only generic data on fire/burns or burns which were not further characterized, so how many of these cases might have been chemical skin injuries cannot be determined. Twelve US states (24%) did have some specific data on chemical skin injuries, but these varied from state-to-state. These data reveal that homogenous recording and reporting has been lacking. A standardized national recording and reporting system would be highly desirable.

(For Evidence-Based Medicine, this would be Level II-3.)

Other available data

Other available data on the scope of the problem include the following: occupational data collected by government agencies or derived from government sources; data from US burn centers/burn units; published case series.

(For Evidence-Based Medicine, all of these would be Level III.)

Occupational chemical skin injury data collected by government agencies or derived from government sources

In the US, published data are available from the National Institute for Occupational Safety and Health/Consumer Product Safety Council (NIOSH/CPSC) and certain US regions and states including: Colorado, Massachusetts, New England, North Carolina, Ohio, Utah, and Washington (state) (MMWR 1981; Chatterjee et al. 1986; Rossignol et al. 1986, 1989; McCullough et al. 1998; Hunt et al. 2000; Baggs et al. 2002; Utah Department of Health 2003; Colorado Department of Health and Environment 2003).

The US NIOSH/CPSC carried out a surveillance program for occupational injuries treated in hospital emergency departments (MMWR 1981). An estimated 3.3 million occupational injuries were treated in US Emergency Departments in 1981, with 148,500 (approximately 4.5%) estimated to be burn injuries. Burn etiologies were not reported (MMWR 1981).

In Colorado, an average of 24 State residents died from burn injuries yearly during 1980–1998 (Colorado Department of Health and Environment 2003). Approximately, 330 State residents were hospitalized annually for burn injuries, and about half were caused by scalding, contact with hot objects, or caustic substances exposure (Colorado Department of Health and Environment 2003).

In Massachusetts, Rossignol et al (1986) studied the epidemiology of occupational burn injuries. Twenty-nine (3.5%) chemical skin injuries were found out of 825 total burn injuries including 240 occupational burn injuries (Rossignol et al. 1986).

In the US New England region, Rossingnol et al (1989) reviewed data on adult burn patients admitted to 240 acute-care hospitals. From 1978 to 1979, 485 (30%) of these were occupational and there were 91 (19%) chemical skin injuries (Rossignol et al. 1989).

In North Carolina, burn injuries were the fourth most common cause of death, but which were chemical skin injuries was not reported (Hunt et al. 2000). Thirty-four burn injury deaths (15.3%) and 1720 non-death injuries occurred. Of non-fatal injuries, 709 (41.2%) had exposures to alkaline substances (20%), cleaners and solvents (17%), propane (12%), halogens (7%), inorganic and other acids (4%), hydrocarbons (2%), and other chemicals (38%) (Hunt et al. 2000).

In Ohio, among burn-injured patients treated in Emergency Departments, 124 (66%) were caused by exposure to hot substances, corrosive liquids, or steam (Chatterjee et al. 1986).

In Utah during 1997, 699 patients were admitted to hospital for burns of which 133 were occupational and accounted for 60% of all occupational burns in workers aged 25–44 years (Utah Department of Health 2003).

In Washington (state), McCullough et al. (1998) and Baggs et al. (2002) studied occupational burns. Of 27,232 Workers' Compensation claims for work-related burns during 1989–1993, 28.6% were a chemical skin injury (McCullough et al. 1998), which represents about 1558 cases of chemical skin injuries annually. Baggs et al. (2002) studied occupational burns in Washington (state) during 1994–1998. 20,123 Workers' Compensation claims were submitted over this period. While only 1.5% of burned workers were hospitalized, this represented 5% of incurred costs incurred (in excess of $US 5 million). In workers with chemical skin injuries, those in hazardous waste clean-up and the chemical industry were at highest risk (Baggs et al. 2002).

Data from US burn centers/burn units

Data available from burn centers/burn units in Boston, Massachusetts and Iowa City, Iowa in the US permit some estimation of the morbidity of chemical skin injuries and the ratio between severe and mild cases (Leonard et al. 1982; Wibbenmeyer et al. 1999).

In Boston from 1976 to 1980, 857 patients were admitted to a specialized burn center (Leonard et al. 1982). Thirty-five (4%) had skin chemical injuries. Responsible chemicals included a variety of acids (hydrochloric, sulfuric, hydrofluoric, chlorosulfonic, trichloroacetic, and undetermined) (10 cases) and alkaline caustic substances (lye, cement) (9 cases). Chemical exposures were occupational in 51% of cases. In 7 cases (20%) the injuries were due to deliberate chemical assaults. While some patients had relatively immediate copious water flushing, others did not. The delayed water flushing patients had a 5-fold higher incidence of full-thickness injuries. However, even immediate and copious water flushing failed to prevent chemical skin injuries in all cases (Leonard et al. 1982).

In Iowa City, of those patients admitted to a specialized burn center, 94 out of a total 2762 had chemical skin injuries (3.3%) (Wibbenmeyer et al. 1999). Responsible chemicals included anhydrous ammonia (31/94; 34%), acids (14; 15%), alkaline caustic substances (68; 72%), organic chemical agents (6; 6%), and undetermined chemical agents (5; 5%). The majority of these were occupational. One patient died and 36/94 (38%) required skin grafting, some needing multiple such procedures. Noted complications included: wound infections, pneumonitis, cardiac dysrhythmias, and myocardial infarction (overall, 24/94; 25.5%). Sequelae developed in 27/94 (28.7%) of patients. Early and copious water flushing did not prevent some serious chemical skin injuries from developing (Wibbenmeyer et al. 1999).

Published US case series

In a San Diego burn center, from 1977 to 1982 there were 232 cases of all types of occupational burns. Chemical skin injuries were 4% (Inancsi and Guidotti 1987). Of these chemical skin injury patients, one-half were permanently disabled. The median hospital admission was 12 days. The median time from hospital discharge to return to work was 13 days in those not permanently disabled. Chemical skin injuries were not common, but they were often severe (Inancsi and Guidotti 1987).

In an Atlanta burn center, from 1987 to 1990 (approximately 3-½ years), there were 844 admissions. Of these, there were 33 chemical skin injury patients (3.9%) who had a mean TBSA of 9.0% and an overall survival of 90.9% (Renz and Sherman 1992). Three deaths occurred from chemical skin injuries (Renz and Sherman 1992).

Fifty-one patients were studied to evaluate whether immediate water flushing was adequate (Sykes et al. 1986). “Adequate” treatment was defined as immediate dilution or neutralization therapy (Sykes et al. 1986). Most patients were young men with occupational injuries. Of responsible chemicals, the largest numbers were alkalis (sodium and potassium hydroxides), sulfuric acid, gasoline, anhydrous ammonia, white phosphorus, and hydrofluoric acid. Of the fatal cases, 4 out of 5 were work-related. While the group with immediate water flushing usually had a lesser duration of burn center admission and decreased mortality, it did not prevent injuries or a 9.5% mortality (Sykes et al. 1986).

From 2 New York hospitals during 1957–1963, Bromberg et al. (1965) reviewed 273 chemical skin injury patients or about 39 such patients annually. About equally represented were accidental exposures and deliberate assaults with caustic substances. Alkalis (potassium hydroxide, sodium hydroxide) were responsible for 208/237 cases (75%), resulting in more severe injuries than did acids. The head and neck were the most frequently involved body areas. Many patients also had corneal burns. A subset of 95 patients were described in more detail who had either continuous water flushing in a shower, brief water flushing (30–60 min), continuous water soaks, or open treatment. Shower water flushing decreased the time until skin grafting could be done to 22 days, as compared to 26–34 days with the other modalities, and decreased the average length of hospitalization to 19 days as compared to 23–39 days with the other modalities. Skin grafting necessity was 20% less in the group with continuous water flushing (Bromberg et al. 1965).

“Lye” is a liquid metal hydroxide, most often sodium or potassium hydroxide. It is a strong alkali chemical. Wolfort et al (1970) reported on skin injuries in 416 patients treated at two hospitals in Baltimore from 1952 to 1968, or approximately 25 such patients annually. Among these, 42 had lye injuries involving 5–60% of the TBSA, with only 9 resulting from workplace accidents. The majority were deliberate chemical assaults. The mean hospital admission duration was 32 days. The one death that occurred was attributed to an anesthetic accident. Noted complications were tympanic membrane perforations (from liquid lye running into the external auditory canal), parotid fistulas, more potential for formation of keloids than usually seen with thermal burns, and early development of Marjolin's malignant ulcers in injury scars (noted at 3–9 years following lye injuries as opposed to an average of 34 years following thermal burns). In these 2 hospitals, treatment protocols were early water flushing and then 12–24 h of continuous flushing with water in a shower (Wolfort et al. 1970). Despite this, all 42 lye-exposed patients developed chemical skin injuries requiring debridement and skin grafting (Wolfort et al. 1970).

During a 19-year period from 1950 to 1986, Curreri et al (1970) described 111 patients with chemical skin injuries treated at the US Army Institute of Surgical Research. Ninety-six of these patients had white phosphorus chemical skin injuries, 5 were injured with concentrated sulfuric acid, 3 with sulfur mustard, and 4 with other chemicals. Those patients with chemical skin injuries had a longer healing period than seen in patients with burns of other etiologies. However, there was less mortality in the chemical skin injury group versus the group with burns of other etiologies: 5.4% versus 10.5% for burns of all causes (Curreri et al. 1970).

During a 17-year period from 1969 to 1985, Mozingo et al. (1988) described 87 patients with chemical skin injuries treated at the US Army Institute of Surgical Research. The most common chemical responsible was white phosphorus (49 patients). Other responsible chemicals were acids (13 patients), alkalis (10 patients), organic solvents (5 patients), and a variety of other chemicals (15 patients). Other than those with white phosphorus injuries, patients with chemical skin injuries had shorter hospital admissions than other burn patients. Among the 38 such patients, the average TBSA was 29.8% and the average third-degree TBSA injury was 17.8%. Mortality was 26.3%. Among patients not injured by white phosphorus, noted complications were joint contracture (3 cases), pneumonia (2 cases), burn wound infection (2 cases), blindness (2 cases), myocardial infarction (2 cases), phenol toxicity (2 cases), pulmonary embolus (2 cases), brain death (1 case), formate toxicity (1 case), nitrate toxicity (1 case), pancreatitis (1 case), and other (7 cases) (Mozingo et al. 1988).

In a review of data from the US National Burn Repository and the literature, 12 cases of cement (calcium hydroxide) chemical skin injuries were found (Chung et al. 2007). These injuries occurred in men aged 15–64 years. The involved TBSA was 0.25–10%, exposure durations were from 1 to 6 h, delay to evaluation and treatment of 1 day to 2 weeks was noted, and the hospitalization duration ranged from 2-14 days. Six of these cement-exposed patients needed skin grafting. Instances of cement soaked into pants or spilled inside boots were common and workers with occupational exposures were more likely to need skin grafting (Chung et al. 2007).

Discussion

Psychosocial complications

Much of the literature discusses the psychosocial issues afflicting burn patients regardless of etiology, not separating out chemical skin injuries from other causes. Such reported issues have included: anxiety, depression, post-traumatic stress disorder (PTSD), social isolation and withdrawal (said to be on a fear-avoidance basis), a variety of quality of life issues such as difficulties with sexuality and intimacy, a negative impact on perceived body image, difficulties with coping with daily life, sleep disorders, and economic difficulties (Yu and Dimsdale, 1999; Falder et al. 2009; Tagkalakis and Demiri, 2009; De Sousa, 2010; Rimmer et al. 2010; Wisely et al. 2010; Wiechman, 2011; Dahl et al. 2012; Connell et al. 2013; Ghezeljeh et al. 2013).

Given the nature and the extent of chemical skin injuries, psychosocial sequelae may be long-term. These can include severe mental trauma with depression, suicidal ideation, social anxiety and avoidance, social withdrawal, lowered self-esteem, lowered self-concept, and for those with visible disfigurement, appearance-related distress with social anxiety and avoidance, anxiety, and depression, particularly common in those with facial disfigurement (Mannan et al. 2006; Milton et al. 2010).

(For Evidence-Based Medicine, these would be Level II-3.)

Financial cost of chemical skin injuries

Few published data are available on the financial costs of chemical skin injuries. Such published available data are summarized below.

(For evidence-Based Medicine, the following would be Level III.)

Baggs et al. (2002) reviewed work-related burn injuries in Washington (state) during 1994–1998. There were 20,123 Workers' Compensation claims submitted during this time frame. Only 1.5% of burned workers were admitted to hospital, but this represented 5% of the costs incurred which were in excess of 5 million $US. Anderson et al. (2011) showed that in Washington state, 10.3% of all burns were chemical skin injuries among 329 studied patients. Total cost for all studied patients was $US 872,089.00. Medical costs were significantly higher when a co-morbid psychiatric diagnosis was made, and 62 of such patients accounted for 48% of the total cost (Anderson et al. 2011).

In a study from a teaching hospital in North India, among all burn patients (n = 797) total costs were $US 845,237, with an average per patients cost of $US 1,060.50 (Ahuja and Goswami 2013). Mean duration of hospitalization was 7.86 days (range: 1–62 days). Total surgical interventions numbered 299. Chemical skin injuries were not separated from total burn injuries in this article.

A Swiss study examined the epidemiology and costs of work-related burns (de Roche et al. 1994). The authors found that 4.6% of all accidents in Switzerland were burns and that 3% of all work-related accidents were burns. Based on population demographics, these authors estimated that there were approximately 36,000 burn injuries per year with 5% of these requiring hospital admission and one-third of those requiring treatment in a specialized burn center. Of 6,814 burn injuries in 1984, 58% (3,952) were work-related. The total cost for burn care was 17.7 million Swiss Francs (approximately 1.78 million $US at the exchange rate of 1 Swiss Franc = $US 0.99382), with 19% for medical care and the rest for other compensation. These authors did not separate chemical skin injuries from other burn etiologies (de Roche et al. 1994).

Water versus amphoteric solution for skin decontamination

In an Amicus Curie brief submitted to United States Court for the District of Columbia (Case Number 1:13-CV-01177 (RMC)), the international Alcoa Aluminum Company and the United Steel Workers Union cited the data shown in Table 6, noting that Diphoterine^® solution (Laboratoire Prevor, Valmondois, France) was available for immediate skin decontamination at industrial sites other than in the US.

Table 6. First aid rate, serious injury rates in Alcoa locations where Diphotnerine^® is or is not available for emergent decontamination (Data Courtesy of the International Alcoa Aluminum Company and the United Steelworkers Union).

Location	First aid rate	Serious injury rate
Western Australia*	1.95	0.32
Jamaica*	0.16	0.00
Latin America*	0.18	0.02
Europe*	0.25	0.04
Point Comfort, Texas, USA†	5.04	0.70

* Locations where Diphoterine^® solution was available for skin decontamination.

† Location where Diphoterine^® solution was not available for skin decontamination.

In Table 6, note the striking differences between places where Diphoterine^® solution skin decontamination was available and the United States where Diphoterine^® was not available. The use of Diphoterine^® solution at Alcoa facilities outside the US was initially based on an independent study at 3 alumina refinery facilities in Australia by Donoghue (2010) of 180 workers exposed to alkaline chemical substances who were able to decide whether to use water decontamination first (n = 42) or Diphoterine^® solution first (n = 138).

Chemical skin injuries were a median TBSA of 1% (maximum 38%). The duration of alkaline substance skin contact was not different between the water and Diphoterine^® solution decontamination groups (Donoghue 2010). In the Diphoterine^® solution first group, the clinical outcomes were significantly better (p < 0.001) (Table 7) (Donoghue 2010).

Table 7. Data adapted from Donoghue (2010).

Clinical severity	Water first	Diphoterine^® solution first
None	9 (21.4%)	73 (52.9%)
Erythema	23 (54.8%)	54 (39.1%)
Blisters	8 (19%)	10 (7.2%)
More severe	2 (4.8%)	1 (0.7%)
Totals	42 (100%)	138 (100%)

(For Evidence-Based Medicine, this would be Level II-2).

Three recently published studies have addressed the issue of dermal decontamination with Diphoterine^® solution versus water for corrosive chemical exposures in the hospital (burn unit, UK), Emergency Department/Prehospital Care setting (France/Belgium), or industrial clinic/hospital (India) (Zack-Williams et al. 2015; Fortin et al. 2017; Kulkarni and Jeffery 2018).

In a retrospective 2-year study in a UK burn unit comparing delayed Diphoterine^® solution to water flushing, Zack-Williams et al. (2015) found that there was a beneficial significant wound pH change. Similar findings were noted in an Italian normal volunteer study with dermal exposure to 70% glycolic acid (Cavalini et al. 2010).

A multicenter retrospective study from France and Belgium (Fortin et al. 2017) of Emergency Department or Prehospital use of Diphoterine^® solution for early or somewhat delayed flushing of corrosive chemical skin exposures found that there was decreased pain following its application (mostly likely due to active arresting of the chemical skin injury processes) as well as a reduced incidence of sequelae (Fortin et al. 2017).

A prospective study of all chemical skin injuries evaluated and treated at the Ahsirwad Clinic, Boisar, India was performed over a 14-month period from September 16, 2015 to November 21, 2016 (Kulkarni and Jeffery 2018). These authors compared patients with chemical splashes only rinsed with water at the incident site (n = 56) with those who received similar water rinsing followed by decontamination with Diphoterine^® solution at the clinic/hospital (n = 9). The following outcome measures were recorded: injury mechanism, delay to first aid treatment, type of first aid treatment administered, improvement of pain following first aid treatment, site and size of chemical skin injury(ies), lost work time, time to injury healing based on unblinded clinical assessment, time to healing, and costs of chemical skin injury treatment (Kulkarni and Jeffery 2018).

The most commonly involved chemicals were corrosive substances, with sulfuric acid being the most common (42%) (with a 98% concentration involved in approximately one-half of such cases), followed by sodium hydroxide (22%) (Kulkarni and Jeffery 2018). In the water-only group, the average TBSA injury was 5% while the average TBSA injury in the Diphoterine^® solution group was 3%. Body areas involved were most often the hands, wrists, forearms, thighs, and feet with some patients having injuries in multiple areas including the face, shoulders, back, chest, neck, and ankles (Kulkarni and Jeffery 2018).

The water-only group had an average delay to rinsing initiation of approximately 12 min. The Diphoterine^® solution group also received water rinsing at the incident site, followed by Diphoterine^® solution rinsing at the hospital with an average delay of approximately 27 min. These authors were unable to determine the method and length of water rinsing (Kulkarni and Jeffery 2018).

Lost work time was an average of 16.75 days in the water-only group compared to 4.67 in the Diphoterine^® solution group (p = 0.14) (Kulkarni and Jeffery 2018). Unblinded clinically assessed healing time was 13.65 days in the water-only group and 3.24 days in the Diphoterine^® solution group (p = 0.01). Pain assessed with a 0–10 visual analog scoring system before and after water-only irrigation or water followed by Diphoterine^® solution was reduced from 5.7 to 4.1 with water only irrigation and from 7.0 to 3.1 after Diphoterine^® solution irrigation (p = 0.001). Financial costs of treatment were an average of $US 205 in the water-only group and $US 111 in the Diphoterine^® solution group (which included the cost of the rinsing solution) (p = 0.50) (Kulkarni and Jeffery 2018).

(For Evidence-Based Medicine, this would be Level II-1.)

Conclusions

Chemical skin injuries are a significant clinical issue in the US, with data from various available sources suggesting that of all dermal burn injuries, from 2 to 5% and, in some studies or publications a significantly larger percentage, are due to chemical skin injuries.

Chemical skin injuries differ significantly from thermal burns and other burn etiologies in their mechanisms of action. Chemical skin injuries are painful and the pH of water-flushed injuries may remain outside the generally-accepted physiological range (pH 5.5–9.0). Water flushing does not always stop the mechanism of action of chemical agents, especially for strong corrosive substances, allowing the tissue injury process(es) to be continuously ongoing.

While passive water flushing of chemically-splashed skin, as soon as possible after exposure, is a generally recommended first aid measure because it can remove a significant portion of the splashed chemical agent from the skin surface, improved alternative active flushing solutions should be considered as the occupational, medical, psychological, and fiscal repercussions from such chemical skin injuries can be significant.

Declaration of interest

The regular employment affiliation of the authors is shown on the cover page. The authors were compensated by Laboratoire Prevor, either as consultants or employees for preparation of this review. Diphoterine^® solution, developed and marketed by Laboratoire Prevor, is reviewed in this paper. The preparation of the review, conclusions drawn, and the recommendations made are the exclusive professional work product of the authors and may not necessarily be those of the employers or the financial sponsor of the review. None of the authors have participated in regulatory or legal proceeding during the past five years related to the contents of the paper.