- Email: [email protected]
Cutaneous drain opener burns: Report from a tertiary care burns unit
Burns Open 3 (2019) 39–41
Contents lists available at ScienceDirect
Burns Open journal homepage: www.burnsopen.com
Cutaneous drain opener burns: Report from a tertiary care burns unit Abdullah Said Al-Busaidi a, Zainab Said Al-Hashimy b, Karim Haridi c, Musab Sulaiman Al Bulushi b, Ayman Ali Elnahas c, Sheikh Mohammad Ashik Iqbal Faruquee c, Hassan Ahmed Mahmoud c, Falah Khairy Jalud Al Maliki c, Adel Mohammed Hashish c, Aml Eid Saleh c, Fathy Elsaid Shoeib c, Said Saud Al-Busaidi c,⇑ a
College of Medicine & Health Sciences, Sultan Qaboos University, Muscat, Oman Directorate of Pharmacy and Medical Stores, Khoula Hospital, Muscat, Oman c Department of Plastic, Reconstructive and Craniofacial Surgery, Khoula Hospital, Muscat, Oman b
a r t i c l e
i n f o
Article history: Received 5 February 2019 Received in revised form 21 March 2019 Accepted 24 March 2019 Available online 26 March 2019 Keywords: Drain Alkali Acid Burns Chemical
a b s t r a c t Background: Chemical burn injuries are generally industrial, but it can happen at home. Drain opener is one of the common causes of this type of burns. Drain openers are available in powder and liquid forms and contain either sodium hydroxide or sulfuric acid which causes burns when it gets in contact with the skin. This article reviews drain opener burns which presented to a tertiary care burns unit. Methods: A retrospective study of all drain opener chemical burns which presented to Khoula hospital, Muscat, Oman between 01.01.2013 and 31.12.2017. Results: There were 126 cases of drain opener burns (56% of all chemical burns). 80% of the patients were males. The mean age was 29.6 years. 18% of the patients were children. 93% of the patients had 10% or less of total body surface area (TBSA) affected. Upper limb was most commonly involved followed by lower limb and head and neck area. 37.3% of the patients had superficial dermal burns, 29.4% had mixed superficial and deep dermal burns and 33.3% had deep dermal or full thickness burns. There was no systemic poisoning in any of the cases. One of the patients required escharotomy. Two patients required ventilation. 60% of the patients had first aid given at the time of injury. Washing with tap water was the first aid given for all patients. 38% of the patients required surgery. 38% of the patients had hypertrophic scarring, 14% had hyperpigmented scars and 5% developed contracture. There were no mortalities. Conclusion: Drain openers are a common cause of domestic chemical burns in our community. These burns do not usually involve a very large area but can cause significant morbidity. The injury keeps happening despite warning signs on the bottles and the care taken by the users. More awareness needs to be created and clear warning signs must be kept on the bottles in order to reduce this type of injury. Ó 2019 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
1. Introduction There are more than 25,000 chemicals in use for various purposes like industry, agriculture and cleaners [1]. Some of these chemicals are harmful and can cause burns if not handled correctly. Chemical burns may involve skin, eyes, lungs or upper gastrointestinal tract if ingested. Chemical burns are not as common as scald or flame burns [1] but there is variation in the incidence among different countries. In Oman a prospective study found chemical burns constitute around 3.4% of all burn injuries [2]. Similarly a report from Canada showed ⇑ Corresponding author. E-mail address: [email protected] (S.S. Al-Busaidi).
chemical burns constitute 2.6% of total admission to a burn unit [3]. While other reports showed slightly higher incidence for example a report from China showed incidence of 18.64% in a western Zhejiang Province [4]. Chemical burns are mostly occupational injuries in industrial countries [4,5], but in other countries chemical injuries are mostly domestic. Household chemical burn injuries are caused by chemicals used for various purposes at home. Drain opener is one of the common causes of this type of burns. Developed countries have effective prevention programs that help in reducing the incidence of all types of burns, but developing countries are lacking such programs [2] which make the incidence of such injuries higher. Understanding the extent of the problem in developing countries will help in developing preventive measures
https://doi.org/10.1016/j.burnso.2019.03.002 2468-9122/Ó 2019 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
40
A.S. Al-Busaidi et al. / Burns Open 3 (2019) 39–41
Table 1 Total body surface area (TBSA) involved. TBSA (%)
Number of patients
1–10 11–20 >20
117 (93%) 6 (5%) 3 (2%)
that are applicable to these countries. This article reviews drain opener cutaneous burns which presented to a tertiary care hospital in Sultanate of Oman.
no patient required fasciotomy. Two patients required ventilation. 76 (60%) patients had first aid given at the time of injury. Washing with tap water was the first aid given for all patients. 48 (38%) of the patients required surgery. The most common burn sequel was hypertrophic scarring which was reported in 48 (38%) patients. Hyperpigmentation was reported in 18 patients (14%). 6 patients (5%) developed contracture and 4 patients (3%) developed hypopigmented scars. There were no mortalities reported over the study period. Out of the 76 patients who had first aid 23 (30%) required surgery and 24 (32%) developed hypertrophic scarring. 4. Discussion
2. Material and methods Khoula hospital is a tertiary care hospital located in Muscat, the capital of Oman. The hospital burns unit is the central unit of the country. The hospital has a computerized medical record systems (Al-Shifa). A search in the database for the files containing the word ‘‘chemical” was done for the period of 01.01.2013– 31.12.2017. Chemical burn injuries that were seen as an outpatient in the clinic or casualty and as inpatient in the burns unit were included in the study. The analysis included demographic data, total body surface area involved, parts of body involved, first aid given, need for ventilation, need for escharotomy or fasciotomy, systemic poisoning, need for surgery and outcome including scar characteristic. The data were entered in an excel spread sheet and analysed. 3. Results Over the period of the study 224 patients with chemical burns were identified. 126 (56%) cases had injury by drain opener. Patients with drain opener burns were included in this analysis and other burns were excluded. There were 101 males (80%) and 25 females (20%). Age range was 1–86 years (mean: 29.6 years). Children (1–12 years old) were 23 (18%). The majority of patients (117) had 10% or less of total body surface area (TBSA) affected (Table 1). Burn distribution according to the involved body parts: Head and neck area was involved in 40 patients, trunk was involved in 25 patients, upper limb was involved in 74 patients, lower limb was involved in 47 patients, and perineum was involved in 6 patients. Out of the 74 patients with upper limb burns, the hand was involved in 22 patients. Superficial dermal burns were reported in 47 (37.3%) patients, mixed (superficial dermal and deep dermal) burns in 37 (29.4%) patients and deep (deep dermal or full thickness) burns in 42 (33.3%) patients. There was no systemic poisoning reported in any of the cases. One of the patients required escharotomy and
Domestic chemical burns can be accidental injuries, selfinflicted injuries or resulting from an assault. Drain openers are common household chemicals. In this review we found 56% of domestic chemical burns that presented to our hospital are caused by drain opener. This finding is not unusual as higher figure (75%) was reported from Saudi Arabia [6], a neighboring country with similar socioeconomic status. Drain openers are available in powder and liquid forms. Drain openers are either acid based, commonly sulfuric acid or alkali based, commonly sodium hydroxide [7,8]. In either cases when it is mixed with water, the reaction is exothermic where heat is produced [9]. The burns caused by the drain opener can be pure chemical burns or combination of chemical and thermal injury. The skin stains dark when it gets in contact with the chemical [10] which make assessment of the depth of burns very difficult on the first few days [1]. Early debridement using techniques such as hydrosurgery may be helpful in removing the necrotic superficial layer of partial thickness burns and preserving the healthy layer (Fig. 1). Full thickness burns may require tangential excision with knife and may need more than one debridement before skin grafting. Direct contact of the chemical with a body part results in a wide areas of burns but if it is a splash injury, which commonly happen when the chemical is poured in a drain which is completely blocked and filled with water, result in very small areas of burn that are scattered over a large area of the body. These small areas, if deep, are not possible to graft and usually are left to heal by secondary intention. This results in scars that may become hyperpigmented or hypertrophic. Skin type of this study population may also played a role in development of hypertrophic scarring and hyperpigmentation. About 67% of the burns were either superficial dermal or mixed superficial dermal and deep dermal. This could be due to the fact that more than 60% of the patients received first aid at the time of injury. Irrigation with water is the most appropriate first aid
Fig. 1. Dark discolouration of chemical burn with difficult depth assessment.
A.S. Al-Busaidi et al. / Burns Open 3 (2019) 39–41
for chemical burns. Immediate debridement or wet packs were not found to be superior to water irrigation in reducing the chemical injury [11]. When the first aid patients group was analysed, the incidence of hypertrophic scarring and the need for surgery was less. This may indicate that first aid is helpful in reducing the extent of injury and subsequently the need for surgery and development of hypertrophic scarring. The injuries in this study were all accidental. The most common part affected was the upper limb. These findings were seen in other reports [5] of accidental chemical burns. Non accidental chemical burns injuries usually involve the face [12,10]. We found drain opener chemical burns predominantly affect the males. Male predominance was also seen in assault cases [12] and in work related injuries [13]. Children are affected when they play with the chemical if it is kept within their reach. The number of children in our case was small. Similar findings were reported by other studies [14]. Drain opener injury risk can be reduced by adequate and clear warnings on the bottles. Hazards warning on the bottles found to be effective but depend on the warning area, amount of information given and risk level indicators [15]. Other studies showed that even if there was no warning on drain opener, still the majority of people will take simple precautions like using gloves and storing the product away from children [16]. Despite the precautions and people awareness of the risk of chemical burns, still accidental injury can happen. Restriction of availability of certain drain openers, burns prevention programs and creation of more awareness can reduce domestic chemical burns incidence.
5. Conclusion Drain openers are the most common cause of domestic chemical burns in our community. These burns do not usually involve a very large area but can cause significant morbidity. The injury keeps happening despite warning signs on the bottles and the care taken by the users. This type of injury should be taken into account when designing burns prevention programs. Certain regulations should be implemented to reduce the incidence of such injuries.
Ethical consideration Permission was taken from the patients prior to start of study and taking of photographs. The patients were made aware that information and pictures taken were for academic purpose and publication.
41
Conflict of interest None. Funding None. Appendix A. Supplementary data Supplementary data to this article can be found online at https://doi.org/10.1016/j.burnso.2019.03.002. References [1] Palao R, Monge I, Ruiz M, Barret JP. Chemical burns: pathophysiology and treatment. Burns 2010;36:295–304. https://doi.org/10.1016/j. burns.2009.07.009. [2] Al-Shaqsi S, Al-Busaidi S, Al-Kashmiri A, Alaraimi R, Al-Buloushi T. Epidemiology of burn in sultanate of Oman. World J Plast Surg 2016;5(1):2–7. [3] Cartotto RC, Peters WJ, Neligan PC, Douglas LG, Beeston J. Chemical burns. CJS 1996;39(3):205–2011. [4] Ye C, Wang X, Zhang Y, Ni L, Jiang R, Liu L, et al. Ten-year epidemiology of chemical burns in western Zhejiang Province, China. Burns 2016;42:668–74. https://doi.org/10.1016/j.burns.2015.12.004. [5] Koh Dong-Hee, Lee Sang-Gil, Kim Hwan-Cheol. Incidence and characteristics of chemical burns. Burns 2017;43:654–64. https://doi.org/10.1016/j. burns.2016.08.037. [6] Pitkanen J, Al-Qattan MM. Epidemiology of domestic chemical burns in Saudi Arabia. Burns 2001;27:376–8. [7] Bond SJ, Schnier GC, Sundine MJ, Maniscalco SP, Groff DB. Cutaneous burns caused by sulfuric acid drain cleaner. J Trauma 1998;44(3):523–6. [8] Al-Qattan MM, Pitkanen J. Delayed primary excision and grafting of full thickness alkali burns of the hand and forearm. Burns 2001;27:398–400. [9] Dinis-Oliveira RJ, Carvalho F, Moreira R, Proenca JB, Santos A, Duarte JA, et al. Clinical and forensic signs related to chemical burns: a mechanistic approach. Burns 2015;41:658–79. https://doi.org/10.1016/j.burns.2014.09.002. [10] Das KK, Olga L, Peck M, Morselli PG, Salek AJM. Management of acid burns: experience from Bangladesh. Burns 2015;41:484–92. https://doi.org/10.1016/ j.burns.2014.08.003. [11] Tan T, Wong DSY. Chemical burns revisited: What is the most appropriate method of decontamination? Burns 2015;41:761–3. https://doi.org/10.1016/j. burns.2014.10.004. [12] Mannan A, Ghani S, Clarke A, Butler PEM. Cases of chemical assault worldwide: a literature review. Burns 2007;33:149–54. https://doi.org/10.1016/j. burns.2006.05.002. [13] Li Wei, Wu Xiaofeng, Gao Chengjin. Ten-year epidemiological study of chemical burns in Jinshan, Shanghai, PR China. Burns 2013;39:1468–73. https://doi.org/10.1016/j.burns.2013.03.012. [14] D’Cruz R, Pang TCY, Harvey JG, Holland AJA. Chemical burns in children: aetiology and prevention. Burns 2015;41:764–9. https://doi.org/10.1016/j. burns.2014.10.020. [15] Viscusi WK, Magat WA, Huber J. Informational regulation of consumer health risks: an empirical evaluation of hazard warnings. RAND J Econ 1986;17 (3):351–6. [16] Viscusi WK. Toward a proper role for hazard warning in products liability cases. J Prod Liability 1991;13:139–63.
Contents lists available at ScienceDirect
Burns Open journal homepage: www.burnsopen.com
Cutaneous drain opener burns: Report from a tertiary care burns unit Abdullah Said Al-Busaidi a, Zainab Said Al-Hashimy b, Karim Haridi c, Musab Sulaiman Al Bulushi b, Ayman Ali Elnahas c, Sheikh Mohammad Ashik Iqbal Faruquee c, Hassan Ahmed Mahmoud c, Falah Khairy Jalud Al Maliki c, Adel Mohammed Hashish c, Aml Eid Saleh c, Fathy Elsaid Shoeib c, Said Saud Al-Busaidi c,⇑ a
College of Medicine & Health Sciences, Sultan Qaboos University, Muscat, Oman Directorate of Pharmacy and Medical Stores, Khoula Hospital, Muscat, Oman c Department of Plastic, Reconstructive and Craniofacial Surgery, Khoula Hospital, Muscat, Oman b
a r t i c l e
i n f o
Article history: Received 5 February 2019 Received in revised form 21 March 2019 Accepted 24 March 2019 Available online 26 March 2019 Keywords: Drain Alkali Acid Burns Chemical
a b s t r a c t Background: Chemical burn injuries are generally industrial, but it can happen at home. Drain opener is one of the common causes of this type of burns. Drain openers are available in powder and liquid forms and contain either sodium hydroxide or sulfuric acid which causes burns when it gets in contact with the skin. This article reviews drain opener burns which presented to a tertiary care burns unit. Methods: A retrospective study of all drain opener chemical burns which presented to Khoula hospital, Muscat, Oman between 01.01.2013 and 31.12.2017. Results: There were 126 cases of drain opener burns (56% of all chemical burns). 80% of the patients were males. The mean age was 29.6 years. 18% of the patients were children. 93% of the patients had 10% or less of total body surface area (TBSA) affected. Upper limb was most commonly involved followed by lower limb and head and neck area. 37.3% of the patients had superficial dermal burns, 29.4% had mixed superficial and deep dermal burns and 33.3% had deep dermal or full thickness burns. There was no systemic poisoning in any of the cases. One of the patients required escharotomy. Two patients required ventilation. 60% of the patients had first aid given at the time of injury. Washing with tap water was the first aid given for all patients. 38% of the patients required surgery. 38% of the patients had hypertrophic scarring, 14% had hyperpigmented scars and 5% developed contracture. There were no mortalities. Conclusion: Drain openers are a common cause of domestic chemical burns in our community. These burns do not usually involve a very large area but can cause significant morbidity. The injury keeps happening despite warning signs on the bottles and the care taken by the users. More awareness needs to be created and clear warning signs must be kept on the bottles in order to reduce this type of injury. Ó 2019 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
1. Introduction There are more than 25,000 chemicals in use for various purposes like industry, agriculture and cleaners [1]. Some of these chemicals are harmful and can cause burns if not handled correctly. Chemical burns may involve skin, eyes, lungs or upper gastrointestinal tract if ingested. Chemical burns are not as common as scald or flame burns [1] but there is variation in the incidence among different countries. In Oman a prospective study found chemical burns constitute around 3.4% of all burn injuries [2]. Similarly a report from Canada showed ⇑ Corresponding author. E-mail address: [email protected] (S.S. Al-Busaidi).
chemical burns constitute 2.6% of total admission to a burn unit [3]. While other reports showed slightly higher incidence for example a report from China showed incidence of 18.64% in a western Zhejiang Province [4]. Chemical burns are mostly occupational injuries in industrial countries [4,5], but in other countries chemical injuries are mostly domestic. Household chemical burn injuries are caused by chemicals used for various purposes at home. Drain opener is one of the common causes of this type of burns. Developed countries have effective prevention programs that help in reducing the incidence of all types of burns, but developing countries are lacking such programs [2] which make the incidence of such injuries higher. Understanding the extent of the problem in developing countries will help in developing preventive measures
https://doi.org/10.1016/j.burnso.2019.03.002 2468-9122/Ó 2019 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
40
A.S. Al-Busaidi et al. / Burns Open 3 (2019) 39–41
Table 1 Total body surface area (TBSA) involved. TBSA (%)
Number of patients
1–10 11–20 >20
117 (93%) 6 (5%) 3 (2%)
that are applicable to these countries. This article reviews drain opener cutaneous burns which presented to a tertiary care hospital in Sultanate of Oman.
no patient required fasciotomy. Two patients required ventilation. 76 (60%) patients had first aid given at the time of injury. Washing with tap water was the first aid given for all patients. 48 (38%) of the patients required surgery. The most common burn sequel was hypertrophic scarring which was reported in 48 (38%) patients. Hyperpigmentation was reported in 18 patients (14%). 6 patients (5%) developed contracture and 4 patients (3%) developed hypopigmented scars. There were no mortalities reported over the study period. Out of the 76 patients who had first aid 23 (30%) required surgery and 24 (32%) developed hypertrophic scarring. 4. Discussion
2. Material and methods Khoula hospital is a tertiary care hospital located in Muscat, the capital of Oman. The hospital burns unit is the central unit of the country. The hospital has a computerized medical record systems (Al-Shifa). A search in the database for the files containing the word ‘‘chemical” was done for the period of 01.01.2013– 31.12.2017. Chemical burn injuries that were seen as an outpatient in the clinic or casualty and as inpatient in the burns unit were included in the study. The analysis included demographic data, total body surface area involved, parts of body involved, first aid given, need for ventilation, need for escharotomy or fasciotomy, systemic poisoning, need for surgery and outcome including scar characteristic. The data were entered in an excel spread sheet and analysed. 3. Results Over the period of the study 224 patients with chemical burns were identified. 126 (56%) cases had injury by drain opener. Patients with drain opener burns were included in this analysis and other burns were excluded. There were 101 males (80%) and 25 females (20%). Age range was 1–86 years (mean: 29.6 years). Children (1–12 years old) were 23 (18%). The majority of patients (117) had 10% or less of total body surface area (TBSA) affected (Table 1). Burn distribution according to the involved body parts: Head and neck area was involved in 40 patients, trunk was involved in 25 patients, upper limb was involved in 74 patients, lower limb was involved in 47 patients, and perineum was involved in 6 patients. Out of the 74 patients with upper limb burns, the hand was involved in 22 patients. Superficial dermal burns were reported in 47 (37.3%) patients, mixed (superficial dermal and deep dermal) burns in 37 (29.4%) patients and deep (deep dermal or full thickness) burns in 42 (33.3%) patients. There was no systemic poisoning reported in any of the cases. One of the patients required escharotomy and
Domestic chemical burns can be accidental injuries, selfinflicted injuries or resulting from an assault. Drain openers are common household chemicals. In this review we found 56% of domestic chemical burns that presented to our hospital are caused by drain opener. This finding is not unusual as higher figure (75%) was reported from Saudi Arabia [6], a neighboring country with similar socioeconomic status. Drain openers are available in powder and liquid forms. Drain openers are either acid based, commonly sulfuric acid or alkali based, commonly sodium hydroxide [7,8]. In either cases when it is mixed with water, the reaction is exothermic where heat is produced [9]. The burns caused by the drain opener can be pure chemical burns or combination of chemical and thermal injury. The skin stains dark when it gets in contact with the chemical [10] which make assessment of the depth of burns very difficult on the first few days [1]. Early debridement using techniques such as hydrosurgery may be helpful in removing the necrotic superficial layer of partial thickness burns and preserving the healthy layer (Fig. 1). Full thickness burns may require tangential excision with knife and may need more than one debridement before skin grafting. Direct contact of the chemical with a body part results in a wide areas of burns but if it is a splash injury, which commonly happen when the chemical is poured in a drain which is completely blocked and filled with water, result in very small areas of burn that are scattered over a large area of the body. These small areas, if deep, are not possible to graft and usually are left to heal by secondary intention. This results in scars that may become hyperpigmented or hypertrophic. Skin type of this study population may also played a role in development of hypertrophic scarring and hyperpigmentation. About 67% of the burns were either superficial dermal or mixed superficial dermal and deep dermal. This could be due to the fact that more than 60% of the patients received first aid at the time of injury. Irrigation with water is the most appropriate first aid
Fig. 1. Dark discolouration of chemical burn with difficult depth assessment.
A.S. Al-Busaidi et al. / Burns Open 3 (2019) 39–41
for chemical burns. Immediate debridement or wet packs were not found to be superior to water irrigation in reducing the chemical injury [11]. When the first aid patients group was analysed, the incidence of hypertrophic scarring and the need for surgery was less. This may indicate that first aid is helpful in reducing the extent of injury and subsequently the need for surgery and development of hypertrophic scarring. The injuries in this study were all accidental. The most common part affected was the upper limb. These findings were seen in other reports [5] of accidental chemical burns. Non accidental chemical burns injuries usually involve the face [12,10]. We found drain opener chemical burns predominantly affect the males. Male predominance was also seen in assault cases [12] and in work related injuries [13]. Children are affected when they play with the chemical if it is kept within their reach. The number of children in our case was small. Similar findings were reported by other studies [14]. Drain opener injury risk can be reduced by adequate and clear warnings on the bottles. Hazards warning on the bottles found to be effective but depend on the warning area, amount of information given and risk level indicators [15]. Other studies showed that even if there was no warning on drain opener, still the majority of people will take simple precautions like using gloves and storing the product away from children [16]. Despite the precautions and people awareness of the risk of chemical burns, still accidental injury can happen. Restriction of availability of certain drain openers, burns prevention programs and creation of more awareness can reduce domestic chemical burns incidence.
5. Conclusion Drain openers are the most common cause of domestic chemical burns in our community. These burns do not usually involve a very large area but can cause significant morbidity. The injury keeps happening despite warning signs on the bottles and the care taken by the users. This type of injury should be taken into account when designing burns prevention programs. Certain regulations should be implemented to reduce the incidence of such injuries.
Ethical consideration Permission was taken from the patients prior to start of study and taking of photographs. The patients were made aware that information and pictures taken were for academic purpose and publication.
41
Conflict of interest None. Funding None. Appendix A. Supplementary data Supplementary data to this article can be found online at https://doi.org/10.1016/j.burnso.2019.03.002. References [1] Palao R, Monge I, Ruiz M, Barret JP. Chemical burns: pathophysiology and treatment. Burns 2010;36:295–304. https://doi.org/10.1016/j. burns.2009.07.009. [2] Al-Shaqsi S, Al-Busaidi S, Al-Kashmiri A, Alaraimi R, Al-Buloushi T. Epidemiology of burn in sultanate of Oman. World J Plast Surg 2016;5(1):2–7. [3] Cartotto RC, Peters WJ, Neligan PC, Douglas LG, Beeston J. Chemical burns. CJS 1996;39(3):205–2011. [4] Ye C, Wang X, Zhang Y, Ni L, Jiang R, Liu L, et al. Ten-year epidemiology of chemical burns in western Zhejiang Province, China. Burns 2016;42:668–74. https://doi.org/10.1016/j.burns.2015.12.004. [5] Koh Dong-Hee, Lee Sang-Gil, Kim Hwan-Cheol. Incidence and characteristics of chemical burns. Burns 2017;43:654–64. https://doi.org/10.1016/j. burns.2016.08.037. [6] Pitkanen J, Al-Qattan MM. Epidemiology of domestic chemical burns in Saudi Arabia. Burns 2001;27:376–8. [7] Bond SJ, Schnier GC, Sundine MJ, Maniscalco SP, Groff DB. Cutaneous burns caused by sulfuric acid drain cleaner. J Trauma 1998;44(3):523–6. [8] Al-Qattan MM, Pitkanen J. Delayed primary excision and grafting of full thickness alkali burns of the hand and forearm. Burns 2001;27:398–400. [9] Dinis-Oliveira RJ, Carvalho F, Moreira R, Proenca JB, Santos A, Duarte JA, et al. Clinical and forensic signs related to chemical burns: a mechanistic approach. Burns 2015;41:658–79. https://doi.org/10.1016/j.burns.2014.09.002. [10] Das KK, Olga L, Peck M, Morselli PG, Salek AJM. Management of acid burns: experience from Bangladesh. Burns 2015;41:484–92. https://doi.org/10.1016/ j.burns.2014.08.003. [11] Tan T, Wong DSY. Chemical burns revisited: What is the most appropriate method of decontamination? Burns 2015;41:761–3. https://doi.org/10.1016/j. burns.2014.10.004. [12] Mannan A, Ghani S, Clarke A, Butler PEM. Cases of chemical assault worldwide: a literature review. Burns 2007;33:149–54. https://doi.org/10.1016/j. burns.2006.05.002. [13] Li Wei, Wu Xiaofeng, Gao Chengjin. Ten-year epidemiological study of chemical burns in Jinshan, Shanghai, PR China. Burns 2013;39:1468–73. https://doi.org/10.1016/j.burns.2013.03.012. [14] D’Cruz R, Pang TCY, Harvey JG, Holland AJA. Chemical burns in children: aetiology and prevention. Burns 2015;41:764–9. https://doi.org/10.1016/j. burns.2014.10.020. [15] Viscusi WK, Magat WA, Huber J. Informational regulation of consumer health risks: an empirical evaluation of hazard warnings. RAND J Econ 1986;17 (3):351–6. [16] Viscusi WK. Toward a proper role for hazard warning in products liability cases. J Prod Liability 1991;13:139–63.