Journal of Plastic, Reconstructive & Aesthetic Surgery (2010) 63, e358ee363

The Nitric acid burn trauma of the skin*

L. Kolios a,*, E. Striepling b, G. Kolios c, K.-D. Rudolf b, K. Dresing a,
J. Dörges d, K.M. Stürmer a, E.K. Stürmer a

a
Department of Trauma, Plastic and Reconstructive Surgery, Georg-August University of Goettingen,
Robert-Koch-Str. 40, 37075 Goettingen, Germany
b
Department of Hand Surgery, Plastic and Microsurgery, Centre of Burn Injuries, Berufsgenossenschaftliches
Unfallkrankenhaus Hamburg, Germany
c
Plastic, Reconstructive and Aesthetic Surgery, Klinikum Bremen-Mitte, Bremen, Germany
d
Department of Trauma and Handsurgery, Evang. Krankenhaus Weende, Goettingen, Germany

Received 24 June 2009; received in revised form 20 July 2009; accepted 2 September 2009

KEYWORDS Summary Nitric acid burn traumata often occur in the chemical industry. A few publications ad-
Nitric acid; dressing this topic can be found in the medical database, and there are no reports about these
Chemical burn; traumata in children.
Young; A total of 24 patients, average 16.6 years of age, suffering from nitric acid traumata were treated.
Skin; Wound with I burns received open therapy with panthenol-containing creams. Wound of II and
Wound appearance; higher were initially treated by irrigation with sterile isotonic saline solution and then by covering
Treatment with silver-sulphadiazine dressing. Treatment was changed on the second day to fluid-absorbent
foam bandages for superficial wounds (up to IIa depth) and occlusive, antiseptic moist bandages
in combination with enzymatic substances for IIb eIII burns. After the delayed demarcation, ne-
crectomy and mesh-graft transplantation were performed. All wounds healed adequately.
Chemical burn traumata with nitric acid lead to specific yellow- to brown-stained wounds with
slower accumulation of eschar and slower demarcation compared with thermal burns. Remaining
wound eschar induced no systemic inflammation reaction. After demarcation, skin transplantation
can be performed on the wounds, as is commonly done.
The distinguishing feature of nitric-acid-induced chemical burns is the difficulty in differentia-
tion and classification of burn depth. An immediate lavage should be followed by silver sulphadia-
zine treatment. Thereafter, fluid-absorbent foam bandages or occlusive, antiseptic moist
bandages should be used according to the burn depth. Slow demarcation caused a delay in perform-
ing surgical treatments.
ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by
Elsevier Ltd. All rights reserved.

*
The work was presented in part as an oral presentation at the DAV congress (German Association of Burn Injuries) in Leogang, Austria, in
January 2009.
* Corresponding author. Tel.: þ49 551 39 22462; fax: þ49 551 39 8991.
E-mail address: leilakolios@freenet.de (L. Kolios).

1748-6815/$ - see front matter ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjps.2009.09.001
The Nitric Acid Burn Trauma of the Skin e359

Chemical burn traumata associated with nitric acid burns treatment scheme are presented on the basis of a school
often occur in the chemical industry and during hazardous accident involving 24 individuals.
materials’ transportation. The frequency of such accidents is,
on average, 2% of all chemical burns in the UK1 and 88 trau- Patients and methods
mata per year in Germany.2 Only a few cases of nitric acid
burns were related to the accidents occurring in the educa-
A total of 24 patients received nitric-acid injuries during
tional system.1 Though nitric acid burns are severely trau-
a chemistry lesson in secondary school, when a vitreous 5-l
matic, there has been no concurrent and standardised
container fell down and the acid spattered in the class-
conception of its treatment so far.
room. The patients were 18.54 years old on average (pupils
Liquid nitric acid or its vapours injure several organ
16.6 years, teacher 63 years). Nine of them showed nitric-
systems to various degrees, depending on the concentration
acid-induced skin burns.Twenty patients suffered from mild
of the solution. The skin is injured due to protein denatur-
inhalation traumata. All skin lesions were initially irrigated
ation processes if it comes in contact with nitric acid. Due to
with water and then, in the hospital, burns were rinsed with
a xanthoprotein reaction, meaning a nitration of the
sterile isotonic saline solution for at least 15 min until the
benzene ring of aromatic amino acids, direct skin contact
evaluation of the burns.
with nitric acid leads to coagulative tissue damage with
Patients with I burns received open therapy with pan-
characteristic persistent yellow staining of the wound.3,4 A
thenol-containing creams. II burns were dressed with fat
diffusion or penetration into deeper tissue layers, as known
gauze and an occlusive bandage with silver sulphadiazine
for hydrofluoric acid injuries, does not occur with nitric acid
was applied to supply an antimicrobial, dehydration-pro-
burns.5 Skin contact with low concentration of vapours of
tected environment for the wound. All wounds were
nitric acid leads to burning pain, redness and inflamma-
reevaluated daily. On the second post-burn day, for wounds
tion.3,6 II- to III-degree chemical burns with subsequent scar
which showed an increasingly yellow-stained appearance,
development may be expected after direct contact with
the therapy was changed. IIa assumed wounds were
concentrated acid.3 Superficial burns occur after 5 s of
treated with fluid-absorbent foam bandages, which were
contact and full-thickness burns after 30 s.7
easy to remove and did not alter the appearance of the
Disposal of nitric acid can also affect the respiratory
wounds. An open panthenol-containing treatment followed
tract due to exposure to vapours. Typical inhalation
after 10 days of bandage treatment.
traumata with all degrees of severity have been docu-
The deeper wounds (IIb eIII ) showed thick, dry yellow
mented.3,6,8 Ingestion of nitric acid leads to gastrointes-
eschar on the second day and were treated with occlusive,
tinal chemical burns ranging from mucosal irritation to
antiseptic, moist bandages (octenidine with phenoxy-
perforations, depending on the concentration of the acid
ethanol) with several dressing changes per day. Because
and the total contact time.9,10,11 Furthermore, when
these wounds demarcated very slowly and assessment of
ocular contact with nitric acid or its vapours occurs,
the burn depth was difficult, an enzymatic therapy was
ocular damage ranges from severe ulceration and necrosis
added on the sixth post-burn day. Surgical treatment,
of the cornea and lens, from resulting ablepsia to
including necrectomy and mesh-graft transplantation, was
increased lacrimation.3,9 A methemoglobinaemia with
performed on post-burn day 12.
following haemolysis can also occur due to the formation
An analgesic (with paracetamol or NSAR) and fluid-
of nitric gas (NOx).12 In addition, the resulting haemolytic
substituting therapy (Ringer’s-lactate-solution) was applied
products and metabolic acidosis can lead to renal tubular
in accordance with international burn guidelines and stan-
necrosis and acute renal failure.3,12 Nitric acid does not
dards.16 Inhalation, ingestion and ocular traumata, as well as
accumulate in the body as it is rapidly broken down into
renal or haematological pathologies, were documented and,
its constituent ions, which are excreted in the urine.13
when confirmed, treated, but not further evaluated in this
Nitric acid, also known as hydrogen nitrate, is an anor-
study, because they were not the focus of our interest. The
ganic oxygen acid of nitrogen with the molecular formula
primary therapy and the treatment phase during the first 3e4
HNO3. At room temperature, concentrated nitric acid (65%
weeks were demonstrated, even though most patients were
HNO3) is a colourless or yellow to brown liquid with
in an ambulant follow-up care over a 1-year duration.
a pungent odour.8 The etching properties of the compound
result from its acidic characteristics, as well as its oxidising
properties. Nitric acid reacts violently with metals and Results
many organic materials, and these reactions may be
explosive.6 It is used in the production of fertilisers, Nine patients showed skin burns with I eIII depth. A total
explosive and staining substances, and in the metal indus- of 55.5% had IIb eIII wound areas. Mostly burns were
try.9The workplace exposure limit (UK) to nitric acid is splash-like, but some also exhibited a laminar character
4 ppm (10.3 mg me3).14 Depending on the concentration, (Fig. 1). In 66.6% of the patients, less than 5% of the body
the acid mixture is classified in UN Hazard Class 8 and surface was burned. In 11.1%, up to 10% and in 22.2% of the
marked with the EU hazard r-phrase R 35.8 patients up to 15% of the body surface was traumatised
Only a few medical reports addressing the nitric-acid (Table 1). The head and neck areas as well as the upper and
burn trauma, its acute treatment and its follow-up therapy lower extremities were the most affected, depending on
can be found in recent medical literature.7,15 Moreover, clothing that was worn when the burn occurred. In 66.6%,
information about this kind of burn traumata occurring in hands and joints were involved.
children and juveniles is rare. In this study, the clinical Chemical skin burns induced by nitric acid initially
appearance of nitric-acid-induced burn wounds and the showed a bright yellow to brown staining with surrounding
e360 L. Kolios et al.

red and oedematous swelling (Figures. 1e3). Sustained

Table 1 Absolute and percental number of injured
eschars were developed on these wounds rather than blis-
patients, concerning burn depth, affected body surface and
ters. Patients reported pain with a caustic character. On
localisation of the nitric acid induced burn trauma of the
the second day, wounds were intensively stained yellow or
skin.
brown (Figs. 2, 3). In superficial wounds, this staining
remained until the scurf came off on days 10e14. After burn depth patients %
physiological healing, partly depigmented or partly yellow burn depth
or brown hyperpigmented skin remained. With the non- I 9 100
surgical treatment applied, all superficial (I eIIa ) wounds II a 9 100
healed adequately within 14 days. II b 4 44.4
Deeper chemical wounds were difficult to evaluate due III 1 11.1
to staining and slow demarcation. No systemic reactions or
inflammatory symptoms were observed with the outlined % affected body surface
therapy. Thus, it was possible to observe these wounds for <5 6 66.6
a longer time than typical burn wounds. Antibiotic therapy < 10 1 11.1
was not necessary. After the initial increase in staining, < 15 2 22.2
these wounds received enzymatic therapy that provided localisation
a stable situation and demarcation on days 10e12 (Fig. 3). head/neck 7 77.7
Thereafter, surgical therapy including necretomy and torso 2 22.2
mesh-graft transplantation was carried out and the wounds upper extremity 7 77.7
healed adequately within 10 days (Fig. 3). In retrospect, hand 1 11.1
especially in the splash-formed wounds, IIb areas were lower extremity 6 66.6
difficult to distinguish; therefore, they did not receive knee 2 22.2
a surgical therapy. They healed but with scar tissue ancle joint 3 33.3
formation (Fig. 2) and subjects reported stabbing pain.

Discussion in the knowledge. On the basis of the presented 24 patients,

Nitric acid is a widely used chemical in various sectors of
industry,7 where accidents occur consistently.1,2 No specific
information about the emergency management or further
therapies of nitric acid burn traumata were available in the
medical databases. Only publications about common chem-
ical burns can be found and the therapeutic approaches are
geared to the guidelines and standards of burn care and
common toxicology.1,7,9 Assessment of burn depth is often
difficult and the decision whether to excise the wound is not
always clear.1 On the basis of a single school accident
involving an accidental spill of nitric acid, we examined the
treatment of nitric-acid burn traumata to help close this gap
which is a comparably high number of acutely injured
patients, we were able to study and analyse the morphology
of the nitric-acid burn trauma in detail.
Skin contact with liquid nitric acid leads to specific,
intensive yellow- to brown-stained wounds with the
building of an eschar. This appearance makes the evalua-
tion of the wounds, including determination of burn depth
and necessity of surgical treatment, difficult as compared
with classical burn wounds. Even in a retrospective view, no
typical marks could be identified, which facilitate the
evaluation of the nitric acid wounds.
In summary, the treatment regime that we proposed
began with intensive lavage of the injured areas to dilute

Figure 1 Different forms of appearance of nitric acid induced skin lesions 1 hour after trauma. a: superficial, brown-stained
lesions of the face. b: II splash-formed chemical burn of the shoulder. c: IIb-III laminar chemical burn of the lower leg.
The Nitric Acid Burn Trauma of the Skin e361

Figure 2 Appearance of IIa-b chemical burn on day 1 with relatively pale staining, on day 2 with intensified yellow-brown
staining and partly existence of eschars and completely but partly scarred healing on day 22.

the acid. This is essential for the further development of

the wounds since the extent of the chemical burn depends
on the concentration of the acid solution and the contact
time of the substance with the skin.4,9
Therapy with silver sulphadiazine protects against
dehydration and provides an antimicrobial effect against
a broad spectrum of bacteria, including Gram-negative
species and Candida albicans.16 For the initial treatment of
nitric-acid-induced wounds, this treatment is fast, safe and
soothing, due to the cooling effect of silver sulphadiazine.
However, these effects could also be reached by other
external cream applications (e.g., Lavasept gel), which
have the advantage of allowing a better wound evaluation.
Therefore, we recommended foam bandages (Mepilex)
for the chemical wounds of IIa depth, which were fluid
absorbent and achieved proper wound conditions, without
influencing the appearance of the wounds for the further
treatment from day 2e6. They were easy to remove, and
the wounds could be re-evaluated daily without problems.
This treatment promoted a physiological healing process.
The occlusive, antiseptic, moist bandages (octenidine with
phenoxyethanol, Octenisept) for deeper (IIb eIII ) wounds
were chosen because of the thick eschar that appeared on
the wound. Several dressing changes a day allowed a better
monitoring of wound healing.
Definitive classification of the burn depth was difficult,
because of the intensive staining of the burn areas and the
capillary refill test, which allows the differentiation of IIb
from III depth in classical burn wounds, was not appli-
cable. Examination of the wound pain could not be clearly
defined due to the juvenile age of the patients. In addition,
the demarcation of the wounds took a longer time (up to
10e12 days) than with ordinary burn lesions. To facilitate
wound demarcation, we added a therapy with enzymatic
substances (Iruxol) from the sixth post-burn day onwards Figure 3 Deep dermal and partly III burns 1 hour after
till a further 6 days until surgical therapy of wounds with trauma with intensified yellow staining on the second day and
IIb and IIIa depth was carried out. Such a long observation beginning demarcation from the 6th day under enzymatic
was possible because the wounds remained stable without therapy. The healing situation on day 26, 10 days after mesh-
signs of inflammation. Notably, there were no systemic graft transplantation.
e362
reactions (increasing C-reactive protein, leucocytosis,
bradycardia or fever) observed, which usually occurr if
systemic inflammation takes place as a result of delayed
necrectomy of the burn wounds. All wounds healed
adequately with the regimen we chose. In retrospect, the
enzymatic and also the surgical therapy could have been
done two days earlier. A definite demarcation was not
necessary because extension of the chemical burn in
deeper layers did not occur and a stable wound situation
has been reached 4e6 days after surgery.
To overcome the difficulties in the differentiation of IIa
from IIb wounds, it was helpful to await the demarcation
process and to delay surgical therapy. In three patients,
smaller splash-formed areas healed as a scar built up
above, which signaled IIb wound depth. In the initial phase
of treatment, these burns were difficult to recognise and
they did not receive surgical therapy. The wounds were
healed and the patients did not want further therapies.
Clinical experience with nitric-acid-induced wounds is
rare. The indication of modern, permanent, remaining
wound-covering methods (e.g., Biobrane and Suprathel)
cannot be recommended. They do not allow an accurate
examination of the wounds and due to the difficulties in
determining the differentiation of the burn depth, the
necessity of surgical intervention cannot be determined
when using these dressings.
The nitric-acid-induced wound areas with advance heal-
ing can be treated similar to normal burn wounds with pan-
thenol-containing externa, sun protection and, if necessary,
with silicone products to reduce the extent of scars.
When an accident with nitric acid occurs, all other
possibly affected organ systems must be examined.
Pulmonary emergency diagnostics and therapy are impor-
tant: monitoring of peripheral oxygenation, thoracic X-
rays, oxygen donation and periodical steroid application.17
Inoculation traumata are to be rinsed out extensively,
decontaminated with diphoterines/chelates and treated
with panthenol-containing gel after ophthalmologic
consultation.18 In the case of oral ingestion, regurgitation is
contraindicated to avoid another contact of the acid with
the oesophageal mucosa. Application of any liquid for
dilution and of proton pump inhibitors to prevent inflam-
mation and strictures is necessary, as is a gastro-
duodenoscopy.11,19e21 To reduct Met-Hb in case of
a methemoglobinaemia, application of toluidine-blue,
methylene-blue, thionine or ascorbic acid is recom-
mended.9,22 A renal affection requires forced diuresis, if
necessary supported by mannitol and bicarbonate.12
The presented 24 patients were monitored regarding
symptoms of nitric acid inhalation and ingestion and e in
case of symptoms e they received an adequate therapy.
Finally, none suffered from complications.
Chemical burn traumata from nitric acid occur through
xanthoprotein reaction that produces characteristic
yellow- to brown-stained wounds with building of eschars.
Due to the appearance of the wound, the differentiation of
burn depth is difficult. Treatment should be done using
conventional wound covering methods that allow safe and
daily re-evaluation of the wound, rather than using
modern, permanent, remaining wound bandages. Chemical
burns with nitric acid demarcate more slowly than thermal
burns. A remaining wound eschar induces no systemic
L. Kolios et al.
inflammation reaction, as compared with thermal burn
wounds. After demarcation, wounds can be skin-trans-
planted in the common fashion.
Acknowledgements
Thanks are due to the medical personnel of all participating
clinics and departments for their help in the treatment of
the patients.
Conflict of interest
We declare that we have no proprietary, financial,
professional or other personal interest of any nature or
kind in any product, service and/or company that could be
construed as influencing the position presented in, or the
review of, the article titled, ‘The Nitric Acid Burn Trauma
of the Skin’.
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