Floor Stripper Burn

William Abouhassan, MD and Jonathan Bath, MBBS, BSc

Division of Burn Reconstructive Surgery, Johns Hopkins Burn Center, Baltimore, MD

Correspondence: williamaboumd@hotmail.comPublished February 15, 2008

A 34-year-old African American man presents to the emergency department afteraccidentally spilling floor stripper into his left boot. He allowed his foot to remain exposedfor approximately 3 hours. When he arrived home and removed his boot and sock, he noticedthe skin of his forefoot sloughing and found the lesion depicted above.

Physical examination reveals a young healthy appearing man in no acute distress. Thelesion is isolated only to the portion of his body exposed to the “floors stripper.” Figures 1and 2 demonstrate these lesions.

He has no other complaints besides the abnormal appearance of his left foot, which heequates to chemical exposure. The patient has a medical history of type 1 diabetes, renalinsufficiency, and hypertension.

QUESTIONS

1. What is the diagnosis?2. What is the pathophysiology of this condition?3. What are the special circumstances of this lesion affecting treatment?4. How should one treat this injury?5. What are the consequences if this lesion is ignored?

DISCUSSION

Rather, based on the specific history, this is clearly a chemical burn. Although chemical burninjuries are rare (3% of all burns), approximately 30% of burn deaths are due to chemicalinjuries. Fortunately, for the aforementioned patient, the total body surface area exposedis so minimal that it precludes a life-threatening injury; however, because of its location,significant morbidity exists if not treated properly.

All burn wounds, whether chemical or thermal, injure through denaturation of proteins.To best understand the pathophysiology of a chemical injury, one must identify the activeingredient(s). This is readily available in the Materials Safety Data Sheet. Most householdcleaners, specifically floor strippers, are alkaline in nature. Alkalis injure with liquefactivenecrosis, allowing the alkali to penetrate deeper into the injured tissue in contrast to acids,which cause coagulative necrosis and are therefore more readily contained in upper layers

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Figure 1. Dorsum of left foot.

Figure 2. Close-up view of affected foot.

of the skin. Floor stripper is a corrosive agent, in that it denatures tissue protein on contact.These agents also lead to eschar formation with a shallow ulcer, as depicted above.

There are many special circumstances to this injury. Primarily, the morbidity is highbecause of its location. Having affected the extensor surface of the foot, it can lead tosignificant decline in function. Moreover, the skin over this surface is relatively thin andthe agent burns relatively deep; thus, it is likely that a third-degree burn has occurred.Because of the full-thickness loss, wound coverage can be a challenge and will requirespecial techniques. Lastly, with the history of diabetes, if not treated efficiently, cellulitis islikely.

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ABOUHASSAN AND BATH

This lesion will not heal with conservative treatment. This will likely be a deep excision,leaving no healthy dermis behind and exposing tendon, muscle, and possibly bone. Autograftremains the best medium of coverage; however, a matrix must be present for autograft tobe accepted. With no intact dermis, dermal analogues must be considered. Integra is acombination of bovine collagen and glycosaminoglycan chondroitin-6-sulfate in a porousdistribution to allow for vascular ingrowth. Integra is placed on a freshly excised woundwith a silicone layer on its exterior. Two to 3 weeks later, the silicone is removed and thinautograft is placed on the newly vascularized bed. Alloderm is processed isolated dermisfrom cadaveric skin. Placement of a vacuum-assisted dressing over any split-thickness skingraft should be considered. This helps protect against shearing forces and significantlypromotes vascularization.

If left untreated, cellulitis is inevitable. Moreover, loss of the forefoot is possiblebecause of secondary infection of the deep structures. If infection is controlled, but surgeryavoided, contractural deformities of the toes will occur. An extension deformity of the toesat the metatarsophalangeal joint level is common when the burns involve the dorsum of thefoot and ankle. This deformity is largely due to scarring and scar contracture following thedestruction of the skin over the dorsum of the foot.

REFERENCES

Argenta LC, Morykwas MJ, Marks MW, Defranzo AJ, Molnar JA, David LR. Vacuum-assisted closure: state ofclinic art. Plast Reconstr Surg. 2006;117(7 suppl):127S–42.

Hemington-Gorse S, Pellard S, Wilson-Jones N, Potokar T. Foot burns: epidemiology and management. Burns.2007;33(8):1041–5.

Herndon DN. Total Burn Care. 3rd ed. New York: Saunders; 2007:chaps 16, 42, and 59.

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