burns 43 (2017) 654 –664

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Incidence and characteristics of chemical burns

Dong-Hee Koh a , Sang-Gil Lee b , Hwan-Cheol Kim c, *

a
Department of Occupational Environmental Medicine, International St. Mary’s Hospital, Catholic Kwandong
University, Incheon, South Korea
b
Occupational Safety and Health Research Institute, Korea Occupational Safety and Health Agency, Ulsan, South Korea
c
Department of Occupational and Environmental Medicine, Inha University School of Medicine, 100 Inharo, Nam-gu,
Incheon, South Korea

article info abstract

Article history: Objectives: Chemical burns can lead to serious health outcomes. Previous studies about
Accepted 31 August 2016 chemical burns have been performed based on burn center data so these studies have
provided limited information about the incidence of chemical burns at the national level. The
aim of this study was to evaluate the incidence and characteristics of chemical burns using
nationwide databases.
Keywords: Methods: A cohort representing the Korean population, which was established using a
Chemical burns national health insurance database, and a nationwide workers’ compensation database were
Burns used to evaluate the incidence and characteristics of chemical burns. Characteristics of the
Corrosion affected body region, depth of burns, industry, task, and causative agents were analyzed
from two databases. The incidence of chemical burns was calculated according to
employment status.
Results: The most common regions involving chemical burns with hospital visits were the
skin followed by the eyes. For skin lesions, the hands and wrists were the most commonly
affected regions. Second degree burns were the most common in terms of depth of skin
lesions. The hospital visit incidence was 1.96 per 10,000 person-year in the general
population. The compensated chemical burns incidence was 0.17 per 10,000 person-year.
Employees and the self-employed showed a significantly increased risk of chemical burns
undergoing hospital visits compared to their dependents.
Conclusion: Chemical burns on the skin and eyes are almost equally prevalent. The working
environment was associated with increased risk of chemical burns. Our results may aid in
estimating the size of the problem and prioritizing prevention of chemical burns.
ã 2016 Elsevier Ltd and ISBI. All rights reserved.

to serious health outcomes, including skin burns benefiting

1. Introduction
Burns are one of the most common occupational injuries.
Burns can be caused by heat, electricity, or chemical exposure.
Chemical burns are reported to comprise 1.4–8.5% of all
admission cases due to burns [1]. Chemical burns can lead
from skin grafts. For example, severe hydrofluoric acid burns
can lead to skin burns as well as life-threatening hypocalce-
mia, which can eventually lead to death. Chemical burns on
the eyes can also lead to permanent damage in visual function
[2]. Inhalation or ingestion of caustic agents can cause severe
complications in internal organs such as the esophagus and

* Corresponding author.
E-mail address: carpediem@inha.ac.kr (H.-C. Kim).
http://dx.doi.org/10.1016/j.burns.2016.08.037
0305-4179/ã 2016 Elsevier Ltd and ISBI. All rights reserved.

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 burns 43 (2017) 654 –664
lungs, even leading to death. Even in milder cases, reactive
airway dysfunction syndrome (RADS) can also occur after
inhalation of acid or alkali [3].
The causative agents of chemical burns may vary
according to geographical location, population structure,
and industrial structure. Acids and alkalis are the most
common types of causative agents involved in chemical
burns. For acids, sulfuric acid, hydrochloric acid and hydro-
fluoric acid are representative agents, and for alkalis, sodium
hydroxide and potassium hydroxide are representative
agents. Both acid and alkali agents can cause immediate
skin burns when one is exposed. Acids and alkalis are
extensively used in electroplating and semiconductor
manufacturing industries. These are also widely used in
various industries including wastewater treatment facilities,
laboratories and restaurants. Solvents also can cause skin
burns. For example, contact with dichlormethane does not
cause burns immediately but when the contact is prolonged
(e.g., a worker wears a glove with a pin-hole and does not
recognize it for several hours) it causes skin burns [4]. Other
chemicals such as white phosphorus used for ammunition
production can also cause chemical burns [5]. The various
causative agents and affected body parts extracted from the
literature are listed in Supplementary Table 1.
Chemical burns can occur in occupational settings, domes-
tic non-intentional injury and criminal assault, but occupa-
tional settings are reported to comprise up to 67.8% of all
chemical burns admissions [6]. Chemical burns often lead to
serious health problems and disabilities. To prevent chemical
burns, epidemiological studies regarding the incidence and
characteristics are necessary as a priority. Many studies
examined characteristics of chemical burn in terms of
demographics of patients, causative agents, depth of burn,
and total burn surface area (TBSA). However, these studies
were mainly conducted by reviewing records of patients
admitted in burn centers [7]. These burn center-based studies
provided detailed information on chemical burns but because
these studies were based on severe cases with admission to
hospitals, it has been impossible to estimate the overall
incidence including minor chemical burns which did not
undergo admission. According to Heinrich’s rule, for every one
major injury in the workplace, 29 are minor injuries and 300
cause no injuries [8]. Aforementioned studies have limitations
to estimate the overall size of chemical burns, and in addition,
these studies could only provide the incidence in regions
where hospitals were located.
In the present study, we aimed to estimate the chemical
burn incidence in the general Korean population using
representative, nationwide databases. In addition, we in-
tended to examine characteristics of chemical burns, which
would aid efforts to prevent chemical burns.
2. Methods
2.1. Data source for the general population
Korea has a single insurer system which is operated by the
National Health Insurance Service (NHIS). The NHIS covers all
citizens, except for 3% of the population under the Medical Aid
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655
Program (MAP) [9]. NHIS has collected claim data, including
eligibility data and medical treatment records. Recently, the
NHIS publicly released the National Health Insurance Service-
National Sample Cohort (NHIS-NSC) database. The NHIS-NSC
consisted of one million Koreans (2% of the population)
sampled from the entire population in 2002 using a complex
multistage sampling method [10]. The eligibility status of the
one million Koreans, medical treatment records, and periodic
health checkups records were all followed until 2013 and were
integrated into the NHIS-NSC database. We used this NHIS-
NSC database to elucidate the incidence and characteristics of
chemical burns.
We restricted the study period from 2009 to 2013. The
reason in this regard was that the medical treatment records of
the people under the MAP were incomplete before 2008 in the
NHIS-NSC. We used 2008 data for detecting non-incident
cases, thus, we excluded chemical burn subjects who visited
the hospitals for out- or in-patient care both in 2008 and 2009,
consecutively. We further restricted age groups to between 20
and 60 years of age because we aimed to examine chemical
burns in the working age population.
Chemical burns cases were operationally defined using
the Korean Classification of Diseases (KCD) code which was
based on the 10th revision of the Internation Classification of
Diseases (ICD-10). The three-digit ICD codes for chemical
burns are listed in Table 2. Chemical burns were categorized
by the body part of the burns, the depth of the burns, and the
extent of the burns (TBSA). The body parts afflicted by the
chemical burns were simply categorized into skin, eye (T26),
and internal organs (respiratory (T27) and gastrointestinal
tract (T28)). Skin chemical burns were sub-categorized into
five regions in terms of affected region: head & neck (T20),
shoulder & trunk (T21), upper extremities (T22), hand & wrist
(T23), lower extremities (T24), and foot &ankle (T25). For
classifying the depth of chemical burns on the skin (T20-T25,
T29, T30), the 4th digit of the ICD was used: 4, 5, 6, 7 represent
unspecific, first, second, and third degree burns, respective-
ly. Only a few cases were recorded using the extent of
chemical burns (T32 code). If a patient visited a hospital
between 2009 and 2013 and the conditions were coded as one
of the chemical burns, the patients were regarded to have
had a chemical burn.
In the NHIS system, insured persons are divided into
‘employee insured’ and ‘self-employed insured’ [11]. The self-
employed insured is a category other than the employed
insured and its dependents include self-employed persons,
farmers and fishermen. We further divided the insured
category into three groups in terms of job status: employee
(employee insured policyholder), self-employed (self-em-
ployed policyholder), and dependents (dependents of employ-
ee insurance policyholders or self-employed insurance
policyholders, or people under the MAP).
2.2. Workers’ compensation data
Korea has a single workers’ compensation insurance system
which is operated by the Korea Workers’ Compensation &
Welfare Service (COMWEL) [12]. It covers all workplaces with
one or more workers. An average of 1.7 million companies
and 14.7 million workers between 2009 and 2013 were
656 burns 43 (2017) 654 –664
covered by the workers’ compensation system [13]. If a
worker is treated through this workers’ compensation
system, his or her claim will not be presented in the NHIS
database, thus the NHIS and workers’ compensation data-
base are mutually exclusive.
We obtained nationwide data of chemical burns that were
compensated for, for the years 2009–2013 from the workers’
compensation database. The data consisted of information
about the age and gender of injured workers, affected body
region and depth of burns (free-text), industry type and size of
the companies, and a brief history of the incidents (free-text).
Information about the causative agents and tasks done by the
injured workers were extracted from the brief history of the
incidents by an occupational medicine specialist (DHK). The
affected body regions and depths of burns were also extracted
and coded according to the ICD-10 scheme, but some of body
regions or depths of burns overlapped. For this reason, some
cases were coded ‘Head & upper extremities’ for affected body
region and ‘Second to third degree’ for depth of burns as shown
in Table 2.
2.3. Statistical analysis
We evaluated the distributions of the age, year of injury,
affected body region, and depth of skin burns by gender,
using the NHIS-NSC. Also, we estimated the hospital visit
incidence and 95% confidence intervals (CIs), according to
the body part and insurance type by gender. CIs of the
incidences were calculated, using the ‘epitools’ package of
statistical software R [14]. We assumed the chemical burn
occurrences follow Poisson distributions, which is the
conventional probability model for non-contagious diseases
[15]. We calculated the relative risks (RRs) of the hospital
visits, according to the insurance type, adjusting for age and
gender using the NHIS-NSC. Poisson regression models were
employed when calculating RRs and CIs. To do so, case and
person-year were collated in tables by age group in 5-year
intervals, gender, and insurance type. In the Poisson
regression models, the number of cases was incorporated
as a dependent variable, while age group, gender, and
insurance type were incorporated as categorical variables,
and log-transformed person-year was incorporated as an
offset. A diagnostic test of the models was performed, and as
a result, no significant violation of assumptions was found in
the residual analyses [16].
In addition, we evaluated the distributions of the age,
year of injury, affected body region, and depth of skin
burns by gender using the workers’ compensation data. We
also estimated incidence and 95% CIs of compensated
chemical burns. To evaluate the characteristics of the
compensated chemical burns, we further examined the
distributions of industry type, task, and size of company by
gender, and causative agents by body part (skin, eye, and
internal organs).
2.4. Ethics
This study protocol was reviewed and approved by the
Institutional Review Board of Inha University Hospital (IN-
HAUH 2016-01-011).
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3. Results
A total of 605 patients aged 20–59 years old in the NHIS-NSC
cohort visited hospitals for chemical burns between 2009 and
2013 period (Table 1). In terms of age at hospital visit, 30–39 for
males and 50–59 for females were the most frequent age
categories. However, no significant difference was observed
between age categories both in men and women. As for year of
injury, the largest number of patients visited hospitals in 2013.
Especially in males, a significant difference was observed
within the year of injury (p=0.01). The eye (50.16%) was the
most commonly affected body part for males, while the skin
(53.45%) was the most commonly affected body part for
females. For skin lesions, the hands and wrists were the most
common body region both in males and females. In terms of
depth of the burns, second degree burns were the most
common type, then followed by first and third degrees.
However, 27.7% of all cases did not report the specific depth
of the burns.
Meanwhile, for the workers’ compensation data, 1237
patients aged 18–80 years old were treated for chemical burns
between 2009 and 2013 (Table 1). In terms of age of chemical
burn, 30–39 for males and 40–49 for females were the most
frequent age categories. Significant differences in age catego-
ries were observed both in men (p<0.01) and women (p<0.01).
As for the year of injury, the largest number of patients visited
hospitals in 2012. No significant difference in the year of injury
was observed either in males or females. The skin was the
most commonly affected body part for both males (78.84%) and
females (68.75%). For skin lesions, the hands and wrists were
the most common body region for males, while the shoulders
and upper extremities were the most common body regions for
females. In terms of depth of the burns, second degree burns
were the most common type, followed by third and first degree
burns. However, 25.77% of all cases did not report any specific
depth of burns.
Overall hospital visit incidence of chemical burns in the
NHIS-NSC cohort was 1.96 per 10,000 person-years (95%CI:
1.80–2.12) (Table 2). The person-year for males and females in
the NHIS-NSC cohort was 1,574,601 and 1,517,063 person-
years, respectively. The incidences between both genders
were not significantly different. Skin lesions yielded the
highest incidence of chemical burns for females, but the eyes
showed the highest incidence for males. As for insurance type,
employee and self-employee showed greater incidences than
dependents.
Meanwhile, for the workers’ compensation data, the
compensated chemical burn incidence was 0.17 per 10,000
person-years (95%CI: 0.16–0.18) (Table 2). Person-years were
replaced with the number of workers (73,443,698) covered by
the workers’ compensation system between 2009 and 2013,
irrespective of age. The skin showed the highest incidence
among all body parts. Due to the lack of the number of workers
covered by worker’s compensation by gender, gender-specific
incidence could not be calculated.
Age- and gender-adjusted incidence rate ratios (RRs) by
insurance type in the NHIS-NSC cohort are shown in Table 3.
For men, only employee insured showed a significantly
increased RR (1.40, 95%CI: 1.04–1.87) compared to dependents,
 Table 1 – General characteristics of chemical burns in the National Health Insurance Service-National Sample Cohort (NHIS-NSC) and workers’ compensation data.
Characteristics NHIS-NSC (2009–2013) Workers’ compensation (2009–2013)
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Male Female Total Male Female Total

N % N % N % N % N % N %
Gender 315 290 605 965 272 1237

Age 15–19 – – – – – – 5 0.52 1 0.37 6 0.49

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20–29 65 20.64 68 23.44 133 21.98 159 16.48 45 16.54 204 16.49
30–39 101 32.06 66 22.76 167 27.61 276 28.60 40 14.71 316 25.55
40–49 78 24.76 69 23.79 147 24.30 251 26.01 82 30.15 333 26.92
50–59 71 22.54 87 30.00 158 26.12 201 20.83 80 29.41 281 22.72
60–69 – – – – – – 69 7.15 20 7.35 89 7.19
70–79 – – – – – – 3 0.31 4 1.47 7 0.57
80–89 – – – – – – 1 0.10 0 0.00 1 0.08

burns 43 (2017) 654 –664

Year 2009 48 15.24 60 20.69 108 17.85 168 17.41 64 23.53 232 18.76
2010 57 18.10 52 17.93 109 18.02 200 20.73 53 19.49 253 20.45
2011 67 21.27 65 22.41 132 21.82 176 18.24 47 17.28 223 18.03
2012 58 18.41 54 18.62 112 18.51 215 22.28 57 20.96 272 21.99
2013 85 26.98 59 20.34 144 23.80 206 21.35 51 18.75 257 20.78

Region (ICD-code) Head and neck (T20) 20 6.35 14 4.83 34 5.62 105 10.88 23 8.46 128 10.35
Trunk (T21) 6 1.90 10 3.45 16 2.64 20 2.07 7 2.57 27 2.18
Shoulder and upper extremities (T22) 12 3.81 33 11.38 45 7.44 80 8.29 52 19.12 132 10.67
Wrist and hand (T23) 32 10.16 40 13.79 72 11.9 183 18.96 37 13.60 220 17.78
Hip and lower limb (T24) 27 8.57 28 9.66 55 9.09 125 12.95 28 10.29 153 12.37
Ankle and foot (T25) 17 5.40 11 3.79 28 4.63 57 5.91 18 6.62 75 6.06
Multiple body regions (T29) 12 3.81 4 1.38 16 2.64 117 12.12 15 5.51 132 10.67
Body region unspecified (T30) 16 5.08 14 4.83 30 4.96 9 0.93 0 0.00 9 0.73
Classified according to extent of body surface involved (T32) 0 0 1 0.34 1 0.17 – – – – – –
Head and upper extremities – – – – – – 36 3.73 4 1.47 40 3.23
Hand and upper extremities – – – – – – 6 0.62 1 0.37 7 0.57
Foot and lower extremities – – – – – – 23 2.38 2 0.74 25 2.02
Confined to eye and adnexa (T26) 158 50.16 122 42.07 280 46.28 174 18.03 68 25.00 242 19.56
Respiratory tract (T27) 1 0.32 2 0.69 3 0.50 17 1.76 2 0.74 19 1.54
Gastrointestinal tract (T28) 14 4.44 11 3.79 25 4.13 11 1.14 15 5.51 26 2.10

Depth of skin burns First degree 12 8.45 14 9.09 26 8.78 6 0.79 6 3.21 12 1.27
Second degree 79 55.63 87 56.49 166 56.08 332 43.68 96 51.34 428 45.20
Second to third degree – – – – – – 60 7.89 15 8.02 75 7.92
Third degree 11 7.75 11 7.14 22 7.43 152 20.00 36 19.25 188 19.85
Not reported 40 28.17 42 27.27 82 27.7 210 27.63 34 18.18 244 25.77

657
658 burns 43 (2017) 654 –664

Table 2 – Incidence (number of cases per 10,000 person-year) of chemical burns in the National Health Insurance Service-National Sample Cohort (NHIS-NSC) and workers’

<0.01–0.01
while in women, both self-employed insured (1.56, 95%CI: 1.09–

95% CI
0.85–1.08
0.80–1.02
0.06–0.13

1.62–2.41
2.06–2.61
1.42–1.85

1.80–2.12

0.12–0.14
0.03–0.04

0.16–0.18
2.23), and employee insured (1.52, 95%CI: 1.18–1.96) showed
significantly increased RRs compared to dependents.
As for workers’ compensation data, ‘Manufacture of
chemicals and chemical products’, ‘Plating and anodizing of
Incidence
Total

metals’, and ‘General construction’ were common industry

0.96
0.91
0.09

1.99
2.32
1.63

1.96

0.13
0.03
0.01

0.17
categories for males, while, for females, ‘Food and beverage,
personal service activities and business support service’ and
the ‘Education’ industry category dominated (Table 4). In
terms of tasks, ‘Manufacturing process, unspecified’, ‘Mainte-
Case

1237
nance and repair of industrial facility’, and ‘Plating’ were
297
280

104
278
223

605

947
245
28

45
common tasks involved with compensated chemical burns for
males, while, for females, ‘Restaurant and cafeteria worker’
dominated, followed by ‘Laboratory’ tasks (Table 4) were
0.87–1.20
0.67–0.96
0.05–0.15

1.75–3.36
1.91–2.82
1.35–1.89

1.70–2.14
95% CI

common. As for the size of the company, companies hiring less

than five workers showed the largest portion for males (28%),
–
–
–

– while for females, companies hiring 16–29 workers showed the

largest portion (23%) (Table 4).
Female

Incidence

In the workers’ compensation data, ‘Cleaning agent,

1.02
0.80
0.09

2.46
2.33
1.60

1.91

unspecified’, ‘Sulfuric acid’, and ‘Chemical, unspecified’ were

–
–
–

common causative agents for skin chemical burns, while, for

eye burns, ‘Sodium hydroxide’ and ‘Cleaning agent, unspeci-
fied’ were common causative agents (Table 5). As for internal
Case
155
122

106
145

290

187

272

organs (respiratory and gastrointestinal tracts) burns, ‘Clean-

13

39

68
17

ing agent, unspecified’ was the most common causative agent

(Table 5).
0.76–1.06
0.85–1.17
0.05–0.16

1.38–2.27
1.98–2.69
1.32–2.09

1.79–2.23
95% CI

4. Discussion
–
–
–

–
Incidence

Most previous studies about the incidences of chemical burns

Male

0.90
1.00
0.10

1.78
2.31
1.67

2.00

in Korea have been conducted based on the experiences at

–
–
–

burn centers in hospitals, thus these studies only provided in-

patient incidence around areas in which the hospitals were
located. In the present study, we attempted to overcome the
Internal organs, respiratory and gastrointestinal tracts; CI, confidence interval.
Case

shortcomings by analyzing a nationally representative health

142
158

172

315

760
177

965
15

65

78

28

insurance claim database which included in-and out-patient

claim records for all areas in Korea. In addition, we elucidated
characteristics of chemical burns using a nationwide workers’
Internal organs

Internal organs
Self-employed

compensation database.
Dependent
Employee

Chemical burns comprised 1.6% of all types of burns in a

study based on a big burn center in Korea [17]. In Hong Kong,
Skin

Skin
Eye

Eye

chemical burns comprised 5.45% of adult burns based on a

burn center report [18]. Chemical burns accounted for up to
16.5% of burns in the 1980s in the UK [7]. As for a working
Characteristics

Insurance type

population, the U.S. Bureau of Labor Statistics (BLS) reported

the incidence of chemical burns in 2006 was 1 per 10,000 full-
Body part

Body part

time workers, and chemical burns comprised 0.6% of occupa-

compensation data (2009–2013).

Total

Total

tional injuries and illness resulting in loss of work time [2]. In

the present study, our results show that the chemical burn
incidence could be up to 2.13 persons per 10,000 in the general
working-aged population (Table 2; 1.96 from NHIS-NSC cohort
Workers’ compensation

+0.176 from workers’ compensation data).

In most studies, the most common place where chemical
burns occurred was in industrial settings [19,20]. Incidents
involving chemicals may occur throughout all the lifecycle of
Database

NHIS-NSC

many chemicals from production, transportation, handling,

and to disposal [19]. In a study of occupational skin disease
carried out for 4000 workers in 104 companies in Greece, 5.3%
of workers experienced chemical burns, and 13% of industrial

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 burns 43 (2017) 654 –664 659

Table 3 – The relative risk (RR) of chemical burns by insurance type in the National Health Insurance Service-National Sample
Cohort (NHIS-NSC), adjusting for age (2009–2013).

Insurance type Men Women Total

RR 95% CI RR 95% CI RR 95% CI

Self-employed 1.13 0.79–1.62 1.56 1.09–2.23 1.29 1.01–1.65
Employee 1.40 1.04–1.87 1.52 1.18–1.96 1.49 1.23–1.79
Dependent Ref Ref Ref

CI, confidence interval.

Table 4 – Chemical burns by industry, task and size of company in workers’ compensation (2009–2013).
Characteristics Male Female Total

N % N % N %
Industry Agriculture 5 0.52 0 0 5 0.39
Forestry 4 0.41 2 0.74 6 0.47
Operation of fish cultivating and fish farms and services incidental to 1 0.10 0 0 1 0.08
fishing
Manufacture of basic iron and steel and cast of metals 9 0.93 0 0 9 0.70
Manufacture of basic precious and non-ferrous metals 6 0.62 0 0 6 0.47
Manufacture of cement 4 0.41 0 0 4 0.31
Manufacture of ceramic ware 3 0.31 0 0 3 0.23
Manufacture of chemicals and chemical products 144 14.92 7 2.57 151 11.73
Manufacture of coke, hard-coal and lignite fuel briquettes and refined 1 0.10 0 0 1 0.08
petroleum products
Manufacture of concrete and non-metallic mineral products, and 20 2.07 1 0.37 21 1.63
fabricated metal products
Manufacture of electrical equipment 9 0.93 0 0 9 0.70
Manufacture of electronic components, computer, radio, television and 38 3.94 3 1.10 41 3.19
communication equipment and apparatuses
Manufacture of food products 26 2.69 17 6.25 43 3.34
Manufacture of glass and glass products 7 0.73 1 0.37 8 0.62
Manufacture of machinery and equipment 52 5.39 4 1.47 56 4.35
Manufacture of medicaments, perfumes and cosmetics 6 0.62 3 1.10 9 0.70
Manufacture of precision and optical instruments, and other precision 6 0.62 1 0.37 7 0.54
instruments
Manufacture of pulp, paper and paper products 6 0.62 0 0 6 0.47
Manufacture of rubber products 4 0.41 0 0 4 0.31
Manufacture of textiles and apparel 33 3.42 4 1.47 37 2.87
Manufacture of transport equipment 11 1.14 2 0.74 13 1.01
Manufacture of wooden products of wood and cork 1 0.10 0 0 1 0.08
Manufacture of leather, luggage, footwear and jewelry 2 0.21 0 0 2 0.16
Plating and anodizing of metals 116 12.02 4 1.47 120 9.32
Shipbuilding, maintenance and repair services 3 0.31 1 0.37 4 0.31
Other manufacturing 14 1.45 1 0.37 15 1.17
Electricity, gas, steam and air conditioning supply 2 0.21 1 0.37 3 0.23
Cleaning of building and industrial facilities, and waste collection, 56 5.80 9 3.31 65 5.05
disposal and materials recovery
General construction 154 15.96 2 0.74 156 12.12
Wholesale trade, retail trade, maintenance and repair services 27 2.80 4 1.47 31 2.41
Transit and ground passenger transportation 3 0.31 1 0.37 4 0.31
Transport of parcels 1 0.10 0 0 1 0.08
Water transport and freight handling 6 0.62 0 0 6 0.47
Freight trucking 16 1.66 0 0 16 1.24
Support activities for transportation 2 0.21 0 0 2 0.16
Warehousing 3 0.31 0 0 3 0.23
Food and beverage, personal service activities, and business support 100 10.36 78 28.68 178 13.83
service
Printing and publishing activities 5 0.52 1 0.37 6 0.47
Financial institutions, insurance and pension funding 2 0.21 0 0 2 0.16

(continued on next page)

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660 burns 43 (2017) 654 –664

Table 4 (continued)
Characteristics Male Female Total

N % N % N %
Professional, scientific and technical services 11 1.14 10 3.68 21 1.63
Maintenance and repair services of motor vehicles and motorcycles 1 0.10 0 0 1 0.08
Cleaning and pest control services of building and industrial facilities 39 4.04 16 5.88 55 4.27
Golf courses and racetrack operation 1 0.10 0 0 1 0.08
Public administration, defense and social security 0 0 3 1.10 3 0.23
Education 1 0.10 77 28.31 78 6.06
Human health and social work activities 3 0.31 19 6.99 22 1.71
Extraterritorial organizations and bodies 1 0.10 0 0 1 0.08

Task Agriculture 3 0.31 2 0.74 5 0.39

Pesticide application 3 0.31 2 0.74 5 0.39
Forestry 1 0.10 0 0 1 0.08
Fish farm 1 0.10 0 0 1 0.08
Livestock 1 0.10 0 0 1 0.08
Manufacturing process, unspecified 293 30.36 33 12.13 326 25.33
Maintenance and repair of industrial facility 105 10.88 4 1.47 109 8.47
Dyeing 2 0.21 0 0 2 0.16
Plating 125 12.95 3 1.10 128 9.95
Painting 9 0.93 0 0 9 0.70
Carrying containers in the workplace 26 2.69 4 1.47 30 2.33
Degreasing and rust-removing 20 2.07 0 0 20 1.55
Cleaning of the workplace 15 1.55 6 2.21 21 1.63
Cleaning of roadside sign 1 0.10 0 0 1 0.08
Cleaning of glasses and external walls 37 3.83 9 3.31 46 3.57
Cleaning of hospital 2 0.21 2 0.74 4 0.31
Cleaning of public bath and sauna 3 0.31 3 1.10 6 0.47
Cleaning of restroom 5 0.52 7 2.57 12 0.93
Cleaning of school 1 0.10 1 0.37 2 0.16
Cleaning of swimming pool 1 0.10 0 0 1 0.08
Car wash 3 0.31 0 0 3 0.23
Waste collection, disposal and materials recovery 9 0.93 0 0 9 0.70
Wastewater treatment 34 3.52 1 0.37 35 2.72
Construction 93 9.64 1 0.37 94 7.30
Waterproofing 1 0.10 0 0 1 0.08
Retailer 1 0.10 1 0.37 2 0.16
Loading and unloading of chemicals 63 6.53 3 1.10 66 5.13
Door to door transport 1 0.10 0 0 1 0.08
Warehouse 1 0.10 0 0 1 0.08
Restaurant and cafeteria workers 60 6.22 142 52.21 202 15.70
Hairdresser 0 0 1 0.37 1 0.08
Jeweler 0 0 2 0.74 2 0.16
Laboratory 32 3.32 38 13.97 70 5.44
Laundry 8 0.83 0 0 8 0.62
Snow-removing work 2 0.21 0 0 2 0.16
Soap-making 0 0 1 0.37 1 0.08
Vehicle maintenance and repair 2 0.21 0 0 2 0.16
Working in clinics and dentistry 1 0.10 6 2.21 7 0.54

Size of company >2000 workers 16 1.66 6 2.21 22 1.78

1000–1999 workers 7 0.73 7 2.57 14 1.13
500–999 workers 17 1.76 7 2.57 24 1.94
300–499 workers 16 1.66 7 2.57 23 1.86
200–299 workers 27 2.80 7 2.57 34 2.75
100–199 workers 52 5.39 8 2.94 60 4.85
50–99 workers 75 7.77 21 7.72 96 7.76
30–49 workers 81 8.39 34 12.50 115 9.30
16–29 workers 142 14.72 63 23.16 205 16.57
10–15 workers 99 10.26 32 11.76 131 10.59
5–9 workers 157 16.27 27 9.93 184 14.87
<5 workers 274 28.39 53 19.49 327 26.43
Unknown 2 0.21 0 0 2 0.16

Total 965 100 272 100 1237 100

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 burns 43 (2017) 654 –664 661

Table 5 – The causative agents extracted from workers’ compensation data (2009–2013).
Agent S E I Agent S E I
4-ter-Butylcatechol (TBC) 1 0 0 Formic acid 7 0 0
Acetic acid 14 8 2 FRP hardener 1 1 0
Acid chemical, unspecified 14 6 0 Gold (18 K) testing solution 1 0 0
Acid cleaning agent 7 1 1 Gypsum 3 0 0
Adhesive 10 0 0 Hardener, unspecified 0 1 2
Adhesive remover 1 0 0 Hydrochloric acid 38 9 8
Alkali chemical 8 5 1 Hydrofluoric acid 77 4 1
Alkali cleaning agent 53 14 3 Hydrogen peroxide 4 0 0
Aluminate-based cement accelerating agent 1 0 0 Iodine 0 2 0
Aluminum sulfate 1 0 0 Lubricant 1 0 0
Ammonia 6 5 1 Manganese solution 0 1 0
Ammonia bifluoride 1 0 0 Metam sodium 1 0 0
Ammonium nitrate 1 0 0 Methanol 0 1 0
Ammonium sulfate 1 0 0 Methyl ethyl ketone (MEK) 0 1 0
Antiseptics 4 0 0 Methyl metacrylate (MMA) 0 1 0
Boric acid 2 0 0 Methylene chloride 2 2 0
Bromic acid 1 0 0 Molybdenum disulfide 1 0 0
Bromine compounds 1 0 0 Nickel sulfamate 1 0 0
Bromoacetyl bromide 2 0 0 Nitric acid 45 4 7
Calcium chloride 1 1 0 Paint 0 4 0
Calcium hydroxide 2 1 0 Paint remover 3 1 0
Calcium oxide 5 4 0 Pesticide 3 1 0
Car battery fluid 0 2 0 Phenol 11 1 0
Cashew nut shell liquid (CNSL) 1 0 0 Phenyltrichlorosilane 0 1 0
Cement 57 15 0 Phosphoric acid 4 0 0
Chemical, unspecified 108 27 3 Phthalic anhydride 1 0 0
Chloroform 1 1 0 Plating agent, unspecified 45 7 0
Chromic acid 5 3 0 Potassium hydroxide 6 0 0
Cleaning agent, unspecified 136 34 11 Reagent, unspecified 1 0 0
Cresol 3 0 0 Refrigerant, unspecified 1 0 0
Cupric sulfate 1 1 0 Sodium aluminate 2 0 0
Deodorant 1 0 0 Sodium cyanide 1 0 0
Detergent 2 0 0 Sodium hydroxide 78 47 0
Dimethyl sulfate 1 0 0 Sodium hypochlorite (NaClO) 5 10 4
Dimethylaminoethyl acrylate 1 0 0 Sulfuric acid 118 5 1
Dyeing agent 2 0 0 Surfactant, unspecified 1 1 0
Epoxy 2 2 0 Tetrachlorosilane (SiCl4) 3 0 0
Etching agent 3 1 0 Tetraethylammonium hydroxide (TMAH) 1 0 0
Ethylene 1 0 0 Thinner, unspecified 0 1 0
Ethylene diamine 1 0 0 Trichloroacetic acid (TCA) 2 0 0
Fast-setting cement waterproofing agent 0 1 0 Trifluoroacetic acid 2 0 0
Ferric chloride (FeCl3) 0 1 0 UV coating agent 9 0 0
Fire extinguisher fluid 1 0 0 Wastewater treatment agent, unspecified 1 0 0
Fluid used for grouting 0 2 0 Waterproofing agent 0 1 0
Flux 3 0 0 Wood vinegar 0 1 0
Gas flux 0 1 0 Xylene 0 1 0

S, skin burns; E, eye burns; I, internal organ (respiratory, gastrointestinal tract) burns.

cleaning workers suffered chemical burns [21]. A study in
Bulgaria reported that domestic chemical burns are more
frequent than industrial chemical burns [22]. In the UK, a study
analysed chemical burns between 1981 and 1987 and reported
industrial causes as 76% of the incidences, yet, a subsequent
study conducted between 2003 and 2011 reported incidence at
35% which was less than the an incidence rate of 43% for
domestic chemical burns [7]. This might be due to the
introduction of strict safety and heath regulations, and the
shift of economic structure from a manufacturing to a service
industry [7]. In the present study, the employees were at a 49%
increased risk of chemical burns than dependents in the NHIS-
NSC cohort (Table 5), which implies work-related causes
played a significant role in chemical burns in the general
population. The self-employed also were at an increased risk
of chemical burns but only for females, which may be due to
the job characteristics for women. Typically, women who are
cleaning restaurants and cafeterias including school cafeterias
comprised more than half of the chemical burns for females
according to workers’ compensation data (Table 4). From this
result, we suspect that many women are working in small
restaurants commonly run by families and they might claim
for national health insurance services (NHIS) rather than going
to the workers’ compensation system. These women will be a
group benefiting from special attention on the prevention of
chemical burns.

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662 burns 43 (2017) 654 –664
Chemical burns have been reported to be more frequent in
men than women [7]. In a few studies, the male to female ratio
was about 3:1 for chemical burned patients [6,22,23]. However,
the male:female ratio varied higher to 10:1 in a study in Iran [1].
Contrastingly, a study performed in India reported that
females (54%) were more commonly injured than males,
which might also be attributable to the high rate of assault
(29%) and suicide (13%) [24]. In our study, the incidences of
chemical burns for both males and females calculated from
NHIS-NSC cohort were similar to each other in the general
population (Table 4). However, regarding workers’ compensa-
tion data, chemical burns for males were more frequent than
those for females (3.5:1). Because we did not obtain the
information about the male to female ratio for workers covered
by the workers’ compensation system, we could not calculate
gender-specific incidences of compensated chemical burns
exactly, yet, our results may indicate that chemical burns are
also prevalent for women and chemical burns for women
should not be neglected.
The working age is the most common age group in which
chemical burns occur [25]. In a study in China, it was reported
that the working age of 15–60 years old comprised 89.2% of all
chemical burn admissions [6]. In our workers’ compensation
data, the working age of 20–59 years old also comprised 91.7% of
all compensated chemical burns (Table 1).
In terms of jobs, in a study in China, it was reported that
‘workers’ comprised 64.7% of all admissions due to chemical
burns followed by farmers (13.3%) and managing clerks (5%)
[6]. Chemical burns have also been frequently reported in the
mining industry. The U.S. Mine Safety and Health Agency
(MSHA) reported that chemical burns were the most common
type of chemical-related injuries, accounting for 57% of all
cases, followed by coal workers pneumoconiosis (24%) during
the period 1999–2006. Eyes were the most common body part
burned and acids and alkalis were the most common types of
causative agents [26]. In a study in Saudi Arabia, chemical
burns from car battery spillage were reported, which even
caused chemical burns in children [23]. In a study in Serbia, it
was reported that an explosion of car batteries comprised 8% of
all eye chemical injuries [27]. From the brief history of
incidents in our workers’ compensation data, a few typical
exposure scenarios could be formulated. In men, workers
wearing gloves with a pinhole or tear did their job using acids
or alkalis and they recognized pain on their hands only after
work finished and found their skin had discolored. Another
scenario will be construction workers who wore boots and
experienced chemical burns around the calf area when the
cement mortar had overflowed into boots, or when a worker’s
pants had became wet with cement containing fluids. In
women, cafeteria workers who had their elbows burned while
degreasing an overhead hood would be a typical scenario.
Newly employed women wore gloves when they were cleaning
hoods using alkali fluids and raise their hands over their
shoulders. Accordingly, alkali fluid can easily run down and
stagnate at the elbow area. This then leads to chemical burns
in the upper extremities typically, not in the hands. This
scenario implies the importance of education to prevent
chemical burns. Performing laboratory tasks was also a
common job type for women. For internal organ burns,
cafeteria workers who swallowed alkali cleaning agents
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mistaking them for tea or water would be a typical scenario.
Adding peculiar colors, smells, and tastes into those cleaning
agents will be helpful to prevent further gastrointestinal tract
chemical burns.
In terms of causative agents, acids and alkalis are the most
common agents. In a study in China, it was reported that acid
and alkali comprised 61.01% and 32.36%, respectively, of
incidents [6]. In a study from Saudi Arabia, ‘cleaner’ burns are
the most common etiologic agents. Incidents usually occurred
at home when the cleaners were used for clogged drains and
the reflux of cleaner from the drains caused injury [23]. In a
burn center-based study in Iran, tar was the most common
causative agent, not acids or alkalis [1]. In our workers’
compensation data, acids and alkalis were the most common
causative agents. Cleaning agents especially, which are used in
restaurants and cafeterias (alkali), and building cleanings
(acid), were the typical agents.
As for body region of skin chemical burns, a study reported
that the lower limb was the most common region of chemical
burns [6]. However, other studies reported that hands and
wrists, or upper extremities, were the most common burn
regions [1,6]. While a study in India reported that heads and
necks comprised 37% of injuries, and which is the most
commonly affected region, this incidence may be due to high
rates of assault [24]. Use of acid and chemicals for assault,
robberies, and suicide has become a big issue, especially in
developing countries [28]. In our study, hands were most
common body region in the NHIS-NSC cohort and workers’
compensation data, except for women in the workers’
compensation data. Women workers were most affected in
their upper extremities doing a cleaning job as
aforementioned.
Ocular burns have been reported to comprise 15.5% of all
eye injuries and 72.3% of ocular burns were reported to be
work-related in German studies [29,30]. Chemical ocular burns
accounted for 19.6% of eye injuries in a study in Taiwan [18].
Acids and alkalis are the most common causative agents in eye
injury and alkalis were reported to be more common than
acids [31]. In our study, eye burns comprise 46% of chemical
burns for the NHIS-NSC cohort while the same burns comprise
20% of chemical burns for the workers’ compensation data.
These variations may be due to the fact that people perceived
eye injury seriously so they tend to visit hospitals immediately,
whereas only some of them with severe injury went through
workers’ compensation.
In terms of the depth of the burns, in the burn center-based
studies, third degree burns or deep injuries were the most
common depth of burns [22,24]. In our study, second degree
burns were the most common depth of burns both for the
NHIS-NSC cohort and workers’ compensation data. First
degree burns were the second most common type in the
NHIS-NSC cohort, but third degree burns were the second most
common type for the workers’ compensation data. This result
indicates that severely injured workers are more likely to go
with the workers’ compensation system, while minor burns
are more likely to go the NHIS. This suspicion is also suggested
by the fact that chemical burn incidence in the employed was
higher than that for dependents by 0.69 per 10,000 person-year
in the NHIS-NSC cohort (Table 2). However, the chemical burn
incidence in workers’ compensation data was only 0.17 per
 burns 43 (2017) 654 –664
10,000 person-year, which may imply that some work-related
chemical burns were transferred out of the workers’ compen-
sation system. Employers do not wish to hold occupational
injuries among their workplace safety records because it
potentially causes them some disadvantages such as labor
inspector’s visits and the increase of premiums [32].
The mechanisms of chemical burns involved were through
oxidation, reduction, corrosion, protoplasmic poison, by
vesicants, and by desiccants [33]. Acids with a pH<2 can lead
to coagulation necrosis, and alkalis with a pH>11.5 can lead to
tissue injury through liquefaction necrosis. The potential
hazards of weak fluoric acid in as low as 5% concentrations are
often neglected as it does not cause immediate skin lesions; it
may lead to skin burns after 2–3h without treatment [19].
Organic solvents dissolve the lipid membrane of cells and
disrupt the cellular protein structure [33]. Chemical burns
often cause serious consequences. The mortality rate due to
chemical burns has been reported to be up to 13.8% [5]. Chronic
exposure to strong acid mists, such as sulfuric acid, is known to
even cause laryngeal cancers [34].
The ways of preventing chemical burns have been
extensively discussed in previous papers [6,19]. In summary,
prevention will benefit from further education of workers,
managerial improvement, and governmental regulations.
Primary emergency responses, including massive water
irrigation, and on-site shower equipment are necessary. In
the acid/alkali manufacturing industry, workers should be
given regular safety education programs. The causative agents
can expose all workers as well as the general population from
its production, transportation, usage, and finally disposal/
recycling. For example, acid leaked from car batteries can
cause chemical burns in children as well as workers [23]. Thus,
environmental exposure management should not be ne-
glected, including a phasing out of toxic ingredients from
cleaning agents dispersed for home use. Managerial efforts
should be also emphasized because of the unavoidable nature
of occupational injury despite precautions. Governmental
inspections are also important to urge companies, as well as
exposed workers, to keep up with relevant standards to
prevent chemical burns. In terms of the size of the company,
small companies hiring less than five workers comprised 26%
of all chemical burns, which indicates that the priority of
prevention should be placed on workers in small scale
enterprises.
The NHIS-NSC database is a large-scale cohort, represent-
ing Korea population, but several limitations have been
reported [10]. The most important one would be a potential
bias from mis-coding of disease status. For example, ‘T265:
corrosion of cornea and conjunctival sac’ can be mis-coded as
non-injurious conditions such as ‘H169: non-specific keratitis’.
The coding error may lead to underestimation of true
incidence, but it is an inherent limitation of insurance
databases.
In summary, we estimated chemical burn incidence,
including in- and out-patient cases in the general population,
and examined the characteristics of chemical burns by
analyzing workers’ compensation data. Our results would
provide essential data to develop the basis of preventative
schemes. Although our study is the first study estimating
nationwide chemical burn incidences, more incidents not
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663
undergoing hospitalisation are likely to happen according to
Heinrich’s 1 major incident–29 minor incidents–300 non-injury
incidents rules [8]. Accordingly, further preventive measures
are indictated to protect people from chemical burns.
Conflict of interest
The authors declare that they have no conflict of interests.
Acknowledgement
This work was supported by a research fund from Catholic
Kwandong University International St. Mary’s Hospital
(CKURF-201601250001).
Appendix A. Supplementary data
Supplementary data associated with this article can be found,
in the online version, at http://dx.doi.org/10.1016/j.
burns.2016.08.037.
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