Burns and beauty nails

Abstract

A case involving a five-month-old girl brought to the emergency department with burns over her abdomen is described. The child was reported to have spilled two small bottles of beauty nail adhesive on her clothes while her mother was preparing dinner. After undressing the infant, the mother discovered several lesions on the child’s abdomen and quickly sought medical attention. Given the unusual circumstances of the presentation, the child was hospitalized for both treatment and supervision. The beauty nail adhesive contained cyanoacrylate. In addition to its well-appreciated adhesive capacity, cyanoacrylate, in the presence of cotton or other tissues, is known to produce an exothermic reaction that may cause burns. Cyanoacrylate-based products, due to their possible adverse effects, should be kept away from children as advised. Odd injuries should always raise concerns about the possibility of inflicted injury.

CASE PRESENTATION

The on-call paediatrician in a university hospital was contacted by a physician working at a walk-in clinic after examining a five-month-old child for lesions on the abdomen. The history provided by the mother stated that just after finishing her manicure, she had left her child playing in her stationary activity centre while preparing dinner. On hearing loud crying, she rushed to the child and realized that the beauty nail products from two small bottles had spilled onto the infant’s clothes. After undressing the infant, several lesions were discovered on her abdomen, and the mother quickly sought medical attention. The physician was asked to refer the baby and her parents to the emergency department, given the unusual history and physical findings, for further evaluation and treatment.

The mother explained that she had believed that the two small bottles left on the side of a coffee table were out of the child’s reach. Although the caps had been placed on the bottles, the bottles were not sealed. No one observed how the child, who was in her stationary activity centre, had managed to grab the bottles and spill their contents onto her clothes. The mother discovered the lesions after removing the child’s pyjamas and bodysuit. The parents reported that they had not rubbed or washed the infant’s skin. The wounds had been cleaned with sterile water and bandaged at the walk-in clinic. On presentation to the emergency department, the child appeared well and had just been bottle fed. Her vital signs were normal for her age. On physical examination, the child was alert, well hydrated and appeared comfortable. Head and neck examination did not show any lesion or trace of the products, which, if found, may have suggested ingestion. Cardiopulmonary auscultation was normal, as were her abdominal sounds. On the abdomen (Figure 1), four adjacent lesions were identified as second-degree burns: two bullous lesions measuring 15 mm × 10 mm, one bullous lesion measuring 10 mm × 25 mm, and a fourth larger lesion measuring 50 mm × 70 mm. No characteristic pattern of any known objects was observed within the burns. No other lesions or scars were found on the child’s body. Musculoskeletal examination did not reveal any pain, swelling or reduced spontaneous movement. The parents had brought the two bottles with them in a plastic bag for identification.

Figure 1).

Second-degree burns on the abdomen of a five-month-old girl

At the time, it was not believed that the contents of the bottles were capable of causing such burns, especially through two layers of clothing, and it was explained to the parents that their child’s condition necessitated hospitalization. In addition to regular observation of the wounds and analgesia, the parents were informed that additional specialists would be consulted. The parents, while cooperating, expressed their concern regarding the doctors’ suspicions of possible neglect or abuse. The burns were first covered with paraffin gauze and a sterile dressing. Subsequently, flamazine was applied over the wounds. Acetaminophen was the only additional medication prescribed during the observation period.

Toxicologists were consulted regarding the products provided by the parents. The two 15 mL bottles contained commercially available beauty nail adhesives, which consisted of resins, with one being more liquid than the other. Both contained cyanoacrylate, an instant adhesive. The two most common forms, ethyl-cyanoacrylate (ECA) and methyl-cyanoacrylate (MCA), are commonly used both industrially and at home (1). ECA-based adhesives are most commonly known by their trade names, such as Super Glue (Super Glue Corp, USA) and Krazy Glue (Krazy Glue, USA). ECA-based adhesives are liquid monomers that polymerize on contact with a hydroxyl group (−OH) (ie, water). This reaction, or hydroxylation, is exothermic. Nevertheless, a single skin contact with cyanoacrylate is unlikely to produce significant burns under normal circumstances; in fact, a single application of liquid MCA or ECA to the skin is considered to be safe, but repeated contacts may produce irritation (1). However, an important and notable exception is when the adhesive comes into contact with cotton fibres. Contact with cotton fibres produces a violent exothermic reaction that is capable of igniting the fibres, with the potential to cause substantial burns if the fabric is worn next to the skin. It is hypothesized that the cellulose in cotton fibres contains hydroxyl groups that may accelerate the exothermic reaction (2). Because of this, some material safety data sheets for cyanoacrylate warn not to wear cotton gloves when handling it because of the risk of injuries (3,4). Due to their toxicity, other cyanoacrylate derivatives with longer chains were created specifically for medical purposes, such as butyl-cyanoacrylate and octyl-cyanoacrylate. Because they are more slowly degraded, they allow tissues to eliminate their byproducts (ie, cyanoacetate and formaldehyde) and, thus, reduce the inflammatory response. The longer-chain derivatives are commonly used as tissue adhesives for the repair of lacerations and incisions and, more recently, as a physical barrier in the treatment of abrasions and wounds (5). In the present case, the beauty nail adhesives had been sold in Canada with the advisory “keep away from children” written on the back of each bottle.

DISCUSSION

To our knowledge, there are only three case reports of skin burns associated with cyanoacrylate in the literature, each of them related to an accidental spill of the glue onto a cotton fabric worn next to the skin (6–8). While the pyjamas in the present case were made of 100% cotton fibres, the bodysuit underneath was made of 30% cotton and 70% bamboo fibres. The undergarment is believed to have possibly provided some protection to the infant. The authors are aware of only one other report in the literature of a cyanoacrylate burn involving a child. In 2011, Clarke (6) described a case involving a two-year-old child with a 100 mm × 30 mm burn on the left leg caused by a cyanoacrylate-based glue used for common housekeeping chores. The child had presented while still wearing his cotton pyjamas, leading to a clearer link between the adhesive and the burn. In the present case, because the parents’ report was the only proof provided for the unusual cause of the burns, abuse or neglect still had to be considered.

Multiple causes of burns have been reported in children, although most (up to 70%) result from scalds (9). Chemical burns are less frequently reported, accounting for <10% of burns treated in emergency departments. They usually occur in older children and outside the home (10). In the literature, the prevalence of intentional burn injuries among children varies from 0.2% (11) up to 16% (12) of burn-related hospitalizations, depending on the inclusion or exclusion of burns from neglect and abuse. Elements that should raise suspicions of an intentional burn can be classified according to the pattern of injury and its circumstances. Uniformity in burn depth (which may imply that a child was restrained), bilateral symmetry, skin sparing within an area of burn or a recognizable shape or pattern (ie, an object) should raise concerns for abuse. Furthermore, the lack of witnesses, an incompatible mechanism of injury or one that does not fit the child’s stage of development, the presence of other bruises or lesions, and a history of previous abuse raise the suspicion for inflicted injury (13).

CONCLUSION

The next morning, the father returned with the child’s clothes and some pictures. According to the photographs provided, the stationary activity centre was at the same level as the table. On inspection of the bodysuit, it appeared that some skin had peeled off on its removal. After observation, analgesia and wound care, no deterioration of the wounds was noted. Discussion with the child protection and dermatology team ensued. Based on their opinion, a review of the literature, the child’s development and findings on physical examination, the story given, the relative location of the table, and examination of the clothes and bottles, no further investigation was performed. The child was discharged with planned dermatological follow-up for unintentional second-degree burns due to cyanoacrylate.

We reported the present case for three reasons. First, to inform health care providers that cyanoacrylate, a widely available instant adhesive, may cause skin problems and even severe burns on contact with cotton or wool. Second, to remind practitioners that anticipatory guidance regarding the safe use and storage of domestic products is an important part of health maintenance. Finally, to advocate for child safety by reminding health professionals that an unusual or unexplained injury should always raise concerns about the possibility of an intentionally inflicted injury.