"A lot of times, when the patients are injured in this way, it's because they're not trying to kill the patients but cause them disfigurement and pain as opposed to death," said Dr. Julie Caffrey, interim director of the Johns Hopkins Adult Burn Center at Johns Hopkins Bayview Medical Center.
Caffrey has treated chemical burn victims from various countries, including Nigeria, Colombia and Sudan. They are typically young women who have either upset their husbands or done something that might cause the family shame or embarrassment, she said. The attacks are used as a form of punishment, and their impacts on health can be lifelong.
Health impacts of acid
When a chemical like sulfuric or hydraulic acid hits the skin, it causes coagulation necrosis, an accidental cell death that leads to tissue ulceration. It's that ulceration that has such damaging effects, Caffrey said. The burn will continue until the acid is removed.
Depending on the severity of the injury, an acid burn can cause lifelong deformities, including blindness if it gets into the eyes, she said. Some patients may have permanent damage to their facial features and scarring that affects the ability to create expressions.
"We can do lots of surgeries to improve appearance, but we can never get back to normal," Caffrey said. "It will never be what it was before the area was injured."
Many patients suffer from chronic pain, she said, specifically nerve pain that has to be managed by specialists and oftentimes requires multiple medications. Psychological side effects may also manifest, such as acute stress disorder, which can lead to post-traumatic stress disorder, she said.
"The patients feel fearful leaving the house that they might undergo attack, but they also undergo a lot of problems with accepting their appearance and dealing with what they look like now," Caffrey said.
Patients may become recluses out of fear of being stared at or made fun of, she said.
Acids and bases
There are two types of chemical burns, said Dr. Ryan Stanton, an emergency physician in Lexington, Kentucky, and spokesman for the American College of Emergency Physicians: acid burns and basic burns.
Acids have a pH level of less than 7 -- which is the pH level of water -- and get more dangerous as they approach 1, while bases have a pH level of over 7 and become more dangerous as they get closer to 14.
Although acid attacks are more common, getting attacked with a basic solution can cause more harm, Stanton said.
"The (acid burns) kind of clot things up and scar it over, whereas basic burns are more liquefactive, meaning they keep burning through," he said.
The acids that are typically used in these attacks, such as hydrochloric and sulfuric, can be found online or easily obtained by someone with access to a lab, he said. Acid is more commonly associated with physical damage, which is why it's probably used in more attacks than basic solutions, Stanton explained.
Some household cleaning products are acidic, and some are basic, he said. Though they are typically mild, they can cause physical harm if not properly handled, such as a basic chemical like dishwashing detergent.
"People don't realize how bad that can be. You can get it into your fingers or get it into your eyes, and it can cause continuous harm," he said.
Stanton's own wife accidentally got some onto her contact solution, causing burns in her eyes that required her to go to the emergency room.
But acids and bases that are at the most dangerous levels are typically found in factories and industrial settings, Stanton said.
What to do if you're burned
"The first and most important thing is to take off any type of clothing that might have come into contact with the agent," Caffrey said. The next step should be hosing off with water or showering to let the chemical run off the body.
"With almost any of these, it's irrigation, irrigation, irrigation," Stanton said.
Chemicals should typically be washed off with water immediately, he said, with the exception of hydrofluoric acid, which gets worse with water and needs to be removed with a calcium solution. But this chemical is less common in acid attacks.
If the burn is severe, a doctor will have to debride the wound, taking off any dead tissue, Caffrey said. Once the depth of the burn is determined, the patient may have surgical excisions and skin grafting to begin the recovery process.
"We like to believe that the plastic surgery starts with the first excision," Caffrey said. "When done correctly, you try to get the best results possible. But most likely, these patients will undergo reconstructive surgery at some point in their lifetime."
Advice for bystanders and health professionals
recently published in the medical journal BMJ advised both bystanders and health professionals on how to help an acid burn victim.
"Bystanders who come to the aid of the victim of an attack can have an important role in minimizing further injury," the paper said. "The victim should be removed from ongoing exposure as soon as possible. Irrigation of the affected area with copious amounts of water is vital to remove the chemical and should be performed as soon as possible to minimize the long term effects of scarring and need for surgical reconstruction."
Health professionals should give a rapid airway assessment and give intravenous fluids for rehydration, the editorial advised. The victim should be washed off until the pH level of the exposed area has returned to normal. If their eyes were exposed, their pH should be checked 15 to 30 minutes after irrigating to make sure there isn't re-exposure from acid potentially in the folds of the eyelids.
"Public education is needed on how to deal with these injuries, as immediate treatment can substantially improve the outcome," the editorial said. "Similarly, ambulance service responders and health professionals in emergency departments must have clear guidance on immediate steps to minimize secondary harm and training on how to deal with these devastating, life changing attacks."