Double-Covered Skin Areas Are at High-Risk for Scald and Chemical Burns in a Cross-Sectional Analysis of NEISS 2000–2018

Burn epidemiology and complications have been well studied,[1,2] but data on double-covered skin burns, including the pubic region, buttocks, and breasts, is limited. Our objectives were to analyse the epidemiology and burn mechanism/sources of double-covered skin. The National Electronic Injury Surveillance System (NEISS) database was retrospectively searched using keywords ‘pubic’, ‘buttock’, and ‘breast’, 1/1/2000–12/31/2018, with date, age, sex, race, disposition, location, and source collected. Chi-square tests compared admission rates and burn sources of each skin area (P < 0.05). There was a total of 455 double-covered burns: 381 pubic (83.73%), 61 buttock (13.41%), and 13 breast (2.86%) areas, with 50.99% children, 68.13% males, 39.56% Whites, and 23.74% Blacks [Table 1]. Injuries most commonly occurred at home (67.03%), with particularly high admission rates for pubic burns (16.80%, P < 0.05), compared to the buttock (6.56%) and breast (0.00%). Overall, scald was the most common burn source (63.30%), especially boiling water, followed by chemicals (16.48%), most frequently household cleaners [Table 2].Table 1: Demographics and characteristics of burns to breast, buttock, and pubic skin in NEISS, 2000–2018Table 2: Top sources for scald and chemical burns in NEISS, 2000–2018Among the three double-covered skin areas, pubic burns were by far the most common, with the highest hospitalisation rates. Similarly, in a retrospective study of 71,895 burns, overall mortality for genital burn vs. nongenital burn patients were significantly higher (17.0% vs. 4.7%; P < 0.0001), and genital burns independently predicted mortality when controlling for age, ethnicity, inhalation injury, burn depth and body surface area (adjusted odds ratio [AOR] 1.520, 1.188–1.944, P < 0.0001).[3] Pubic skin has a thin stratum corneum, making it easily penetrable and prone to severe burns. The American Burn Association’s 2019 Burn Care Prevention guidelines recommend burn centre referral for genital burns, given the historically high severity of these burns.[4] Our finding of a male predominance for pubic skin burns is consistent with a retrospective study of 393 genital burns at a level-1 burn centre,[5] reporting a 64.4% male prevalence of pubic burns. The high proportion of affected males with pubic burns may be due to males vs. females having greater pubic surface area and possibly engaging in more risk-taking behaviours. Liquids, particularly scald and chemical, were the most common burn sources in double-covered skin. Since scalds from boiling water were common in the paediatric population, hot water should always be monitored and kept away from children. Chemical burns may be prevented by closing household cleaners immediately after use and storing them in cabinets. For buttocks, contact burn was commonly due to heating pads, stove/grills, and iron-related products. Therefore, we recommend using heated devices at lower settings and turning them off when not in use, covering heating pads with fabric, and using oven mitts when touching the stove. NEISS included only emergency department cases with some missing information on burn mechanisms. Sample sizes were small for buttock and breast burns, limiting our analysis. The pubic region, buttocks, and breasts are typically protected by double layers of clothing but are at high-risk of scald and chemical burns, especially in young males. Given the high admission rate for pubic burns, dermatologists should educate patients on proper prevention and first-aid guidance at both the individual and community levels. List of Abbreviations NEISS: National Electronic Injury Surveillance System. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.