What is the recommended treatment for bilateral chemical hand burns with intact blisters and no fever 72 hours post-occurrence?

Treatment for Chemical Hand Burns at 72 Hours Post-Injury with Intact Blisters

For bilateral chemical hand burns presenting 72 hours after injury with intact blisters and no fever, you should leave the blisters intact, apply a greasy emollient (50% white soft paraffin with 50% liquid paraffin) over the entire burn area, cover with non-adherent dressings, and refer immediately to a specialized burn center given the bilateral hand involvement. 1, 2

Critical Initial Actions

Immediate Referral Required

• Burns involving the hands require specialized burn center care regardless of size or depth because of the high risk of permanent disability and the likely need for surgical intervention 1
• The 72-hour delay does not change this requirement—bilateral hand involvement mandates specialist evaluation 1, 2
• Do not delay referral while attempting outpatient management 3

Blister Management

• Leave all blisters intact—do not unroof or completely remove them 1, 2
• The detached epidermis acts as a biological dressing that improves healing and reduces pain 1, 2
• If blisters are tense and causing significant discomfort, decompress by piercing and aspirating fluid while preserving the blister roof 1, 2
• This approach is supported by multiple guidelines showing intact blisters improve outcomes 1

Wound Care Protocol

Cleansing

• Gently irrigate the wounds with warmed sterile water, saline, or dilute chlorhexidine (1:5000) 1
• Avoid high-pressure irrigation as this may drive bacteria into deeper tissue layers 1
• Remove any visible debris or residual chemical agent 3

Topical Application

• Apply a greasy emollient such as 50% white soft paraffin with 50% liquid paraffin over the entire burn surface, including intact blisters 1, 2
• Alternatively, use petrolatum-based antibiotic ointment (such as bacitracin or polymyxin) 1, 2, 4
• Consider aerosolized formulations to minimize shearing forces during application 1
• Avoid preparations containing known sensitizers or irritants 1

Antimicrobial Considerations

• Apply topical antimicrobial agents ONLY to sloughy or obviously infected areas, not to the entire burn surface 1, 2
• At 72 hours post-injury without fever or signs of infection, routine topical antimicrobials are not indicated 1, 2
• If antimicrobials are needed, silver-containing products may be considered, but use should be limited if extensive areas are involved due to absorption risk 1
• Do not start systemic antibiotics prophylactically—they are only indicated if clear signs of infection develop 1, 3

Dressing Selection

• Cover with non-adherent dressings such as Mepitel or Telfa directly over the emollient 1, 2, 4
• Apply a secondary absorbent foam or burn dressing (such as Exu-Dry) to collect exudate 1
• Change dressings daily and monitor for signs of infection 2

Pain Management

• Administer over-the-counter analgesics such as acetaminophen or NSAIDs for pain control 1, 5
• These medications are well-tolerated and generally recommended for burn pain 1

Monitoring for Complications

Signs Requiring Urgent Re-evaluation

• Increasing pain, redness, or swelling beyond the initial burn margins 2
• Purulent discharge or foul odor 2
• Fever or systemic signs of infection 3
• Subepidermal pus formation 1
• Wound conversion (deepening of the burn) 1, 2
• Delayed healing beyond expected timeframes 1, 3

Infection Risk

• Chemical burns to the hands have substantial morbidity risk even without infection 6, 7
• The 72-hour timeframe means the window for prophylactic antibiotics (if they were indicated) has passed 1
• Focus on meticulous wound care and close monitoring rather than empiric antibiotics 3

Critical Pitfalls to Avoid

• Do not apply ice or ice water—this can cause additional tissue damage 1, 5
• Do not apply butter, oil, or home remedies 5, 4
• Do not break or completely unroof blisters—this significantly increases infection risk 2, 5
• Do not use prolonged external cooling at 72 hours post-injury—the cooling window is within the first 3 hours, and hypothermia risk outweighs benefits now 1, 3
• Do not delay specialist referral—bilateral hand burns require specialized care regardless of apparent severity 1, 2, 3

Why Burn Center Referral is Essential

The American Burn Association criteria explicitly state that second- or third-degree burns involving the hands should be treated in specialized burn centers because: 1

• Hands may require surgical intervention to prevent permanent disability 1
• Specialized treatments including potential debridement, grafting, or flap coverage may be needed 1, 6
• Aggressive range-of-motion therapy and hand therapy are crucial to prevent debilitating contractures 8, 7, 9
• Chemical burns often result in full-thickness defects with frequent involvement of underlying structures 6
• Even with optimal initial management, postburn scar contractures can severely limit hand function 7, 9