What is the treatment for a patient with a history of exposure to sodium bicarbonate (NaHCO3) in a dialysis unit, presenting with light thickening of the skin above the wrist?

Management of Skin Thickening After Sodium Bicarbonate Exposure in Dialysis Unit

Immediate Assessment and Decontamination

The priority is immediate and thorough decontamination with copious water, as this is the most effective method for removing chemical irritants from skin and preventing further tissue damage. 1

• Remove any contaminated clothing or materials that may have contacted the affected area above the wrist 1
• Flush the affected skin with large volumes of water for at least 15-20 minutes to ensure complete removal of sodium bicarbonate residue 1
• Avoid using alkaline hypochlorite solutions (0.5%) for decontamination, as these are contraindicated for compromised skin and should only be used on intact skin 1

Clinical Evaluation

This presentation is consistent with irritant contact dermatitis from sodium bicarbonate exposure, which can cause skin thickening (lichenification) as a chronic response to chemical irritation.

• Assess for signs of chemical burn including erythema, edema, blistering, or skin breakdown beyond the described thickening 1
• Evaluate whether the exposure was a single acute event or represents chronic low-level exposure from workplace practices 1
• Document the extent and severity of skin changes, as this will guide treatment intensity 2

Treatment Protocol

Primary Management

• Apply emollients liberally and frequently to the affected area, as xerosis (dry skin) is extremely common in dialysis patients and can lower the threshold for skin irritation 1, 3
• Consider topical corticosteroids (low-to-medium potency) for 1-2 weeks if significant inflammation or pruritus accompanies the thickening, though this is not specifically addressed in dialysis guidelines 2

Symptomatic Relief if Pruritus Present

• If itching develops, recognize that 42-44.8% of hemodialysis patients experience pruritus, which can be exacerbated by skin barrier disruption 1, 3, 4
• Topical capsaicin 0.025% cream applied four times daily may provide marked relief if pruritus becomes severe, with studies showing complete remission in approximately 29% of dialysis patients (5 of 17 completing treatment) 1
• Oral antihistamines such as doxepin 10 mg twice daily may achieve complete resolution in 58% of cases, though drowsiness occurs in 50% of patients 1

Prevention of Recurrence

Implement strict workplace safety protocols to prevent future exposures, as dialysis staff face routine risk of chemical contact. 1

• Ensure proper personal protective equipment (PPE) including gloves and gowns when handling sodium bicarbonate solutions or cleaning dialysis equipment 1
• Replace PPE immediately if it becomes soiled with any chemical solutions during dialysis procedures 1
• Perform hand hygiene with soap and water or alcohol-based hand rubs after any potential chemical exposure 1
• Review facility protocols for environmental cleaning and disinfection to ensure adequate protection for staff 1

Monitoring and Follow-up

• Reassess the affected area in 1-2 weeks to ensure improvement with conservative management 2
• If skin thickening persists beyond 4 weeks despite treatment, or if signs of infection develop, refer to dermatology for further evaluation 2
• Document the exposure incident according to occupational health protocols, as this represents a workplace chemical exposure requiring reporting 1

Important Caveats

Do not apply topical antibiotic ointments routinely to the irritated skin, as guidelines recommend against this practice except for specific dialysis catheter protocols. 2

• Avoid glycol-containing ointments if the patient has any polyurethane dialysis equipment, as certain manufacturers contraindicate this combination 2
• Be aware that dialysis patients have increased susceptibility to skin complications, with 88% experiencing cutaneous manifestations and 69% having xerosis 4
• Recognize that sodium bicarbonate solutions used in dialysis (particularly 8.4% hypertonic solutions) are caustic and can cause significant tissue damage with prolonged contact 5, 6, 7