Dermal and ocular toxic exposures occur when chemicals, biological toxins, industrial agents, or household products directly contact the skin or eyes. The severity depends on:

• Chemical type (acid, alkali, organic solvent, pesticide, phenol, heavy metal)

• Concentration and duration of exposure

• Lipid solubility (affects skin penetration)

• Surface area exposed

• Patient factors (age, skin integrity, contact lenses, pre-existing dermatitis)

These exposures can cause local tissue destruction, systemic absorption, or permanent vision loss, making them true medical emergencies.

Risk Factors

Environmental & Occupational

• Industrial workers (cleaning agents, pesticides, petroleum, cement)

• Laboratory staff

• Agricultural workers (organophosphates, herbicides)

• Mechanics (solvents, fuels)

Household

• Children exposed to detergents/bleaches

• Cosmetic chemicals (hair relaxers, dyes)

• Accidental splashes while cleaning

• Battery acid exposure

Patient Factors

• Thin skin (infants, elderly)

• Open wounds, eczema, burns

• Contact lens use (retains toxins in eye)

• Delayed irrigation

Signs and Symptoms

Skin Exposure

Mild

• Burning sensation

• Redness (erythema)

• Itching

• Dryness

Moderate

• Blistering

• Severe pain

• Edema

• Chemical burns

Severe

• Necrosis (especially alkali)

• Gray/white leathery tissue

• Systemic toxicity (organophosphate, phenol, cyanide)

• Shock (large surface burns)

Eye Exposure

Early

• Tearing (lacrimation)

• Photophobia

• Redness

• Foreign body sensation

• Blepharospasm

Progressive

• Corneal clouding

• Decreased visual acuity

• Severe pain

• Conjunctival ischemia

Late

• Corneal ulceration

• Perforation

• Permanent blindness

Diagnostic Criteria

Diagnosis is clinical and exposure-based:

• Definite history of chemical contact

• Visible tissue injury consistent with chemical burn

• pH abnormality of ocular surface (acid <7, alkali >7.5)

• Progressive symptoms despite initial washing

• Evidence of systemic absorption

Investigations

For Skin Exposure

• Electrolytes (large burns)

• Renal function tests (systemic toxins)

• Serum cholinesterase (organophosphate)

• Toxicology screening when unknown agent

• ECG if cardiotoxic agent suspected

For Eye Exposure

• Ocular pH testing (litmus paper)

• Fluorescein staining → corneal epithelial defect

• Slit lamp examination

• Visual acuity assessment

• Orbital imaging if penetrating injury suspected

Treatment

Non-Pharmacological Management

1. Management of Skin Contamination

Immediate Decontamination (Most Important Step)

• Remove all clothing and personal effects

• Brush off dry powders before washing

• Irrigate exposed skin with copious running water (minimum 20–30 minutes)

• Use soap for oily or lipophilic substances

• Avoid neutralizing chemicals (causes exothermic reaction)

• Healthcare workers must wear gloves, apron, and eye protection

• Place contaminated clothing in sealed transparent plastic bag

Special Situations

• Phenol → wash with polyethylene glycol (if available) or copious water

• Metals (sodium, potassium, lithium) → brush off before water

• Pesticides → prolonged washing required

2. Management of Eye Contamination

Emergency irrigation must begin immediately — do NOT wait for examination

• Remove contact lenses immediately

• Irrigate continuously with saline or clean water

• Use topical anesthetic (tetracaine) to allow adequate irrigation

• Evert eyelids and remove trapped particles

• Recheck ocular pH every 5 minutes

• Perform fluorescein staining after irrigation

Urgent ophthalmology referral if:

• Corneal opacity

• Persistent pain

• Reduced vision

• Limbal ischemia

• Any alkali burn

Surgical / Specialist Referral

Immediate referral required for:

• Deep dermal burns

• Necrosis

• Compartment syndrome

• Ocular injury beyond conjunctiva

• Suspected perforation

• Systemic toxicity from dermal absorption

Pharmacological Treatment

Skin Exposure

• Analgesics (paracetamol / opioids if severe)

• Tetanus prophylaxis

• Topical antibiotics for secondary infection

• Steroids (only under specialist guidance)

• Specific antidotes (e.g., atropine + pralidoxime for organophosphate)

Eye Exposure

• Topical antibiotic drops (prevent infection)

• Cycloplegics (reduce pain and spasm)

• Lubricating drops

• Vitamin C (ascorbate) promotes collagen repair

• Doxycycline (reduces corneal melting)

• Steroids — short course under ophthalmologist

• Anti-glaucoma therapy if increased intraocular pressure

Prevention

Educate patients and caregivers:

Do’s

• Store chemicals in original containers

• Use protective gloves and eye protection

• Keep chemicals out of reach of children

• Read labels carefully

• Use child-resistant caps

Don’ts

• Transfer chemicals into drink bottles

• Leave containers open

• Remove product labels

• Store chemicals near food

• Allow children to observe unsafe handling