Iatrogenic patterned scar secondary to branding.

Sir,

Branding refers to a traditional practice of creating burns on the skin with a hot iron rod or metallic object.[1] The technique causes wounding, which heals with secondary intention, leaving permanent scars. In most cases, the aim is to produce a permanent patterned scar.[1] But, this is done without the basic understanding of healing or anticipating the possibility of formation of hypertrophic and keloidal scars. The patient may develop such scars, especially if the branding is done after puberty.[2] The possibility of hypertrophic and keloidal scars increases significantly since the wound gets infected and takes longer to heal without proper wound care as done in the quackery practices. In several Asian and African societies, where traditional medicine is still widely prevalent, branding is used as “counter irritation”. This involves brief use of moderately intense pain to relieve chronic pain.[3] Many local and systemic complications are described following traditional branding. We report a case of patterned keloidal scar secondary to banding done for osteoarthritis of knee.

A 45-years-old female came with a complaint of raised scars over both the knees. On careful history-taking, she revealed it as consequent to branding. Patient had bilateral knee joint pain since two years. She had tried several treatment options in allopathy, Ayurveda, and homeopathy. She consulted a traditional healer a month back, who did branding on the anterior aspect of both the knees with hot bangles. Patient had pain and ulcer over the branding site, which healed over a period of 4 weeks, leaving behind the present lesions. It was associated with mild and occasional itching. No personal or family history suggestive of keloidal tendency, hypertension, or diabetes was elicited.

On examination, the patient had multiple raised, non-tender keloidal scars arranged in regular rows over the anterior aspects of both the knees [Figures 1 and 2]. X-ray of knee joint showed features of osteoarthritis. Routine blood and urine examination were within normal limits. Intralesional triamcinolone acetonide was given to each of the larger lesions, which reduced the size of the lesions with residual scars.

Figure 1

Patterned scar over both knees

Figure 2

Close-up view showing raised scar arranged in rows

Human branding is the process, in which a mark is made on the skin of a living person by burning, resulting in permanent scarification. In rural India, branding is practiced as a method of prevention or treatment of many diseases. The family members usually believe that the offending agent comes out of the branding site ridding the body of the disease.[4] Many medical conditions such as post-herpetic neuralgia, backache, sciatica, arthritis, paralysis, facial palsy, ascites, splenomegaly, lymphadenopathy, jaundice, glaucoma, migraine headaches, and sore throat are the main area of target by traditional healers.[5] Branding procedures can cause disfigurement from contractures (especially over joint surfaces), scars, hair loss, keloids, orthokeratotic hyperkeratosis, acanthosis, and squamous cell carcinoma (Marjolins ulcer). Other medical complications include foreign body reaction, oral and tooth complications, aspiration and hypoxia, edema and swelling, infections and viral transmission including hepatitis and HIV.[6789] Raza et al. in their case reports have described many life-threatening complication like septic shock, cavernous sinus thrombosis, and multiple splenic abscesses secondary to branding.[3] We think it is appropriate to report a case of patterned keloidal scar secondary to banding done for osteoarthritis of knee.