The study of folk medicine in ancient cultures has revealed a variety of customs and practices which have survived until the present day. One of the most common ancient techniques used for centuries to relieve pain utilizes "counter irritation" which is the application of a secondary man-made irritant to the site of the original injury. These irritants include, among others, mineral/herbal irritants, massage, firing irons and setons.
In Eastern societies where the practice of modern medicine is inaccessible to a large part of the population, patients seek branding treatments for many medical conditions such as backache, sciatica, arthritis, paralysis, facial palsy, ascites, splenomegaly, lymphadenopathy, jaundice, glaucoma, migraine headaches and sore throat [4
]. Kumar S et al provided a case report of a patient with progressive weakness who underwent branding [2
]. Similarly, Kaatz M et al have described body-modifying concepts and dermatologic problems of its aesthetic use [3
The role of branding as a body art is recognized; however its role in disease management or as a subjective control of pain is unclear [1
]. It is proposed that the secondary inflammatory response to the applied irritant comprising vasodilation, enzyme release, swelling, edema, blebs, vesicles and suppuration may aid leucocytes and opsonins released in the inflamed area, leading to bacterial destruction. In addition, this response aids in the rapid elimination of toxins [1
]. These effects alone, however, cannot explain how counter irritation to the surface of the body can decidedly affect distant internal organs. The influence of counter-irritants may be summarized in a reflex action; for example, the production and conduction of an impulse from the periphery to nerve centers modifies the nerve function and blood supply in distant parts [5
In our case series, faith healers used hot metal rods and coals for branding. It is hypothesized that skin breakdown and improper wound care can lead to severe infections. Thus, local wound infections resulted in exacerbation of current illness and complications like hepatic encephalopathy, subacute bacterial peritonitis, multiple splenic abscesses, cavernous sinus thrombosis and systemic bacterial sepsis in our cases. It is likely that these procedures were done in an unsterile procedure resulting in these complications and therefore carry a larger risk, which outweighs the benefits of short-term pain relief (according to popular belief but without scientific evidence). But severe medical complications of this procedure and its potential risks outweigh the benefits of short-term pain relief.
Wound management can be challenging in these patients. Patients' branded lesions typically look like multiple circular burns ranging in size from 2 to 5 cm across with central sparing of the skin [3
] and they are likely to present complaining of symptoms suggestive of infection. They have diminished resistance to infection and other external noxious agents and like any other third degree burns, parenteral antibiotics fail to penetrate the dead tissue due to poor blood supply. Treatment includes local irrigation of the burns with saline solution and gentle debridement of the eschar if necessary. Infected limbs should be rested and elevated. Silver sulfadiazine or another appropriate antimicrobial agent should be applied to the wound as required [1
]. If cellulite is present, empiric intravenous broad spectrum antibiotic coverage should be initiated (nafcillin, evofloxacin, or cephalosporin) in these patients. However, the extent of the infection and its location help determine what type and route of coverage is required.
In the long-term, branding procedures can cause disfigurement from contractures (especially over joint surfaces), scars, hair loss, keloids, orthokeratotic hyperkeratosis, acanthosis and squamous cell carcinoma (Marjolin's 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 [3
Branding has recently become more fashionable in Western countries [1
], where it is increasingly practised as body art. In these settings branding is usually performed in safe conditions, or with more precautions against serious infection, and is not used for counter irritation as it is in people whose health is already seriously compromised. Branding in Western society is described as a behavior associated with a high level of substance use, sexual intercourse and multiple partners, high risk sexual activity, smoking, marijuana use, suicidal ideation and suicidal and homicidal attempts [9
There are two populations with different cultural backgrounds who seek branding for entirely different reasons. There is no direct association between the behavior associated risk problem in Western populations and the complications seen in our patients. Thus people who seek branding for body-art do not have the same sequelae of acute infections because of better sterile techniques. However, it is unclear whether the use of a sterile procedure in the chronically ill who seek branding would not still result in severe local complications. Thus a careful assessment and discussion of host factors should be an integral aspect in people who seek branding for various reasons.