Unusual ritual burns of the cubital fossa

Abstract

Background: Ritualistic burns have been reported sporadically in the literature. With the globalization of religion, it is inevitable to encounter unusual ritualistic burns unfamiliar to the local community. We present an unusual case of cubital fossa burn by joss sticks. Case presentation: A 56-year-old Chinese lady was admitted to our burns department for 4 × 2 cm full thickness burns over bilateral cubital fossae, which were insensate and had surrounding cellulitis without pus discharge. Examination showed previously healed similar burn marks which were made in the past 3 years on 3 separate occasions. Further probing revealed voluntary participation in a ritualistic burn with joss sticks 8 days ago in London coinciding with the Chinese Hungry Ghost Festival. This religious tour has been held annually in various countries. The ritualistic burn was performed on other believers aged from 3 to 80 years old without the influence of drugs, alcohol or coercion. Her previous joss stick burns healed uneventfully within 1 month. Due to the longer duration of exposure and depth of burn this time, she experienced blistering immediately which became necrotic and insensate in 2 days. This was followed by erythema and pain indicative of surrounding cellulitis before she sought treatment. She underwent burn wound excision to underlying fat and fascia the following day, followed by split-thickness-skin-graft 4 days later. Conclusions: Joss sticks have been lighted for centuries in Asia as part of an ancient tradition of offering smoke to deities. In the Buddhist community, ritualistic burning with joss sticks represents a symbolic rite of passage for monks, or as a reminder not to sin by believers. Joss stick burns have the potential to cause deep penetrating burns, leading to infection, scarring and contracture. In this cosmopolitan society, we must recognize unusual burn wounds and initiate treatment early to decrease morbidity. Keywords: Burns, Joss stick, Incense, Ritual