Chemical Burns Following Massage With Chopped Pulsatilla koreana

Herbal massage is commonly used for cosmetic and antirheumatic purposes in the Republic of Korea. Cutaneous burns can complicate herbal massages, but this is a very rare occurrence. Pulsatilla koreana, the Korean pasque flower, is a species of the genus Pulsatilla from the Ranunculaceae family. It is a perennial plant native to Korea, where it is used in herbal and folk medicine for its antipyretic, analgesic, anti-inflammatory, astringent, and hemostatic effects. Three cases of burns as a result of herbal massages with Pulsatilla koreana are presented herein to increase public awareness about the adverse effects of products used incorrectly for herbal massage.

Although rare, cutaneous burns can complicate herbal massage. Pulsatilla koreana, the Korean pasque flower, is a species of the genus Pulsatilla, which belongs to the Ranunculaceae family. It is a perennial plant native to Korea, where it is used in herbal or folk medicine for its antipyretic, analgesic, anti-inflammatory, astringent, and hemostatic effects. It is not recommended for pregnant women in light of evidence¹ that it can affect menstrual cycle and can cause pregnancy loss and birth defects in animals grazing on the plant. 

The authors report 3 cases of burns from herbal massages with Pulsatilla koreana to increase public awareness about the adverse effects of products used incorrectly in herbal massages.

Case 1
A 67-year-old woman presented to the outpatient clinic of Hanil General Hospital (Seoul, Republic of Korea) with a partial-thickness burn of the left facial cheek. She had heard from her neighbor that Pulsatilla has an anti-wrinkle effect; thus, she massaged her face with chopped Pulsatilla. During the 20-minute massage, she felt a burning sensation. She applied cold water to her face but presented to the outpatient clinic when bullae appeared 1 day after application of Pulsatilla (Figure 1). She underwent irrigation with water, and antiseptic cream was applied. The burn wound healed without scarring after 18 days but left residual hyperpigmentation in the affected areas. 

Case 2
A 57-year-old woman presented to the outpatient clinic of Hanil General Hospital with bilateral partial-thickness burns on her knees. She suffered from rheumatic arthritis involving the knee joints. A neighbor told her that Pulsatilla had positive effects on arthritis symptoms; she massaged her knees with ground Pulsatilla for about 2 hours. After feeling a burning sensation, she initiated cold water irrigation of both knees. However, when the skin of both knees desquamated (Figure 2), she presented to the outpatient clinic where she underwent further irrigation with water and application of antiseptic cream. Her recovery was uneventful and the burns healed within 13 days; she had mild hyperpigmentation after healing. 

Case 3
A 68-year-old woman presented to the outpatient clinic of Hanil General with partial-thickness burns of her right wrist and both cheeks of her face. She had rheumatic arthritis involving her wrists. Similar to case 2, a neighbor informed her that Pulsatilla has beneficial effects on arthritis symptoms and that the plant has a skin-whitening effect. She massaged the affected areas with ground Pulsatilla for about 60 minutes, at which time she felt a burning sensation. She irrigated these areas with cold water before presenting to the outpatient clinic with complaints of painful desquamation of the massaged areas (Figure 3). Further irrigation with water was performed and antiseptic cream was applied. Her recovery was uneventful and the burn wound healed within 15 days; she had mild hyperpigmentation on the affected areas after healing. 

Pulsatilla koreana, owing to its anti-inflammatory effects, is used in oriental herbal medicines. The major components of the methanol extract of Pulsatilla koreana are triterpenoid compounds and bisdesmoside.² In addition, the plant contains the cytotoxic unsaturated lactone protoanemonin (C₃H₄O₂), which is formed by the breakdown of glycoside ranunculin after injury to the plant. The extent of skin irritation also depends on the concentration of protoanemonin present in the plant. The amount of protoanemonin varies widely between species and growth stages; the highest content is in flowering plants. The leaves have been found to be more irritating than the stems and other plant parts.³ After contact with human skin, these chemicals not only produce immediate harm through an inflammatory response but also cause progressive damage, leading to epidermal and dermal lesions. The dermis is more permeable to toxins than the epidermis, and absorption is extremely efficient once the epidermis is destroyed.⁴

Delivery of effective on-site management in a timely fashion directly determines the degree of damage and the prognosis. Immediate management includes removal of involved clothing and footwear, brushing away any dry chemical, and immediate water lavage at the scene.^4,5 This is of such fundamental importance that it demands repetition: water lavage not only dilutes but removes the chemical. Isolated human cases of dermatitis have been treated with standard nonspecific measures, such as wet compresses, topical corticosteroids, and antibiotics.^3,6

The 3 cases presented herein did not require skin graft surgeries as their wounds had been immediately irrigated with massive amounts of water for 30 minutes or more. Water irrigation is the most convenient and effective means of on-site first-aid, because it not only prevents further harm by washing out the chemical but also serves as a cooling agent. If there is no life-threatening concomitant injury, water irrigation should be initiated as early as possible and should continue for a minimum of 30 minutes.⁷

Herbal massage is commonly used for cosmetic and antirheumatic purposes. Older people (> 65 years) particularly believe that natural plants are safer than prescribed medicines. However, natural plants can be cytotoxic. Practitioners should be informed of this cytotoxicity, especially if treating the elderly or people with chronic diseases, who have a higher chance of acting on wrong information from people in their surroundings.

Although chemical burn injuries represent a small portion of total burn injuries, they are unique and require special attention and management because of post-burn scarring and hyperpigmentation. It is important for practitioners to make their elderly patients with chronic diseases aware of the importance of prevention. The gold standard for the treatment of chemical burn injuries remains copious irrigation with water.