|Year : 2014 | Volume
| Issue : 2 | Page : 87-90
Burns of the face in epilepsy: Risk factors and an opportunity for prevention
Abdulrasheed Ibrahim, Malachy Eneye Asuku
Department of Surgery, Division of Burns and Plastic Surgery, Ahmadu Bello University, Zaria, Nigeria
|Date of Web Publication||10-Apr-2015|
Dr. Abdulrasheed Ibrahim
Department of Surgery, Division of Burns and Plastic Surgery, Ahmadu Bello University, Zaria
Source of Support: None, Conflict of Interest: None
Burns are devastating injuries that may occur during altered levels of consciousness in an epileptic seizure. There is a paucity of literature on the profile of epileptic patients with severe burns of the face. This article reports the avoidable risk factors in burn injuries of the face in patients with epilepsy. A review of the medical records for all burn admissions in patients with epilepsy was undertaken from January 2010 to December 2013. Demographic and clinical data of the patients were collected and analyzed. Grading of facial appearance was based on the classification of facial soft-tissue deformities in post-burn patients by Zan et al. All the patients were female and the mean age was 27 years. Age range was 18 - 35 years. Carbamazepine was the commonest antiepileptic drug utilized. Three patients reported the use of herbal medications in addition to antiepileptic drugs while one patient admitted to the use of only herbal medications. Three of these patients presented with full thickness burns of the face and had Type IV post burn facial deformity. There are trends that accord to female gender, low socioeconomic status and poor adherence to antiepileptic drugs in this study. The use of the electronic media (television and radio) is suggested as an effective strategy to increase awareness.
Keywords: Burns, epilepsy, face, prevention, risk factors
|How to cite this article:|
Ibrahim A, Asuku ME. Burns of the face in epilepsy: Risk factors and an opportunity for prevention. Afr J Trauma 2014;3:87-90
| Introduction|| |
Epilepsy is a severe neurological disorder of brain function characterized by an enduring predisposition to generate epileptic seizures. , An estimated 85% of people with epilepsy live in low- and middle-income countries (LMICs), including sub-Saharan Africa.  However, a significant proportion of patients with epilepsy in LMICs do not seek orthodox treatment for epilepsy owing to cost or cultural beliefs. In addition, poor adherence to antiepileptic drugs (AEDs) contributes to poor seizure control.  This is further compounded by limited awareness among epileptics of the risks of injury and burns. 
The increased incidence of burns in people with epilepsy has long been recognized.  Prolonged exposure to heat may occur during the few minutes of unconsciousness that typically accompanies an epileptic attack, resulting in deep and extensive burns of the body including the face. ,,, The face is central to many aspects of social interaction, and any deformity of the face following a burn injury has always been considered as one of the least desirable handicaps.  This is because postburn deformities of the face are characterized by functional, psychological, and esthetic impairment and multiple reconstructive needs that are often difficult and limited. 
There is a paucity of the literature on burns of the face in epileptics in low-resource settings. This article reports the avoidable risk factors in burn injuries of the face in patients with epilepsy. This information will improve awareness and provide potential opportunities for improving the quality-of-life through prevention.
| Patients and Methods|| |
A review of the medical records for all burn admissions in patients with epilepsy was undertaken from January 2010 to December 2013. Patients selected for this review had sustained burns of the face after experiencing a seizure. Six patients fulfilled the criteria for admission to this study. Exclusion criterion was burns in epileptics without involvement of the face. Data were collected for patient demographics: Age, gender, marital status, and socioeconomic status. We also noted type of AED, compliance with medication, and frequency of seizure during the previous 12 months. Other study variables included time and place of burn injury, circumstances of burn injury, and the grading of facial appearance. Grading of facial appearance was based on the classification of facial soft tissue deformities in postburn patients by Zan et al. 
| Results|| |
All the patients were female, and the mean age was 27 years. Only one of the patients was single, and five of the patients were identified to be of a low socioeconomic status. [Table 1] carbamazepine was the most common AED utilized. None of the patients utilized combination therapy drugs. Three patients reported the use of herbal medications in addition to AEDs while one patient admitted to the use of only herbal medications. Only one patient readily volunteered information on drug compliance. All seizures in this series occurred during household tasks at night and in the kitchen while cooking. [Table 2] four of the patients were alone at home when the seizure occurred. Three of these patients presented with full thickness burns of the face and had type IV postburn facial deformity [Figure 1].
|Figure 1: (a) Type IV facial deformity (case 1). (b) Type IV facial deformity (case 4). (c) Type III facial deformity (case 6)|
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|Table 2: Circumstance of burn and classification of postburn facial deformity |
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| Discussion|| |
The patients in this study were within the age group 18-35. They were all female with a majority belonging to the low socioeconomic class. This demographic profile correlates with the report by Minn.  Gender has been established as a key predictor of the likelihood of experiencing a burn during a seizure, with females being twice as likely to have suffered such an injury because they were often burned while cooking.  Unlike with choices regarding driving or job selection, women in most developing countries can hardly choose to live without cooking.  Almost all the patients in our series were from a low socioeconomic class and were extremely unlikely to afford a microwave oven. Furthermore, perennial lack of electricity in the setting they come from mandates the use of alternative and often hazardous sources for domestic use, including open fires from firewood and locally fabricated kerosene stoves. , An interesting finding in this study is that five out of the six patients were married, and the diagnosis of epilepsy was made before marriage. This is remarkable given the social stigma of epilepsy, which in many communities strongly manifests as refusal of marriages to epileptics.  The demographic trend in this study is thus instructive because epilepsy affects the young and virile with profound effects on attainment of personal goals and quality of life.  The focus on risk factors and prevention of burns of the face in epileptics is essentially about developing these observations.
Many African societies view epilepsy as an inherited condition hence families of epileptics are stigmatized. Epilepsy is also perceived in several developing countries as a disease inflicted on a person either by a spirit or an enemy and can, therefore, not be treated by orthodox medicine. This belief reinforced by ignorance and poverty is documented in several studies in LMICs.  This possibly explains why four of our patients were using herbs. Only one patient had the well-controlled seizure as measured by frequency in the preceding 12 months. This is dismal given that seizure frequency is widely acknowledged as a risk factor for burns. , In view of this significant finding, seizure frequency can be nearly eliminated as a risk factor for burns by a firm and consistent encouragement of patients to establish regular visits to the doctor's office for treatment.  It is crucial to ensure compliance with medications. Knowledge of risk factors and outcome may also improve patient compliance.  This may be emphasized by distribution of seizure-related burn prevention brochure to the patient and family members. ,,
Complex visual stimuli induced by flames may trigger reflex seizures especially with the use of open flames with firewood.  An epileptic seizure usually lasts 2-5 min during which time interval major deep burns can occur, because exposure to a heat source of > 71°C for I-2 s will produce a full skin thickness injury.  In the ictal or postictal state, the epileptic lacks the ability to withdraw from hot objects.  All the patients had severe burns of the face; type III (Multiple unit deformities involving a total unit and adjacent units) was seen in two patients while type IV (Subtotal and or total deformities of the face) was seen in four patients. This may also indicate the lack of availability of immediate first aid at the scene of the burn injury.  In our series, the burn was witnessed by the brother (case 2) and mother (case 6). There were no witnesses at the time of seizure and burns in the other patients. This suggests that our patients with epilepsy were alone at home, possibly reflecting ignorance to the consequences of leaving such patients alone. The proposition that patients with epilepsy should refrain from flame-related household chores is probably not practical. The potential for reducing future morbidity from burns in persons with epilepsy is, therefore, in this area. It would be more realistic to have an accompanying person available during household chores.  The cost of excessive dependency must be balanced against the benefits of preventing a devastating and irreversible burn injury to the face. 
Patients with epilepsy are generally encouraged to live as normal a life as possible. Nonetheless, in doing so, they are at risk of injury to themselves and others during the peri-ictal period. The incidence and nature of seizure-related burn injuries differ from those that occur in the general population, and the associated risk is an important factor in guiding a prevention program.  There is a need to strengthen the capacity to encourage measures promoting public health awareness regarding epilepsy.  Several studies have shown the effectiveness of televised campaigns and audio presentations for health-related prevention programs.  A television or radio program in the vernacular language of the community will be most useful.  It is critical that these programs adhere to the socio-cultural values of the community. A campaign that demonstrates burn prevention and safety skills such as isolation of all cooking sites with open flames, supervision and ready access to first aid, is likely to be more effective compared with one against total use of open flames. ,
| Conclusion|| |
There are trends that accord to the female gender, low socioeconomic status, and poor adherence to AEDs in this study. The electronic media (television and radio) based on socio-cultural norms is suggested as an effective strategy to increase awareness in burn prevention and fire safety. The possibility of disfigurement demonstrates that burn prevention in epileptics must be aggressively administered.
| References|| |
Botan A. Epilepsy and full-thickness burns. Ann Burns Fire Disasters 2010;23:67-71.
Fisher RS, van Emde Boas W, Blume W, Elger C, Genton P, Lee P, et al.
Epileptic seizures and epilepsy: Definitions proposed by the International League Against Epilepsy (ILAE) and the International Bureau for Epilepsy (IBE). Epilepsia 2005;46:470-2.
Kariuki SM, Matuja W, Akpalu A, Kakooza-Mwesige A, Chabi M, Wagner RG, et al.
Clinical features, proximate causes, and consequences of active convulsive epilepsy in Africa. Epilepsia 2014;55:76-85.
Jang YC, Lee JW, Han KW, Han TH. Burns in epilepsy: Seven years of experience from the Hallym Burn Center in Korea. J Burn Care Res 2006;27:877-81.
Kinton L, Duncan JS. Frequency, causes, and consequences of burns in patients with epilepsy. J Neurol Neurosurg Psychiatry 1998;65:404-5.
Rimmer RB, Bay RC, Foster KN, Jones MA, Wadsworth M, Lessard C, et al.
Thermal injury in patients with seizure disorders: An opportunity for prevention. J Burn Care Res 2007;28:318-23.
Spitz MC. Severe burns as a consequence of seizures in patients with epilepsy. Epilepsia 1992;33:103-7.
Unglaub F, Woodruff S, Demir E, Pallua N. Patients with epilepsy: A high-risk population prone to severe burns as a consequence of seizures while showering. J Burn Care Rehabil 2005;26:526-8.
Abdulrasheed I, Eneye AM. Philtral columns and nostril shapes in nigerian children: A morphometric and aesthetic analysis. Plast Surg Int 2013;2013:382754.
Zan T, Li H, Gu B, Liu K, Xie F, Xie Y, et al.
Surgical treatment of facial soft-tissue deformities in postburn patients: A proposed classification based on a retrospective study. Plast Reconstr Surg 2013;132:1001e-14e.
Minn YK. Who burned and how to prevent? Identification of risk for and prevention of burns among epileptic patients. Burns 2007;33:127-8.
Onwuekwe IO, Onodugo OD, Ezeala-Adikaibe B, Aguwa EN, Ejim EC, Ndukuba K, et al.
Pattern and presentation of epilepsy in Nigerian Africans: A study of trends in the southeast. Trans R Soc Trop Med Hyg 2009;103:785-9.
Jiburum BC, Olaitan PB, Otene CI. Burns in epileptics: Experience from enugu, Nigeria. Ann Burns Fire Disasters 2005;18:148-50.
Karacaoglan N, Uysal A. Deep burns following epileptic seizures. Burns 1995;21:546-9.
Tiamkao S, Shorvon SD. Seizure-related injury in an adult tertiary epilepsy clinic. Hong Kong Med J 2006;12:260-3.
Atiyeh BS, Costagliola M, Hayek SN. Burn prevention mechanisms and outcomes: Pitfalls, failures and successes. Burns 2009;35:181-93.
Mabogunje OA, Khwaja MS, Lawrie JH. Childhood burns in Zaria, Nigeria. Burns 1987;13:298-304.
[Table 1], [Table 2]