Introduction
Since its introduction on the market in 2007, the number of reports on injuries caused by the overheating, ignition or explosion of electronic nicotine delivery systems (ENDS) has increased significantly. These injuries appear to have different causes, the most important one being lithium-ion battery overheating leading to ignition or explosion (“thermal runaway”).
Methods
A retrospective analysis of our burn database was performed from January 2007 until March 2019 for injuries caused by or related to using an ENDS. 
Results
Since 2007, two male patients (45 and 47 years old) were treated at our burn center for ENDS related injuries. Their batteries came into contact with metal objects, creating an external short circuit which led these batteries to go into thermal runaway, inside the patients’ pockets. This resulted in combined chemical and flame burns. In both patients the upper legs were involved (TBSA 9%) and in one patient the fingers were involved as well.  Both patients suffered a partial-thickness burn with one patient also having a patch of full-thickness burn (Fig 1). Laser Doppler Imaging (LDI scan) resulted in an estimated healing time of more than 21 days with a clear indication for surgery in both patients (Fig 2). Although enzymatic debridement (NexoBrid®, Mediwound) is not recommended in the treatment of chemical burns, we successfully made use of this treatment option in both cases (Fig 3 and 4). The wounds were then treated conservatively until complete wound healing (Fig 5). The mean time to complete wound closure was 48 days (range 35 – 61). Despite this long healing time, no hypertrophic scarring was observed at follow-up (Fig 6). No clinical nor laboratory adverse events occurred, proving the safety and value of enzymatic debridement after ENDS related burns.
Conclusion
In two patients, off label use of enzymatic debridement was performed successfully in the treatment of a combined chemical (alkali) and flame burn. In literature, caution is recommended when exposing alkali burns to irrigation with water, as contact between the chemical compounds and water sets off an exothermic reaction. Although the use of mineral oil is advised by most authors, we believe other substances like Diphoterine® could be recommended as well to eradicate the chemical compounds in deep burns, followed by the safe and effective use of enzymatic debridement.

1 - Combined chemical and flame burns due to an electronic nicotine delivery system: first report on neutralization of the chemical product, followed by enzymatic debridement