Cultural Dermatoses: A Review John C. Howard, DO,* Sergey Arutyunyan, DO, MS,** Jere Mammino, DO, FAAD, FAOCD,*** Stanley Skopit, DO, MSE, FAAD, FAOCD****

*Resident, Department of Dermatology, Larkin Community Hospital, South Miami, FL ** Traditional Rotating Intern, Larkin Community Hospital, South Miami, FL ***Medical Director, Orlando Dermatology Residency, Orlando, FL ****Program Director, Dermatology Residency Training Program, Larkin Community Hospital, South Miami, FL

Disclosures: None Correspondence: John C. Howard, DO; Department of Dermatology, Larkin Community Hospital, 7031 SW 62nd Ave., South Miami, FL 33143; ph: 305-284-7500

Abstract Minorities are expected to make up more than half of the U.S. population by 2044 and of the U.S. child population much sooner. Meanwhile, between 2012 and 2016, the number of insured individuals among minority groups such as Blacks, Hispanics, and non-white non-Hispanics increased significantly.As demographics continue to change, and as more minority individuals gain access to healthcare, dermatology practices will see a shift toward a minority patient base. Recognizing and understanding dermatoses linked to non-U.S. cultural practices will be invaluable for maintaining thriving patient-physician relationships and achieving successful clinical outcomes. In this review, we describe various cultural dermatoses -- skin conditions caused by culture-specific therapeutic, cosmetic, and/or religious practices -- of ethnic and racial groups found in the United States.

Introduction such as fever, congestion, pneumonia, asthma, , The population of the United States is becoming abdominal discomfort, acute myelitis, lower back pain, headaches, and nephritis.4,7,8 It has also been increasingly diverse as the growth of the minority 6 population outpaces the growth of the non- used to eliminate toxins from the body. The areas used for cupping most commonly include the back, Hispanic White population. Recent projections 4 estimate more than half of the U.S. populace will chest, abdomen, and buttocks. The mechanism of belong to a minority group (any group other than cupping is based on creating a vacuum effect. This is non-Hispanic White) by 2044. When the minority achieved by lighting an alcohol-soaked cotton ball population accounts for more than 50% of the total or piece of paper and placing it in a cup. The cup is U.S. population, the U.S. will be what some have inverted onto the skin, the flame gets terminated described as a “majority-minority” nation.1 The due to lack of oxygen, and air begins to cool, creating child population in the United States is even more a vacuum. This leads to the suction of the skin into diverse and is expected to experience the “majority- the cup and subsequent damage of superficial Figure 1 1 blood vessels in the papillary dermis, resulting in minority” crossover much sooner. Additionally, 4,6 the U.S. Census Bureau estimates that in 2015, circular erythema or ecchymosis (Figure 1). leads to parallel ecchymotic streaks12 or petechiae12 the foreign-born segment of the U.S. population These circular burns in a child who was treated with on the skin of the affected patients and may even cupping therapy might be easily mistaken for child was the highest since 1910, comprising 13.5% of 9 lead to burns, as the oiled skin has been reported the populace. That number is projected to increase abuse. Although circular, ecchymotic lesions are to catch fire.13 to approximately 20% by 2060.1 In 2015, the U.S. the most common presentation of cupping, linear purpuric streaks can also be seen if a lubricant is foreign-born population was born in Africa (~5%), 7 Possible causes of allergic contact the Americas (~53%), Asia (~30.6%) and Europe used to move the cup around to cover a larger area. Capsaicin treatment (~11.1%).2 Capsaicin is an active component of the chili Moxibustion peppers commonly used as condiments in Latin- Moxibustion is commonly practiced in Asian 10,14 The Patient Protection and Affordable Care Act 5,6 American food preparations. Topical capsaicin (PPACA), commonly known as Obamacare, was cultures. This therapy is used for treating fever, preparations have been safely and successfully enacted in 2010. A U.S. Department of Health asthma, , and abdominal pain and used in various fields of medicine. For instance, consists of burning moxa herb (Artemisia vulgaris) and Human Services report indicates that between 5,6,8 the agent has been used by dermatologists for 2012 and 2016, reduction in the uninsured rate either on the skin or very close to the skin. a wide range of conditions, such as neurogenic was greatest among Black non-Hispanics, with 3 Indirect moxibustion, the more commonly used pain or pruritus, brachioradial pruritus, pruritus million people gaining health-insurance coverage.3 variant, involves burning of the moxa stick near the of hemodialysis, , , The second highest reduction was seen among skin until it becomes erythematous. A less-common apocrine , , Hispanic adults, with 4 million gaining health- variant of this technique, direct moxibustion, lipodermatosclerosis, and .15,16 3 entails burning cones of the wood directly on the insurance coverage. 10 However, peeling the peppers with bare hands while skin, leading to second-degree burns. Although cooking may lead to erythema, edema, burning pain, most lesions caused by moxibustion are transient, 14 As the population makeup of the United States 10 and irritation. It is important to keep capsaicin continues to change, and as more people gain access permanent scarring has been reported. Similarly to dermatitis on the differential because patients may those produced by cupping, these lesions might be to healthcare, it is likely that dermatology practices 5 not recall the exposure, as handling the peppers is across the nation will see a shift in their patient base. mistaken for signs of abuse in adults and children. part of their routine. In this review, we attempt to raise awareness about both therapeutic and cosmetic cultural practices Coining To alleviate the symptoms of capsaicin dermatitis, of various ethnic and religious groups and review Coining (cao gio in Vietnamese) or spooning (gua patients are advised to wash their hands with soap associated dermatological manifestations associated sa in Chinese) is a widely used technique in Asian and water and apply vegetable oil. The use of high- cultures in Vietnam, China, Thailand, Malaysia with those practices. 4,10,11 potency corticosteroids and topical anesthetics has and Indonesia. This therapy is used to treat also been reported.14 Furthermore, to prevent this fever, flu, headaches, and myalgia and is believed to condition, patients are advised to wear gloves when Cultural Practices improve these symptoms by improving circulation peeling the peppers. in soft tissues.11 Coining is performed by applying and Associated Conditions water or aromatic oils onto the skin of the chest and Toothpaste Cupping back and subsequently rubbing the skin with a coin Cupping is a technique used widely in the Asian, 11 Toothpaste-induced allergic in a downward motion until the skin is reddened. usually affects the index finger of individuals Latin American, Middle Eastern , and Eastern While a coin is widely used in this remedy, the European cultures.4-6 In the United States, cupping from Southeast Asia who use their index finger 5 literature also reports use of several other tools, such to rub toothpaste over their teeth. In one report, is practiced primarily by Russian immigrants. It as combs and porcelain spoons. Coining usually has been used for treating a wide range of ailments toothpaste-induced allergic contact dermatitis

CULTURAL DERMATOSES: A REVIEW of the index finger presented concurrently with darker pigment but also shortens drying time, is important as it can be reversed if hairstyle dermatitis of the lip.17 reducing the time required for henna sessions modifications are made. Sikh individuals should be from 12 hours (when red henna is used) to less advised to tie loosely during the day and leave Colored string than two hours.29 PPD-enhanced black henna it untied during the night.40 Colored-string-induced allergic contact dermatitis has been associated with not only allergic contact results from wearing colored strings around the dermatitis but also papulovesicular eruptions, Prayer nodules neck, arms, or waist and is common in South bullae formation, and erythema multiforme-like Prayer nodules are painless calluses that occur in Asian individuals. These strings may cause skin reactions.26,28,30,31 Emerging evidence of long- response to repeated pressure to the skin while friction, leading to allergic reactions. Furthermore, term or even permanent adverse effects associated praying. These nodules have been reported in depigmentation may develop at the sites of skin with the use of PPD-enhanced black henna individuals of Christian, Buddhist, and Muslim contact due to the chemicals in the string, leading are particularly concerning. Leukoderma, post- faiths and are most common in elderly Latin- 18 6,41,42 to linear leukoderma. inflammatory hyperpigmentation, keloids, and type American women and Muslim men. These I hypersensitivity reaction leading to angioedema lesions have most commonly been reported on Drawstring and acute renal failure have been described in the knees, ankles, and dorsum of the feet in these 41,43 Drawstring dermatitis results from wearing the the published literature.32-34 Since the practice of populations. Among Muslims, the forehead traditional clothes favored by many South Asians. henna is an integral part of spiritual and traditional is also a common location. Position modification Clothes like the sari, a traditional dress worn by rituals in many cultures, it is important to educate while praying can prevent these nodules, and women in India, Pakistan, Bangladesh, and Sri patients about potential side effects of black-henna topical use of 40% urea ointment can be used to 44 Lanka, and salwaar, the baggy trousers worn by preparations and advise them to choose red henna treat them. men and women from the same cultures, are tightly as their decorative agent of choice. tied with a drawstring at the waist. This results in Scarification friction and may cause irritation as well as lead to Acne Scarification is practiced in many parts of Africa lichenification, post-inflammatory leukoderma, for aesthetic and cultural purposes, with scars hyperpigmentation, and koebnerization of existing Pomade acne is a caused by pomades, indicating rank in society, family, clan, and tribe 19,20 45 dermatoses like vitiligo and . substances used to straighten hair and lubricate the and also serving as decoration. Sometimes A case of squamous cell carcinoma at the scalp. Pomade contains high-melting hydrocarbons scarring is performed on youth for medical reasons. 19 drawstring-friction site has also been reported. that allow the substance to stay in the hair longer For example, in Ethiopia, placing superficial scars Loose drawstrings have been recommended to than gels and sprays.35 Pomade acne primarily around the eye is believed to prevent eye disease prevent this condition. Weight reduction is also affects individuals from African American and and improve vision (Figure 3). Some governments recommended in these patients since fatty tissue Latin American cultures.10,35 Clinically, these are now banning this practice, considering it child is proinflammatory and a major source of tumor lesions manifest as perifollicular papules, pustules, abuse and a contributor to the spread of HIV. necrosis factor-alpha, which may lead to significant and closed comedones and occur on the forehead, 21 inflammatory response. temples, and cheeks.10,35,36 Pearling Pearling, also known as penile beading, is the Bindi Steroidal acne practice of permanently implanting small objects Bindi, also known as kumkum or tilak, is a disc- Steroidal acne is caused by excessive use of potent shaped ornament worn by Indian women for topical corticosteroids on the face. These lesions 4 socio-religious purposes. It is applied to the usually present in individuals from Asian cultures forehead, between the eyebrows, to indicate with darker skin types who use topical steroids to marital status, but can also be worn as a fashion lighten their skin.35 accessory.4,22 Historically, the bindi has been made from turmeric pastes with addition of various Acquired dyes to complement the color of the dress. Also, Acquired trichorrhexis nodosa is a hair disorder that bindi discs have been made of nickel or polyvinyl results from external physical or chemical insults chloride with a resinous adhesive material.23,24 that damage the hair shaft. The proximal variant Several adverse reactions to bindi materials have of trichorrhexis nodosa affects proximal hair and been reported, including allergic dermatitis, contact is most common among African Americans.10 This leukoderma, hyperpigmentation, and foreign-body condition is caused by excessive 4,22,25 granuloma. Reports in the published literature with hot combs and ceramic flat irons, permanent Figure 2 describe contact dermatitis to nickel dyes, such weaves, brushing and combing, or use of chemicals as Brilliant Lake Red R, Disperse Blue 124, and and hair dyes.10,37 The examination of hair will Disperse Blue 106, as well as chemical additives, reveal one or more nodes presenting as white specks such as thimerosal and gallate mix and para- on the affected hair shaft. Since breakage of the tertiary-butylphenol.4,22-24 hair occurs close to the skin surface, patients may present with areas of alopecia.10,38 The distal variant Henna of trichorrhexis nodosa is more common in White Henna, also known as hina, is a natural dye or Asian individuals. This variant is characterized by derived from the leaves of the Lawsonia inermis nodes and breakage that occur several inches from plant. This product is frequently used to dye skin, the scalp, producing hair that appears uneven. This 26 hair, fingernails, leather, silk, and fur. Although condition is caused by excessive hair styling and is widely used in South Asian, Middle Eastern, and commonly associated with longitudinal splitting, North African cultures, many reported cases of commonly known as split ends.38 adverse dermatologic reactions to henna involve patients who were not part of these cultures and received a henna tattoo or were otherwise exposed Traction alopecia is a hair-loss disorder that to henna products.27 Pure henna, known as “red commonly presents in the African American henna,” is hypoallergenic and has rarely been population and in men practicing the Sikh religion associated with adverse reactions, with only two (Figure 2).10,39 Like acquired trichorrhexis nodosa, reported cases of red-henna contact dermatitis traction alopecia results from physical insults to the in the literature.4,28 However, there are multiple hair. Various styling techniques, such as braiding, reports of contact dermatitis associated with “black cornrowing, and tightly rolling the hair, have been henna,” a preparation consisting of red henna associated with this condition.10 Sikh men tie their and pigment enhancers such as coffee, black tea, hair into a tight knot on the vertex area of the head 4,27 39 animal urine, and paraphenylenediamine (PPD). and twist facial hair into a knot under the chin. Figure 3 PPD is a coal-tar hair dye that not only enhances Early recognition and diagnosis of traction alopecia

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HOWARD, ARUTYUNYAN, MAMMINO, SKOPIT