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, acne, 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 dermatitis 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, atopic dermatitis, 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, aquagenic pruritus, pruritus ani, The second highest reduction was seen among skin until it becomes erythematous. A less-common apocrine chromhidrosis, lichen simplex chronicus, variant of this technique, direct moxibustion, 15,16 Hispanic adults, with 4 million gaining health- lipodermatosclerosis, and alopecia areata. 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 contact dermatitis 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 hair 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.