Dermatoses Due to Indian Cultural Practices
Identifieur interne : 000505 ( Pmc/Corpus ); précédent : 000504; suivant : 000506Dermatoses Due to Indian Cultural Practices
Auteurs : Divya Gupta ; Devinder Mohan ThappaSource :
- Indian Journal of Dermatology [ 0019-5154 ] ; 2015.
Abstract
A wide prevalence of socio-religious and cultural practices in the Asian subcontinent often leads to multitude of skin diseases which may be missed by the dermatologists because of a lack of awareness. ‘Henna’ use causes IgE-mediated hypersensitivity reactions and contact dermatitis. ‘Kumkum’ application can result in pigmented contact dermatitis and lichen planus pigmentosus. Sticker ‘bindis’ and ‘alta’ induce contact leukoderma. Irritant and allergic contact dermatitis occurs after playing with ‘Holi’ colors. Threading and drawstring dermatitis lead to koebnerization of pre-existing dermatoses, infections and even squamous cell carcinoma of skin. Mild irritant reactions and contact sensitization occur secondary to balm and hair oil use. ‘Mudichood’ represents the comedogenic effect of hair oils combined with occlusion and humidity. Aromatherapy oils can cause contact dermatitis and photosensitive reactions. Heavy metal and steroid toxicity along with severe cutaneous adverse effects like erythroderma can occur as a consequent to the use of alternative medicines. Squamous cell carcinoma due to chronic heat exposure from the heating device “
Url:
DOI: 10.4103/0019-5154.147778
PubMed: 25657390
PubMed Central: 4318059
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PMC:4318059Le document en format XML
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<front><div type="abstract" xml:lang="en"><p>A wide prevalence of socio-religious and cultural practices in the Asian subcontinent often leads to multitude of skin diseases which may be missed by the dermatologists because of a lack of awareness. ‘Henna’ use causes IgE-mediated hypersensitivity reactions and contact dermatitis. ‘Kumkum’ application can result in pigmented contact dermatitis and lichen planus pigmentosus. Sticker ‘bindis’ and ‘alta’ induce contact leukoderma. Irritant and allergic contact dermatitis occurs after playing with ‘Holi’ colors. Threading and drawstring dermatitis lead to koebnerization of pre-existing dermatoses, infections and even squamous cell carcinoma of skin. Mild irritant reactions and contact sensitization occur secondary to balm and hair oil use. ‘Mudichood’ represents the comedogenic effect of hair oils combined with occlusion and humidity. Aromatherapy oils can cause contact dermatitis and photosensitive reactions. Heavy metal and steroid toxicity along with severe cutaneous adverse effects like erythroderma can occur as a consequent to the use of alternative medicines. Squamous cell carcinoma due to chronic heat exposure from the heating device “<italic>kangri</italic>
” is seen in Kashmiris. Prayer nodules in Muslims and traction alopecia in Sikhs illustrate how religious practices can negatively affect the skin. With increasing globalization and migration, the practice of indigenous customs and traditions is no longer limited to regional territories, making it imperative for the dermatologists to be acquainted with the cutaneous side effects they can cause.</p>
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<pmc article-type="review-article"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">Indian J Dermatol</journal-id>
<journal-id journal-id-type="iso-abbrev">Indian J Dermatol</journal-id>
<journal-id journal-id-type="publisher-id">IJD</journal-id>
<journal-title-group><journal-title>Indian Journal of Dermatology</journal-title>
</journal-title-group>
<issn pub-type="ppub">0019-5154</issn>
<issn pub-type="epub">1998-3611</issn>
<publisher><publisher-name>Medknow Publications & Media Pvt Ltd</publisher-name>
<publisher-loc>India</publisher-loc>
</publisher>
</journal-meta>
<article-meta><article-id pub-id-type="pmid">25657390</article-id>
<article-id pub-id-type="pmc">4318059</article-id>
<article-id pub-id-type="publisher-id">IJD-60-3</article-id>
<article-id pub-id-type="doi">10.4103/0019-5154.147778</article-id>
<article-categories><subj-group subj-group-type="heading"><subject>Review Article</subject>
</subj-group>
</article-categories>
<title-group><article-title>Dermatoses Due to Indian Cultural Practices</article-title>
</title-group>
<contrib-group><contrib contrib-type="author"><name><surname>Gupta</surname>
<given-names>Divya</given-names>
</name>
<xref ref-type="aff" rid="aff1"></xref>
</contrib>
<contrib contrib-type="author"><name><surname>Thappa</surname>
<given-names>Devinder Mohan</given-names>
</name>
<xref ref-type="aff" rid="aff1"></xref>
<xref ref-type="corresp" rid="cor1"></xref>
</contrib>
</contrib-group>
<aff id="aff1"><italic>From the Department of Dermatology and Sexually Transmitted Diseases (STD), Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India</italic>
</aff>
<author-notes><corresp id="cor1"><italic><bold>Address for correspondence:</bold>
Dr. Devinder Mohan Thappa, Department of Dermatology and Sexually Transmitted Diseases (STD), Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry - 605 006, India. E-mail: <email xlink:href="dmthappa@gmail.com">dmthappa@gmail.com</email>
</italic>
</corresp>
</author-notes>
<pub-date pub-type="ppub"><season>Jan-Feb</season>
<year>2015</year>
</pub-date>
<volume>60</volume>
<issue>1</issue>
<fpage>3</fpage>
<lpage>12</lpage>
<history><date date-type="received"><month>3</month>
<year>2014</year>
</date>
<date date-type="accepted"><month>4</month>
<year>2014</year>
</date>
</history>
<permissions><copyright-statement>Copyright: © Indian Journal of Dermatology</copyright-statement>
<copyright-year>2015</copyright-year>
<license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by-nc-sa/3.0"><license-p>This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.</license-p>
</license>
</permissions>
<abstract><p>A wide prevalence of socio-religious and cultural practices in the Asian subcontinent often leads to multitude of skin diseases which may be missed by the dermatologists because of a lack of awareness. ‘Henna’ use causes IgE-mediated hypersensitivity reactions and contact dermatitis. ‘Kumkum’ application can result in pigmented contact dermatitis and lichen planus pigmentosus. Sticker ‘bindis’ and ‘alta’ induce contact leukoderma. Irritant and allergic contact dermatitis occurs after playing with ‘Holi’ colors. Threading and drawstring dermatitis lead to koebnerization of pre-existing dermatoses, infections and even squamous cell carcinoma of skin. Mild irritant reactions and contact sensitization occur secondary to balm and hair oil use. ‘Mudichood’ represents the comedogenic effect of hair oils combined with occlusion and humidity. Aromatherapy oils can cause contact dermatitis and photosensitive reactions. Heavy metal and steroid toxicity along with severe cutaneous adverse effects like erythroderma can occur as a consequent to the use of alternative medicines. Squamous cell carcinoma due to chronic heat exposure from the heating device “<italic>kangri</italic>
” is seen in Kashmiris. Prayer nodules in Muslims and traction alopecia in Sikhs illustrate how religious practices can negatively affect the skin. With increasing globalization and migration, the practice of indigenous customs and traditions is no longer limited to regional territories, making it imperative for the dermatologists to be acquainted with the cutaneous side effects they can cause.</p>
</abstract>
<kwd-group><kwd><italic>Alta</italic>
</kwd>
<kwd><italic>alternative medicine</italic>
</kwd>
<kwd><italic>bindi</italic>
</kwd>
<kwd><italic>drawstring dermatitis</italic>
</kwd>
<kwd><italic>henna</italic>
</kwd>
<kwd><italic>holi dermatoses</italic>
</kwd>
<kwd><italic>kumkum</italic>
</kwd>
<kwd><italic>mudichood</italic>
</kwd>
<kwd><italic>prayer nodules</italic>
</kwd>
<kwd><italic>traction alopecia</italic>
</kwd>
</kwd-group>
</article-meta>
</front>
<body><boxed-text position="float"><p><bold>What was known?</bold>
</p>
<p>Most of the evidence regarding dermatoses secondary to Indian cultural practices is scattered in the literature and comes from case reports and case series.</p>
</boxed-text>
<sec sec-type="intro" id="sec1-1"><title>Introduction</title>
<p>In the Asian subcontinent, the presence of various socio-religious and cultural practices along with widespread use of complementary and alternative medicine frequently result in a host of secondary dermatoses. With increasing migration and sharing of cultures, it is vital for dermatologists to be familiar with these dermatoses. This review focuses on Indian cultural and religious practices and traditional medicines which can result in skin disorders.</p>
<sec id="sec2-1"><title></title>
<sec id="sec3-1"><title>Henna</title>
<p>The history and origin of henna is hard to trace with centuries of migration and cultural interaction. The active ingredient of henna is lawsone (2-hydroxy-1, 4-naphthoquinone).[<xref rid="ref1" ref-type="bibr">1</xref>
] It is derived from the leaves and flowers of <italic>Lawsonia inermis</italic>
, family Lythraceae, a plant which grows in hot climates of northern Africa and western and southern Asia.[<xref rid="ref2" ref-type="bibr">2</xref>
] Hence, it is not surprising that the use of henna has flourished in these regions.</p>
<p>In India, henna is used as <italic>Mehndi</italic>
[<xref ref-type="fig" rid="F1">Figure 1</xref>
] and also as a hair dye. In the West, henna has gained popularity in recent years as a temporary tattoo as it does not require any piercing (pseudo-tattooing).[<xref rid="ref3" ref-type="bibr">3</xref>
] Traditionally, several medicinal properties are attributed to henna. It is also believed to act as a preservative for leather and cloth as it repels pests and mildew.</p>
<fig id="F1" position="float"><label>Figure 1</label>
<caption><p>Mehndi (Henna) design on the hands of a Hindu bride</p>
</caption>
<graphic xlink:href="IJD-60-3-g001"></graphic>
</fig>
<p>Pure henna rarely causes allergic reactions.[<xref rid="ref4" ref-type="bibr">4</xref>
] However, cases of palpebral eczema, allergic contact dermatitis and immediate-type hypersensitivity with urticaria, rhinitis, conjunctivitis and bronchial asthma have been recorded,[<xref rid="ref1" ref-type="bibr">1</xref>
<xref rid="ref5" ref-type="bibr">5</xref>
<xref rid="ref6" ref-type="bibr">6</xref>
] with type-I hypersensitivity being confirmed by both skin prick test[<xref rid="ref7" ref-type="bibr">7</xref>
] and radio allergen sorbent test (RAST).[<xref rid="ref8" ref-type="bibr">8</xref>
] In most cases, allergic reactions are caused by coloring agents like para-phenylenediamine (PPD) (“Black henna”), diaminotoluenes and diaminobenzenes which are added to pure henna for quicker drying and deeper color intensity.[<xref rid="ref1" ref-type="bibr">1</xref>
] In one study, the prevalence of patch test positivity to PPD among beauticians and hairdressers was 35%, whereas it was only 3% to pure henna.[<xref rid="ref9" ref-type="bibr">9</xref>
] In fact, the percentage of PPD may be as high as 64% in products purporting to be henna.[<xref rid="ref10" ref-type="bibr">10</xref>
] Heavy metals like nickel and cobalt, which are often present in henna tattoo mixtures, have also been proposed as inciting agents for sensitization.[<xref rid="ref4" ref-type="bibr">4</xref>
] PPD has been known to cause severe generalized vesicular erythema multiforme-like reaction,[<xref rid="ref11" ref-type="bibr">11</xref>
] and contact angioedema[<xref rid="ref12" ref-type="bibr">12</xref>
] progressing to involve pharynx, larynx and bronchi with hoarseness of voice and stridor.[<xref rid="ref13" ref-type="bibr">13</xref>
] More seriously it may cause acute renal failure and ultimately death due to renal tubular necrosis.[<xref rid="ref14" ref-type="bibr">14</xref>
] It has been reported to cause pruritus, severe bullous contact dermatitis,[<xref rid="ref15" ref-type="bibr">15</xref>
] post inflammatory hypo or hyperpigmentation,[<xref rid="ref2" ref-type="bibr">2</xref>
<xref rid="ref16" ref-type="bibr">16</xref>
] persistent leukoderma,[<xref rid="ref17" ref-type="bibr">17</xref>
] hypertrichosis,[<xref rid="ref18" ref-type="bibr">18</xref>
] lichenoid reactions[<xref rid="ref19" ref-type="bibr">19</xref>
] and keloids.[<xref rid="ref20" ref-type="bibr">20</xref>
<xref rid="ref21" ref-type="bibr">21</xref>
] Hyperbilirubinemia was observed in glucose-6-phosphate dehydrogenase (G6PD)-deficient individuals exposed to henna, due to oxidative hemolysis.[<xref rid="ref22" ref-type="bibr">22</xref>
] These patients may have been previously sensitized to PPD through exposure to hair or textile dyes, black rubber products, plastics, oils, adhesive tapes, shoes, petrol, certain cosmetics, and ballpoint pens.[<xref rid="ref11" ref-type="bibr">11</xref>
<xref rid="ref19" ref-type="bibr">19</xref>
] The mechanism of sensitization is based on the conversion (by oxidation) of the pro-hapten (PPD) to the hapten (quinone diamine) that can react directly with a protein, causing irritation of the skin and mucous membranes of the sensitive individuals.[<xref rid="ref22" ref-type="bibr">22</xref>
] There have been demands for legislation that prohibits the use of PPD in black henna tattoos. Therefore, patch tests for PPD and heavy metals should be conducted when henna-related allergic contact dermatitis occurs, along with additional tests as necessary.</p>
</sec>
<sec id="sec3-2"><title>Kumkum/sindoor/tilak/tika</title>
<p>‘Kumkum’ (available as powder and liquid) is usually applied to the center of the forehead, occasionally dusted on the front of the neck or used on the hair parting as “<italic>Sindoor</italic>
” (vermilion) to denote the woman's marital status.[<xref rid="ref23" ref-type="bibr">23</xref>
] Although majority of Hindu women use kumkum, dermatitis due to it develops only in a few. This can be explained by either individual susceptibility or constant use for a prolonged period. It is also a common practice for males, especially priests, to use kumkum for religious purposes.[<xref rid="ref24" ref-type="bibr">24</xref>
]</p>
<p>Nath and Thappa[<xref rid="ref23" ref-type="bibr">23</xref>
] found pigmented contact dermatitis [<xref ref-type="fig" rid="F2">Figure 2</xref>
] in 76% of the patients and allergic contact dermatitis in 24% of the patients using kumkum. Forehead was the most common site, followed by the glabellar area, hair parting, abdomen, and neck [<xref ref-type="fig" rid="F3">Figure 3</xref>
]. The surrounding skin may be involved if the kumkum trickles down the skin in sweat.[<xref rid="ref25" ref-type="bibr">25</xref>
] Other presentations include only brown or slate gray hyperpigmentation without clinically overt dermatitis[<xref rid="ref25" ref-type="bibr">25</xref>
<xref rid="ref26" ref-type="bibr">26</xref>
] and lichen planus pigmentosus.[<xref rid="ref25" ref-type="bibr">25</xref>
] ’<italic>Chandan</italic>
’ or sandalwood paste in kumkum can also cause photoallergic reactions, and these patients must also undergo a photo patch test.[<xref rid="ref24" ref-type="bibr">24</xref>
]</p>
<fig id="F2" position="float"><label>Figure 2</label>
<caption><p>Kumkum-induced pigmented contact dermatitis</p>
</caption>
<graphic xlink:href="IJD-60-3-g002"></graphic>
</fig>
<fig id="F3" position="float"><label>Figure 3</label>
<caption><p>Allergic contact dermatitis extending up to glabella and hair parting. Note that patient continues to wear the bindi in spite of active dermatitis</p>
</caption>
<graphic xlink:href="IJD-60-3-g003"></graphic>
</fig>
<p>In India, it is often difficult to obtain the exact constituents of kumkum from the manufacturers for patch testing. The present knowledge of the constituents of kumkum comes from a limited number of case reports and case series. The commercially prepared kumkum has been shown to contain Brilliant Lake Red R, Sudan I, aminoazobenzene, canaga oil, fragrances, groundnut oil, tragacanth gum, turmeric powder,[<xref rid="ref27" ref-type="bibr">27</xref>
] thimerosal, gallate mix, PPD, Kathon CG, benzotriazol, tert-butyl hydroquinone,[<xref rid="ref23" ref-type="bibr">23</xref>
] parabens,[<xref rid="ref23" ref-type="bibr">23</xref>
<xref rid="ref27" ref-type="bibr">27</xref>
] ’<italic>chandan</italic>
’,[<xref rid="ref24" ref-type="bibr">24</xref>
] chalk powder colored with various azo dyes[<xref rid="ref25" ref-type="bibr">25</xref>
] and other dyes (coal tar dyes, toluidine red, erythrosine, and lithol red calcium salt).[<xref rid="ref28" ref-type="bibr">28</xref>
] The red-colored powder “<italic>sindoor</italic>
” contains mercury and the black paste lead sulfide.[<xref rid="ref25" ref-type="bibr">25</xref>
] It is common to see saffron, ash or camphor being smeared onto the neck or forehead skin in the temples (personal observation).</p>
</sec>
<sec id="sec3-3"><title>Bindi</title>
<p>The terms kumkum and bindi overlap somewhat, but are not synonymous. Kumkum is always applied with paste or powder and can cover the face or other parts of the body. On the other hand, a bindi may be paste or a sticker and is worn only between the eyes. Self-adhesive bindis (sticker bindis) are disposable substitutes for older liquid bindis, and are popular because of their ease of application.[<xref rid="ref24" ref-type="bibr">24</xref>
]</p>
<p>Contact leukoderma is one of the most frequent manifestations of sticker bindis [<xref ref-type="fig" rid="F4">Figure 4</xref>
].[<xref rid="ref29" ref-type="bibr">29</xref>
<xref rid="ref30" ref-type="bibr">30</xref>
<xref rid="ref31" ref-type="bibr">31</xref>
] In a study of 864 cases of chemical leukoderma, 104 (12%) cases were due to adhesive bindi.[<xref rid="ref32" ref-type="bibr">32</xref>
] It is possible that bindi-induced depigmentation may be more common in patients predisposed to vitiligo,[<xref rid="ref33" ref-type="bibr">33</xref>
] and chemical leukoderma must be excluded with certainty from every case of idiopathic vitiligo.[<xref rid="ref32" ref-type="bibr">32</xref>
] Irritation, pruritus and erythema may be seen prior to the development of depigmentation.[<xref rid="ref31" ref-type="bibr">31</xref>
] The lag period between use and depigmentation is highly variable, ranging from a few weeks to a few years. Other presentations include allergic contact dermatitis [<xref ref-type="fig" rid="F5">Figure 5</xref>
][<xref rid="ref34" ref-type="bibr">34</xref>
] and granuloma formation.[<xref rid="ref35" ref-type="bibr">35</xref>
]</p>
<fig id="F4" position="float"><label>Figure 4</label>
<caption><p>Bindi leukoderma</p>
</caption>
<graphic xlink:href="IJD-60-3-g004"></graphic>
</fig>
<fig id="F5" position="float"><label>Figure 5</label>
<caption><p>Allergic contact dermatitis to sticker bindi</p>
</caption>
<graphic xlink:href="IJD-60-3-g005"></graphic>
</fig>
<p>The sticker bindis are made up of circular discs of polyvinylchloride (PVC)[<xref rid="ref31" ref-type="bibr">31</xref>
] and the adhesive material contains para-tertiary butyl phenol (PTBP),[<xref rid="ref31" ref-type="bibr">31</xref>
<xref rid="ref32" ref-type="bibr">32</xref>
<xref rid="ref36" ref-type="bibr">36</xref>
] the concentration of which may be as high as 80%.[<xref rid="ref36" ref-type="bibr">36</xref>
] These agents cause depigmentation through their melanocytotoxic effect. Other allergens implicated in causation of contact dermatitis due to bindi include epoxy resins,[<xref rid="ref37" ref-type="bibr">37</xref>
] Disperse Blue 124, Disperse Blue 106,[<xref rid="ref38" ref-type="bibr">38</xref>
] nickel[<xref rid="ref34" ref-type="bibr">34</xref>
] and thimerosal and gallate mix.[<xref rid="ref39" ref-type="bibr">39</xref>
]</p>
<p>The treatment of bindi leukoderma hinges upon early recognition of the condition and cessation of use of sticker bindis, which can be difficult as most married Hindu women are strongly conditioned to wear a bindi at all times. Other modalities include topical steroids and melanocyte transfer surgery.[<xref rid="ref40" ref-type="bibr">40</xref>
]</p>
</sec>
<sec id="sec3-4"><title>Alta</title>
<p>Alta is a red-colored dye applied by women hailing from West Bengal to the border of their feet during religious and social functions. Sometimes, the Hindu bride steps into a plate of alta before crossing the threshold of her in-laws house for the first time. Alta can cause dermatitis followed by depigmentation at the site of application.[<xref rid="ref41" ref-type="bibr">41</xref>
] Ghosh and Mukhopadhyay found the frequency of alta-induced depigmentation to be 1.2% of all chemical leukoderma cases.[<xref rid="ref32" ref-type="bibr">32</xref>
] Chemical agents in alta include azo dyes and PPD.[<xref rid="ref41" ref-type="bibr">41</xref>
] Bajaj <italic>et al</italic>
. found solvent yellow 3,[<xref rid="ref42" ref-type="bibr">42</xref>
] Crocein Scarlet MOO (CSM) (brilliant crocein) and rhodamine B (tetraethyl rhodamine) in alta by chromatographic and spectroscopic analysis.[<xref rid="ref41" ref-type="bibr">41</xref>
]</p>
</sec>
<sec id="sec3-5"><title>Holi dermatoses</title>
<p>Holi is a harvest festival in which people symbolically smear dry powdered colors (“<italic>Abeer</italic>
” or “<italic>Gulal</italic>
”) and spray water soluble colors on each other. These synthetic colors are sold in an unregulated manner in roadside markets and no checks can be enforced on the product composition leading to an annual spurt in dermatoses each year immediately following Holi.[<xref rid="ref43" ref-type="bibr">43</xref>
]</p>
<p>The Holi colors contain many hazardous chemicals [<xref ref-type="table" rid="T1">Table 1</xref>
][<xref rid="ref44" ref-type="bibr">44</xref>
] and heavy metals like asbestos or silica, which can cause respiratory problems, skin diseases and eye problems. Many of the water-soluble colors have an alkaline base.[<xref rid="ref44" ref-type="bibr">44</xref>
] Sometimes, mica or powdered glass is added as sparkling agent to the colors.[<xref rid="ref43" ref-type="bibr">43</xref>
]</p>
<table-wrap id="T1" position="float"><label>Table 1</label>
<caption><p>Harmful chemicals in Holi colors</p>
</caption>
<graphic xlink:href="IJD-60-3-g006"></graphic>
</table-wrap>
<p>In a study of 42 patients with Holi dermatoses, Ghosh <italic>et al</italic>
.[<xref rid="ref45" ref-type="bibr">45</xref>
] found itching to be the most common symptom (60%) followed by burning sensation, pain, and oozing. Eczematous lesions were the most common (57%), followed by erosions, scaling, erythema, urticaria, and acute nail-fold inflammation. Aggravation of pre-existing skin disorders (acne, eczema, and paronychia) and secondary pyoderma occurred in 31% and 7% patients, respectively. Vigorous scrubbing with abrading materials to remove color from the skin led to facial abrasions. The most common site of involvement was the face and other areas of exposed skin. Hand involvement was seen secondary to preparation of the colored solutions. Photosensitivity, tenderness and acute exfoliation due to sunburn have been reported.[<xref rid="ref43" ref-type="bibr">43</xref>
]</p>
</sec>
<sec id="sec3-6"><title>Mudichood</title>
<p>This rare condition, the literal meaning of which is “hair-heat” in Malayalam language, is commonly seen in young women in the southern tropical parts of India, especially in Kerala. Women from this area wash and oil their long hair daily and then leave it to dry in the sun. This condition represents a nonspecific follicular reaction to oil aggravated by moist environment and profuse sweating.[<xref rid="ref46" ref-type="bibr">46</xref>
]</p>
<p>Mudichood is characterized by itchy, pigmented lichenoid dermatitis with follicular, flat-topped scaly papules on the pinnae,[<xref rid="ref47" ref-type="bibr">47</xref>
] nape of neck, upper back and even forearm.[<xref rid="ref48" ref-type="bibr">48</xref>
] The papules have a thin keratinous rim, and there is a slight depression in the center. Manual removal of adherent scales leaves a hyperpigmented base.[<xref rid="ref49" ref-type="bibr">49</xref>
] Koebner's phenomenon has been noted.[<xref rid="ref46" ref-type="bibr">46</xref>
] Long-standing cases may show confluence of papules.[<xref rid="ref49" ref-type="bibr">49</xref>
]</p>
<p>Histopathology is characterized by focal parakeratosis, acanthosis and occasional suprapapillary thinning. Cells with large vacuolated nuclei are seen in superficial layers of the epidermis. The dermal papillae appear edematous, and the capillaries may be dilated.[<xref rid="ref46" ref-type="bibr">46</xref>
<xref rid="ref49" ref-type="bibr">49</xref>
]</p>
<p>Treatment with 3-5% salicylic, short hair and regular washing with shampoos helps prevent this condition.[<xref rid="ref46" ref-type="bibr">46</xref>
<xref rid="ref49" ref-type="bibr">49</xref>
]</p>
</sec>
<sec id="sec3-7"><title>Threading</title>
<p>Threading is a cheap and effective, though painful, method of removal of facial vellus hairs, which is commonly come across in beauty salons of South Asia and the Middle East. Most women are unaware of the possible complications of this procedure which include transient erythema, edema, irritant dermatitis, and pigmentary changes like hyperpigmentation as well as depigmentation.[<xref rid="ref50" ref-type="bibr">50</xref>
] In particular, threading-induced trauma can lead to koebnerization of pre-existing dermatoses, especially vitiligo.[<xref rid="ref51" ref-type="bibr">51</xref>
] Infections like folliculitis, verrucae, pseudofolliculitis, molluscum contagiosum[<xref rid="ref52" ref-type="bibr">52</xref>
] and bullous impetigo[<xref rid="ref53" ref-type="bibr">53</xref>
] can arise. Verma proposed that threading-induced disruption of the dermal-epidermal junction allowed seeding of human papilloma virus (HPV), which could have been present on the threading equipment, on the beautician's hands, or on other parts of the patient's body. Damage to the melanocyte stem cell reservoir in the bulge area of hair follicle was believed to lead to depigmentation.[<xref rid="ref51" ref-type="bibr">51</xref>
] Aseptic techniques should be followed by the beautician to prevent infectious complications.[<xref rid="ref54" ref-type="bibr">54</xref>
]</p>
</sec>
<sec id="sec3-8"><title>Ayurveda/alternative medicines</title>
<p>Complementary and alternative medicines (CAMs) are used both for dermatological and non-dermatological indications, with side effects which are often dermatological in nature. In India, the AYUSH system—Ayurveda, Yoga and naturopathy, Unani, Siddha, Homeopathy—is popular because of its wide acceptability and accessibility, low cost and a perceived lack of side effects. Globally also, the use of CAMs is on the rise, as borne by one study in which up to 30% of attendees in a city-based hospital in United Kingdom were found to have used CAMs at some point of time or other.[<xref rid="ref55" ref-type="bibr">55</xref>
]</p>
<p>These drugs are often dispensed in small paper or plastic packets, and there is no documentation of what drug has been prescribed. However, on detailed analysis, one in five herbal medicine products was shown to contain potentially harmful levels of heavy metals like lead, mercury, arsenic, chromium and cadmium.[<xref rid="ref56" ref-type="bibr">56</xref>
] Arsenic can cause punctate palmoplantar keratoderma, leukomelanoderma, arsenical keratosis, Bowen's disease, squamous cell carcinoma,[<xref rid="ref57" ref-type="bibr">57</xref>
] and non-cirrhotic portal fibrosis.[<xref rid="ref58" ref-type="bibr">58</xref>
] Mercury can cause gingivitis, stomatitis, excessive salivation, acrodynia,[<xref rid="ref58" ref-type="bibr">58</xref>
] tylotic eczema, dryness of the skin, skin ulceration and erythroderma.[<xref rid="ref59" ref-type="bibr">59</xref>
] Chromates, in addition, can cause allergic contact dermatitis in sensitized individuals.</p>
<p>Apart from heavy metals, injudiciously prescribed oral or topical steroids in CAMs not only modify the picture of a disease, but also lead to side effects like weight gain, hypertrichosis and depigmentation at the site of application.[<xref rid="ref60" ref-type="bibr">60</xref>
]</p>
<p>The authors have seen patients of pemphigus and pyodermas, with skin lesions smeared with dry paste of <italic>neem</italic>
(<italic>Azadirachta indica</italic>
) leaves [<xref ref-type="fig" rid="F6">Figure 6</xref>
] or sandalwood/turmeric powder [<xref ref-type="fig" rid="F7">Figure 7</xref>
], resulting in disease flare, irritant dermatitis, secondary infection, and even life-threatening sepsis.</p>
<fig id="F6" position="float"><label>Figure 6</label>
<caption><p>Neem paste applied over acute eczema</p>
</caption>
<graphic xlink:href="IJD-60-3-g007"></graphic>
</fig>
<fig id="F7" position="float"><label>Figure 7</label>
<caption><p>Sandalwood paste applied over scalp folliculitis</p>
</caption>
<graphic xlink:href="IJD-60-3-g008"></graphic>
</fig>
</sec>
<sec id="sec3-9"><title>Aromatherapy/essential oils</title>
<p>Aromatherapy, or essential oils therapy, is using a plant's aroma-producing oils (essential oils) taken from its flowers, leaves, bark, or roots to treat disease. Mustard, coconut, linseed, and gingelly oils are used commonly in India for massage or “<italic>maalish</italic>
”. However, essential oils can cause side-effects like allergic or irritant contact dermatitis,[<xref rid="ref61" ref-type="bibr">61</xref>
<xref rid="ref62" ref-type="bibr">62</xref>
<xref rid="ref63" ref-type="bibr">63</xref>
] photosensitive reactions[<xref rid="ref63" ref-type="bibr">63</xref>
] and perioral and intraoral dematitis with cheilitis.[<xref rid="ref64" ref-type="bibr">64</xref>
] The popular aromatherapy oil of bergamot, which contains furocoumarins, primarily bergapten (5-methoxypsoralen), possesses phototoxic properties. Bullous phototoxic skin reactions can develop even without direct contact, simply after exposure to aerosolized aromatherapy oil.[<xref rid="ref65" ref-type="bibr">65</xref>
] In one study, hand dermatitis was found to occur in up to 23% of massage therapists[<xref rid="ref66" ref-type="bibr">66</xref>
] and risk factors for its development included contact with essential oils and history of atopic dermatitis.[<xref rid="ref67" ref-type="bibr">67</xref>
]</p>
<p>Dermatitis can occur secondary to allergens like lavender,[<xref rid="ref63" ref-type="bibr">63</xref>
] peppermint,[<xref rid="ref64" ref-type="bibr">64</xref>
] neomycin, fragrance mix,[<xref rid="ref68" ref-type="bibr">68</xref>
] ylang-ylang oil, lemongrass oil, sandalwood oil, clove oil,[<xref rid="ref69" ref-type="bibr">69</xref>
] olive oil,[<xref rid="ref70" ref-type="bibr">70</xref>
] black cumin,[<xref rid="ref71" ref-type="bibr">71</xref>
] curcumin,[<xref rid="ref72" ref-type="bibr">72</xref>
] French marigold,[<xref rid="ref73" ref-type="bibr">73</xref>
] jasmine, rosewood,[<xref rid="ref74" ref-type="bibr">74</xref>
] tea-tree oil[<xref rid="ref75" ref-type="bibr">75</xref>
] and many others. Cross-reactivity between distillate and main allergen can occur.[<xref rid="ref69" ref-type="bibr">69</xref>
]</p>
<p>Patch test is important for investigating individuals with suspected aromatherapy allergy and the battery should always include patient's own products.[<xref rid="ref69" ref-type="bibr">69</xref>
] Gas chromatography has been advocated for the diagnosis of multiple allergies to essential oils.[<xref rid="ref76" ref-type="bibr">76</xref>
]</p>
</sec>
<sec id="sec3-10"><title>Hair oils</title>
<p>The application of oil to the hair is believed to prevent hair loss and make the hair stronger. Mustard oil, coconut oil, amla oil and almond oil are commonly used by the Indian population in addition to various Ayurvedic or herbal hair oils containing menthol, camphor, sesame, rosemary and thyme.[<xref rid="ref77" ref-type="bibr">77</xref>
] Both beneficial and harmful skin effects have been ascribed to these agents. Coconut oil was shown to decrease colonization of <italic>Staphylococcus aureus</italic>
in atopic skin.[<xref rid="ref78" ref-type="bibr">78</xref>
] Garg and Muller demonstrated that saturated and unsaturated fatty acids in mustard, coconut and amla oil inhibited the growth of dermatophytes. Amla oil had the maximum toxicity against <italic>Microsporum canis</italic>
, <italic>M. gypseum</italic>
and <italic>Trichophyton rubrum</italic>
, while <italic>Trichophyton mentagrophytes</italic>
was most susceptible to coconut oil. They attributed the low incidence of tinea capitis in India to the widespread use of hair oils.[<xref rid="ref79" ref-type="bibr">79</xref>
] Topical application of a polyherbal formulation containing the popular herb <italic>Eclipta alba</italic>
(“<italic>bhringraj</italic>
”) on rat skin led to an increase in the number of anagen hair follicles and decrease in time required for complete hair growth.[<xref rid="ref80" ref-type="bibr">80</xref>
]</p>
<p>Conversely, mustard oil has been implicated in causing pityriasis rosea-like eruption which was subsequently confirmed by patch testing.[<xref rid="ref81" ref-type="bibr">81</xref>
] Almond oil application led to percutaneous sensitization and contact dermatitis in an atopic child.[<xref rid="ref82" ref-type="bibr">82</xref>
] Although contact allergy to pure coconut oil is rare, mild irritant reactions and sensitization to coconut derivatives like cocamidopropyl betaine,[<xref rid="ref83" ref-type="bibr">83</xref>
<xref rid="ref84" ref-type="bibr">84</xref>
] cocamidopropyl dimethylamine,[<xref rid="ref84" ref-type="bibr">84</xref>
] coconut diethanolamide,[<xref rid="ref85" ref-type="bibr">85</xref>
] and cocamidopropyl PG dimonium chloride phosphate[<xref rid="ref86" ref-type="bibr">86</xref>
] have been reported. However, it must be noted that these adverse effects were secondary to topical cutaneous application of the oils and/or occupational exposure, and not because of use over scalp.</p>
</sec>
<sec id="sec3-11"><title>Balms</title>
<p>Self-medication with topical balms to relieve headache, muscle and joint pain is common in South East Asia. Most balms contain methyl salicylate, menthol and camphor. Tiger balm, a Chinese herbal medicament commonly used in India, which additionally combines peppermint, clove oil, cajuput oil, cassia oil and ammonia solution,[<xref rid="ref87" ref-type="bibr">87</xref>
] can cause contact dermatitis.[<xref rid="ref88" ref-type="bibr">88</xref>
] However, upon patch testing, only a mild irritant reaction was observed and the authors opined that it was safe when applied openly.[<xref rid="ref87" ref-type="bibr">87</xref>
] Cross reaction to balsam of Peru was noted.[<xref rid="ref88" ref-type="bibr">88</xref>
]</p>
</sec>
<sec id="sec3-12"><title>Drawstring dermatitis</title>
<p>Drawstring dermatitis is a type of frictional dermatitis that can result from traditional tightly worn garments like “<italic>sari</italic>
” and “<italic>salwaar-kameez</italic>
”. <italic>Sari</italic>
is worn over a petticoat fastened at the waist with drawstrings. <italic>Salwaar</italic>
is a baggy pant, held up at the waist by drawstrings or an elastic band. The resulting chronic friction at the waist can lead to lichenified grooves, post inflammatory depigmentation/leukoderma [<xref ref-type="fig" rid="F8">Figure 8</xref>
] and koebnerization of pre-existing dermatoses like vitiligo [<xref ref-type="fig" rid="F9">Figure 9</xref>
] and lichen planus.[<xref rid="ref89" ref-type="bibr">89</xref>
] Chronic friction combined with sweating and humid environment of the tropics predisposes to candida, dermatophytes and bacterial infections [<xref ref-type="fig" rid="F10">Figure 10</xref>
].[<xref rid="ref89" ref-type="bibr">89</xref>
] Rarely, squamous cell carcinoma has been reported.[<xref rid="ref89" ref-type="bibr">89</xref>
] Prevention of the condition lies in weight reduction and tying the drawstrings loosely, especially in those inclined to develop koebnerizing conditions.[<xref rid="ref54" ref-type="bibr">54</xref>
]</p>
<fig id="F8" position="float"><label>Figure 8</label>
<caption><p>Drawstring dermatitis—pressure leukoderma</p>
</caption>
<graphic xlink:href="IJD-60-3-g009"></graphic>
</fig>
<fig id="F9" position="float"><label>Figure 9</label>
<caption><p>Drawstring dermatitis—lip vitiligo with koebnerization at waist</p>
</caption>
<graphic xlink:href="IJD-60-3-g010"></graphic>
</fig>
<fig id="F10" position="float"><label>Figure 10</label>
<caption><p>Drawstring dermatitis—dermatophyte infection</p>
</caption>
<graphic xlink:href="IJD-60-3-g011"></graphic>
</fig>
</sec>
<sec id="sec3-13"><title>Prayer nodules in Muslims</title>
<p>These have been described as “religious equivalents of an occupational callus”.[<xref rid="ref90" ref-type="bibr">90</xref>
] During prayer, Muslims adopt a squatting position and repeatedly touch their forehead on a prayer stone. Repeated pressure and friction leads to formation of callosities over forehead,[<xref rid="ref91" ref-type="bibr">91</xref>
] knees, ankles and dorsa of feet.[<xref rid="ref90" ref-type="bibr">90</xref>
] Over the forehead they present as discrete, lichenified areas or soft nodules, 1-1.5 cm in size, with or without comedones, over the medial end of the eyebrows. Age-related changes and actinic damage are believed to contribute to the formation of lesions.[<xref rid="ref91" ref-type="bibr">91</xref>
] Histology shows hyperkeratosis, acanthosis, epidermoid cysts,[<xref rid="ref91" ref-type="bibr">91</xref>
] hypergranulosis, dermal papillary fibrosis, and dermal vascularization.[<xref rid="ref92" ref-type="bibr">92</xref>
] Mucin deposition has been described.[<xref rid="ref93" ref-type="bibr">93</xref>
] Advice regarding alteration of position while praying and topical use of 40% urea ointment can treat this condition.[<xref rid="ref90" ref-type="bibr">90</xref>
]</p>
</sec>
<sec id="sec3-14"><title>Traction alopecia of Sikhs</title>
<p>In the Sikh religion, men are prohibited from cutting the hair on their scalp and face. The scalp hair is tied into a tight knot on the vertex area of scalp over which a turban is worn and the beard hair is twisted into a knot under the chin.[<xref rid="ref94" ref-type="bibr">94</xref>
] Over a period of time, the sustained pull inflicts continuous physical trauma to the hair shafts and results in permanent alopecia.[<xref rid="ref94" ref-type="bibr">94</xref>
] A sharply circumscribed band-like scarring alopecia develops at the frontal hairline[<xref rid="ref95" ref-type="bibr">95</xref>
] as well as along the sides of the mandible.[<xref rid="ref96" ref-type="bibr">96</xref>
] A biopsy shows loss of hair follicles, fibrous stelae and scant dermal inflammatory infiltrate.[<xref rid="ref95" ref-type="bibr">95</xref>
] Hair should be tied loosely during the day and left open at night.[<xref rid="ref95" ref-type="bibr">95</xref>
] Topical steroids may give some relief in initial stages.[<xref rid="ref94" ref-type="bibr">94</xref>
] Once the alopecia has become irreversible, restorative hair transplantation remains the only effective intervention.[<xref rid="ref95" ref-type="bibr">95</xref>
]</p>
</sec>
<sec id="sec3-15"><title>Kangri cancer</title>
<p>This is a squamous cell carcinoma (SCC) that occurs due to keeping lighted coal in a <italic>kangri</italic>
basket (used in remote hilly regions of Kashmir) close to the skin in winter to keep warm. The <italic>kangri</italic>
basket, which holds burning coal and dried <italic>chinar</italic>
(<italic>Platanus orientalis</italic>
) leaves, is held between the thighs or over the lower abdomen for prolonged periods of 12-18 hours a day.[<xref rid="ref97" ref-type="bibr">97</xref>
] Early changes include dyspigmentation, erythema ab igne, induration and thickening over medial aspect of upper third of the thighs. Malignant transformation is heralded by development of exophytic growths[<xref rid="ref97" ref-type="bibr">97</xref>
] and ulcers which often get secondarily infected.[<xref rid="ref98" ref-type="bibr">98</xref>
] Tar from <italic>chinar</italic>
leaves and other combustion products were shown to be co-carcinogens in one study.[<xref rid="ref99" ref-type="bibr">99</xref>
]</p>
</sec>
</sec>
</sec>
<sec sec-type="conclusion" id="sec1-2"><title>Conclusion</title>
<p>Cultural and socio-religious beliefs influence our daily lives and have the potential to introduce health hazards in our body. In this era of globalization, cultural practices cut across geographical boundaries. Raising awareness among physicians with regards to “cultural dermatology” is thus important. Modern dermatologists should be sensitive to ethno-cultural aspects of dermatoses and must be encouraged to ask directed questions about the same. This is especially relevant in migrant populations who are trying to integrate into new societies and thus may be hesitant to volunteer such information unless specifically asked for. Testing for safety of various chemicals being used or added in these cosmetic products like essential oils, balms, henna, bindis, kumkum and holi colors should be regulated. The constituents of the products need to be put on the cover. Most of the evidence regarding the above-mentioned adverse effects comes from case reports and hence establishing a causal link to the perpetrating agent is difficult. A systematic research into this complex area is called for. The cutaneous manifestations resulting from Indian socio-cultural practices are summarized in <xref ref-type="table" rid="T2">Table 2</xref>
.</p>
<table-wrap id="T2" position="float"><label>Table 2</label>
<caption><p>Dermatoses secondary to Indian cultural practices</p>
</caption>
<graphic xlink:href="IJD-60-3-g012"></graphic>
</table-wrap>
<boxed-text position="float"><p><bold>What is new?</bold>
</p>
<p>This is a comprehensive and an inclusive review for ready referral for physicians who are not aware of the various skin disorders that can result from Indian socioreligious and cultural habits.</p>
</boxed-text>
</sec>
</body>
<back><fn-group><fn fn-type="supported-by"><p><bold>Source of support:</bold>
Nil</p>
</fn>
<fn fn-type="conflict"><p><bold>Conflict of Interest:</bold>
Nil.</p>
</fn>
</fn-group>
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