Chapter 63 Cultural dermatology
1. A child from southern India has had a recent decline in school performance and is noted to be anemic. On examination, the child has adorable, dark, mascara-like makeup around her eyes. As an astute cultural dermatologist, you suspect that the makeup is the cause of the difficulties in school and the hematologic profile. What is the name for the traditional Indian eye makeup?
2. What is surma made from? How did it affect the child?
Surma (kohl) is a fine powder resembling mascara that is applied to the margins of the palpebral conjunctiva. It was originally made from antimony sulfide or from carbon soot, but now it is often adulterated with lead sulfide.
Mojdehi GM, Gurtner J: Childhood lead poisoning through kohl, Am J Public Health 86:578–587, 1996.
3. A Vietnamese child is seen in the emergency department with an earache and, on examination, is noted to have several linear ecchymoses on her back. The physician suspects child abuse as the cause of the bruises, but the interpreter says it is not. What caused the marks on the child?
Cao gió (phonetically pronounced gow yaw), or coin rubbing. This is a traditional Vietnamese medical practice. The traditional healer massages the patient’s skin with a liniment and then rubs a metal object, usually a coin, forcefully over the area. Petechiae and linear ecchymoses often develop. These have been mistaken many times for stigmata of battering by Western providers who are unfamiliar with cao gió.
Yeatman GW, Dang VV: Cao gió (coin rubbing), JAMA 244:2748–2749, 1980.
4. An older Chinese man is noted to have dozens of fairly uniform round scars on his back. They resemble self-inflicted cigarette burns, only much larger. The patient is unconcerned about the lesions and indicates that someone like you, a doctor perhaps, did this to him. What ancient Chinese medical practice produces burn scars?
5. What is moxibustion?
It is derived from the words moxa and combustion. Moxa is from mokusa, the Japanese word for wormwood (Artemisia moxa of the sagebrush and absinthe genus), is a commonly used combustible medicinal herb. Moxibustion is the ancient oriental medical practice of igniting medicinal herbs on the skin. When the healer extinguishes the flame, the herb’s therapeutic properties supposedly enter the body. A burn scar is the necessary sequela of properly conducted moxibustion. The sites on which moxibustion is performed are often the same as those used in acupuncture, and it, along with cupping and acupressure, is considered to be a nonneedle forms of acupuncture. The practice is still taught in Chinese colleges of traditional medicine.
6. Can acupuncture cause dermatologic problems?
Yes. In a large survey of more than 6300 acupuncture patients in the United Kingdom, patients reported at least one adverse event in about 10% of cases; however, only 3 patients had a serious adverse event. There have been reports of abundant petechiae (in one case, resembling meningococcemia) caused by acupuncture needles. Hematomas and ecchymoses occur frequently. Pyoderma, prolonged anesthesia, needle breakage, burns, itching, foreign body granuloma, “carcinoma of the skin,” and the Koebner phenomenon have been reported. Transmission of HIV and hepatitis virus has occurred via acupuncture needles.
8. Where did the practice of tattooing start?
Archaeologic evidence, such as human remains, shows that tattooing was part of indigenous cultures worldwide. For whatever reasons, tattoos were used in ancient Europe, the Mediterranean region and Middle East, southern Asia, northern Japan, the Americas, and throughout the Pacific islands.
Levy J, Sewell M, Goldstein N: A short history of tattooing, J Dermatol Surg Oncol 5:851–856, 1979.
10. What culture has the most elaborate tattoos?
The Marquesan Islanders of French Polynesia once applied tattoos to almost the entire body. Hawaiians, Samoans (Fig. 63-1), and New Zealand Maoris also had extensive tattoos. The practice is experiencing a cultural resurgence in many Polynesian groups today. Japanese tattoos (horimono) are often regarded as the most skillful and artistically prepared.
12. Sailors sometimes have rooster and pig tattoos on their lower legs. Does this have a meaning?
Yes, many ethnic groups, cultures, and even subcultures, including sailors, have tattoos with specific meanings. For example, the reason that sailors tattoo a rooster and pig on their lower legs (Fig. 63-2) or feet is that these barnyard animals do not swim, and they believe that if the ship sinks, or they are thrown overboard, having the tattoo will get them to land quickly. Other examples of tattoos with specific meanings include an anchor, meaning that the sailor had sailed the Atlantic Ocean, or a fully-rigged sail ship, indicating that the sailor had sailed around Cape Horn.
13. Who is the Ice Man? Why are his tattoos so important?
The Ice Man is the name given to the 5200-year-old frozen corpse of a Bronze Age hunter found preserved in the ice of a Tyrolean glacier on the border of Austria and Italy. He had 15 groups of tattoos that are noteworthy because they are neither decorative nor on exposed surfaces. Most of the Ice Man’s tattoos are on standard acupuncture sites. Subsequent radiographic examinations of the body revealed old traumas at appropriate sites and strengthen the notion that the Ice Man’s tattoos served as a form of therapy, akin to acupuncture.
Figure 63-2. Sailor with tattoos of a rooster and pig on his leg.
(Courtesy of the Fitzsimons Army Medical Center teaching files.)
Dorfer L, Moser M, Bahr F, et al: A medical report from the Stone Age? Lancet 354:1023–1025, 1999.
14. A man from rural Nigeria has several sets of small parallel scars on his face. He says that his village doctor made these with a sharp stone when the man was young. What are ritually placed incisions called?
16. What is an omega brand?
It symbolizes the rite of passage by initiates entering the American college fraternity Omega Psi Phi. Although not officially sanctioned by the fraternity’s national office, tens of thousands of men (and many “little sisters”) have voluntarily permitted themselves to be branded on the deltoid or pectoral region with hot metal in the shape of the Greek letter O.
19. While on a surfing trip to an outer island of Fiji, you notice that many of the men have dry, scaly skin. You guess there must be a hyperendemic focus of X-linked ichthyosis. The villagers laugh when you ask if the men are born that way and explain that the skin problem is called kani and is caused by drinking too much yanggona. What is this?
21. Your favorite professor has invited you to accompany her on an assessment of a refugee camp in southern Africa. In the camp, you see hundreds of children and adults with a strikingly similar shiny, slightly erosive eruption along exposed areas of their clavicular regions and forearms. What is this eruption?
22. Why is pellagra abundant in the refugee camps?
The inadequate food supplies available in the camps are often heavily reliant on corn-based products that have insufficient levels of nicotinic acid (niacin). This explanation also accounts for the pellagra outbreaks in the southern United States in orphanages and prisons, and among sharecroppers in the early 20th century, where the diet was based almost exclusively on corn.
23. What is betel nut? Who chews it?
Betel nut refers to the fruit of the areca palm (Areca catechu) that is typically chewed when wrapped in betel leaves (Piper betle). It is chewed extensively in many cultures from Pakistan to Micronesia. It has been estimated that 0% to 20% of the world chews betel nut. There are many variations with some cultures adding lime, clove, cardamom, catechu, or even tobacco. This compound is chewed by men and women alike, presumably for the mild psychoactive muscarinic properties of the alkaloids found in the areca nut and the eugenol found in the betel leaf. Asian and Pacific island immigrants to the United States often continue this practice. Technically, there is no betel nut; “betel” refers to the leaves and the “nut” is actually the areca nut which is technically a drupe. Betel leaves have been reported to cause mottled dyschromia of the skin, perhaps as a chemical contact dermatitis.
24. What dermatologic changes are associated with chewing betel nut?
Betel nut chewing stains the teeth, gingiva, and oral mucosa. The color ranges from red to black, depending on the preparation used. Chewers regard the color change as cosmetically appealing. More worrisome, however, is the greatly increased risk of oral squamous cell carcinomas in chewers, attributable to both the areca nut and the lime.
Norton SA: Betel: consumption and consequences, J Am Acad Dermatol 38:81–88, 1998.
25. The visa of a Somali family living in your town has expired. The mother is fighting deportation because she fears that her daughters will be compelled to undergo circumcision if they return to Mogadishu. What is female circumcision?
26. What are the complications of female circumcision?
There can be medical (infections), surgical (hemorrhage), reproductive (fetal death), sexual (dyspareunia), psychological (chronic anxiety), social (peer pressures), and legal (immigration status) complications to the procedure. On the other hand, failure to perform the procedure may also have adverse cultural consequences. An interesting aside is the unsupported hypothesis that infibulation has hastened the spread of HIV infection in Africa by promoting exposure to blood during intercourse.
Key Points: Cultural Dermatology
1. There is an increased mobility and immigration of different cultures and ethnic groups into Western countries, and health care providers are increasingly exposed to different changes in the skin related to different cultural practices.
2. Western health care providers who are not aware of these differences may mistake cultural health care for child or spouse abuse (e.g., cao gió).
3. Western “cosmetic” procedures (e.g., breast augmentation, circumcision, liposuction) and non-Western cultural practices (e.g., voluntary female circumcision, scarification) are very similar in that they are approved by the culture that utilizes the practice and are often viewed with distaste from the perspective of a different culture.
28. What about culturally sanctioned surgical alterations of male genitalia?
Dozens of these exist, including the religion-associated ritual circumcisions of Judaism, Islam, and the Seventh Day Adventist faith. Many Western societies practice widespread routine circumcision of neonates. Australian aborigines practiced subincision, an incision of the distal ventral penis exposing the urethra. Ancient Pompeians practiced hemicastration (removal of one testicle) as a manhood rite. Many cultures practice the simple release of the ventral frenulum. Occupational castration (eunuchs of the seraglio), punitive castrations, and gender-altering surgery among transsexuals have also received varying degrees of cultural acceptance throughout history.
29. What are artificial penile nodules?
Objects placed permanently under the skin of the prepuce or penile shaft, purportedly to enhance the partner’s pleasure during intercourse. Other names include tancho nodules and bulleetus. It is most commonly practiced in East Asian nations (e.g., Thailand and Philippines). In Japan, members of the yakuza, or Japanese criminal underground, often have artificial penis nodules.
Norton SA: Fijian penis marbles: an example of artificial penile nodules, Cutis 51:295–297, 1993.
30. Your cousin is marrying a woman from Mumbai (Bombay). On the wedding day, the bride’s hands are painted with an intricate filigree-like pattern of reddish-brown pigment. What is this form of ornamentation called?
31. Describe the use of henna on the skin.
Henna is a natural red-brown pigment obtained from the plant Lawsonia inermis. It is used to prepare ceremonial body paint used in many Middle Eastern and South Asian societies. It is most commonly used by women on the palms and soles, especially for celebrations such as weddings. Henna is now commonly used in a deritualized fashion by Western women.
32. Are there any medical problems associated with henna?
Yes, but they are rare. Some people develop irritant contact dermatitis using henna. Henna may also cause hemolysis in G6PD-deficient individuals after percutaneous absorption. Also, some henna preparations contain para-phenylenediamine additives that can induce cutaneous and pulmonary allergic reactions (Fig. 63-3).
33. A patient with a referral to the otolaryngology clinic mistakenly arrives in the dermatology clinic. You see that the consultation is to “rule out congenital absence of the uvula.” Sure enough, on your examination, there is no uvula. What gives?
Your patient is missing the uvula due not to a congenital absence but due, instead, to a perinatal uvulectomy. This procedure is performed in many societies from West Africa to the Middle East. The usual explanation is that uvulectomy alleviates problems associated with vomiting or cough. It is performed by nonphysicians on infants or toddlers. Uvulectomy is also performed by Western physicians as a treatment for obstructive sleep apnea. The name of this procedure, uvulopalatopharyngoplasty, is bigger than the tissue that is removed. (Avoid confusing UPPP with PUPPP, which is a skin disease.)
34. A 51-year-old Muslim woman from Saudi Arabia is noted to have asymptomatic thickening and hyperpigmentation on the forehead, knees, ankles, and on the dorsa of her feet. What does she have?
She has “prayer marks.” Prayer marks with this distribution are most common in Muslims who pray for prolonged periods. The changes are due to the repeated prolonged friction and pressure associated with praying. Prayer marks are not confined to Muslims and may be seen in any religious person who prays for prolonged periods.
Abanmii AA, Al Zouman AY, Al Hussaini H, Al-Asmari A: Prayer marks, Int J Dermatol 43:985–986, 2002.
35. A 22-year-old man from India presents with tinea cruris that involves the penis. What most likely accounts for this highly atypical clinical distribution of infection?
The man most likely wears a langota, which is a semiocclusive undergarment that is associated with increased involvement of the penis in patients with tinea cruris. At one time, in some parts of India, it was the only type of underwear that many men used; it is still used by some men. In some parts of India, it is still considered to be the garment of choice for various athletic endeavors such as traditional wrestling, martial arts training, and gymnastics. A very similar garment called the fundoshi is worn in Japan.
Pandey SS, Chandra S, Guha PK, et al: Dermatophyte infection of the penis. Association with a particular undergarment, Int J Dermatol 20:112–114, 1981.
