Dermatoses due to Indian cultural practices.

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 "kangri" 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.

What was known?

Most of the evidence regarding dermatoses secondary to Indian cultural practices is scattered in the literature and comes from case reports and case series.

Introduction

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.

Henna

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).[1] It is derived from the leaves and flowers of Lawsonia inermis, family Lythraceae, a plant which grows in hot climates of northern Africa and western and southern Asia.[2] Hence, it is not surprising that the use of henna has flourished in these regions.

In India, henna is used as Mehndi [Figure 1] 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).[3] 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.

Figure 1

Mehndi (Henna) design on the hands of a Hindu bride

Pure henna rarely causes allergic reactions.[4] However, cases of palpebral eczema, allergic contact dermatitis and immediate-type hypersensitivity with urticaria, rhinitis, conjunctivitis and bronchial asthma have been recorded,[156] with type-I hypersensitivity being confirmed by both skin prick test[7] and radio allergen sorbent test (RAST).[8] 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.[1] 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.[9] In fact, the percentage of PPD may be as high as 64% in products purporting to be henna.[10] Heavy metals like nickel and cobalt, which are often present in henna tattoo mixtures, have also been proposed as inciting agents for sensitization.[4] PPD has been known to cause severe generalized vesicular erythema multiforme-like reaction,[11] and contact angioedema[12] progressing to involve pharynx, larynx and bronchi with hoarseness of voice and stridor.[13] More seriously it may cause acute renal failure and ultimately death due to renal tubular necrosis.[14] It has been reported to cause pruritus, severe bullous contact dermatitis,[15] post inflammatory hypo or hyperpigmentation,[216] persistent leukoderma,[17] hypertrichosis,[18] lichenoid reactions[19] and keloids.[2021] Hyperbilirubinemia was observed in glucose-6-phosphate dehydrogenase (G6PD)-deficient individuals exposed to henna, due to oxidative hemolysis.[22] 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.[1119] 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.[22] 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.

Kumkum/sindoor/tilak/tika

‘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 “Sindoor” (vermilion) to denote the woman's marital status.[23] 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.[24]

Nath and Thappa[23] found pigmented contact dermatitis [Figure 2] 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 [Figure 3]. The surrounding skin may be involved if the kumkum trickles down the skin in sweat.[25] Other presentations include only brown or slate gray hyperpigmentation without clinically overt dermatitis[2526] and lichen planus pigmentosus.[25] ’Chandan’ or sandalwood paste in kumkum can also cause photoallergic reactions, and these patients must also undergo a photo patch test.[24]

Figure 2

Kumkum-induced pigmented contact dermatitis

Figure 3

Allergic contact dermatitis extending up to glabella and hair parting. Note that patient continues to wear the bindi in spite of active dermatitis

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,[27] thimerosal, gallate mix, PPD, Kathon CG, benzotriazol, tert-butyl hydroquinone,[23] parabens,[2327] ’chandan’,[24] chalk powder colored with various azo dyes[25] and other dyes (coal tar dyes, toluidine red, erythrosine, and lithol red calcium salt).[28] The red-colored powder “sindoor” contains mercury and the black paste lead sulfide.[25] It is common to see saffron, ash or camphor being smeared onto the neck or forehead skin in the temples (personal observation).

Bindi

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.[24]

Contact leukoderma is one of the most frequent manifestations of sticker bindis [Figure 4].[293031] In a study of 864 cases of chemical leukoderma, 104 (12%) cases were due to adhesive bindi.[32] It is possible that bindi-induced depigmentation may be more common in patients predisposed to vitiligo,[33] and chemical leukoderma must be excluded with certainty from every case of idiopathic vitiligo.[32] Irritation, pruritus and erythema may be seen prior to the development of depigmentation.[31] 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 [Figure 5][34] and granuloma formation.[35]

Figure 4

Bindi leukoderma

Figure 5

Allergic contact dermatitis to sticker bindi

The sticker bindis are made up of circular discs of polyvinylchloride (PVC)[31] and the adhesive material contains para-tertiary butyl phenol (PTBP),[313236] the concentration of which may be as high as 80%.[36] These agents cause depigmentation through their melanocytotoxic effect. Other allergens implicated in causation of contact dermatitis due to bindi include epoxy resins,[37] Disperse Blue 124, Disperse Blue 106,[38] nickel[34] and thimerosal and gallate mix.[39]

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.[40]

Alta

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.[41] Ghosh and Mukhopadhyay found the frequency of alta-induced depigmentation to be 1.2% of all chemical leukoderma cases.[32] Chemical agents in alta include azo dyes and PPD.[41] Bajaj et al. found solvent yellow 3,[42] Crocein Scarlet MOO (CSM) (brilliant crocein) and rhodamine B (tetraethyl rhodamine) in alta by chromatographic and spectroscopic analysis.[41]

Holi dermatoses

Holi is a harvest festival in which people symbolically smear dry powdered colors (“Abeer” or “Gulal”) 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.[43]

The Holi colors contain many hazardous chemicals [Table 1][44] 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.[44] Sometimes, mica or powdered glass is added as sparkling agent to the colors.[43]

Table 1

Harmful chemicals in Holi colors

In a study of 42 patients with Holi dermatoses, Ghosh et al.[45] 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.[43]

Mudichood

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.[46]

Mudichood is characterized by itchy, pigmented lichenoid dermatitis with follicular, flat-topped scaly papules on the pinnae,[47] nape of neck, upper back and even forearm.[48] 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.[49] Koebner's phenomenon has been noted.[46] Long-standing cases may show confluence of papules.[49]

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.[4649]

Treatment with 3-5% salicylic, short hair and regular washing with shampoos helps prevent this condition.[4649]

Threading

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.[50] In particular, threading-induced trauma can lead to koebnerization of pre-existing dermatoses, especially vitiligo.[51] Infections like folliculitis, verrucae, pseudofolliculitis, molluscum contagiosum[52] and bullous impetigo[53] 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.[51] Aseptic techniques should be followed by the beautician to prevent infectious complications.[54]

Ayurveda/alternative medicines

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.[55]

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.[56] Arsenic can cause punctate palmoplantar keratoderma, leukomelanoderma, arsenical keratosis, Bowen's disease, squamous cell carcinoma,[57] and non-cirrhotic portal fibrosis.[58] Mercury can cause gingivitis, stomatitis, excessive salivation, acrodynia,[58] tylotic eczema, dryness of the skin, skin ulceration and erythroderma.[59] Chromates, in addition, can cause allergic contact dermatitis in sensitized individuals.

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.[60]

The authors have seen patients of pemphigus and pyodermas, with skin lesions smeared with dry paste of neem (Azadirachta indica) leaves [Figure 6] or sandalwood/turmeric powder [Figure 7], resulting in disease flare, irritant dermatitis, secondary infection, and even life-threatening sepsis.

Figure 6

Neem paste applied over acute eczema

Figure 7

Sandalwood paste applied over scalp folliculitis

Aromatherapy/essential oils

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 “maalish”. However, essential oils can cause side-effects like allergic or irritant contact dermatitis,[616263] photosensitive reactions[63] and perioral and intraoral dematitis with cheilitis.[64] 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.[65] In one study, hand dermatitis was found to occur in up to 23% of massage therapists[66] and risk factors for its development included contact with essential oils and history of atopic dermatitis.[67]

Dermatitis can occur secondary to allergens like lavender,[63] peppermint,[64] neomycin, fragrance mix,[68] ylang-ylang oil, lemongrass oil, sandalwood oil, clove oil,[69] olive oil,[70] black cumin,[71] curcumin,[72] French marigold,[73] jasmine, rosewood,[74] tea-tree oil[75] and many others. Cross-reactivity between distillate and main allergen can occur.[69]

Patch test is important for investigating individuals with suspected aromatherapy allergy and the battery should always include patient's own products.[69] Gas chromatography has been advocated for the diagnosis of multiple allergies to essential oils.[76]

Hair oils

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.[77] Both beneficial and harmful skin effects have been ascribed to these agents. Coconut oil was shown to decrease colonization of Staphylococcus aureus in atopic skin.[78] 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 Microsporum canis, M. gypseum and Trichophyton rubrum, while Trichophyton mentagrophytes was most susceptible to coconut oil. They attributed the low incidence of tinea capitis in India to the widespread use of hair oils.[79] Topical application of a polyherbal formulation containing the popular herb Eclipta alba (“bhringraj”) on rat skin led to an increase in the number of anagen hair follicles and decrease in time required for complete hair growth.[80]

Conversely, mustard oil has been implicated in causing pityriasis rosea-like eruption which was subsequently confirmed by patch testing.[81] Almond oil application led to percutaneous sensitization and contact dermatitis in an atopic child.[82] Although contact allergy to pure coconut oil is rare, mild irritant reactions and sensitization to coconut derivatives like cocamidopropyl betaine,[8384] cocamidopropyl dimethylamine,[84] coconut diethanolamide,[85] and cocamidopropyl PG dimonium chloride phosphate[86] 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.

Balms

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,[87] can cause contact dermatitis.[88] However, upon patch testing, only a mild irritant reaction was observed and the authors opined that it was safe when applied openly.[87] Cross reaction to balsam of Peru was noted.[88]

Drawstring dermatitis

Drawstring dermatitis is a type of frictional dermatitis that can result from traditional tightly worn garments like “sari” and “salwaar-kameez”. Sari is worn over a petticoat fastened at the waist with drawstrings. Salwaar 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 [Figure 8] and koebnerization of pre-existing dermatoses like vitiligo [Figure 9] and lichen planus.[89] Chronic friction combined with sweating and humid environment of the tropics predisposes to candida, dermatophytes and bacterial infections [Figure 10].[89] Rarely, squamous cell carcinoma has been reported.[89] Prevention of the condition lies in weight reduction and tying the drawstrings loosely, especially in those inclined to develop koebnerizing conditions.[54]

Figure 8

Drawstring dermatitis—pressure leukoderma

Figure 9

Drawstring dermatitis—lip vitiligo with koebnerization at waist

Figure 10

Drawstring dermatitis—dermatophyte infection

Prayer nodules in Muslims

These have been described as “religious equivalents of an occupational callus”.[90] 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,[91] knees, ankles and dorsa of feet.[90] 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.[91] Histology shows hyperkeratosis, acanthosis, epidermoid cysts,[91] hypergranulosis, dermal papillary fibrosis, and dermal vascularization.[92] Mucin deposition has been described.[93] Advice regarding alteration of position while praying and topical use of 40% urea ointment can treat this condition.[90]

Traction alopecia of Sikhs

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.[94] Over a period of time, the sustained pull inflicts continuous physical trauma to the hair shafts and results in permanent alopecia.[94] A sharply circumscribed band-like scarring alopecia develops at the frontal hairline[95] as well as along the sides of the mandible.[96] A biopsy shows loss of hair follicles, fibrous stelae and scant dermal inflammatory infiltrate.[95] Hair should be tied loosely during the day and left open at night.[95] Topical steroids may give some relief in initial stages.[94] Once the alopecia has become irreversible, restorative hair transplantation remains the only effective intervention.[95]

Kangri cancer

This is a squamous cell carcinoma (SCC) that occurs due to keeping lighted coal in a kangri basket (used in remote hilly regions of Kashmir) close to the skin in winter to keep warm. The kangri basket, which holds burning coal and dried chinar (Platanus orientalis) leaves, is held between the thighs or over the lower abdomen for prolonged periods of 12-18 hours a day.[97] 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[97] and ulcers which often get secondarily infected.[98] Tar from chinar leaves and other combustion products were shown to be co-carcinogens in one study.[99]

Conclusion

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 Table 2.

Table 2

Dermatoses secondary to Indian cultural practices

What is new?

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.