Kangri: A boon or bane for Kashmiris.

Sir,

Kangri cancer is peculiar to the valley of Kashmir as people of all age groups are accustomed to warm their bodies during harsh winters by the use of Kangri baskets. In fact, the clinical spectrum of skin cancer in Kashmir valley is entirely different from the rest of the country, which has been attributed to the use of Kangri in this geographical region. Kangri is an indigenous fire pot used and tucked in between thighs and abdomen to generate warmth, especially during the cold winter months in Kashmir valley (coldest and northern most part of the country). Kangri is a clay bowl weaved into a willow wicker, which is kept beneath the traditional Kashmiri clothing known as the Pheran [Figure 1a–c]. If a person is wearing a jacket, it may be used as a hand warmer. It is approximately 6 inches in diameter and reaches a temperature of approximately 150°F. Although it protects from cold weather, the prolonged use of Kangri may result in the formation of erythema ab igne, a reticulate hypermelanosis with erythema, which may transform into Bowen's disease [Figure 2], which usually develops after an average of 4–5 years, and finally cancer, most commonly squamous cell carcinoma [Figures 3 and 4].[12] William Elmslie first documented squamous cell carcinoma of skin among Kashmiris, and correctly ascribed it to the use of Kangri.[3] Theodore Maxwell confirmed these findings in 1879.[4] Kangri cancer usually starts as a papular growth over erythema ab igne. With time, these lesions usually ulcerate and grow exponentially. Heat is the prime causative factor. Products of combustion, wood ash, and volatile substances may play a secondary role. Squamous cell carcinoma is the most common type of malignancy, and the most common site is the lower extremities (thighs) followed by anterior abdomen. The most common type of presentation is a noduloulcerative growth, with history of pain and bleeding.[56]

Figure 1

(a) Traditional Kashmiri Kangri. (b, c) Traditional Kashmiri Pheran with Kangri and use of Kangri by a Kashmiri women

Figure 2

Erythema ab igne over the medial aspect of the left thigh

Figure 3

Bowen's disease with Squamous cell carcinoma on a background of erythema ab igne over the medial aspect of the right thigh

Figure 4

Hematoxylin and eosin (×10 and ×40) stained sections showing (a, b) Bowen's disease. Epidermis shows atypical cells with nuclear hyperchromasia and cytoplasmic vacuolisation. Basal layer is preserved and shows palisading and (c) squamous cell carcinoma (×100 H and E). Tumor cells showing marked nuclear hyperchromasia and abundant cytoplasm with individual cell dyskeratosis seen at some foci

Although Kangri does bestow a momentary victory on a Kashmiri in his conflict with chilai-kalan—the coldest part of winter, it does make them pay in the long run, in the form of Kangri cancer and its complications.

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Conflicts of interest

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