Cultural practices affecting the skin of children

Parisa Ravanfar and James G. Dinulos

SectSection of Dermatology, Dartmouth-Hitchcock
Medical Center, Lebanon, New Hampshire, USA
Correspondence to Dr Parisa Ravanfar, Section of
Dermatology, Dartmouth-Hitchcock Medical Center, 1
Medical Center Dr, Lebanon, NH 03756, USA
Tel: +1 603 653 9400;
e-mail: parisa.ravanfar@hitchcock.org
Current Opinion in Pediatrics 2010, 22:423431
Purpose of review
Cultural practices that present with dermatologic manifestations in the pediatric
population are common. However, such skin manifestations are often poorly understood
in western medicine and lesions are misdiagnosed, with child abuse being a common
misdiagnosis.
Recent findings
The 2000 Census counted approximately 28 million first-generation immigrants in the
United States. As populations are increasing in diversity, there are an increasing number
of physical presentations from diverse cultural practices. Physicians will begin to
encounter skin findings that they may have never seen before. It is, therefore, imperative
for physicians to be aware of such cultural practices and the cutaneous findings
associated with them.
Summary
Numerous cultural practices may present with skin manifestations in children. It is,
therefore, important for pediatricians to be aware of such practices and their associated
skin lesions for proper diagnosis and management. Various cultural practices with
cutaneous findings will be covered in this article.

Keywords
abuse, cultural practice, cutaneous, ethnic, remedies, skin, traditional

Curr Opin Pediatr 22:423431

2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
1040-8703

each stroke being 46 in. in length (see Fig. 1). This is

Introduction
Approximately 30% of United States population consists
of people of color. With the rapidly changing demo-
graphics of the population, many medical practitioners
will find themselves treating patients from cultures they
have never previously encountered in their medical
practice. There are numerous cultural practices that
can lead to cutaneous manifestations. Frequently,
patients and families do not offer this information when
they see their physician due to embarrassment and fear of
judgment. Misdiagnosis and improper treatment is far too
common. There have been cases of parental suicide after
misdiagnosis of child abuse [1]. Recognition and cultural
awareness of such cutaneous findings are essential in
proper medical care.
Coin rubbing and spooning
Coin rubbing or spooning is the cultural practice of
repeated pressured strokes over lubricated skin with a
smooth edge such as a worn coin, a metal cap with a
rounded edge, a ceramic Chinese soup spoon, an even-
honed animal bone, a water buffalo horn, a piece of jade,
or a piece of ginger root. The process involves placing the
smooth edge against the preoiled skin surface, pressing
down firmly, and then moving down the muscles, with
1040-8703 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
also referred to as friction stroking and follows along the
pathway of the acupuncture meridians on the surface of
the skin, which in this case is on the spine. The resulting
extravasation of blood leads to petechiae and ecchy-
moses, which is referred to in Chinese medicine as the
Sha rash. Typical skin lesions consist of linear ecchy-
motic streaks along the back in a Christmas tree pattern
(see Fig. 2).
This process of spooning is called Gua Sha in Chinese
and literally means to scrape away fever. In Vietnamese,
the term for this practice is cao : gio (pronounced cow
yaw), and translates roughly as to scrape wind, as in
Vietnamese culture to catch a cold or fever is often
referred to as to catch wind. In Indonesia, it is a
traditional Javanese technique, known as kerikan, which
literally means scraping technique. The French have
named this practice as tribo-effleurage or friction strok-
ing. It is also used in other Southeast Asian cultures such
as Cambodian and Laotian.
The process of coining or spooning is relatively benign.
Patients often deny pain from the procedure. However,
many families who practice this technique are often
afraid to bring their children to see physicians for fear
of misunderstanding as child abuse. There have been
DOI:10.1097/MOP.0b013e32833bc352

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 424 Dermatology
Figure 1 Coining being performed on the back
Reproduced by courtesy of EthnoMed.org.
multiple reports of parents falsely accused of child abuse
due to the skin lesions seen from this traditional practice
[2]. It should also be noted that the skin is often initially
lubricated with heated medical oils or balms and sub-
Figure 2 Ecchymotic streaks on the back secondary to coining
therapy
Reproduced by courtesy of EthnoMed.org.
Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
sequently rubbed. Such oils include camphor, menthol,
wintergreen oil, eucalyptus oil, peppermint oil, and cin-
namon oil. The use of these heated lubricants has been
associated with burns [3], contact dermatitis, and toxicity.
There are case reports of camphor toxicity secondary to
coin rubbing with camphor balm [4]. Camphor is found in
common cold remedies such as Vicks vapor rub. Although
the US Food and Drug Administration has banned more
than 11% camphorated oil in the United States due to
cases of toxicity in children, higher percentage oils are
easily obtained outside the United States, such as in
Canada, and toxicity is not uncommon in the United
States [5]. Serious camphor intoxication often exhibits
neurologic manifestations such as irritability, hyperre-
flexia, tonic muscular contraction, myoclonic jerks, con-
fusion, coma, and apnea. Seizures are also common and
may be the first manifestation [68]. Death is often due
to respiratory failure or status epilepticus [5].
A similar traditional Chinese medical therapy is Ba Sha,
meaning to pull out fever or tsien sha. The method is
basically pinching by grabbing the skin, followed by
forceful flicking between the fingers until petechiae
appear [9]. Tendons, the center of the brow, base of
the nose, between the eyes, the neck, chest, or back are
common locations for this technique. The findings of
petechiae are difficult to distinguish from child abuse,
requiring high awareness from the physician.
Gridding
Gridding is an underreported folk remedy that is most
commonly practiced in Russian cultures as well as
Ukraine and other eastern regions of the former Soviet
Union [10]. Gridding describes the practice of painting
the back with iodine in a criss-cross pattern [10]. This
results in a hyperpigmented grid-like pattern on the back
(see Fig. 3). This practice is typically used as a treatment
for respiratory illness because the topical application of
iodine results in a warm and mild burning sensation that
is thought to aid in relief of cough and congestion [10].
The process of gridding is often well tolerated; however,
there have been a few case reports [11,12] of high
concentrations of topical iodine leading to chemical burns
with maceration or abrasion of skin.
Cupping
The traditional practice of cupping dates from as early as
3000 B.C. and has been practiced in a variety of cultures
worldwide, including Egyptian, Chinese, Greek, Euro-
pean, and Middle-Eastern cultures. Cupping is the prac-
tice of creating a small area of low air pressure next to the
skin with a cup leading to suction. Various tools, methods,
and procedures are used in creating this reduced air
pressure. The cups themselves can be of various shapes
 Cultural practices affecting the skin of children Ravanfar and Dinulos 425

Figure 3 Iodine gridding Figure 4 Cutaneous manifestation of cupping in a child

Reproduced with permission from Pappano [10].

and sizes, as well as made of various materials, with the

Reproduced by courtesy of Ethnomed.org.
most common being glass or plastic. The suction required
may be obtained by heating the cup or the air inside it
with an open flame or a bath in hot scented oils, followed
by placing the cup against the skin. As the air inside the
Moxibustion
cup cools, it contracts and pulls the skin inside. Vacuums
Moxibustion is a traditional Chinese medicine therapy
have also been created with mechanical suction pumps
that is also used in other Asian cultures such as Japanese,
located at the top of the cup. Cups may be used singly or
Korean, Vietnamese, Tibetan, and Mongolian. The pro-
in multiples to cover a larger area. They may also be
cedure involves using moxa, or mugwort herb, by either
placed over an acupuncture needle. Skin may be lubri-
placing it on an acupuncture point and directly burning it
cated with oils to allow gradual movement of the cup
on the skin or indirectly burning by lighting one end of a
across the skin, which may lead to a contact dermatitis to
moxa stick and either holding it 12 in. away from the
the oils applied. More commonly in Middle-Eastern
skin or placing it on or around inserted acupuncture
cultures, the skin may be lanced prior to placing the
needles (see Fig. 5). This often leads to erythema and
cup, so that the vacuum draws blood into the cup as part
commonly causes burns, especially with the direct appli-
of the treatment; this is referred to as wet cupping and is
cation. Moxibustion may cause secondary burns and
also a form of bloodletting. It is also worth mentioning
permanent scars. It is important for the physician to
that, in Turkey, traditional practices to treat jaundice
recognize these scars, as they may mimic signs of physical
include cutting the babys forehead, the back of the ears,
abuse such as those seen with cigarette burns.
and the wrists with a razor blade [13].

The practice of cupping often leads to annular ecchy-
moses and annular hyperpigmentation across the skin
(see Fig. 4). Skin lesions can also consist of hematomas as
well as skin lacerations in wet cupping. The use of oils for
lubrication can cause a contact dermatitis with erythema,
edema, blisters, and scaling in areas of direct contact.
There is also potential for cutaneous burns with the use of
fire cupping.
Phytophotodermatitis and photodermatitis
Phytophotodermatitis causes skin lesions that result from
the interaction of ultraviolet light with photosensitizing
compounds present in various plants. The resulting skin
lesions due to phototoxicity can manifest as erythema,
hyperpigmentation, vesicles, bullae, or all. Lesions are
often in unusual shapes and can appear within hours to
days of exposure. The most common areas affected are

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 426 Dermatology
Figure 5 Moxibustion using acupuncture needles, following cupping therapy
Reproduced by courtesy of commons.wikimedia.org/wiki/Category:Moxibustion.
the hands, face, and mouth due to handling and eating;
however, other areas can be affected, especially in chil-
dren, such as when fruit juices are dripped over areas of
the body while consuming (Fig. 6). There have been
reports [1418] of these skin lesions being misdiagnosed
as child abuse, scalding, herpes, and fungal infections.
The most common phytophotodermatitis is that of lime
juice. Lime juice is used in various cultures as a folk
remedy for numerous ailments in addition to being a
common food ingredient. In particular, Hispanic cultures
frequently use lime juice as a home remedy for various
ailments, such as for acne, fungal infections, and scars, as
well as for skin and hair lightening. These uses often lead
to phytophotodermatitis when concurrently exposed to
sunlight (Fig. 7a and b [19]). Other agents that can cause
phototoxic effects include lemons, celery, carrots,
oranges, parsley, parsnips, tobacco, figs, garlic, and hot
peppers, in addition to numerous other agents.
Berloque dermatitis refers to a phototoxic reaction that
occurs from exposure of fragrance products that contain
bergamot oil to sunlight. Bergapten, or 5-methoxypsor-
alen, is the photoactive component of bergamot oil from
the bergamot citrus. The bergamot oil is derived from
lime peel and is commonly used as a fragrance in per-
fumes, colognes, aromatherapy oils, lotions, soaps, and
various other toiletries. Although less commonly used in
the United States due to dermatitis, it is still frequently
found in products from other countries. This phototoxic
Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
reaction produces a range of following cutaneous lesions:
erythema, brown/red hyperpigmentation, blisters, and
desquamation (Figs 8 and 9). Lesions are often in a linear
pattern corresponding to area of application. Other con-
figurations include drop-like, pendant-like, and, import-
ant to the pediatric population, in the shape of hand-
prints. There has even been a report [20] of misdiagnosed
child abuse that was subsequently found to be berloque
dermatitis from an Ecuadorian cologne, causing extreme
stress and anxiety to an Ecuadorian family.
Phototoxic dermatitis can have a subtle history, such as
cases in which mothers carried their infants outside after
using a phototoxic agent, thus resulting in a photoder-
matitis in the infant.
Contact dermatitis
Contact dermatitis is a general term for a cutaneous
reaction that results from contact with either an irritating
or an allergy-producing agent. Irritant contact dermatitis
is inflammation of the skin, typically seen as erythema,
mild edema, and scaling. Irritant contact dermatitis is a
nonspecific cutaneous response secondary to direct
chemical contact. Allergic contact dermatitis, on the other
hand, is inflammation of the skin, leading to varying
degrees of erythema, edema, and vesicles. It is a delayed
type (type 4 T-cell) hypersensitivity reaction, resulting
from cutaneous contact with a specific allergen to which
 Cultural practices affecting the skin of children Ravanfar and Dinulos 427
Figure 6 Phytophotodermatitis
Reproduced by courtesy of Dermnet.com.
the patient has developed an allergic sensitivity. There
are countless agents that can cause such reactions. For
example, topical cultural remedies for diaper rash that can
Figure 7 Phytophotodermatitis and limes
Physical examination revealed tender skin (phytophotodermatitis; a) with vesicles (arrow) and tense bullae (arrowhead) atop erythematous, edematous
plaques on her dorsal hands, forearms, and chest. Symmetric, discrete, erythematous patches studded with tiny vesicles were found on her back (limes;
b). Reproduced with permission from Pomeranz and Karen [19].
Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
cause a contact dermatitis include gentian violet, chamo-
mile tea, primrose oil, egg white, cornstarch, and
cooking oil.
Henna
Henna is derived from a plant and is used in multiple
cultures for various reasons. Henna is most commonly
known for its use as a temporary ornamental tattoo
applied traditionally in Indian, Middle Eastern, and
Mediterranean cultures. However, it is also used as a
hair dye, hair shampoo and conditioner, fingernail pol-
ish, and antifungal agent, and as a medicinal herb.
Henna can cause an allergic contact dermatitis in some
people, as seen in Fig. 10. The most common allergen in
henna products is para-phenylenediamine (PPD),
which is added to henna dye to make the color blacker
and to speed up dyeing. PPD may be a very potent
contact sensitizer and cross-reacts with other agents
such as other hair dyes. It should also be kept in mind
when a scalp rash is seen, as it is not only found in
some hair products but also cross-reacts with hair dyes.
Henna application is also used in some cultures for
medicinal purposes as treatment for seborrheic derma-
titis and fungal infections. Skin manifestations of a
contact dermatitis include erythema, scaling, edema,
and pruritus.
There have been multiple reports of topical henna indu-
cing hemolytic anemia in children with glucose-6-phos-
phate dehydrogenase (G6PD) deficiency. In Turkey,
some tribes celebrate arrival of the first boy in the family
with henna application to the infants body and there are
multiple reports of percutaneous absorption with sub-
sequent hemolysis [2123]. Unfortunately, the popu-
lations associated with G6PD deficiency are often the
same populations that utilize henna. There have been
 428 Dermatology

Figure 8 Berloque dermatitis due to bergamot oil and sun exposure

Reproduced by courtesy of Dermnet.com.

Figure 9 Berloque dermatitis due to bergamot oil and sun reports of large henna applications to infants and children
exposure celebrating their births and birthdays causing severe
hyperbilirubinemia and even death in patients with
homozygous G6PD deficiency [2123].

Cultural remedies in caring for the umbilical

stump
There are several cultural remedies in caring for the
infants umbilical stump. Most involve application of a
substance. Some agents applied to the neonates umbi-
lical stump include salt and lime juice. For example, in
some Turkish populations, ash, olive oil, tar, or coffee is
applied to the umbilical stump. In one report [13], over a
third of Turkish women stated that they applied olive oil
to their babys umbilical stump, and a smaller portion

Figure 10 Contact dermatitis due to henna tattoo

Reproduced by courtesy of Dermnet.com. Reproduced by courtesy of Ethnomed.org.

Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Cultural practices affecting the skin of children Ravanfar and Dinulos 429

applied coffee or tar to the stump. Similarly, application Figure 11 Traction alopecia
of nutmeg, castor oil, or spider webs to the umbilical
stump has been observed in Haitian culture. As expected,
such application may be associated with irritant derma-
titis and occasional infection.

The use of spider webs on wounds dates back centuries

and they have been used in various cultures including
AfricanAmerican and Haitian as a hemostatic agent.
Spider webs contain Hageman factor and, therefore,
provide hemostasis. However, there have been reports
of not only infection from application of contaminated
spider webs, but also associated tetanus [24]. Neonatal
tetanus secondary to wrapping of the umbilical stump
with spider webs has been very rarely reported [24].

Salting
Salting of the neonate is a cultural practice that is unique Reproduced by courtesy of Ethnomed.org.
to Turkey. Salt is believed to deter supernatural spirits
that bring sickness and death. Salting of the neonate is an
old cultural practice seen in some areas of Turkey and
consists of scrubbing the neonates entire body with table Toothpaste
salt for an hour. It is performed in order to increase the The application of toothpaste to wounds, mainly burns, is
likelihood of the baby being healthy. Unfortunately, a cultural remedy mainly used in Greece and Iran. It
excessive amounts of salt can lead to epidermolysis provides a cooling sensation due to the menthol and is
and sodium absorption through the skin, resulting in
severe, life-threatening hypernatremia [25]. Skin findings
resemble those of scalded skin as well as very dry, Figure 12 Acne keloidalis nuchae
dehydrated skin [25].

Aloe vera
Application of heated aloe vera to the skin is commonly
practiced in the Hispanic population. Aloe vera alone is
an uncommon cause of contact dermatitis; however,
heated aloe vera can cause erythema, burns, scarring from
overheated application, or all.

Capsaicin dermatitis
Capsaicin dermatitis is commonly seen in the Hispanic
population due to chilli peppers being frequently used for
flavoring in the Latino diet. Contact with the chilli
peppers can cause an erythematous skin rash.

Gentian violet
The topical application of gentian violet is used as a
natural remedy in numerous cultures for the treatment of
infection, mainly fungal or yeast infections. In the His-
panic population, it is used as an antiseptic agent. Gen-
tian violet is commonly used for diaper rash, thrush, and
mouth sores. The application of gentian violet leads to a
purple discoloration that can last for days and, rarely, may
Reproduced by courtesy of CrutchfieldDermatology.com.
be mistaken for ecchymoses.

Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 430 Dermatology
thought to aid in healing and relieve pain; however, it
should be noted that toothpaste also contains abrasives
and can lead to wound infection as well as prolonging
healing time.
Daveners dermatosis
Daveners dermatosis is a unique skin finding seen
exclusively in Jewish boys who attend Jewish seminaries,
classically Orthodox Jewish Talmudic seminaries (Yeshi-
vas) [26]. The lesion is a linear, vertical, midline, hyper-
pigmented patch with ill-defined borders present on the
skin overlying the bony protuberances of the inferior
thoracic and lumbar vertebrae. This skin manifestation
is associated with friction from the rigid backrests against
the lower back that is caused by the characteristic sway-
ing motion that traditionally occurs with Torah studying
or davening (praying) and, therefore, termed Daveners
dermatosis [26]. It is a benign skin finding and often
unrecognized by the patient. It is commonly considered a
badge of honor in this population.
Pomade acne
Most commonly reported in AfricanAmerican cultures,
but also seen in Haitian and Hispanic cultures, pomade
Figure 13 Erythema ab igne
After weeks of application of a heating pad. Reproduced with permission from NEJM. Copyright 2007 Massachusetts Medical Society.
Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
acne occurs secondary to hair grooming products that
spread to the forehead and other areas of the face. The
pomade or other hair products contain comedogenic
substances that cause acne. The typical presentation is
an acneiform eruption of the forehead and temples com-
posed mainly of uniform closed comedones with
occasional papulopustules.
Traction alopecia
Traction alopecia is most often seen in AfricanAmerican
girls, but can be seen in other populations as well. It is
hair thinning and scalp hair loss that results from hair-
styles that cause tension on the hair follicles (Fig. 11).
The pattern varies on the hairstyle, but is often sym-
metric. Hairstyles associated with traction alopecia
include tight braids, cornrowing, tightly rolled hair, and
dread locks. Hair becomes thin and fragile. If early
recognition and diagnosis with discontinuation is not
made, permanent hair loss may ensue.
Acne keloidalis nuchae
Acne keloidalis nuchae is a chronic and progressive
folliculitis seen as follicular-based papules, pustules,
and subsequent keloids (see Fig. 12). It is most com-
 Cultural practices affecting the skin of children Ravanfar and Dinulos 431
monly seen on the back of the neck of Hispanic and
AfricanAmerican men and is associated with very
close haircuts.
Heating pads
Application of heating pads is used worldwide. The
application of heating pads can result in erythema as well
as burns. The chronic use of heating pads can lead to
the dermatologic manifestation of erythema ab igne.
Erythema ab igne is a reticular erythematous or violac-
eous hyperpigmentation of the skin that results from
chronic exposure to infrared radiation (see Fig. 13
[27]). Erythema ab igne is often mistaken for livedo,
cutis marmorata, and varicoceles, and unnecessary
systemic workups are frequently obtained. Proper recog-
nition can avoid further workup. No laboratory, radiolo-
gic, or other workup is necessary and treatment is simply
discontinuation of use of the heating pad. Hyperpigmen-
tation gradually resolves, but can take years.
Conclusion
There are numerous potential cutaneous findings in the
pediatric population due to cultural practices. Awareness
of such cultural practices will aid in proper diagnosis,
increasing cultural awareness, and establishing patient
rapport. One must also be cognizant not to appear judg-
mental, condescending, or reprimanding; thus allowing
for a relationship of trust and proper communication.
Acknowledgement
There are no conflicts of interest.
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