Pigmentation Disorders

Religious practices can lead to cutaneous changes, and awareness of these changes is of paramount importance in establishing the cause. We review the cutaneous changes related to religious practices, including the Semitic religions, Hinduism, and Sikhism (Table). The most widely followed Semitic religions are Christianity, Islam, and Judaism. Christianity and Islam collectively account for more than half of the world’s population.¹

Christianity
Christian individuals are prone to blisters that develop below the knees due to repeated kneeling in prayer.² A case of allergic contact dermatitis to a wooden cross made from Dalbergia nigra has been reported.³ Localized swelling with hypertrichosis due to muscular hypertrophy in the lower neck above the interscapular region has been described in well-built men who lift weights to bear pasos (floats with wooden sculptures) during Holy Week in Seville, Spain.⁴

Islam
Cutaneous signs of piety have been well documented in Muslim individuals. The most common presentation is hyperpigmentation of the forehead, usually noted as a secondary finding in patients seeking treatment of unrelated symptoms.⁵ Cutaneous changes in this region correspond with the area of the forehead that rests on the carpet during prayer. Macules typically present on the upper central aspect of the forehead close to the hairline and/or in pairs above the medial ends of the eyebrows; sometimes 3 or 4 lesions may be present in this area with involvement of the nasion (Figure 1).⁶

In Saudi Arabia where Sunni Islam predominates, Muslim individuals observe prayer 5 times per day. Calluses have been observed in areas of the body that are frequently subject to friction during this practice.⁷ For instance, calluses are more prominent on the right knee (Figure 2) and the left ankle, which bear the individual’s weight during prayer, and typically become nodular over time (Figure 3). In Arabic, these calluses are referred to as zabiba.⁸

A notable finding in followers of Shia Islam, which predominates in Iran, is the development of small nodules on the forehead, possibly caused by rubbing the forehead on a flat disclike prayer stone called a mohr during daily prayer,⁹ which is said to enhance public esteem.¹⁰ The nodules generally are asymptomatic, but some individuals experience minimal pain on pressure.⁸ Ulceration of the nodules has rarely been observed.⁷

Limited access to thick and soft carpets and rarely bony exostoses or obesity are factors associated with prayer that can lead to skin changes (known as prayer signs), as they render the skin sensitive to pressure. Localized alopecia may occur on the forehead in individuals with low or pointed hairlines. An unexplained finding noted by one of the authors (K.A.) in some elderly Muslim individuals is that hair located on the forehead at the point of pressure during prayer remains pigmented, while the rest of the hair on the scalp turns white. Hyperpigmentation of the knuckles may be seen in individuals who use closed fists to rise from the ground following prayer. Except for mild hyperpigmentation of the knees,⁷ Muslim women rarely develop these changes, as they either do not pray,¹⁰ particularly during menstruation or puerperium, or they have more subcutaneous fat for protection.⁷ Some Muslim individuals who pray regularly at home may be conscious of these skin changes and therefore use a soft pillow to rest the forehead during prayer.

The histopathologic findings of prayer signs depend on the extent of lichenification and typically show compact hyperkeratosis or orthokeratosis, hypergranulosis, acanthosis, and mild dermal inflammation.⁸ Increased dermal vascularization and papillary fibrosis unlike that seen in lichen simplex chronicus have been described from skin changes in the lower limbs due to prayer practices.⁷ Additional findings in forehead biopsies include multiple comedones and epidermoid cysts in elderly patients showing a foreign body granulomatous reaction to hair fragments.¹⁰ Deposition of mucinous material in the dermal collagen in a prayer nodule on the forehead has been described in a Shiite individual, possibly due to repetitive microtrauma from the use of a prayer stone.⁹ Infections developed from sharing communal facilities or performing ritual sacrifices (eg, tinea,¹¹ orf¹²) are prevalent during the yearly Hajj pilgrimage at Makkah, Saudi Arabia, in addition to other infectious and noninfectious dermatoses.¹³ Muslim women wearing headscarves secured at the neck with a safety pin have developed vitiligo at that site due to friction.¹⁴ Occasionally, Muslim individuals may apply perfumes before prayers, which may cause allergic contact dermatitis.

Judaism
Hyperpigmentation has been described in Jewish men at Talmudic seminaries due to the practice of reciting scriptures, which involves a rocking motion known as daven that leads to friction on the back.¹⁵ Lesions associated with this practice typically appear as isolated macules or a continuous linear patch over the skin of the bony protuberances of the inferior thoracic and lumbar vertebrae. Allergic contact dermatitis has been reported in Jewish individuals due to exposure to a variety of agents during religious practices, such as potassium dichromate, which is present in the leather used to make phylacteries or tefillin (boxes containing scripture that are secured to the forehead with straps that are then tied to the left arm during prayer). This finding has been noted in some or all areas of contact including the forehead, scalp, neck, left wrist, and waist.¹⁶

It is customary for both Orthodox Jewish and Muslim women to be concealed by clothing, which predisposes them to vitamin D deficiency^17,18 but also protects them from developing malignant melanoma.¹⁹ Neonates have developed genital herpetic infections following circumcision due to the ancient practice of having the mohel (the person who performs the Jewish circumcision) suck on the wound until the bleeding stops.²⁰

Hinduism
Hinduism espouses an eclectic philosophy of life subsuming numerous beliefs involving guardian deities, invoked by sacred marks, symbols, and rituals. Marks generally are placed on the forehead or other specified sites on the body. Sandalwood paste as well as vibhuti and kumkum powders most commonly are used, which can cause allergic contact dermatitis. Vibhuti is holy ash prepared by burning balls of dried cow dung in a fire pit with rice husk and clarified butter. Kumkum is prepared by alkalinizing turmeric powder, which turns red in color. A case of contact allergic dermatitis was reported in a Hindu priest who regularly used sandalwood paste on the forehead and as a balm for an ailment of the hands and feet.²¹ In our experience, vibhuti also has caused dermatitis on the forehead as well as on the neck and arms. The main difference between the 2 eruptions is that sandalwood dermatitis generally is localized to the center of the forehead as a circular or vertical mark or often in the center of the left palm, which is used to mix sandalwood powder with water to make a paste (Figure 4), while vibhuti contact dermatitis typically presents as a broad horizontal patch on the forehead because the powder is smeared with the middle 3 fingers (Figure 5). Perfumes used by some Muslim individuals before prayer that are applied on the clothes can mimic this type of contact dermatitis, but eruptions typically are confined to the fingers and palms.²² Contact dermatitis caused by necklaces made with beads of the stem of the Ocimum sanctum (holy basil) plant and seeds of the evergreen tree Elaeocarpus ganitrus have been reported.²³ Calluses are sometimes seen in individuals who meditate for long hours while sitting in a cross-legged position and usually occur on or uncommonly below the lateral malleolus of the right foot, similar to practitioners of yoga.²⁴

Hemorrhaging and crusting below the lateral malleolus of the right foot have been reported in Buddhist monks due to sitting in a cross-legged position for prolonged periods of meditation.²⁵ Hyperpigmentation of the knees, ankles, and interphalangeal joints of the feet has been seen after sitting in the traditional Japanese meditative position.²⁶ Tattoos of Hindu gods are common, while tattoos are forbidden in Islam and Judaism. Attributes of prominent deities branded on the body may be seen. Discrete sarcoidlike nodules along the axillae and chest wall have been attributed to a Hindu ritual (kavadi) that is performed annually as a form of self-inflicted punishment for their sins in which devotees pierce the chest wall with spokes to form a base over a heavy cage in which offerings are carried, and skewers passed through the cheeks have resulted in similar nodules in the oral cavity.^27,28 Consumption of cow’s urine during rituals may induce acute urticaria.²⁹ Lichen planus of the trunk³⁰ and leukoderma of the waist³¹ may be induced by köbnerization or contact allergy from wearing sacred threads, respectively.

Sikhism
Sikhism, a religion founded in the 15th century, epitomizes the high-water mark of the syncretism between Hinduism and Islam. Men must abstain from cutting their hair; pulling and knotting the hair to maintain a coiffure can cause traction alopecia in the submandibular region and the frontal and parietal areas of the scalp as well as ridging and furrowing of the scalp resembling cutis verticis gyrata. Fixer, a product used to keep the beard intact, can cause contact dermatitis. The tight broad band of cloth (known as a ribbon) that is worn around the head to keep hair intact beneath a turban may cause forehead lesions. Discoid lupus erythematosus–like lesions or painful chondrodermatitis of the pinnae due to pressure from wearing a starched turban have been observed, also called “turban ear” from prominence of both anthelices.^32,33 A case of a Sikh man who developed oral sarcoidal lesions from body piercing has been reported.²⁸

Conclusion
Knowledge of the religious practices of patients would help in recognizing puzzling and peculiar dermatoses. It may not be possible to eliminate the causes of these conditions, but methods to reduce their effects on the skin can be discussed with patients.

Acknowledgments—We are grateful to the valuable help rendered by Joginder Kumar, MD, New Delhi, India, and C. Indira, MD, Hyderabad, India.

Religious practices can lead to cutaneous changes, and awareness of these changes is of paramount importance in establishing the cause. We review the cutaneous changes related to religious practices, including the Semitic religions, Hinduism, and Sikhism (Table). The most widely followed Semitic religions are Christianity, Islam, and Judaism. Christianity and Islam collectively account for more than half of the world’s population.¹

Christianity
Christian individuals are prone to blisters that develop below the knees due to repeated kneeling in prayer.² A case of allergic contact dermatitis to a wooden cross made from Dalbergia nigra has been reported.³ Localized swelling with hypertrichosis due to muscular hypertrophy in the lower neck above the interscapular region has been described in well-built men who lift weights to bear pasos (floats with wooden sculptures) during Holy Week in Seville, Spain.⁴

Islam
Cutaneous signs of piety have been well documented in Muslim individuals. The most common presentation is hyperpigmentation of the forehead, usually noted as a secondary finding in patients seeking treatment of unrelated symptoms.⁵ Cutaneous changes in this region correspond with the area of the forehead that rests on the carpet during prayer. Macules typically present on the upper central aspect of the forehead close to the hairline and/or in pairs above the medial ends of the eyebrows; sometimes 3 or 4 lesions may be present in this area with involvement of the nasion (Figure 1).⁶

In Saudi Arabia where Sunni Islam predominates, Muslim individuals observe prayer 5 times per day. Calluses have been observed in areas of the body that are frequently subject to friction during this practice.⁷ For instance, calluses are more prominent on the right knee (Figure 2) and the left ankle, which bear the individual’s weight during prayer, and typically become nodular over time (Figure 3). In Arabic, these calluses are referred to as zabiba.⁸

A notable finding in followers of Shia Islam, which predominates in Iran, is the development of small nodules on the forehead, possibly caused by rubbing the forehead on a flat disclike prayer stone called a mohr during daily prayer,⁹ which is said to enhance public esteem.¹⁰ The nodules generally are asymptomatic, but some individuals experience minimal pain on pressure.⁸ Ulceration of the nodules has rarely been observed.⁷

Limited access to thick and soft carpets and rarely bony exostoses or obesity are factors associated with prayer that can lead to skin changes (known as prayer signs), as they render the skin sensitive to pressure. Localized alopecia may occur on the forehead in individuals with low or pointed hairlines. An unexplained finding noted by one of the authors (K.A.) in some elderly Muslim individuals is that hair located on the forehead at the point of pressure during prayer remains pigmented, while the rest of the hair on the scalp turns white. Hyperpigmentation of the knuckles may be seen in individuals who use closed fists to rise from the ground following prayer. Except for mild hyperpigmentation of the knees,⁷ Muslim women rarely develop these changes, as they either do not pray,¹⁰ particularly during menstruation or puerperium, or they have more subcutaneous fat for protection.⁷ Some Muslim individuals who pray regularly at home may be conscious of these skin changes and therefore use a soft pillow to rest the forehead during prayer.

The histopathologic findings of prayer signs depend on the extent of lichenification and typically show compact hyperkeratosis or orthokeratosis, hypergranulosis, acanthosis, and mild dermal inflammation.⁸ Increased dermal vascularization and papillary fibrosis unlike that seen in lichen simplex chronicus have been described from skin changes in the lower limbs due to prayer practices.⁷ Additional findings in forehead biopsies include multiple comedones and epidermoid cysts in elderly patients showing a foreign body granulomatous reaction to hair fragments.¹⁰ Deposition of mucinous material in the dermal collagen in a prayer nodule on the forehead has been described in a Shiite individual, possibly due to repetitive microtrauma from the use of a prayer stone.⁹ Infections developed from sharing communal facilities or performing ritual sacrifices (eg, tinea,¹¹ orf¹²) are prevalent during the yearly Hajj pilgrimage at Makkah, Saudi Arabia, in addition to other infectious and noninfectious dermatoses.¹³ Muslim women wearing headscarves secured at the neck with a safety pin have developed vitiligo at that site due to friction.¹⁴ Occasionally, Muslim individuals may apply perfumes before prayers, which may cause allergic contact dermatitis.

Judaism
Hyperpigmentation has been described in Jewish men at Talmudic seminaries due to the practice of reciting scriptures, which involves a rocking motion known as daven that leads to friction on the back.¹⁵ Lesions associated with this practice typically appear as isolated macules or a continuous linear patch over the skin of the bony protuberances of the inferior thoracic and lumbar vertebrae. Allergic contact dermatitis has been reported in Jewish individuals due to exposure to a variety of agents during religious practices, such as potassium dichromate, which is present in the leather used to make phylacteries or tefillin (boxes containing scripture that are secured to the forehead with straps that are then tied to the left arm during prayer). This finding has been noted in some or all areas of contact including the forehead, scalp, neck, left wrist, and waist.¹⁶

It is customary for both Orthodox Jewish and Muslim women to be concealed by clothing, which predisposes them to vitamin D deficiency^17,18 but also protects them from developing malignant melanoma.¹⁹ Neonates have developed genital herpetic infections following circumcision due to the ancient practice of having the mohel (the person who performs the Jewish circumcision) suck on the wound until the bleeding stops.²⁰

Hinduism
Hinduism espouses an eclectic philosophy of life subsuming numerous beliefs involving guardian deities, invoked by sacred marks, symbols, and rituals. Marks generally are placed on the forehead or other specified sites on the body. Sandalwood paste as well as vibhuti and kumkum powders most commonly are used, which can cause allergic contact dermatitis. Vibhuti is holy ash prepared by burning balls of dried cow dung in a fire pit with rice husk and clarified butter. Kumkum is prepared by alkalinizing turmeric powder, which turns red in color. A case of contact allergic dermatitis was reported in a Hindu priest who regularly used sandalwood paste on the forehead and as a balm for an ailment of the hands and feet.²¹ In our experience, vibhuti also has caused dermatitis on the forehead as well as on the neck and arms. The main difference between the 2 eruptions is that sandalwood dermatitis generally is localized to the center of the forehead as a circular or vertical mark or often in the center of the left palm, which is used to mix sandalwood powder with water to make a paste (Figure 4), while vibhuti contact dermatitis typically presents as a broad horizontal patch on the forehead because the powder is smeared with the middle 3 fingers (Figure 5). Perfumes used by some Muslim individuals before prayer that are applied on the clothes can mimic this type of contact dermatitis, but eruptions typically are confined to the fingers and palms.²² Contact dermatitis caused by necklaces made with beads of the stem of the Ocimum sanctum (holy basil) plant and seeds of the evergreen tree Elaeocarpus ganitrus have been reported.²³ Calluses are sometimes seen in individuals who meditate for long hours while sitting in a cross-legged position and usually occur on or uncommonly below the lateral malleolus of the right foot, similar to practitioners of yoga.²⁴

Hemorrhaging and crusting below the lateral malleolus of the right foot have been reported in Buddhist monks due to sitting in a cross-legged position for prolonged periods of meditation.²⁵ Hyperpigmentation of the knees, ankles, and interphalangeal joints of the feet has been seen after sitting in the traditional Japanese meditative position.²⁶ Tattoos of Hindu gods are common, while tattoos are forbidden in Islam and Judaism. Attributes of prominent deities branded on the body may be seen. Discrete sarcoidlike nodules along the axillae and chest wall have been attributed to a Hindu ritual (kavadi) that is performed annually as a form of self-inflicted punishment for their sins in which devotees pierce the chest wall with spokes to form a base over a heavy cage in which offerings are carried, and skewers passed through the cheeks have resulted in similar nodules in the oral cavity.^27,28 Consumption of cow’s urine during rituals may induce acute urticaria.²⁹ Lichen planus of the trunk³⁰ and leukoderma of the waist³¹ may be induced by köbnerization or contact allergy from wearing sacred threads, respectively.

Sikhism
Sikhism, a religion founded in the 15th century, epitomizes the high-water mark of the syncretism between Hinduism and Islam. Men must abstain from cutting their hair; pulling and knotting the hair to maintain a coiffure can cause traction alopecia in the submandibular region and the frontal and parietal areas of the scalp as well as ridging and furrowing of the scalp resembling cutis verticis gyrata. Fixer, a product used to keep the beard intact, can cause contact dermatitis. The tight broad band of cloth (known as a ribbon) that is worn around the head to keep hair intact beneath a turban may cause forehead lesions. Discoid lupus erythematosus–like lesions or painful chondrodermatitis of the pinnae due to pressure from wearing a starched turban have been observed, also called “turban ear” from prominence of both anthelices.^32,33 A case of a Sikh man who developed oral sarcoidal lesions from body piercing has been reported.²⁸

Conclusion
Knowledge of the religious practices of patients would help in recognizing puzzling and peculiar dermatoses. It may not be possible to eliminate the causes of these conditions, but methods to reduce their effects on the skin can be discussed with patients.

Acknowledgments—We are grateful to the valuable help rendered by Joginder Kumar, MD, New Delhi, India, and C. Indira, MD, Hyderabad, India.

Religious practices can lead to cutaneous changes, and awareness of these changes is of paramount importance in establishing the cause. We review the cutaneous changes related to religious practices, including the Semitic religions, Hinduism, and Sikhism (Table). The most widely followed Semitic religions are Christianity, Islam, and Judaism. Christianity and Islam collectively account for more than half of the world’s population.¹

Christianity
Christian individuals are prone to blisters that develop below the knees due to repeated kneeling in prayer.² A case of allergic contact dermatitis to a wooden cross made from Dalbergia nigra has been reported.³ Localized swelling with hypertrichosis due to muscular hypertrophy in the lower neck above the interscapular region has been described in well-built men who lift weights to bear pasos (floats with wooden sculptures) during Holy Week in Seville, Spain.⁴

Islam
Cutaneous signs of piety have been well documented in Muslim individuals. The most common presentation is hyperpigmentation of the forehead, usually noted as a secondary finding in patients seeking treatment of unrelated symptoms.⁵ Cutaneous changes in this region correspond with the area of the forehead that rests on the carpet during prayer. Macules typically present on the upper central aspect of the forehead close to the hairline and/or in pairs above the medial ends of the eyebrows; sometimes 3 or 4 lesions may be present in this area with involvement of the nasion (Figure 1).⁶

In Saudi Arabia where Sunni Islam predominates, Muslim individuals observe prayer 5 times per day. Calluses have been observed in areas of the body that are frequently subject to friction during this practice.⁷ For instance, calluses are more prominent on the right knee (Figure 2) and the left ankle, which bear the individual’s weight during prayer, and typically become nodular over time (Figure 3). In Arabic, these calluses are referred to as zabiba.⁸

A notable finding in followers of Shia Islam, which predominates in Iran, is the development of small nodules on the forehead, possibly caused by rubbing the forehead on a flat disclike prayer stone called a mohr during daily prayer,⁹ which is said to enhance public esteem.¹⁰ The nodules generally are asymptomatic, but some individuals experience minimal pain on pressure.⁸ Ulceration of the nodules has rarely been observed.⁷

Limited access to thick and soft carpets and rarely bony exostoses or obesity are factors associated with prayer that can lead to skin changes (known as prayer signs), as they render the skin sensitive to pressure. Localized alopecia may occur on the forehead in individuals with low or pointed hairlines. An unexplained finding noted by one of the authors (K.A.) in some elderly Muslim individuals is that hair located on the forehead at the point of pressure during prayer remains pigmented, while the rest of the hair on the scalp turns white. Hyperpigmentation of the knuckles may be seen in individuals who use closed fists to rise from the ground following prayer. Except for mild hyperpigmentation of the knees,⁷ Muslim women rarely develop these changes, as they either do not pray,¹⁰ particularly during menstruation or puerperium, or they have more subcutaneous fat for protection.⁷ Some Muslim individuals who pray regularly at home may be conscious of these skin changes and therefore use a soft pillow to rest the forehead during prayer.

The histopathologic findings of prayer signs depend on the extent of lichenification and typically show compact hyperkeratosis or orthokeratosis, hypergranulosis, acanthosis, and mild dermal inflammation.⁸ Increased dermal vascularization and papillary fibrosis unlike that seen in lichen simplex chronicus have been described from skin changes in the lower limbs due to prayer practices.⁷ Additional findings in forehead biopsies include multiple comedones and epidermoid cysts in elderly patients showing a foreign body granulomatous reaction to hair fragments.¹⁰ Deposition of mucinous material in the dermal collagen in a prayer nodule on the forehead has been described in a Shiite individual, possibly due to repetitive microtrauma from the use of a prayer stone.⁹ Infections developed from sharing communal facilities or performing ritual sacrifices (eg, tinea,¹¹ orf¹²) are prevalent during the yearly Hajj pilgrimage at Makkah, Saudi Arabia, in addition to other infectious and noninfectious dermatoses.¹³ Muslim women wearing headscarves secured at the neck with a safety pin have developed vitiligo at that site due to friction.¹⁴ Occasionally, Muslim individuals may apply perfumes before prayers, which may cause allergic contact dermatitis.

Judaism
Hyperpigmentation has been described in Jewish men at Talmudic seminaries due to the practice of reciting scriptures, which involves a rocking motion known as daven that leads to friction on the back.¹⁵ Lesions associated with this practice typically appear as isolated macules or a continuous linear patch over the skin of the bony protuberances of the inferior thoracic and lumbar vertebrae. Allergic contact dermatitis has been reported in Jewish individuals due to exposure to a variety of agents during religious practices, such as potassium dichromate, which is present in the leather used to make phylacteries or tefillin (boxes containing scripture that are secured to the forehead with straps that are then tied to the left arm during prayer). This finding has been noted in some or all areas of contact including the forehead, scalp, neck, left wrist, and waist.¹⁶

It is customary for both Orthodox Jewish and Muslim women to be concealed by clothing, which predisposes them to vitamin D deficiency^17,18 but also protects them from developing malignant melanoma.¹⁹ Neonates have developed genital herpetic infections following circumcision due to the ancient practice of having the mohel (the person who performs the Jewish circumcision) suck on the wound until the bleeding stops.²⁰

Hinduism
Hinduism espouses an eclectic philosophy of life subsuming numerous beliefs involving guardian deities, invoked by sacred marks, symbols, and rituals. Marks generally are placed on the forehead or other specified sites on the body. Sandalwood paste as well as vibhuti and kumkum powders most commonly are used, which can cause allergic contact dermatitis. Vibhuti is holy ash prepared by burning balls of dried cow dung in a fire pit with rice husk and clarified butter. Kumkum is prepared by alkalinizing turmeric powder, which turns red in color. A case of contact allergic dermatitis was reported in a Hindu priest who regularly used sandalwood paste on the forehead and as a balm for an ailment of the hands and feet.²¹ In our experience, vibhuti also has caused dermatitis on the forehead as well as on the neck and arms. The main difference between the 2 eruptions is that sandalwood dermatitis generally is localized to the center of the forehead as a circular or vertical mark or often in the center of the left palm, which is used to mix sandalwood powder with water to make a paste (Figure 4), while vibhuti contact dermatitis typically presents as a broad horizontal patch on the forehead because the powder is smeared with the middle 3 fingers (Figure 5). Perfumes used by some Muslim individuals before prayer that are applied on the clothes can mimic this type of contact dermatitis, but eruptions typically are confined to the fingers and palms.²² Contact dermatitis caused by necklaces made with beads of the stem of the Ocimum sanctum (holy basil) plant and seeds of the evergreen tree Elaeocarpus ganitrus have been reported.²³ Calluses are sometimes seen in individuals who meditate for long hours while sitting in a cross-legged position and usually occur on or uncommonly below the lateral malleolus of the right foot, similar to practitioners of yoga.²⁴

Hemorrhaging and crusting below the lateral malleolus of the right foot have been reported in Buddhist monks due to sitting in a cross-legged position for prolonged periods of meditation.²⁵ Hyperpigmentation of the knees, ankles, and interphalangeal joints of the feet has been seen after sitting in the traditional Japanese meditative position.²⁶ Tattoos of Hindu gods are common, while tattoos are forbidden in Islam and Judaism. Attributes of prominent deities branded on the body may be seen. Discrete sarcoidlike nodules along the axillae and chest wall have been attributed to a Hindu ritual (kavadi) that is performed annually as a form of self-inflicted punishment for their sins in which devotees pierce the chest wall with spokes to form a base over a heavy cage in which offerings are carried, and skewers passed through the cheeks have resulted in similar nodules in the oral cavity.^27,28 Consumption of cow’s urine during rituals may induce acute urticaria.²⁹ Lichen planus of the trunk³⁰ and leukoderma of the waist³¹ may be induced by köbnerization or contact allergy from wearing sacred threads, respectively.

Sikhism
Sikhism, a religion founded in the 15th century, epitomizes the high-water mark of the syncretism between Hinduism and Islam. Men must abstain from cutting their hair; pulling and knotting the hair to maintain a coiffure can cause traction alopecia in the submandibular region and the frontal and parietal areas of the scalp as well as ridging and furrowing of the scalp resembling cutis verticis gyrata. Fixer, a product used to keep the beard intact, can cause contact dermatitis. The tight broad band of cloth (known as a ribbon) that is worn around the head to keep hair intact beneath a turban may cause forehead lesions. Discoid lupus erythematosus–like lesions or painful chondrodermatitis of the pinnae due to pressure from wearing a starched turban have been observed, also called “turban ear” from prominence of both anthelices.^32,33 A case of a Sikh man who developed oral sarcoidal lesions from body piercing has been reported.²⁸

Conclusion
Knowledge of the religious practices of patients would help in recognizing puzzling and peculiar dermatoses. It may not be possible to eliminate the causes of these conditions, but methods to reduce their effects on the skin can be discussed with patients.

Acknowledgments—We are grateful to the valuable help rendered by Joginder Kumar, MD, New Delhi, India, and C. Indira, MD, Hyderabad, India.

A recent online study by Gerami et al in the Journal of the American Academy of Dermatology highlighted a new genomic method using messenger RNA to classify pigmented lesions as benign or malignant using a noninvasive adhesive patch developed by DermTech International. Patches were applied to the surface of pigmented lesions (42 melanomas; 22 nevi), vigorously rubbed, removed, frozen, and sent to the proprietary laboratory for RNA extraction and gene expression analysis. Then each lesion was excised for pathologic review. A 2-gene signature was discovered, including CMIP and LINC00518, differentiating melanoma from nevi with sensitivity of 97.6% and specificity of 72.7%.

What’s the issue?

Along with our evolving understanding and case-specific use of noninvasive modalities to diagnose difficult pigmented lesions, we add this test to the number of other tests and imaging approaches that seem perhaps too good to be true. A test that strips epithelial cells and involves no wound care but explores true gene differences likely sits better with us than surface microscopy, dermoscopy, and other imaging because, in this case, it provides a signature. A result. Similar to a pregnancy test, right? We wish. The diversity of pigmented lesions, especially the ones that stump us even on pathologic review, will likely prove too cryptic for 1 test to decode, but as these modalities evolve, their signatures will hopefully merge between researchers and industry to create a pigmented lesion map that we can all read. What noninvasive modalities do you use in your practices for pigmented lesions? How do you think this test will fit in?

We want to know your views! Tell us what you think.

A recent online study by Gerami et al in the Journal of the American Academy of Dermatology highlighted a new genomic method using messenger RNA to classify pigmented lesions as benign or malignant using a noninvasive adhesive patch developed by DermTech International. Patches were applied to the surface of pigmented lesions (42 melanomas; 22 nevi), vigorously rubbed, removed, frozen, and sent to the proprietary laboratory for RNA extraction and gene expression analysis. Then each lesion was excised for pathologic review. A 2-gene signature was discovered, including CMIP and LINC00518, differentiating melanoma from nevi with sensitivity of 97.6% and specificity of 72.7%.

What’s the issue?

Along with our evolving understanding and case-specific use of noninvasive modalities to diagnose difficult pigmented lesions, we add this test to the number of other tests and imaging approaches that seem perhaps too good to be true. A test that strips epithelial cells and involves no wound care but explores true gene differences likely sits better with us than surface microscopy, dermoscopy, and other imaging because, in this case, it provides a signature. A result. Similar to a pregnancy test, right? We wish. The diversity of pigmented lesions, especially the ones that stump us even on pathologic review, will likely prove too cryptic for 1 test to decode, but as these modalities evolve, their signatures will hopefully merge between researchers and industry to create a pigmented lesion map that we can all read. What noninvasive modalities do you use in your practices for pigmented lesions? How do you think this test will fit in?

We want to know your views! Tell us what you think.

A recent online study by Gerami et al in the Journal of the American Academy of Dermatology highlighted a new genomic method using messenger RNA to classify pigmented lesions as benign or malignant using a noninvasive adhesive patch developed by DermTech International. Patches were applied to the surface of pigmented lesions (42 melanomas; 22 nevi), vigorously rubbed, removed, frozen, and sent to the proprietary laboratory for RNA extraction and gene expression analysis. Then each lesion was excised for pathologic review. A 2-gene signature was discovered, including CMIP and LINC00518, differentiating melanoma from nevi with sensitivity of 97.6% and specificity of 72.7%.

What’s the issue?

Along with our evolving understanding and case-specific use of noninvasive modalities to diagnose difficult pigmented lesions, we add this test to the number of other tests and imaging approaches that seem perhaps too good to be true. A test that strips epithelial cells and involves no wound care but explores true gene differences likely sits better with us than surface microscopy, dermoscopy, and other imaging because, in this case, it provides a signature. A result. Similar to a pregnancy test, right? We wish. The diversity of pigmented lesions, especially the ones that stump us even on pathologic review, will likely prove too cryptic for 1 test to decode, but as these modalities evolve, their signatures will hopefully merge between researchers and industry to create a pigmented lesion map that we can all read. What noninvasive modalities do you use in your practices for pigmented lesions? How do you think this test will fit in?

We want to know your views! Tell us what you think.

The Diagnosis: Blaschkoid Punctate Vitiligo

Based on the patient’s clinical appearance as well as the histologic findings, the diagnosis of vitiligo was made. Although vitiligo is certainly not uncommon and punctate vitiligo is a known clinical presentation,¹ punctate vitiliginous depigmentation conforming to lines of Blaschko is unique. Follicular repigmentation in a patch of vitiligo potentially could lead to this “spotty” appearance, but our patient maintained that the band was never confluently depigmented and that small macules arose within normally pigmented skin. The patient’s adult age at onset makes this case even more unusual.

Follicular repigmentation in vitiligo is fairly well understood, as the perifollicular pigment is formed by upward migration of activated melanoblasts in the outer root sheath.² Follicular depigmentation as well as selective or initial loss of melanocytes around hair follicles in early vitiligo has not been described. It is unclear if the seemingly folliculocentric nature of the patient’s vitiliginous macules was a false observation, coincidental, or actually related to selective melanocyte loss around follicles.

Blaschkoid distribution has been described in numerous skin disorders and is known to be based on genetic mosaicism.³ Most of these disorders are X-linked and/or congenital. However, many acquired skin conditions have been described exhibiting blaschkoid distribution, such as vitiligo, psoriasis, lichen planus, atopic dermatitis, and mycosis fungoides.^4,5

Confettilike depigmentation has been described as an unusual clinical variant of vitiligo.¹ It also has been reported after psoralen plus UVA therapy in patients with more classic vitiligo,⁶ numerous domestic chemicals,⁷ and in association with mycosis fungoides.⁸ In these cases, punctate lesions were disseminated, symmetric on extremities, or limited to areas exposed to chemicals.

The Diagnosis: Blaschkoid Punctate Vitiligo

Based on the patient’s clinical appearance as well as the histologic findings, the diagnosis of vitiligo was made. Although vitiligo is certainly not uncommon and punctate vitiligo is a known clinical presentation,¹ punctate vitiliginous depigmentation conforming to lines of Blaschko is unique. Follicular repigmentation in a patch of vitiligo potentially could lead to this “spotty” appearance, but our patient maintained that the band was never confluently depigmented and that small macules arose within normally pigmented skin. The patient’s adult age at onset makes this case even more unusual.

Follicular repigmentation in vitiligo is fairly well understood, as the perifollicular pigment is formed by upward migration of activated melanoblasts in the outer root sheath.² Follicular depigmentation as well as selective or initial loss of melanocytes around hair follicles in early vitiligo has not been described. It is unclear if the seemingly folliculocentric nature of the patient’s vitiliginous macules was a false observation, coincidental, or actually related to selective melanocyte loss around follicles.

Blaschkoid distribution has been described in numerous skin disorders and is known to be based on genetic mosaicism.³ Most of these disorders are X-linked and/or congenital. However, many acquired skin conditions have been described exhibiting blaschkoid distribution, such as vitiligo, psoriasis, lichen planus, atopic dermatitis, and mycosis fungoides.^4,5

Confettilike depigmentation has been described as an unusual clinical variant of vitiligo.¹ It also has been reported after psoralen plus UVA therapy in patients with more classic vitiligo,⁶ numerous domestic chemicals,⁷ and in association with mycosis fungoides.⁸ In these cases, punctate lesions were disseminated, symmetric on extremities, or limited to areas exposed to chemicals.

The Diagnosis: Blaschkoid Punctate Vitiligo

Based on the patient’s clinical appearance as well as the histologic findings, the diagnosis of vitiligo was made. Although vitiligo is certainly not uncommon and punctate vitiligo is a known clinical presentation,¹ punctate vitiliginous depigmentation conforming to lines of Blaschko is unique. Follicular repigmentation in a patch of vitiligo potentially could lead to this “spotty” appearance, but our patient maintained that the band was never confluently depigmented and that small macules arose within normally pigmented skin. The patient’s adult age at onset makes this case even more unusual.

Follicular repigmentation in vitiligo is fairly well understood, as the perifollicular pigment is formed by upward migration of activated melanoblasts in the outer root sheath.² Follicular depigmentation as well as selective or initial loss of melanocytes around hair follicles in early vitiligo has not been described. It is unclear if the seemingly folliculocentric nature of the patient’s vitiliginous macules was a false observation, coincidental, or actually related to selective melanocyte loss around follicles.

Blaschkoid distribution has been described in numerous skin disorders and is known to be based on genetic mosaicism.³ Most of these disorders are X-linked and/or congenital. However, many acquired skin conditions have been described exhibiting blaschkoid distribution, such as vitiligo, psoriasis, lichen planus, atopic dermatitis, and mycosis fungoides.^4,5

Confettilike depigmentation has been described as an unusual clinical variant of vitiligo.¹ It also has been reported after psoralen plus UVA therapy in patients with more classic vitiligo,⁶ numerous domestic chemicals,⁷ and in association with mycosis fungoides.⁸ In these cases, punctate lesions were disseminated, symmetric on extremities, or limited to areas exposed to chemicals.

The spectrum of idiopathic ultraviolet-induced dermatoses includes the most severe variant, polymorphous light eruption (PMLE), in which erythematous papules, papulovesicles, and plaques form from a delayed type IV hypersensitivity reaction to the sun. Its milder cousins, benign summer light eruption and juvenile springtime eruption, are milder, more transient variants.

Patients may experience sudden-onset, pruritic, sometimes painful papules and papulovesicles or cheilitis within 30 minutes to several hours of exposure to UV light in areas normally covered in the winter months. The rash subsides over 1-7 days (or sooner with effective topical steroid administration and strict sun avoidance) and without scarring. Occasionally, patients experience systemic flulike symptoms after sun exposure. Triggers can be UVA, UVB, or UVC. However, because most cases appear in the spring, describing these variants as benign summer light eruption is something of a misnomer.

These seasonal rashes are often underrecognized in skin of color patients, particularly those with Fitzpatrick skin types III-VI, because many practitioners assume a protective role of melanin (Photochem. Photobiol. Sci. 2013;12:65-77). A study by Kerr and Lim identified 280 patients with photodermatoses; 135 (48%) were African American, 110 (40%) were white, and 35 (12%) were other ethnicities. They noted a significantly higher proportion of African Americans with PMLE, compared with whites (J. Am. Acad. Dermatol. 2007;57:638-43). Also, Native Americans have a hereditary form of PMLE with autosomal dominant inheritance that can involve the face and is most common in patients with Fitzpatrick skin types III-VI.

For sun-sensitive patients, and especially skin of color patients, diagnosis and treatment include ruling out other photosensitive diseases such as systemic lupus, and then counseling about the importance of sun avoidance and the use of sunscreens, which include both UVA and UVB protection. Prophylactic phototherapy or photochemotherapy at the beginning of spring for several weeks may prevent flare-ups throughout the summer. PUVA (psoralen and UVA) therapy, as well as UVB phototherapy, have been successful at preventing flares in several studies. Topical steroids, antihistamines, and oral prednisone are mainstays of treatment for severe flares, alone or in combination with phototherapy. For severe cases, or those recalcitrant to first-line treatment, antimalarials, azathioprine, and thalidomide have been used with variable efficacy.

Particularly at this time of year, I always ask patients with photo-distributed rashes about their ethnicities. One can never assume ethnicity, culture, skin type, background, or even photosensitivity based on skin color alone. I have been surprised by the many patients with dark skin who may have Native American origins who present with photosensitive rashes, or the many patients with hereditary photosensitive rashes with fair skin. Our beautiful, multicultural society makes it harder to define or categorize dermatoses by skin type alone, based on the definitions we have set for skin type in our literature today.

Dr. Talakoub and Dr. Wesley are co-contributors to a monthly Aesthetic Dermatology column in Skin & Allergy News. Dr. Talakoub is in private practice at McLean (Va.) Dermatology Center. Dr. Wesley practices dermatology in Beverly Hills, Calif.

The spectrum of idiopathic ultraviolet-induced dermatoses includes the most severe variant, polymorphous light eruption (PMLE), in which erythematous papules, papulovesicles, and plaques form from a delayed type IV hypersensitivity reaction to the sun. Its milder cousins, benign summer light eruption and juvenile springtime eruption, are milder, more transient variants.

Patients may experience sudden-onset, pruritic, sometimes painful papules and papulovesicles or cheilitis within 30 minutes to several hours of exposure to UV light in areas normally covered in the winter months. The rash subsides over 1-7 days (or sooner with effective topical steroid administration and strict sun avoidance) and without scarring. Occasionally, patients experience systemic flulike symptoms after sun exposure. Triggers can be UVA, UVB, or UVC. However, because most cases appear in the spring, describing these variants as benign summer light eruption is something of a misnomer.

These seasonal rashes are often underrecognized in skin of color patients, particularly those with Fitzpatrick skin types III-VI, because many practitioners assume a protective role of melanin (Photochem. Photobiol. Sci. 2013;12:65-77). A study by Kerr and Lim identified 280 patients with photodermatoses; 135 (48%) were African American, 110 (40%) were white, and 35 (12%) were other ethnicities. They noted a significantly higher proportion of African Americans with PMLE, compared with whites (J. Am. Acad. Dermatol. 2007;57:638-43). Also, Native Americans have a hereditary form of PMLE with autosomal dominant inheritance that can involve the face and is most common in patients with Fitzpatrick skin types III-VI.

For sun-sensitive patients, and especially skin of color patients, diagnosis and treatment include ruling out other photosensitive diseases such as systemic lupus, and then counseling about the importance of sun avoidance and the use of sunscreens, which include both UVA and UVB protection. Prophylactic phototherapy or photochemotherapy at the beginning of spring for several weeks may prevent flare-ups throughout the summer. PUVA (psoralen and UVA) therapy, as well as UVB phototherapy, have been successful at preventing flares in several studies. Topical steroids, antihistamines, and oral prednisone are mainstays of treatment for severe flares, alone or in combination with phototherapy. For severe cases, or those recalcitrant to first-line treatment, antimalarials, azathioprine, and thalidomide have been used with variable efficacy.

Particularly at this time of year, I always ask patients with photo-distributed rashes about their ethnicities. One can never assume ethnicity, culture, skin type, background, or even photosensitivity based on skin color alone. I have been surprised by the many patients with dark skin who may have Native American origins who present with photosensitive rashes, or the many patients with hereditary photosensitive rashes with fair skin. Our beautiful, multicultural society makes it harder to define or categorize dermatoses by skin type alone, based on the definitions we have set for skin type in our literature today.

Dr. Talakoub and Dr. Wesley are co-contributors to a monthly Aesthetic Dermatology column in Skin & Allergy News. Dr. Talakoub is in private practice at McLean (Va.) Dermatology Center. Dr. Wesley practices dermatology in Beverly Hills, Calif.

The spectrum of idiopathic ultraviolet-induced dermatoses includes the most severe variant, polymorphous light eruption (PMLE), in which erythematous papules, papulovesicles, and plaques form from a delayed type IV hypersensitivity reaction to the sun. Its milder cousins, benign summer light eruption and juvenile springtime eruption, are milder, more transient variants.

Patients may experience sudden-onset, pruritic, sometimes painful papules and papulovesicles or cheilitis within 30 minutes to several hours of exposure to UV light in areas normally covered in the winter months. The rash subsides over 1-7 days (or sooner with effective topical steroid administration and strict sun avoidance) and without scarring. Occasionally, patients experience systemic flulike symptoms after sun exposure. Triggers can be UVA, UVB, or UVC. However, because most cases appear in the spring, describing these variants as benign summer light eruption is something of a misnomer.

These seasonal rashes are often underrecognized in skin of color patients, particularly those with Fitzpatrick skin types III-VI, because many practitioners assume a protective role of melanin (Photochem. Photobiol. Sci. 2013;12:65-77). A study by Kerr and Lim identified 280 patients with photodermatoses; 135 (48%) were African American, 110 (40%) were white, and 35 (12%) were other ethnicities. They noted a significantly higher proportion of African Americans with PMLE, compared with whites (J. Am. Acad. Dermatol. 2007;57:638-43). Also, Native Americans have a hereditary form of PMLE with autosomal dominant inheritance that can involve the face and is most common in patients with Fitzpatrick skin types III-VI.

For sun-sensitive patients, and especially skin of color patients, diagnosis and treatment include ruling out other photosensitive diseases such as systemic lupus, and then counseling about the importance of sun avoidance and the use of sunscreens, which include both UVA and UVB protection. Prophylactic phototherapy or photochemotherapy at the beginning of spring for several weeks may prevent flare-ups throughout the summer. PUVA (psoralen and UVA) therapy, as well as UVB phototherapy, have been successful at preventing flares in several studies. Topical steroids, antihistamines, and oral prednisone are mainstays of treatment for severe flares, alone or in combination with phototherapy. For severe cases, or those recalcitrant to first-line treatment, antimalarials, azathioprine, and thalidomide have been used with variable efficacy.

Particularly at this time of year, I always ask patients with photo-distributed rashes about their ethnicities. One can never assume ethnicity, culture, skin type, background, or even photosensitivity based on skin color alone. I have been surprised by the many patients with dark skin who may have Native American origins who present with photosensitive rashes, or the many patients with hereditary photosensitive rashes with fair skin. Our beautiful, multicultural society makes it harder to define or categorize dermatoses by skin type alone, based on the definitions we have set for skin type in our literature today.

Dr. Talakoub and Dr. Wesley are co-contributors to a monthly Aesthetic Dermatology column in Skin & Allergy News. Dr. Talakoub is in private practice at McLean (Va.) Dermatology Center. Dr. Wesley practices dermatology in Beverly Hills, Calif.

The Diagnosis: Carotenemia

Laboratory parameters including thyroid function testing as well as total protein and bilirubin levels were within reference range. Testing revealed multiple food allergies to almonds, oranges, cashews, garlic, peanuts, and cantaloupe. The patient was treated with a dietary expansion based on his allergy testing.

ß-Carotene converts to vitamin A in the intestine and acts as a lipochrome. Lack of conversion can be noted as an inborn error of metabolism.¹ Many green, yellow, and orange fruits and vegetables contain ß-carotene, including carrots, sweet potatoes, squash, green beans, papayas, and pumpkins.^1-3 ß-Carotene also is used as a vitamin supplement⁴ or therapeutic agent in photosensitive disorders such as genetic porphyrias.⁵

ß-Carotene can accumulate in the stratum corneum and impart a yellow color to the skin when the circulating levels are high; this coloration is termed carotenemia.^1,4 Carotenemia is common in infants and young children who have diets rich in green and orange vegetable purees.⁶ Carotenemia limited to thick areas of the skin, such as the palms and soles, can be seen in adults who eat large amounts of carrots; generalized carotenemia is rare.^1,4

Carotenemia is a benign condition of excess cutaneous buildup of ß-carotene through excessive intake of carotene-rich foods^1-4 or nutritional supplements⁷ or through association with anorexia, liver disease, renal disease, hypothyroidism, or diabetes mellitus.^1,4,8,9 Carotene deposits usually are most notable in areas with thick stratum corneum, such as the nasolabial folds, palms, and soles, as opposed to areas such as the conjunctivae and mucosa.^1,4

Carotenemia may mimic jaundice and should be differentiated through scleral examination for icterus and bilirubin levels. Carotene levels can be tested but generally are unnecessary. Carotenemia can be seen in liver or renal disease and can exacerbate the yellow coloration seen in jaundiced individuals.^1,4,9

Because it is a benign condition, the pathology usually is limited to skin discoloration, as seen in our patient. Although this condition can be reversed with a modified diet, our patient had multiple food allergies that further restricted his vegetarian diet, thereby limiting the modifications that he was willing to make to his diet.

The Diagnosis: Carotenemia

Laboratory parameters including thyroid function testing as well as total protein and bilirubin levels were within reference range. Testing revealed multiple food allergies to almonds, oranges, cashews, garlic, peanuts, and cantaloupe. The patient was treated with a dietary expansion based on his allergy testing.

ß-Carotene converts to vitamin A in the intestine and acts as a lipochrome. Lack of conversion can be noted as an inborn error of metabolism.¹ Many green, yellow, and orange fruits and vegetables contain ß-carotene, including carrots, sweet potatoes, squash, green beans, papayas, and pumpkins.^1-3 ß-Carotene also is used as a vitamin supplement⁴ or therapeutic agent in photosensitive disorders such as genetic porphyrias.⁵

ß-Carotene can accumulate in the stratum corneum and impart a yellow color to the skin when the circulating levels are high; this coloration is termed carotenemia.^1,4 Carotenemia is common in infants and young children who have diets rich in green and orange vegetable purees.⁶ Carotenemia limited to thick areas of the skin, such as the palms and soles, can be seen in adults who eat large amounts of carrots; generalized carotenemia is rare.^1,4

Carotenemia is a benign condition of excess cutaneous buildup of ß-carotene through excessive intake of carotene-rich foods^1-4 or nutritional supplements⁷ or through association with anorexia, liver disease, renal disease, hypothyroidism, or diabetes mellitus.^1,4,8,9 Carotene deposits usually are most notable in areas with thick stratum corneum, such as the nasolabial folds, palms, and soles, as opposed to areas such as the conjunctivae and mucosa.^1,4

Carotenemia may mimic jaundice and should be differentiated through scleral examination for icterus and bilirubin levels. Carotene levels can be tested but generally are unnecessary. Carotenemia can be seen in liver or renal disease and can exacerbate the yellow coloration seen in jaundiced individuals.^1,4,9

Because it is a benign condition, the pathology usually is limited to skin discoloration, as seen in our patient. Although this condition can be reversed with a modified diet, our patient had multiple food allergies that further restricted his vegetarian diet, thereby limiting the modifications that he was willing to make to his diet.

The Diagnosis: Carotenemia

Laboratory parameters including thyroid function testing as well as total protein and bilirubin levels were within reference range. Testing revealed multiple food allergies to almonds, oranges, cashews, garlic, peanuts, and cantaloupe. The patient was treated with a dietary expansion based on his allergy testing.

ß-Carotene converts to vitamin A in the intestine and acts as a lipochrome. Lack of conversion can be noted as an inborn error of metabolism.¹ Many green, yellow, and orange fruits and vegetables contain ß-carotene, including carrots, sweet potatoes, squash, green beans, papayas, and pumpkins.^1-3 ß-Carotene also is used as a vitamin supplement⁴ or therapeutic agent in photosensitive disorders such as genetic porphyrias.⁵

ß-Carotene can accumulate in the stratum corneum and impart a yellow color to the skin when the circulating levels are high; this coloration is termed carotenemia.^1,4 Carotenemia is common in infants and young children who have diets rich in green and orange vegetable purees.⁶ Carotenemia limited to thick areas of the skin, such as the palms and soles, can be seen in adults who eat large amounts of carrots; generalized carotenemia is rare.^1,4

Carotenemia is a benign condition of excess cutaneous buildup of ß-carotene through excessive intake of carotene-rich foods^1-4 or nutritional supplements⁷ or through association with anorexia, liver disease, renal disease, hypothyroidism, or diabetes mellitus.^1,4,8,9 Carotene deposits usually are most notable in areas with thick stratum corneum, such as the nasolabial folds, palms, and soles, as opposed to areas such as the conjunctivae and mucosa.^1,4

Carotenemia may mimic jaundice and should be differentiated through scleral examination for icterus and bilirubin levels. Carotene levels can be tested but generally are unnecessary. Carotenemia can be seen in liver or renal disease and can exacerbate the yellow coloration seen in jaundiced individuals.^1,4,9

Because it is a benign condition, the pathology usually is limited to skin discoloration, as seen in our patient. Although this condition can be reversed with a modified diet, our patient had multiple food allergies that further restricted his vegetarian diet, thereby limiting the modifications that he was willing to make to his diet.

Dyschromias are one of the most common skin concerns among women and persons of color. In the April issue of Journal of Drugs in Dermatology, Dr. S.J. Kang and associates conducted an excellent study to determine whether racial or ethnic groups are treated differently for dyschromia.

The investigators searched the National Ambulatory Medical Care Survey (NAMCS) database for visits including the diagnosis of dyschromia (ICD-9 codes 709.00 or 709.09) during an 18-year period (1993-2010). They found 24.7 million visits for dyschromia and 5,531,000 patients with a sole diagnosis of dyschromia. Of those with a sole diagnosis of dyschromia, 76% were seen by a dermatologist, and more than half were female. Seventy-five percent were white, 11% African American, 7% Asian/Pacific Islander, and 9% Hispanic, although Asians demonstrated the highest number of visits per 100,000 persons.

In this review, hydroquinone monotherapy was the most commonly prescribed medication by dermatologists. Combination therapy with hydroquinone plus a retinoid and corticosteroid was utilized for women 10 times more than for men. African American patients were less likely to be prescribed combination therapy or receive procedures (such as cryotherapy, chemical peels or lasers). Additionally, sunscreens were recommended less often to black and Asian patients, compared with white patients.

While the underlying reason for dyschromia plays a role in the type of treatment given, overall combination therapies are often more effective than therapy with hydroquinone alone. This study demonstrates that combination therapy may be under-utilized in patients of color.

In my practice, I find that unless the patient’s skin is completely hydroquinone-naive, combination therapy with hydroquinone, retinoid, and corticosteroid is often a first-line treatment that may achieve faster results. Sun protection is a vital component in the treatment of dyschromia, and it is recommended for every patient, regardless of race or ethnicity. Nonhydroquinone topical agents containing ingredients such as kojic acid, arbutin, licorice, niacinamide, resveratrol, and superficial chemical peels are also used in all ethnic groups. In my Asian, Hispanic, and African American or darker-skinned patients, I do use caution with deeper peels and lasers and often perform a test spot first if this type of therapy is considered.

Dr. Wesley practices dermatology in Beverly Hills, Calif.

Dyschromias are one of the most common skin concerns among women and persons of color. In the April issue of Journal of Drugs in Dermatology, Dr. S.J. Kang and associates conducted an excellent study to determine whether racial or ethnic groups are treated differently for dyschromia.

The investigators searched the National Ambulatory Medical Care Survey (NAMCS) database for visits including the diagnosis of dyschromia (ICD-9 codes 709.00 or 709.09) during an 18-year period (1993-2010). They found 24.7 million visits for dyschromia and 5,531,000 patients with a sole diagnosis of dyschromia. Of those with a sole diagnosis of dyschromia, 76% were seen by a dermatologist, and more than half were female. Seventy-five percent were white, 11% African American, 7% Asian/Pacific Islander, and 9% Hispanic, although Asians demonstrated the highest number of visits per 100,000 persons.

In this review, hydroquinone monotherapy was the most commonly prescribed medication by dermatologists. Combination therapy with hydroquinone plus a retinoid and corticosteroid was utilized for women 10 times more than for men. African American patients were less likely to be prescribed combination therapy or receive procedures (such as cryotherapy, chemical peels or lasers). Additionally, sunscreens were recommended less often to black and Asian patients, compared with white patients.

While the underlying reason for dyschromia plays a role in the type of treatment given, overall combination therapies are often more effective than therapy with hydroquinone alone. This study demonstrates that combination therapy may be under-utilized in patients of color.

In my practice, I find that unless the patient’s skin is completely hydroquinone-naive, combination therapy with hydroquinone, retinoid, and corticosteroid is often a first-line treatment that may achieve faster results. Sun protection is a vital component in the treatment of dyschromia, and it is recommended for every patient, regardless of race or ethnicity. Nonhydroquinone topical agents containing ingredients such as kojic acid, arbutin, licorice, niacinamide, resveratrol, and superficial chemical peels are also used in all ethnic groups. In my Asian, Hispanic, and African American or darker-skinned patients, I do use caution with deeper peels and lasers and often perform a test spot first if this type of therapy is considered.

Dr. Wesley practices dermatology in Beverly Hills, Calif.

Dyschromias are one of the most common skin concerns among women and persons of color. In the April issue of Journal of Drugs in Dermatology, Dr. S.J. Kang and associates conducted an excellent study to determine whether racial or ethnic groups are treated differently for dyschromia.

The investigators searched the National Ambulatory Medical Care Survey (NAMCS) database for visits including the diagnosis of dyschromia (ICD-9 codes 709.00 or 709.09) during an 18-year period (1993-2010). They found 24.7 million visits for dyschromia and 5,531,000 patients with a sole diagnosis of dyschromia. Of those with a sole diagnosis of dyschromia, 76% were seen by a dermatologist, and more than half were female. Seventy-five percent were white, 11% African American, 7% Asian/Pacific Islander, and 9% Hispanic, although Asians demonstrated the highest number of visits per 100,000 persons.

In this review, hydroquinone monotherapy was the most commonly prescribed medication by dermatologists. Combination therapy with hydroquinone plus a retinoid and corticosteroid was utilized for women 10 times more than for men. African American patients were less likely to be prescribed combination therapy or receive procedures (such as cryotherapy, chemical peels or lasers). Additionally, sunscreens were recommended less often to black and Asian patients, compared with white patients.

While the underlying reason for dyschromia plays a role in the type of treatment given, overall combination therapies are often more effective than therapy with hydroquinone alone. This study demonstrates that combination therapy may be under-utilized in patients of color.

In my practice, I find that unless the patient’s skin is completely hydroquinone-naive, combination therapy with hydroquinone, retinoid, and corticosteroid is often a first-line treatment that may achieve faster results. Sun protection is a vital component in the treatment of dyschromia, and it is recommended for every patient, regardless of race or ethnicity. Nonhydroquinone topical agents containing ingredients such as kojic acid, arbutin, licorice, niacinamide, resveratrol, and superficial chemical peels are also used in all ethnic groups. In my Asian, Hispanic, and African American or darker-skinned patients, I do use caution with deeper peels and lasers and often perform a test spot first if this type of therapy is considered.

Dr. Wesley practices dermatology in Beverly Hills, Calif.

In this episode of our monthly dermatology podcast, we bring you an expert update on vitiligo research, a dose of humor from our columnist, Dr. Alan Rockoff, and the top news on edermatologynews.com.

In this episode of our monthly dermatology podcast, we bring you an expert update on vitiligo research, a dose of humor from our columnist, Dr. Alan Rockoff, and the top news on edermatologynews.com.

In this episode of our monthly dermatology podcast, we bring you an expert update on vitiligo research, a dose of humor from our columnist, Dr. Alan Rockoff, and the top news on edermatologynews.com.

DENVER – Vitiligo has been known for thousands of years, but only in the past six decades have researchers begun to better understand it and uncover genes associated with the disorder.

Dr. Richard A. Spritz, one of the leaders in vitiligo research, says that scientists are very close to understanding the condition’s pathogenesis. He is embarking on another analysis of data from a large genetic study, which could double the number of known vitiligo genes, putting the disorder on par with other autoimmune diseases such as type 1 diabetes and rheumatoid arthritis.

At the Society of Pediatric Dermatology’s annual meeting, held immediately before the annual meeting of the American Academy of Dermatology, Dr. Spritz spoke about what is known so far about vitiligo and what the future holds. Dr. Spritz is professor and director of the Human Medical Genetics and Genomics Program at the University of Colorado, Aurora.

nmiller@frontlinemedcom.com

On Twitter @naseemsmiller

DENVER – Vitiligo has been known for thousands of years, but only in the past six decades have researchers begun to better understand it and uncover genes associated with the disorder.

Dr. Richard A. Spritz, one of the leaders in vitiligo research, says that scientists are very close to understanding the condition’s pathogenesis. He is embarking on another analysis of data from a large genetic study, which could double the number of known vitiligo genes, putting the disorder on par with other autoimmune diseases such as type 1 diabetes and rheumatoid arthritis.

At the Society of Pediatric Dermatology’s annual meeting, held immediately before the annual meeting of the American Academy of Dermatology, Dr. Spritz spoke about what is known so far about vitiligo and what the future holds. Dr. Spritz is professor and director of the Human Medical Genetics and Genomics Program at the University of Colorado, Aurora.

nmiller@frontlinemedcom.com

On Twitter @naseemsmiller

DENVER – Vitiligo has been known for thousands of years, but only in the past six decades have researchers begun to better understand it and uncover genes associated with the disorder.

Dr. Richard A. Spritz, one of the leaders in vitiligo research, says that scientists are very close to understanding the condition’s pathogenesis. He is embarking on another analysis of data from a large genetic study, which could double the number of known vitiligo genes, putting the disorder on par with other autoimmune diseases such as type 1 diabetes and rheumatoid arthritis.

At the Society of Pediatric Dermatology’s annual meeting, held immediately before the annual meeting of the American Academy of Dermatology, Dr. Spritz spoke about what is known so far about vitiligo and what the future holds. Dr. Spritz is professor and director of the Human Medical Genetics and Genomics Program at the University of Colorado, Aurora.

nmiller@frontlinemedcom.com

On Twitter @naseemsmiller