Cultural Practices

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Many cultures use folk health remedies to treat various illnesses. Some common cultural methods used include cupping, coining, spooning, moxibustion, caida de mollera, and salting. These widely practiced alternative forms of medicine create marks on the skin, such as petechiae, purpura, and hyperpigmentation, that often mimic physical abuse.

Cupping has been used in Middle Eastern, Asian, Latin American, and Eastern European cultures as a form of therapy to treat ailments including pain, poor appetite, fever, and congestion. In the United States, this technique is practiced primarily by Russian immigrants. In dry cupping, a heated cup is applied to the skin, creating a suction force from the cooling and contracting air. This is typically applied to the back and thought to “draw out” the ailment. Circular burns from the heat and central bruising and petechiae from the suction effect can be mistaken for abuse. Wet cupping involves the same type of practice but applied to previously abraded skin.

Coining, also called coin rubbing or cao gio, is practiced by many Vietnamese Americans to treat minor ailments such as fever, headache, and chills. In this ancient Vietnamese folk remedy, the edge of a coin is used to rub oiled skin. This technique is usually applied to the back and results in linear erythematous patches, petechiae, or purpura. Although most of the complications have been minor burns, there have been a few reported cases of serious complications from coining requiring skin grafts when the heated oil on the skin caught fire. Quat sha, also known as spooning, is similar to coining and is used in China to rid the body of illness. This procedure results in a linear pattern of ecchymosis when a porcelain spoon is used to rub wet skin.

Moxibustion involves burning rolled pieces of moxa herb (mugwort or Artemisia vulgaris) over the skin above acupuncture points and allowing it to burn until the onset of pain. It is used in Asian cultures for a variety of symptoms, including fever and abdominal pain. The lesions of moxibustion appear as a pattern of discrete, circular, target-like burns that may be confused with cigarette burns from child abuse.

Caida de mollera refers to the presence of a sunken anterior fontanelle in an infant that is believed in some Mexican American subcultures to cause a variety of symptoms including poor feeding, irritability, and diarrhea. Attempts to correct this condition may involve oral suction over the fontanelle by a folk healer, slapping of the soles of the feet, or shaking of the infant upside down. The shaking is usually nonviolent and generally thought not to cause significant resultant injury. Caida de mollera is an improbable cause of shaken baby syndrome.

Salting is an old Turkish custom thought to improve the health of a newborn’s skin. It involves the application of salt to the skin. Rare cases of epidermolysis, severe hypernatremia, and even death have been reported in a few infants that had been intermittently salted since birth.

Ayurveda is a form of traditional Indian medicine that sometimes involves adding heavy metals, including lead, arsenic, and mercury, to herbal medicines.

Scarification is a custom in some African cultures involving the intentional burning or cutting of the skin to produce scars. Keloid formation is often the desirable end point. Tattooing refers to the marking of the skin or mucous membranes with ink. Scarification and tattooing may be performed for a variety of reasons, including therapeutic, cultural, aesthetic, religious, and social. The most common complications from scarification include keloid formation, squamous cell carcinoma, and bloodborne infections if the blade is used without sterilization (hepatitis B, hepatitis C, HIV). Common complications from tattooing include hypersensitivity reactions, scarring / keloid formation, allergic contact dermatitis, contact urticaria, foreign body reactions, MRI-induced burns, infections (impetigo, cellulitis, abscess, hepatitis B, hepatitis C, HIV, syphilis, leprosy, leishmaniasis) and koebnerization (such as with lichen planus or psoriasis). Serious complications such as candidal endophthalmitis, systemic zygomycosis, spinal abscesses, cystic macular degeneration, and retinal vasculitis have been reported.

Some belief systems, such as Vodou and Santeria in Haiti, Cuba, Mexico, and other Latin American countries, are deeply integrated into daily life, comprising their own health care belief systems of healing and well-being practices. These patients may embrace multiple or hybrid health care models and may pursue multiple sources of treatment, including traditional / spiritual healers or religious leaders. These cultures have a particularly complex relationship with mental health ailments, which may be attributed to supernatural forces or curses. Patients may suppress psychiatric symptoms and be reluctant to seek mental health services due to associated stigmas. In addition, what may initially appear as psychosis or delusional thinking based on the standards of Western psychiatry may be culturally normative for the patient.

Understanding cultural practices, which populations typically employ unique remedies, and how to gather an appropriate cultural history can help avoid misdiagnosis and prevent further trauma.

Look For

Cupping often produces 4- to 6-cm circular burns from the heat and central ecchymosis and petechiae from the suction effect.

In coining or spooning, the edge of a smooth object, such as a coin or spoon, rubbed against the skin (typically on the back) produces linear erythematous patches, petechiae, or purpura. Ecchymotic streaks, often in a parallel and in symmetrical distribution, are characteristic.

The lesions of moxibustion appear as a pattern of small discrete, circular, target-like burns that may be confused with cigarette burns from child abuse. The practice can lead to second-degree burns, with bullae progressing to scar formation.

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