Commentary

Improving Dermatologic Care for South Asian Patients: Understanding Religious and Cultural Practices

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Practice Points

  • Providers should familiarize themselves with traditional garments of Sikhism and Islam, including head coverings and other symbolic items.
  • Inform patients about health-conscious methods of wearing traditional headwear, such as removing certain headwear at night and tying hair in methods to avoid causing traction alopecia.
  • Talk through each aspect of the skin examination while it is being performed and expose the least amount of skin necessary during the process. Offer the patient a chaperone or a same-gender provider, if possible.
  • Empower patients to assist in adjusting garments themselves to help the physician visualize all parts of the skin.


 

References

Dermatologists must understand the religious and cultural practices of various populations in order to provide optimal patient-centered care. In particular, patients of South Asian background have specific traditions and needs that may be unfamiliar to many providers and may affect the approach to their dermatologic care. These include the strong role of traditional garments and hair practices, the cultural emphasis on modest dress and limiting skin exposure in South Asian society, and the presence of anti–South Asian racism and religious discrimination in the United States.1 Sikhism, Islam, and Hinduism are the predominant religions among the South Asian population, and followers of these faiths constitute nearly 40% of the world population.2,3 By becoming familiar with the unique health care needs of this patient population, dermatologists can become key players in reducing health care disparities.

Traditional garments are particularly important in both Sikhism and Islam. Sikhs began wearing symbolic garments in the 16th century as markers of their identity during periods of religious persecution. Today, many Sikhs continue to maintain this tradition of wearing the Five Ks—kesh (uncut hair, often tied in a turban), kanga (wooden hair comb), kirpan (symbolic dagger), kachha (cotton underwear), and kara (steel bracelet).2 Similarly, Islamic traditions also provide guidance for clothing. Many Muslim women wear the hijab (headscarf), a garment that originated as protective headgear for nomadic desert cultures and has come to symbolize modest dress. Traditionally, the hijab is worn in the presence of all men who are not immediate relatives, although patients may make exceptions for medical care. Some Muslim men also may cover their heads with a skullcap and/or maintain long beards (occasionally dyed with henna pigment) as a way of keeping continuity with the tradition of the Prophet Muhammad and his companions.3

Certain styles of headwear can cause high tension on hair follicles and have been associated with traction alopecia.4 Persistent use of the same turban, hijab, or comb also may lead to seborrheic dermatitis or fungal scalp infections. Dermatologists should advise patients about these potential challenges and suggest modifications in accordance with the patient’s religious beliefs; for example, providers can suggest removing headwear at night, using prophylactic antifungal shampoos, and/or tying the hair in a ponytail or loosening the headgear to reduce traction.

Although Hinduism does not have a unifying garment or hair tradition in the vein of Sikhism or Islam, all 3 religions share a strong emphasis on bodily modesty, which may affect dermatologic examinations. Patients from all 3 religions may seek to expose as little skin as possible during a physical examination, and many patients may be uncomfortable with a physician of the opposite gender. Dermatologists may find the following practices to be helpful5:

• Talk through each aspect of the skin examination while it is being performed and expose the least amount of skin necessary during the process

• Offer the patient a chaperone or a same-gender provider, if possible

• Empower patients to assist in adjusting garments themselves to help the physician visualize all parts of the skin

Some Sikhs also may have specific concerns regarding cutting their hair. One aspect of kesh is that every hair is sacred, and thus, many Sikhs refrain from removing hair on any part of the body. As such, providers should carefully obtain the patient’s informed consent before performing any procedure or physical examination maneuvers (eg, hair pull test) that may result in loss of hair.2

Physicians of all disciplines can help address these challenges through increased outreach and cultural awareness; for example, dermatologists can create skin care pamphlets translated into various South Asian languages and distribute them at houses of worship or other community centers. This may help patients identify their skin needs and seek appropriate care. The onus must be on physicians to make these patients feel comfortable seeking care by creating nonjudgmental, culturally knowledgeable clinical environments. When asking about social history, the physician might consider asking an open-ended question such as, “What role does religion/spirituality play in your life?” They can then proceed to ask specific questions about practices that might affect the patient’s care.5

Given the current coronavirus disease 2019 pandemic, South Asian patients may be even further discouraged from seeking dermatologic care. By understanding religious traditions and taking steps to address biases, dermatologists can help mitigate health care disparities and provide culturally competent care to South Asian patients.

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