Cross-Cultural Rash

Mohit Chawla, MD, Laura Klug, PharmD, and Shailendra Saxena, MD, PhD
Creighton University Medical Center, Omaha, Nebraska

Mohit Chawla, MD; Laura Klug, PharmD; and Shailendra Saxena, MD, PhD

Creighton University Medical Center, Omaha, Nebraska

Chawla M, Klug L, Saxena S. Cross-cultural rash. Consultant. 2013;53(12):905.



A 28-year-old Burmese male presented with complaints of an upper respiratory infection, including dry cough and fever. 

Physical Examination

A complete physical was performed which was otherwise normal with the exception of a very distinct rash on the patient’s upper back (Figure). After further questioning, it was found that the rash was of cultural origin.

The rash was an erythematous, papular, circular rash covering his upper back. There were no secondary infections and the rash was not warm or tender to the touch. 

cross culture


The patient revealed that his culture’s traditional medicine dictates that when someone becomes ill, the skin on the back, neck, or forehead is pulled tightly to remove “foreign germs” or “heat” from the body. The skin is pulled at different sites and monitored to see if it becomes red; this indicates that the “foreign germs” or “heat” is leaving the body. Once an individual responds to this treatment, it will be used again for future illness. The belief is that illness—especially that involving fever—is the body telling the individual that it needs this treatment again. This patient reports having his skin pulled several times to remove the “heat.” 


Sociocultural factors can impact a patient’s behavior regarding health and well- being, as well as affect the physician-patient relationship. For the patient, cultural differences can dictate recognition of symptoms, thresholds for seeking care, and comprehension of diagnostic and treatment strategies. Cross-cultural care emphasizes communicating effectively to promote quality health care for patients from diverse sociocultural backgrounds. Evidence shows that educating health care clinicians in cross-cultural care can improve knowledge, attitudes, and skills, and increase satisfaction of patient-provider relationships. In order to promote cultural competence, the Accreditation Council on Graduate Medical Education has required physicians-in-training to demonstrate sensitivity and responsiveness to a patient’s culture as part of its professionalism competency.1

The 2010 US Census reported 39.9 million foreign-born residents living in the United States.2 With this increasing population, as well as a growing population of refugees, it is important for primary care physicians to be aware that a rash may be due to cultural rituals. This awareness can prevent further unnecessary and costly diagnostic testing, referral, or treatment for the patient and is essential for a successful therapeutic patient-provider relationship.1


  1. Beach MC, Price EG, Gary TL, et al. Cultural competence: a systematic review of health care provider educational interventions. Med Care. 2005;43:356.
  2. U.S. Census Bureau; The Foreign-Born Population in the United States: 2010. Available at: Accessed February 18, 2013.