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Pitfall Prayer Marks: Recognition and Appropriate Treatment: A Case report

and Review of Literature

Article  in  Dermatologic Therapy · December 2019

DOI: 10.1111/dth.13176

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Received: 19 November 2019 Accepted: 23 November 2019
DOI: 10.1111/dth.13176

THERAPEUTIC HOTLINE: SHORT PAPER

Pitfall prayer marks: Recognition and appropriate treatment:

A case report and review of literature

Nicole Fosse1 | Anna C. Rast1 | Andrea Kammermann2 | Joanna Sonderegger1 |

Alexander Navarini1 | Mohamad Goldust1,3,4 | Oliver Brandt2 | Simon M. Mueller1

1
Department of Dermatology, University
Hospital Basel, Basel, Switzerland Abstract
2
Department of Pediatrics, University Hospital Prayer marks are asymptomatic callosities resulting from repeated, extended
Bern, Bern, Switzerland
pressure, and friction exerted on bony prominences when praying on hard ground.
3
Department of Dermatology, University of
Rome G. Marconi, Rome, Italy A 41-year-old woman with ulcerative colitis treated with infliximab was referred to
4
Department of Dermatology, University our clinic due to skin changes on her feet that were suspected to be drug eruptions.
Medical Center Mainz, Mainz, Germany
The patient presented several asymptomatic, hyperpigmented, and hyperkeratotic
Correspondence plaques over the lateral malleoli suggesting that the lesions had a mechanical cause.
Nicole Fosse, Department of Dermatology,
Further exploration revealed that the patient, a practicing Muslim, prays in a sitting
University Hospital Basel, Petersgraben
4, 4031 Basel, Switzerland. position called “Julus” several times a day. After color marking, the lesions over the
Email: nicole.fosse@usb.ch
lateral feet left a precise imprint on the underlay when the patient was asked to imi-
tate the praying posture—thus proving the origin of the skin lesions. We searched
the database on July 31, 2019 using the terms «prayer marks» OR «prayer nodules»
OR “prayer callosities.” Only electronically available publications were reviewed. Rec-
ognition of prayer marks is important to avoid misdiagnosis, performance of unneces-
sary diagnostic procedures, and to enhance the intercultural competence of clinicians
who practice in multicultural societies.

KEYWORDS

comorbidities, Muslim, prayer marks, religious

1 | I N T RO DU CT I O N
Prayer marks are asymptomatic callosities resulting from repeated,
extended pressure, and friction exerted on bony prominences when
praying on hard ground (Orenay & Sarifakioglu, 2015). Among the
Muslim community, these marks may be considered as signs of reli-
gious dedication and piety, since praying five times a day is the sec-
ond most important of Islam's five pillars (Abanmi, Al Zouman, Al
Hussaini, & Al-Asmari, 2002). In Muslims, the location of prayer
marks varies depending on the four praying postures «Waquf»
(standing), «Ruku» (bowing), «Sajda» (prostration), and «Julus»
(sitting; Figure 1a,b). These marks can be located on the head
(zebibah zabība, «raisin», «Prayer's bump»), the knees, or dorsa
of the feet (talar callosity, «Prayer foot» as in our case)— especially the
left foot attributed to a typical praying position (Abanmi et al., 2002;
Monk & Lowenstein, 2014; Orenay & Sarifakioglu, 2015; Saif &
Woywodt, 2009). Usually, prayer marks are insignificant and
painless callosities, however, they have been reported to indi-
cate the worsening of an underlying chronic disease such as
diabetes mellitus, chronic obstructive pulmonary disease or myosi-
tis ossificans (Cangiano, Chisti, Pietroni, & Smith, 2011; Çarlı,
lu, & Turgut, 2016; Monk & Lowenstein, 2014; Papadakis
Cömertog
et al., 2016; Sharma, Sharma, & Aggarwal, 2011). As shown in our
case whose prayer marks have been mistaken for “drug eruptions”
they may not be recognized by physicians unaware of the origin of
this kind of skin changes. In addition to our case report, we
searched our in-house photo library for further examples and per-
formed a review of the literature on prayer marks, focusing on their
localization and their clinical use as possible indicators of
comorbidities.

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2 of 5 FOSSE ET AL.

F I G U R E 1 (a) «Sajda» (prostration) and

(b) «Julus» (sitting)

F I G U R E 2 Left:
hyperpigmented and
hyperkeratotic plaques over the
lateral malleoli of a 41-year old
patient; right: detail of the prayer
marks of the right foot

FIGURE 3 Left: prayer mark

on/below the right knee due to
the position "julus"; right: prayer
mark on the head ("zebibah",
"raisin", "prayer's bump") due to
the position "sajda"

2 | C A S E P RE S E N T A T I O N four patients with prayer marks, two of which are depicted in

A 41-year-old woman with ulcerative colitis treated with infliximab
was referred to our department due to skin changes suspected as
«drug eruptions» on her feet. She presented several asymptomatic,
hyperpigmented, and hyperkeratotic plaques over the lateral malleoli,
which suggested that the lesions were caused mechanically Figure 2.
Further exploration revealed that the patient, a practicing Muslima,
prays in a sitting position called «Julus» several times a day. After color
marking, the lesions over the lateral feet left a precise imprint on the
underlay when the patient was asked to imitate the praying posture—
thus proving the origin of the skin lesions. The patient was treated
with a keratolytic cream containing urea 10% twice a day for 4 weeks.
In the further course, the patient did not apply the cream on a regular
basis and continued praying, therefore, the lesions were still persistent
2 years later. A summary with the key findings in literature review is
shown in the Table 1. The search of our photo-library yielded another
Figure 3.
3 | DI SCU SSION
The skin and its appendages have had spiritual aspects since ancient
times as expressed by specific clothing regulations or the coverage,
styling, coloring, and decoration of the skin in religious or spiritual cer-
emonies (Shenefelt & Shenefelt, 2014). Prayer marks may additionally
emphasize this special relationship between skin and religion. We
report the case of a Muslim woman with prayer marks on the feet,
which were initially misdiagnosed as “drug eruptions.” According to
our review, misinterpretation of prayer marks appears to be possible.
The awareness of prayer marks in clinicians of Western countries may
be low, which may surprise considering that the number of Muslims
worldwide is estimated at 1.57 billion making them the second largest
 TABLE 1 Publications on prayer marks including their country of publication, number of patients, their clinical presentation, special characteristics and comments made by the authors

Localization
Number of
FOSSE ET AL.

Countries of patients (n) reported Nasal Comorbidities, special Explanation provided by the
Publications publication with prayer marks Head Knees Feet Elbows bridge characteristics authors
Harahap, 1981 Indonesia 1 x – – – – n/a n/a
O'Goshi, Aoyama, Japan 1 x – – – – Mucin deposition found in n/a
& Tagami, 1998 histopathology
Mishriki, 1999 United States 1 x – – – – Fading of a callus may indicate n/a
an underlying disease that
disrupts praying habits
Goodheart, 2001 United States 1 – x – – – Roman catholic Repeated kneeling in church
Roberts, Katsimihas, & United Kingdom 1 – – x – – Lymphangitis and general Prayer mark was the portal of
Wade, 2001 malaise entry for the pathogen that
led to cellulitis.
Abanmi et al., 2002 Saudi Arabia 349 x x x – – n/a n/a
Barankin, 2004 Canada 1 x x x x n/a n/a
Saif & Woywodt, 2009 United Kingdom 1 – – x – n/a n/a
Ur Rehman & Asfour, 2010 Canada 1 – – x – Buddhist monk n/a
Cangiano et al., 2011 Bangladesh 1 – x x x Lesions on elbows as a result of The patient altered his used
worsening of pre–existing praying position because of
COPD increasing breathlessness.
Sharma et al., 2011 India 1 x x – – Acute anterior wall myocardial n/a
infarction
Monk & Lowenstein, 2014 United States 1 – – x – History of diabetes mellitus and n/a
hypertension
Ramesh & Al Aboud, 2014 India n/a x x x – x Review of cutaneous signs of n/a
piety in Christianity, Islam,
Judaism, Hinduism and
Sikhism
Orenay & Sarifakioglu, 2015 Turkey 1 x x – – n/a n/a
Çarlı et al., 2016 (8) Turkey 1 – – x – Myositis ossificans Prayer marks can be
associated with myositis
ossificans.
Papadakis et al., 2016, Greece 29 x x x – Diabetes mellitus, venous Prayer marks associated with
insufficiency and peripheral diabetes mellitus, venous
neuropathy insufficiency and peripheral
neuropathy may predispose
leg ulcers
3 of 5

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4 of 5
religious community after Christians 2009 (Altalib, Elzamzamy, Fattah,
Ali, & Awaad, 2019). Even under the assumption that only a minority
of Muslims prays on a regular basis in the above-described positions,
the small number of publications on prayer marks may be remarkable
and partly explain why clinicians from Western countries may not be
familiar with them. However, due to globalization and immigration of
war refugees from Muslim countries, prayer marks are likely to be
seen more commonly in regions of predominantly other religions.
Therefore, it is important to recognize prayer marks and react to them
with due respect. Prayer marks are usually asymptomatic, the clinical
pattern is characterized by (symmetric) thickening, lichenification, and
hyperpigmentation on typical sites (i.e., front head, over bony promi-
nences of the extremities). However, as suggested in previous studies,
atypical lesions may occur, possibly indicating an underlying disease.
For example, shortness of breath due to chronic obstructive airway
disease may result in an altered praying position with prominent
prayer marks on the elbows (Cangiano et al., 2011). Conversely, the
fading of a callus may indicate an underlying disease that disrupts
praying habits (Mishriki, 1999). Local complications resulting from
prayer marks (e.g., ulcerations, bleeding) may rarely occur in patients
with concomitant vascular or neuropathic diseases, especially in dia-
betes (Papadakis et al., 2016). In one case, a prayer mark on the ankle
acted as a portal for cellulitis leading to significant morbidity. The
authors proposed to use the term “Mecca foot” in this context
(Roberts et al., 2001). Due to repetitive minor traumas, myositis
ossificans have been reported to be associated with prayer marks
(Çarlı et al., 2016). However, another publication reported prayer
marks in connection with a concomitant disease (e.g., anterior wall
myocardial infarction) that we considered as mere, unrelated coinci-
dence (Sharma et al., 2011). In contrast to reports of a koebnerization
(isomorphic reaction) due to Indian culture practices (Gupta & Thappa,
2015), we found no reports of psoriasis or lichen planus developed on
prayer marks. In our experience, prayer marks are usually not the main
complaint seeking medical advice. Males presenting with a “zebibah”
on their forehead are usually aware and proud of it as a sign of sincere
religious dedication. They are likely to clarify potential misinterpreta-
tion made by clinicians. However, less common prayer marks in
women—as present in our case—may be more misleading for clinicians
not familiar with such marks. Treatment of prayer marks is usually not
necessary and may only be initiated upon patient request. Treatment
options include topical keratolytic agents (e.g., salicylic acid 10–20%
three times per week for 4 weeks) or mechanical abrasion using a
pumice stone or nail file (Monk & Lowenstein, 2014). Protective cloth-
ing and soft prayer rugs may be useful to reduce hyperkeratinization
(Ur Rehman & Asfour, 2010), however, the lesions will perpetuate if
the prayer habits remain unchanged. Interestingly, prayer marks have
not been reported exclusively in Muslims (Ramesh & Al Aboud, 2014).
They can also occur in Buddhists who meditate for a long time in a
cross-legged sitting position (ur Rehman & Asfour, 2010). Repeated
kneeling in praying Christians may induce blisters below the knees
(Goodheart, 2001) and many other religious or cultural practices may
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FOSSE ET AL.
induce further cutaneous signs summarized elsewhere (Gupta &
Thappa, 2015; Lilly & Kundu, 2012; Vashi, Patzelt, Wirya, Maymone, &
Kundu, 2018). Notably, “stigmatists” such as Saint Francis of Assisi
presenting (arguably self-inflicted) bleeding skin marks (“stigmata”)
corresponding to the crucifixion wounds are considered blessed ser-
vants of God in Christian Mysticism (Barankin, 2004; Cross, 2005).
4 | CONC LU SION
Recognition of prayer marks is important to avoid misdiagnosis, per-
formance of unnecessary diagnostic procedures, and to enhance the
intercultural competence of clinicians who practice in multicultural
societies. Prayer marks usually do not require further investigation
and treatment can be offered if requested.
CONFLIC T OF INT ER E ST
None.
OR CID
Mohamad Goldust https://orcid.org/0000-0002-9615-1246
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How to cite this article: Fosse N, Rast AC, Kammermann A,
et al. Pitfall prayer marks: Recognition and appropriate
treatment: A case report and review of literature. Dermatologic
Therapy. 2020;33:e13176. https://doi.org/10.1111/dth.
13176