Forensic Science, Medicine and Pathology

https://doi.org/10.1007/s12024-019-00115-4

REVIEW

Skin lesions and traditional folk practices: a medico-legal perspective

Alessia Viero 1,2 & Alberto Amadasi 1,3 & Alberto Blandino 1,4 & Alessandra Kustermann 1 & Massimo Montisci 2 &
Cristina Cattaneo 1,4

Accepted: 28 March 2019

# Springer Science+Business Media, LLC, part of Springer Nature 2019

Abstract
The correct assessment of signs of abuse on the skin is a challenge of utmost importance for both clinical and forensic applications.
This review aims to investigate how differing cultural behaviors influence the perception of abuse, focusing on the need for a
multidisciplinary approach and investigation. A literature search for articles that discussed folk practices from a forensic perspective
was performed; articles with reference to abuse in the description of the main folk healing techniques and with reference to the
differential diagnosis between physical abuse and skin injuries due to folk healing techniques were selected. A synoptic table of all
skin injuries produced by folk healing techniques, divided by geographical area, was created. This table can be used as a tool for the
thorough assessment of typical signs detectable on the skin, thus aiding in a differential diagnosis. The first approach to the patient
represents a crucial step toward the identification of abuse; forensic practitioners ought to be aware of the existence of folk healing
techniques which may mimic signs that can be interpreted as physical abuse in children and adults.

Keywords Clinical forensic medicine . Physical abuse . Bruising . Folk healing techniques . Differential diagnosis

Introduction be superimposable to typical abuse-related injuries [2, 3].

Physical abuse in children and adults is a serious form of
violation of human rights, sometimes still shrouded in silence.
The presence of bruises is one of the most common manifes-
tations of this kind of abuse [1].
However, forensic practice has shown that sometimes or-
dinary explanations may lay behind injuries mimicking
bruises, especially when the morphological appearance may
* Alberto Amadasi
albertoamadasi@libero.it
1
SVSeD service - IRCCS Cà Granda Policlinico di Milano – Clinica
Mangiagalli, via Commenda 12, 20122 Milan, Italy
2
Department of Legal and Occupational Medicine, Toxicology and
Public Health, University-Hospital of Padova, Via Falloppio 50,
35121 Padova, Italy
3
Sede di Medicina Legale, Dipartimento di Scienze Mediche e
Chirurgiche, Università di Bologna, via Irnerio 49,
40126 Bologna, Italy
4 bruising, the authors performed a literature search aimed at
Sezione di Medicina Legale e delle Assicurazioni, Dipartimento di
Scienze Biomediche per la Salute, via Mangiagalli 37,
20133 Milan, Italy
Therefore, it is very important for health professionals to be
aware of these possible confounding factors in order to outline
and assess cases of suspected violence, thus avoiding interpre-
tative errors of skin abnormalities, especially in cases of pat-
terned bruises [4].
In particular, in a multiethnic scenario, the suspected victim
could be unable to explain what happened because of age,
language difficulties, fear of blame or lack of social context
consciousness. Therefore, forensic pathologists ought to be
aware of the existence of cultural practices, also defined as
folk healing techniques, which may mimic signs of physical
abuse in children and adults.
Nevertheless, despite the presence of an extensive body of
scientific literature on this topic, traditional medicine and cul-
tural practices are not frequently included in the differential
diagnosis of suspected cases of abuse and skin findings, even
though they are patterned, and may still be misinterpreted as
injuries caused by physical abuse.
Herein, in order to stress the importance for health profes-
sionals to be familiar with these practices in cases of suspected
abuse and to avoid diagnostic errors in the interpretation of
analyzing the typical features of injuries produced by such
cultural practices, with an analysis of all forensic cases in

which the application of these techniques posed problems of
differential diagnosis with abuse, both in adults and children.
The final aim of this article, to our knowledge the first of its
kind from a forensic perspective, will be the production of a
synoptic reference table of skin injuries characteristic of the
main folk healing techniques, divided into geographical areas,
useful for forensic pathologists in cases of suspected abuse in
adults or children coming from geographic areas where these
techniques are commonly practiced, or when assessing immi-
grants and refugees.
Materials and methods
Review of the literature
A literature search was first conducted using the Medline
Database (PubMed.gov; US National Library of Medicine-
National Institute of Health) and free text protocols (i.e.
“Asian massage techniques”, “Folk medicine”, “Cultural
Practices”, “Cupping”, “Coining”, “Gua sha”,
“Ecchymoses”, “Abuse”) individually combined through the
Boolean operator “AND”. Further studies were then identified
by reviewing the reference lists of the papers that were found
in this search. At the same time filters such as full-text, pub-
lication date from January 1960 to October 2018, and English
language were activated. The search resulted in more than 50
articles, which were only included in our study if they met at
least one of the criteria of inclusion of reference to abuse in the
description of the main folk healing techniques or reference to
the differential diagnosis between physical abuse and skin
injuries due to folk healing techniques.
The full-text of the selected papers was analyzed including
data such as the first author’s name, year of publication, type
of paper, subject of investigation and kind of folk healing
technique described. Information was extracted and included
in an electronic database.
Results
Thirty-six (36) papers fulfilled the inclusion criteria and were
included in the investigation. Among these, 11 (29.73%) were
case reports, 9 (25%) original articles, 10 (27%) consisted of
commentaries, notes, a research letter, a letter to editor and
correspondence, and 6 (16.22%) were defined as a review.
Moreover, 35 papers dealt with the living, among which 20
were focused solely on child, 3 on both a child and an adult
and 13 on only an adult. Only 1 paper was related to post
mortem investigation.
Regarding the described folk healing techniques, Coining
was described in 31 of the selected papers, Cupping and
Spooning in 18, Moxibustion in 14, Pinching in 4, Salting in
Forensic Sci Med Pathol
3, Kerok, Kos Khyal, Khoud Lam and Maquas in 2 and Ba
Sha, Gridding, Sapi and Tui Na in 1 of the selected papers.
The extracted data are summarized in Table 1.
Discussion
Maltreatment of children is a major public health crisis, and it
is estimated that each year more than 3 million children are
victims of abuse. Physical abuse is one of the most common
forms of child maltreatment and cutaneous injuries represent
the most recognizable and common manifestation of abuse
[21]. Depending on the type of force involved, specific injury
patterns are produced on the body of the child, the morphol-
ogy and localization of which are forensically relevant in
terms of diagnostic classification as child abuse.
Therefore, the correct diagnosis of injuries has a fundamen-
tal role in the establishment and/or the continuation of inves-
tigation on maltreatment or injury in general, and once a trau-
matic injury has been observed and recorded, there is an even
greater challenge to accurately diagnose the abnormal skin
findings as being either accidental or as a result of abuse. In
particular there is a lack of a coherent and comprehensible
explanation for accidental injury assuming exclusion of pos-
sible differential diagnosis in cases that are highly suspicious
for abuse [9].
Forensic practice has repeatedly shown that there are some-
times ordinary explanations for injuries that have a nearly
identical morphological appearance to those that are typically
abuse-related [9], so it is important to remember that findings
which appear to result from abuse can be manifestations of
benign childhood injuries and medical conditions with similar
presentations [23].
Therefore, although the detection of child maltreatment is
critical and of paramount importance to ensure the child’s
physical and psychological well-being, investigators must al-
so remember that a misdiagnosis can be traumatizing to the
child, family, and those individuals suspected of the abuse.
Child abuse is a topic that makes most physicians uncom-
fortable, partly because of having little or no training in rec-
ognizing the problem, and forensic pathologists are often
called by clinicians to help distinguish intentional injuries at-
tributable to child abuse from accidental ones as well as from
skin mimickers of inflicted injury.
Depending on the nature of the force and the scale of the
attack, cutaneous manifestations of physical abuse [21] in-
clude bruises and abrasions followed by lacerations, scratches,
soft tissue edema, strap marks, hematomas, thermal injuries in
the form of scalds and burns, bites, choke marks, throttling
marks or skin necrosis resulting from sustained exposure to
very cold temperatures [9].
As mentioned, the differential diagnosis between folk prac-
tices and maltreatment may be a challenge: the appearance of
Forensic Sci Med Pathol

Table 1 Data that were extracted from the papers included in the study after a literature search

Authors Year Journal Type Subject Folk practice description

Vashi NA et al. [5] 2018 J Am Acad Dermatol Article Adult Coining, Cupping, Moxibustion, Salting, Spooning
Marion t et al. [6] 2018 JAMA Dermatol Note Adult-Child Coining, Spooning
Wiwanitkit V [7] 2017 Indian J Dermatol Case Report Adult Spooning
Tanner BS et al. [8] 2016 J Forensic Sci Case Report Adult (Dead) Coining, Cupping, Moxibustion, Sapi, Spooning
Tsokos M [9] 2015 Forensic Sci Med Pathol Review Child Coining, Spooning
Aprile A et al. [10] 2015 Forensic Sci Int Case Report Adult Coining, Kerok, Kos Khyal, Khoud Lam, Spooning
Li Z et al. [11] 2015 J Forensic Leg Med Short report Child Ba Sha
Odhav A et al. [12] 2013 Int J Dermatol Correspondence Adult Spooning
Lilly E et al. [13] 2012 Int J Dermatol Review Adult-Child Coining, Cupping, Moxibustion, Spooning
Tan AK et al. [14] 2011 Malays Fam Physician Case Report Child Coining
Harris TS [15] 2010 J Pediatr Health Care Article Child Coining, Cupping
Ravanfar P et al. [16] 2010 Curr Opin Pediatr Review Child Ba Sha, Coining, Cupping, Gridding, Moxibustion, Spooning
Ribeiro CS et al. [17] 2010 Leg Med (Tokyo) Case Report Child Tui Na, Cupping, Moxibustion
Allen SA et al. [18] 2009 Wien Klin Wochenschr Case Report Adult Spooning
Nielsen A [19] 2009 J Bodyw Mov Ther Article Adult Coining, Kerok, Kos Khyal, Khoud Lam, Spooning
Swerdlin A et al. [20] 2007 J Am Acad Dermatol Article Adult Coining, Cupping, Moxibustion, Salting, Spooning
Kos L et al. [21] 2006 Pediatr Dermatol Review Child Coining, Cupping, Maquas, Moxibustion, Spooning
Heymann WR [22] 2005 J Am Acad Dermatol Commentary Child Coining
Mudd SS et al. [23] 2004 J Pediatr Health Care Article Child Coining, Cupping, Spooning
Flores G et al. [24] 2002 Pediatr Emerg Care Article Child Coining, Cupping, Moxibustion, Spooning
Rampini SK et al. [25] 2002 JAMA Research Letter Adult Coining
Davis RE [26] 2000 J Am Acad Nurse Pract Article Child Coining
Wong HC et al. [27] 1999 CMAJ Correspondence Adult Coining, Cupping, Moxibustion
Hansen KK et al. [28] 1998 Child Abuse Negl Review Child Coining, Cupping, Maquas, Moxibustion, Pinching,
Salting, Spooning
Look KM et al. [29] 1997 J Forensic Sci Review Child Coining, Cupping, Moxibustion, Spooning
Uba L [30] 1992 Public Health Rep Article Adult Coining, Cupping, Moxibustion, Pinching
Buchwald D et al. [31] 1992 West J Med Article Adult Coining, Cupping, Moxibustion, Pinching
Rosenblat H et al. [32] 1989 CMAJ Case Report Child Coining, Spooning
Muecke MA [33] 1983 Am J Public Health Commentaries Adult Coining, Cupping, Moxibustion, Pinching
Asnes RS et al. [34] 1981 J Pediatr Case report Child Cupping
Tan A [35] 1981 JAMA Correspondence Adult-Child Coining
Du JN [36] 1980 Can Med Assoc J Case report Child Coining, Cupping
Primosch RE et al. [37] 1980 J Am Dent Assoc Case Report Child Coining
Yeatman GW et al. [38] 1980 JAMA Case Report Child Coining
Keller EL et al. [39] 1977 Am J Dis Child Commentaries Child Coining
Yeatman GW et al. [40] 1976 Pediatrics Note Child Coining
Anh N [41] 1976 JAMA Correspondence Child Coining

the lesions may not be well defined when compared to the
typical characteristics described in the literature.
As a clear example, Figs. 1, 2 and 3 show a case of “Gua
Sha” in which the characteristics are far from unequivocally
diagnostic, making differential diagnosis even more difficult.
Moreover, when evaluating skin lesions the common
mimickers of bruises which must be taken into consideration
are Mongolian spots, Hematological disorders (including he-
mophilia, Von Willebrand disease, congenital platelet abnor-
malities such as Bernard-Soulier syndrome, aplastic anaemia,
Wiskott-Aldrich, acquired diseases such as leukemia, neuro-
blastoma, idiopathic thrombocytopenic purpura-ITP, bone mar-
row failure, hepatic impairment, immune thrombocytopenic
purpura, drug ingestion and vitamin K deficiency), vasculitis,
Henoch Schonlein Purpura-HSP, Hemorrhagic edema of infan-
cy-AHEI, connective tissue disorders (including Ehlers Danlos
syndrome, osteogenesis imperfecta), erythema nodosum,
phytophotodermatitis, hemangiomas, purpura fulminans of
meningococcemia, and, rarely, incontinentia pigmenti.
Abuse by burning comprises approximately 6% to 20% of
all child abuse cases and burns to the skin can be electrical,
chemical, thermal, or radiant. There are a number of medical
conditions, such as bullae, which may produce skin findings
that resemble burns. The differential diagnosis of burns in pos-
sible victims of child abuse is extensive. Potential mimickers of
first-degree burns include cellulitis, sunburn, fixed drug erup-
tion, contact dermatitis, and phytophotodermatitis while lesions
simulating second-degree burns include dermatitis
herpetiformis, staphylococcal scalded skin syndrome, bullous
fixed drug eruption, toxic epidermal necrolysis, epidermolysis
bullosa, and bullous impetigo [15, 20].
In addition to the aforementioned conditions, even numer-
ous traditional folk medical practices, that seem innocuous
although they leave temporary cutaneous marks such as

Fig. 1 “Gua-Sha” on a 6-year old female showing the overall features of bruises on the back
bruising and burns, may represent a diagnostic minefield, es-
pecially for examiners unfamiliar with these practices, since
they could be mistaken for signs of physical abuse in adults or
children who come from geographic areas where these tech-
niques are commonly practiced, or are immigrants and refu-
gees [21, 27].
Among these practices, the most common are cupping (al-
so named ventosas) used by Russian, Asian, and Mexican-
American cultures [33], pinching [28, 33] and skin scraping
[29], i.e. coining (also named cao gio) used in China and
Forensic Sci Med Pathol
South East Asia [14, 25, 28, 35, 36, 38–41], and spooning
(also named gua sha), which is used in China.
Similar practices exist in Indonesia, known as Kerik or
kerokan. Other ethnic terms include Khuoud Lam or Kuong
in Laos and Kos khyal or Koo kchall in Cambodia [12, 15,
19]. The lesions produced by the aforementioned practices can
be mistaken for abuse stigmata because they produce respec-
tively discrete circular burns with central ecchymosis and pe-
techiae or linear purpuric streaks (cupping), bruises or welts
on the site of treatment (pinching) and ecchymoses
Forensic Sci Med Pathol
Fig. 2 The appearance of bruises on the neck and shoulders in a “Gua-Sha” case
traditionally in a “pine tree” pattern (skin scraping) [5] and
there have been multiple reports of parents falsely accused of
child abuse due to the skin lesions seen from these traditional
practices [16].
Another common practice, which leads to circular or target
like burns and sometimes scarring which may be confused
with cigarette burns [16], is moxibustion which is used by
Laotian, Cambodian, Chinese and Japanese cultures [28]. A
similar procedure, called toullmos, is also practiced by the
Skolt Lapp population in Finland [5].
These aforementioned practices, however, do not comprise
an exhaustive list since there are numerous other folk traditional
practices described in the literature which lead to similar cuta-
neous signs that need to be recognized, including Ba Sha [11],
Gridding, Maquas, Sapi, Salting, Tui Na and Wet Cupping.
With globalization of socioethnic practices and widespread
immigration, as multiculturalism has become more the norm
than the exception, physicians increasingly encounter patients
from varying backgrounds who follow different customs [13]
and it is particularly important to be aware of folk healing
remedies used to treat various illnesses in other cultures [26,
31] which produce skin lesions that may be mistaken for abuse
[22]. In such cases the differential diagnosis both in children
and in adults can be challenging since skin lesions following
these techniques may be difficult to recognize, especially in
children and in migrant adults and refugees with limited pro-
ficiency in English who may have difficulty explaining their
traditional practices and how the skin injuries were produced
[6, 10]. Barriers such as fear of blame, miscommunication,
inadequate understanding, cultural and traditional differences,
and different perceptions and attitudes toward these therapeu-
tic practices, may in fact prevent adult patients from revealing
them to physicians and this inadequate understanding and/or
miscommunication can provide fertile ground for suspecting
abuse when a coherent and comprehensible explanation for
the observed injuries is lacking [9, 10].
The distinction between self-inflicted and unintentional
wounds is also of critical importance during post mortem

Fig. 3 The appearance of bruises on the neck in a “Gua-Sha” case
investigation and traumatic rituals and therapies can make it
difficult to determine the cause of inflicted blunt and sharp
force trauma. In these cases where inflicted injuries are ob-
served, a thorough investigation into decedents’religion and
traditional folk and socio-ethnic practices is necessary in
order to properly evaluate and certify medicolegal autopsy
cases [8].
In this era of migration and diffusion of cultural customs,
which are not usually considered abusive [17] but that may
produce skin lesions [5, 10], into mainstream practice, a care-
ful awareness of these culture-related treatments and rituals is
advisable for forensic pathologists, who must maintain a high
level of suspicion but also be open minded when they encoun-
ter such cases; being unaware of the range of different patterns
that can be due to these techniques can lead to a misdiagnosis
of skin injuries produced by folk techniques and have signif-
icant forensic implications [8], perhaps leading to inappropri-
ate legal charges [7, 10, 12, 18, 24, 29, 30, 32, 34, 37].
Even though several articles described the presence and
features of these folk remedies and despite previous authors
already stating that forensic pathologists must be aware of the
Forensic Sci Med Pathol
range of different patterns that traditional folk techniques may
result in, the literature search we performed demonstrated that
most of the available studies mainly consist of case reports and
that there are still cases of misdiagnosis of physical abuse in
patients undergoing such cultural practices. It was also noted
that only one paper described the cutaneous signs resulting
from cultural practices on cadavers during post mortem exam-
ination and it would be useful to expand such post-mortal
studies to include skin injuries resulting from other cultural
practices not treated in the aforementioned article [8].
Moreover, despite the clinical forensic practitioner being
the person who is often called by clinicians to help distinguish
intentional injuries attributable to child abuse from accidental
ones or from skin mimickers of inflicted injury, it is important
to highlight that only 5 of the 36 selected papers were pub-
lished in journals dedicated to forensic issues, and that 4 of
these were case reports.
We therefore propose that a synoptic reference table of all
skin lesions characteristic of the main folk healing techniques,
divided into geographical area, be compiled in order to pro-
vide practitioners with an easy reference in practice for cases
Table 2 Synoptic reference table of characteristic bruises produced by the most commonly seen folk practices

Folk Geographic area Technique description Indications Body area Injuries description Adverse effects
practices

Ba Sha also China Pinching by grabbing the skin, followed - To treat fever. Center of the brow, base of the nose, Petechiae. No description.
known as by forceful flicking between the between the eyes, neck, chest, back
Tsien sha fingers until petechiae appear. tendons.
Forensic Sci Med Pathol

Coining also Cambodia, China, Massaging the lubricated symptomatic - To relax. Temples and forehead, bridge of the nose, - Cutaneous hyperemia and linear - Brain bleeding
known as Indigenous skin with heated or medicated - To stimulate different meridian points of inter palpebral space, thyroid cartilage, erythema that may progress to - Camphor toxicity
Cao Gio, families, ointment and balms and then firmly the body in order to remove “negative and occipital depression over the back, multiple petechiae, hematomas secondary to
Coin Laos, Malaysia, and vigorously rubbing and scraping energies” through the skin that are spine, both sides of thoracic vertebrae, or purpura and disappear in coining with
Rubbing, Southeast Asia, in a symmetrical downward linear and believed to cause illnesses. anterior chest, base of the neck, the about 1 week. camphor balm,
Coin Thailand, Vietnam parallel fashion until streaks, petechiae - To treat fever, convulsions, seizures, intercostal or supraclavicular spaces, - Patterned linear, bilateral, parallel burns
Rolling, or purpura on the skin are created. The colds, rhinorrhea, cough, pain, shoulders, flexor region of the elbows and symmetrical linear - Cerebellar
Cao Giu instruments used to perform the heatstroke, headaches, chills, and knees. ecchymoses or ecchymotic hematoma with
scraping are hard objects with smooth respiratory problems, vomiting, streaks, usually following the herniation
edges, such as the edge of a jar cap, a functional internal organ problems, intercostal spaces, in a “tiger - Contact
hardboiled egg covered with hair, the musculoskeletal problems, pain relief, stripe” or “pine tree”, a dermatitis and
serrated edge of a coin, a buffalo horn, and body warmth. “Christmas tree” fashion. toxicity after
a comb, a spoon, an animal bone, a application of
water buffalo bone or a piece of jade. heated
The procedure takes about 15 to lubricants
20 min to perform. -
Hyperpigmenta-
tion
- One case of fire of
oiled skin
described.
- Renal contusion
and transient
microscopic
hematuria
Cupping also Cambodia, Central Applying a warmed cup, jar or glass bulb - To treat and heal pain (e.g. muscle and Trunk, especially the back, shoulders, - Annular burns sometimes - Blisters because
known as African Republic, with one end open on the skin over the joint pain, chronic chest and lower chest, in particular the presternal covered with crusts. of oils for
Ventosas, East Europe, Latin general area of discomfort for 5 to back pain), headache, stroke paralysis, region, abdomen, thorax or lumbar - Blue-red circular erythematous lubrication
Ba Guan America, Mexico, 20 min. Alternatively, a cotton ball sinusitis, colds, sore throat, coughs, area and buttocks. symmetrical patches with - Circular burns
Dry Middle East, soaked in alcohol can be ignited and difficulty breathing, fever, acne, defined borders, firstly - Contact
cupping Southern China and placed in the jar or cup. The cups abscesses, indigestion, stomach ache, edematous and subsequently dermatitis
Southeast Asia themselves can be of various shapes poor appetite, abdominal pain, ecchymotic from the suction - Edema
and sizes, as well as made of various diarrhea, gastrointestinal complaints, effect. - Erythema ab igne
materials, with the most common menstrual irregularity and - Linear purpuric streaks. -
being glass or plastic. Cupping can polymyalgia rheumatic. - Skin abrasions. Hyperpigmenta-
also be performed along the back or tion
thigh to cover a greater area if a - Koebnerization
lubricant oil is used to allow gradual - One case of
movement of the cup across the skin. panniculitis
Modern cupping may use suction described
devices, instead of cooling air, to - Ulcer
create the negative pressure, with
mechanical suction pumps located at
the top of the cup.
Gridding Former Soviet Union, Painting a grid-like pattern onto the back - To treat respiratory illness. Back. - Chemical burns with skin Hypothyroidism.
Russia, Ukraine with iodine abrasion
- Hyperpigmented criss-cross
pattern
Kerok also Indonesia Applying coconut or cajuput oil, balsam, - To relax. Back, spine, base of the neck, intercostal Linear, symmetrical, ecchymotic - Brain bleed
known as menthol lubricant, or water to the skin - To treat colds and other flu-like diseases or supraclavicular spaces: the chest is pattern in a “tiger stripe” - Camphor
Kerokan, as a skin lubricant. The skin is then (i.e. fever and malaise, rhinorrhea), less frequently used as the site of fashion. intoxication
Kerik press-stroked and rubbed repeatedly pain, heatstroke, respiratory problems, application. - Minor burns
Table 2 (continued)

Folk Geographic area Technique description Indications Body area Injuries description Adverse effects
practices

for approximately five minutes with a functional internal organ problems, - Renal contusion
sharp object until petechiae and musculoskeletal problems. and hematuria
ecchymoses occur.
Khoud Lam Laos Applying an oil, balsam, menthol - To relax. Spine, back, chest, base of the neck, Linear, symmetrical, ecchymotic - Brain bleed
also known lubricant, or water to the skin. The skin - To treat fever, rhinorrhea, pain, intercostal or supraclavicular spaces. pattern in a “tiger stripe” - Camphor
as Kuong is then press-stroked and rubbed heatstroke, respiratory problems, fashion. intoxication
repeatedly for approximately five functional internal organ problems, - Minor burns
minutes with a sharp object until musculoskeletal problems. - Renal contusion
petechiae and ecchymoses occur. and hematuria
Kos Khyal Cambodia Applying an oil, balsam, menthol - To relax. Spine, back, chest, base of the neck, Linear, symmetrical, ecchymotic - Brain bleed
also known lubricant, or water to the skin. The skin - To treat fever, rhinorrhea, pain, intercostal or supraclavicular spaces. pattern in a “tiger stripe” - Camphor
as Ga-sal is then press-stroked and rubbed heatstroke, respiratory problems, fashion. intoxication
repeatedly for approximately five functional internal organ problems, - Minor burns
minutes with a sharp object until musculoskeletal problems and body - Renal contusion
petechiae and ecchymoses occur. warmth. and hematuria
Maquas Arabia, Bedouin Applying hot metal spits near an area of - To drain purulent material from the Area of illness. Small, deep burns. No description.
cultures, Russia illness. burn.
Moxibustion China, Japan, Korea, Rolling pieces of moxa herb (mugwort or - To relieve a variety of symptoms, Over acupuncture points, especially the Erythema ab igne, pattern of small - Abscess
Mongolia, Tibet, Artemisia vulgaris) or yarn into a small including fever, ear infections, head neck and torso. discrete circular, target-like - Allergic contact
Vietnam cone, igniting it on the skin over abdominal pain, digestive disorders, burns, especially with the direct dermatitis
acupuncture points and allowing it to enuresis, temper tantrums, verrucae, application. - Cellulitis
burn until the onset of pain. breech presentation, stroke -
rehabilitation, cancer care. Hyperpigmenta-
tion
- Keloids
- Permanent scars
- Pregnancy related
complications
- Pruritus
- Secondary burns
Pinching China, Vietnam Applying pressure to points felt to be key - To treat headaches, cough or vomiting. Between eyebrows, in Ecchymotic marks. No description.
to symptomatology by pinching the - To bring toxic “wind” to the body sternocleidomastoid muscle insertion
skin to the point of producing a surface. at the sternum.
contusion.
Sapi Native Americans Scraping and scratching with thorns, - To purify. Chest, arms, and legs. Linear healed abrasions. - Scratching scars
claws, needles, husks, or other items - scars associated
until bleeding and by superficially with cutting
marking skin surfaces.
Salting Turkey Scrubbing a neonate’s body with table - To improve the health of a newborn’s Whole body. Epidermolysis. Severe
salt. skin. hypernatriemia,
death.
Spooning also China Massaging the symptomatic skin areas - To relax. Determined by the location of symptoms. - Cutaneous hyperemia and linear - Camphor
known as with mentholated topical ointment, - To rid the body of “bad winds” that In particular, the forehead, bridge of erythema that may progress to intoxication and
Gua Sha, tiger balm or warm oil and then cause illnesses, relieving inflammation the nose, inter palpebral space, multiple petechiae, hematomas toxicity
Spoon forcefully and repeatedly rubbing, within soft tissue. occipital depression over the back, or purpura that disappear in secondary to
Rubbing, scraping, scratching and firmly - To treat mild to severe conditions like spine, base of the neck, back, chest or, about 1 week. spooning with
Quat Sha, press-stroking, in a unidirectional colds, congestion, flu, fever, intercostal or supraclavicular spaces, - Patterned linear, bilateral, parallel camphor balm
Cheut Sah, manner and in a symmetrical rhinorrhea, acute or chronic pain, both sides of thoracic vertebrae, and symmetrical linear - Cerebellar
Kua Sha downward linear and parallel (medial heatstroke, chills, headaches, seizures, thyroid cartilage, flexor region of the ecchymoses or ecchimotic hematoma with
to lateral) fashion, with each stroke respiratory problems (e.g. asthma, elbows and knees. streaks, usually following the herniation
being 4–6 in length, for approximately bronchitis, emphysema, cough), poor intercostal spaces, in a “tiger - Contact
five minutes until ecchymotic streaks appetite, vomiting, functional internal stripe” or “pine tree”, a dermatitis
on the intact skin are created, both on organ problems, musculoskeletal “Christmas tree” fashion. -
adults and children without medical problems (e.g. fibromyalgia, severe Hyperpigmenta-
supervision. The smooth-edged strain, spasm or injury). tion
Forensic Sci Med Pathol
Forensic Sci Med Pathol

- One case of fire of

- Renal contusion
Adverse effects
that may be suspected to be due to physical abuse of adults

and transient

No description.

No description.
microscopic
- Minor burns
and/or children. This would be especially useful when

hematuria
oiled skin
described
assessing people from geographical areas where these prac-
tices are commonly performed.
In particular the synoptic reference table includes a descrip-

Multiple circular and oval bruises

tion of the technique, the alternative names of the same tech-

petechiae, occasional burns,

Patterned ecchymotic lesions,
nique, the rationale behind its use, the description of the pos-

symmetrical distribution.
with regular pattern and

erythema, hematomas,
sible injuries it may cause, the anatomical sites where the
Injuries description

technique is commonly carried out, and the possible conse-

skin lacerations.
quent effects (Table 2).
It has to be stressed that these techniques usually lead to the
formation of symmetrical, clustered and regular bruising,
which can give rise to the inclusion of these methods among
possible differential diagnosis, especially in persons with ori-
gins from countries where these techniques are applied with a
certain frequency.
In cases when maltreatment or abuse is suspected, a thor-
ough multidisciplinary investigation must be performed, tak-
Acupuncture points.

ing into consideration the anamnesis, social situation and cul-

tural context, and the characteristics of the injuries, with the
No description.
Body area

ability to request further dermatological and/or infectious

counseling together with advanced diagnostics (for instance,
imaging techniques, laboratory analyses, and consultation by
medical specialists) when diagnostic doubts are present on the
re-establish functioning in the body.

bringing blood to the surface of the

mechanism of production of skin findings. Moreover, the use

- To stimulate the flow of blood and

- To relieve internal congestion by

of a cultural mediator in cases involving individuals from

fluids, relative blockages and

other cultures certainly has to be considered an essential factor

in such cases.
Finally, after a thorough examination of the whole body in
a calm and neutral atmosphere, complete documentation of
Indications

the findings, including photographic material with a visual

skin.

scale, must always be performed in addition to a detailed

description of the type, dimensions and morphology of all
injuries [9].
bone, a piece of jade, a metal cap with
a rounded edge, a piece of ginger root,
scraping can be the edge of a jar cap, a

fingers, often used together with other

which produce bleeding-scarification,

so that the vacuum draws blood into
metal coin, a comb, a water buffalo
heated spoon, the smooth edge of a

Massaging (i.e. pushing and grasping)

acupuncture points with hands and

Making abrasions or small cut marks

a ceramic Chinese soup spoon or
instrument used to perform the

Conclusions
types of cultural practices.
special scraping spoon.
Technique description

In conclusion, even though several articles described the pres-

See Moxibustion.

ence and features of injuries or skin marks that can be caused

by folk remedies, there are still cases of misdiagnosis of phys-
the cup.

ical abuse in patients undergoing such cultural practices.

Furthermore, most of the studies that are currently available
concern different types of injuries with a constant focus on
non forensic clinical points of view and almost all the articles
Geographic area

covering clinical and diagnostic issues still lack a thorough

Middle East

global assessment of the problem from a medicolegal perspec-

Finland

tive. An analysis of the literature, that could have fundamental

Table 2 (continued)

China

applications in the forensic field, or any meaningful research

on such a peculiar issue has never been performed. Giving
Wet cupping

value to the fact that differing cultural customs may influence

practices

Toullmos

the perception of abuse, the synoptic table in this paper should

Tui na
Folk

be a manageable tool for forensic pathologists to use in every


day practice in cases of suspected physical abuse of adults or
children who come from regions where these techniques are
commonly performed.
Key points
1. Physical abuse in children and adults is a serious form of
violation of human rights and bruises are one of the most
common manifestations of this kind of abuse.
2. With globalization of socioethnic practices and wide-
spread immigration physicians increasingly encounter pa-
tients from varying backgrounds who follow different
customs which produce skin lesions that may be mistaken
for abuse.
3. Traditional medicine and cultural practices are not fre-
quently included in the differential diagnosis of suspected
cases of abuse and skin findings may still be
misinterpreted as injuries caused by physical abuse, espe-
cially when the suspected victim could be unable to ex-
plain what happened.
4. Forensic practitioners ought to be aware of the existence
of cultural practices, also defined as folk healing tech-
niques, which may mimic signs of physical abuse in chil-
dren and adults.
Compliance with ethical standard
Conflict of interest None of the authors have conflicts of interest.
Ethical approval This article does not contain any studies with human
participants or animals performed by any of the authors.
Informed consent Informed consent the article does not contain any
studies with human participants requesting their informed consent.
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