Prayer marks

A 42-year-old Muslim woman presented with complaints of asymptomatic raised skin lesions over the bilateral feet and knees for a 5-year duration, initially started over the right foot and then progressed to involve the bilateral foot and knee region. She gives a history of praying five times daily in a sitting position (Julus). No other risk factors or comorbidities were present. On examination, well-defined hyperkeratotic lichenified plaques and thick callosities were noted mainly on the pressure-bearing sites of lateral feet, bilateral lateral malleoli, and knee [Figure 1a-c]. The rest of the cutaneous examination was within normal limits. Hence, the diagnosis of Prayer marks was considered and treated with a keratolytic cream.

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Figure 1:

(a) Thick hyperkeratotic plaques and callosities noted over the left foot and malleolus. (b) Thick hyperkeratotic plaques and callosities noted over the right foot and malleolus. (c) Thick lichenified plaque over the anterior aspect of both knees.

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Prayer marks are common skin manifestations in people who pray regularly, especially among Muslims but have also been reported among Buddhists and Christians. The site of the lesions depends on the type of praying position such as sitting (Julus), bowing (ruku), prostration (sajda), and standing (Waquf). In the sitting position (Julus), the callosities are seen in the ankle, malleoli, and dorsum of feet referred to as the prayers foot, whereas the marks that occur in the forehead are referred to as Prayers bump or zebibah or devout sign, especially in males. Recognizing these marks help to differentiate from other clinical mimics and also localization of these lesions can serve as a clue to underlying illness such as chronic obstructive pulmonary disease, cardiac disease, and neuropathic disease. Rarely, these lesions can be complicated by ulceration, fissuring leading to cellulitis known as Mecca feet. Treatment can be done by mechanical abrasion with pumice stone along with topical keratolytic, and preventive measures such as soft clothing and woolen prayer mats can be used.^[1]