Saree is a type of female costume unique to Indian subcontinent. This includes a superficial cloth and a skirt underneath which is fastened securely to the waist by a cord. Persistent and long term wearing of this costume has resulted in waist dermatoses.1 However this waist dermatoses giving rise to malignancy is rare. We present a case of 40 year old lady who presented with ulcer over waist line following chronic irritation due to saree which turned out to be squamous cell carcinoma. Patient was operated. Post operative follow up of one year has shown her to be disease free.

Introduction

Dermatoses like allergic and non-allergic contact
dermatitis2 and dermatophytosis3 are more common in body folds especially when associated with increased sweating.
Saree including its skirt can cause chronic irritation along waist line. These tight garments induce various dermatoses along the waist in our female patients.1 This is often aggravated by the hot and humid climate of certain areas. Pigmentation and mild scaling over the waist have become so common in females in India that they have started considering it as normal.1

We present a case of waist line dermatoses giving rise to squamous cell carcinoma which is rare.

Case Report

We present a case of a 40 year old lady, farmer by occupation who came with a non healing ulcer in the right lumbar region along the waistline since 6 months. Initially there was coarsening of skin and hyperpigmentation of that area followed by atrophy and hypopigmentation. This was associated with a burning sensation and serous discharge which recently turned foul smelling. The patch of skin gave way to form an ulcer which rapidly overgrew its edges within a span of 6 months. On direct questioning she gave history of tight wearing of saree for 25 years. She took treatment from the local practitioner, however ulcer grew in size over a period of time.

Clinical examination revealed an ulcer measuring 7 cms x 5 cms with everted edges, illdefined margins and serosanguinous discharge from the ulcer bed (Fig.1). Ulcer was tender on palpation, did not bleed on touch. Surrounding skin was hyperpigmented and scaly. On left side 8 cm x 5 cm hyperpigmented plaque was seen over the waist line. Bilateral nontender, discrete, firm, mobile inguinal lymphadenopathy was present. Biopsy from the right side ulcer showed invasive squamous cell carcinoma. Biopsy from left side lesion showed waist dermatoses. FNAC of bilateral inguinal lymph nodes showed Reactive lymphadenitis. Impression was Right sided Squamous cell carcinoma (Saree cancer) and left sided saree dermatoses.

Patient was worked up for surgery. Wide excision with primary grafting was done. Histopathology confirmed Squamous cell carcinoma with free resection margins. Inguinal lymphadenopathy also resolved after a course of antibiotics. Post-operative course was uneventful. Follow up of one year has shown patient to be disease free

Fig. 1 : Picture showing skin ulcer along right side of waist line.

Discussion

Saree is a type of female costume unique to Indian subcontinent. Whether it is an ideal outfit for our climate is debatable. To make matters worse, they wear a skirt underneath fastened securely to the waist by a cord. These tight garments induce various dermatoses along the waist in our female patients.1 This is often aggravated by the hot and humid climate of certain areas.

Various dermatoses like allergic and non-allergic contact dermatitis2 and dermatophytosis3 are more common in body folds especially when associated with increased sweating.

Pigmentation and mild scaling over the waist have become so common in Indian females that they have started considering it as normal. Dermatoses giving rise to malignancy is rare. In our patient dermatoses finally changed into squamous cell carcinoma on the right side. However, on the left side of waist line it remained the same. Though, there was bilateral inguinal lymphadenopathy, it turned out to be reactive and responded to course of antibiotics. This shows that this malignancy is slow to spread. Moreover dermatoses if persistent over a long period only, will give rise to malignancy like in our case.

A study conducted could not find any association with factors, which are commonly accompanied by flexural dermatoses like diabetes,4 obesity and atopy.5

The only factor determining the frequency of waist dermatoses in our patients is the tightness with which they tie the cord of their skirt along their waist.1 Hence one study has recommended to use broad belts with hooks, instead of the thin cord, which will considerably reduce the pressure over the site.1

To summarise, waist dermatoses due to saree can rarely present as malignancy i.e. saree cancer. This entity should be always kept as a differential so that treatment can be instituted early for better prognosis.

Acknowledgement

We would like to thank Dean and Dr. MG Rathod Head of the Department of Surgery, Grant Medical College and Sir JJ Group of Hospitals for granting us permission to publish this case report.

References

1. Eapen BR, Shabana S, Anandan S. Waist dermatoses in Indian women wearing saree. Indian J Dermatol Venereol Leprol 2003; 69 : 88-89.
2. James C, Shaw M. Allergic and non allergic eczematous dermatitis. Immunology and Allegry Clinics of North America 1996; 16 : 119-35.
3. Rinaldi MG. Dermatophytosis: epidemiological and microbiological update. J Am Acad Dermatol 2000; 43 : S120-124.
4. Sibbold RG. Skin and diabetes. Endocrinol Metab Clin North Am 1996; 25 : 463-72.  
5. Hanifin JM, Rajka RG. Diagnostic features of atopic dermatitis. Acta Derm Venereal (Stockh) 1980; 92 (suppl. 144) : 44-7.