Devout Sign (Prayer Mark)

Clinical Image

A 65 year old asymptomatic man came for routine follow up in the hypertension clinic. There was no significant past medical history except for hypertension, for which he was on Amlodipine 5mg once a day for the last 10 years. No allergies were documented. However, he was noted to have a hyper pigmented macula (Figure 1) on the centre of the fore head.

The patient’s history revealed that it was a result of him kneeling and praying 5 times a day with his forehead touching a prayer mat since early childhood. He had developed these 5 years ago. This hyper pigmented macule is the result of the forehead’s repeated contact with a prayer mat [1]. These prayer marks are also found in other locations due to sustained pressure of bony prominences; such as the knees, ankles and dorsum of the feet. They are more common in men and can lead to chronic skin changes such as hyper pigmentation, thickening and lichenification [1]. It has also been noted that prayer marks herald the onset of new disease and worsening of chronic disease [2,3].

    

    

    Figure 1:  Overall survival, autologous stem cell transplant (ASCT) versus no ASCT (p=0.12).