Introduction {#sec1-1}
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**What was known?**

Thermal stimuli such as Kangri use are known to cause dysplastic changes and skin cancer.

Kangri cancer is peculiar to the valley of Kashmir as the people of all age groups are accustomed to warm their bodies by the use of Kangri baskets.\[[@ref1]\] Kangri is an indigenous fire pot used and tucked in between thighs and abdomen to generate warmth especially during the colder winter months. Kangar is a clay bowl weaved into a willow wicker, which is kept beneath the traditional Kashmiri clothing called as the Pheran. If a person is wearing a jacket, it may be used as a hand warmer. It is about 6 inches in diameter. The prolonged use of Kangri may result in the formation of erythema ab igne, a reticulate hypermelanosis with erythema which may transform into cancer.\[[@ref2]\] William Elmslie first documented squamous cell carcinoma of skin among Kashmiris, and correctly ascribed it to the use of Kangri. Theodre Maxwell confirmed these findings in 1879. Kangri cancer usually starts as a papular skin growth over erythema ab igne. With time these lesions usually ulcerate and grow exponentially. Heat is the prime factor. Products of combustion, wood ash and volatile substances may play a secondary part.\[[@ref3]--[@ref5]\]

Materials and Methods {#sec1-2}
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This is a prospective hospital based study which is being conducted on patients attending the outpatient department of Dermatology, STD and Leprosy at SMHS hospital, an associated hospital of govt. medical College in Srinagar. All the patients attending the department and presenting with suspicious lesions due to Kangri use (i.e., erythema ab igne, papular or nodular skin growths) were taken up for the study. A detailed history including the use of Kangri (which included the duration of Kangri use, modes of use of Kangri, duration of erythema ab igne, time interval between erythema ab igne and the development of bowen\'s disease and SCC) was taken for each patient, and a physical examination including cutaneous and systemic examination was done in each patient. Skin biopsy which consisted of either punch biopsy, edge biopsy or an excisional biopsy depending on the individual case were done in patients who presented with suspicious lesions suggestive of a malignant growth and were sent for histopathological examination. After confirming the diagnosis a wide surgical excision was performed in patients with bowen\'s disease, and the patients with biopsy documented SCC were sent to the department of surgery for further management.

Results {#sec1-3}
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We came across the following observations:

![](IJD-58-188-g001)

During the period of 8 months, a total of 40,000 patients were registered in our department. We observed a total of 30 cases (0.075%) in whom skin changes due to Kangri use were present. Erythema ab igne, a reticulate hypermelanosis with erythema was observed in all 30 cases. The patients gave the history of using the Kangri especially for 3-4 winter months only every year for 5-6 hours daily. The cutaneous changes were especially observed in the elderly age group (50-65 years). Females were more frequently affected as compared to males. However there was no difference in the age group being affected between males and females. There was no other significant history. The anteromedial aspect of thighs was the most common site of affliction, followed by anterior abdomen and legs. Bowen\'s disease was noticed over the background of erythema ab igne in 20 cases, and the most common presentation was an erythematous crusted scaly plaque, with associated history of itching and burning. Histopathological differences were not noted in different patients. Squamous cell carcinoma was observed in 10 cases on a background of erythema ab igne. The most common presentation was a nodulo-ulcerative growth over a background of erythema ab igne, with associated history of pain and bleeding. Bowen\'s disease and squamous cell carcinoma were confirmed by histopathology \[Figures [1](#F1){ref-type="fig"}--[6](#F6){ref-type="fig"}\].

![Kangri](IJD-58-188-g002){#F1}

![Bowen\'s disease on a background of erythema ab igne](IJD-58-188-g003){#F2}

![Bowen\'s disease on a background of erythema ab igne](IJD-58-188-g004){#F3}

![Histopathological picture of bowen\'s disease (Haematoxylin and Eosin 40×)](IJD-58-188-g005){#F4}

![Squamous cell carcinoma and bowen\'s disease](IJD-58-188-g006){#F5}

![Histopathological picture of squamous cell carcinoma (Haematoxylin and Eosin 40×)](IJD-58-188-g007){#F6}

Discussion {#sec1-4}
==========

Various studies from India have reported squamous cell carcinoma as the most common type of skin malignancy. The clinical spectrum of skin cancer in Kashmir valley is however entirely different from the rest of the country, because of the presence of Kangri cancer - a type of squamous cell carcinoma, which is indigenous to the Kashmiris.\[[@ref2]--[@ref4]\]

Maxwell was the first to report the skin cancer of lower extremities from Kashmir valley in 1879 and rightly attributed it to the use of Kangri - an indigenous fire pot used and tucked in between thighs and anterior abdomen to generate warmth during the colder winter months. This type of cancer (i.e., Kangri cancer) is most commonly seen over the lower extremities and anterior abdominal wall, and it begins with erythema ab igne (i.e., reticulate hypermelanosis with erythema) over which papular skin growths develop after a variable period. With time these lesions ulcerate and grow exponentially. These tumors behave aggressively with a substantial risk of loco-regional metastasis in 20-50%. Because of its unique geographical location there is a dearth of literature regarding the natural history of Kangri cancer. The sequence of events believed to lead to Kangri cancer are erythema ab igne followed by bowen\'s disease and finally squamous cell carcinoma.\[[@ref6][@ref7]\] Erythema ab igne, a reticulate hypermelanosis with erythema was observed in all 30 cases. The anteromedial aspect of thighs was the most common site of affliction, followed by anterior abdomen and legs. The duration from erythema ab igne to bowen\'s disease was approximately 10-15 years. Prolonged continuous use and intimate contact with the Kangri and elderly, idle sitting age group were found to be predominantly affected by bowen\'s disease and squamous cell carcinoma. The most common mode of using the Kangri was underneath the traditional Kashmiri cloak - the Pheran in between thighs and abdomen. Most of the patients reported itching and burning sensation with continuous use of Kangri after the development of erythema ab igne, which was present for an average of 10-15 years approximately before the development of bowen\'s disease. Bowen\'s disease was the most common type of pre-malignant lesion observed in our study. The increased frequency and its location were both attributed to the use of Kangri. The most common type of clinical presentation was an erythematous crusted plaque on a background of erythema ab igne. The next common type of presentation was an itchy painless erythematous plaque on a background of erythema ab igne. Induration and pain were not noted in case of bowen\'s disease. No other pre-malignant lesion was observed in the patients in the affected region, although actinic keratosis was observed in the sun-exposed areas in most of the patients. Squamous cell carcinoma was the most common type of malignancy observed and the most common site was the lower extremities (thighs) followed by anterior abdomen, which was again attributed to the use of Kangri. The most common type of presentation was a nodulo-ulcerative growth, with a history of pain and bleeding. The average duration from bowen\'s disease to the development of SCC was approximately 3-6 years.\[[@ref8]--[@ref10]\]

To conclude, Kangri although does bestow a momentary victory on a Kashmiri in his conflict with chilai-kalan (the coldest part of winter), but it does make them pay in the long run in the form of Kangri cancer and its complications. Although this is a preliminary study we will be studying more of such cases in the future.

**What is new?**

Skin cancers induced by Kangri exposure are mostly of squamous cell carcinoma type and are seen over covered parts of the body.

**Source of Support:** Nil

**Conflict of Interest:** Nil.
