1. Flagellate dermatoses

2. Flagellation of Christ by Rubens

3. The Flagellation of Our Lord Jesus Christ, William-Adolphe Bouguereau

4. Shi'ites in Pakistan flagellate themselves during the Moharram procession.

5. flagellate dermatoses as religious punishment

6. Causes of flagellate dermatoses

7. IJDVL: 2014 : 80 : 2 : 149 Flagellate dermatoses
Flagellate dermatoses are uncommon figurate dermatoses characterized by parallel linear or curvilinear arrangement simulating the marks of whiplashes.
True flagellation/mechanical Flagellation has been used in various religions for penance or punishment.  Whipping has also been used to "discipline" children, but in the modern context flagellate marks on children should arouse a suspicion of child abuse.  . Sadomasochistic behavior involves voluntary whipping of oneself or the partner for sexual gratification.  Artefactual whiplash marks may be produced for tangible or intangible gains in malingering and other psychiatric illnesses. Chemotherapy induced flagellate dermatitis and pigmentation Bleomycin is a polypeptide chemotherapeutic agent with predominant adverse reactions in the cutaneous and respiratory systems presumably due to the lack of inactivating enzyme, hydrolase in these tissues.  The common mucocutaneous lesions described are pigmentation (~50%), alopecia (~50%)  and flagellate dermatitis (8-66%).   . The rash heals with persistent flagellate hyperpigmentation . Pigmentation has also been described without pruritus or rash. Although it usually appears after a cumulative dose >100 U; it has also been reported after doses as small as 14 U used for intralesional injections of verrucae. Peplomycin is a bleomycin derivative with reduced pulmonary toxicity that is used for lymphomas and prostatic carcinoma. It has also been implicated in flagellate erythema by mechanisms similar to bleomycin.  Docetaxel is a taxane with a high rate of cutaneous reactions including flagellate dermatitis.
Rheumatological diseases Dermatomyositis is known to produce linear lesions variously described as centripetal flagellate erythema,  zebra-like striped erythema,  and linear streaks  . In contrast to bleomycin-induced flagellate dermatitis, erythema is more pronounced than pigmentation. The trauma of scratching appears to play an important role, as in the bleomycin induced rash.  Adult-onset Still's disease is an autoimmune disease occasionally associated with flagellate erythema.

8. IJDVL: 2014 : 80 : 2 : 149 Flagellate dermatoses ( Continue)
Toxin-induced Shiitake mushrooms (Lentinus edodes) are commonly used in Asian cuisines and are known to produce flagellate dermatitis (toxicoderma).  The rash is very pruritic, predominantly truncal and does not generally heal with pigmentation. Toxicoderma is probably caused by a lentinan-like polysaccharide, which is denatured by cooking and thus occurs only on eating raw or under-cooked mushrooms.   Cnidarians (Portuguese man-of-war and jellyfish)  contain nematocysts in their tentacles which discharge by an osmotic process when injected in the prey. Most human envenomations are caused by Anthozoa (anemones and corals), Hydrozoa (Portuguese man-of-war and hydroids), Scyphozoa (the true jellyfish) or Cubozoa (the box jellyfish). Initially, the victim experiences a severe burning pain in skin that comes in contact with the tentacles followed within minutes by a zigzag, whip-like pattern of raised red wheals 2-3 mm wide. Though about 80% of cases are limited to skin manifestations, some have systemic effects including malaise, vomiting, dyspnea and tachycardia. Rove beetles of family Staphylinidae and genus Paederus contain a vesicant, pederin and produce lesions only when they are crushed on the skin. A wheal forms at the sites followed by a blister within h, which may be a linear "whiplash dermatitis." 
Other pruritic dermatoses Many other itchy dermatoses may present with linear marks simulating flagellate dermatitis . Dermatographism may produce a flagellate pattern . Phytophotodermatitis and poison ivy dermatitis may cause flagellate lesions where the leaves have brushed the cutaneous surface. Neurotic excoriations mimicking a flagellate pattern Hypereosinophilic syndrome Two men with HIV infection who had unusual cutaneous manifestations of hypereosinophilic syndrome, exfoliative erythroderma and linear flagellate plaques.  Chikungunya fever induced flagellate pigmentation Chikungunya fever commonly causes hyperpigmentation such as accentuation of melasma, pigmentation of nose, periorbital melanosis and irregular and flagellate patterns on the trunk and extremities. It is primarily considered a post-inflammatory response with the chikungunya virus probably triggering intraepidermal melanin dispersion or retention.  Idiopathic flagellate pigmentation Pise et al., have reported a case with flagellate pigmentation without any systemic illness, pruritus or drug intake.  The flagellate marks did not follow the lines of Blaschko. It appears that rarely, flagellate pigmentation may be idiopathic; though the diagnosis should be one of exclusion.

9. Public flogging of a slave in Rio de Janeiro, Brazil - work of French painter Jean-Baptiste Debret (1768–1848).

10. Self-flagelation is ritually performed in the Philippines during Holy Week (on Good Friday, before Easter).

12. Pain and the erotic Postcard from the Krafft Ebing Collection
Pain and the erotic Postcard from the Krafft Ebing Collection. The Wellcome Library, London.
'Lots of Noise from Such a Little Box'

13. A group of people engaged in a modern secular ritual called pulling

14. The Martyrdom of St. Barbara by Wilhelm Kalteysen von Aachen, a medieval spectacle of ritual execution, reflecting sadomasochism's "polymorphis fantasies" of pain,

15. Child abuse

16. Factitious dermatitis Dermatitis artefacta is defined as the deliberate and conscious production of self-inflicted skin lesions to satisfy an unconscious psychological or emotional need. Patients with this condition require both dermatologic assessment and psychosocial support.

17. Chemotherapy induced flagellate dermatitis Bleomycin
Bleomycin is a glycopeptide antitumor antibiotic and antiviral drug produced by the bacterium Streptomyces verticillus. Bleomycin refers to a family of structurally related compounds. When used as an anticancer agent, the chemotherapeutical forms are primarily bleomycin A2 and B2. The drug is used in the treatment of Hodgkin's lymphoma ,squamous cell carcinomas, and testicular cancer, as well as in the treatment of plantar warts and as a means of effecting pleurodesis. The mechanism of action involves breaking DNA strands.
Bleomycin is on the World Health Organization's List of Essential Medicines that are needed for a basic health system

18. Peplomycin, Peplomycin, a bleomycin-related cytostatic agent

19. Chemotherapy induced flagellate dermatitis Docetaxel
Docetaxel is a clinically well-established anti-mitotic chemotherapy medication that works by interfering with cell division. Docetaxel is approved by the FDA for treatment of locally advanced or metastatic breast cancer, head and neck cancer, gastric cancer, hormone-refractory prostate cancer and non small-cell lung cancer. Docetaxel can be used as a single agent or in combination with other chemotherapeutic drugs as indicated depending on specific cancer type and stage.

20. Chemotherapy induced flagellate dermatitis Bendamustine
Bendamustine is a nitrogen mustard used in the treatment of chronic lymphocytic leukemia and lymphomas. It belongs to the family of drugs called alkylating agents.

21. Bleomycin induced flagellate dermatitis

22. Skin lesions due to bleomycin

23. Skin biopsy revealing an inflammatory dermal infiltration (arrow) suggesting drug eruption.

24.  Bleomycin induced flagellate dermatitis with linear erythematous streaks involving the (a) upper back, (b) buttocks, (c) left arm, (d) right arm and (e) multiple erythematous papules involving the interdigital clefts and dorsum of both hands JCrT,2013  : 9  : 3 : 500

25. Acquired hyperpigmentations
Acquired hyperpigmentations. Flagellate Dermatitis– Linear urticariform lesions, some with a slight superficial blistering, located on the lateral side of the chest, which appeared 15 days after the initiation of treatment with bleomycin An. Bras. Dermatol.89 Rio de Janeiro  2014  

26.  IJDVL: 2014  : 5  : 4: 517  Lesser known evil of a commonly used devil-bleomycin induced flagellate dermatitis 
Bleomycin is a glycopeptide used in oncology as a chemotherapeutic agent for Hodgkins disease, germ cell tumors, and pleurodesis of malignant pleural effusions. Though the pulmonary toxicity of bleomycin is well known, its cutaneous side effects are uncommon. The cutaneous effects of bleomcyin range from generalized hyperpigmentation, sclerodermoid changes, erythema multiforme, gangrene, to flagellate dermatosis.  First reported in 1970,  the incidence of bleomycin induced flagellate dermatosis varies from 8 to 20%.  The exact mechanism of bleomycin induced flagellate dermatosis is unclear and is hypothesized to be due to raised local levels of the drug in the skin. This in turn is due to low levels of bleomycin hydrolase in the skin.  There is no specific treatment for bleomycin induced flagellate dermatosis and the skin lesions are usually self-limiting.

27. Neurotic excoriations mimicking a flagellate pattern

28. Dermatographism in a flagellate pattern

29. Flagellate erythema

30. Flagellate erythema

31. Flagellate erythema

32. Dermatomyositis  Telangiectatic macules and papules on the breast in a patient with longstanding disease

33. Acquired hyperpigmentations. Poikiloderma of Civatte
 Acquired hyperpigmentations. Poikiloderma of Civatte. Note the grid-like hyperpigmentation, affecting the lateral areas and base of the neck in a 51 years-old phototype 3 woman. Observe photodamage lesions and a lighter area correspondings to the region shaded by the chin An. Bras. Dermatol.89 Rio de Janeiro  2014  

34. Adult-Onset Still’s Disease
Adult-onset Still’s disease (often called AOSD) is a relatively rare condition. It begins with fever and may lead to arthritis and a distinctive salmon-colored bumpy rash. Classified as an inflammatory illness, the disease often causes fatigue and swelling in joints, tissues, organs, and lymph nodes. the condition persists or recurs. In children, a similar condition exists called juvenile idiopathic arthritis. .

35. Shiitake mushroom Dermatol Alergol :Published online 2014 Jun 13
Shiitake mushroom Dermatol Alergol :Published online 2014 Jun 13.  Flagellate dermatitis after consumption of Shiitake mushrooms

36. Shiitake mushroom An. Bras. Dermatol. 87 no.3 Rio de Janeiro , 2012

37. Shiitake mushrooms (Lentinus edodes) (Figure 1), a woodland type of mushrooms used in Japanese/Chinese cuisine, are the second-most common edible mushrooms in the world. The precise number of tons consumed per year is not known but is estimated in the 10,000-ton range worldwide [1]. In addition to its culinary properties (Umami), an antihypertensive effect, reduction of elevated cholesterol levels and an anticarcinogenic property are known. For this reason, the Shiitake mushroom plays a large role in traditional Asian medicine.
A severely-itching dermatitis (toxicoderma) following consumption of the mushroom was first reported by Nakamura in 1977 [2]. Typically, 24–48 h after eating raw or half-cooked Shiitake mushrooms, the patient developed severely-itching, isolated or grouped papules or papulovesicles with striped, infiltrated erythemas, which arose in a Köbner phenomenon due to stripe-like scratching [3].
The preferred localizations of the dermatosis are the trunk, extremities and the nape area, less often the face or hair-covered scalp [2]. No life-threatening systemic reactions have been documented thus far. The usually spontaneous regression of skin symptoms lasts from a few days to several weeks

38. Parallel, striped whiplash-like infiltrated erythemas with severe itching on the trunk Flagellate dermatitis after consumption of Shiitake mushrooms

39. Papulovesicles on urticarial erythemas on the right shoulder Flagellate dermatitis after consumption of Shiitake mushrooms

40. Close-up view of parallel, striped whiplash-like infiltrated erythemas on the trunk Flagellate dermatitis after consumption of Shiitake mushrooms

41. Histopathology :severe edema of the Stratum papillare, mild focal (not spreading) acute lymphocytic eczema reaction, superficial, cuff-shaped perivascular lymphocytic infiltrate Flagellate dermatitis after consumption of Shiitake mushrooms

42. Shiitake dermatitis

43. Shiitake dermatitis
Shiitake dermatitis is due to lentinan which is found in shiitake mushrooms. This substance is broken down by heat so the dermatitis only occurs following ingestion of raw or lightly cooked shiitake mushrooms.Lentinan is well known for its health benefits (eg, lowering blood pressure and serum cholesterol). In Japan, lentinan is used therapeutically in cancer treatment and a flagellate dermatitis following such treatment has been well documented.

44. Cnidaria
Cnidaria is a phylum containing over 10,000 species of animals found exclusively in aquatic and mostly marine environments. Their distinguishing feature is cnidocytes, specialized cells that they use mainly for capturing prey. Their bodies consist of mesoglea, a non-living jelly-like substance, sandwiched between two layers of epithelium that are mostly one cell thick. They have two basic body forms: swimming medusae and sessile polyps, both of which are radially symmetrical with mouths surrounded by tentacles that bear cnidocytes. Both forms have a single orifice and body cavity that are used for digestion and respiration, and some have simple eyes. Not all cnidarians reproduce sexually. Many have complex lifecycles with asexual polyp stages and sexual medusae, but some omit either the polyp or the medusa stage.

45. Paederus Aesthet Dermatol. 2011; 4(11): 44. Paederus Dermatitis
it has given its name to paederus dermatitis, a characteristic skin irritation that occurs if one of the insects is crushed against skin.

46. Aesthet Dermatol. 2011; 4(11): 44 Paederus Dermatitis

47. Phytophotodermatitis
Phytophotodermatitis (PPD) is a cutaneous phototoxic inflammatory eruption resulting from contact with light-sensitizing botanical substances and long-wave ultraviolet (UV-A nm) radiation. The eruption usually begins approximately 24 hours after exposure and peaks at hours. The phototoxic result may be intensified by wet skin, sweating, and heat
A 26-year-old female airline flight attendant exposed to lime while serving drinks en route to the Caribbean. During the Caribbean layover, she had significant sun exposure. The combination of lime juice and sun exposure led to a drip-pattern blister formation on the dorsal forearm consistent with phytophotodermatitis.

48. Phytophotodermatitis
Phytophotodermatitis, also known as "Lime Disease" (not to be confused with Lyme Disease), "Berloque dermatitis", or "Margarita photodermatitis" is a chemical reaction which makes skin hypersensitive to ultraviolet light. It is frequently mistaken for hereditary conditions such as atopic dermatitis or chemical burns, but it is caused by contact with the photosensitizing compounds found naturally in some plants and vegetables like parsnips, citrus fruits, and more. Symptoms can be burning, itching, stinging, and large blisters that slowly accumulate over time.

49. Phytophotodermatitis

50. Plants that cause phytophotodermatitis
Parasnip Lime
Wild carrot
Parsley

51. Poison Ivy Dermatitis
"Leaves of three - let it be!" aptly describes this woody vine with 2-4" leaflets in groups of three. The center leaf has a longer stem than the other two. Poison ivy clings to tree trunks and other vertical surfaces with hair-like aerial rootlets that grow out of the stem. If a climbing surface isn't available, poison ivy will grow as a free standing shrub. The leaves of poison ivy turn shades of red and purple in fall.
Poison ivy is caused by an allergic reaction (allergic contact dermatitis) to the oily coating that covers of these plants. The resinous coating is called "urushiol". These are called Rhus plants after the old scientific name (it was changed to toxidendron). A person doesn't have to come in direct contact with the leaves, roots, or branches of Rhus plants to get the rash. One can get it from contaminated clothing. Even in winter the leafless stems and vines can cause the familiar skin rash.
Dogs and other animals are not affected by poison ivy, but people can get the rash by petting a dog that's been exposed.
The rash itself is not contagious, and the fluid in the blisters does not spread the rash. Poison ivy dermatitis appears as soon as four hours or as long as 10 days after the exposure, depending on individual sensitivity and the amount exposure. As the rash appears, any sensitivity a person had begins to increase. One starts to react to the slightest traces of a few molecules on the skin. This causes the rash to appear to be spreading, even after treatment has begun.
 Poison ivy dermatitis rashes are self-limited; sooner or later they clear up without treatment. Letting nature take its course with mild poison ivy dermatitis is reasonable, but severe rashes need treatment to ease the misery and disability they cause. The very first time this rash is gotten, it lasts longer than a repeat attack, often 3 or 4 weeks.

52. Poison Ivy Dermatitis

53. Hypereosinophilic syndrome
The hypereosinophilic syndrome (HES) is a disease characterized by a persistently elevated eosinophil count (≥ 1500 eosinophils/mm³) in the blood for at least six months without any recognizable cause, with involvement of either the heart, nervous system, or bone marrow.
HES is a diagnosis of exclusion, after clonal eosinophilia (such as leukemia) and reactive eosinophilia (in response to infection, autoimmune disease, atopy, hypoadrenalism, tropical eosinophilia, or cancer) have been ruled out.
If left untreated, HES is progressively fatal. It is treated with glucocorticoids such as prednisone. The addition of the monoclonal antibody mepolizumab may reduce the dose of glucocorticoids

54. Chikungunya fever
Chikungunya virus is transmitted to people by mosquitoes. The most common symptoms of chikungunya virus infection are fever and joint pain. Other symptoms may include headache, muscle pain, joint swelling, or rash There is no vaccine to prevent or medicine to treat chikungunya virus infection. Travelers can protect themselves by preventing mosquito bites. When traveling to countries with chikungunya virus, use insect repellent, wear long sleeves and pants, and stay in places with air conditioning or that use window and door screens. .

55. Rash from chikungunya on the right foot

56. Chikungunya fever An A. aegypti mosquito biting a person
Transmission electron micrograph of Chikungunya virus particles

57. Gordon, a whipped slave, photo taken at Baton Rouge, 1863
Gordon, a whipped slave, photo taken at Baton Rouge, The scars are clearly visible because of keloid formation

58. Whip
 riding crop
A leather cat o' nine tails 
stockwhip
bullwhip

59. Whip
Longeing whip
signal whip
metal whip