Skip to main content

What Is the Cause of These Annular Lesions?

What Is the Cause of These Annular Lesions?

Diagnosis: Postinflammatory hyperpigmentation related to cupping    

Cupping is an ancient therapeutic technique used in a wide array of conditions. There are many types of cupping therapy, but the most common techniques are dry cupping and wet cupping. Dry cupping involves applying a heated glass cup to a patient’s skin, and negative pressure suctions the skin into the cup. Wet cupping involves piercing the skin to release blood into the cup while applying the suction cup.1-4   

Mechanism of Cupping
The exact mechanism of action of cupping therapy remains to be established. Cupping therapy is thought to increase tissue nitric oxide. Smooth muscle relaxation, an increase in blood circulation, and changes in local tissue structure are thought to be mediated by this release of nitric oxide. Cupping is also postulated to activate the immune system and modify serum cytokine levels at the sites of treatment. In addition, cupping may also modify pain through activation of selective nerve fibers.2,5 

Table1

Indications
Cupping is indicated in both localized and systemic ailments. Cupping can be used to treat localized ailments including headache, lower back pain, neck pain, and knee pain. Systemic ailments that may benefit from cupping therapy include hypertension, rheumatoid arthritis, and skin disorders and are summarized in Table 1.6-13

Table 2

Adverse Effects
Cupping therapy is often asymptomatic. However, both dermatologic and systemic side effects of cupping have been observed. Following cupping therapy, patients may experience burning, irritation, pain, or pruritus at the site of cupping.9,14-28 Side effects are more common when cupping is performed by either unqualified personnel or by patients themselves, or when sequential cupping sessions are performed for longer than 1 month. Adverse events are also more common with wet cupping than with dry cupping.1 The adverse effects of cupping are summarized in Table 2.9,14-27  

Clinical Presentation
After cupping therapy, the skin may present with bulla, burns, erythema, or purpura. Some patients may subsequently develop hyperpigmentation (Figures 1, 2) or scarring at the site of cupping.28,29  

F1

Differential Diagnosis
The well-demarcated and symmetric distribution of lesions suggests an exogenous cause. However, an allergic or irritant contact dermatitis should be considered in the differential. Other considerations include child or elder abuse, trauma, resolving erythema multiforme, diffuse fixed drug eruption, and resolving papulosquamous conditions such as nummular dermatitis, pityriasis rosea, and tinea corporis. 

F2Treatment 
Postinflammatory hyperpigmentation associated with cupping is a common side effect seen in 4% of patients within 1 month of treatment. Hence, hyperpigmented annular lesions are expected to occur with subsequent treatments. Progressive fading of these lesions may occur with time. Therefore, a watchful waiting approach should be taken by clinicians.18 

Our Patient 
Our patient reported undergoing cupping therapy for back pain once per week for 1 year. He was aware of the hyperpigmented skin changes secondary to his therapy. However, the benefit of this treatment was preferred by our patient, and he was not concerned about the darkening of his skin at the treatment sites.

Conclusion
Cupping is a form of alternative medicine that can be used not only for systemic disorders, but also for some dermatologic conditions. Cupping therapy is generally a safe treatment, with low risk of serious side effects. However, dermatologic adverse events can be associated with cupping, including ecchymoses, purpura, and postinflammatory hyperpigmentation.


Ms Appiah is a student at the University of California, San Diego, School of Medicine in La Jolla, CA. Dr Cohen is an adjunct professor of dermatology at Touro University California College of Osteopathic Medicine in Vallejo, CA, and a dermatologist at San Diego Family Dermatology in National City, CA.  

Disclosures: The authors report no relevant financial relationships.


References

1. Soliman Y, Hamed N, Khachemoune A. Cupping in dermatology: a critical review and update. Acta Dermatovenerol. 2018;27(2):103-107. doi:10.15570/actaapa.2018.21

2. Al-Bedah AMN, Elsubai IS, Qureshi NA, et al. The medical perspective of cupping therapy: effects and mechanisms of action. J Tradit Complement Med. 2018;9(2):90-97. doi:10.1016/j.jtcme.2018.03.003

3. Yoo SS, Tausk F. Cupping: East meets West. Int J Dermatol. 2004;43(9):664-665. doi:10.1111/j.1365-4632.2004.02224.x

4. Ahmadi A, Schwebel DC, Rezaei M. The efficacy of wet-cupping in the treatment of tension and migraine headache. Am J Chin Med. 2008;36(1):37-44. doi:10.1142/S0192415X08005564

5. Nimrouzi M, Mahbodi A, Jaladat AM, Sadeghfard A, Zarshenas MM. Hijamat in traditional Persian medicine: risks and benefits. J Evid Based Complementary Altern Med. 2014;19(2):128-136. doi:10.1177/2156587214524578

6. Azizpour A, Nasimi M, Shakoei S, Mohammadi F, Azizpour A. Bullous pemphigoid induced by Hijama therapy (cupping). Dermatol Pract Concept. 2018;8(3):163-165. doi:10.5826/dpc.0803a01

7. Hong TT, Wu LX. Clinical observation on pricking bloodletting therapy at Back-Shu acupoints plus Chinese herbal mask in treating patients with acne. J Acupunct Tuina Sci. 2013;11:286-2888. doi:10.1007/s11726-013-0711-4

8. Yao J, Li NF. Clinical observation on pricking and blood-letting and cupping with a three-edge needle for treatment of acute eczema. Article in Chinese. Zhongguo Zhen Jiu. 2007;27(6):424-426.

9. Hon KLE, Luk DCK, Leong KF, Leung AKC. Cupping therapy may be harmful for eczema: a PubMed search. Case Rep Pediatr. 2013;2013:605829. doi:10.1155/2013/605829

10. Sang J, Wang S, Lu X. Needling and cupping used to treat 20 cases of erysipelas.
J Tradit Chin Med. 2003;23(2):116.

11. Cao H, Zhu C, Liu J. Wet cupping therapy for treatment of herpes zoster: a systematic review of randomized controlled trials. Altern Ther Health Med. 2010;16(6):48-54.

12. Malik IA, Akhter S, Kamal MA. Treatment of psoriasis by using hijamah: a case report. Saudi J Biol Sci. 2015;22(1):117-121. doi:10.1016/j.sjbs.2014.09.004

13. Li L, Ding J. Treatment of urticaria with cupping at back-shu points: a report of 40 cases. J Trad Chin Med. 2001;21(1):37-38. 

14. Xu, J, Lin R, Wang J, et al. Effect of acupuncture anesthesia on acne vulgaris of pricking-bloodletting cupping: a single-blind randomized clinical trial. J Trad Chin Med. 2013;33(6):752-756. doi:10.1016/s0254-6272(14)60007-8

15. Kirschner RH, Stein RJ. The mistaken diagnosis of child abuse. A form of medical abuse? Am J Dis Child. 1985;139(9):873-875. doi:10.1001/archpedi.1985.02140110027022

16. Sandler AP, Haynes V. Nonaccidental trauma and medical folk belief: a case of cupping. Pediatrics.1978;61(6):921-922.

17. Iblher N, Stark B. Cupping treatment and associated burn risk: a plastic surgeon’s perspective. J Burn Care Res. 2007;28(2):355-358. doi:10.1097/BCR.0B013E318031A267

18. Al-Rubaye KQA. The clinical and histological skin changes after the cupping therapy (Al-Hijamah). J Turk Acad Dermatol. 2012;6(1):1261. 

19. Lee JH, Cho JH, Jo DJ. Cervical epidural abscess after cupping and acupuncture. Complement Ther Med. 2012;20(4):228-231. doi:10.1016/j.ctim.2012.02.009

20. Kim TH, Kim KH, Choi JY, Lee MS. Adverse events related to cupping therapy in studies conducted in Korea: a systematic review. Eur J Integr Med. 2014;6(4):434-440. doi:10.1016/j.eujim.2013.06.006

21. Jung YJ, Kim JH, Lee HJ, et al. A herpes simplex virus infection secondary to acupuncture and cupping. Ann Dermatol. 2011;23(1):67-69. doi:10.5021/ad.2011.23.1.67

22. Silverman AK, Laing KF, Swanson NA, Schaberg DR. Activation of herpes simplex following dermabrasion: report of a patient successfully treated with intravenous acyclovir and a brief review of the literature. J Am Acad Dermatol. 1985;13(1):103-108. doi:10.1016/S0190-9622(85)70151-X

23. Fatahzadeh M, Schwartz RA. Human herpes simplex virus infections: epidemiology, pathogenesis, symptomatology, diagnosis, and management. J Am Acad Dermatol. 2007;57(5):737-763. doi:10.1016/j.jaad.2007.06.027

 24. Lee HJ, Park NH, Yun HJ, Kim S, Jo DY. Cupping therapy-induced iron deficiency anemia in a healthy man. Am J Med. 2008;121(8):e5-e6. doi:10.1016/j.amjmed.2008.04.014

25. Sohn IS, Jin ES, Cho JM, et al. Bloodletting-induced cardiomyopathy: reversible cardiac hypertrophy in severe chronic anaemia from long-term bloodletting with cupping. Eur J Echocardiogr. 2008;9(5):585-586. doi:10.1016/j.euje.2007.06.010

26. Lee JS, Ahn SK, Lee SH. Factitial panniculitis induced by cupping and acupuncture. Cutis. 1995;55(4):217-218. 

27. Moon SH, Han HH, Rhie JW. Factitious panniculitis induced by cupping therapy. J Craniofac Surg. 2011;22(6):2412–2414. doi:10.1097/SCS.0b013e318231fed6

28. Aboushanab TS, Al Sanad S. Cupping therapy: an overview from modern medicine perspective. J Acupunct Meridian Stud. 2018;11(3):83-87. doi:10.1016/j.jams.2018.02.001

29. Moura CC, Chaves ECL, Cardoso ACLR, Nogueira DA, Corrêa HP, Chianca TCM. Cupping therapy and chronic back pain: systemic review and meta-analysis. Rev Lat Am Enfermagem. 2018;26:e3094. doi:10.1590/1518-8345.2888.3094

Back to Top