Research DOI: 10.6003/jtad.

1261a1

The Clinical and Histological Skin Changes After the

Cupping Therapy (Al-Hijamah)
Kadhim Qasim Ali Al-Rubaye,* MSc, PhD

Address: *Department of Dermatology, College of Medicine. Basra University, Iraq

E-mail: [email protected]
* Corresponding Author: Kadhim Qasim Ali Al-Rubaye MSc. PhD. Head of the Department of Dermatology, Basra
General Hospital, Iraq

Published:
J Turk Acad Dermatol 2012; 6 (1): 1261a1.
This article is available from: http://www.jtad.org/2012/1/jtad1261a1.pdf
Key Words: Cupping Therapy, Al-Hijamah

Abstract
Background: Cupping Therapy (CT) has been reported as treatment for several skin conditions such
as acne, post herpetic neuralgia, psoriasis, atopic dermatitis and urticaria. Although it is often
considered as part of the Traditional Chinese Medicine (TCM), it has been widely practiced in the
Middle East and the rest of the world for centuries. In Basra, a city in the southern part of Iraq, cupping
therapy is often used by alternative medicine practitioners for treating skin disorders. However, limited
is known about the clinical and histological effects of cupping therapy on the skin.
Objectives: To investigate the immediate and delayed effect of CT on the skin, clinically and
histologically.
Material and Methods: TWe visited alternative and herbal medicine clinics that practice cupping
therapy in Basra. Questionnaires were given to the patients and the alternative medicine practitioners
to explore their experience with cupping therapy in terms of the presenting complaints and symptoms
following therapy. The different types of application techniques and the immediate and delayed
clinical changes on the skin following cupping therapy have been recorded. Ten skin biopsies were
taken from male participants to investigate the histological changes in the application sites.
Results: One hundred and thirty five patients were enrolled in the study. Of them, 102 (75.6%) were
males and 33 (24.4 %) were females. The presenting complaints in males were back pain (29.4 %),
Sciatica pain (15.7%) then headache (12.7%). In females, the presenting complaints were frozen
shoulder (30.3%), back pain (18.2%), joint pain (12.1%) and gynecological causes (9.1%). Skin diseases
were the presenting complaints in 4.9% of the males and 3% of the females. They included psoriasis,
vitiligo, and eczema. Following cupping therapy, the immediate signs were erythema, swelling,
bruising, bleeding, bullae formation and sings of cutting as results of cutting the skin for bloodletting.
Patients reported discomfort ranging from slight tingling sensation to severe pain. Delayed clinical
effects were scars in 6% of cases and patches of post inflammatory hyper-pigmentation with or without
ring of ecchymosis in 4 % of total cases 30 days after cupping therapy. In all other cases complete
healing of the skin was within three weeks. No adverse events were noted in our study. Histological
changes following cutting and bloodletting were mild oedema, vacuolization and longitudinal fissure
as a result of cutting in the epidermis. In the dermis, histological changes were dermal oedema and
bleeding in the upper and lower parts of the dermis. No cellular infiltration was noted.
Conclusion: Cupping therapy is associated with distinctive early and late clinical changes.
However, it is safe procedure and most of these changes are reversible within three weeks. There
were no adverse events as a result of the therapy. The efficacy of cupping therapy in treatment is
beyond the scope of this study and further studies are needed.

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Introduction range in size from 1 to 3 inches (25 mm – 75

mm) across the opening. Plastic and glass are
The Chinese have been practicing the cup-
the most common materials used today, rep-
ping for at least three thousand years along
lacing the horn, pottery, bronze and bamboo
with massage, acupuncture and Moxibustion
cups used in earlier times. The low air pres-
cupping form to relieve the stagnation of Qi,
sure required may be created by heating the
believed to be the vital energy or life force,
cup or the air inside it with an open flame or
and blood, both locally and in the organs [1,
a bath in hot scented oils, then placing it aga-
2]. Practitioners of the traditional Chinese
inst the skin. As the air inside the cup cools,
medicine (TCM) believe that diseases are
it shrinks in size and draws the skin slightly
caused by stagnant or blocked Qi and that
inside. More recently, a mechanical suction
cupping is able to unblock and correct the
pump is connected to a one way valve located
balance in the flow of Qi, thereby restoring
at the top of the cup. Rubber cups are also
health [3]. In Eastern Asia, cupping is a po-
available that squeeze the air out and adapt
pular alternative therapy [4, 5]. It was
to uneven or bony surfaces [8].
mentioned in the oldest recorded medical
textbook, Ebers Papyrus, written in appro- In practice, cups are normally used only on
ximately 1550 BC in Egypt [6]. softer tissue that can form a good seal with
the edge of the cup. A one big cup or few cups
Complementary and Alternative Medicine
may be used to cover a larger area. They may
(CAM) has become very popular and it has
be used by themselves or placed over an acu-
gained credibility within some biomedical he-
puncture needle. Skin may be lubricated, al-
alth care centers [6]. Surveys showed that
lowing the cup to move across the skin
approximately one third of population in the
slowly. The skin may be lanced before placing
UK and a slightly higher percentage in the
the cup so that the vacuum draws fluids, pri-
USA have used CAM [7]. Cupping Therapy
marily blood, into the cup as part of the tre-
(CT) is an ancient form of CAM that has been
atment [6, 8].
practiced in most cultures for many conditi-
ons such as high blood pressure, infections, The most common sites on which the cups
pains, mental disorders, heart diseases and are applied are the back, chest, abdomen,
a variety of circularly diseases, and skin di- and buttock; areas of abundant muscle [5].
sorders [6, 8]. The cups are typically left in place for 5-10
minutes or sometimes more. The after-effects
The cupping procedure basically involves
of cupping often include erythema, edema,
creating a small area of low air pressure next
and ecchymosis in a characteristic circular
to the skin. This can be through applying a
cup like device on the skin. These cups can Table 2. Immediate and Delayed Clinical
vary in shapes from balls to bells, and may Changes After Cupping
Sites of
Table 1. The Indications for Cupping Therapy in Immediate effect Delayed effect
cuppin
Males and Females
1. Multiple cuttings 1. Scare of cutting 1. Back chest
Males Females skin
Diseases of skin 2. Abdomen
No.(%) No (%) 2. Erythema 2. Bruising buttock
Back pain 30 (29.4) 6 (18.2) 3. Circular ecchy- 3. Hyperpigmenta- 3. Legs
mosis tion
Sciatica 16 (15.7) 2 (6.1) 4. Arms
4. Swelling 4. Circular ecchy-
Headaches 13 (12.7) 2 (6.1) 5. Face
mosis
5. Bruising and
Frozen shoulder 9 (8.8) 10 (30.3)
bleeding
Joint pain 12 (11.8) 4 (12.1) 6. Discomfort
Skin problem 5 (4.9) 1 (3.0) 7. Pain
Blood pressure 7 (6.9) 1 (3.0) 8. Light headache

Polycythemia 1 (1.0) --- 9. Sweating

10. Warmth
Gynaecological --- 3 (9.1)
11. Tingling sensa-
Others 9 (8.8) 4 (12.1) tion

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arrangement. These bruises may take days to

several weeks to subside [4, 5].
The Arabic name for cupping therapy is “Al-
Hijamah” which means to reduce in size i.e.
to return the body back to its natural state by
the application of suction cups to the skin to
draw out stagnant, congested blood and Vital
Force, as well as other stagnant or morbid
humors. The practice of Al-Hijamah has been
part of Middle Eastern cultural practice for
thousands of years [9]. Those who perform Figure 1. The placed cup on the back skin
cupping therapy are called cupping therapist,
traditional healer or traditional cupper. six, or 10 incisions all made by fully sterilized bla-
des.
The aims of this article are to describe skin
3. Bloodletting. The cup is placed back on the
changes (signs and symptoms) and the histo-
skin. Negative pressure is applied to collect blood
logical changes which result from cupping in the cup (Figure 1).
therapy. 4. Removal. The cup is removed, and the process
is repeated 1-2 times.
5. Dressing.
Materials and Methods
It is a tradition to advise the client to fast 12 hr be-
Part of the study included was questionnaire fore the procedure and then have some dates and
based. Cupping practitioners in Basra were asked water. Treatments are usually scheduled every 4
to fill questionnaires to explore their experience to 6 months depending on the condition treated.
with CT. This part also involved clinical observa- Immediate skin changes were recorded and pati-
tion of the skin changes following cupping therapy. ents were asked to describe their experience. Pati-
183 clients (125 males and 58 females) were en- ents were followed up for 30 days to monitor their
rolled in this study. 48 clients were excluded be- skin changes. Ten Skin biopsies were taken only
cause of incomplete information or loss of follow from male patients. The histological findings were
up leaving 135 patients (102 males and 33 fema- recorded immediately after the cupping session
les) who completed the study. All patients were and 3 days later.
older than 18 years. An informed consent was
taken prior to the study. Information sheets were
given to the clients. Blood pressure, pulse rate and Results
temperature were taken. Hemoglobin and fasting
blood glucose were testes when indicated. The hea- One hundred eighty three clients (125 males
ler used words from the Holy Quran and Prophet and 58 females) were enrolled in this study.
Mohammed’s (May God peace and blessings be However, only 135 (102 males (75.6%) and 33
upon him) sayings such as " The 17th, 19th or 21st (24.4%) females) completed the whole study
day (of the Islamic, lunar month) are the best time giving a participation rate of (73.8%). Clients’
for Al-Hijamah but avoid wednesdays and satur- ages ranged between 18-61 years of age.
days”. The healers use their fingers and illustrated
diagrams to find the right spots to place the cups Back pain was the commonest indication for
avoiding bony parts and coetaneous veins. Cup- cupping therapy in males (29.4% of cases) fol-
ping therapy equipments included a hand suction lowed by sciatica and headaches in 15.7%
pump, 6-12 plastic cups and anti-septic wipes. All and 12.7 % of cases respectively. In females,
CT procedures were fully sterile. The procedure re-
frozen shoulder (30.3%) was the commonest
quired about 20 minutes and it involved 5 phases:
indication, followed by back pain (18.2%) and
1. Primary sucking. The cup is placed on the se- joint pain (12.1%). Skin diseases presented in
lected site. A negative pressure is created using 5.9% of total cases. Five cases (4.2%) were
manual suction. The cup clings to the skin and is males (two cases of psoriasis, two cases of vi-
left for a period of 3 to 5 minutes. tiligo and one case of eczema) and one case
2. Scarification. Superficial incisions are made on was female with psoriasis (3%) (Table 1).
the skin using 15–22 Gauge surgical blades. These
incisions were 0.1 mm in depth and 0.5 cm in Following cupping therapy, the immediate
length in 2 or more rows each with a set of four, signs were erythema, swelling, bruising, blee-

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ding, bullae formation (Figure 2) as results of

cutting the skin for bloodletting. Patients re-
ported discomfort ranging from slight tingling
sensation to sever pain. Delayed clinical ef-
fects were scars in 6% of cases and patches
of post inflammatory hyper-pigmentation
with or without ring of ecchymosis (Figure 3)
in 4 % of total cases 30 days post cupping
therapy (Table 2). In all other cases complete
healing of the skin was within three weeks.
Histological changes (Figures 4, 5) in epi-
dermis included mild oedema, vacuolization
and perpendicular breaks in the upper part
of epidermis results from bloodletting proce- Figure 4. In epidermis mild oedema and
dure. In the dermis, there were upper and vacuolization and upper dermal oedema
lower dermal oedema and bleeding with no
cellular infiltration.

Discussion
Complementary and alternative therapy
(CAM) such as cupping therapy has become
increasingly popular for treating skin disor-

Figure 5. Deep dermal bleeding and rupture of

blood vessel

ders [10]. Yet, dermatologists are still unfa-

miliar with it and most of them have some
misconceptions. The popularity of CAM con-
tinued to grow in developed countries such as
USA, Norway during the first decade on the
Figure 2. Showing the bulla formation 21st century [11, 12, 13]. This might indicate
after sucking
a shift in attitude regarding CAM within the
conventional health care system.
There is still some controversy around the ef-
fectiveness of cupping therapy. Few small
scale studies has reported some clinical ef-
fects for wet cupping when used as an adju-
vant to conventional drugs [14]. Thama et al.
proposed a multi-layered finite element model
in describing the behavior of the skin and un-
derlying soft-tissue layers when subjected to
cupping [15]. The skin becomes red due to
the congestion of blood flow. Cupping relieves
this local congestion. Cupping can be classi-
fied into three types according to the suction
Figure 3. Red rings and ecchymoses after pressure: Light Cupping: where a weak suc-
cupping which subside within weeks tion is used. This is suitable for children and

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elderly people. Medium Cupping: where me- 5) The combination of cupping and acupunc-
dium pressure is used. This is possibly the ture model by assuming that stimulation of
commonest type of cupping. Strong Cupping specific points on the skin harmonizes the
where the suction is very strong and therefore control systems of the body.
it is not suitable for children and elderly pe-
In Iraq, only medically qualified personnel or
ople. Another classification divides cupping
related health care providers are allowed to
therapy into seven types: Moving Cupping or
provide health care to patients. Most indige-
Massage Cupping where oil is applied to the
nous healer professional are, therefore, ille-
skin and the cup is moved gently on the skin.
gal.
Needle Cupping in which acupuncture is used
in conjunction with cupping. Hot Cupping in Our study showed that back pain in males
which dried mugwort (Artemisia vulgaris) lea- (29.4%) and frozen shoulder in female (30.3%)
ves, sometimes called by its oriental name were the commonest complaints among pati-
Moxa, is used. Flash Cupping in which several ents having cupping therapy. This concludes
medium cupping are preformed several times in that cupping therapy has a role in pain con-
quick succession along the area being treated trol. Farhadi et al. [17] found that wet cup-
to stimulate it. Bleeding Cupping which is also ping therapy was associated with clinically
called Full Cupping or Wet Cupping. In this significant pain relief at 3-month follow-up.
procedure a surgical instrument is use to Wet cupping therapy improved lower back
scrape the skin and the cup is then applied to pain intensity, pain-related disability, and
collect blood. Herbal Cupping in which herbal medication use (p < 0.01) than the control
tincture is applied onto the cup before suction. group. In the US, acupuncturists use cupping
Finally, water Cupping which is the least prac- therapy to treat 20% of all low back pain pa-
ticed method. It involves filling a third of the cup tients [18]. Cupping is believed to stimulate
with warm water [6, 8]. pain receptors which lead to increase the fre-
quency of impulses, therefore ultimately lea-
CT can be divided into two broad categories:
ding to closure of the pain gates and hence
Dry Cupping Therapy (DCT) and Wet Cupping
pain reduction [19].
Therapy (WCT). DCT Therapy tends to be
practiced more commonly in the Far-East Skin diseases presented in 5.9% of our cases.
whereas WCT is favoured in the Middle East Five cases (4.2%) were males (Two cases of
and Eastern Europe [9]. psoriasis, Two cases of vitiligo and one case
of eczema) and one case of psoriasis (3%) in
The concept of cupping is to let out “bad blood”
females. Cupping was used widely to treat
that is believed to be harmful to the body and
skin conditions [10, 12, 20]. Cupping has
this will also improve the flow of Qi, which is
been used in the treatment of vitiligo where
believed to be the life energy, which travels
blister roofs induced by cupping were able to
throughout the body in channels called meri-
regiment vitiliginous patches in 80% of the
dians [8]. There are five different explanatory
patients with good coloring match, without
models for the action of cupping [1, 16]:
any cosmetic disfigurement at the donor sites
1) Humoural pathology based on the concept [21]. In another study [22], cupping and Chi-
that blood is one of the four vital fluids that nese herbs treatment for vitiligo were more ef-
explain human activity, health and illness. fective than medical treatment (p<0.05).
Similar findings were found in neurodermati-
2) Withdrawal of superficial ‘bad blood’. Ac-
tis eczema and psoriasis, acne, post herpetic
cording to this model, the disease is in ‘bad
neuralgia, atopic dermatitis, urticaria and
blood’ so when ‘ill substances’ are drained
pruritis [23, 24, 25, 26, 27, 28].
away, the disease leaves.
Cups in our study were commonly applied on
3) Healthful effects of blood extraction. Lesse-
the back, chest, abdomen, and buttock where
ning the total blood volume improves the qua-
good bulk of muscles were present. This was
lity of the remaining blood.
the approach in other studies [3, 5]. Patients
4) Counter-irritation model that irritation of complained from tingling sensation and tight-
the body surfaces relieves pressure of underl- ness as a result of bloodletting and suction.
ying structures. This action may be related to The echymosis and bleeding were the com-
physiological effects of the nervous system. mon immediate skin changes in cupping. This

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