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Abstract: Cupping therapy as a curative skill has been developed and applied throughout history. Despite reports of adverse effects, this therapy is considered to be relatively safe with no systemic reviews documenting negative side effects. The aim of this study was to explore methods that avoid the adverse effects sometimes associated with this therapy. Methods. Clinical records of 14 out-patients and inpatients that visited the First Hospital of Jilin Uni-versity (Changchun, China) for management of burn injuries caused by cupping therapy were retrospectively reviewed. Characteristics, history of injury, and treatment of each patient was collected and analyzed. Results. Burn injury induced by cupping therapy was not uncommon. Most of the injuries were mild to moderate and cured by conservative methods without severe complications. The use of wet cupping was more prevalent among injured patients than dry cup-ping. Conclusion. Cupping therapy as an ancient alternative treat-ment is still popular with a large number of devoted practitioners. Although there is the potential for injury during the application of this therapy, this is mostly preventable. Standardized training for health care professionals and increased the awareness among the public about the proper methods to administer this therapy to avoid adverse effects is important.

Key words: cupping therapy, burns, alternative medicine

WOUNDS 2014;26(7):214-220

From the Burns and Plastic Reconstruction Unit, First Hospital of Jilin University, Changchun, Jilin Province, China

Address correspondence to:Lu Lai-Jin, MD, PhD Burns and Plastic Reconstruction UnitFirst Hospital of Jilin UniversityNo. 3302 Jilin Road, Changchun 130031Jilin Province, Chinabu_dong007@163.com

Disclosure: The authors disclose no financial or other conflicts of interest.

Burns Induced by Cupping Therapy in a Burn Center in Northeast China

Zhao Jing-Chun, MD; Yu Jia-Ao, MD, PhD; Xian Chun-Jing, MD; Shi Kai, MD, PhD; Lu Lai-Jin, MD, PhD

As a part of the time-honored tradition in China, cupping therapy has a long history of application, even becoming intertwined with people’s everyday lives as they turn to this therapy to improve

their general health status or relieve tiredness. In ancient Chinese philoso-phy there are 2 opposing life forces, yin and yang, whose balance is af-fected by antithetical factors (eg, hot or cold, excess or deficiency). There are believed to be certain areas of the skin that become hypersensitive when the function of an organ is impaired. When these points are con-nected with a particular organ they are linked to form a meridian (Figure 1).1 Cupping is thought to realign and balance the flow of vital energy or life force called qi.2 In the presence of illness or injury, proponents believe the qi is disturbed, resulting in too much or too little at certain points in

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the body. The practitioner diagnoses any imbalances in the qi and attempts to restore them with cupping ther-apy (Figure 2). A flammable substance, such as alcohol, herbs, or paper, is placed in a cup made of glass, metal, wood, or bamboo. The material inside the cup is set on fire to create a vacuum. As the fire goes out, the cup is placed upside down over qi pathways on the body to treat various health conditions according to tradi-tional Chinese medicine. Broadly speaking, there are 2 types of cupping: dry cupping and wet cupping (ie, controlled bleeding). The dry cupping procedure com-monly involves creating a small area of low air pressure next to the skin. In wet cupping therapy, mild suction is created using a cup and a pump, or heat suction, on the selected area and left for a specific number of minutes. The cup is then removed and small superficial skin incisions are made using a cupping scalpel. A sec-ond suction period is used to carefully draw out a small quantity of blood.

Although there is a paucity of large-scale, rigorously designed randomized controlled trials to warrant its ef-ficacy, cupping therapy as a prevalent traditional com-plementary and alternative treatment maintains popu-larity all over the world, especially in Asian and Middle East countries.3 Cupping is mainly recommended for treating pain4; herpes zoster5; some respiratory condi-tions such as bronchitis, asthma, and congestion6; and arthritis.7 Although advocates promote its curative ef-fects in the management of chronic disease and pain, a number of adverse reports related to the application of this therapy, such as burns,8-11 anemia, skin pigmenta-tion,12 epidural abscess,13 iatrogenic bullae,14 and ac-quired hemophilia A have been reported.15 Fleshy sites

on the body, such as the back and stomach and, to a lesser extent, the arms and legs, are the preferred sites for treatment and, subsequently, are where injuries most often occur. Although there are some case reports about burns caused by cupping therapy, 8-11 most are single cases and no systemic review is available. This study looked at the medical records of outpatients and inpatients who presented to the First Hospital of Jilin University for management of burn injuries induced by cupping therapy.

MethodsClinical records from both outpatients and inpa-

tients who visited the First Hospital of Jilin University from October 2008 to August 2012 for the management of burn injuries induced by cupping therapy were ret-rospectively reviewed. This study received Institutional Review Board approval from the First Hospital of Jilin University. Fourteen records (9 males, 5 females) with a mean age of 38.8 years (range from 15 to 61 years) were available. Nine of these were outpatients and 5 were inpatients. Characteristics, history of injury, and treatment of each patient were collected (Table 1).

ResultsBurn injury induced by cupping therapy is often

treated on the burn and plastic reconstruction unit at the First Hospital of Jilin University. Most of the in-juries in this study were mild or moderate and could be treated with conservative methods without severe complications (10 out of 14, 71.4%) and 4 patients had sequelae after healing. A 54-year-old female (pa-tient 4) developed hypopigmentation and a 61-year-old male (patient 14) developed hyperpigmentation. Two patients developed scars in this case series (patients 11 and 13). The mean contact time of the cup with the skin was 8.9 minutes (range 3 to 30 minutes). The mean time to healing of the subsequent burn injury was 9.9 days (range 3 to 23 days). Compared to wet cupping, dry cupping was more prevalent among this group of patients (12 out of 14, 85.7%).

Typical case presentation. A 28-year-old man (pa-tient 2, Table 1) received burns on his back when he was treated with cupping therapy intended to relieve tiredness from hard physical work and was sent to the authors’ department for definitive management. Ac-cording to the account of the patient, the practitioner used too much alcohol to moisten the inner surface of the cupping glass. The cupping procedure lasted for 8

Keypoints

•Cuppingisthoughttorealignandbalancetheflowof vital energy or life force called qi.2

•Although advocates promote its curative effectsin the management of chronic disease and pain, a number of adverse reports related to the appli-cation of this therapy, such as burns,8-11 anemia, skin pigmentation,12 epidural abscess,13 iatrogen-ic bullae,14 and acquired hemophilia A have been reported.15

•Clinical records frombothoutpatients and inpa-tients who visited the First Hospital of Jilin Uni-versity from October 2008 to August 2012 for the management of burn injuries induced by cupping therapy were retrospectively reviewed.

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minutes which, according to the medical history pro-vided by the practitioner was within the average time tolerated by most individuals. The patient felt severe pain on his back during the therapy and, when the practitioner removed the cupping glasses, burns were found on the patient’s back. The practitioner attributed the burns to high sensitivity of the patient’s skin. The patient was diagnosed with a superficial dermal burn affecting 1% total body surface area (Figure 3). The pa-tient was treated as an inpatient and his burn managed in the author’s clinic.Dressings were changed daily in the clinic and the wound healed within 7 days. There was no evidence of scarring or pigmentation.

DiscussionAlthough it is believed that cupping therapy dates

from as early as 3000 B.C., the earliest record of cup-ping is in Ebers Papyrus which describes Egyptians use of cupping in 1550 B.C. This ancient treatment of cupping therapy is still popular in many countries and regions. The therapy has its origins in the belief that human ailments were the reason evil spirits entered into the body or mind, and could be withdrawn by “sucking” these diseases out.9 Moreover, Greek physi-cian Hippocrates held a belief that organs congested by 1 of the 4 cardinal humors, (ie, blood, phlegm, yel-low bile, and black bile) could be relieved by expelling

Table 1. Background characteristics of the patients.

No. Gender Age Indication /purpose

Cupping method

Location Contact time

(minutes)

Time before treatment (hours)

Burn degree

TBSA (%)

Time to healing (days)

Complica-tions

1* M 43 Back pain Dry Back, shoulder

10 1.5 1st, 2nd (a)

2 5 None

2* M 28 Relieve tiredness

Dry Back 8 3 2nd (a) 1 7 None

3* M 39 Improve health

Dry Back 5 2 1st, 2nd(a)

2 6 None

4 F 54 Insomnia Dry Back, neck

6 2.5 2nd (a), 2nd (b)

7 16 Hypopig-mentation

5* M 33 Improve health

Dry Back 7 6 1st 3 3 None

6* F 23 Improve health

Dry Back 6 3 1st, 2nd (a)

5 7 None

7* F 15 Back pain Dry Back 9 1 1st 1 4 None

8 M 57 Improve health

Dry Back 10 0.5 2nd (a) 2 9 None

9* F 40 Hyperten-sion

Dry Back 11 6 1st, 2nd (a)

4 11 None

10 F 44 Back pain Dry Back, shoulder

8 5 2nd 3 8 None

11 M 21 Dog bite Wet Left forearm

3 56 2nd 1 23 None

12* M 46 Improve health

Dry Back 6 7 1st, 2nd (a)

5 7 None

13* M 39 Sting and infection

Wet Right forearm

30 96 2nd 1 19 Hypertro-phic scar

14 M 61 Stroke rehabili-tation

Dry Back, shoulder, neck

6 4.5 2nd (a), 2nd (b)

6 18 Hypopig-mentation

TBSA: Total body surface area; *: Outpatient; 1st: first degree burn; 2nd (a): superficial second degree burn; and 2nd (b): deep second degree burn

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the causative pathology to the skin’s surface using cup-ping therapy.10

The balance of the yin and yang is affected by hot or cold, excess or deficiency, and internal or external factors, and traditional Chinese medicine supposes certain skin areas become hypersensitive when organ function is impaired. Theses points connected with a particular organ are linked to form a meridian,1 and ancient Chinese medicine practitioners supposed that cupping therapy could influence the circulation of the body to maintain a balance between the qi life-force antipoles yin and yang, thereby restoring health or al-leviating illness.2 In the presence of illness or injury, proponents of cupping therapy think the qi has been

disturbed. The cupping practitioner diagnoses any im-balances in the qi by analyzing the patient’s complaints and feeling the pulse of the patient, then attempts to restore them. Cupping is recommended for treating pain,16 herpes zoster,4 bronchial congestion,6 and ar-thritis.7 Moreover, cupping is also supposed to be effec-tive in easing depression.16

There are 2 classic types of cupping therapy: dry or wet. Dry cupping pulls local underlying soft tissue up into a cupping vessel, whereas in wet cupping, an incision is made to let blood outflow before cupping is applied.10

Most of the patients in this study sustained dry cup-ping and only 2 wet cupping therapies were performed (patient 11 and 13). This outcome is different from the results of the review study by Cao and colleagues17 in

Figure 1. Some vital points lined up symmetrically on the back that the ancient Chinese thought could com-municate with each other or with other organs, thereby maintain inner balance of the body, also called acupunc-ture points.

Figure 2. Dysfunction of these points is believed to cause disease. Cupping therapy can regulate their function, ulti-matelyinfluencinginnerbalance.

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which wet cupping was used in a majority of the study population. Dry cupping therapy is usually recom-mended because it is considered more gentle and safe. In addition, most people in modern times receive cup-ping therapy not to treat an illness, but rather in the hope that the procedure will make them more healthy

and robust. These individuals seek out practitioners as they do not want to hurt themselves by making the incisions necessary for wet cupping therapy. However, since most of the practitioners of cupping therapy in China are specially trained by other practitioners in-stead of being certified by an official institution, they may lack the required knowledge and skills essential to properly perform cupping therapy. Different cus-toms and traditions may also account for the variety of cupping therapy methods, including the materials and equipment used, the contact time of the cup with the skin, dry or wet cupping, and so on.

There are a number of reasons cupping therapy en-joys worldwide popularity as a complementary therapy. It has been utilized for thousands of years and is deeply rooted in people’s minds as a beneficial treatment. Be-cause people are already accustomed to this traditional medicine, they don’t always pay much attention to its ef-fectiveness; it could even be considered a placebo from some perspectives. Individuals living with chronic pain may turn to cupping therapy when modern medicine offers little or no relief, or when they are worried about the side effects of long-term prescription drug use. As an alternative therapy, cupping is easily accessible and more affordable than pharmaceuticals.

Burn injuries induced by cupping therapy have been reported in previous studies. Iblher and Stark2 report-ed a case of a 59-year-old Greek woman who received cupping treatment from her husband for management of her chronic back pain. During the treatment, the petroleum container fell and spilled the contents over the patient, whose skin subsequently caught on fire. Sandler and Haynes8 reported a case of an 11-year-old girl who experienced a burn injury after she received cupping therapy for treatment of back and shoulder pain. The treatment was administered by the girl’s mother, who inverted small glasses flamed with alcohol on the skin of the child’s back. Kose and colleagues9 reported a case of a 30-year-old male who tried to re-lieve his back pain by applying cupping therapy him-self. Burned cotton soaked with alcohol from the cup spread over his back and caught fire. Sagi et al10 re-ported a case of a 57-year-old woman with diabetes who underwent cupping therapy administered by her husband to treat leg pain. During one of the treatments, her husband mistakenly used an alcohol container as a cupping glass and lit the alcohol on fire, resulting in a burn injury to the woman. Kulahci et al11 reported a case of a 32-year-old man who suffered from burns

Keypoints

•Ancient Chinese medicine practitioners supposedcuppingcouldinfluencethecirculationofthebodyand maintain a balance between the qi life-force an-tipoles yin and yang in the body, thereby restoring health or alleviating illness.2

•Drycuppingpullslocalunderlyingsofttissueupintoa cupping vessel, whereas in wet cupping, an inci-sionismadetoletbloodoutflowbeforecuppingisapplied.10

Figure 3. Burns induced by cupping therapy on the back of a 28-year-old man (see arrows). Dressings were changed every day and the wounds healed in 7 days without scarring.DO N

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when receiving cupping therapy from his mother to treat back pain.

Despite several single case reports of cupping ther-apy-related burn injuries, no systematic reviews of this adverse effect are available. Based on the authors’ ex-periences, burn injuries that occurred during cupping therapy are usually a result of one of the following:

1) The practitioner uses too much alcohol to moist-en the inner surface of the cupping vessel (this is the most common reason for the injuries of the patients who present to the author’s department with burns from cupping and often causes small burns).

2) The container that holds the alcohol is accidently knocked over during cupping therapy.

3) The materials used to start the fire needed to produce the vacuum effect cause a burn injury. Prac-titioners usually use a piece of paper or cotton that is soaked with alcohol to heat the air before application. In some cases, a hasty practitioner applies the cupping vessel to the acupuncture point before the alcohol has burned away which subsequently results in a burn.

4) Therapy may last for too long (ie, more than 30 minutes) or the skin is too sensitive to heat (eg, in some older people skin becomes thin and vulnerable, while in some children skin is too tender to bear the hot cups). In some wet cupping therapies, the barrier function of the skin has disappeared due to the inci-sion made, and the freshly exposed soft tissue is non-resistant to heat.

In this case series, the cupping-induced burn in-juries were not usually serious and could be treated with conservative dressing changes. Only 2 patients (patients 11 and 14) developed scars. Patient 11 was bitten by a dog on his left forearm and, when the wound became red, swollen, and did not heal, one of the patient’s relatives (who was also the neighborhood traditional medicine specialist) treated him with wet cupping therapy. Unfortunately, this practitioner used too much alcohol to moisten the inner surface of the cup and the patient was burned. Patient 13 was stung by a mosquito on his right forearm; he scratched the area until the skin was broken. He sought out cupping therapy to alleviate the symptoms, but the practitioner performed the therapy for more than 30 minutes, and the patient was burned. In addition to the burn and infection, cicatricial diathesis may also be attributed to the scar formation in this patient.

Despite the potential risks associated with cupping therapy, it still plays a vital role in many people’s daily

lives. As previously mentioned, although the potential risks are known, the belief that cupping has curative ef-fects on the correction of some disturbance and helps to remodel the normal function of the body remains.

In light of the above reports, the authors came to the conclusion that most injuries associated with cup-ping therapy can be attributed to improper application. Good management and careful monitoring are needed to bring the therapy under control to the degree that it does not become harmful to the people who use it. Increasing the awareness of the public and making sure practitioners have standardized training may minimize the occurrence of burns. Using a small pump placed on the bottom of the cup instead of open flame can also produce the vacuum effect while avoiding burn injuries.

ConclusionDespite the lack of systematic evidence that sup-

ports the curative effect of this nonsurgical interven-tion, cupping therapy is still practiced. Faulty tech-nique and operation in producing the vacuum effect in the cups is the leading etiology of burns. With stan-dardized management and careful monitoring, most cupping therapy-related burn injuries are preventable.

References1. Hiddlestone HJ. Where health is patriotism. Visit of

New Zealand medical delegationto China: 20 August-9

September 1974. N Z Nurs J. 1974; 80(529):509-516.

2. Iblher N, Stark B. Cupping treatment and associated

burn risk: a plastic surgeon’s perspective. J Burn Care

Res. 2007;28:355-358.

3. Yoo SS Tausk F. Cupping: East meets west. Int J Derma-

tol.2004;43(9):664–665.

4. Lauche R, Cramer H, Haller H, et al. My back has shrunk:

the influence of traditional cupping on body image in

patients with chronic non-specific neck pain. Forsch

Komplementmed.2012;19(2):68-74.

Keypoints

•Inspiteofitsrisks,thebeliefremainsthatcuppinghas curative effects on some disturbances and helps to remodel the normal function of the body.

•Increasingpublicawarenessandensuringpractitio-ners have standardized training may minimize the occurrence of burns.

•Withstandardizedmanagementandcarefulmonitor-ing, most cupping therapy-related burn injuries are preventable.

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Jing-Chun et al

220 WOUNDS® www.woundsresearch.com

5. Cao H, Zhu C, Liu J. Wet cupping therapy for treat-

ment of herpes zoster: a systematic review of ran-

domized controlled trials. Altern Ther Health Med.

2010;16(6):48-54.

6. Wang SP. Observation of cupping therapy in treating

62 cases of bronchial asthma [in Chinese]. Guiding J

Traditional Chinese Med Pharmacol. 2009;15(10):56.

7. Zhang SJ, Liu JP, He KQ. Treatment of acute gouty ar-

thritis by blood-letting cupping plus herbal medicine. J

Tradit Chin Med. 2010;30(1):18-20.

8. Sandler AP, Haynes V. Nonaccidental trauma and

medical folk belief: a case of cupping. Pediatrics.

1978;61(6):921-922.

9. Kose AA, Karabağli Y, Cetin C. An unusual cause of

burns due to cupping: complication of a folk medicine

remedy. Burns. 2006;32(1):126-127.

10. Sagi A, Ben-Meir P, Bibi C. Burn hazard from cupping-

-an ancient universal medication still in practice. Burns

Incl Therm Inj. 1988;14(4):323-325.

11. Kulahci Y, Sever C, Sahin C, Evinc R. Burn caused by

cupping therapy. J Burn Care Res. 2011;32(2):e31.

12. Kim KH, Kim TH, Hwangbo M, Yang GY. Anaemia and

skin pigmentation after excessive cupping therapy by

an unqualified therapist in Korea: a case report. Acu-

punct Med. 2012;30(3):227-228.

13. Lee JH, Cho JH, Jo DJ. Cervical epidural abscess after

cupping and acupuncture. Complement Ther Med.

2012;20(4):228-231.

14. Lin CW, Wang JT, Choy CS, Tung HH. Iatrogenic bullae

following cupping therapy. J Altern Complement Med.

2009;15(11):1243-1245.

15. Weng YM, Hsiao CT. Acquired hemophilia A associ-

ated with therapeutic cupping. Am J Emerg Med.

2008;26(8):970:e1-2.

16. Cao H, Liu J, Lewith GT. Traditional Chinese Medicine

for treatment of fibromyalgia a systematic review of

randomized controlled trials. J Altern Complement

Med. 2010;16(4):397-409.

17. Cao H, Han M, Li X, et al. Clinical research evidence

of cupping therapy in China: a systematic literature re-

view. BMC Complement Altern Med. 2010;10:70.

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