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Case Study
Iatrogenic Bullae Following Cupping Therapy
Che-Wei Lin, M.D., M.P.P.H.,
1
Jimmy Tse-Jen Wang, M.D.,
1
Cheuk-Sing Choy, M.D., M.M.S.,
1
and Heng-Hsin Tung, R.N., Ph.D.
2
Abstract
Background: Cupping therapy is a popular technique in Traditional Chinese Medicine. Cupping is the application
of a vacuum to a closed system cup on a specific area of skin.
Subject and setting: A 55-year-old, previously healthy man presented at our emergency department (ED) due to
tingling and a painful sensation on his back after receiving cupping therapy while on his private airplane.
Physical examination of the patient’s back revealed multiple blisters within circular marks of differing sizes and
varying shades of redness, petechiae, and ecchymosis.
Results: After regular, judicious changes of sterile dressing over several weeks at our ED, the vesicle healed well
and left no visible scars.
Conclusions: Although bleeding, erythema, edema, and ecchymosis are created on purpose to achieve acu-
puncture point microcirculation, complications such as burn injury and thrombocytopenia also have been re-
ported. We report a case of cupping-related blisters as a result of changes in atmospheric pressure related to the
unexpected descent of an airplane.
Introduction
Cupping therapy is a popular technique in Traditional
Chinese Medicine. The mechanism of cupping involves
the application of a vacuum to closed system cup on a specific
area of skin. Underlying this technique is the fact that the
vacuum force on the particular point or acupuncture point can
unblock or modify vital energy to relieve pain and other
systemic disorders. Erythema, edema, and ecchymosis are the
most common complications; however, they are created on
purpose to affect acupuncture point microcirculation. Ad-
ditionally, burn injuries due to cupping also have been re-
ported. We present a case of a rarely seen complication of
iatrogenic bullae due to cupping therapy.
Case Report
A 55-year-old, previously healthy man presented at our
emergency department (ED) due to tingling and a painful
sensation on his back after receiving cupping therapy while
on his private airplane. The patient ignored the pain and
attributed it to the aftereffects of cupping therapy until his
colleagues noted vesicles over his back after landing and
then removal of the cups.
At presentation at our ED, his vital signs were stable and
the medical review of systems revealed no other significant
symptoms. His past medical and personal history were also
unremarkable. Physical examination of patient’s back re-
vealed multiple blisters within circular marks of differing
sizes and varying shades of redness, petechiae, and ecchymo-
sis. The lesions were located where the vacuum cups had been
originally positioned ( bF1
Figs. 1 and bF2
2). After thorough steriliza-
tion of our patient’s back, we used a 27 G½-inch needle to
aspirate and then covered the lesions with a dressing.
The fluid in the vesicles was clear and contained neither
bloody fluid nor pus aspirate. Nevertheless, the fluid was
sent for a laboratory workup. The vesicle fluid analysis came
back normal, without signs of infection in the culture, Gram
stain, or tissue biopsy. After regular, judicious changes of
sterile dressing over several weeks at our ED, the vesicles
healed well and left no visible scars. This case serves as a
reminder to physicians who have had no prior encounters
with cupping of the importance of taking a history and not
mistaking cupping-related skin lesions as child abuse when
seen in children or as manifestation of a systemic disease.
Sterile methods and meticulous wound care are also of im-
portance to prevent superimposed infection or scarring.
Discussion
Cupping therapy has been an integral part of Traditional
Chinese Medicine for more than 2000 years.
1
Cupping ther-
apy also has been reported as part of Western medicine
as early as 1938 in medical textbooks
2
and as a means of
1
Department of Emergency Medicine, Taipei Medical University Hospital, Taipei, Taiwan.
2
Department of Nursing, National Taipei College of Nursing, Taipei, Taiwan.
THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE
Volume 15, Number 10, 2009, pp. 1–2
ªMary Ann Liebert, Inc.
DOI: 10.1089=acm.2009.0282
1
ACM-2009-0282-Lin_1P
Type: case-report
ACM-2009-0282-Lin_1P.3d 09/22/09 12:10am Page 1
expelling evil spirits.
1
The theory behind cupping in Chinese
medicine is that it affects the circulation of certain body areas
and is able to modify the bioenergy or qi and, therefore,
restore balance to the qi life-force antipoles of yin and yang
in the body that, in turn, restore health or relieve chronic
pain.
1–3
Cups are usually placed on the neck, back, abdomen,
and sometimes even on the face, depending on practitioner’s
preference and patient’s ailments.
Cup materials have evolved from the original bull horns
1
to
those made of glass or plastic. The mechanism of cupping
creates a vacuum effect on the skin, with the resulting nega-
tive pressure resulting in capillary rupture. Edema, erythema,
and ecchymosis of the skin are the aftereffects of capillary
rupture. Cups are placed on the skin for 5–10 minutes. The
original method employs alcohol-soaked cotton, at the base of
the cup, which is then lit. The process of heating and then
cooling of air the inside the cup produces the vacuum and
suction effects in the closed system. This is why some cupping
therapies have burn injuries as a complication.
1
The modern
method uses a manual hand pump to produce the suction
effect.
According to the patient’s statement, the equipment used
was a manual hand pump for which apparently normal
suctioning pressure was applied. However, after in-depth
inquiry, the patient recalled that, during the vacuuming and
cupping process, the flight captain decreased the flight alti-
tude unexpectedly to avoid turbulence and a thunderstorm.
We suspect that with the decreasing flight altitude and the
subsequent increase in cabin pressure, the negative pressure,
or vacuum effect, inside the cup increased, according to the
ideal gas law. The patient recalled that the plastic cola bottle
next to him became compressed during the sudden decrease
in flight altitude. Furthermore, the duration of cupping
therapy on our patient was greater than 20 minutes. We thus
hypothesize that the cutaneous blisters were caused by the
creation of a greater than normal vacuum pressure, and the
longer vacuum time caused a separation of the epidermal
layer from the dermal base of skin.
Alternative therapies have become increasingly accepted
in both Eastern and Western cultures, and various cutaneous
manifestations of cupping have been reported in the litera-
ture. However, to a physician unfamiliar with cupping
therapy, misdiagnoses of cupping therapy lesions as cuta-
neous manifestations of systemic diseases are possible. We
report here a different situation, one in which cutaneous
blisters can develop during cupping therapy. The change in
cabin pressure was thought to have caused the bruising and
vesicles noted in our patient. This case serves as a pertinent
reminder to physicians who have had no prior encounters
with cupping not to mistake skin lesions as child abuse when
seen in children or as a manifestation of a systemic disease.
4
This does not, however, detract from the importance of
history taking. When physicians encounter patients with the
characteristic skin lesions of cupping therapy, they should
obtain a history regarding whether the patient had sought
alternative therapy. Sterile methods and meticulous wound
care are also of importance to prevent superimposed infec-
tions or scarring.
Finally, complications of cupping therapy due changes in
atmospheric pressure should be part of our patient education
when patients have history of cupping therapy or decide in
the future to seek alternative therapies. Fortunately, our
patient presented early to our ED, where a careful history,
early recognition of skin lesions, and meticulous wound care
prevented superimposed infections. The lesions healed
without subsequent scarring or complications.
Disclosure Statement
No competing financial interests exist bAU1
.
References
1. Iblher N, Stark B. Cupping treatment and associated burn
risk: A plastic surgeon’s perspective. J Burn Care Res 2007;
28:355–358.
2. Tham LM, Lee HP, Lu C. Cupping: From a biomechanical
perspective. J Biomech 2006;39:2183–2193.
3. Yoo SS, Tausk F. Cupping: East meets West. Int J Dermatol
2004;43:664–665.
4. Asnes RS, Wisotsky DH. Cupping lesions simulating child
abuse. J Pediatr 1981;99:267–268.
FIG. 1. Circular, cutaneous impressions on the back of a male
patient as result of vacuum cupping, a Chinese traditional
physiotherapy. Ecchymosis, petechiae, and bullae of various
sizes and colors are visible where cupping was applied
AU2 c.
FIG. 2. Close-up view of the same patient. Sanguineous
blisters due to changes in vacuum pressure relating to
change in flight altitude are seen bAU3
.
2 LIN ET AL.
ACM-2009-0282-Lin_1P.3d 09/22/09 12:10am Page 2
AUTHOR QUERY FOR ACM-2009-0282-LIN_1P
AU1: Disclosure Statement accurate? If not, please amend as needed. Please note such statements must appear in
all peer-reviewed papers.
AU2: Please contact Ms. Billie M. Spaight at bsp8@rcn.com for information on getting Fig. 1 printed in color.
AU3: Please contact Ms. Billie M. Spaight at bsp8@rcn.com for information on getting Fig. 2 printed in color.
ACM-2009-0282-Lin_1P.3d 09/22/09 12:10am Page 3
