Clinical Challenge: Circular Areas of Erythema on the Back

Cupping is a form of complementary and alternative medicine (CAM) that is popular in Asia, Eastern Europe, Latin America and the Middle East. The method involves placing an ignited alcohol-soaked cotton in a glass cup and then placing the heated...

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Cupping is a form of complementary and alternative medicine (CAM) that is popular in Asia, Eastern Europe, Latin America and the Middle East. The method involves placing an ignited alcohol-soaked cotton in a glass cup and then placing the heated cup on an area of the skin. Once the cup is placed, cooling of the air creates a vacuum. The suction is thought to improve blood circulation by drawing out stagnant blood and toxins. 

Cupping is also commonly performed on acupuncture points on the body with the belief of stimulating the body’s vital energy. Cupping is typically performed on the back but can also be done on the abdomen, chest and buttock. Although there is no evidence from randomized control studies regarding its efficacy, cupping is used to treat many disorders such as headache, indigestion, menstrual irregularity and chronic lower back pain.

Diagnosis

The typical lesions that result from cupping are characterized by circular areas of erythema that can become edematous and ecchymotic as a result of blood vessel breakage in the papillary dermis.

Linear purpuric streaks can also be seen in a variant of cupping, which involves lubricating the cup and moving it around to cover a larger area of skin.

At times, cupping lesions can be mistaken for abuse, so a thorough history should be taken from the patient.

Other answer choices

Besides cupping, other therapeutic cultural practices can include acupuncture, coining and moxibustion. Acupuncture involves placing sterile into the body with the belief that the vital energy between organs can be altered. The needles can either be manually or electrically stimulated; however, some practices require no stimulation.

Ecchymoses, petechiae and subcutaneous hematomas can result; however, only a small percentage of patients will experience these complications. 

Coining, also known as spooning, involves rubbing an area of oiled skin with a spoon in a linear and symmetric fashion, mostly commonly in a “pine tree” formation. Linear erythema typically results with possible progression to petechiae or purpura. 

Lastly, moxibustion involves placing dried moxa (Artemisia vulgaris) over acupuncture points and then igniting the herb. The herb can either be extinguished before the burning fibers touch the skin or it is allowed to completely burn out.

This burning out can result in target-like first or second degree burns.  Like cupping, skin lesions resulting from coining and moxibustion can mimic abuse so it is important for the practitioner to recognize these practices.

References

1. Bolognia J, Jorizzo JL and Schaffer JV. “Chapter 133: Complementary and Alternative Medicine.” Dermatology. St. Louis, Mo.: Mosby/Elsevier, 2012. 
2. Lilly E, Kundu RV. Dermatoses secondary to Asian cultural practices. Int J Dermatol. 2012;51(4):372-379.