What Is the Cause of These Annular Lesions?

A 36-year-old man with a history of chronic back pain presented for evaluation of an atypical nevus on the right leg. A complete skin examination was performed. A dark brown 2- x 2-mm macule was found on his right thigh. Further skin examination revealed multiple 3-cm, annular, hyperpigmented patches scattered across the upper and mid back (Figure 1). 

What Is The Diagnosis?
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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 

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

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  

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. 

Treatment 
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

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