Cupping Therapy for Herpes Zoster

Wet cupping is a traditional Chinese medicine therapy commonly used in treating herpes zoster in China, and clinical studies have shown that wet cupping may have beneficial effect on herpes zoster compared with western medication.

We included randomized controlled trials on wet cupping for herpes zoster. We searched PubMed, the Cochrane Library (Issue 3, 2008), China Network Knowledge Infrastructure (CNKI), Chinese Scientific Journal Database (VIP), and Wan Fang Database. All searches ended in February 2009. Two authors extracted data and assessed the trials quality independently. RevMan 5.0.18 software was used for data analysis with effect estimate presented as relative risk (RR) and mean difference (MD) with a 95% confidence interval (CI).

8 RCTs involving 651 patients were included, and the methodological quality of trials was generally fair in terms of randomization, blinding and intention-to-treat analysis. Meta-analyses showed wet cupping was superior to medications regarding the number of cured patients (RR 2.49, 95%CI 1.91 to 3.24, p<0.00001), the number of patients with improved symptoms (RR 1.15, 95%CI 1.05 to 1.26, p=0.003), and reducing the incidence rate of postherpetic neuralgia (RR 0.06, 95%CI 0.02 to 0.25, p=0.0001). Wet cupping plus medications was significantly better than medications alone on number of cured patients (RR 1.93, 95%CI 1.23 to 3.04, p=0.005), but no difference in symptom improvement (RR 1.00, 95%CI 0.92 to 1.08, p=0.98). There were no serious adverse effects with related to wet cupping therapy in the included trials.

Wet cupping appears to be effective in treatment of herpes zoster. However, further large, rigorous designed trials are warranted.

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Herpes zoster, commonly with the pain and rush on skin, is caused by the infection of latent varicella zoster virus (VZV). VZV usually persists asymptomatically in the dorsal root ganglia of anyone who has had chickenpox, reactivating from its dormant state in about 25% of people to travel along the sensory nerve fibres and cause vesicular lesions in the dermatome supplied by the nerve[1]. The classical clinical presentation of herpes zoster starts with a mild-to-moderate burning or tingling in or under the skin of a given surface, often accompanied by fever, chills, headache, stomach upset and general malaise. The pain associated with shingles varies in intensity from mild to severe, the lesions usually begin to dry and scab 3–5 days after appearing. Total duration of the disease is generally between 7–10 days, and the most common complication associated with herpes zoster is the development of postherpetic neuralgia (PHN), a condition where pain accompanying the rash persists long after the lesions have healed.

Herpes zoster has a high infection rate, which is increasing by years. Some studies showed that the infection rate of herpes zoster and the intensity of the pain were relative with age, and the elderly were at greater risk for developing this disease. Early treatment can be more effective to release the pain and reduce the duration of disease [2]. The objective of conventional therapy in the treatment of herpes zoster is to accelerate the healing of the lesions, reduce the accompanying pain, and prevent complications. Medications typically prescribed included antiviral agents, corticosteroids, analgesics, non-steroidal anti-inflammatory drugs, and tricyclic antidepressants [3].

In Traditional Chinese Medicine, herpes zoster is called She Chuan Chuang, its pathological mechanism is insufficient of anti-pathogenic energy, toxin invades the body and transformation into heat, damp-heat spreading to the skin; or is stagnation of liver qi, and extreme heat generate wind, the fire depressed in skin; or is damp-heat in spleen and stomach, and spreading to the skin [2]. The treatment including herbal decoction, Chinese formulated products, acupuncture, moxibustion, cupping therapy and so on.

Cupping therapy is a method mainly using horn, bamboo or glass cups on patients’ skin by creating minus pressure inside the cups, which exerts as an approach for diagnosis, treatment and prevention of diseases [4]. There are many types of cupping therapy, but 8 types of cupping are commonly used in clinical practice, i.e., empty cupping, moving cupping, retained cupping, needle cupping, moxa cupping, wet cupping, herbal cupping and water cupping [5]. Wet cupping, also called full (bleeding) cupping, was the most favored and practiced cupping method of all by the early practitioners, who particularly in Europe, employed the Bleeding cupping technique in order to purge foul blood, which was considered the source of disease, from the body. It can be used in the treatment of a sudden increase in blood pressure, and in discharging pus from boils and furuncles, which represents excess, with blood-heat and stagnation. Sterilize the selected points with alcohol and make a very small incision with a triangle-edged needle or, using a plum-blossom needle, firmly tap the point for a short time to cause bleeding. Once the point is bled, choose a cup and apply a strong cupping method to the point. The blood will quite quickly be observed being drawn slowly into the cup. If the incision is sufficient, blood with about 30–60 ml can be expected to be drawn into the cup. Remove the cup after 5 or 10 minutes with attention and care. Cupping regulates the flow of qi and blood. It helps to draw out and eliminate pathogenic factors such as damp and heat. Cupping also moves qi and blood and opens the pores of the skin, thus precipitating the removal of pathogens through the skin itself [6].

From literature, we found some clinical trial reports on wet cupping therapy for herpes zoster, but there is no systematic review about the therapeutic effect of the therapy. Therefore, this review aims to evaluate the beneficial and harmful effects of wet cupping therapy for treatment of herpes zoster in randomized trials.

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Inclusion Criteria
Parallel randomized controlled trials (RCTs) of wet cupping compared with no treatment, placebo or basic medical therapy in patients with herpes zoster and PHN were included. Combined therapy of wet cupping and other interventions compared with other interventions in RCTs was also included. Outcome measures include reductions in severity of pain, duration of relief of pain, percentage of cured patients and the incidence rate of PHN. Multiple publications reporting the same groups of participants were excluded. Combined therapy of wet cupping and acupuncture compared with medication or other interventions except acupuncture was also excluded. There was no limitation on language and publication type.

Identification and selection of studies
We searched China Network Knowledge Infrastructure (CNKI) (1979–2009), Chinese Scientific Journal Database VIP (1989–2009), Wan Fang Database (1985–2009), PubMed (1966–2009) and the Cochrane Library (Issue 3, 2008), all the searches ended at February 2009. The search terms included “post-herpetic neuralgia”, “PHN”, “herpes zoster”, “zona”, or “shingles” combined with “venesection”, “phlebotomy therapy”, “three edged needle”, “triangle-edged needle”, “ventouse”, “cupping” or “blood-letting”. Two authors (HJ Cao and CJ Zhu) selected studies for eligibility and checked against the inclusion criteria independently.

Data extraction and quality assessment
Two authors (HJ Cao and CJ Zhu) extracted the data from the included trials independently. Quality of the included trials was evaluated according to following categories [7]. Category A (good): studies have the least biases and their results are considered valid. These studies are likely to consist of (1) clear description of the population, setting, interventions and comparison groups; (2) appropriate measurement of outcomes; (3) appropriate statistical and analytical methods; (4) no reporting errors; (5) less than 20 percent dropouts; (6) clear reporting of dropouts; and (7) appropriate consideration and adjustment for potential confounders. Category B (fair): studies are susceptible to some degrees of biases that are not sufficient to invalidate the results. These studies may have sub-optimal adjustments for potential confounders and may also lack certain information that is needed to assess limitations and potential problems. Category C (poor): studies have significant biases which may invalidate the results. These studies either do not consider potential confounders or do not make adjustments for them appropriately. These studies may have critical flaw in design, analysis and/or reporting, missing information and/or discrepancies in reporting.

Data analysis
Data were summarized using relative risk (RR) with 95% confidence intervals (CI) for binary outcomes or mean difference (MD) with 95% CI for continuous outcomes. Revman5.0.18 software was used for data analyses. Meta-analysis was used if the trials had a good homogeneity on study design, participants, interventions, control, and outcome measures. Publication bias was explored by funnel plot analysis.

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Description of studies
After primary searches from seven databases, 389 citations were identified, and the majority was excluded due to obvious ineligibility, and full text papers of 14 studies were retrieved. At last, 8 [8–15] trials were included in this review, 5 trials [16–20] were excluded as they used wet cupping therapy combined with acupuncture or moxibustion compared with other medications, 1 trial [21] was excluded due to the ineligible data reporting (Figure 1: The process of including and excluding studies). The characteristics of included and excluded trials were listed in Table 1 (Characteristics of included studies) and Table 2 (Studies excluded from the review and reasons for exclusion).
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