CASE REPORT
Paradoxical, Cupping-Induced Localized Psoriasis: A Koebner Phenomenon Reid Vender and Ronald Vender Background: Cupping therapy is a traditional Chinese medicine used to heal psoriasis. The Koebner phenomenon is the occurrence of psoriatic lesions at the site of cutaneous injury. Objective: To describe the first case of biopsy-proven cupping-induced localized psoriasis, an example of the Koebner phenomenon. Methods: The histopathology of the lesions is described. A brief review of the literature regarding cupping therapy and its efficacy are discussed. Results: A 45-year-old Asian male presented himself to the dermatology clinic for further treatment of his psoriasis. Four unusually circular plaques on the lower back were discovered. Pathologic diagnosis revealed an early lesion of psoriasis. on further inquiry, the patient admitted to undergoing a recent ‘‘cupping’’ procedure in an attempt to cure his condition. Conclusion: The efficacy of cupping therapy is controversial, and psoriatic patients may develop localized psoriasis through koebnerization as a result of cupping therapy rather than achieve desirable therapeutic benefits. Contexte: La pose de ventouses (cupping therapy) est une technique employe´e en me´decine traditionnelle chinoise pour gue´rir le psoriasis. De son coˆte´, le phe´nome`ne de Ko¨bner est l’apparition de le´sions psoriasiques au sie`ge de le´sions cutane´es. Objectif: L’e´tude visait a` exposer le premier cas de psoriasis local, provoque´ par la pose de ventouses et ave´re´ par biopsie, conside´re´ comme un exemple du phe´nome`ne de Ko¨bner. Me´thode: Il sera tout d’abord question de l’histopathologie des le´sions; suivront un bref examen de la documentation sur la pose de ventouses et une discussion sur son efficacite´. Re´sultats: Un homme de 45 ans, d’origine asiatique, s’est pre´sente´ de sa propre initiative au centre de dermatologie pour recevoir d’autres traitements pour le psoriasis. Quatre plaques inhabituellement rondes ont e´te´ observe´es, a` l’examen, dans le bas du dos. Le diagnostic reposant sur l’examen histopathologique a re´ve´le´ une le´sion pre´coce de psoriasis; soumis a` d’autres questions, le patient a admis avoir eu recours, peu de temps avant, au traitement par la pose de ventouses dans une tentative de gue´rison de la maladie. Conclusions: L’efficacite´ de la pose de ventouses ne fait pas l’unanimite´, et des patients souffrant de´ja` de psoriasis peuvent voir apparaıˆtre des le´sions psoriasiques locales a` la suite de ce traitement, par phe´nome`ne de Ko¨bner, au lieu d’obtenir des re´sultats the´rapeutiques souhaitables.
E PRESENT A CASE of a 45-year-old Asian male who presented to the dermatology clinic with a 4month history of pruritic, diffuse, erythematous, welldefined plaques on his trunk. He admitted to using topical
W
From Dermatrials Research Inc., and Division of Dermatology, McMaster University, Hamilton, ON. Address reprint requests to: Reid Vender, Dermatrials Research Inc., 132 Young Street, Hamilton ON L8N 1V6; e-mail: [email protected].
DOI 10.2310/7750.2014.14109 # 2014 Canadian Dermatology Association
320
calcipotriol/betamethasone dipropionate gel and ointment, with little relief. A clinical diagnosis of psoriasis was made. His past medical history includes hypertension and mild alcohol consumption. The patient had no previous dermatologic history. The patient weighed 80 kg and had a body mass index of 26.5. Bloodwork revealed normal serum glucose, creatinine, estimated glomerular filtration rate, fasting cholesterol, aspartate aminotransferase, alanine aminotransferase, and complete blood count. Triglycerides were slightly elevated. Histopathology revealed slight spongiotic psoriasiform epidermal hyperplasia with focal parakeratosis and scale crust associated with a sparse superficial perivascular
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 19, No 3 (May/June), 2015: pp 320–322
Vender and Vender
infiltrate consisting of lymphocytes, histiocytes, and scattered eosinophils. The periodic–acid Schiff (PAS) stain was negative for fungi. The dermatopathologist reported no unequivocal evidence of psoriasis in the sections. The differential diagnosis included subacute nummular dermatitis as well as subacute allergic contact dermatitis. Rarely, this pattern of inflammation may be due to drug hypersensitivity. The histologic features were suggestive but not unequivocally diagnostic of spongiotic psoriasiform dermatitis. This patient was then prescribed phototherapy but was only able to attend eight sessions due to a conflicting work schedule. Subsequently, he was prescribed oral acitretin at a dose of 10 mg per day for 1 month. The patient returned to the clinic and complained that his eruption was getting worse. A physical examination revealed that, clinically, there was no change in the extent, erythema, scale, or thickness of the eruption on his trunk. However, four circular plaques on the lower back, evenly spaced and of uniform size, were discovered (Figure 1). On further inquiry, the patient admitted to undergoing a ‘‘cupping’’ procedure within the past 2 weeks in an attempt to cure his skin condition. The patient consented to another punch biopsy of one of the circular plaques to confirm a diagnosis of psoriasis. This second histopathology revealed a superficial perivascular infiltrate of lymphocytes with mild psoriasiform epidermal hyperplasia, focal mounds of parakeratosis containing neutrophils, and tortuous dilated blood vessels in the papillary dermis (Figure 2). A PAS stain was negative for fungal hyphae. Pathologic diagnosis was confirmed as an early lesion of psoriasis.
Figure 1. Circular, psoriatic plaques on the lower back.
Figure 2. Medium-power histopathology revealing psoriasis (hematoxylin-eosin stain, 320 original magnification).
The patient’s acitretin was increased to 25 mg per day, with slow improvement of the psoriasis over the next 4 months. Blood monitoring revealed worsening of triglyceridemia, which was subsequently managed by diet. We therefore present an interesting case of localized psoriasis induced by cupping and a classic example of the Koebner phenomenon.
Discussion Cupping therapy is a traditional Chinese medicine (TCM) used to heal psoriasis. In TCM, psoriasis is described as ‘‘blood heat, which subsequently developed into blood dryness and blood stasis,’’1 and the Koebner phenomenon is denoted by excessive blood heat, an internal factor causing psoriasis, and the invasion of wind heat, an external factor causing the white scales of psoriasis.2 The National Psoriasis Foundation defines Koebner phenomenon as ‘‘psoriasis plaques that form at the site of a skin injury.’’3 The pathogenesis of Koebner phenomenon is unknown; however, there are immunologic, vascular, dermal, neural, genetic, hormonal, and infectious theories. Likewise, growth factors, drugs, cytokines, stress proteins, adhesion molecules, and autoantigens may also be involved.4,5 Koebnerization as an immune-mediated response has been studied, and levels of elastase-positive and interleukin-17positive cells have been found to rise rapidly, whereas Tbetpositive cells increase gradually, peaking after other cell levels decrease when a skin injury occurs.6 The therapeutic approach commonly taken to eliminate blood heat and blood stasis is ultimately to activate the blood through cupping.2 The general method of cupping
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 19, No 3 (May/June), 2015: pp 320–322
321
Cupping-Induced Local Koebnerized Psoriasis
therapy requires a plastic or glass bell-shaped or spherical cup, 1 to 3 inches in diameter, to be placed on the skin. The negative gauge pressure inside the cup is created by heating the air inside and letting it cool or through the use of an attached pump. Many types of cupping exist, where cups may be placed over an acupuncture needle (needle cupping), skin may be lubricated (moving cupping), or skin may be pricked for bloodletting (wet cupping).7 The efficacy of cupping therapy is controversial. ElDomyati and colleagues recognized cupping therapy as an effective alternative or complementary therapy for certain dermatoses but not for eight cases of psoriasis in an Egyptian study.8 However, Dong and colleagues observed that all of their 32 psoriasis patients had significantly lower Psoriasis Area and Severity Index scores (reduction of 15.49 6 7.42) in a Chinese study assessing the efficacy of moving cupping.9 Likewise, Zhang and colleagues found high, undefined ‘‘efficacy rates’’ (68.75%, 91.17%, and 84.37%) for three random groups consisting of a total of 98 participants with plaque psoriasis in a Chinese study also assessing the efficacy of moving cupping.10 Note that all of these cases were also receiving ultraviolet B and topical calcipotriol as well as herbal baths, and there was no control group. There has been one other report in China of Koebner phenomenon induced by cupping therapy in a psoriasis patient in the past literature.11 Yu and colleagues described similar findings of discoid psoriatic plaques, not proven by biopsy, associated with cupping therapy. However, our report is the first case of biopsy-proven cupping-induced localized psoriasis in an Asian patient residing in North America.
Conclusion Psoriatic patients may develop localized psoriasis through koebnerization as a result of cupping therapy rather than achieve desirable therapeutic benefits. Paradoxically,
322
psoriatic plaques may form where they were intended to be therapeutically eliminated.
Acknowledgments Thank you to Jay Jambrosic, MD, FRCPC, for providing histopathologic interpretation and photomicrographs. Financial disclosure of authors and reviewers: None reported.
References 1. Lin XR. Psoriasis in China. J Dermatol 1993;20:746–55. 2. Iliev E, Broshtilova V. Traditional Chinese medicine principles in the pathogenesis and treatment of psoriasis vulgaris. Semin Integr Med 2003;1:145–50, doi:10.1016/S1543-1150(03)00027-9. 3. National Psoriasis Foundation. Koebner phenomenon. 2014. Available at: http://www.psoriasis.org/about-psoriasis/causes/koeb ner (accessed June 29, 2014). 4. Camargo CM, Brotas AM, Ramos-e-Silva M, Carneiro S. Isomorphic phenomenon of Koebner: facts and controversies. Clin Dermatol 2013;31:741–9, doi:10.1016/j.clindermatol.2013.05.012. 5. Sagi L, Trau H. The Koebner phenomenon. Clin Dermatol 2011; 29:231–6, doi:10.1016/j.clindermatol.2010.09.014. 6. Hendriks AG, Keijsers RR, Seyger MM, et al. Are newly discovered drivers of immune-mediated skin disorders expressed in normal skin regenerating from standardized surface injury? Dermatology 2014;228:255–60, doi:10.1159/000358008. 7. Al-Rubaye KQA. The clinical and histological skin changes after the cupping therapy (Al-Hijamah). J Turk Acad Dermatol 2012;6: 1261a1. 8. El-Domyati M, Saleh F, Barakat M, Mohamed N. Evaluation of cupping therapy in some dermatoses. Egypt Dermatol Online J 2013;9:2. 9. Dong Y, Liu H, Gu Y, Zhang C. Curative effect of movable cupping therapy combing Chinese medicinal on common plaque psoriasis in 32 cases. J Beijing Univ Tradit Chin Med 2012. 10. Zhang C, Li B, Feng L, et al. Study on the relativity between the frequency and effect in plaque psoriasis with moving cupping therapy. China J Tradit Chin Med Pharm 2012. 11. Yu RX, Hui Y, Li CR. Ko¨ebner phenomenon induced by cupping therapy in a psoriasis patient. Dermatol Online J 2013; 19:18575.
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 19, No 3 (May/June), 2015: pp 320–322
Paradoxical, Cupping-Induced Localized Psoriasis: A Koebner Phenomenon Reid Vender and Ronald Vender Background: Cupping therapy is a traditional Chinese medicine used to heal psoriasis. The Koebner phenomenon is the occurrence of psoriatic lesions at the site of cutaneous injury. Objective: To describe the first case of biopsy-proven cupping-induced localized psoriasis, an example of the Koebner phenomenon. Methods: The histopathology of the lesions is described. A brief review of the literature regarding cupping therapy and its efficacy are discussed. Results: A 45-year-old Asian male presented himself to the dermatology clinic for further treatment of his psoriasis. Four unusually circular plaques on the lower back were discovered. Pathologic diagnosis revealed an early lesion of psoriasis. on further inquiry, the patient admitted to undergoing a recent ‘‘cupping’’ procedure in an attempt to cure his condition. Conclusion: The efficacy of cupping therapy is controversial, and psoriatic patients may develop localized psoriasis through koebnerization as a result of cupping therapy rather than achieve desirable therapeutic benefits. Contexte: La pose de ventouses (cupping therapy) est une technique employe´e en me´decine traditionnelle chinoise pour gue´rir le psoriasis. De son coˆte´, le phe´nome`ne de Ko¨bner est l’apparition de le´sions psoriasiques au sie`ge de le´sions cutane´es. Objectif: L’e´tude visait a` exposer le premier cas de psoriasis local, provoque´ par la pose de ventouses et ave´re´ par biopsie, conside´re´ comme un exemple du phe´nome`ne de Ko¨bner. Me´thode: Il sera tout d’abord question de l’histopathologie des le´sions; suivront un bref examen de la documentation sur la pose de ventouses et une discussion sur son efficacite´. Re´sultats: Un homme de 45 ans, d’origine asiatique, s’est pre´sente´ de sa propre initiative au centre de dermatologie pour recevoir d’autres traitements pour le psoriasis. Quatre plaques inhabituellement rondes ont e´te´ observe´es, a` l’examen, dans le bas du dos. Le diagnostic reposant sur l’examen histopathologique a re´ve´le´ une le´sion pre´coce de psoriasis; soumis a` d’autres questions, le patient a admis avoir eu recours, peu de temps avant, au traitement par la pose de ventouses dans une tentative de gue´rison de la maladie. Conclusions: L’efficacite´ de la pose de ventouses ne fait pas l’unanimite´, et des patients souffrant de´ja` de psoriasis peuvent voir apparaıˆtre des le´sions psoriasiques locales a` la suite de ce traitement, par phe´nome`ne de Ko¨bner, au lieu d’obtenir des re´sultats the´rapeutiques souhaitables.
E PRESENT A CASE of a 45-year-old Asian male who presented to the dermatology clinic with a 4month history of pruritic, diffuse, erythematous, welldefined plaques on his trunk. He admitted to using topical
W
From Dermatrials Research Inc., and Division of Dermatology, McMaster University, Hamilton, ON. Address reprint requests to: Reid Vender, Dermatrials Research Inc., 132 Young Street, Hamilton ON L8N 1V6; e-mail: [email protected].
DOI 10.2310/7750.2014.14109 # 2014 Canadian Dermatology Association
320
calcipotriol/betamethasone dipropionate gel and ointment, with little relief. A clinical diagnosis of psoriasis was made. His past medical history includes hypertension and mild alcohol consumption. The patient had no previous dermatologic history. The patient weighed 80 kg and had a body mass index of 26.5. Bloodwork revealed normal serum glucose, creatinine, estimated glomerular filtration rate, fasting cholesterol, aspartate aminotransferase, alanine aminotransferase, and complete blood count. Triglycerides were slightly elevated. Histopathology revealed slight spongiotic psoriasiform epidermal hyperplasia with focal parakeratosis and scale crust associated with a sparse superficial perivascular
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 19, No 3 (May/June), 2015: pp 320–322
Vender and Vender
infiltrate consisting of lymphocytes, histiocytes, and scattered eosinophils. The periodic–acid Schiff (PAS) stain was negative for fungi. The dermatopathologist reported no unequivocal evidence of psoriasis in the sections. The differential diagnosis included subacute nummular dermatitis as well as subacute allergic contact dermatitis. Rarely, this pattern of inflammation may be due to drug hypersensitivity. The histologic features were suggestive but not unequivocally diagnostic of spongiotic psoriasiform dermatitis. This patient was then prescribed phototherapy but was only able to attend eight sessions due to a conflicting work schedule. Subsequently, he was prescribed oral acitretin at a dose of 10 mg per day for 1 month. The patient returned to the clinic and complained that his eruption was getting worse. A physical examination revealed that, clinically, there was no change in the extent, erythema, scale, or thickness of the eruption on his trunk. However, four circular plaques on the lower back, evenly spaced and of uniform size, were discovered (Figure 1). On further inquiry, the patient admitted to undergoing a ‘‘cupping’’ procedure within the past 2 weeks in an attempt to cure his skin condition. The patient consented to another punch biopsy of one of the circular plaques to confirm a diagnosis of psoriasis. This second histopathology revealed a superficial perivascular infiltrate of lymphocytes with mild psoriasiform epidermal hyperplasia, focal mounds of parakeratosis containing neutrophils, and tortuous dilated blood vessels in the papillary dermis (Figure 2). A PAS stain was negative for fungal hyphae. Pathologic diagnosis was confirmed as an early lesion of psoriasis.
Figure 1. Circular, psoriatic plaques on the lower back.
Figure 2. Medium-power histopathology revealing psoriasis (hematoxylin-eosin stain, 320 original magnification).
The patient’s acitretin was increased to 25 mg per day, with slow improvement of the psoriasis over the next 4 months. Blood monitoring revealed worsening of triglyceridemia, which was subsequently managed by diet. We therefore present an interesting case of localized psoriasis induced by cupping and a classic example of the Koebner phenomenon.
Discussion Cupping therapy is a traditional Chinese medicine (TCM) used to heal psoriasis. In TCM, psoriasis is described as ‘‘blood heat, which subsequently developed into blood dryness and blood stasis,’’1 and the Koebner phenomenon is denoted by excessive blood heat, an internal factor causing psoriasis, and the invasion of wind heat, an external factor causing the white scales of psoriasis.2 The National Psoriasis Foundation defines Koebner phenomenon as ‘‘psoriasis plaques that form at the site of a skin injury.’’3 The pathogenesis of Koebner phenomenon is unknown; however, there are immunologic, vascular, dermal, neural, genetic, hormonal, and infectious theories. Likewise, growth factors, drugs, cytokines, stress proteins, adhesion molecules, and autoantigens may also be involved.4,5 Koebnerization as an immune-mediated response has been studied, and levels of elastase-positive and interleukin-17positive cells have been found to rise rapidly, whereas Tbetpositive cells increase gradually, peaking after other cell levels decrease when a skin injury occurs.6 The therapeutic approach commonly taken to eliminate blood heat and blood stasis is ultimately to activate the blood through cupping.2 The general method of cupping
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 19, No 3 (May/June), 2015: pp 320–322
321
Cupping-Induced Local Koebnerized Psoriasis
therapy requires a plastic or glass bell-shaped or spherical cup, 1 to 3 inches in diameter, to be placed on the skin. The negative gauge pressure inside the cup is created by heating the air inside and letting it cool or through the use of an attached pump. Many types of cupping exist, where cups may be placed over an acupuncture needle (needle cupping), skin may be lubricated (moving cupping), or skin may be pricked for bloodletting (wet cupping).7 The efficacy of cupping therapy is controversial. ElDomyati and colleagues recognized cupping therapy as an effective alternative or complementary therapy for certain dermatoses but not for eight cases of psoriasis in an Egyptian study.8 However, Dong and colleagues observed that all of their 32 psoriasis patients had significantly lower Psoriasis Area and Severity Index scores (reduction of 15.49 6 7.42) in a Chinese study assessing the efficacy of moving cupping.9 Likewise, Zhang and colleagues found high, undefined ‘‘efficacy rates’’ (68.75%, 91.17%, and 84.37%) for three random groups consisting of a total of 98 participants with plaque psoriasis in a Chinese study also assessing the efficacy of moving cupping.10 Note that all of these cases were also receiving ultraviolet B and topical calcipotriol as well as herbal baths, and there was no control group. There has been one other report in China of Koebner phenomenon induced by cupping therapy in a psoriasis patient in the past literature.11 Yu and colleagues described similar findings of discoid psoriatic plaques, not proven by biopsy, associated with cupping therapy. However, our report is the first case of biopsy-proven cupping-induced localized psoriasis in an Asian patient residing in North America.
Conclusion Psoriatic patients may develop localized psoriasis through koebnerization as a result of cupping therapy rather than achieve desirable therapeutic benefits. Paradoxically,
322
psoriatic plaques may form where they were intended to be therapeutically eliminated.
Acknowledgments Thank you to Jay Jambrosic, MD, FRCPC, for providing histopathologic interpretation and photomicrographs. Financial disclosure of authors and reviewers: None reported.
References 1. Lin XR. Psoriasis in China. J Dermatol 1993;20:746–55. 2. Iliev E, Broshtilova V. Traditional Chinese medicine principles in the pathogenesis and treatment of psoriasis vulgaris. Semin Integr Med 2003;1:145–50, doi:10.1016/S1543-1150(03)00027-9. 3. National Psoriasis Foundation. Koebner phenomenon. 2014. Available at: http://www.psoriasis.org/about-psoriasis/causes/koeb ner (accessed June 29, 2014). 4. Camargo CM, Brotas AM, Ramos-e-Silva M, Carneiro S. Isomorphic phenomenon of Koebner: facts and controversies. Clin Dermatol 2013;31:741–9, doi:10.1016/j.clindermatol.2013.05.012. 5. Sagi L, Trau H. The Koebner phenomenon. Clin Dermatol 2011; 29:231–6, doi:10.1016/j.clindermatol.2010.09.014. 6. Hendriks AG, Keijsers RR, Seyger MM, et al. Are newly discovered drivers of immune-mediated skin disorders expressed in normal skin regenerating from standardized surface injury? Dermatology 2014;228:255–60, doi:10.1159/000358008. 7. Al-Rubaye KQA. The clinical and histological skin changes after the cupping therapy (Al-Hijamah). J Turk Acad Dermatol 2012;6: 1261a1. 8. El-Domyati M, Saleh F, Barakat M, Mohamed N. Evaluation of cupping therapy in some dermatoses. Egypt Dermatol Online J 2013;9:2. 9. Dong Y, Liu H, Gu Y, Zhang C. Curative effect of movable cupping therapy combing Chinese medicinal on common plaque psoriasis in 32 cases. J Beijing Univ Tradit Chin Med 2012. 10. Zhang C, Li B, Feng L, et al. Study on the relativity between the frequency and effect in plaque psoriasis with moving cupping therapy. China J Tradit Chin Med Pharm 2012. 11. Yu RX, Hui Y, Li CR. Ko¨ebner phenomenon induced by cupping therapy in a psoriasis patient. Dermatol Online J 2013; 19:18575.
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 19, No 3 (May/June), 2015: pp 320–322
