Sir,

The appearance of psoriasis-like lesions on healthy skin in patients with psoriasis following trauma is known as Koebner phenomenon (KP). KP associated with cupping is rarely observed. To our knowledge, all existing reports to date have shown that psoriasis was diagnosed before cupping therapy. Herein, we report the case of a male presenting with psoriasis-like lesions in the trunk after cupping therapy eventually diagnosed with psoriasis vulgaris and treated as such.

A 52-year-old patient with no medical history consulted for pruritic, erythematous lesions on the trunk evolving for one month after cupping therapy. A clinical examination found multiple erythematous papules of 1 mm in a linear arrangement and grouped into spherical islands located at the level of the application area of the suction cup on the back (Fig. 1a). The methodical scraping of Brocq was positive, as well as the dermoscopy showing vessels in a homogeneous point (Fig. 1b), evoking the diagnosis of psoriasis. The rest of the somatic examination found scaly, erythematous plaques of psoriasis on the legs and scalp unknown to the patient. The diagnosis of psoriasis vulgaris was made clinically and later confirmed by a skin biopsy, then the patient was put on phototherapy and topical corticosteroids with an improvement.

Figure 1: a) Clinical image of lesions at the site of application of suction cups on the back. b) Dermoscopic appearance showing homogeneous vascularization.

Heinrich Koebner reported the emergence of new psoriatic lesions in the unaffected skin region following injury/trauma to healthy skin areas of psoriatic patients [1]. This is known as Koebner phenomenon and occurs mainly in patients with active psoriasis. Its pathogenesis remains uncertain [2]. However, it may be triggered by various mechanisms, including drugs, chronic pressure on the skin, sun exposure, scratching, skin trauma, hot water burns, and certain UV therapies [3].

There is a long list of agents that may trigger the development of Koebner phenomenon, in particular cupping therapy, or dry Hijama, which is a traditional Chinese medicine [4] whose effectiveness in the treatment of certain dermatoses is controversial. El-Domyati et al. recognized cupping therapy as an effective alternative or complementary method for some dermatoses, yet not for eight cases of psoriasis in an Egyptian study.

However, KP associated with cupping is rarely observed [4,5]. There are some case reports of KP associated with cupping in patients with psoriasis. Sharquie and Al-Jarallaseptont observed that sixteen patients with psoriasis had new lesions at the cupping site approximately two weeks after the procedure. The mechanism of CT inducing isomorphic reactions is unknown [2]. Yu et al. [4] and Pavlov and Dimitrova [5] proposed a hypothesis that cupping is a form of trauma, causing both epidermal cell damage and skin inflammation to produce the KP. The appearance of KP suggests that cupping therapy should be considered as a potential traumatic behavior responsible for this phenomenon, as shown by the case described by Lin Tang et al. [6] and by our patient.

To our knowledge, all existing reports to date have shown that psoriasis was diagnosed before cupping therapy. Now, we report the case of a male presenting with psoriasis-like lesions on the trunk after cupping eventually diagnosed with psoriasis.

This case underlined that cupping, which is frequently used nowadays, may also be a cause of PK, hence the interest of a meticulous clinical and dermoscopic examination which may help in the diagnosis.

Consent

The examination of the patient was conducted according to the principles of the Declaration of Helsinki.

REFERENCES

1. Diani M, Cozzi C, Altomare G. Heinrich Koebner and his phenomenon. JAMA Dermatol. 2016;15:919.

2. Monteagudo B, Cabanillas M, Iriarte P, Ramírez-Santos A, León-Muinos E, et al. Clindamycin-induced maculopapular exanthema with preferential involvement of striae distensae:A Koebner phenomenon?. Acta Dermatovenerol Croat. 2018;26:61-3.

3. Acar EM, Has S, Kilitci A, Kemeriz F. Circumscribed juvenile pityriasis rubra pilaris (type Koebnerising after a hot water burn:Mild disease with maximum Koebner response. Acta Dermatovenerol Croat. 2019;27:47-9.

4. Yu RX, Hui Y, Li CR. Köebner phenomenon induced by cupping therapy in a psoriasis patient. Dermatol Online J. 2013;19:18575.

5. Pavlov S, Dimitrova M. Koebner phenomenon caused by bloodletting and cupping therapy in a patient with psoriasis. Scripta Scientifica Med. 2019;51:24-8.

6. Tang L, Liao Y, Xu J, Li C. Koebner phenomenon induced by cupping therapy in the unstable stage of psoriasis:A case report. Dermatol Ther. 2021;34:e14852.