Wet Cupping (Hijama)

Early records and the wider history of cupping

Cupping in general has a long and contested history. A narrative review of the history of cupping, written by authors who use the Arabic term Hijama for the practice, reports that the exact origin is a matter of controversy and that its use is documented in early Egyptian and Chinese medical practice. The review found inconsistent data on origins, definitions, instruments and procedures over the centuries, and reports that cupping fell out of favor in the seventeenth and mid-eighteenth centuries before recovering popularity in modern medicine.

A review of cupping in rheumatic diseases cites the Ebers Papyrus, dated by its authors to about 1550 B.C., as the earliest recorded reference, and lists Chinese, Arabic, Greek and Prophetic medicine among the traditions that have practiced different types of cupping. The sources read for this page do not give dated detail on Greek or Roman bloodletting practice, and nothing here should be taken as tracing a single continuous line from those periods to present-day wet cupping.

Arabic-Islamic and Persian medical traditions

A concept analysis of Prophetic Medicine, the body of health practices that scholars link to Muslim-majority regions of the Middle East and North Africa, names wet cupping among its core attributes alongside items such as black seed and dates. The authors link its uptake to cultural background and spiritual belief, among other factors. A survey of practitioners in Qatar similarly notes that cupping has a cultural and religious context that helps explain its use in Arab and Muslim countries. This page reports how scholars describe that context and offers no religious ruling on the practice.

A critical review of what it calls Islamic Medicine treats Hijama as one of four strands, alongside Traditional or Yunani practice, Prophetic Medicine and Ruqya. Its author discusses how Hijama has been promoted as a lost sunna and reports concern about the absence of effective training and about claims of miraculous results. Persian medical texts, reviewed in a separate article, describe headaches as disturbances of temperament and name both phlebotomy and wet cupping among the responses, a framework that differs from the Islamic framing and from Chinese theory.

Chinese bleeding cupping

In Chinese practice the same procedure is known as bleeding cupping. A systematic review of Chinese clinical literature places the earliest cupping records in a silk manuscript found in a Han dynasty tomb in 1973, and counts 550 clinical studies published between 1959 and 2008, of which 319 (58.0 percent) used bleeding cupping as the main intervention. A later review notes that cupping has been applied as a formal modality in hospitals across China since 1950.

Names used for the practice

Hijama (also spelled hijamah, and written al-hijamah with the Arabic article) is the Arabic word for cupping, and in English-language literature it is often used for the wet form specifically. Wet cupping is distinguished from dry cupping by the addition of skin incision: one case report describes wet cupping as relatively invasive, involving scarification with needles or surgical blades before cupping so that blood is drawn into the cup. Chinese-language literature uses bleeding cupping or wet cupping, and several reviews use blood pricking and cupping for related combinations.

Names for related procedures vary by region. A case report of an adolescent describes a traditional phlebotomy procedure called Al-Fashdu as a well-known Islamic medicine-based treatment, and the critical review of Islamic Medicine places Hijama alongside Yunani medicine and Prophetic Medicine rather than treating the terms as interchangeable. The Machipedia page Unani Medicine covers the Yunani tradition and the page Traditional Chinese Medicine covers the Chinese framework.

Place within the cupping family

This page is one member of the wider Machipedia family described on the page Cupping Therapy, which should be read for general background. Related Machipedia pages include Dry Cupping and Fire Cupping, which describe other forms, and Leech Therapy and Gua Sha, which cover separate traditional practices that are sometimes discussed alongside cupping. One overview of cupping proposes its own classification of cupping types and sets, and reviews differ in how they group the types, so counts in one source may not match another.

What a session is described as involving

Reviews describe wet cupping in general terms as suction cups applied to the skin, followed by superficial incision of the skin and reapplication of cups so that a small amount of blood is drawn out. Dry cupping, by contrast, uses suction alone. This page does not describe sites, depth, volume or hygiene steps, and it is not a guide to performing the procedure. Practitioners range from traditional Chinese medicine practitioners in hospital and clinic settings to Al-Hijama practitioners in community centers; one survey in Qatar covered 120 practitioners at five such centers.

Explanations offered for its effects

A review of mechanisms lists six theories proposed for cupping in general: the pain-gate theory, diffuse noxious inhibitory controls, reflex zone theory, a nitric oxide theory, activation of the immune system, and a blood detoxification theory. The review authors state that the theories may overlap, that no single theory explains the whole range of reported effects, and that further research is needed to support or refute them. Practitioners in the Prophetic and Chinese traditions give their own explanations, which this page does not treat as tested.

Conditions studied in clinical literature

Wet cupping has been studied or used for a wide range of complaints. A review of wet cupping trials lists low back pain, hypertension, brachialgia, carpal tunnel syndrome, chronic neck pain, metabolic syndrome, migraine, oxygen saturation in smokers with chronic obstructive pulmonary disease, and oral and genital ulcers in Behcet disease. Reviews of the wider cupping literature in China list herpes zoster, facial paralysis, cough and dyspnea, acne, lumbar disc herniation and cervical spondylosis as common targets. Listing a condition here describes what has been studied or claimed and says nothing about whether wet cupping helps.

Traditional rationales

Within Persian medicine texts, headaches are attributed to disturbances of temperament and are said to be treated by phlebotomy or wet cupping according to type. The Prophetic Medicine concept analysis lists cultural background, spiritual belief, lower cost, perceived safety and dissatisfaction with conventional treatment among the factors associated with using such practices. The critical review of Islamic Medicine reports that Hijama has been promoted with claims of miraculous results, which that author disputes. These statements describe motives and claims and are not evidence of effect.

Overall state of the evidence

A systematic review of wet cupping trials, searched to February 2016, found 14 randomized trials across many conditions. Nine favored wet cupping over their comparators and five showed no significant between-group differences, with variable risk of bias reported. A broader review found 135 randomized trials of cupping published from 1992 to 2010, generally of low methodological quality, with wet cupping used in most. No Cochrane review specific to wet cupping was identified in the PubMed and Europe PMC searches run for this page.

Low back pain

For low back pain, a meta-analysis of 10 studies in 690 patients found a significant reduction in pain intensity with wet cupping but not with dry cupping, with very high heterogeneity. A meta-analysis of 13 trials in 1,088 participants found that blood pricking and cupping was superior to other treatments for pain and disability in nonspecific low back pain,, with few high-grade studies. A third meta-analysis of 11 trials in 921 participants pooled all cupping types and found improvement in pain at 2 to 8 weeks, no continuing improvement at one month or at 3 to 6 months, and high heterogeneity.

Migraine and headache

A meta-analysis of 18 trials with 1,446 participants found that treatment success was higher with cupping than comparators, with the improvement significant only in the wet cupping subgroup, while quality of life measured by the Migraine Disability Scale did not improve. An open-label randomized trial of wet cupping in migraine gave monthly sessions for three months and then randomized 109 participants to stop or continue for 12 months; those who continued had lower pain and disability scores. The open-label design and absence of a sham arm limit what that trial can show.

Hypertension, lipids and metabolic conditions

For hypertension, a review of seven randomized trials of wet cupping, most not of high methodological quality, found small studies suggesting lower blood pressure than with antihypertensive medication, but the authors state that no firm conclusions can be drawn. An earlier review found only two eligible trials and called the evidence not convincing. A review of five studies in 489 people with metabolic syndrome, pooling several cupping types, found reductions in waist circumference and LDL cholesterol but no significant effect on blood pressure, total cholesterol, triglycerides or fasting glucose. A small trial of 47 healthy young men without hyperlipidemia reported lower LDL cholesterol after wet cupping than in an untreated control group over three weeks. No diabetes-specific trial was among the sources reviewed.

Herpes zoster

A review of eight randomized trials with 651 patients with herpes zoster compared wet cupping with medication and reported higher rates of trial-defined recovery and lower postherpetic neuralgia incidence with wet cupping, while wet cupping added to medication showed no difference in symptom improvement. The trials were of generally fair quality, and the authors called for larger trials.

International training benchmarks

The World Health Organization published benchmarks for training in traditional Chinese medicine in 2010, setting out expected subjects and competencies for TCM practitioner programs, including basic skills in sterilization and disinfection under external medicine. Benchmarks for acupuncture and Tuina are published as separate documents. The TCM benchmarks document does not name cupping, so it cannot be read as a cupping-specific standard.

Training concerns raised in scholarship

Scholarly sources raise training as an open issue. The Qatar practitioner survey concluded that regular training programs and standardization of safety protocols are needed, and the critical review of Islamic Medicine describes an absence of effective training for Hijama and sets out accredited courses as the author's proposed route to improvement. No professional body register or code of ethics for wet cupping practitioners was found in the sources reviewed.

Infection and bloodborne pathogens

Because wet cupping breaks the skin, the authors of several reviews and case reports identify infection as its main safety concern. A practitioner survey in Qatar restates literature linking Hijama to transmission of hepatitis B, hepatitis C and HIV when equipment is inadequately sterilized, and reports that cupping was the transmission route in a substantial proportion of hepatitis C cases in epidemiological evidence from Saudi Arabia. A case report with literature review found no case reports of hepatitis secondary to cupping, while noting studies that identified acupuncture and cupping as risk factors for hepatitis C in Egypt and hepatitis D in Iran, presumably through infected needles. These accounts rest on associations, not measured rates per treatment.

The Qatar survey of 120 practitioners at five centers found that about half did not adhere to established safety guidelines, with hand hygiene, equipment sterilization, use of disposable lancets and documentation frequently neglected. This was one country and a self-administered questionnaire.

Case reports of serious harm

Published case reports describe serious infections after wet cupping. A 33-year-old woman developed disseminated Staphylococcus aureus infection with liver and kidney injury, an iliopsoas abscess and gastrointestinal bleeding, with severe anemia, and recovered with antibiotics. A 35-year-old man developed a sacroiliac abscess with osteomyelitis requiring six months of treatment, and a 12-year-old developed disseminated Staphylococcus aureus infection after a traditional phlebotomy procedure, treated with surgical drainage and intravenous antibiotics. One report notes that cupping has no rigorous adverse-event registration system, so case reports cannot indicate frequency.

Milder and trial-reported harms

A literature review reports that scar formation, burns, headache, itching, dizziness, anemia and panniculitis are relatively frequent after cupping, usually mild and self-limiting, and that the authors consider wet cupping to carry a higher infection risk than dry cupping because the skin barrier is broken. Anemia is listed among the reported effects, and the sources read do not quantify it for repeated sessions. In trials, seven of the low back pain trials in one meta-analysis mentioned no adverse reactions, one reported mild syncope in three participants that resolved with rest, and the herpes zoster, migraine and broader cupping reviews reported no serious adverse effects in the trials they included. Trials were generally small, so these findings cannot rule out rare events.

Suitability and care boundaries

The sources reviewed do not provide a consolidated list of contraindications for wet cupping. The Qatar survey notes that a licensed nurse is expected to assess contraindications before the procedure but does not list them. Whether wet cupping is suitable for a particular person is a matter for a qualified clinician. Wet cupping should not delay or replace necessary medical care.