What Cupping Therapy Is
Cupping therapy — also called cupping in international literature — is an ancient technique that uses cups (made of glass, plastic, or silicone) applied over the skin to generate local negative pressure. This suction pulls skin and subcutaneous tissue into the cup, forming the characteristic purplish mark that may persist for several days. The technique was described in Chinese, Egyptian, and Greco-Roman medical texts, and remains in use across various contemporary traditions.
Before describing indications, epistemic candor is important: the evidence base for cupping therapy is smaller and of lower methodological quality than that of systemic acupuncture or dry needling. Most studies are small, of short duration, with moderate or high risk of bias, and technical difficulty in creating an adequate control group (sham-cupping is hard). Where more consistent evidence exists — such as in some forms of chronic musculoskeletal pain as an adjunct — the effects described are, in general, modest and short-term.
Modalities
The main technical variants in contemporary medical use are:
Dry cupping
Application of cups without breaching the skin. Negative pressure is created by mechanical suction (pump) or by prior heating of the cup interior (classic flame technique). The most commonly used modality in the medical office.
Wet cupping (Hijama)
After the initial application of dry cupping, small skin scarifications or punctures are made and the cup is reapplied, drawing out a small amount of blood. Traditional modality in Arab medicine; modern medical use is restricted and demands rigorous antisepsis due to infectious risk.
Sliding cupping (cup massage)
Oil or cream is applied to the skin and the cup is glided over the tissue. It functions as a deep massage assisted by suction. Common indication for myofascial trigger points.
Static cupping
The cups remain in place for 5 to 15 minutes. The most common variant.
Flash cupping (rapid movement)
Successive rapid application and removal in one area. A milder stimulus than static cupping.
Proposed Mechanisms (and What We Still Do Not Know)
The mechanisms of cupping therapy are still not fully elucidated. The hypotheses most discussed in the biomedical literature are:
Local microcirculation modulation
Negative pressure increases blood flow in the skin and subcutaneous tissue immediately after application. This effect is demonstrable by imaging, but the relationship between this local hyperemia and symptom relief is not fully established.
Myofascial release
Mechanical suction can separate adherent tissue planes and reduce tension at underlying myofascial trigger points — similar to what is sought with manual myofascial release techniques. Studies with elastography suggest changes in local tissue stiffness.
Cutaneous mechanoreception and spinal modulation
Intense stimulation of cutaneous mechanoreceptors can modulate pain transmission at the spinal level — a mechanism analogous to that of TENS or skin brushing.
Controlled inflammatory response
Local pressure creates a controlled microinjury that may activate pro-resolving mediators. A theoretically attractive hypothesis, but poorly demonstrated in clinical studies.
Placebo and contextual effect
The visually striking nature of the technique (purplish marks, therapist attention, ritualization of the session) likely contributes meaningfully to the observed clinical effect — a factor difficult to separate from the specific effect in blinded studies.
Indications Where the Evidence Is Less Fragile
The conditions in which randomized clinical trials or systematic reviews suggest benefit as an adjunct are mainly:
Chronic non-specific low back pain
The indication with the most studies. Systematic reviews show short-term pain reduction (generally 4-12 weeks), with modest effect size and low-to-moderate quality of evidence. Usually used as an adjunct to exercise and standard medical treatment.
Chronic neck pain
Small studies suggest a short-term analgesic effect, mainly when combined with massage or exercise. High heterogeneity between studies.
Chronic tension-type headache
Some evidence of reduction in frequency or intensity as part of a multimodal protocol. Studies of low statistical power.
Shoulder impingement syndrome and myofascial cervicobrachialgia
Frequent clinical use associated with the treatment of trigger points. Mostly observational evidence.
Localized myofascial pain with active trigger points
Sliding or static cupping over trigger points may produce release similar to deep massage. Useful when manual palpation is poorly tolerated by the patient.
In non-musculoskeletal conditions frequently promoted (asthma, hypertension, digestive disorders), the clinical evidence is insufficient to support systematic use.
What a Session Looks Like
Typical steps of a cupping session in a medical office
- 01
Brief history and physical examination of the treated region — confirmation of active trigger points or muscle tension
- 02
Skin antisepsis with alcohol solution
- 03
Application of oil if sliding cupping; dry skin if static cupping
- 04
Application of the cups by mechanical suction or heating — generally 4 to 12 cups per session
- 05
Stay of 5 to 15 minutes (static cupping) or 5 to 10 minutes of active sliding
- 06
Cup removal — sensation of decompression; there may be local tenderness
- 07
A purplish mark forms and lasts, in general, 3 to 10 days — it is not a traumatic hematoma and is not a sign of "toxin removal"
Total session duration is generally 15 to 30 minutes. The typical frequency is 1 to 2 sessions per week in the active phase, with response evaluation after 4 to 6 sessions.
Safety, Risks, and Contraindications
Cupping therapy has an acceptable overall safety profile when performed by a trained professional, but it is not free of risks. The most relevant complications:
Lasting skin marks
The purplish mark is the expected "side effect", but it can bother patients who need to expose the skin (summer, social events, an upcoming wedding). In darker skin, post-inflammatory hyperpigmentation may persist longer.
Blisters and burns (flame technique)
Cupping by heating (the classic fire technique) carries a burn risk if poorly executed. The mechanical aspirative modality is safer.
Infectious risk in wet cupping (Hijama)
The version with scarification carries a real risk of infection and disease transmission if antisepsis is inadequate. It should only be performed in a medical setting with disposable materials.
Extensive hematomas
Greater risk in patients on anticoagulants, antiplatelet agents, or with capillary fragility. Requires technical adjustment or contraindication.
Compartment syndrome and deep muscle injury
Extremely rare events described in the literature — generally associated with very intense or repeated sessions in a short interval.
Positioning in Pain Medicine
In evidence-based medical practice, cupping therapy occupies an auxiliary position in multimodal plans — it is not a first-line treatment for any condition. It tends to make more sense as:
Adjunct to acupuncture or dry needling
In patients with myofascial pain, it can be combined with acupuncture to potentiate work on hard-to-reach trigger points or in deeper muscles.
Adjunct to therapeutic exercise
It may reduce pain enough for the patient to tolerate and progress in an exercise program — which is the intervention with the most lasting effect on chronic musculoskeletal pain.
Alternative for patients who do not tolerate needles
Patients with belonephobia may accept cupping as a therapeutic entry, transitioning later to other techniques if desired.
Management of regional chronic tension
For patients with diffuse complaints of "tension" in the trapezius, lumbar region, or posterior body, cupping may produce relevant short-term subjective relief.
There is no evidence-based justification for cupping therapy in: hypertension treatment, "detoxification", weight loss, immunity enhancement, treatment of cancers, or viral diseases. Promises in that direction should be viewed with skepticism.
Myths and Facts
Myth vs. Fact
The color of the cupping mark indicates the level of toxins in the body.
The color is the result of local capillary extravasation — the greater the fragility of the capillaries and the pressure applied, the darker the mark. It does not correspond to any marker of toxin or disease.
Cupping "removes stagnant blood".
Dry cupping does not remove blood. Wet cupping (Hijama) removes a small amount — but there is no evidence that this blood is "different" from circulating blood or contains specific substances to be eliminated.
The darker the mark, the more the session worked.
The intensity of the mark depends more on capillary fragility, suction intensity, and application time than on clinical response. Darker marks do not correlate with better outcomes.
The cupping seen at the Olympics (athletes) proves that it works for sports recovery.
The viral image of athletes with cupping marks created interest, but the clinical evidence on cupping for sports recovery is limited and mixed. Small studies suggest possible short-term benefit in pain perception; magnitude and duration remain uncertain.
Cupping therapy treats hypertension, asthma, diabetes, or digestive problems.
There is no robust clinical evidence supporting the use of cupping as a treatment for these conditions. Patients should maintain the standard medical treatment indicated for each one.
Cupping has no side effects.
Marks are expected and may bother some patients; in patients on anticoagulants or with fragile skin, significant hematomas may occur; wet cupping has real infectious risk. "Painless and side-effect-free" cupping is a misleading simplification.
Frequently Asked Questions
Frequently Asked Questions
The suction produces an intense sensation of pressure and pull on the skin that most patients tolerate well, but it can be uncomfortable. It is not a sharp pain. Cup removal is generally painless.
Generally, 3 to 10 days. Patients with capillary fragility, on anticoagulants, or with darker skin may have longer-lasting marks (up to 2 weeks).
Light activity, yes. Intense training, especially involving the treated region, is better postponed for 24-48 hours — the area may be sensitive and tissue recovery still in progress.
There is no fixed number. In general, it makes sense to try 4 to 6 sessions and reassess the response. If there has been no perceptible change, it is usually time to redirect the strategy.
In general yes, with lower pressure and shorter time, and always disclosing the medication. Marks and hematomas may be larger. Under full anticoagulation with hemorrhagic risk, it may be better to avoid.
Yes. There is no contraindication. Just avoid the breast region.
Coverage varies. Some insurers cover it as part of integrative medical sessions; others do not. Check your specific plan.
Home kits are available. Light dry cupping, in an accessible region, with prior supervision from a physician, can be done at home. But the correct application of points, adequate intensity, and identification of contraindications are part of the medical indication.