TCM is a holistic system of health and healing that places importance on maintaining the balance between an individual’s internal energy and the external environment.⁷ It is rooted in three essential components: qi (energy), blood, and body fluids.⁸ Illness is believed to be a result of disruption to the flow or balance of qi.⁸ TCM consists of two main pillars: physical treatments, which include acupuncture and moxibustion, and chemical treatments, which involve the use of herbs, minerals, and animal materials, typically administered topically or orally.⁹

A large motivation for TCM, especially amongst immigrant populations in the United States, is the emphasis it places on diagnosing the individual, not just the disease. Practitioners aim to assess the overall state of imbalance in the person’s body by gaining an understanding of the individual’s symptoms, environment, emotional state, and body function, a process known as “symptom identification” or “zheng.”¹⁰ Notably, 76% of Western-trained practitioners in China also integrate some form of TCM in their practice.¹¹

Immigrant patients in the United States often report that their understanding of TCM is primarily informed by “traditional wisdom” passed through generations of family members, community networks, or through the internet.¹² Oftentimes, parents report that they are unable to articulate the purpose and intentions behind their cultural practices or that hospitals do not address their concerns through the lens of which they view health, leading to disconnect and mistrust.¹²

TCM practices relevant to dermatology include coining, cupping, spooning, and moxibustion, which all involve intentional physical manipulation of the skin and can produce dermatoses such as ecchymoses, erythema, and petechiae. Dermatologists play a crucial role in investigating whether lesions are a result of abuse or alternative therapy.³ These traditional techniques often create bruises that are symmetrical, clustered, and present in a regular pattern, which may prompt a consideration of abuse in a differential diagnosis when clinicians are unfamiliar with the practice.¹³

Coining, also known as gua sha in Chinese or cao gio in Vietnamese, is a form of folk-derived dermabrasion therapy commonly used in Southeast Asian countries. Gua sha directly translates to “scrape away fever” in Chinese, and Cao gio translates to “scrape wind” in Vietnamese; wind referring to “catching a cold or fever.”¹⁴ These practices are often employed for minor illnesses including coughs, fevers, chills, sore throats, and upper respiratory infections.¹⁵ It is performed by applying cotton swabs soaked with hot oils and balms to the back and chest, massaging the skin to maintain its warmth, and using firm downward strokes with the coin, ceramic Chinese soup spoon, a piece of jade, or a water buffalo horn along the borders of the spine and ribs, following the pathway of acupuncture points.^14,16,17 Effectiveness of this practice is measured by the production of linear petechiae and ecchymoses on the chest and back, often in a pine tree shape (Figure 1).¹⁸

Figure 1.

The practice is associated with minimal discomfort and no significant side effects, with the lesions disappearing in about 1 week.²⁰ Although patients report feeling little pain during the procedure, there are adverse effects that may arise, most commonly contact dermatitis from camphor, menthol, eucalyptus oil, and other topicals used.¹⁴ Rarely, topicals used may potentially cause systemic toxicity if systemically absorbed. This has been reported with camphor, which can be absorbed transdermally fairly quickly, facilitated by a broken skin barrier such as with wounds from coining/spooning.²¹ Camphor toxicity can present with nausea, vomiting, diarrhea, lip cyanosis, and neurological issues such as confusion.²¹ If excess pressure is applied, soft tissue contusion injuries may occur - one such case was reported of epiglottitis secondary to gua sha performed over the throat, so care should be taken when near critical structures.²² One rare case was reported of a patient with burns sustained from topical oil catching on fire.²³ For safer application of gua sha, the Occupational Safety and Health Administration (OSHA) guidelines recommend using single-use stroking devices and gloving both hands with nitrile or vinyl gloves to reduce the risk of contact dermatitis. All tools should be washed and decontaminated after use. OSHA also advises using single-serving portions of lubricants to avoid contamination and disposing of any leftovers.²⁴

Cupping, also known as hijama, is an ancient practice with origins in cultures across the globe including Egypt, China, and the Middle East. It has traditionally been utilized to improve energy and blood circulation, while also promoting wellness by relieving stress and anxiety.²⁵ The technique involves creating negative suction inside brass, steel, or glass cups either using a flame, electrical, or manual suction.^26,27 Cups are placed on the skin for 5-10 minutes in sets of 4, 6, or 10, targeting areas with prominent muscle, including the back, chest, abdomen, or buttocks.²⁸ The negative pressure applied to the skin by the cups causes trauma to the superficial vessels of the skin, leading to edema, erythema, and ecchymosis in characteristic round or oval shapes (Figure 2A, 2B, 2C).²⁸ Cutaneous findings usually spontaneously resolve within days to weeks and are traditionally considered to be evidence that the illness or toxins are being drawn out of the body.^19,28 Modifications include use of lubricants or “wet cupping,” which can affect cutaneous manifestations. When lubricants are applied to help glide the cups along the skin, this can create linear purpuric streaks.²⁷ Wet cupping is a variation in which superficial incisions are made on the skin prior to cup placement, or adding needles placed at the base of the cup (Figure 2D). This method compromises the skin barrier and carries an increased risk of infection.²⁷

Cupping is becoming increasingly popular as a management option for a variety of health conditions. It has been proposed as an adjunctive treatment for postherpetic neuralgia associated with cutaneous shingles.²⁹ More recently, cupping has also been utilized to produce blisters for suction blister grafting in the treatment of vitiligo.³⁰ In pediatric patients, cupping is often applied to the abdomen to relieve constipation and promote laxative effects.³¹ Cupping is considered a relatively safe procedure with relatively mild adverse effects outside of skin changes. The most common adverse effects are scar formation and burns, with rarely reported other adverse effects including headache, pruritus, anemia, skin infection, panniculitis, hyperpigmentation, and muscle tension.³²

Figure 2A.

Figure 2B.

Figure 2C.

Figure 2D.

Moxibustion is a technique used for more than 2500 years in East Asia that involves rolling the herb moxa, also known as Artemisia vulgaris or mugwort, into a cone and burning it over acupuncture points until pain is felt.^19,34 In some variations, the moxa may be burned on top of acupuncture needles or placed 1 to 2 cm away from the skin, known as indirect moxibustion, which allows the heat to penetrate without direct contact (Figure 3A).¹⁹

This technique is frequently applied to the lower extremities, specifically to joints such as knees or ankles (Figure 3B).³⁴ Moxibustion is believed to aid in stimulating blood flow and alleviating pain.³⁴ It has been traditionally used in pediatric conditions including infantile diarrhea and nutrition-related disease, chronic cough, and myopia.^35–37 Although it is generally considered a safe practice when performed with proper technique, the most common side effects of moxibustion are allergic reactions to the herb, burns, and infections including cellulitis and hepatitis C from using non-sterile needles.³⁸ The discrete, target-like burns produced by moxibustion are often mistaken for cigarette burns.³⁹ However, cigarette burns tend to be randomly distributed compared to strategic, organized placement for moxibustion.

Figure 3A.

Figure 3B.

A full discussion on cutaneous signs of abuse is outside of the scope of this paper, but herein we outline a recommended approach to differentiating findings of TCM practices from abuse. When a patient presents with skin findings that are clearly caused by external factors, such as multiple perfectly round, linear, or geometric bruise- or burn-like patches, clinicians should consider TCM practices in their differential as well as non-accidental trauma. There should not be significant trauma present with TCM, such as hematomas or fractures, which would be concerning for abuse. Taking note of affected areas of the body is important; genital, buttock, or facial lesions would be very concerning for abuse and generally atypical for TCM practices.

Providers should explain each component of an evaluation for child abuse to the patient and families to minimize distrust and trauma. Clinicians should ask patients/families in a non-judgmental fashion about the lesions and any TCM practices without accusation or assumption that abuse is taking place.⁵⁷ If patients have engaged in TCM practices, they should be able to clearly explain the method, timing, and indication, which should be consistent with the skin exam findings. This can help reduce bias and mistrust in healthcare interactions, and the clinician can simply document findings and explanations so other healthcare providers can be aware and mitigate future concerns.

If the cutaneous findings related to TCM practices are causing distress to the patient and are included in their presenting concern, investigation into any methods causing adverse effects as above can be undertaken—ie, assessment for allergic contact dermatitis or secondary skin infection—and patients can be educated about how to safely continue these practices with adaptations to reduce risks, if continuation is desired by the patient and safe per the clinician.

If answers are inconsistent with exam findings, as with any history taking, this should raise suspicion for abuse. A delay between injury and seeking care is suspicious, and often occurs with inflicted burns.⁵⁸ Children and elderly patients with disabilities, behavioral problems, developmental delay or neurologic conditions respectively, and unstable home situations are at increased risk for abuse.^58,59 Clinical findings should be photographed and added to the medical record. Patients with suspected abuse should not be interviewed in the presence of the suspected abuser.^2,39,59,60 Rather, tactful ways should be sought to remove the abuser as to not arouse their suspicion and risk further harm to the patient. If the patient seems uncomfortable or unwilling to disclose, but there is a strong suspicion of abuse, the interviewer can begin with general questions about their home and safety.⁶⁰

Given the increasing use of herbal TCM products and the variability in composition and quality of formulations, dermatologists should routinely and specifically inquire about herbal TCM use when obtaining a medication history, as patients may not voluntarily disclose their use of alternative therapies due to fear of criticism or lack of consideration of “medications.” Unlike other countries, the United States does not regulate or standardize formulations of herbal products as they are considered dietary supplements, resulting in variability in the purity, concentration, and active ingredients of commercially available preparations.⁶¹ Adverse effects can be considered intrinsic or extrinsic to the herbal compound. Intrinsic effects include toxicity, overdose, anaphylaxis, carcinogenicity, and teratogenicity, often associated with chemical or herbal therapy, whereas extrinsic effects are attributed to poor manufacturing practices that lead to contamination, inaccurate preparations and labelling, and a lack of standardization.⁶¹

Patients who choose to utilize commercially available herbal TCM products should be counseled and encouraged to choose products from reputable manufacturers that adhere to established good manufacturing practices and, when available, products that have undergone third-party verification.⁶² Programs such as the United States Pharmacopeia (USP) Dietary Supplement Verification Program assess products for identity, potency, and quality, while third-party certification provides additional assurance pertaining to composition and contamination. However, USP verification for herbal products has been historically limited, so dermatologists should emphasize other indications of product quality such as transparent labeling, reliable manufacturing practices, and independent testing when available.⁶³ If a dermatologist is recommending any supplement, they should also review patients’ current medications to assess the risk of potential interactions.

Although studies suggest potential dermatologic applications and complications of TCM, the current evidence is limited by small sample sizes, short follow-up periods, and variability in methodology and study quality. Future dermatologic studies should prioritize larger, well-designed randomized controlled trials using standardized interventions and longer follow-up periods. These improvements would allow for more clinically meaningful outcomes and better characterization of treatment durability and adverse effects. In particular, greater standardization and characterization of herbal formulations would strengthen the reproducibility of studies evaluating TCM therapies for atopic dermatitis and psoriasis. Additionally, further investigation into dermatologists’ recognition of TCM-associated cutaneous findings may help inform educational strategies to improve differentiation of culturally mediated skin findings from signs of abuse.

364764 Table 1.

The authors have no relationships or conflicts of interest to disclose.

The authors have no funding sources to disclose.