（Yinghua He） (Guanhu Yang)

Abstract: This topic is mainly based on modern clinical literature, research, analysis, and conclusion to prove the clinical application and effectiveness of acupuncture combined with cupping therapy in the treatment of herpetic zoster neuralgia. Through a computer search of China Wanfang Data Network from 2011 to 2022, statistical data of 127 clinical reports on “acupuncture combined with cupping for herpes zoster neuralgia” were obtained. After the second manual screening, 30 articles were included. Using data analysis, icon expression, and other methods to support and demonstrate. It proves that “the treatment of acupuncture combined with cupping for the prevention and treatment of herpes zoster neuralgia” has a high effective rate and high cure rate, which can shorten the course of treatment, relieve pain, and improve the quality of life of patients. This method can be used in patients with neuralgia in the acute phase of herpes zoster and can also be used in patients with postherpetic neuralgia. And because acupuncture and cupping are simple to operate, easy to master, and highly reproducible in the clinical practice of traditional Chinese medicine, this research is specially done to facilitate clinical promotion.

Keywords: Acupuncture; Cupping， Herpes zoster， Neuralgia

Herpes zoster (HZ), or shingles, is a common dermatological disease. The disease is caused by the initial infection of varicella virus (Varicella-Zoster Virus, VZV) which remains dormant in the sensory nerve ganglia in many years. and when the hosts immune function declines, the virus reactivates. The main clinical manifestations include Clustered skin vesicles and neuralgia. This type of herpes is self-limiting, usually beginning to scab over after 2 weeks, and gradually dissipating. Typically, what causes greater suffering is neuropathic pain caused by the virus invading the nerve roots. The pain manifests as spontaneous, hypersensitivity to stimuli and abnormal sensations. Postherpetic Neuralgia (PHN) is defined as nerve pain that persists for more than 1 month after the lesions have healed. 45% of PHN patients may experience anxiety, depression, and an inability to concentrate., etc. About 60% of PHN patients have suicidal thoughts. In 30% to 50% of HZ patients, the pain can last for more than one year, with some cases lasting up to 10 years or longer (Consensus on Diagnosis and Treatment of Postherpetic Neuralgia after Herpes Zoster, 2016).

The combination of acupuncture and cupping therapy has shown satisfactory therapeutic effects in the treatment of postherpetic neuralgia (PHN). This method can be applied during the acute phase as well as in chronic pain conditions of PHN patients. It can be used alone or in combination with Western medicine. By organizing and summarizing clinical evidence from practice, the aim is to provide evidence and promote the use of this approach in order to relieve and alleviate the pain of patients.

Materials and methods

According to the statistical data of the studies collected from China Wanfang Data Network between 2011 to 2022 through computer retrieval, 127 articles were obtained using “acupuncture”, “cupping”, “herpes zoster” and “neuralgia” as keywords. We included “filiform needles”, “plum-blossom needles”, “three-edged needles”, “electroacupuncture”, etc., combined with literature on cupping treatment, and excluded studies including “fire needles”, “floating needles”, “pressing needles”, “rolling needles”, “traditional Chinese herbal medicine”, “Miao medicine”, “Western medicine”, “moxibustion”, “thread moxibustion”, “Zhuang medicine”, “far infrared rays”, etc. Based on these criteria 30 studies were included in our analysis.

1.Pain Score: Visual Analog Scale (VAS) (Image source: MedSci Measuring System)

2.Efficacy evaluation: a. Cure: VAS score after treatment is 0 points; b. Significantly effective: VAS score decreased after treatment but >= 4 points; c. Effective: VAS score decreased by > = 2 points after treatment, but < 4 points; d. Ineffective: After treatment, the VAS score decreased by < 2 points or the score remained unchanged or even increased. (Van Roo JD, 2011)

3.Hamilton Depression Rating Scale (HAMD)

4.Quality of Life Assessment Form （Dermatology Life Quality Index，DLQI）

5.Pittsburgh Sleep Quality Index (PSQI)

6.Pain Relief Time: The time required for 30% pain relief、

The 30 included literatures were researched, analyzed and evaluated

Summary of the basic treatment plan: multi-point acupuncture around the local area of the herpes lesions, acupuncture on the affected meridians and related Jiaji points, acupuncture with cupping on flat areas where cups will adhere, only acupuncture on uneven areas where cups will not adhere. Use sterile needles and acupuncture tools and select glass cups or vacuum suction cups which can be thoroughly cleaned or disposed of after use. Wear disposable sterile gloves. Follow routine disinfection procedures and keep the treated area clean and dry after treatment.

Results and Evaluation

The samples of observation group and treatment group were P>0.05, there was no significant difference.

N-Sample size, d-days (unit of time), min-minutes (unit of time), PHN-postherpetic neuralgia, HAMD-Hamilton Rating Scale for Depression, VAS-Visual Analog Scale for pain rating.

1.scussion by category of different control groups: Discussion by category according to the selection of the observation group and the control group.

Apuncture combined with cupping vs. Western medicine, 10 articles: Through the following conclusions, it is demonstrated that acupuncture combined with cupping is superior to Western medicine in treating herpes zoster neuralgia. See below

Acupuncture combined with cupping vs. simple acupuncture, 5 articles: Through the following conclusions, it is demonstrated that acupuncture combined with cupping is superior to simple acupuncture in treating herpes zoster neuralgia. See below.

(Acupuncture combined with cupping + Western medicine) vs. Western medicine, 3 articles: Through the following conclusions, it is confirmed that acupuncture combined with cupping is effective in treating herpes zoster neuralgia. In clinical treatment, acupuncture combined with cupping therapy can be used in conjunction with Western medicine to relieve pain effectively and quickly for patients. See below.

(Acupuncture combined with cupping + western medicine) vs (acupuncture + western medicine), 6 articles: Through the following conclusions, it is proved that acupuncture combined with cupping and western medicine can relieve herpes zoster neuralgia better than those treatments without cupping as a control group. See below.

Clinical observation of acupuncture combined with cupping. (No control group), 6 articles: Through the following conclusions, it is shown that acupuncture combined with cupping has a significant effect on herpetic neuralgia. See below.

2.The Classification and Discussion of Different Courses of the Disease: According to acute herpetic neuralgia and chronic pain PHN, classify and discuss.

Acupuncture combined with cupping in the treatment of acute herpes zoster: Among the 30 accepted articles, 10 of them were addressing acute herpes zoster. Through the following conclusions, it is demonstrated that acupuncture combined with cupping is effective in treating acute herpes zoster, treating neuralgia, and effectively preventing the occurrence of PHN. See below.

Acupuncture combined with cupping for the treatment of PHN: Among the 30 studies adopted, 20 of them addressed chronic pain and PHN.

Through the following conclusions, it is demonstrated that acupuncture combined with cupping shows significant effectiveness in treating postherpetic neuralgia PHN. See below.

3.

Comprehensive analysis and summary: Based on the above analysis, 30 selected literatures were summarized and analyzed as follows. The results demonstrate that acupuncture combined with cupping therapy is an effective and significantly beneficial treatment for postherpetic neuralgia (PHN). Please refer to the figure below for detailed information.

Discussion

For patients with acute herpes zoster, the main purpose of treatment is to heal the skin lesions, relieve pain, and prevent the occurrence of PHN. Modern medicine offers active antiviral interventions, and the clinical use of neurotrophic agents, analgesics, and other medications, which have shown certain efficacy. The early use of antiviral drugs does have a blocking effect on the virus, but some patients still suffer from unbearable pain. Many HZ patients experience pain before the appearance of the rash, which often leads to missed optimal treatment timing and prolonged pain. Long-term and large-scale use of analgesic drugs can damage the liver and kidneys and irritate the gastrointestinal mucosa, which can cause acute and long-term issues that cannot be ignored. Although many PHN patients take neurotrophic agents for extended periods, the relief of pain-related suffering is not always significant. The development of drug tolerance due to long-term medication in PHN patients is also a factor that needs to be considered.

The encircling needling technique in traditional Chinese acupuncture originated from the “Leopard Spot Needling” and “Yang Needling” methods described in the “Ling Shu o Guan Zhen” section. The technique of needling the collaterals derives from “Collateral Needling” among the nine needling techniques mentioned in the “Ling Shu o Guan Zhen.” It states, “The defensive qi stays where it is, while the pathogenic qi is expelled by needling and the application of stones.” This refers to the theory of needling the superficial layers of the skin. Modern medical research has confirmed that bloodletting therapy can accelerate local blood circulation, aid in the resolution of local tissue inflammation and edema, alleviate nerve irritation and compression and promote nerve repair and regeneration (Bo Dongsheng, 2012; Chen Qiang, Chen Yunling, 2013). In the book “Clinical Guidelines and Medical Cases,” it is stated, “Long-standing pain can be alleviated by strengthening the righteous qi and dispelling pathogenic factors, leading to recovery. When it enters the collaterals, any lingering pathogenic factors within the qi and blood of the collaterals, whether deficiency or excess, cold or heat, can all result in pain relief.” Exogenous evils invade the body and enter through the meridians, where evil qi remains, causing the human body to feel pain. At this time, it is necessary to strengthen the body and eliminate the evil, and then cup after pricking, so that the toxic qi can be eliminated and the pain relieved.

《Medical Origins》 said, “If there are evils in the blood, they must be removed. If the blood that comes out is black, it will eventually turn red, and once it turns red one should stop the bleeding, otherwise the treatment can be harmful.” Modern research has confirmed that the negative pressure produced by cupping can induce a series of neuroendocrine responses in nerves and muscles and at the same time stimulate the metabolism of the skin lesion area to stimulate and accelerate the removal of metabolic waste and toxic factors, thereby shortening the course of the disease, effectively treating herpes zoster neuralgia, and preventing and postherpetic neuralgia. Cupping can also promote local blood circulation in skin lesions, enhance the permeability of blood vessel walls, and improve the body’s tolerance to pain, thereby effectively relieving pain. (Lu Shoukang, 2007)

In conclusion, acupuncture combined with cupping therapy can achieve significant therapeutic effects in the clinical treatment of postherpetic neuralgia (PHN)

Conclusion and Outlook

Based on literature retrieval and analysis, it can be concluded that acupuncture combined with cupping therapy provides superior efficacy in the treatment of postherpetic neuralgia (PHN) compared to acupuncture alone, as well as Western medicine’s analgesics, antiviral drugs, and neurotrophic agents. The early application of acupuncture plus cupping therapy has the highest efficacy rate, significantly reducing the duration of pain in herpes zoster, preventing, and minimizing the occurrence of postherpetic neuralgia, improving patients’quality of life, and alleviating or eliminating depression. This method can be applied not only to patients in the acute phase of herpes zoster but also to a wide range of PHN patients. And, because acupuncture and cupping are simple to apply, easy to replicate, low in cost, non-toxic, and have limited side effects in TCM clinical practice, this study aims to promote its application in clinical settings. In clinical application, it can be carried out simultaneously with Western medicine treatment or alone, and there is no contradiction or conflict with modern medicine. Clinically, it can also be expanded to treat neuralgia caused by other diseases and relieve pain for patients on a larger scale.

When performing acupuncture and cupping therapy, it is important to be mindful of the regulations and restrictions set by local acupuncture authorities. At the same time, it is hoped that laws and regulations related to traditional Chinese medicine can be established and implemented to respect clinical efficacy and relieve patients’pain. Non-vesicular herpes zoster, which is difficult to diagnose, can lead to treatment delays. Therefore, early treatment methods such as acupuncture combined with cupping are particularly valuable in providing relief for patients with this type of condition. Infrared therapy using a red-light lamp is often used in conjunction with acupuncture and cupping therapy for postherpetic neuralgia. Unfortunately, this study did not include a joint discussion on the combination of these treatments. It is hoped that future research can provide better organization and evidence for the combined use of these therapies. Floating needles, beryllium needles, and fire needles have also been gradually reported for their effectiveness in treating postherpetic neuralgia. However, due to factors such as specialization, technicality, patient acceptance, as well as regional regulations, their widespread application is limited. Therefore, they have not been included in this discussion.

Author information：

Yingwen He, Furong Chinese clinic，Arizona, USA 85716；

Guanhu Yang，holds a Bachelor’s degree in Traditional Chinese Medicine from Zhejiang Chinese Medical University, a Master’s degree from Nanjing Chinese Medical University, and a Ph.D. in Respiratory Medicine from Kanazawa Medical University in Japan. He completed his postdoctoral research in Pulmonary Biology at Cincinnati Children’s Hospital Medical Center in the United States. Currently, he serves as a Clinical Professor at Ohio University College of Medicine, a visiting professor at eleven medical colleges and universities including Beijing University of Chinese Medicine, and the Director of the International Acupuncture and Rehabilitation Research Institute at Wenzhou Medical University. Additionally, he holds the position of Vice President in several professional committees of the World Federation of Chinese Medicine Societies. In the state of Ohio, USA, he operates two traditional Chinese medicine clinics. He is a special invited reviewer for over 30 SCI journals, including Pharmacological Research, and serves as an editorial board member for Chinese Acupuncture and World Journal of Acupuncture. He is also the Associate Editor of the International Journal of Clinical Acupuncture. Associate editor, New England Journal of Traditional Chinese Medicine.