Articles

The Role of Bloodletting and Cupping in Severe Acute Urticaria and Angioedema as Skin Emergencies in Persian Medicine
1Department of Persian Medicine, School of Persian Medicine, Iran University of Medical Sciences, Tehran, Iran
2Student Research Committee, Iran University of Medical Sciences, Tehran, Iran
3Research Institute for Islamic and Complementary Medicine, Iran University of Medical Sciences, Tehran, Iran
Correspondence to:Fatemeh Eghbalian
Department of Persian Medicine, School of Persian Medicine, Iran University of Medical Sciences, Tehran, Iran
Tel: +98-912-434-6038
E-mail: dreghbalian@gmail.com
This is an Open-Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
J Pharmacopuncture 2022; 25(1): 7-14
Published March 31, 2022 https://doi.org/10.3831/KPI.2022.25.1.7
Copyright © The Korean Pharmacopuncture Institute.
Abstract
Methods: This was a narrative review of PM studies identified by searching medical databases using search terms related to these diseases, as well as risk-associated keywords such as “fatal”, “death”, “life-threatening”, “emergency”, “cupping”, and “bloodletting”. Data were then compared, interpreted, and analyzed.
Results: PM scholars consider the human body as a unified whole and believe in an inner power (Nature) which stems from the body. When the presence of excessive hot substances cause an imbalance of bodily humors, Nature directs their heated vapors sharply toward the skin, thus causing Shara andMaShara. If there is a high risk of inflammation spreading to vital organs under severe conditions, urgent manual interventions are crucial.
Conclusion: In serious conditions of urticaria and angioedema, Fasd or bloodletting and Hijama can be effective in speeding up the control of lesions and reducing morbidity and mortality. Consequently, the development of integrated Persian and conventional medicines may provide new therapeutic pathways for skin emergencies.
Keywords
INTRODUCTION
According to the World Health Organization, an emergency patient is someone whose health is threatened if not treated promptly [1, 2]. When acute injuries or illnesses from exacerbations of chronic diseases are life-threatening, immediate care is needed [3]. In dermatology, the rapid diagnosis of potentially life-threatening skin conditions is important in order to avoid serious complications. Progressive edema, scaly erythematous skin eruptions, large and infectious blisters, extensive petechiae and purpura, and the co-occurrence of skin lesions with fever, severe pain, or a disruption in vital signs may indicate the presence of serious conditions such as angioedema, anaphylactic shock, Stevens-Johnson syndrome, or Rocky Mountain spotted fever [4-7]. In these situations, prompt medical attention and resolution in the emergency department is crucial [1, 2].
In total, 8-20% of patients admitted to the emergency department present with dermatologic manifestations [4, 8]. Urticaria typically presents as sudden erythematous, raised, and pruritic lesions caused by the release of inflammatory mediators including histamine from mast cells. In 50% of cases, urticaria is accompanied by angioedema. Although these skin conditions are usually self-limiting, mucocutaneous airway inflammation can be life-threatening in itself, or might contribute to anaphylactic shock [4, 6, 8]. Recent studies have reported that urticaria and angioedema are among the most common dermatological reasons patients are admitted to emergency rooms [1, 2, 9, 10]. In emergency cases, airway patency must be ensured. Intravenous epinephrine or corticosteroids, followed by antihistamines, are recommended as initial treatments [4, 9].
High medical costs, uncertain insurance, and limited access to ambulances all emphasize the need to increase pre-hospital expertise in the management of medical emergencies conditions including severe urticaria and angioedema, especially in lower- and middle-income countries [3, 11].
Traditional and Complementary Medicine (TCM), also known as non-conventional medicine, has emerged as an important part of healthcare systems in almost all countries, and the demand for these services is increasing [12]. Acute and chronic illnesses have been treated by Persian Medicine (PM) scholars for thousands of years [13-15]. PM is a holistic medicine that believes in the immense complexity of the whole body and its various organs [16]. Before molecular aspects in medicine came to the fore, the humoral theory was the dominant paradigm of medicine in the civilized world. In PM, the term
PM scholars have described inflammatory dermatologic diseases which appear closely compatible with some skin rashes described in conventional medicine. In particular, the symptoms and causes of
MATERIALS AND METHODS
This narrative review incorporated specialized books and articles describing the emergency treatment of urticaria and angioedema. First, the valid and primary sources of PM were examined. These included
In total, 25 main PM books written in Arabic or Persian and published between the 9th and 19th centuries were identified. Our initial search of relevant medical databases further identified more than 1200 articles published between 1990 and 2021. With the application of initial restrictions based on selected keywords, the number of eligible studies decreased. Two reviewers met and deliberated to finalize the selection of suitable studies through consensus. In total, 46 papers and 13 books were selected for this review. The collected data were then compared and examined from the perspectives of PM and conventional medicine. The process of article selection is featured in Fig. 1.
-
Figure 1. Flow chart showing the process of selecting the relevant documents.
RESULTS
1. Clinical manifestations of emergent conditions
1) The perspective of Persian Medicine
PM maintains that a large portion of ingested food goes through multiple stages of digestion in the stomach, liver, vessels, and tissues to form normal humor. The remainder is turned into waste or unusable substances, and excreted in the form of feces, urine, sweat, nasal and lung secretions, menstrual blood, or imperceptibly through skin pores [13, 26]. PM scholars believe that the heart, brain, liver, and stomach play a more important role in health and disease than the skin. On the other hand, the skin is a vitally important excretory organ. When other pathways of the body are disrupted or large amounts of unhealthy waste are produced, Nature (as a wise force in the body) directs the extra substances to non-principal organs like the skin in order to protect more critical organs. Accumulation of these waste products generates swelling in the form of
Urticaria is one of the most common allergic skin diseases, with a prevalence of nearly 20% in the general population. Urticarial lesions or wheals present as extremely pruritic, circumscribed, elevated, and erythematous plaques of varying sizes. Although urticaria is often self-limiting, it sometimes leads patients to seek treatment in the emergency room [4, 30, 31]. Acute urticaria is the most common skin disease treated in the emergency room [9, 32]. Also, patients with chronic urticaria may be referred to the emergency department if they experience disease exacerbation [9].
Excoriations of the skin in severe acute urticaria may result from vigorous scratching [33]. Chronic urticaria may be accompanied by systemic symptoms such as fatigue, headache, flushing, joint swelling and pain, nausea, abdominal pain, palpitations, and wheezing. Urticaria in this subgroup is more severe and longer-lasting, and often association with anxiety and depression [33, 34]. Cutaneous small-vessel vasculitis as well as renal, musculoskeletal and pulmonary involvement can accompany these systemic symptoms in patients with long-lasting, painful urticaria [35, 36]. Exacerbation of symptoms at might may contribute to restlessness. Patients may therefore present at the emergency department seeking faster alleviation of their symptoms.
Angioedema accompanies urticaria in 50% of cases, and presents as sudden and severe erythema or swelling in areas with loose connective tissue, such as the face, lips, mouth, throat, larynx, uvula, extremities, genitalia, and the bowel wall. It is typically characterized by pain to a greater extent than itching [37]. Angioedema is typically self-limiting, but can also be life-threatening. Bowel wall edema may cause abdominal pain, nausea, vomiting, and diarrhea, while airway obstruction in severe cases may cause dyspnea and hypoxemia [4]. In both urticaria and angioedema, mast cells, granulocytes, and monocytes activate the inflammatory cascade and release mediators such as histamine, platelet-activating factor (PAF) and cytokines [37, 38]. The sudden systemic release of inflammatory mediators may cause an acute and life-threatening anaphylactic reaction. Hypotension, loss of consciousness, diarrhea, vomiting, abdominal cramps, laryngeal edema, and bronchospasm are some of its typical features. The early recognition and treatment of anaphylaxis is therefore crucial [39]. The similarities between the clinical manifestations and complications of
-
Table 1 . The similarities of
Shara andMashara with urticaria and angioedema.Urticaria Shara Angioedema Mashara Signs and
symptomsTransient, circumscribed, raised, and erythematous plaques in variable size with the itchy or burning sensation Sudden, swollen, erythematous, and itchy rashes of different size Sudden and severe erythema or swelling Very hot and pruritus swelling Affected site The superficial layer of the skin The skin Deep in the skin of the face, hands, and genital area On the face and forehead, especially around the eyes and nose Pain incidence Pain due to scratching and trauma to the skin if severe itching persists or the possibility of urticarial vasculitis Pain due to itching More pain than itching Painful Pathogenesis Sudden systemic release of inflammatory mediators Sudden moves of hot blood and its vapors towards the skin and mucosa Sudden systemic release of inflammatory mediators especially in head and neck Sudden moves of hot blood and its vapors towards the skin and mucosa especially of the head and neck Complications Anxiety and depression, fatigue, headache, joint pain and swelling, hot flashes, nausea and abdominal pain, palpitations, wheezing, and fever Restlessness, fainting, fever, fatigue, nausea, and discoloration of the lips and limbs Abdominal pain, nausea, vomiting, and diarrhea in gut wall edema
Dyspnea or hypoxemia in airway obstruction and the risk of anaphylactic shockRestlessness, thirst, and fever
Shortness of breath
Death if involved the heart
2. Therapeutic approach
It is essential that physicians are able to distinguish the benign forms of urticaria and angioedema from potentially severe and life-threatening conditions, particularly when first visiting a newly admitted patient [7]. In emergency rooms as well as outpatient clinics, a combined interventional approach drawing from both conventional and complementary medicine could assist recovery and improve survival in affected patients [40, 41].
1) The perspective of Persian MedicineAccording to the principles of patient management defined by PM, the physician helps Nature to balance itself in order to improve a patient’s lifestyle, including optimal sleep, movement and rest, evacuation and retention, psychological and mental reactions, as well as nutrition. Medications and manual interventions (
(1) The importance of nature deviating during emergency conditions
In severe cases of inflammatory skin lesions, including acute, progressive
In PM, manual interventions are used during two phases: first, to prevent harm to patients during acute attacks, and second, before the onset of these attacks, in order to prevent disease relapse [15, 44, 46]. In life-threatening cases of
In
-
Table 2 . Recommended places for
Fasd andHijamat in severeShara andMashara .Disease Phlebotomy veins Hijama placesShara (Urticaria)Median cubital vein
Basilica veinDepending on the location of lesions Mashara (Angioedema)Cephalic vein
Nasofrontal vein
Angular vein
Sublingual veinLegs
Various pharmacological treatments are often prescribed on an outpatient basis to prevent mast cell mediator release and provide symptomatic relief. These include first and second-generation H1-antihistamines, H2-antihistamines, leukotriene receptor antagonists, immunosuppressive agents, and glucocorticoids [37, 38]. In severe and generalized urticaria and angioedema, when there is a risk of anaphylaxis, patients should be assessed and treated promptly to prevent life-threatening respiratory and cardiovascular complications. Epinephrine injection, immediate intubation in cases of impending airway obstruction, oxygen administration, intravenous fluids, antihistamines, and glucocorticoids are the mainstay of treatment in critical cases [50, 51].
DISCUSSION
Although some skin conditions are self-limiting and can be treated on an outpatient basis, others can be life-threatening, and require immediate care [4, 52]. Severe urticaria and angioedema increase the risk of anaphylaxis, which requires hospitalization and urgent care [52]. Differentiating mundane skin ailments from serious and life-threatening conditions such as severe urticaria and angioedema require immediate treatment, and can be challenging for physicians to manage [4, 9].
A signification proportion of patients across the world are turning to TCM as a cost-effective form of treatment [12, 45]. Numerous studies have shown the important role of these therapies in the treatment of various diseases [53-56]. In contrast, very few studies have explored the role of TCM, especially PM, in the prevention and treatment of life-threatening diseases that need immediate care [40, 41]. Meng et al. found that, although Traditional Chinese medicine is widely recognized as effective in treating chronic diseases, some TCM therapies like blowing air to the ear, nose insufflating therapy, acupuncture, and moxibustion are potent in many acute and urgent medical conditions [40]. In PM, Nature as an innate power controls all aspects of the body [18, 57]. Deviating Nature by phlebotomy and wet cupping, two common manual interventions used in PM, plays an important role in protecting the principal organs of the body by purifying the blood [46, 58, 59].
Eghbalian et al. described the role of saphenous vein phelobotomy and wet cupping performed on the back of legs in the treatment of epilepsy from the perspective of PM. The authors also noted that emergency bloodletting in patients with epilepsy may be performed based on the patient’s condition [46]. In a similar fashion, Atyabi et al. studied the role of wet cupping and phlebotomy in alleviating various causes of headaches in PM. The researchers believed that
Ma et al. conducted a randomized control trial in 2020 and reported that bloodletting therapy can be an effective complementary treatment in chronic urticaria [62].
Although the mechanism of bloodletting is yet not clear in conventional medicine, draining the body’s heat or excess energy, imbalance the Qi-Blood circulation, and cleaning the channels and collaterals are possible bloodletting roles in Traditional Chinese Medicine (TCM) [43].
Apart from many studies on the importance of bloodletting and cupping in the treatment of diseases, no studies have yet published on skin emergencies and the effect of these manual interventions in Persian Medicine.
This novel study described
CONCLUSIONS
It is worth mentioning that PM manual therapies may have great potential for being applied as immediate interventions under urgent conditions of urticaria and angioedema to increase the survival and recovery rate in patients.
Future experimental and clinical efforts could be spent on PM research and then applied in emergency medicine.
CONFLICT OF INTEREST
The authors declare that they have no conflict of interest.
FUNDING
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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Related articles in JoP

Article
Review Article
J Pharmacopuncture 2022; 25(1): 7-14
Published online March 31, 2022 https://doi.org/10.3831/KPI.2022.25.1.7
Copyright © The Korean Pharmacopuncture Institute.
The Role of Bloodletting and Cupping in Severe Acute Urticaria and Angioedema as Skin Emergencies in Persian Medicine
Maryam Taghavi Shirazi1,2 , Hoorieh Mohammadi Kenari1,3
, Fatemeh Eghbalian1,3*
1Department of Persian Medicine, School of Persian Medicine, Iran University of Medical Sciences, Tehran, Iran
2Student Research Committee, Iran University of Medical Sciences, Tehran, Iran
3Research Institute for Islamic and Complementary Medicine, Iran University of Medical Sciences, Tehran, Iran
Correspondence to:Fatemeh Eghbalian
Department of Persian Medicine, School of Persian Medicine, Iran University of Medical Sciences, Tehran, Iran
Tel: +98-912-434-6038
E-mail: dreghbalian@gmail.com
This is an Open-Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Objectives: Some dermatological diseases can be life-threatening. Urticaria and angioedema are common reasons for patients to seek treatment at an emergency department. Severe, generalized urticaria and angioedema can endanger patients’ lives by involving the airways and causing anaphylactic shock. The humor-based Persian Medicine (PM) concepts of Shara andMaShara, referring to two kinds of skin lesions, have similarities to urticaria and angioedema, respectively. This article aims to provide scientific evidence regarding the application of PM as an early intervention strategy in the emergency management of urticaria and angioedema.
Methods: This was a narrative review of PM studies identified by searching medical databases using search terms related to these diseases, as well as risk-associated keywords such as “fatal”, “death”, “life-threatening”, “emergency”, “cupping”, and “bloodletting”. Data were then compared, interpreted, and analyzed.
Results: PM scholars consider the human body as a unified whole and believe in an inner power (Nature) which stems from the body. When the presence of excessive hot substances cause an imbalance of bodily humors, Nature directs their heated vapors sharply toward the skin, thus causing Shara andMaShara. If there is a high risk of inflammation spreading to vital organs under severe conditions, urgent manual interventions are crucial.
Conclusion: In serious conditions of urticaria and angioedema, Fasd or bloodletting and Hijama can be effective in speeding up the control of lesions and reducing morbidity and mortality. Consequently, the development of integrated Persian and conventional medicines may provide new therapeutic pathways for skin emergencies.
Keywords: urticaria, angioedema, emergencies, persian medicine
INTRODUCTION
According to the World Health Organization, an emergency patient is someone whose health is threatened if not treated promptly [1, 2]. When acute injuries or illnesses from exacerbations of chronic diseases are life-threatening, immediate care is needed [3]. In dermatology, the rapid diagnosis of potentially life-threatening skin conditions is important in order to avoid serious complications. Progressive edema, scaly erythematous skin eruptions, large and infectious blisters, extensive petechiae and purpura, and the co-occurrence of skin lesions with fever, severe pain, or a disruption in vital signs may indicate the presence of serious conditions such as angioedema, anaphylactic shock, Stevens-Johnson syndrome, or Rocky Mountain spotted fever [4-7]. In these situations, prompt medical attention and resolution in the emergency department is crucial [1, 2].
In total, 8-20% of patients admitted to the emergency department present with dermatologic manifestations [4, 8]. Urticaria typically presents as sudden erythematous, raised, and pruritic lesions caused by the release of inflammatory mediators including histamine from mast cells. In 50% of cases, urticaria is accompanied by angioedema. Although these skin conditions are usually self-limiting, mucocutaneous airway inflammation can be life-threatening in itself, or might contribute to anaphylactic shock [4, 6, 8]. Recent studies have reported that urticaria and angioedema are among the most common dermatological reasons patients are admitted to emergency rooms [1, 2, 9, 10]. In emergency cases, airway patency must be ensured. Intravenous epinephrine or corticosteroids, followed by antihistamines, are recommended as initial treatments [4, 9].
High medical costs, uncertain insurance, and limited access to ambulances all emphasize the need to increase pre-hospital expertise in the management of medical emergencies conditions including severe urticaria and angioedema, especially in lower- and middle-income countries [3, 11].
Traditional and Complementary Medicine (TCM), also known as non-conventional medicine, has emerged as an important part of healthcare systems in almost all countries, and the demand for these services is increasing [12]. Acute and chronic illnesses have been treated by Persian Medicine (PM) scholars for thousands of years [13-15]. PM is a holistic medicine that believes in the immense complexity of the whole body and its various organs [16]. Before molecular aspects in medicine came to the fore, the humoral theory was the dominant paradigm of medicine in the civilized world. In PM, the term
PM scholars have described inflammatory dermatologic diseases which appear closely compatible with some skin rashes described in conventional medicine. In particular, the symptoms and causes of
MATERIALS AND METHODS
This narrative review incorporated specialized books and articles describing the emergency treatment of urticaria and angioedema. First, the valid and primary sources of PM were examined. These included
In total, 25 main PM books written in Arabic or Persian and published between the 9th and 19th centuries were identified. Our initial search of relevant medical databases further identified more than 1200 articles published between 1990 and 2021. With the application of initial restrictions based on selected keywords, the number of eligible studies decreased. Two reviewers met and deliberated to finalize the selection of suitable studies through consensus. In total, 46 papers and 13 books were selected for this review. The collected data were then compared and examined from the perspectives of PM and conventional medicine. The process of article selection is featured in Fig. 1.
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Figure 1. Flow chart showing the process of selecting the relevant documents.
RESULTS
1. Clinical manifestations of emergent conditions
1) The perspective of Persian Medicine
PM maintains that a large portion of ingested food goes through multiple stages of digestion in the stomach, liver, vessels, and tissues to form normal humor. The remainder is turned into waste or unusable substances, and excreted in the form of feces, urine, sweat, nasal and lung secretions, menstrual blood, or imperceptibly through skin pores [13, 26]. PM scholars believe that the heart, brain, liver, and stomach play a more important role in health and disease than the skin. On the other hand, the skin is a vitally important excretory organ. When other pathways of the body are disrupted or large amounts of unhealthy waste are produced, Nature (as a wise force in the body) directs the extra substances to non-principal organs like the skin in order to protect more critical organs. Accumulation of these waste products generates swelling in the form of
Urticaria is one of the most common allergic skin diseases, with a prevalence of nearly 20% in the general population. Urticarial lesions or wheals present as extremely pruritic, circumscribed, elevated, and erythematous plaques of varying sizes. Although urticaria is often self-limiting, it sometimes leads patients to seek treatment in the emergency room [4, 30, 31]. Acute urticaria is the most common skin disease treated in the emergency room [9, 32]. Also, patients with chronic urticaria may be referred to the emergency department if they experience disease exacerbation [9].
Excoriations of the skin in severe acute urticaria may result from vigorous scratching [33]. Chronic urticaria may be accompanied by systemic symptoms such as fatigue, headache, flushing, joint swelling and pain, nausea, abdominal pain, palpitations, and wheezing. Urticaria in this subgroup is more severe and longer-lasting, and often association with anxiety and depression [33, 34]. Cutaneous small-vessel vasculitis as well as renal, musculoskeletal and pulmonary involvement can accompany these systemic symptoms in patients with long-lasting, painful urticaria [35, 36]. Exacerbation of symptoms at might may contribute to restlessness. Patients may therefore present at the emergency department seeking faster alleviation of their symptoms.
Angioedema accompanies urticaria in 50% of cases, and presents as sudden and severe erythema or swelling in areas with loose connective tissue, such as the face, lips, mouth, throat, larynx, uvula, extremities, genitalia, and the bowel wall. It is typically characterized by pain to a greater extent than itching [37]. Angioedema is typically self-limiting, but can also be life-threatening. Bowel wall edema may cause abdominal pain, nausea, vomiting, and diarrhea, while airway obstruction in severe cases may cause dyspnea and hypoxemia [4]. In both urticaria and angioedema, mast cells, granulocytes, and monocytes activate the inflammatory cascade and release mediators such as histamine, platelet-activating factor (PAF) and cytokines [37, 38]. The sudden systemic release of inflammatory mediators may cause an acute and life-threatening anaphylactic reaction. Hypotension, loss of consciousness, diarrhea, vomiting, abdominal cramps, laryngeal edema, and bronchospasm are some of its typical features. The early recognition and treatment of anaphylaxis is therefore crucial [39]. The similarities between the clinical manifestations and complications of
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Table 1
The similarities of
Shara andMashara with urticaria and angioedema.Urticaria Shara Angioedema Mashara Signs and
symptomsTransient, circumscribed, raised, and erythematous plaques in variable size with the itchy or burning sensation Sudden, swollen, erythematous, and itchy rashes of different size Sudden and severe erythema or swelling Very hot and pruritus swelling Affected site The superficial layer of the skin The skin Deep in the skin of the face, hands, and genital area On the face and forehead, especially around the eyes and nose Pain incidence Pain due to scratching and trauma to the skin if severe itching persists or the possibility of urticarial vasculitis Pain due to itching More pain than itching Painful Pathogenesis Sudden systemic release of inflammatory mediators Sudden moves of hot blood and its vapors towards the skin and mucosa Sudden systemic release of inflammatory mediators especially in head and neck Sudden moves of hot blood and its vapors towards the skin and mucosa especially of the head and neck Complications Anxiety and depression, fatigue, headache, joint pain and swelling, hot flashes, nausea and abdominal pain, palpitations, wheezing, and fever Restlessness, fainting, fever, fatigue, nausea, and discoloration of the lips and limbs Abdominal pain, nausea, vomiting, and diarrhea in gut wall edema
Dyspnea or hypoxemia in airway obstruction and the risk of anaphylactic shockRestlessness, thirst, and fever
Shortness of breath
Death if involved the heart
2. Therapeutic approach
It is essential that physicians are able to distinguish the benign forms of urticaria and angioedema from potentially severe and life-threatening conditions, particularly when first visiting a newly admitted patient [7]. In emergency rooms as well as outpatient clinics, a combined interventional approach drawing from both conventional and complementary medicine could assist recovery and improve survival in affected patients [40, 41].
1) The perspective of Persian MedicineAccording to the principles of patient management defined by PM, the physician helps Nature to balance itself in order to improve a patient’s lifestyle, including optimal sleep, movement and rest, evacuation and retention, psychological and mental reactions, as well as nutrition. Medications and manual interventions (
(1) The importance of nature deviating during emergency conditions
In severe cases of inflammatory skin lesions, including acute, progressive
In PM, manual interventions are used during two phases: first, to prevent harm to patients during acute attacks, and second, before the onset of these attacks, in order to prevent disease relapse [15, 44, 46]. In life-threatening cases of
In
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Table 2
Recommended places for
Fasd andHijamat in severeShara andMashara .Disease Phlebotomy veins Hijama placesShara (Urticaria)Median cubital vein
Basilica veinDepending on the location of lesions Mashara (Angioedema)Cephalic vein
Nasofrontal vein
Angular vein
Sublingual veinLegs
Various pharmacological treatments are often prescribed on an outpatient basis to prevent mast cell mediator release and provide symptomatic relief. These include first and second-generation H1-antihistamines, H2-antihistamines, leukotriene receptor antagonists, immunosuppressive agents, and glucocorticoids [37, 38]. In severe and generalized urticaria and angioedema, when there is a risk of anaphylaxis, patients should be assessed and treated promptly to prevent life-threatening respiratory and cardiovascular complications. Epinephrine injection, immediate intubation in cases of impending airway obstruction, oxygen administration, intravenous fluids, antihistamines, and glucocorticoids are the mainstay of treatment in critical cases [50, 51].
DISCUSSION
Although some skin conditions are self-limiting and can be treated on an outpatient basis, others can be life-threatening, and require immediate care [4, 52]. Severe urticaria and angioedema increase the risk of anaphylaxis, which requires hospitalization and urgent care [52]. Differentiating mundane skin ailments from serious and life-threatening conditions such as severe urticaria and angioedema require immediate treatment, and can be challenging for physicians to manage [4, 9].
A signification proportion of patients across the world are turning to TCM as a cost-effective form of treatment [12, 45]. Numerous studies have shown the important role of these therapies in the treatment of various diseases [53-56]. In contrast, very few studies have explored the role of TCM, especially PM, in the prevention and treatment of life-threatening diseases that need immediate care [40, 41]. Meng et al. found that, although Traditional Chinese medicine is widely recognized as effective in treating chronic diseases, some TCM therapies like blowing air to the ear, nose insufflating therapy, acupuncture, and moxibustion are potent in many acute and urgent medical conditions [40]. In PM, Nature as an innate power controls all aspects of the body [18, 57]. Deviating Nature by phlebotomy and wet cupping, two common manual interventions used in PM, plays an important role in protecting the principal organs of the body by purifying the blood [46, 58, 59].
Eghbalian et al. described the role of saphenous vein phelobotomy and wet cupping performed on the back of legs in the treatment of epilepsy from the perspective of PM. The authors also noted that emergency bloodletting in patients with epilepsy may be performed based on the patient’s condition [46]. In a similar fashion, Atyabi et al. studied the role of wet cupping and phlebotomy in alleviating various causes of headaches in PM. The researchers believed that
Ma et al. conducted a randomized control trial in 2020 and reported that bloodletting therapy can be an effective complementary treatment in chronic urticaria [62].
Although the mechanism of bloodletting is yet not clear in conventional medicine, draining the body’s heat or excess energy, imbalance the Qi-Blood circulation, and cleaning the channels and collaterals are possible bloodletting roles in Traditional Chinese Medicine (TCM) [43].
Apart from many studies on the importance of bloodletting and cupping in the treatment of diseases, no studies have yet published on skin emergencies and the effect of these manual interventions in Persian Medicine.
This novel study described
CONCLUSIONS
It is worth mentioning that PM manual therapies may have great potential for being applied as immediate interventions under urgent conditions of urticaria and angioedema to increase the survival and recovery rate in patients.
Future experimental and clinical efforts could be spent on PM research and then applied in emergency medicine.
CONFLICT OF INTEREST
The authors declare that they have no conflict of interest.
FUNDING
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Fig 1.

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Table 1 . The similarities of
Shara andMashara with urticaria and angioedema.Urticaria Shara Angioedema Mashara Signs and
symptomsTransient, circumscribed, raised, and erythematous plaques in variable size with the itchy or burning sensation Sudden, swollen, erythematous, and itchy rashes of different size Sudden and severe erythema or swelling Very hot and pruritus swelling Affected site The superficial layer of the skin The skin Deep in the skin of the face, hands, and genital area On the face and forehead, especially around the eyes and nose Pain incidence Pain due to scratching and trauma to the skin if severe itching persists or the possibility of urticarial vasculitis Pain due to itching More pain than itching Painful Pathogenesis Sudden systemic release of inflammatory mediators Sudden moves of hot blood and its vapors towards the skin and mucosa Sudden systemic release of inflammatory mediators especially in head and neck Sudden moves of hot blood and its vapors towards the skin and mucosa especially of the head and neck Complications Anxiety and depression, fatigue, headache, joint pain and swelling, hot flashes, nausea and abdominal pain, palpitations, wheezing, and fever Restlessness, fainting, fever, fatigue, nausea, and discoloration of the lips and limbs Abdominal pain, nausea, vomiting, and diarrhea in gut wall edema
Dyspnea or hypoxemia in airway obstruction and the risk of anaphylactic shockRestlessness, thirst, and fever
Shortness of breath
Death if involved the heart
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Table 2 . Recommended places for
Fasd andHijamat in severeShara andMashara .Disease Phlebotomy veins Hijama placesShara (Urticaria)Median cubital vein
Basilica veinDepending on the location of lesions Mashara (Angioedema)Cephalic vein
Nasofrontal vein
Angular vein
Sublingual veinLegs
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