Acupuncture in Dermatology: An Update to a Systematic Review

Abstract

Objectives:

Acupuncture is an important Traditional Chinese Medicine modality based on the fundamental theory that disease is caused by disruptions in the body's qi. Understanding the use of acupuncture in dermatology is important due to the rising prevalence of complementary and alternative medicine use. A systematic review published in 2015 found that acupuncture improves outcomes in several dermatological diseases. We performed a systematic review of studies that have been done since then to present updated evidence.

Methods:

A systematic search of MEDLINE, EMBASE, and the Cochrane Central Register was performed. Studies were limited to clinical trials, controlled studies, case reports, comparative studies, and systematic reviews published in the English language. Studies involving moxibustion, electroacupuncture, or blood-letting were excluded.

Results:

Results showed that acupuncture improves clinical outcomes in uremic pruritus, atopic dermatitis, urticaria, and itch. Acupuncture does not significantly reduce postoperative itch in patients undergoing cesarean section under spinal anesthesia.

Conclusions:

While there are some promising studies that support the use of acupuncture for skin diseases, additional large-scale, randomized, sham-controlled trials need to be performed to present consistent high-level evidence of acupuncture's role in dermatology.

Introduction

Acupuncture is a Traditional Chinese Medicine (TCM) modality that primarily uses needles to stimulate specific points on the body to restore the balance of qi, or vital energy in the human body.¹ Other variations that use heat or moxibustion, cupping, suction, or pressure are also practiced. Traditionally, acupuncture is usually used in conjunction with other modalities in TCM.² The basis of acupuncture is the theory that disease is caused by disruptions in the body's qi, which flows along channels, or meridians that form a network throughout the body.^2,3

Acupuncture is used complementarily to modern medicine and independently with a long history of use in China, Taiwan, Japan, and Korea.^4,5 The National Institutes of Health (NIH) declared that there was scientific evidence of acupuncture's efficacy in select clinical situations in 1997 as acceptable alternatives to mainstay treatments or adjunct treatments. These situations included postoperative and chemotherapy nausea and vomiting, postoperative dental pain, addiction, fibromyalgia, menstrual cramps, headaches, and musculoskeletal pains such as osteoarthritis, low back pain, and tennis elbow.⁶ Acupuncture use in the general population in the United States was estimated at a prevalence between 0.6% and 1.4% in 2007.⁷ An understanding of acupuncture in treating skin disease is vital as the number of patients seeking complementary and alternative medicines increases. A systematic review in 2015 by Ma and Sivamani concluded that acupuncture improves outcome measures in several dermatological conditions, including dermatitis, chloasma, pruritus, urticaria, hyperhidrosis, and facial elasticity.⁸ Since then, many new studies on acupuncture in skin disease have been completed. Herein, we present a systematic review from 2014 onward that assesses the results and quality of the studies that investigate the use of acupuncture to treat a variety of dermatological disorders.

Methods

Study selection

A systematic search of Pubmed, EMBASE, and Cochrane Central Register was performed looking for articles from January 1, 2014 to December 31, 2020 (Fig. 1). Search terms included Acupuncture [AND] (“dermatology,” “skin disease,” “atopic dermatitis,” “psoriasis,” “hidradenitis suppurativa,” “pruritus,” “urticaria,” “dermatitis,” “rosacea,” “itch,” “melasma,” “acne,” and “wart”). We originally followed the 2015 systematic review protocol that only used “dermatology,” “skin disease,” and “acupuncture” as search terms, but then adjusted our methods to include the more commonly found dermatological conditions in our search to identify additional articles. Seven hundred thirty-six articles across all three electronic databases were initially found. We replicated the 2015 systematic review's inclusion criteria, which included studies in English evaluating acupuncture or acupressure as the main treatment modality in dermatological conditions. Studies that used moxibustion, electroacupuncture, or blood-letting as forms of acupuncture were excluded. Case reports, clinical trials, controlled studies, comparative studies, and systematic reviews were included. Systematic reviews were included for reference review. After abstract and title review, a total of 23 articles in the English language were included.

FIG. 1.

PRISMA flow diagram. From Moher D, Liberati A, Tetzlaff J, Altman DG; The PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLoS Med 2009;6:e1000097. For more information, visit www.prisma-statement.org.

Data extraction, grading evidence levels, and risk of bias

Data extracted included study characteristics (author, year, study design), study population (size, age), condition treated, interventions (acupuncture and control), outcome measurements, and main results and conclusions.

Level of evidence was graded by using guidelines from the Oxford Center for Evidence-Based Medicine (OCEBM) tool with levels from I-V. Level I studies include systematic reviews of randomized controlled trials (RCTs) or n-of-1 trials. Level II studies include RCTs or observational studies with dramatic effect. Level III evidence is defined as nonrandomized controlled cohort/follow-up studies. Level IV includes case-series, case-control studies, or historically controlled studies, and level V evidence is mechanism-based reasoning.⁹ The OCEBM tool instructs users to grade up or down a level depending on the specific studies' quality, imprecision, indirectness, consistency, and absolute effect size.

Risk of bias was assessed by using the Evidence Project risk-of-bias tool, which is a tool developed to assess risk of bias in reviews that include both randomized and nonrandomized trials.¹⁰

Results

Twenty-three studies were identified in total, and results are summarized in Table 1. Dermatological conditions investigated were psoriasis (n = 2), atopic dermatitis (AD; n = 4), itch (n = 2), urticaria (n = 1), chronic idiopathic pruritus (n = 1), postoperative itch/pruritus (n = 2), uremic pruritus (n = 5), seborrheic alopecia (n = 1), acne (n = 1), hidradenitis suppurativa (n = 1), lichen simplex chronicus (n = 1), warts (n = 1), and melasma (n = 1). Acupuncture resulted in statistically significant improvements in outcome measures in 10 out of 14 of the completed studies found. Efficacy was determined by a combination of level of evidence and improvement in outcome measures. Eight studies had level II evidence, two had level III, three had level IV, and one had level V; no studies with level I evidence were found, and ongoing studies were not graded.

Table 1.

Results Table—Acupuncture in Dermatology

Study	Level of evidence	Design	Intervention and location	Intervention frequency and duration	Comparison	Outcome measures	Results
Psoriasis
Mahović and Mrsić¹¹	V	Case report of a 49-year-old female patient with migraines and psoriasis	Acupuncture on the head, arms, and legs was given for migraine treatment	Once a day for 10 days every 2–3 days	None	None	A significant improvement in the plaques was observed during the acupuncture course for the migraines
Deng et al.¹²	NA^a	Two-arm, parallel, assessor-blinded, randomized control trial 180 patients (18–70 years)	Auricular acupressure CO14, TF4, CO18, AT4, and CO124	Once weekly for 4 weeks plus calcipotriol-betamethasone ointment	Calcipotriol-betamethasone ointment only once daily	PASI VAS DLQI	Ongoing, no results published
AD
Kang et al.¹³	II	Randomized, double-blinded, sham-controlled, preliminary trial with three arms 30 adult patients (19+ years)	6 acupoints: LI11, ST36, and PC6 bilaterally +19 additional depending on individual symptoms	VA1: Three times weekly for 4 weeks VA2: twice weekly for 4 weeks	SA twice weekly for 4 weeks	SCORAD EASI VAS (Pruritus) VAS (Insomnia) POEM DLQI PPT STAXI CES-D	Significant difference VA1/VA2 vs. SA (p = 0.005) Significant difference between the VA1 and SA group (p < 0.05) No significant difference No significant difference Significant difference among the three groups at week 8 (p = 0.045) Significant difference among the three groups at week 8 (p = 0.024) No significant difference No significant difference No significant difference
Lee and Park¹⁴	III	Single-center, observer-blinded, prospective, randomized comparative clinical pilot trial 14 adult patients (20–50 years)	Bilateral LI11	Three times weekly for 4 weeks	Needle embedding treatment once weekly for 4 weeks	SCORAD TEWL DLQI Skin hydration	Significant decrease in both groups from baseline with no significant differences between the two treatment groups (p < 0.05) (p < 0.05) Significant increase in both groups from baseline with no significant differences between the two treatment groups (p < 0.05) (p < 0.05)
Park et al.¹⁵	NA^a	Randomized, double-blind, sham-controlled trial 36 mild-to-moderate AD patients (19–65 years)	Six fixed acupoints: LI11, ST36, and PC6 bilaterally +10 additional customized acupoints	Twice weekly for 4 weeks of acupuncture	SA twice weekly for 4 weeks	SCORAD, EASI, QoL, POEM, DLQI, dyspepsia symptoms, abdominal exam using PPT algometer	Ongoing, no results published.
Cree and Rotter¹⁶	NA^a	Randomized, controlled trial with three arms 120 patients (18–65 years)	Not specified	Arm 2: eight treatments 1 week apart for 30 min each	Arm 1: Five osteopathy treatments 2 weeks apart for 45 min each Arm 3: No intervention given	VAS DLQI Topical corticosteroid use SCORAD EASI SF-12	Ongoing, no results published
Itch/pruritus/urticaria
Mazda et al.²¹	II	Randomized, placebo controlled, double-blinded trial 30 adult patients (18–50 years) scheduled for cesarean delivery under spinal anesthesia with intrathecal morphine to assess morphine-induced pruritus	LI4, PC6, LI11, and SJ6 bilaterally	Given the day before C-section and removed 48 h postoperatively	SA given in the same timeline as the acupuncture group	Incidence of postoperative morphine-induced pruritus	No significant difference in acupuncture (10/15) and sham group (10/15) (67% vs. 67%, p = 1.000 and RR 1.0 [95% CI 0.60 to 1.66])
Min et al.¹⁸	II	Randomized, crossover, participant-blinded trial split into two studies 20 healthy participants (18–50 years) were given 1% histamine on volar aspect of forearm and medial aspect of foot of nondominant side after acupuncture or placebo treatment	Study 1: LI11, SP10, PC6, PC3, PC7, HT7, and ST36 on the patient's nondominant side Study 2: same points but excluded LI11	Study 1: stainless steel needles manipulated for 9 sec repeated every 5 min over 20 min Study 2: used titanium needles instead	Tactile stimulation by gentle tapping with a size 5.46 von Frey filament 5 min over 20 min (Study 1) and over 5 min (Study 2)	VAS Skin blood perfusion Heart rate variability fMRI of putamen	Significantly lower in acupuncture arm vs. placebo for both arm (p < 0.001) and foot (p < 0.001) Mean perfusion unit significantly lower in acupuncture arm vs. placebo (p = 0.036) No significant difference between groups No significant change in functional connectivity of putamen
Orr et al.²⁰	II	Randomized controlled patient-blind trial 80 patients undergoing elective C-section under spinal anesthesia	LI11 point	Prophylactic acupuncture before C-section	0.3 mm stud at TB10 point	Itch-free patients VAS	Nonsignificant difference between acupuncture vs. control at 3–5 h (24%, 18%, p = 0.5) and at 24 h (24%, 13%, p = 0.2) No reduction between groups
Sacchelli et al.¹⁷	IV	Randomized, pilot study with two arms 10 adult patients (mean age: 65.8 years) with chronic itch	Arm 1: SP6, SP10, LI11, ST36 Arm 2: additional 2 acupoints according to patient's specific diagnosis	Once weekly for 4 weeks followed by a 4-week break and then a fifth session	None	VAS ISS Objective signs of pruritus	Decrease in mean score at session 5 (1.9) vs. baseline (5) Decrease in number of patients with moderate-to-severe score at session 5 (8) vs. baseline (0) Absent at session 5 in all patients vs. present in 7 patients at baseline
Manway et al.¹⁹	IV	Uncontrolled, nonrandomized, pilot study 10 adult patients (18+ years) with chronic idiopathic pruritus	32 standard acupuncture points across the body with additional local points directed toward localized severe itching	10 acupuncture treatments 1 week apart	None	ESR CRP Perceived itch	1 patient possessed an elevated ESR pretreatment that returned to normal post-treatment No differences in CRP were noted Overall, 7 of 10 patients reported relief from itching after treatment
Shi et al.³³	NA^a	Randomized, sham-controlled, participant- and assessor-blinded pilot trial 60 adult patients (18–70 years) with CU	GV20, GV24, LI11, CV12, ST25, and SP10 points	Acupuncture 5 sessions weekly for 2 weeks	SA 5 sessions weekly for 2 weeks	UAS, VAS, DLQI, HAMD, and HAMA	Ongoing, no results published
Uremic pruritus
Nahidi et al.²²	II	Multicenter, randomized, patient-blinded, controlled trial 30 patients (18–65 years) under hemodialysis	SP6, SP10, LV3, LI4, and LI11	Acupuncture for 30 min for 6 weeks (amount weekly unspecified) plus 200 mg oral gabapentin daily for 6 weeks	SA plus 200 mg oral gabapentin daily for 6 weeks	VAS	Significant difference between groups after treatment (p < 0.001)
Kiliç and Taşci²³	II	RCT with three arms 75 patients (18+ years) under hemodialysis with uremic pruritus	LI-II (laterality not specified)	Three times a week for 4 weeks of acupressure (arm 1) or TEAS (arm 2) during the first half of every hemodialysis session	Normal clinical treatment of antihistamine tablets was also given to the other two groups	VAS Number of antihistamine tablets used	Significant difference in acupuncture vs. control (p = 0.013) and TEAS group vs. control (p = 0.004) and significant difference in all groups vs. baseline (acupressure, p < 0.001; TEAS, p < 0.001; control, p < 0.05) Significant difference in acupressure and TEAS group vs. control (p < 0.05)
Yan et al.²⁴	II	Randomized controlled assessor-blinded trial 71 patients (20–65 years) undergoing hemodialysis with uremic pruritus	CO10, CO14, CO15, TF4, CO18, and AT4	Auricular acupressure three times weekly for 6 weeks with Vaccaria seeds	Tape control without Vaccaria seed, participants were informed that the tape contained TCM	VAS Serum histamine levels	Significantly greater decrease in mean score of acupressure vs control group at week 6 (p < 0.0001) Significantly greater decrease in acupressure vs control group at week 6 (p = 0.0290)
Rehman et al.²⁵	NA^a	Multicenter, open-label, parallel group, prospective RCT Adult patients (18+ years)	Acupressure points KI-1 bilaterally	6 min with 3 min per foot daily for 8 weeks	Zolpidem 10mg once daily for 8 weeks	PSQI EQ5D-3L 5D itch scale	Ongoing, no results published
Aval²⁶	NA^a	RCT 30 patients (18–65 years) under hemodialysis with uremic pruritus who have failed conventional treatment	SP10, ST36, LI4, LV3, and SP6	Two times a week, for 6 weeks	SA right outside the acupoints used	VAS Mast cells per 40 × magnification, Giemsa stain QoL	Ongoing, no results published
Other
Brustin et al.²⁸	II	Randomized, participant-blinded, trial 18 adult (20–70 years) patients with chronic cutaneous warts of 2 years or more with history of unsuccessful conventional treatment	SP 6, LR 13, LU 6, ST 36, LI 10, GV 3, and CV 12 bilaterally	1 session weekly for 4 weeks lasting 30 min	SA, patients were allowed to crossover after 4 sessions of placebo	Complete clinical clearance of all lesions 3 months after the last therapeutic session Cytokine levels	36% of acupuncture-treated warts disappeared vs. 0% in placebo (p = 0.007) Significant decrease in TNF-α concentration in the lesion cleared vs. uncleared group
Encarnacion and Iniego²⁷	III	Single-blinded, randomized controlled clinical trial 32 adult patients with Lichen Simplex Chronicus	Unspecified	Two to three times weekly for 4 weeks in addition to topical corticosteroid BID	Topical corticosteroid BID only	DLQI VAS score	Mean difference at 4 weeks was significantly larger vs. placebo Significantly lower at weeks 2 and 4 vs. placebo (no p-value provided)
Rerksuppaphol et al.²⁹	IV	Randomized, uncontrolled, trial with two groups 45 adult women with melasma	Group 1: Facial (rims of lesions) or facial Group 2: Facial + body electro-acupuncture CV6, bilateral LI4, SP10, ST36, LR3, and SP6	Twice weekly for 8 weeks	None	Change in melasma size Change in melasma pigmentation	Significant decrease in melasma size in both groups vs. baseline (p < 0.001) Significant decrease in pigmentation vs. baseline in facial acupuncture only (p = 0.002)
Chen et al.³⁰	NA^a	RCT 60 adult (18–50 years) patients	GV20, GB20, EX-HN-1, ST44, and LV3	Three times weekly for 4 weeks as a course for a total of three courses	Regular shampoo care once every 2 days	Skin lesion score, hair loss, scalp condition, hair regeneration, and DLQI	Ongoing, no results published
Kou et al.³¹	NA^a	Randomized control trial 66 adult (16–40 years) patients with acne grade II or above	LI4, LI11, LU5, UB40, UB13, UB12, ST36, SP6, and SP9	30 sessions of acupuncture for 30 min	Topical vitamin A cream once a day for 4 weeks	Skin lesions score scale, complexion, emotion, urination, stool, sleep, appetite, and menstruation	Ongoing, no results published
Daveluy ³²	NA^a	Randomized controlled, participant-blinded trial 32 patients (18+ years)	5 points on the ears bilaterally	Two treatments total spaced 1 week apart	SA 2 points for liver and 1 point for stomach at the ears bilaterally	Pain numerical rating score	Ongoing, no results published

AD, atopic dermatitis; CES-D, Center for Epidemiologic Studies-Depression Scale; CRP, C-reactive protein; CU, chronic urticaria; DLQI, Dermatology Life Quality Index; EASI, Eczema Area Severity Index; EQ5D-3L, Euro quality of life 5D; ESR, erythrocytic sedimentation rate; HAMA, Hamilton Anxiety Scale; HAMD, Hamilton Depression Scale; ISS, Itch Severity Score; NA, not applicable; PASI, Psoriasis Area Severity Index; POEM, Patient Oriented Eczema Measure; PPT, pressure pain threshold; PSQI, Pittsburgh Sleep Quality Index; QoL, quality of life; RCT, randomized controlled trial; SA, sham acupuncture; SCORAD, Scoring Atopic Dermatitis Index; SF-12, General health related quality of life; STAXI, State-Trait Anger Expression Inventory; TCM, Traditional Chinese Medicine; TEAS, transcutaneous electrical acupoint stimulation; TEWL, trans-epidermal water loss; UAS, urticaria activity score; VA, verum acupuncture; VAS, Visual Analogue Scale.

Due to ongoing study with no published results.

Risk of bias is reported in Table 2; the Evidence Project tool does not give a summary score due to possible misleading effects and differences in the weight of each item. We explored the possibility of giving an interpretation of the overall estimated risk of bias for each study. However, the Evidence Project has not done so to date and does not provide guidelines for assigning these values.¹⁰ Therefore, we only compared whether one trial had a “higher” or “lower” risk of bias than another and left overall interpretation up to the reader. Studies were ordered in the same order as the results table, and ongoing studies were not assessed.

Table 2.

Evidence Project Risk-of-Bias Tool Assessment

Study	Cohort	Control or comparison group	Pre-/postintervention data	Random assignment of participants to the intervention	Random selection of participants for assessment	Follow-up rate of 80% or more	Comparison group equivalent on sociodemographics
Psoriasis
Itch/pruritus/urticaria
Mahović and Mrsić¹¹	No	No	No	NA	No	NA	NA
AD
Kang et al.¹³	Yes	Yes	Yes	Yes	No	Yes	Yes
Lee and Park¹⁴	Yes	Yes	Yes	Yes	No	Yes	Yes
Mazda et al.²¹	Yes	Yes	No	Yes	No	Yes	No
Min et al.¹⁸	Yes	Yes	Yes	Yes	No	NA	Yes
Orr et al.²⁰	Yes	Yes	No	Yes	No	Yes	Not reported
Sacchelli et al.¹⁷	Yes	No	Yes	NA	No	Yes	NA
Manway et al.¹⁹	Yes	No	Yes	NA	No	Yes	NA
Uremic pruritus
Nahidi et al.²²	Yes	Yes	Yes	Yes	No	Yes	No
Kiliç and Taşci²³	Yes	Yes	Yes	Yes	No	Yes	Yes
Yan et al.²⁴	Yes	Yes	Yes	Yes	No	Yes	Yes
Other
Brustin et al.²⁸	Yes	Yes	Yes	Yes	No	Yes	Not reported
Encarnacion and Iniego²⁷	Yes	Yes	Yes	Yes	No	Not reported	Not reported
Rerksuppaphol et al.²⁹	Yes	No	Yes	NA	No	Yes	Yes

AD, atopic dermatitis; NA, not applicable.

Psoriasis

The only publication found for psoriasis was a case report of a 49-year-old woman treated with acupuncture for migraines with a noted concurrent improvement in her psoriasis.¹¹ However, a two-arm parallel, assessor-blinded, RCT that will assess 180 adult patients with psoriasis is currently ongoing. The study will evaluate the Psoriasis Area Severity Index), Visual Analogue Scale (VAS), and Dermatology Life Quality Index (DLQI).¹²

Atopic dermatitis

A double-blinded, sham-controlled, randomized trial with three arms found a significant difference in Scoring Atopic Dermatitis Index (SCORAD), Eczema Area Severity Index (EASI), Patient Oriented Eczema Measure (POEM), and DLQI in the two verum acupuncture arms versus the sham acupuncture (SA) arm. However, no significant differences were observed in VAS pruritus or VAS itch scores between groups.¹³ An observer-blinded, prospective, randomized, clinical pilot trial compared acupuncture with needle embedding treatment and found significant differences from baseline to study completion in SCORAD, trans-epidermal water loss, DLQI, and skin hydration but no significant differences between groups.¹⁴ There are two ongoing RCTs for AD. One is a randomized, double-blind, sham-controlled trial of 36 mild-to-moderate AD adult patients and will evaluate SCORAD, EASI, quality of life (QoL), POEM, DLQI, and dyspepsia symptoms.¹⁵ The other has three arms with 120 adult AD patients and will compare acupuncture with osteopathy and no treatment. It will assess VAS, DLQI, topical corticosteroid use, SCORAD, EASI, and general health-related QoL (SF-12).¹⁶

Itch, pruritus, and urticaria

A randomized, uncontrolled pilot study on chronic itch found decreases in VAS, Itch Severity Score (ISS) compared with baseline; significance was not assessed, and there were no calculated p-values. In addition, objective signs of pruritus were absent at weeks 5 and 7.¹⁷ Another study investigated histamine-induced itch and was a randomized, crossover, participant-blind trial that gave 20 healthy patients 1% histamine after acupuncture or placebo treatment. VAS was significantly decreased in the acupuncture arm versus placebo. The same study also assessed skin blood perfusion to measure itch subjectively and found significant decreases in the acupuncture arm versus placebo.¹⁸

An uncontrolled nonrandomized pilot study of 10 adult patients with chronic idiopathic pruritus found that 7 of 10 patients reported relief and noted 1 patient with elevated ESR return to normal after treatment. Significance was not assessed, because no p-values were calculated.¹⁹

For postoperative itch prevention, a patient-blinded RCT prophylactically gave acupuncture or shame acupuncture to 80 patients undergoing elective cesarean section who were administered spinal anesthesia. There was a nonsignificant trend to reduce itch in the acupuncture group and no reduction in the mean or median VAS score between groups.²⁰ A randomized, double-blind, placebo-controlled trial assessed morphine-induced pruritus on 30 adult patients scheduled for C-section under spinal anesthesia with intrathecal morphine. Acupuncture or SA was given prophylactically the day before the C-section and removed 48 h postoperatively. They found no significant difference in the incidence of postoperative pruritus.²¹

Uremic pruritus

All five studies found were RCTs. All three completed studies found significantly decreased VAS in acupuncture compared with control in patients undergoing hemodialysis with uremic pruritus. The first study compared acupuncture with SA in 30 adult patients in a multicenter, patient-blinded RCT.²² The second completed study is an RCT of 75 patients with three arms that compared acupressure, transcutaneous electrical acupoint stimulation, and normal clinical treatment of antihistamine tablets. In addition to a significantly decreased VAS in the acupressure group, this study also observed a significant decrease in antihistamine tablets used in the treatment groups versus control.²³ The last completed study is an assessor-blind RCT that compares auricular acupressure with Vaccaria seeds to a tape control in 71 patients. In addition to VAS, it also found a significantly greater decrease in serum histamine levels in the acupressure versus control group.²⁴ One ongoing RCT will be assessing acupressure, and the outcomes will be the Pittsburgh Sleep Quality Index, Euro QoL 5DEQ (5D-3L), and 5D itch scale.²⁵ The other will be assessing acupuncture with outcomes of VAS, mast cells per 40 × magnification, and QoL.²⁶

Other

A single-blinded RCT assessed 32 adult patients with lichen simplex chronicus and found significantly larger improvements in DLQI and significantly lower VAS scores in treatment versus placebo.²⁷ A participant-blinded RCT assessed 18 adult patients with a history of warts for 2 years of more with unsuccessful conventional treatment. Significantly more (36%) acupuncture-treated warts disappeared versus the placebo group (0%).²⁸ A randomized uncontrolled trial in 45 adult women with melasma observed a significant decrease in size and pigmentation in the acupuncture treated groups from baseline.²⁹ Three current ongoing RCTs will assess acupuncture in seborrheic alopecia, acne, and hidradenitis suppurative.^30
–32

Discussion

In this systematic review, we have updated on the previously done systematic review in 2015 by Ma and Sivamani. For patients with uremic pruritus, there is consistent level II evidence that acupuncture is an effective treatment modality for treating symptoms of pruritus, which may be due, in part, to decreased histamine levels, as seen in one of the studies. Although the interventions vary slightly in acupoints used, all three completed studies reported significant decreases in VAS score in the intervention group versus control. This supports the previous systematic review that found one RCT and one non-RCT in which acupuncture improved uremic pruritus.⁸

AD has promising results that show it significantly decreases SCORAD and EASI but surprisingly had no significant difference in pruritus or itch VAS scores. However, sample sizes were small: One trial had 14 patients, and the other had 30 patients. Ma and Sivamani's review also observed small sample sizes with five studies involving 20 or fewer participants.⁸ Psoriasis was not found in Ma et al.'s review, and our study only found one case report that is level V evidence. We eagerly await the results of the ongoing RCT of 180 patients, which would likely have a lower risk of bias and a higher level of evidence than the currently included case report.

Two level II evidence studies found that acupuncture was ineffective for prevention of itch in patients given spinal anesthesia for c-section. The 2015 review included one RCT by Jiang et al. that found a significant decrease in pruritus after spinal anesthesia when patients were given prophylactic acupuncture; however, the control in that study was a lack of intervention and not a placebo such as SA.⁸ The studies in our review used SA or studs as their control groups, which resulted in lower risk of bias than the study included in Ma's 2015 review. In addition, Jiang et al.'s trial investigates patients undergoing transurethral prostatic resection whereas the trials in our review assess c-section patients. Therefore, we cannot draw general conclusions about prophylactic acupuncture usage for preventing itch in patients receiving spinal anesthesia, because outcomes may vary due to the different procedures the patients were undergoing. However, current evidence suggests that for c-section patients undergoing spinal anesthesia, acupuncture does not decrease the incidence of postoperative itch.

The role of acupuncture in treating itch has been assessed in several ways. The study using experimentally induced itch with histamine in healthy patients is promising but did not assess patients with disease. Acupuncture decreased VAS, ISS, and objective pruritus signs in one trial on chronic itch but was rated as level IV evidence. One study on chronic idiopathic pruritus was included: It had level IV evidence and found decreased “perceived itch” in patients. The lack of a control group and more objective measures of itch make it difficult to draw conclusions; in addition, the 2015 review did not find any studies on chronic idiopathic pruritus.⁸ Conclusions about the use of acupuncture in itch and chronic idiopathic pruritus cannot be made.

Ma and Sivamani found two RCTs on chronic urticaria that showed acupuncture as effective in decreasing rate and duration of urticarial episodes and increasing clearance rate, which they rated as level II evidence.⁸ Our review only found Shi et al.'s³³ ongoing RCT on chronic urticaria. Ma and Sivamani concluded that acupuncture improves outcome measures in chronic urticaria, and we are unable to include any significant updates to this knowledge.

Ma and Sivamani found one study in favor of acupuncture use in melasma and one against: Both were level I–II evidence, whereas our review only found one additional uncontrolled study of level IV evidence, which found decreases in melasma extent and pigmentation versus baseline. For acne, Ma and Sivamani did not find strong evidence for the use of acupuncture and our review only found one ongoing study with no results published.⁸ No significant conclusions about acupuncture use in melasma or acne can be made.

Limitations to our study include only evaluating articles in English, so we could not assess the entire scope of articles found. The method of blinding used among the studies was highly variable. Some studies blinded participants only, assessors only, or did not blind at all. In addition, control groups had variable treatments with some using SA and others using creams or medications. Outcome measurements were also variable across studies, even when assessing for the same condition. This heterogeneity in studies made it difficult to uniformly assess and compare different studies and, consequently, prevented us from pooling findings in a valid form for meta-analysis. Although limiting inclusion criteria to only RCTs would be ideal, we ultimately decided against it due to our desire to replicate the 2015 systematic review inclusion criteria.

Conclusion

The increasing prevalence of acupuncture usage necessitates a better understanding of its potential uses in dermatology. We conclude that acupuncture may be effective in treating uremic pruritus and chronic urticaria but is not effective in preventing postoperative itch in patients receiving spinal anesthesia when undergoing elective c-section. Other promising conditions for treatment include AD and essential pruritus. Future studies should standardize placebo and blinding methods to control for bias, which could also lead to opportunities for meta-analysis. Additional large-scale RCTs are needed to assess acupuncture in dermatology to solidify efficacy as a valid treatment modality.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding of any sort was provided for this systematic review of the literature.

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