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Acupoint Stimulation for Acne:
A Systematic Review of Randomized Controlled Trials
Hui-juan Cao, PhD,*Guo-yan Yang, BSMed,*Yu-yi Wang, BSMed, and Jian-ping Liu, PhD
ABSTRACT
Background: Acupoint stimulation—including acupuncture, moxibustion, cupping, acupoint injection, and
acupoint catgut embedding—has shown a beneficial effect for treating acne. However, comprehensive eval-
uation of current clinical evidence is lacking.
Objective: The aim of this review was to assess the effectiveness and safety of all acupoint stimulation
techniques used to treat acne vulgaris.
Design: A systematic review was conducted. It included only randomized controlled trials on acupoint stimulation
for acne. Six electronic databases were searched for English and Chinese language studies. All searches ended in May
2012. Studies were selected for eligibility and assessed for quality. RevMan 5.1 software was used for data analysis
with an effect estimate presented as risk ratios (RR) or mean difference (MD) with a 95% confidence interval (CI).
Patients: Studies with subjects who were diagnosed with acne vulgaris, or papulopustular, inflammatory,
adolescent, or polymorphic acne—regardless of gender, age, and ethnicity—were included.
Intervention: Interventions included any acupoint stimulation technique—such as acupuncture, moxibustion,
cupping, acupoint injection, and acupoint catgut embedding—compared with no treatment, placebo, or con-
ventional pharmaceutical medication.
Main Outcome Measure: Reduction of signs and symptoms and presence of adverse effects were examined.
Results: Forty-three trials involving 3453 patients with acne were included. The methodological quality of
trials was generally poor in terms of randomization, blinding, and intention-to-treat analysis. Meta-analyses
showed significant differences in increasing the number of cured patients between acupuncture plus herbal
medicine and herbal medicine alone (RR: 1.60; 95% CI: 1.19–2.14; P=0.002), and between acupuncture plus
herbal facial mask and herbal facial mask alone (RR: 2.14; 95% CI: 1.29–3.55; P=0.003). Cupping therapy was
significantly better than pharmaceutical medications for increasing the number of cured patients (RR: 2.11; 95%
CI: 1.45–3.07; P<0.0001). Serious adverse events were not reported in all included trials.
Conclusions: Acupoint stimulation therapies combined with other treatments appears to be effective for acne.
However, further large, rigorously designed trials are needed to confirm these findings.
Key Words: Acne, Acupoint Stimulation, Systematic Review
INTRODUCTION
Acne is a chronic inflammatory condition of the
skin. This condition most commonly affects areas
where the sebaceous glands are largest and most abundant:
the face; anterior trunk; and upper back.
1
Mild acne is
characterized by comedones, or blackheads, which are di-
lated pores with a plug of keratin. Moderate-to-severe acne
is characterized by whiteheads (small cream-colored, dome-
shaped papules), red papules, pustules, or cysts. Scars, both
Centre for Evidence-based Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China.
*Both authors contributed equally.
MEDICAL ACUPUNCTURE
Volume 25, Number 3, 2013
#Mary Ann Liebert, Inc.
DOI: 10.1089/acu.2012.0906
173
those on the skin and emotional scars can last a lifetime.
Acne affects 80% of adolescents (most commonly from 12
years of age), but it can also affect 54% of adult women
and 40% of adult men (primarily those in their early or
mid-20s).
2
Acne treatment is aimed at decreasing inflammation of
the lesions and accompanying discomfort with the ultimate
goals of improving appearance and preventing or minimizing
scarring and emotional distress.
3
Effective prescription
medications are available, although side-effects—such as
local irritation, teratogenicity, dry skin, hyperlipidemia,
and increased risk of depression—are reported.
4,5
Over-
the-counter preparations and herbal remedies, as well as
skin- hygiene routines and dietary modifications may be
recommended by dermatologists or, more often, are self-
prescribed.
4
In China, in addition to prescription medications, tradi-
tional Chinese therapies are used to treat acne. One such
therapy is acupoint stimulation. Several methods can be
applied: acupuncture with needles; moxibustion, which in-
volves the controlled burning of material, typically mugwort
(Artemisia vulgaris) herb, at certain points or areas of the
body surface; cupping therapy, which involves applying
suction by placing a vacuumized, usually by fire, cup or jar
on acupoints or affected body surfaces to induce local hy-
peremia or hemostasis; acupoint injection, which involves
injecting medication into an acupuncture point; and acu-
point embedding, which involves embedding in the skin
over the acupoint a small needle(s), or medicated catgut.
Acupoint-stimulation methods are based on the Tradi-
tional Chinese Medicine (TCM) view that acne is caused by
any or a combination of several pathogenic factors. These
include intense Lung Heat or Stomach Heat, Damp–Heat
with Blood Stasis, and Qi (vital energy) Stagnation. As the
condition becomes protracted, pathogenic Heat rises and
accumulates in the skin and tissues, which brings on the
lesions.
6
Potential mechanisms of acupoint stimulation for acne
are to relieve Heat toxicity, eliminate Dampness, regulate
the Qi and Blood, and enhance immunologic function.
6
Some studies also mention that acupuncture can stimulate
and balance androgen levels to inhibit excess secretion of
the sebaceous gland.
7
Articles with clinical observations have reported the
efficacy of acupoint-stimulation therapies for acne. A
systematic review
7
assessing seventeen TCM randomized
controlled trials (RCTs) suggests that acupuncture and
moxibustion are better than conventional pharmaceutical
medication for reducing symptoms of acne. Another sys-
tematic review
8
involving twenty-three trials of topical and
oral complementary and alternative medicines (CAMs)
concluded that, poor methodological quality aside, the
evidence suggests that many of these therapies are bio-
logically plausible. However, there has been no systematic
review that evaluated the clinical evidence of all types of
acupoint-stimulation therapies. This systematic review
was performed to assess the effectiveness and safety of
all acupoint-stimulation techniques used to treat acne
vulgaris.
METHODS
Inclusion Criteria
Parallel-group RCTs were included in any data analysis
with interventions for the treatment of acne vulgaris using
any acupoint stimulation technique—such as acupuncture,
moxibustion, cupping, acupoint injection, and acupoint
catgut embedding—compared with no treatment, placebo,
or conventional pharmaceutical medication. Comparisons
also included a combination of acupoint-stimulation tech-
niques, plus other therapies, versus the same other therapies
alone. Participants who were diagnosed with acne vulgaris,
or papulopustular, inflammatory, adolescent, or polymor-
phic acne—regardless of gender, age, and ethnicity—were
included. Primary outcome measures were reduction of
signs and symptoms and presence of adverse effects. Sec-
ondary outcome measures included post-treatment evalua-
tion, participants’ self-assessment of change in lesions after
treatment, psychosocial outcomes, and quality of life (QoL)
measurements.
Identification and Selection of Studies
Searches were conducted in the China Network Knowl-
edge Infrastructure (CNKI, 1979–2012), Chinese Scientific
Journals Database (VIP, 1989–2012), Wan Fang Database
(1985–2012), Chinese Biomedicine (CBM, 1978–2012),
Cochrane Central Register of Controlled Trials (CENTRAL,
1999–2012), and PubMed (1966–2012). All searches ended
in May 2012. Search terms included acupuncture, electro-
acupuncture, auricular therapy, acupoint, meridian, combined
with acne vulgaris and acne. Unpublished postgraduate theses
in Chinese databases were also searched. No language re-
strictions were imposed. Three authors (H.-j.C., G.-y.Y., and
Y.-y.W.) independently selected studies for eligibility and
checked against the inclusion criteria.
Data Extraction and Quality Assessment
Three authors (H.-j.C., G.-y.Y., and Y.-y.W.) indepen-
dently extracted population and intervention characteristics
using self-designed data extraction templates. Disagreements
were resolved by discussion with another author (J.-p.L).
Risk of bias for each study was conducted in accord
with the Cochrane Handbook for Systematic Reviews of
Intervention.
9
Six criteria were applied, as follows: (1) se-
lection bias (random-sequence generation and allocation
174 CAO ET AL.
concealment); (2) performance bias (blinding of participants
and personnel); (3) detection bias (blinding of outcome
assessment); (4) attrition bias (incomplete outcome data);
(5) reporting bias (selective reporting); and (6) other bias.
There were three potential bias judgments: (1) low risk; (2)
high risk; and (3) unclear risk. A study was rated unclear
risk when insufficient details were reported regarding what
happened in the study. A judgment of unclear risk was also
made when what happened in the study was known but the
risk of bias was unknown or when an item was not relevant
to the study, particularly for assessing blinding and in-
complete outcome data or when the outcome assessed by the
item had not been measured in the study.
Data Analysis
Dichotomous data were expressed as risk ratios (RR) with
a 95% confidence interval (CI). Continuous data were ex-
pressed as mean differences ( MDs) with 95% CIs. Statis-
tical heterogeneity was tested by the I
2
test. RevMan 5.1
software (Cochrane Collaboration) was used for data ana-
lyses. Meta-analysis was used if the trials had acceptable
homogeneity (I
2
<85%) of study design, participants, in-
terventions, controls, and outcome measures. Meta-analyses
were performed using fixed-effect
9
models (I
2
<25%) for
homogeneous studies and using random-effects methods
prior to fixed-effect models when there was substantial
heterogeneity (25% <I
2
<85%).
RESULTS
Description of Studies
After primary searches of six databases, 535 citations
were identified. We excluded 484 studies because they
did not meet inclusion criteria. Full-text articles for 51
studies were retrieved. Finally, 43 trials
10–52
were in-
cluded in this review (Fig. 1). Characteristics of included
trials are listed in Table 1. Among the included trials,
fourteen studies
11–15,19,21,26,31,35,42,43,45,46
were unpublished
master’s theses.
The forty-three trials involved a total of 3453 patients,
with an average of 40 participants in each group. Age ran-
ged between 13 and 43, and duration of disease varied from
1 week to 17 years. Ten trials
22,23,25,27,29,38,39,47,48,50
did not
report diagnostic criteria, two trials
10,30
used international
diagnostic criteria, and thirty-three trials reported using one
of four TCM diagnostic criteria.
53–56
Of the thirty-three
trials, six trials
24,36,40,41,43,52
did not report sources for di-
agnostic criteria, and eight trials
11,15,17,20,31,34,37,51
used self-
established diagnostic criteria for acne.
Interventions included acupuncture (electroacupuncture,
auricular acupuncture, and ear point pressure), cupping
therapy, acupoint injection, acupoint catgut embedding,
moxibustion, and combination of acupoint-stimulation
therapies and herbal medicine. Controls included pharma-
ceutical medications and herbal medicine alone. Courses of
treatment ranged from 1 to 12 weeks.
Degree of reduction in clinical symptoms (known as the
cure rate) as the major outcome measurement was reported in
all forty-three included trials. Responses to interventions were
classified as cure,markedly effective,effective,andineffec-
tive.
53
Cure was defined as lesions totally faded (or>95%
faded) and only mild pigmentation and scars remaining.
Markedly effective was defined as lesions faded >60% and
severity of lesions was alleviated. Effective was defined as
lesions faded 20%–59% and severity of lesions was reduced.
Ineffective was defined as lesions faded<20% or worsening
of lesions. Four trials
13,19,43,45
counted the number of skin
lesions, three trials
14,42,45
reported QoL scores, two trials
42,43
reported recurrence rates, and three trials
14,42,43
listed labo-
ratory test results.
Methodological Quality
According to the current authors’ predefined quality-
assessment criteria, all forty-three trials were evaluated
as having a high risk of bias (Fig. 2). Study sample size
varied from 20 to 112 participants, with an average of
40 patients per group. None of the trials reported
sample-size calculation methodology. Fifteen tri-
als
11,12,14,15,19,21,26,30,32,35,42,44–46,48
described randomiza-
tion procedures, using random number tables or computer
generation of random numbers, but only 1 trial
14
reported
adequate allocation concealment. The majority of trials
FIG. 1. Search strategy flow chart.
ACUPOINT STIMULATION FOR ACNE 175
Table 1. Characteristics of 43 Included Trials
Sample size (M/F) Sample age (range, y) Disease duration (average)
Study 1st
author & ref.
Diagnostic
criteria IC I C I C
Baseline
data
comparable?
Chen 2007
10
Chinese
criteria &
Western
criteria
10/26 8/22 22.13 21.63 2.61 y 1.96 y Yes
Chen 2009
11
Nonstandard
Chinese
criteria
30* 60* 22.93 –6.03 21.83 –6.07 4.31 –3.24 y 2.60 –1.92 y Yes
Cheng 2010
12
Chinese
criteria
56
27/23 26/24 21.2 (14–35) 21.5 (13–36) 6.5 m (1 w–5 y) 6.3 m (1 w–6 y) Yes
Fan 2010
13
Chinese
criteria
53
15/10 11/15 22.24 –4.087 22.32 –4.534 1 y–3 y 1 y–3 y Yes
Gong 2005
14
Chinese
criteria
53
9/11 6/14 21.3 21.5 2.89 y 3.57 y Yes
Han 2010
15
Nonstandard
Chinese
criteria
18/28 14/33 25.83 24.68 2.35 y 2.15 y Yes
He 2009
16
Chinese
criteria
54
8/16 10/12 25.2 (17–41) 23.6 (16–38) 20 d–16 y 1 m–17 y Yes
(continued)
176 CAO ET AL.
Table 1. (Continued)
Intervention Control
Duration of
treatment (w) Outcome Adverse events
Warm needling &
moxibustion at: CV 4, CV
6, ST 36, BL 20, & BL 23;
additional points according
to syndrome
differentiation, 30 minutes,
1·/2 d
Acupuncture applied to
same acupoints as for
treatment group, 1 ·/
every other d
9 Response to
intervention
Yes (3 patients in
intervention group had
dry stools, thirst,
irritability)
Bloodletting, followed by
cupping at BL 13 & BL 21,
combined with body
acupuncture 2 ·/w; herbal
medicine, twice per d
Herbal medicine 2 ·/d 4 Response to
intervention
No
Bai Xian Xia Ta Re tablet, 5
pills (adolescents, 3 pills),
3·/d; ear acupressure with
vaccaria seed; main points:
CO 14, CO 4, LO 5,6i;
additional points according
to syndrome
differentiation; patients
instructed to press 1–2 min
1·/w
Bai Xian Xia Ta Re tablet,
5 pills (adolescents, 3
pills) 3 ·/d
4 Response to
intervention
NR
Fire needling & acupuncture
on the lesion area,
1·/every 5 d
Tazarotene cream applied
to lesions at bedtime
every night,
clindamycin gel applied
to lesions 1 ·/every
morning
3 Skin-lesion count;
response to
intervention;
adverse effects
Yes (24 cases in acu
group & 9 cases in
control group had pain;
24 cases in acu group &
6 cases in control group
had redness & swelling
of portions of lesion
area; 13 cases in acu
group & 15 cases in
control had itching in
acupoint areas)
Acupuncture on skin-lesion
area, 30 min 1 ·/every 2;
ear acupressure with
vaccaria seed on CO 18,
TG 2p, AH 6a, CO 14 &
LO 5,6i; patients instructed
to press 3–5 min 2 ·/d
Licorsinc capsule, 0.25 g,
3·/d
4 Laboratory tests;
QoL—Acne;
GAGS; response
to intervention
NR
Acupuncture of abdominal
acupoints: CV 12, CV 10,
CV 6, CV 4, ST 24, ST 26,
KI 13 for 30 min, 3 ·/w,
1·/ every 2 days
Isotretinoin,10 mg, 2 ·/d
for 1 m, then 10 mg
1·/d
8 Response to
intervention
NR
Acupuncture of abdominal
acupoints: CV 12, CV 10,
CV 6, CV 4 ST 24, ST 26;
facial acupoints EX-HN 3,
‘‘ouch’’ point 30 min; TDP
mineral lamp 15–20 min
1·/d for 7 d, then
1·/every 2 d
Topical metronidazole
solution 2 ·/d
3 Response to
intervention
NR
(continued)
ACUPOINT STIMULATION FOR ACNE 177
Table 1. (Continued)
Sample size (M/F) Sample age (range, y) Disease duration (average)
Study 1st
author & ref.
Diagnostic
criteria IC I C I C
Baseline
data
comparable?
Hong 2011
17
Nonstandard
Chinese
criteria
8/11 7/11) 24 (15–36) 23 (14–35) 2.5 (1–10) y 2.2 (1–11) y Yes
Hou 2009
18
Chinese
criteria
55
21/24 18/24 16–38 17–38 2 m–5 y 3 m–4 y NR
Huang 2011
19
Chinese
criteria
54
7/23 7/23 19.23 –3.05 19.03 –3.18 11.57 d –7.55 d 11.47 d –6.72 d Yes
Huang 2010
20
Nonstandard
Chinese
criteria
76* 50* 23 (16–35) 2 m–5 y Yes
Huang 2009
21
Chinese
criteria
54
12/18 10/20 15–45 2 m–2 y Yes
Huang 2011
22
NR 14/16 15/15 21.3 19.9 24.7 m 26.0 m Yes
Jin 2009
23
NR 14/18 12/14 24.5 (18–24) 23 (16–30) (4.7 –1.2) y (4.8 –1.14) y Yes
Lan 2004
24
Chinese
criteria
without
source
0/38 0/34 NR NR Yes
Li 1995
25
NR 35/21 25/15 NR 3 m–6 y NR
(continued)
178 CAO ET AL.
Table 1. (Continued)
Intervention Control
Duration of
treatment (w) Outcome Adverse events
Bloodletting at HX 6,7i, GV
14, BL 13, BL 21 & BL 20
3–5 ·; cupping on GV 14,
BL 13, BL 21 & BL 20 for
10–15 min 2 ·/w; Chinese
medicinal facial mask
2·/w
Chinese medicinal facial
mask 2 ·/w
5 Response to
intervention
NR
Bloodletting, followed by
cupping at GV 14, BL 28,
BL 25, BL 21 & BL 13;
Blood Stasis point,
1·/every 2 d; ear acupoint
needle embedding 3–5 d at
acupoints TF 4, TF 2,CO
18 & TG 2
Bloodletting, followed by
cupping at GV 14, BL
28, BL 25, BL 21 & BL
13; Blood Stasis point
1·/every 2 d
2 Response to
intervention
NR
Acupuncture at ‘‘ouch’’
point, 30 min 1 ·/every 2
d, 3 ·/w; Pi Pa Qing Fei
decoction, 250 mL, 2 ·/d;
Chinese herbal facial
mask, 30 min 1 ·/d
Pi Pa Qing Fei decoction,
250 mL, 2 ·/d; Chinese
herbal facial mask,
30 min 1 ·/d
4 Skin-lesion count;
response to
intervention;
adverse effects
Yes (6 patients in acu
group reported black &
blue of some skin areas
after acupuncture)
Bloodletting, followed by
cupping at GV10, GV14,
BL13, BL15, BL20 for
5–10 min 2 ·/w; herbal
preparation, 50 mL, 3 ·/d;
topical facial cream
Herbal preparation 50 mL,
3·/d; topical facial
cream
4 Response to
intervention
NR
Autologous blood injection at
acupoints LI 11 & BL 13;
EA at skin-lesion area for
30 min, 3 ·/w
Autologous blood
injection at acupoints
LI 11 & BL 13 for
30 min, 3 ·/w
4 Response to
intervention
NR
Autologous blood injection,
4 mL, at bilateral acupoint
ST 36, 1 ·/w
Viaminate capsules,
0.025 g, 3 ·/d;
tetracycline, 0.25 g,
3·/d
3 Response to
intervention
NR
Body & facial acupuncture
30 min once every 2 days;
herbal facial mask applied
for 20 min 1 ·/every 2–3 d
Herbal facial mask
applied 20 min once
every 2–3 d
4 Response to
intervention
NR
Acupuncture at lesion area,
LI 4, SP 36, 30 min 3 ·/w,
3 w/cycle for 2 cycles;
Qing Shen Fen Ci Qing
oral liquid ,20 mL, 3 ·/d
Qin Shen Fen Ci Qing
oral liquid, 20 mL,
3·/d.
6 Response to
intervention;
adverse events
NR
Use point-detection device to
test/stimulate ear points
TG 2p, CO 7, CO 14 & CO
4 for 30 min for 1 m;
herbal decoction 1 ·/d
for 1 m
Herbal decoction 1 ·/d
for 1 m
4 Response to
intervention
NR
(continued)
ACUPOINT STIMULATION FOR ACNE 179
Table 1. (Continued)
Sample size (M/F) Sample age (range, y) Disease duration (average)
Study 1st
author & ref.
Diagnostic
criteria IC I C I C
Baseline
data
comparable?
Li 2009
26
Chinese
criteria
53
0/29 0/30 25.48 –4.09 25.57 –4 .67 <13 y <13y NR
Li 2011
27
NR 48* 48* 22.8 (14–32) 22 m (2 m–10 y) Yes
Li 2011
28
Chinese
criteria
53
10/13 10/12 25.3 (18–39) 24.5 (18–35) 19.17 (1–65 m) 19.36 (2–67m) NR
Liu 2008
29
NR 60* 60* 14-41 2 m–10 y Yes
Liu 2009
30
Chinese
Criteria &
Western
criteria
14/29 39* 23.6 24.1 2 w–5 y 3 m–4 y NR
Lu 2011
31
Nonstandard
Chinese
criteria
21/39 18/42 20.17 –4.48
(13–34)
22.17 –4.12
(14–30)
1 m–10 y 1 m–10 y Yes
Mao 2008
32
Chinese
criteria
54
16/25 43* 16–21 1 w–2 m 1 w–3 m Yes
Mi 2011
33
Chinese
criteria
53
14/16 18/12 22.31 (31–32) 25.27 (16–30) NR Yes
(continued)
180 CAO ET AL.
Table 1. (Continued)
Intervention Control
Duration of
treatment (w) Outcome Adverse events
Herbal decoction, 50 mL,
2·/d; Cuo Ling Ding
applied topically to
lesions; acupoint injection
with 1 mL of danshen
extract at ST 36, 1 ·/every
3–5 d; ear acupuncture at
TF 4, TG 2p, AH 6a & CO
18, 1 ·/every 7 d
Herbal decoction, 50 mL,
2·/d; Cuo Ling Ding
applied topically to
lesions; acupoint
injection with 1 mL of
danshen at ST 36,
1·/every 3–5 d
4 Response to
intervention
NR
Acupuncture at LI 4, SI 3 &
PC 8; herbal decoction;
She Dan cream applied
topically to lesions
Herbal decoction; She
Dan Shuan applied
topically to lesions
12 Response to
intervention
No
Fire needling at ‘‘ouch’’
point, BL 13, BL 15, BL
18, BL 23, CV 4, CV 6,
CV 12 & S 25 1 ·/w for 8
w; Yang He decoction
Yang He decoction 8 Response to
intervention
NR
Autologous blood injection,
5 mL, injection at bilateral
ST 36, 1 ·/w; medications
same as control group
Vitamin B tablet, zinc
gluconate tablet, Luo
Hong enzyme capsule,
Pi Pa Qing Fei
decoction; topical acne
tincture; skin hygiene;
Qing Da enzyme
injection or
triamcinolone injection
1·/w
6 Response to
intervention
NR
Acupuncture for 30 min,
followed by flash cupping
mainly at ST 3, ST 4, ST 6,
ST 7 & SI 18; 10 sessions
per course, 2 courses total
(1 ·/d for the first course,
every other day for the
second course)
Acupuncture mainly at ST
3, ST 4, ST 6, ST 7 &
SI 18, 10 sessions per
course, 2 courses total
(1 ·/d for the first
course, every other d
for the second course)
4 Response to
intervention
No
Flash cupping at DU 14,
followed by needling for
5–10 min & cupping for
5 min, 1 ·/every 2–3 days;
herbal decoction 2 ·/d
Herbal preparation 2 ·/d 4 Response to
intervention
No
Acupuncture at Ex-B 2, ST
36 & LI 4 for 15–30 min,
1·/d for 5 d
Oral minocyclin, 50 mg,
2·/d
1 Response to
intervention
NR
Acupuncture at CV 12, CV
10, CV 4, ST 26, ST 25 or
30 min, 1 ·/every 2 d, 1 m/
course for 2 courses; warm
needling at skin lesion
area; acupoint injection
with danshen injection at
ST 36 & LI 11
Warm needling at skin
lesion area; acupoint
injection with danshen
injection at ST 36 & LI
11
8 Response to
intervention
NR
(continued)
ACUPOINT STIMULATION FOR ACNE 181
Table 1. (Continued)
Sample size (M/F) Sample age (range, y) Disease duration (average)
Study 1st
author & ref.
Diagnostic
criteria IC I C I C
Baseline
data
comparable?
Song 2011
34
Nonstandard
Chinese
criteria
34/26 36/24 20.3 (14–30) 21.1 (13–31) 389 d (7 d–3 y) 392 d (5 d–3 y) Yes
Wang 2011
35
Chinese
criteria
53
10./14 11/13 22.58 (18–32) 22.33 (18_33) >2w >2 w Yes
Wang 2009
36
Chinese
criteria
without
source
35/33 30/30 26.5 25 6 m–7 y 5 m–8 y Yes
Wang 2007
37
Nonstandard
Chinese
criteria
30* 30* 18 d–37 d 10 d–6 y Yes
Wu 2010
38
NR 30* 28* 16–25 15–25 4 m–6 y 3 m–6 y NR
Wu 1998
39
NR 34* 34* 19.5 (16–24) 6 m–4 y NR
Wu 2008
40
Chinese
criteria
without
source
9/21 7/23 26.13 –2.54 24.83 –3.07 15.20w –136 w 14.53 w +187 w Yes
Xie 2009
41
Chinese
criteria
without
source
16/22 18/12 15–38 14–36 1 m–9 y Yes
(continued)
182 CAO ET AL.
Table 1. (Continued)
Intervention Control
Duration of
treatment (w) Outcome Adverse events
Bloodletting, followed by
cupping at GV 14, BL 13,
BL 18, BL 20 & BL21
Vitamin B tablet, oral
metronidazole, or oral
erythromycin; topical
metronidazole 1%–5%,
cream; topical benzoyl
peroxide gel; topical
sulfur preparation;
topical Mei Lu Xiao
Cuo cream
4 Response to
intervention
NR
Acupuncture & guasha at GB
14, SI 18, GV 14, LI 4, LI
11 & S 44 1 ·/every 2 d;
scraping the first lateral of
BL meridian, once per w
Scraping the first lateral of
BL meridian, once
per w
4 Response to
intervention
NR
Acupoint catgut embedding
at BL 13 & ST 36 as main
points; additional points
selected according to
syndrome differentiation,
1·/m; oral herbal
decoction
Oral herbal decoction 8 Response to
intervention
Yes (distending pain
during the acupoint
catgut embedding)
Acupuncture &
moxibustion +acupoint
bloodletting & moving
cupping (acupuncture for
30 min, 1 ·/d; cupping for
5–10 min, 1 ·/every 3 d;
10 sessions as 1 course
Acupuncture &
moxibustion, 1 ·/d
4 Response to
intervention
NR
Bloodletting, followed by
cupping at BL 13, BL 15,
BL 18 , BL 20, BL 21 &
BL 23 for 10–15 min,
1·/every 5–7 d
Oral tanshinone 1 g, 3 ·/d
for 3 w
4 Response to
intervention
NR
Acupoint injection at L I4, LI
11, SP 6 & ST 36 of
extracts of yu xing cao &
dang gui, 4 mL each,
alternating at 1–2
acupoints, 1 ·/every 2 d
Metronidazole tablet,
0.2g, 3 ·/d;
minocycline tablet,
0.05 g, 2 ·/d
3 Response to
intervention
NR
Bloodletting, followed by
cupping once daily at
‘‘ouch’’ points, the BL
channel & at BL 13 until
7–8 mL of blood is let
Tetracycline, 0.25 g,
4·/d; ketoconazole,
2% ,cream 1 ·/d
4 Response to
intervention
NR
Acupuncture at BL 13, GV
14, LI 11, L I4 & SI 18,
with additional points BL
12, LU 11, ST 36 & SP6
for 30 min 1 ·/d;
medicinal facial mask for
30 min 1 ·/d
Medicinal facial mask
30 min 1 ·/d
3 Response to
intervention
NR
(continued)
ACUPOINT STIMULATION FOR ACNE 183
Table 1. (Continued)
Sample size (M/F) Sample age (range, y) Disease duration (average)
Study 1st
author & ref.
Diagnostic
criteria IC I C I C
Baseline
data
comparable?
Xie 2011
42
Chinese
criteria
55
7/22 6/22 25.6
(29.6–21.5)
25.3
(29.3–21.3)
6 m–10 y 5 m–10 y Yes
Xie 2008
43
Chinese
criteria
without
source
23/7 25/5 20.70 –4.35 22.20 –4.27 1.70y –2.46 y 2.30y –2.59 y Yes
Xu
44
2009 Chinese
criteria
54
37/25 17/13 21.3 21.5 1.72 y 1.67 y Yes
Xu
45
2010 Chinese
criteria
55
5/27 6/26 22.97 22.63 2 m–13 y Yes
Yan
46
2006 Chinese
criteria
53
5/27 6/26 22.97 (17–43) 22.63 (18–38) 2 m–13 y 2 w–13 y Yes
Yang
47
2008 NR 31* 31* 22 5 m–7 y NR
Yang
48
2008 NR 16/52 16–35 3 m–2 y Yes
Zhang
49
2007 Chinese
criteria
54
29/27 28/28 22.4 (16–34) 22.1 (15–35) 2.2 y
(15 d–10 y)
2.3 y
(16 d–11 y)
Yes
(continued)
184 CAO ET AL.
Table 1. (Continued)
Intervention Control
Duration of
treatment (w) Outcome Adverse events
Acupuncture at GB14, SI18,
LI4, LI11, ST44, SP6,
GB34, 30 min once every 2
days; acupoint injection of
dan shen extract 4mL each
at BL 13 & BL 18 or BL
20 & BL 23 1 ·/every 2 d
Acupuncture at GB14,
SI18, LI4, LI11, ST44,
SP6, GB34, with
additional points
BL13& BL18 or BL20
& BL23,30 min once
every 2 days.
8 Clinical symptom;
response to
intervention;
recurrence rate;
quality of life;
adverse events
No
Minocycline capsule, 100 mg,
daily at bedtime; catgut
embedding LI 4, LI 11, ST
36, ST 37, BL 25 & BL 21
1·/w; tretinoin cream,
0.025%, applied to lesions
daily at bedtime;
clindamycin gel, 0.1%,
applied to lesions 1 ·/d in
daytime
Minocycline capsule,
100 mg, daily at
bedtime; tretinoin
cream, 0.025%, applied
to lesions daily at
bedtime; clindamycin
gel, 0.1%, applied to
lesions 1 ·/d in
daytime
6 Skin lesion count;
Response to
intervention;
adverse effect;
recurrence rate;
IgG test
Yes (3 cases in
intervention group & 6
cases in control group
reported dizziness; 2
cases in control
reported mild stomach
ache)
Herbal decoction, 150 mL,
twice daily; acupuncture
around the lesion area
30 min once every 2 days
Herbal decoction, 150 mL,
twice daily
4 Response to
intervention
NR
Acupuncture on skin lesion
area 20 min, three times
weekly; Pi Pa Qing Fei
herbal decoction, 50 mL,
2·/w
Pi Pa Qing Fei herbal
decoction, 50 mL, twice
daily
4 Response to
intervention;
WHO QOL-
BREF; lesion
count
No
Facial acupuncture on lesion
area, body acupuncture at
LI 11, SP 6, LR 3 & KI3,
20 min, 3 ·/w, 10 sessions
as 1 course; herbal
decoction, 50 mL, 2 ·/d;
topical San Huang lotion
applied to lesions
Herbal decoction, 50 mL,
2·/d; topical San
Huang lotion applied to
lesions
4 Response to
intervention
NR
Compound Betamethasone
injection, 1 mL with 2%
lidocaine 1–5 mL injection,
at 2 of 4 acupoints: ST 8,
EX-HN 5, SJ 17, ST 6, ST
2, ST4, CV 24; viaminate
25–50 mg, 3 ·/d;
roxithromycin 150 mg
2·/d
Viaminate, 25–50 mg,
3·/d; roxithromycin,
150 mg, 2 ·/d
8 Response to
intervention
Yes
Autologous blood injection,
1 mL, at LI 11 & ST 36
1·/every 3 d
Erythromycin tablets,
0.5 g, 3 ·/d;
ketoconazole cream
applied to lesions 1 ·/d
4 Response to
intervention
NR
Pi Pa Qing Fei decoction
modified according to
syndrome differentiation,
twice daily; dan shen
injection 1mL at bilateral
ST 36 1 ·/w.
Pi Pa Qing Fei decoction
modified according to
syndrome
differentiation, 2 ·/d
6 Response to
intervention
NR
(continued)
ACUPOINT STIMULATION FOR ACNE 185
compared acupoint stimulation therapies and pharmaceutical
medication; thus, blinding could not be applied for patients
and researchers. Six trials
13,25,26,32,45,46
reported the number
of dropouts, but none used intention-to-treat (ITT) analysis.
None of the trials mentioned sources of financial support.
Effect Estimates
Because of variations in study quality, participant char-
acteristics, intervention types, controls, and outcome mea-
sures, results of most trials could not be synthesized by
quantitative methods. Therefore, qualitative methods were
used (Table 2).
Therapeutic effect of acupuncture. Therapeutic ef-
fect of acupuncture for acne was evaluated in 22 studies. Five
studies
13–16,32
compared acupuncture with pharmaceutical
medications. Nine trials
12,19,24,25,27,28,44–46
compared acu-
puncture plus herbal medicine with herbal medicine alone.
Two trials
21,33
compared acupuncture plus acupoint injection
with acupoint injection alone. Two trials
23,41
compared acu-
puncture plus a herbal facial mask with a facial mask alone.
One trial
18
compared acupuncture plus cupping therapy with
cupping therapy alone. One trial
35
compared acupuncture plus
guasha (scraping) with guasha alone. One trial
26
compared
acupuncture plus herbal medicine and acupoint injection with
herbal medicine and acupoint injection alone.
Nineteen trials
12–16,18,19,21,23–25,27,28,32,33,41,44–46
were in-
cluded in four meta-analyses. There were a significant dif-
ference in the number of cured patients between
acupuncture plus herbal medicine and herbal medicine
alone (RR: 1.60; 95% CI: 1.19–2.14; P=0.002; random
model; I
2
=46%; 9 trials), and between acupuncture plus
herbal facial mask and herbal facial mask alone (RR: 2.14;
95% CI: 1.29–3.55; P=0.003; fixed model; I
2
=0%; 2 tri-
als). No difference was seen in the comparison between
acupuncture and pharmaceutical medications (RR: 1.49;
95% CI: 0.82–2.73; P=0.19; random model; I
2
=54%;
5 trials), and in the comparison between acupuncture plus
acupoint injection and acupoint injection alone (RR: 2.00;
95% CI: 0.64–6.29, P=0.24; fixed model; I
2
=0%; 2 trials).
Three trials
13,19,45
reported changes in skin-lesion count.
One study
13
that used a skin-lesion scoring system,
53
showed that acupuncture was superior to pharmaceutical
medication for reducing the skin-lesion area ( MD: -26.95;
95% CI: -31.84 to -22.06; P<0.00001; 1 trial). The re-
maining two trials compared acupuncture plus herbal
medicine with herbal medicine alone. One of the trials
45
found that a combination of acupuncture and herbal medi-
cine was better than herbal medicine alone for reducing
skin lesions (MD: -13.88; 95% CI: -19.17 to -8.59;
P<0.00001, 1 trial), while the other trial
19
showed no dif-
ference between the comparison treatments ( MD: -0.97;
95% CI: -3.06 to 1.12; P=0.36; 1 trial).
QoL (Acne-QoL)
57
was assessed in one trial,
14
finding
that, compared with pharmaceutical medication, acupunc-
ture appeared to significantly improve self-perception ( MD:
3.40; 95% CI: 2.16–4.64; P<0.00001; 1 trial), social
Table 1. (Continued)
Sample size (M/F) Sample age (range, y) Disease duration (average)
Study 1st
author & ref.
Diagnostic
criteria IC I C I C
Baseline
data
comparable?
Zhang
50
2008 NR 25/18 28/15 15–*38 13–*35 1 w–8 y 1 w–6 y NR
Zhang
51
2006 Nonstandard
Chinese
criteria
27/51 30/52 24.2 22.7 1 y–10 y 6 m–*7 y Yes
Zhang
52
2010 Chinese
criteria
without
source
57/55 51/47 22.5 –4.3 21.3 –4.5 3.3 m –2.1 m 3.6 m –2.3 m Yes
186 CAO ET AL.
function (MD: 2.30; 95% CI: 1.23–3.37; P<0.0001; 1 trial),
and emotional function (MD 2.30; 95% CI: 0.74–3.86;
P=0.004; 1 trial).
Therapeutic effect of cupping therapy. Ten trials
evaluated the effectiveness of cupping therapy for acne. Of
the ten trials, four
34,38,40,50
compared cupping therapy with
pharmaceutical medications, three trials
11,20,31
compared
cupping therapy plus herbal medicine with herbal medicine
alone, two trials
30,37
compared cupping plus acupuncture
with acupuncture alone, and one trial
17
compared cupping
plus a herbal facial mask with herbal facial mask alone.
Meta-analysis showed that cupping therapy was signifi-
cantly better than pharmaceutical medications, such as
tanshinone, tetracycline, and ketokonazole (RR: 2.11; 95%
CI: 1.45–3.07; P<0.0001; fixed model; I
2
=6%, 4 trials).
Furthermore, cupping therapy combined with herbal medi-
cine (RR: 1.91; 95% CI: 1.32–2.74; P=0.0005; fixed model;
I
2
=0%; 3 trials) or acupuncture (RR: 1.79; 95% CI: 1.12–
2.86; P=0.01; fixed model; I
2
=6%; 2 trials) was superior to
herbal medicine or acupuncture alone. However, no differ-
ence was found between cupping plus a facial mask and a
facial mask alone (RR: 1.58; 95% CI: 0.72–3.45; P=0.25; 1
trial). As each comparison had fewer than five trials, it was
not meaningful to conduct a funnel-plot analysis.
Therapeutic effect of acupoint injection. Seven trials
evaluated the effect of acupoint injection for acne. Of the seven
trials, three
22,39,48
compared acupoint injection with pharma-
ceutical medication, and four trials compared acupoint injection
plus other treatment with other treatment alone (pharmaceutical
medication,
29,47
acupuncture,
42
and herbal medicine
49
).
Meta-analysis showed that acupoint injection used alone
(RR: 1.51; 95% CI: 1.13–2.03; P=0.006; fixed model;
I
2
=0%; 3 trials) and combined with pharmaceutical
medication (RR: 1.49; 95% CI: 1.12–1.99; P=0.007; fixed
model, I
2
=0%; 2 trials) were significantly better than
Table 1. (Continued)
Intervention Control
Duration of
treatment (w) Outcome Adverse events
Bloodletting, followed by
flash cupping & 15 min of
cup retention at at tender
Transporting points, at GV
14 & at additional points
according to syndrome
differentiation; treat
1·/every 2 d
Tetracycline tablets
500 mg 1 ·/d; Cuo
Chuang Ping ointment
applied to lesions 2 ·/d
4 Response to
intervention
No
Acupuncture & moxibustion,
1·/every other d; 5
sessions as 1 course; 3
courses total
Acupuncture 1 ·/every
other d; 5 sessions as 1
course; 3 courses total
9 Response to
intervention
NR
Acupoint catgut embedding
at BL 13, BL 15, BL 18,
BL 16, BL 20, BL 21, ST
36, LI 11, & SP10;
additional points selected
according to syndrome
differentiation; treat
1·/every 2 w
Viaminate capsules,
50 mg, 2 ·/d; fusidic
acid cream applied to
lesions 2 ·/d
12 Response to
intervention
Yes (5 cases in
intervention group & 4
cases in control
reported dry lips)
*Gender numbers not reported.
M, male; F, female; y, year(s); m, month(s); w, week(s); d, day(s); min, minutes; I, intervention group; C, control group; acu., acupuncture; NR, not
reported; EA, electroacupuncture; QoL or QOL, quality of life; GAGS, Global Acne Grading System; TDP, a specific electromagnetic spectrum; WHO,
World Health Organization; IgG, immunoglobulin G.
FIG. 2. Risk of bias graph shows the review authors’ judgments
about each risk of bias item, presented as percentages across all
included studies.
ACUPOINT STIMULATION FOR ACNE 187
Table 2. Effect of Estimates of Acupoint Stimulation Treatment for Acne on Increasing Numbers
of Cured Patients in 43 Randomized Controlled Trials
Study 1st
author and ref. Comparisons
Effect estimates
[95%CI] P
1. Acupuncture
1.1 Acupuncture versus pharmaceutical medications
Fan 2010
13
Acupuncture with fire needling versus topical tazarotene cream &
clindamycin gel
2.43 [0.74, 7.99]
Gong 2005
14
Body acupuncture +ear acupressure versus licorsinc capsule 2.00 [0.20, 20.33]
Han 2010
15
Abdominal acupuncture versus isotretinoin capsule 0.80 [0.50, 1.27]
He 2009
16
Abdominal & facial acupuncture versus topical metronidazole
solution
1.38 [0.45, 4.24]
Mao 2008
32
Acupuncture versus minocycline 2.34 [1.23, 4.47]
Overall (random, I
2
=54%) RR 1.49 [0.82, 2.73] 0.19
Overall (fixed, I
2
=54%) RR 1.36 [0.97, 1.89] 0.07
1.2 Acupuncture +other treatments versus other treatments alone
1.2.1 Acupuncture +herbal medicine versus herbal medicine alone
Cheng 2010
12
Ear acupressure +Bai Xian Xia Ta Re tablet versus Bai Xian Xia Ta
Re tablet alone
1.33 [1.02, 1.74]
Huang 2011
19
Acupuncture +Pi Pa Qing Fei decoction & herbal facial mask
versus herbal decoction & facial mask alone
2.00 [0.78, 5.15]
Lan 2004
24
Acupuncture +Qin Shen Fen Ci Qing oral liquid versus Qin Shen
Fen Ci Qing liquid alone
1.49 [0.75, 2.96]
Li 1995
25
Auricular therapy +herbal decoction versus herbal decoction alone 2.86 [1.17, 6.97]
Li 2011
27
Acupuncture +herbal decoction and She Dan cream external
application versus herbal decoction & topical She Dan cream
alone
1.07 [0.79, 1.44]
Li 2011
28
Acupuncture +Yang He decoction versus Yang He decoction alone 5.10 [1.72, 15.11]
Xu 2009
44
Acupuncture +herbal decoction versus herbal decoction alone 1.37 [0.60, 3.12]
Xu 2010
45
Acupuncture +Pi Pa Qing Fei decoction versus Pi Pa Qing Fei
decoction alone
2.00 [0.67, 5.98]
Yan 2006
46
Body & facial acupuncture +herbal decoction & topical San Huang
lotion versus herbal decoction & topical San Huang lotion alone
2.00 [0.67, 5.98]
Overall (random, I
2
=46%) RR 1,60 [1.19, 2.14] 0.002
Overall (fixed, I
2
=46%) RR 1.56 [1.30, 1.89] <0.00001
1.2.2 Acupuncture +acupoint injection versus acupoint injection alone
Huang 2009
21
Electroacupuncture plus autologous blood injection versus
autologous blood injection alone
2.00 [0.40, 10.11]
Mi 2011
33
Acupuncture plus acupoint injection versus acupoint injection alone 2.00 [0.40, 10.11]
Overall (random, I
2
=0%) RR 2.00 [0.64, 6.29] 0.24
Overall (fixed, I
2
=0%) RR 2.00 [0.64, 6.29] 0.24
1.2.3 Acupuncture +cupping therapy versus cupping therapy alone
Hou 2009
18
Auricular therapy +wet cupping versus wet cupping alone 1.47 [1.00, 2.18] 0.05
1.2.4 Acupuncture +herbal facial mask versus herbal facial mask alone
Jin 2009
23
Body & facial acupuncture +herbal facial mask versus herbal facial
mask alone
2.17 [0.64, 7.35]
Xie 2009
41
Acupuncture +herbal facial mask versus herbal facial mask alone 2.13 [1.24, 3.68]
Overall (random, I
2
=0%) RR 2.14 [1.30, 3.52] 0.003
Overall (fixed, I
2
=0%) RR 2.14 [1.29, 3.55] 0.003
1.2.5 Acupuncture plus guasha (scraping) versus guasha alone
Wang 2011
35
Acupuncture +guasha versus guasha alone 3.00 [0.92, 9.74] 0.07
(continued)
188 CAO ET AL.
Table 2. (Continued)
Study 1st
author and ref. Comparisons
Effect estimates
[95%CI] P
1.2.6 Acupuncture plus herbal medicine and acupoint injection versus herbal medicine and acupoint injection
Li 2009
26
Auricular therapy +herbal decoction, topical medicine, acupoint
injection versus herbal decoction, topical medicine, & acupoint
injection
1.38 [0.55, 3.49] 0.50
2. Cupping therapy
2.1 Cupping +other interventions versus other interventions alone
2.1.1 Cupping +herbal medicine versus herbal medicine alone
Chen 2009
11
Wet cupping +herbal decoction versus herbal decoction alone 2.33 [0.67, 8.18]
Huang 2010
19
Wet cupping +herbal preparation, topical cream versus herbal
preparation & topical cream
2.06 [1.33, 3.18]
Lu 2011
31
Wet cupping +herbal decoction versus herbal decoction alone 1.44 [0.67, 3.12]
Overall (random, I
2
=0%) RR 1.92 [1.34, 2.76] 0.0004
Overall (fixed, I
2
=0%) RR 1.91 [1.32, 2.74] 0.0005
2.1.2 wet cupping plus acupuncture versus acupuncture alone
Liu 2009
30
Flash cupping plus acupuncture versus acupuncture alone 1.91 [0.99, 3.72]
Wang 2007
37
Moving and wet cupping +acupuncture versus acupuncture alone 1.67 [0.87, 3.20]
Overall (random, I
2
=0%) RR 1,79 [1.12, 2.86] 0.01
Overall (fixed, I
2
=0%) RR 1.79 [1.12, 2.86] 0.01
2.1.3 wet cupping plus facial mask versus facial mask
Hong 2011
17
Wet cupping +herbal facial mask versus herbal facial mask alone 1.58 [0.72, 3.45] 0.25
2.2 wet cupping versus pharmaceutical medication
Song 2011
34
Wet cupping versus vitamin B/metronidazole/erythromycin,
metronidazole cream/benzoyl peroxide gel/sulfur/Mei Lu Xiao
Cuo cream
2.00 [0.80, 4.98]
Wu 2010
38
Wet cupping versus tonshinone 1.07 [0.45, 2.56]
Wu 2008
40
Wet cupping versus tetracycline & ketoconazole cream 2.50 [1.31, 4.77]
Zhang 2008
50
Wet cupping versus tetracycline 2.75 [1.38, 5.48]
Overall (random, I
2
=6%) RR 2.10 [1.42, 3.11] 0.0002
Overall (fixed, I
2
=6%) RR 2.11 [1.45, 3.07] <0.0001
3. Acupoint injection
3.1 Acupoint injection versus pharmaceutical medication
Huang 2011
22
Autologous blood acupoint injection versus viaminate capsule &
tetracycline tablet
2.13 [1.09, 4.16]
Wu 1998
39
Yu xing cao &dang gui acupoint injection versus metronidazole
tablet & minocycline tablet
1.67 [1.09, 2.56]
Yang 2008
48
Autologous blood acupoint injection versus erythromycin tablet &
topical ketoconazole
1.29 [0.71, 2.36]
Overall (random, I
2
=0%) RR 1.51 [1.13, 2.03] 0.006
Overall (fixed, I
2
=0%) RR 1.64 [1.20, 2.24] 0.002
3.2 Acupoint injection +other treatment versus other treatment alone
3.2.1 Acupoint injection +pharmaceutical medication versus pharmaceutical medication alone
Liu 2008
29
Autologous blood acupoint injection +vitamin B/zinc gluconate
tablet/Luo Hong enzyme capsule/Pi Pa Qing Fei decoction/acne
tincture & acupoint injection versus pharmaceutical medication
& acupoint injection
1.43 [1.03, 1.98]
Yang 2008
47
Compound betamethasone injection with 2% lidocaine acupoint
injection +viaminate & roxithromycin versus viaminate &
roxithromycin
1.78 [0.93, 3.40]
Overall (random, I
2
=0%) RR 1.49 [1.12, 1.99] 0.007
Overall (fixed, I
2
=0%) RR 1.79 [1.12, 2.86] 0.01
(continued)
ACUPOINT STIMULATION FOR ACNE 189
medication alone. However, no difference was found be-
tween acupoint injection combined with herbal medicine
(RR: 1.08; 95% CI: 0.83–1.41; P=0.55; 1 trial) or acu-
puncture (RR: 1.45; 95% CI: 0.46–4.59; P=0.53; 1 trial)
compared with herbal medicine or acupuncture alone. As
each comparison had fewer than five trials, it was not
meaningful to conduct a funnel-plot analysis.
One trial
42
reported QoL scores and recurrence rate.
Results showed no difference between acupoint injection
plus acupuncture and acupuncture alone in improving QoL
(MD: -1.76; 95% CI: -3.80 to 0.28; P=0.09; 1 trial) and
in reducing recurrence rate (RR: 0.22; 95% CI: 0.03–1.60;
P=0.13; 1 trial).
Therapeutic effect of acupoint catgut embed-
ding. Three trials
36,43,52
evaluated the therapeutic effect of
acupoint catgut embedding for acne. One study
52
showed
acupoint catgut embedding was superior to pharmaceutical
medication in increasing the number of cured patients (RR:
1.57; 95% CI: 1.15–2.15; P=0.004; 1 trial) and in reducing
recurrence rate (RR: 0.22; 95% CI: 0.08–0.62; P=0.004; 1
trial). One trial
36
showed acupoint catgut embedding com-
bined with herbal medicine was superior to herbal medicine
alone in increasing the number of cured patients (RR:1.85;
95% CI: 1.24–2.77; P=0.003; 1 trial). One study
43
showed
no difference between acupoint catgut embedding plus
pharmaceutical medication and pharmaceutical medication
alone in increasing the number of cured patients (RR:1.40;
95% CI: 0.50–3.92; P=0.52; 1 trial), reducing skin-lesion
area (MD: 2.67; 95% CI: -0.07 to 5.41; P=0.06; 1 trial),
and reducing recurrence rate (RR: 0.48; 95% CI: 0.12–1.88;
P=0.29; 1 trial).
Therapeutic effect of moxibustion. Meta-analysis of
two trials
10,51
showed that a combination of moxibustion
and acupuncture was better than acupuncture alone for in-
creasing the number of cured patients (RR: 1.47; 95% CI:
1.05–2.07; P=0.03; fixed model; I
2
=0%; 2 trials).
Adverse events. Twenty-nine trials did not mention ad-
verse events. Of the fourteen trials
10,11,13,19,27,30,31,36,42,43,45,47,50,52
that did report adverse events, seven trials
11,27,30,31,42,45,50
found no adverse events in both intervention and control
groups. The remaining seven trials reported mild adverse
events in the intervention and control groups (Table 1), such
as thirst, dizziness, redness and swelling of the treated site,
Table 2. (Continued)
Study 1st
author and ref. Comparisons
Effect estimates
[95%CI] P
3.2.2 Acupoint injection +acupuncture versus acupuncture alone
Xie 2011
42
Acupoint injection with danshen extract +acupuncture versus
acupuncture alone
1.45 [0.46, 4.59] 0.53
3.2.3 Acupoint injection +herbal medicine versus herbal medicine alone
Zhang 2007
49
Acupoint injection with danshen extract +Pi Pa Qing Fei decoction
versus herbal decoction
1.08 [0.83, 1.41] 0.55
4. Acupoint catgut embedding
4.1 Acupoint catgut embedding versus Western medication
Zhang 2010
52
Acupoint catgut embedding versus viaminate capsules & fusidic
acid cream
1.57 [1.15, 2.15] 0.004
4.2 Acupoint catgut embedding +other treatment versus other treatment alone
4.2.1 Acupoint catgut embedding +pharmaceutical medication versus pharmaceutical medication alone
Xie 2008
43
Acupoint catgut embedding +minocycline capsule, tretinoin cream/
clindamycin gel versus minocycline capsule, tretinoin cream/
clindamycin gel
1.40 [0.50, 3.92] 0.52
4.2.2 Acupoint catgut embedding +herbal medicine versus herbal medicine alone
Wang 2009
36
Acupoint catgut embedding +herbal decoction versus herbal
decoction alone
1.85 [1.24, 2.77] 0.003
5. Moxibustion
5.1 Moxibustion +acupuncture versus acupuncture alone
Chen 2007
10
Moxibustion +acupuncture versus acupuncture alone 1.67 [0.33, 8.48]
Zhang 2006
51
Moxibustion +acupuncture versus acupuncture alone 1.46 [1.04, 2.05]
Overall (random, I
2
=0%) RR 1.47 [1.05, 2.05] 0.03
Overall (fixed, I
2
=0%) RR 1.47 [105, 2.07] 0.03
CI, confidence interval; RR, risk ratio.
190 CAO ET AL.
and pain or itching in the acupoint area. Serious adverse
events were not reported.
Funnel-plot analysis. Funnel-plot analysis of eight
trials showed significant asymmetry (Fig. 3).
DISCUSSION
This study’s data demonstrated that, in the studies that
were evaluated, acupuncture and cupping therapy used alone
or in combination with pharmaceutical medication appeared
to be more effective than pharmaceutical medication alone in
increasing the number of cured patients with acne. However,
further studies are needed to confirm this finding. The ther-
apeutic effects of acupoint injection, acupoint catgut em-
bedding, and moxibustion were unclear because there was
insufficient evidence from the available studies.
Results of nine meta-analyses found that acupoint-
stimulation therapies combined with other treatments were
significantly more efficacious than other treatments applied
alone. Cupping therapy and acupoint injection appeared to
be superior to pharmaceutical medication, whereas no dif-
ference in efficacy was seen between acupuncture and
pharmaceutical medication. Although across studies, the use
of pharmaceutical medication was not guideline-based or
dosage-consistent (Table 1), acupoint-stimulation therapies,
including acupuncture, cupping, and acupoint injection may
have an equivalent therapeutic effect as medication (anti-
biotics, antiprotozoal, licorsinc, isotretinoin) for acne.
Given that no severe adverse events were reported in the
included studies, the current authors believe that it would be
worthwhile to conduct further, rigorously designed trials on
acupoint-stimulation therapies for the treatment of acne.
This current review revealed that there remains a lack of
well-designed studies on the treatment of acne using acu-
point-stimulation therapies. Methodological quality of the
studies included in this review was generally poor, indi-
cating a high risk of bias. Inadequate application of ran-
domization and absence of blinding were evident in the
majority of trials, causing potential performance bias and
detection bias, because patients and researchers were aware
of the therapeutic interventions. Applying proper blinding
methodology remains a challenge for studies on manual-
healing therapies. Even so, at the very least, blinding of
outcome assessors is highly recommended in such studies.
ITT analysis was not applied in most of the trials and the
funnel-plot indicated that these data may have publication
bias. Intervention response using the ambiguous and sub-
jective terminology of cure, markedly effective, effective,
and ineffective was difficult to interpret and validate across
studies. Consequently, any positive finding needs to be in-
terpreted cautiously. Researchers of future studies should
consider applying more robustly defined intervention re-
sponse measurements, such as one of the existing acne
grading scales.
58
None of the trials reported sample-size
calculation. The current authors strongly recommend that
future RCTs include sample-size estimates to ensure ade-
quate statistical power. Furthermore, sample-size calcula-
tion and analysis of outcomes should be based on the
principle of ITT.
Twelve trials
13,14,16,19,21,23,24,30,44–46,50
used skin-lesion
(‘‘ouch’’ point) areas as the main targets for stimulation,
while other studies
10–12,15,17,18,20,22,25–29,31–43,47–49,51,52
es-
tablished acupoint prescriptions that were followed
throughout the duration of the trials. The limited number of
trials precluded the current authors from ascertaining the
differences in therapeutic effects among these three types of
acupoint-selection methods.
The potential asymmetry of the funnel-plot test (Fig. 3) of
eight trials that examined acupuncture plus herbal medicine,
compared with herbal medicine alone may have been
caused by small study effects or even heterogeneity in in-
tervention effects. Furthermore, as ongoing trials were not
included, and, as all trials were conducted in China, there is
a high potential for publication bias in the current review.
In summary, most of the existing trials were of small size
and had a high risk of bias. Further high-quality, large-scale
studies are needed to confirm the effectiveness of acupoint-
stimulation therapy for treating acne. Randomization
methods need to be described clearly and reported fully.
Blinding of outcome assessors should be attempted as fea-
sibly as possible to minimize performance and assessment
biases. Outcome (response) measures utilizing acne-grading
scales should be applied and should include contiguous
data, such as skin-lesion scores from baseline to study
completion. Analysis of outcomes based on the ITT prin-
ciple is vital as is the application of sample-size calculation.
Reporting of trials should adhere to the Consolidated
Standards OfReporting Trials (CONSORT)
59
to ensure
clarity and completeness of reporting.
FIG. 3. Funnel plot of eight trials for the outcome of number of
patients cured of acne. SE, standard error; RR, relative risk.
ACUPOINT STIMULATION FOR ACNE 191
CONCLUSIONS
Acupoint-stimulation therapy—especially when it is
combined with other treatments—appears to be effective for
treating acne. However, further large, rigorously designed
trials are needed to confirm these findings.
ACKNOWLEDGMENTS
H.-j. Cao and J.-p. Liu were supported by the Research
Capacity Establishment Grant (number 101207007) of
Beijing University of Chinese Medicine. This work was also
supported by the grant numbers 2009ZX09502-028 and
2011ZX09302-006-01-03(5). The authors thank Nissi
S. Wang MS, for content editing of this manuscript.
DISCLOSURE STATEMENT
No competing financial interests exist.
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Address correspondence to:
Jian-ping Liu, PhD
Centre for Evidence-based Chinese Medicine
Beijing University of Chinese Medicine
88# Mail Box
Bei San Huan Dong Lu 11
Chaoyang District, Beijing 100029
China
E-mail: jianping_l@hotmail.com
194 CAO ET AL.
