MEDICAL ACUPUNCTURE

Volume 25, Number 3, 2013

# Mary Ann Liebert, Inc.
DOI: 10.1089/acu.2012.0906

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 the face; anterior trunk; and upper back.1 Mild acne is
characterized by comedones, or blackheads, which are di-

A cne is a chronic inflammatory condition of the

skin. This condition most commonly affects areas
where the sebaceous glands are largest and most abundant:
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.

173
174 CAO ET AL.

those on the skin and emotional scars can last a lifetime. review that evaluated the clinical evidence of all types of
Acne affects 80% of adolescents (most commonly from 12 acupoint-stimulation therapies. This systematic review
years of age), but it can also affect 54% of adult women was performed to assess the effectiveness and safety of
and 40% of adult men (primarily those in their early or all acupoint-stimulation techniques used to treat acne
mid-20s).2 vulgaris.
Acne treatment is aimed at decreasing inflammation of
the lesions and accompanying discomfort with the ultimate
goals of improving appearance and preventing or minimizing METHODS
scarring and emotional distress.3 Effective prescription
medications are available, although side-effects—such as Inclusion Criteria
local irritation, teratogenicity, dry skin, hyperlipidemia,
and increased risk of depression—are reported.4,5 Over- Parallel-group RCTs were included in any data analysis
the-counter preparations and herbal remedies, as well as with interventions for the treatment of acne vulgaris using
skin- hygiene routines and dietary modifications may be any acupoint stimulation technique—such as acupuncture,
recommended by dermatologists or, more often, are self- moxibustion, cupping, acupoint injection, and acupoint
prescribed.4 catgut embedding—compared with no treatment, placebo,
In China, in addition to prescription medications, tradi- or conventional pharmaceutical medication. Comparisons
tional Chinese therapies are used to treat acne. One such also included a combination of acupoint-stimulation tech-
therapy is acupoint stimulation. Several methods can be niques, plus other therapies, versus the same other therapies
applied: acupuncture with needles; moxibustion, which in- alone. Participants who were diagnosed with acne vulgaris,
volves the controlled burning of material, typically mugwort or papulopustular, inflammatory, adolescent, or polymor-
(Artemisia vulgaris) herb, at certain points or areas of the phic acne—regardless of gender, age, and ethnicity—were
body surface; cupping therapy, which involves applying included. Primary outcome measures were reduction of
suction by placing a vacuumized, usually by fire, cup or jar signs and symptoms and presence of adverse effects. Sec-
on acupoints or affected body surfaces to induce local hy- ondary outcome measures included post-treatment evalua-
peremia or hemostasis; acupoint injection, which involves tion, participants’ self-assessment of change in lesions after
injecting medication into an acupuncture point; and acu- treatment, psychosocial outcomes, and quality of life (QoL)
point embedding, which involves embedding in the skin measurements.
over the acupoint a small needle(s), or medicated catgut.
Acupoint-stimulation methods are based on the Tradi- Identification and Selection of Studies
tional Chinese Medicine (TCM) view that acne is caused by Searches were conducted in the China Network Knowl-
any or a combination of several pathogenic factors. These edge Infrastructure (CNKI, 1979–2012), Chinese Scientific
include intense Lung Heat or Stomach Heat, Damp–Heat Journals Database (VIP, 1989–2012), Wan Fang Database
with Blood Stasis, and Qi (vital energy) Stagnation. As the (1985–2012), Chinese Biomedicine (CBM, 1978–2012),
condition becomes protracted, pathogenic Heat rises and Cochrane Central Register of Controlled Trials (CENTRAL,
accumulates in the skin and tissues, which brings on the 1999–2012), and PubMed (1966–2012). All searches ended
lesions.6 in May 2012. Search terms included acupuncture, electro-
Potential mechanisms of acupoint stimulation for acne acupuncture, auricular therapy, acupoint, meridian, combined
are to relieve Heat toxicity, eliminate Dampness, regulate with acne vulgaris and acne. Unpublished postgraduate theses
the Qi and Blood, and enhance immunologic function.6 in Chinese databases were also searched. No language re-
Some studies also mention that acupuncture can stimulate strictions were imposed. Three authors (H.-j.C., G.-y.Y., and
and balance androgen levels to inhibit excess secretion of Y.-y.W.) independently selected studies for eligibility and
the sebaceous gland.7 checked against the inclusion criteria.
Articles with clinical observations have reported the
efficacy of acupoint-stimulation therapies for acne. A
systematic review7 assessing seventeen TCM randomized
Data Extraction and Quality Assessment
controlled trials (RCTs) suggests that acupuncture and Three authors (H.-j.C., G.-y.Y., and Y.-y.W.) indepen-
moxibustion are better than conventional pharmaceutical dently extracted population and intervention characteristics
medication for reducing symptoms of acne. Another sys- using self-designed data extraction templates. Disagreements
tematic review8 involving twenty-three trials of topical and were resolved by discussion with another author ( J.-p.L).
oral complementary and alternative medicines (CAMs) Risk of bias for each study was conducted in accord
concluded that, poor methodological quality aside, the with the Cochrane Handbook for Systematic Reviews of
evidence suggests that many of these therapies are bio- Intervention.9 Six criteria were applied, as follows: (1) se-
logically plausible. However, there has been no systematic lection bias (random-sequence generation and allocation
ACUPOINT STIMULATION FOR ACNE 175

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 I2 test. RevMan 5.1
software (Cochrane Collaboration) was used for data ana-
lyses. Meta-analysis was used if the trials had acceptable FIG. 1. Search strategy flow chart.
homogeneity (I2 < 85%) of study design, participants, in-
terventions, controls, and outcome measures. Meta-analyses
were performed using fixed-effect 9 models (I2 < 25%) for moxibustion, and combination of acupoint-stimulation
homogeneous studies and using random-effects methods therapies and herbal medicine. Controls included pharma-
prior to fixed-effect models when there was substantial ceutical medications and herbal medicine alone. Courses of
heterogeneity (25% < I2 < 85%). 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
RESULTS all forty-three included trials. Responses to interventions were
classified as cure, markedly effective, effective, and ineffec-
Description of Studies tive.53 Cure was defined as lesions totally faded (or > 95%
faded) and only mild pigmentation and scars remaining.
After primary searches of six databases, 535 citations
Markedly effective was defined as lesions faded > 60% and
were identified. We excluded 484 studies because they
severity of lesions was alleviated. Effective was defined as
did not meet inclusion criteria. Full-text articles for 51
lesions faded 20%–59% and severity of lesions was reduced.
studies were retrieved. Finally, 43 trials10–52 were in-
Ineffective was defined as lesions faded < 20% or worsening
cluded in this review (Fig. 1). Characteristics of included
of lesions. Four trials13,19,43,45 counted the number of skin
trials are listed in Table 1. Among the included trials,
lesions, three trials14,42,45 reported QoL scores, two trials 42,43
fourteen studies11–15,19,21,26,31,35,42,43,45,46 were unpublished
reported recurrence rates, and three trials14,42,43 listed labo-
master’s theses.
ratory test results.
The forty-three trials involved a total of 3453 patients,
with an average of 40 participants in each group. Age ran-
Methodological Quality
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 According to the current authors’ predefined quality-
report diagnostic criteria, two trials10,30 used international assessment criteria, all forty-three trials were evaluated
diagnostic criteria, and thirty-three trials reported using one as having a high risk of bias (Fig. 2). Study sample size
of four TCM diagnostic criteria.53–56 Of the thirty-three varied from 20 to 112 participants, with an average of
trials, six trials 24,36,40,41,43,52 did not report sources for di- 40 patients per group. None of the trials reported
agnostic criteria, and eight trials11,15,17,20,31,34,37,51 used self- sample-size calculation methodology. Fifteen tri-
established diagnostic criteria for acne. als11,12,14,15,19,21,26,30,32,35,42,44–46,48 described randomiza-
Interventions included acupuncture (electroacupuncture, tion procedures, using random number tables or computer
auricular acupuncture, and ear point pressure), cupping generation of random numbers, but only 1 trial14 reported
therapy, acupoint injection, acupoint catgut embedding, adequate allocation concealment. The majority of trials
176 CAO ET AL.

Table 1. Characteristics of 43 Included Trials

Sample size (M/F) Sample age (range, y) Disease duration (average) Baseline
Study 1st Diagnostic data
author & ref. criteria I C I C I C comparable?

Chen 200710 Chinese 10/26 8/22 22.13 21.63 2.61 y 1.96 y Yes
criteria &
Western
criteria

Chen 200911 Nonstandard 30* 60* 22.93 – 6.03 21.83 – 6.07 4.31 – 3.24 y 2.60 – 1.92 y Yes
Chinese
criteria

Cheng 201012 Chinese 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
criteria56

Fan 201013 Chinese 15/10 11/15 22.24 – 4.087 22.32 – 4.534 1 y–3 y 1 y–3 y Yes
criteria53

Gong 200514 Chinese 9/11 6/14 21.3 21.5 2.89 y 3.57 y Yes
criteria53

Han 201015 Nonstandard 18/28 14/33 25.83 24.68 2.35 y 2.15 y Yes
Chinese
criteria

He 200916 Chinese 8/16 10/12 25.2 (17–41) 23.6 (16–38) 20 d–16 y 1 m–17 y Yes
criteria54

(continued)
ACUPOINT STIMULATION FOR ACNE 177

Table 1. (Continued)

Duration of
Intervention Control treatment (w) Outcome Adverse events

Warm needling & Acupuncture applied to 9 Response to Yes (3 patients in

moxibustion at: CV 4, CV same acupoints as for intervention intervention group had
6, ST 36, BL 20, & BL 23; treatment group, 1 · / dry stools, thirst,
additional points according every other d irritability)
to syndrome
differentiation, 30 minutes,
1 · /2 d
Bloodletting, followed by Herbal medicine 2 · /d 4 Response to No
cupping at BL 13 & BL 21, intervention
combined with body
acupuncture 2 · /w; herbal
medicine, twice per d
Bai Xian Xia Ta Re tablet, 5 Bai Xian Xia Ta Re tablet, 4 Response to NR
pills (adolescents, 3 pills), 5 pills (adolescents, 3 intervention
3 · /d; ear acupressure with pills) 3 · /d
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
Fire needling & acupuncture Tazarotene cream applied 3 Skin-lesion count; Yes (24 cases in acu
on the lesion area, to lesions at bedtime response to group & 9 cases in
1 · /every 5 d every night, intervention; control group had pain;
clindamycin gel applied adverse effects 24 cases in acu group &
to lesions 1 · /every 6 cases in control group
morning 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 Licorsinc capsule, 0.25 g, 4 Laboratory tests; NR
area, 30 min 1 · /every 2; 3 · /d QoL—Acne;
ear acupressure with GAGS; response
vaccaria seed on CO 18, to intervention
TG 2p, AH 6a, CO 14 &
LO 5,6i; patients instructed
to press 3–5 min 2 · /d
Acupuncture of abdominal Isotretinoin,10 mg, 2 · /d 8 Response to NR
acupoints: CV 12, CV 10, for 1 m, then 10 mg intervention
CV 6, CV 4, ST 24, ST 26, 1 · /d
KI 13 for 30 min, 3 · /w,
1 · / every 2 days
Acupuncture of abdominal Topical metronidazole 3 Response to NR
acupoints: CV 12, CV 10, solution 2 · /d intervention
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

(continued)
178 CAO ET AL.

Table 1. (Continued)
Sample size (M/F) Sample age (range, y) Disease duration (average) Baseline
Study 1st Diagnostic data
author & ref. criteria I C I C I C comparable?

Hong 201117 Nonstandard 8/11 7/11) 24 (15–36) 23 (14–35) 2.5 (1–10) y 2.2 (1–11) y Yes
Chinese
criteria

Hou 200918 Chinese 21/24 18/24 16–38 17–38 2 m–5 y 3 m–4 y NR

criteria55

Huang 201119 Chinese 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
criteria54

Huang 201020 Nonstandard 76* 50* 23 (16–35) 2 m–5 y Yes

Chinese
criteria

Huang 200921 Chinese 12/18 10/20 15–45 2 m–2 y Yes

criteria54

Huang 201122 NR 14/16 15/15 21.3 19.9 24.7 m 26.0 m Yes

Jin 200923 NR 14/18 12/14 24.5 (18–24) 23 (16–30) (4.7 – 1.2) y (4.8 – 1.14) y Yes

Lan 200424 Chinese 0/38 0/34 NR NR Yes

criteria
without
source

Li 199525 NR 35/21 25/15 NR 3 m–6 y NR

(continued)
ACUPOINT STIMULATION FOR ACNE 179

Table 1. (Continued)

Duration of
Intervention Control treatment (w) Outcome Adverse events

Bloodletting at HX 6,7i, GV Chinese medicinal facial 5 Response to NR

14, BL 13, BL 21 & BL 20 mask 2 · /w intervention
3–5 · ; cupping on GV 14,
BL 13, BL 21 & BL 20 for
10–15 min 2 · /w; Chinese
medicinal facial mask
2 · /w
Bloodletting, followed by Bloodletting, followed by 2 Response to NR
cupping at GV 14, BL 28, cupping at GV 14, BL intervention
BL 25, BL 21 & BL 13; 28, BL 25, BL 21 & BL
Blood Stasis point, 13; Blood Stasis point
1 · /every 2 d; ear acupoint 1 · /every 2 d
needle embedding 3–5 d at
acupoints TF 4, TF 2,CO
18 & TG 2
Acupuncture at ‘‘ouch’’ Pi Pa Qing Fei decoction, 4 Skin-lesion count; Yes (6 patients in acu
point, 30 min 1 · /every 2 250 mL, 2 · /d; Chinese response to group reported black &
d, 3 · /w; Pi Pa Qing Fei herbal facial mask, intervention; blue of some skin areas
decoction, 250 mL, 2 · /d; 30 min 1 · /d adverse effects after acupuncture)
Chinese herbal facial
mask, 30 min 1 · /d
Bloodletting, followed by Herbal preparation 50 mL, 4 Response to NR
cupping at GV10, GV14, 3 · /d; topical facial intervention
BL13, BL15, BL20 for cream
5–10 min 2 · /w; herbal
preparation, 50 mL, 3 · /d;
topical facial cream
Autologous blood injection at Autologous blood 4 Response to NR
acupoints LI 11 & BL 13; injection at acupoints intervention
EA at skin-lesion area for LI 11 & BL 13 for
30 min, 3 · /w 30 min, 3 · /w
Autologous blood injection, Viaminate capsules, 3 Response to NR
4 mL, at bilateral acupoint 0.025 g, 3 · /d; intervention
ST 36, 1 · /w tetracycline, 0.25 g,
3 · /d
Body & facial acupuncture Herbal facial mask 4 Response to NR
30 min once every 2 days; applied 20 min once intervention
herbal facial mask applied every 2–3 d
for 20 min 1 · /every 2–3 d
Acupuncture at lesion area, Qin Shen Fen Ci Qing 6 Response to NR
LI 4, SP 36, 30 min 3 · /w, oral liquid, 20 mL, intervention;
3 w/cycle for 2 cycles; 3 · /d. adverse events
Qing Shen Fen Ci Qing
oral liquid ,20 mL, 3 · /d
Use point-detection device to Herbal decoction 1 · /d 4 Response to NR
test/stimulate ear points for 1 m intervention
TG 2p, CO 7, CO 14 & CO
4 for 30 min for 1 m;
herbal decoction 1 · /d
for 1 m

(continued)
180 CAO ET AL.

Table 1. (Continued)
Sample size (M/F) Sample age (range, y) Disease duration (average) Baseline
Study 1st Diagnostic data
author & ref. criteria I C I C I C comparable?

Li 200926 Chinese 0/29 0/30 25.48 – 4.09 25.57 – 4 .67 < 13 y < 13y NR
criteria53

Li 201127 NR 48* 48* 22.8 (14–32) 22 m (2 m–10 y) Yes

Li 201128 Chinese 10/13 10/12 25.3 (18–39) 24.5 (18–35) 19.17 (1–65 m) 19.36 (2–67m) NR
criteria53

Liu 200829 NR 60* 60* 14-41 2 m–10 y Yes

Liu 200930 Chinese 14/29 39* 23.6 24.1 2 w–5 y 3 m–4 y NR

Criteria &
Western
criteria

Lu 201131 Nonstandard 21/39 18/42 20.17 – 4.48 22.17 – 4.12 1 m–10 y 1 m–10 y Yes
Chinese (13–34) (14–30)
criteria

Mao 200832 Chinese 16/25 43* 16–21 1 w–2 m 1 w–3 m Yes

criteria54

Mi 201133 Chinese 14/16 18/12 22.31 (31–32) 25.27 (16–30) NR Yes

criteria53

(continued)
ACUPOINT STIMULATION FOR ACNE 181

Table 1. (Continued)

Duration of
Intervention Control treatment (w) Outcome Adverse events

Herbal decoction, 50 mL, Herbal decoction, 50 mL, 4 Response to NR

2 · /d; Cuo Ling Ding 2 · /d; Cuo Ling Ding intervention
applied topically to applied topically to
lesions; acupoint injection lesions; acupoint
with 1 mL of danshen injection with 1 mL of
extract at ST 36, 1 · /every danshen at ST 36,
3–5 d; ear acupuncture at 1 · /every 3–5 d
TF 4, TG 2p, AH 6a & CO
18, 1 · /every 7 d
Acupuncture at LI 4, SI 3 & Herbal decoction; She 12 Response to No
PC 8; herbal decoction; Dan Shuan applied intervention
She Dan cream applied topically to lesions
topically to lesions
Fire needling at ‘‘ouch’’ Yang He decoction 8 Response to NR
point, BL 13, BL 15, BL intervention
18, BL 23, CV 4, CV 6,
CV 12 & S 25 1 · /w for 8
w; Yang He decoction
Autologous blood injection, Vitamin B tablet, zinc 6 Response to NR
5 mL, injection at bilateral gluconate tablet, Luo intervention
ST 36, 1 · /w; medications Hong enzyme capsule,
same as control group Pi Pa Qing Fei
decoction; topical acne
tincture; skin hygiene;
Qing Da enzyme
injection or
triamcinolone injection
1 · /w
Acupuncture for 30 min, Acupuncture mainly at ST 4 Response to No
followed by flash cupping 3, ST 4, ST 6, ST 7 & intervention
mainly at ST 3, ST 4, ST 6, SI 18, 10 sessions per
ST 7 & SI 18; 10 sessions course, 2 courses total
per course, 2 courses total (1 · /d for the first
(1 · /d for the first course, course, every other d
every other day for the for the second course)
second course)
Flash cupping at DU 14, Herbal preparation 2 · /d 4 Response to No
followed by needling for intervention
5–10 min & cupping for
5 min, 1 · /every 2–3 days;
herbal decoction 2 · /d
Acupuncture at Ex-B 2, ST Oral minocyclin, 50 mg, 1 Response to NR
36 & LI 4 for 15–30 min, 2 · /d intervention
1 · /d for 5 d
Acupuncture at CV 12, CV Warm needling at skin 8 Response to NR
10, CV 4, ST 26, ST 25 or lesion area; acupoint intervention
30 min, 1 · /every 2 d, 1 m/ injection with danshen
course for 2 courses; warm injection at ST 36 & LI
needling at skin lesion 11
area; acupoint injection
with danshen injection at
ST 36 & LI 11

(continued)
182 CAO ET AL.

Table 1. (Continued)
Sample size (M/F) Sample age (range, y) Disease duration (average) Baseline
Study 1st Diagnostic data
author & ref. criteria I C I C I C comparable?

Song 201134 Nonstandard 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
Chinese
criteria

Wang 201135 Chinese 10./14 11/13 22.58 (18–32) 22.33 (18_33) >2 w >2 w Yes
criteria53

Wang 200936 Chinese 35/33 30/30 26.5 25 6 m–7 y 5 m–8 y Yes

criteria
without
source

Wang 200737 Nonstandard 30* 30* 18 d–37 d 10 d–6 y Yes

Chinese
criteria

Wu 201038 NR 30* 28* 16–25 15–25 4 m–6 y 3 m–6 y NR

Wu 199839 NR 34* 34* 19.5 (16–24) 6 m–4 y NR

Wu 200840 Chinese 9/21 7/23 26.13 – 2.54 24.83 – 3.07 15.20w – 136 w 14.53 w + 187 w Yes
criteria
without
source

Xie 200941 Chinese 16/22 18/12 15–38 14–36 1 m–9 y Yes

criteria
without
source

(continued)
ACUPOINT STIMULATION FOR ACNE 183

Table 1. (Continued)

Duration of
Intervention Control treatment (w) Outcome Adverse events

Bloodletting, followed by Vitamin B tablet, oral 4 Response to NR

cupping at GV 14, BL 13, metronidazole, or oral intervention
BL 18, BL 20 & BL21 erythromycin; topical
metronidazole 1%–5%,
cream; topical benzoyl
peroxide gel; topical
sulfur preparation;
topical Mei Lu Xiao
Cuo cream
Acupuncture & guasha at GB Scraping the first lateral of 4 Response to NR
14, SI 18, GV 14, LI 4, LI BL meridian, once intervention
11 & S 44 1 · /every 2 d; per w
scraping the first lateral of
BL meridian, once per w
Acupoint catgut embedding Oral herbal decoction 8 Response to Yes (distending pain
at BL 13 & ST 36 as main intervention during the acupoint
points; additional points catgut embedding)
selected according to
syndrome differentiation,
1 · /m; oral herbal
decoction
Acupuncture & Acupuncture & 4 Response to NR
moxibustion + acupoint moxibustion, 1 · /d intervention
bloodletting & moving
cupping (acupuncture for
30 min, 1 · /d; cupping for
5–10 min, 1 · /every 3 d;
10 sessions as 1 course
Bloodletting, followed by Oral tanshinone 1 g, 3 · /d 4 Response to NR
cupping at BL 13, BL 15, for 3 w intervention
BL 18 , BL 20, BL 21 &
BL 23 for 10–15 min,
1 · /every 5–7 d
Acupoint injection at L I4, LI Metronidazole tablet, 3 Response to NR
11, SP 6 & ST 36 of 0.2g, 3 · /d; intervention
extracts of yu xing cao & minocycline tablet,
dang gui, 4 mL each, 0.05 g, 2 · /d
alternating at 1–2
acupoints, 1 · /every 2 d
Bloodletting, followed by Tetracycline, 0.25 g, 4 Response to NR
cupping once daily at 4 · /d; ketoconazole, intervention
‘‘ouch’’ points, the BL 2% ,cream 1 · /d
channel & at BL 13 until
7–8 mL of blood is let
Acupuncture at BL 13, GV Medicinal facial mask 3 Response to NR
14, LI 11, L I4 & SI 18, 30 min 1 · /d intervention
with additional points BL
12, LU 11, ST 36 & SP6
for 30 min 1 · /d;
medicinal facial mask for
30 min 1 · /d

(continued)
184 CAO ET AL.

Table 1. (Continued)
Sample size (M/F) Sample age (range, y) Disease duration (average) Baseline
Study 1st Diagnostic data
author & ref. criteria I C I C I C comparable?

Xie 201142 Chinese 7/22 6/22 25.6 25.3 6 m–10 y 5 m–10 y Yes
criteria55 (29.6–21.5) (29.3–21.3)

Xie 200843 Chinese 23/7 25/5 20.70 – 4.35 22.20 – 4.27 1.70y – 2.46 y 2.30y – 2.59 y Yes
criteria
without
source

Xu44 2009 Chinese 37/25 17/13 21.3 21.5 1.72 y 1.67 y Yes
criteria54

Xu45 2010 Chinese 5/27 6/26 22.97 22.63 2 m–13 y Yes

criteria55

Yan46 2006 Chinese 5/27 6/26 22.97 (17–43) 22.63 (18–38) 2 m–13 y 2 w–13 y Yes
criteria53

Yang47 2008 NR 31* 31* 22 5 m–7 y NR

Yang48 2008 NR 16/52 16–35 3 m–2 y Yes

Zhang49 2007 Chinese 29/27 28/28 22.4 (16–34) 22.1 (15–35) 2.2 y 2.3 y Yes
criteria54 (15 d–10 y) (16 d–11 y)

(continued)
ACUPOINT STIMULATION FOR ACNE 185

Table 1. (Continued)

Duration of
Intervention Control treatment (w) Outcome Adverse events

Acupuncture at GB14, SI18, Acupuncture at GB14, 8 Clinical symptom; No

LI4, LI11, ST44, SP6, SI18, LI4, LI11, ST44, response to
GB34, 30 min once every 2 SP6, GB34, with intervention;
days; acupoint injection of additional points recurrence rate;
dan shen extract 4mL each BL13& BL18 or BL20 quality of life;
at BL 13 & BL 18 or BL & BL23,30 min once adverse events
20 & BL 23 1 · /every 2 d every 2 days.
Minocycline capsule, 100 mg, Minocycline capsule, 6 Skin lesion count; Yes (3 cases in
daily at bedtime; catgut 100 mg, daily at Response to intervention group & 6
embedding LI 4, LI 11, ST bedtime; tretinoin intervention; cases in control group
36, ST 37, BL 25 & BL 21 cream, 0.025%, applied adverse effect; reported dizziness; 2
1 · /w; tretinoin cream, to lesions daily at recurrence rate; cases in control
0.025%, applied to lesions bedtime; clindamycin IgG test reported mild stomach
daily at bedtime; gel, 0.1%, applied to ache)
clindamycin gel, 0.1%, lesions 1 · /d in
applied to lesions 1 · /d in daytime
daytime
Herbal decoction, 150 mL, Herbal decoction, 150 mL, 4 Response to NR
twice daily; acupuncture twice daily intervention
around the lesion area
30 min once every 2 days
Acupuncture on skin lesion Pi Pa Qing Fei herbal 4 Response to No
area 20 min, three times decoction, 50 mL, twice intervention;
weekly; Pi Pa Qing Fei daily WHO QOL-
herbal decoction, 50 mL, BREF; lesion
2 · /w count
Facial acupuncture on lesion Herbal decoction, 50 mL, 4 Response to NR
area, body acupuncture at 2 · /d; topical San intervention
LI 11, SP 6, LR 3 & KI3, Huang lotion applied to
20 min, 3 · /w, 10 sessions lesions
as 1 course; herbal
decoction, 50 mL, 2 · /d;
topical San Huang lotion
applied to lesions
Compound Betamethasone Viaminate, 25–50 mg, 8 Response to Yes
injection, 1 mL with 2% 3 · /d; roxithromycin, intervention
lidocaine 1–5 mL injection, 150 mg, 2 · /d
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
Autologous blood injection, Erythromycin tablets, 4 Response to NR
1 mL, at LI 11 & ST 36 0.5 g, 3 · /d; intervention
1 · /every 3 d ketoconazole cream
applied to lesions 1 · /d
Pi Pa Qing Fei decoction Pi Pa Qing Fei decoction 6 Response to NR
modified according to modified according to intervention
syndrome differentiation, syndrome
twice daily; dan shen differentiation, 2 · /d
injection 1mL at bilateral
ST 36 1 · /w.

(continued)
186 CAO ET AL.

Table 1. (Continued)
Sample size (M/F) Sample age (range, y) Disease duration (average) Baseline
Study 1st Diagnostic data
author & ref. criteria I C I C I C comparable?

Zhang502008 NR 25/18 28/15 15–* 38 13–* 35 1 w–8 y 1 w–6 y NR

Zhang51 2006 Nonstandard 27/51 30/52 24.2 22.7 1 y–10 y 6 m–* 7 y Yes
Chinese
criteria

Zhang52 2010 Chinese 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
criteria
without
source

compared acupoint stimulation therapies and pharmaceutical ference in the number of cured patients between
medication; thus, blinding could not be applied for patients acupuncture plus herbal medicine and herbal medicine
and researchers. Six trials13,25,26,32,45,46 reported the number alone (RR: 1.60; 95% CI: 1.19–2.14; P = 0.002; random
of dropouts, but none used intention-to-treat (ITT) analysis. model; I2 = 46%; 9 trials), and between acupuncture plus
None of the trials mentioned sources of financial support. herbal facial mask and herbal facial mask alone (RR: 2.14;
95% CI: 1.29–3.55; P = 0.003; fixed model; I2 = 0%; 2 tri-
als). No difference was seen in the comparison between
Effect Estimates
acupuncture and pharmaceutical medications (RR: 1.49;
Because of variations in study quality, participant char- 95% CI: 0.82–2.73; P = 0.19; random model; I2 = 54%;
acteristics, intervention types, controls, and outcome mea- 5 trials), and in the comparison between acupuncture plus
sures, results of most trials could not be synthesized by acupoint injection and acupoint injection alone (RR: 2.00;
quantitative methods. Therefore, qualitative methods were 95% CI: 0.64–6.29, P = 0.24; fixed model; I2 = 0%; 2 trials).
used (Table 2). Three trials13,19,45 reported changes in skin-lesion count.
One study13 that used a skin-lesion scoring system,53
Therapeutic effect of acupuncture. Therapeutic ef- showed that acupuncture was superior to pharmaceutical
fect of acupuncture for acne was evaluated in 22 studies. Five medication for reducing the skin-lesion area (MD: - 26.95;
studies13–16,32 compared acupuncture with pharmaceutical 95% CI: - 31.84 to - 22.06; P < 0.00001; 1 trial). The re-
medications. Nine trials 12,19,24,25,27,28,44–46 compared acu- maining two trials compared acupuncture plus herbal
puncture plus herbal medicine with herbal medicine alone. medicine with herbal medicine alone. One of the trials45
Two trials21,33 compared acupuncture plus acupoint injection found that a combination of acupuncture and herbal medi-
with acupoint injection alone. Two trials23,41 compared acu- cine was better than herbal medicine alone for reducing
puncture plus a herbal facial mask with a facial mask alone. skin lesions (MD: - 13.88; 95% CI: - 19.17 to - 8.59;
One trial18 compared acupuncture plus cupping therapy with P < 0.00001, 1 trial), while the other trial19 showed no dif-
cupping therapy alone. One trial35 compared acupuncture plus ference between the comparison treatments (MD: - 0.97;
guasha (scraping) with guasha alone. One trial26 compared 95% CI: - 3.06 to 1.12; P = 0.36; 1 trial).
acupuncture plus herbal medicine and acupoint injection with QoL (Acne-QoL)57 was assessed in one trial,14 finding
herbal medicine and acupoint injection alone. that, compared with pharmaceutical medication, acupunc-
Nineteen trials 12–16,18,19,21,23–25,27,28,32,33,41,44–46 were in- ture appeared to significantly improve self-perception (MD:
cluded in four meta-analyses. There were a significant dif- 3.40; 95% CI: 2.16–4.64; P < 0.00001; 1 trial), social
ACUPOINT STIMULATION FOR ACNE 187

Table 1. (Continued)

Duration of
Intervention Control treatment (w) Outcome Adverse events

Bloodletting, followed by Tetracycline tablets 4 Response to No

flash cupping & 15 min of 500 mg 1 · /d; Cuo intervention
cup retention at at tender Chuang Ping ointment
Transporting points, at GV applied to lesions 2 · /d
14 & at additional points
according to syndrome
differentiation; treat
1 · /every 2 d
Acupuncture & moxibustion, Acupuncture 1 · /every 9 Response to NR
1 · /every other d; 5 other d; 5 sessions as 1 intervention
sessions as 1 course; 3 course; 3 courses total
courses total
Acupoint catgut embedding Viaminate capsules, 12 Response to Yes (5 cases in
at BL 13, BL 15, BL 18, 50 mg, 2 · /d; fusidic intervention intervention group & 4
BL 16, BL 20, BL 21, ST acid cream applied to cases in control
36, LI 11, & SP10; lesions 2 · /d reported dry lips)
additional points selected
according to syndrome
differentiation; treat
1 · /every 2 w
*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.

function (MD: 2.30; 95% CI: 1.23–3.37; P < 0.0001; 1 trial), Therapeutic effect of acupoint injection. Seven trials
and emotional function (MD 2.30; 95% CI: 0.74–3.86; evaluated the effect of acupoint injection for acne. Of the seven
P = 0.004; 1 trial). trials, three22,39,48 compared acupoint injection with pharma-
ceutical medication, and four trials compared acupoint injection
Therapeutic effect of cupping therapy. Ten trials plus other treatment with other treatment alone (pharmaceutical
evaluated the effectiveness of cupping therapy for acne. Of medication,29,47 acupuncture,42 and herbal medicine49).
the ten trials, four34,38,40,50 compared cupping therapy with Meta-analysis showed that acupoint injection used alone
pharmaceutical medications, three trials11,20,31 compared (RR: 1.51; 95% CI: 1.13–2.03; P = 0.006; fixed model;
cupping therapy plus herbal medicine with herbal medicine I2 = 0%; 3 trials) and combined with pharmaceutical
alone, two trials30,37 compared cupping plus acupuncture medication (RR: 1.49; 95% CI: 1.12–1.99; P = 0.007; fixed
with acupuncture alone, and one trial17 compared cupping model, I2 = 0%; 2 trials) were significantly better than
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; I2 = 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;
I2 = 0%; 3 trials) or acupuncture (RR: 1.79; 95% CI: 1.12–
2.86; P = 0.01; fixed model; I2 = 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 FIG. 2. Risk of bias graph shows the review authors’ judgments
trial). As each comparison had fewer than five trials, it was about each risk of bias item, presented as percentages across all
not meaningful to conduct a funnel-plot analysis. included studies.
188 CAO ET AL.

Table 2. Effect of Estimates of Acupoint Stimulation Treatment for Acne on Increasing Numbers
of Cured Patients in 43 Randomized Controlled Trials

Study 1st Effect estimates

author and ref. Comparisons [95%CI] P

1. Acupuncture
1.1 Acupuncture versus pharmaceutical medications
Fan 201013 Acupuncture with fire needling versus topical tazarotene cream & 2.43 [0.74, 7.99]
clindamycin gel
Gong 200514 Body acupuncture + ear acupressure versus licorsinc capsule 2.00 [0.20, 20.33]
Han 201015 Abdominal acupuncture versus isotretinoin capsule 0.80 [0.50, 1.27]
He 200916 Abdominal & facial acupuncture versus topical metronidazole 1.38 [0.45, 4.24]
solution
Mao 200832 Acupuncture versus minocycline 2.34 [1.23, 4.47]
Overall (random, I2 = 54%) RR 1.49 [0.82, 2.73] 0.19
Overall (fixed, I2 = 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 201012 Ear acupressure + Bai Xian Xia Ta Re tablet versus Bai Xian Xia Ta 1.33 [1.02, 1.74]
Re tablet alone
Huang 201119 Acupuncture + Pi Pa Qing Fei decoction & herbal facial mask 2.00 [0.78, 5.15]
versus herbal decoction & facial mask alone
Lan 200424 Acupuncture + Qin Shen Fen Ci Qing oral liquid versus Qin Shen 1.49 [0.75, 2.96]
Fen Ci Qing liquid alone
Li 199525 Auricular therapy + herbal decoction versus herbal decoction alone 2.86 [1.17, 6.97]
Li 201127 Acupuncture + herbal decoction and She Dan cream external 1.07 [0.79, 1.44]
application versus herbal decoction & topical She Dan cream
alone
Li 201128 Acupuncture + Yang He decoction versus Yang He decoction alone 5.10 [1.72, 15.11]
Xu 200944 Acupuncture + herbal decoction versus herbal decoction alone 1.37 [0.60, 3.12]
Xu 201045 Acupuncture + Pi Pa Qing Fei decoction versus Pi Pa Qing Fei 2.00 [0.67, 5.98]
decoction alone
Yan 200646 Body & facial acupuncture + herbal decoction & topical San Huang 2.00 [0.67, 5.98]
lotion versus herbal decoction & topical San Huang lotion alone
Overall (random, I2 = 46%) RR 1,60 [1.19, 2.14] 0.002
Overall (fixed, I2 = 46%) RR 1.56 [1.30, 1.89] < 0.00001
1.2.2 Acupuncture + acupoint injection versus acupoint injection alone
Huang 200921 Electroacupuncture plus autologous blood injection versus 2.00 [0.40, 10.11]
autologous blood injection alone
Mi 201133 Acupuncture plus acupoint injection versus acupoint injection alone 2.00 [0.40, 10.11]
Overall (random, I2 = 0%) RR 2.00 [0.64, 6.29] 0.24
Overall (fixed, I2 = 0%) RR 2.00 [0.64, 6.29] 0.24
1.2.3 Acupuncture + cupping therapy versus cupping therapy alone
Hou 200918 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 200923 Body & facial acupuncture + herbal facial mask versus herbal facial 2.17 [0.64, 7.35]
mask alone
Xie 200941 Acupuncture + herbal facial mask versus herbal facial mask alone 2.13 [1.24, 3.68]
2
Overall (random, I = 0%) RR 2.14 [1.30, 3.52] 0.003
Overall (fixed, I2 = 0%) RR 2.14 [1.29, 3.55] 0.003
1.2.5 Acupuncture plus guasha (scraping) versus guasha alone
Wang 201135 Acupuncture + guasha versus guasha alone 3.00 [0.92, 9.74] 0.07

(continued)
ACUPOINT STIMULATION FOR ACNE 189

Table 2. (Continued)
Study 1st Effect estimates
author and ref. Comparisons [95%CI] P

1.2.6 Acupuncture plus herbal medicine and acupoint injection versus herbal medicine and acupoint injection
Li 200926 Auricular therapy + herbal decoction, topical medicine, acupoint 1.38 [0.55, 3.49] 0.50
injection versus herbal decoction, topical medicine, & acupoint
injection
2. Cupping therapy
2.1 Cupping + other interventions versus other interventions alone
2.1.1 Cupping + herbal medicine versus herbal medicine alone
Chen 200911 Wet cupping + herbal decoction versus herbal decoction alone 2.33 [0.67, 8.18]
Huang 201019 Wet cupping + herbal preparation, topical cream versus herbal 2.06 [1.33, 3.18]
preparation & topical cream
Lu 201131 Wet cupping + herbal decoction versus herbal decoction alone 1.44 [0.67, 3.12]
2
Overall (random, I = 0%) RR 1.92 [1.34, 2.76] 0.0004
Overall (fixed, I2 = 0%) RR 1.91 [1.32, 2.74] 0.0005
2.1.2 wet cupping plus acupuncture versus acupuncture alone
Liu 200930 Flash cupping plus acupuncture versus acupuncture alone 1.91 [0.99, 3.72]
Wang 200737 Moving and wet cupping + acupuncture versus acupuncture alone 1.67 [0.87, 3.20]
Overall (random, I2 = 0%) RR 1,79 [1.12, 2.86] 0.01
Overall (fixed, I2 = 0%) RR 1.79 [1.12, 2.86] 0.01
2.1.3 wet cupping plus facial mask versus facial mask
Hong 201117 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 201134 Wet cupping versus vitamin B/metronidazole/erythromycin, 2.00 [0.80, 4.98]
metronidazole cream/benzoyl peroxide gel/sulfur/Mei Lu Xiao
Cuo cream
Wu 201038 Wet cupping versus tonshinone 1.07 [0.45, 2.56]
Wu 200840 Wet cupping versus tetracycline & ketoconazole cream 2.50 [1.31, 4.77]
Zhang 200850 Wet cupping versus tetracycline 2.75 [1.38, 5.48]
Overall (random, I2 = 6%) RR 2.10 [1.42, 3.11] 0.0002
Overall (fixed, I2 = 6%) RR 2.11 [1.45, 3.07] < 0.0001
3. Acupoint injection
3.1 Acupoint injection versus pharmaceutical medication
Huang 201122 Autologous blood acupoint injection versus viaminate capsule & 2.13 [1.09, 4.16]
tetracycline tablet
Wu 199839 Yu xing cao & dang gui acupoint injection versus metronidazole 1.67 [1.09, 2.56]
tablet & minocycline tablet
Yang 200848 Autologous blood acupoint injection versus erythromycin tablet & 1.29 [0.71, 2.36]
topical ketoconazole
Overall (random, I2 = 0%) RR 1.51 [1.13, 2.03] 0.006
Overall (fixed, I2 = 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 200829 Autologous blood acupoint injection + vitamin B/zinc gluconate 1.43 [1.03, 1.98]
tablet/Luo Hong enzyme capsule/Pi Pa Qing Fei decoction/acne
tincture & acupoint injection versus pharmaceutical medication
& acupoint injection
Yang 200847 Compound betamethasone injection with 2% lidocaine acupoint 1.78 [0.93, 3.40]
injection + viaminate & roxithromycin versus viaminate &
roxithromycin
Overall (random, I2 = 0%) RR 1.49 [1.12, 1.99] 0.007
Overall (fixed, I2 = 0%) RR 1.79 [1.12, 2.86] 0.01

(continued)
190 CAO ET AL.

Table 2. (Continued)
Study 1st Effect estimates
author and ref. Comparisons [95%CI] P

3.2.2 Acupoint injection + acupuncture versus acupuncture alone

Xie 201142 Acupoint injection with danshen extract + acupuncture versus 1.45 [0.46, 4.59] 0.53
acupuncture alone
3.2.3 Acupoint injection + herbal medicine versus herbal medicine alone
Zhang 200749 Acupoint injection with danshen extract + Pi Pa Qing Fei decoction 1.08 [0.83, 1.41] 0.55
versus herbal decoction
4. Acupoint catgut embedding
4.1 Acupoint catgut embedding versus Western medication
Zhang 201052 Acupoint catgut embedding versus viaminate capsules & fusidic 1.57 [1.15, 2.15] 0.004
acid cream
4.2 Acupoint catgut embedding + other treatment versus other treatment alone
4.2.1 Acupoint catgut embedding + pharmaceutical medication versus pharmaceutical medication alone
Xie 200843 Acupoint catgut embedding + minocycline capsule, tretinoin cream/ 1.40 [0.50, 3.92] 0.52
clindamycin gel versus minocycline capsule, tretinoin cream/
clindamycin gel
4.2.2 Acupoint catgut embedding + herbal medicine versus herbal medicine alone
Wang 200936 Acupoint catgut embedding + herbal decoction versus herbal 1.85 [1.24, 2.77] 0.003
decoction alone
5. Moxibustion
5.1 Moxibustion + acupuncture versus acupuncture alone
Chen 200710 Moxibustion + acupuncture versus acupuncture alone 1.67 [0.33, 8.48]
Zhang 200651 Moxibustion + acupuncture versus acupuncture alone 1.46 [1.04, 2.05]
Overall (random, I2 = 0%) RR 1.47 [1.05, 2.05] 0.03
Overall (fixed, I2 = 0%) RR 1.47 [105, 2.07] 0.03
CI, confidence interval; RR, risk ratio.

medication alone. However, no difference was found be- alone in increasing the number of cured patients (RR: 1.85;
tween acupoint injection combined with herbal medicine 95% CI: 1.24–2.77; P = 0.003; 1 trial). One study43 showed
(RR: 1.08; 95% CI: 0.83–1.41; P = 0.55; 1 trial) or acu- no difference between acupoint catgut embedding plus
puncture (RR: 1.45; 95% CI: 0.46–4.59; P = 0.53; 1 trial) pharmaceutical medication and pharmaceutical medication
compared with herbal medicine or acupuncture alone. As alone in increasing the number of cured patients (RR: 1.40;
each comparison had fewer than five trials, it was not 95% CI: 0.50–3.92; P = 0.52; 1 trial), reducing skin-lesion
meaningful to conduct a funnel-plot analysis. area (MD: 2.67; 95% CI: - 0.07 to 5.41; P = 0.06; 1 trial),
One trial 42 reported QoL scores and recurrence rate. and reducing recurrence rate (RR: 0.48; 95% CI: 0.12–1.88;
Results showed no difference between acupoint injection P = 0.29; 1 trial).
plus acupuncture and acupuncture alone in improving QoL
(MD: - 1.76; 95% CI: - 3.80 to 0.28; P = 0.09; 1 trial) and Therapeutic effect of moxibustion. Meta-analysis of
in reducing recurrence rate (RR: 0.22; 95% CI: 0.03–1.60; two trials10,51 showed that a combination of moxibustion
P = 0.13; 1 trial). and acupuncture was better than acupuncture alone for in-
creasing the number of cured patients (RR: 1.47; 95% CI:
Therapeutic effect of acupoint catgut embed- 1.05–2.07; P = 0.03; fixed model; I2 = 0%; 2 trials).
ding. Three trials36,43,52 evaluated the therapeutic effect of
acupoint catgut embedding for acne. One study52 showed Adverse events. Twenty-nine trials did not mention ad-
acupoint catgut embedding was superior to pharmaceutical verse events. Of the fourteen trials10,11,13,19,27,30,31,36,42,43,45,47,50,52
medication in increasing the number of cured patients (RR: that did report adverse events, seven trials11,27,30,31,42,45,50
1.57; 95% CI: 1.15–2.15; P = 0.004; 1 trial) and in reducing found no adverse events in both intervention and control
recurrence rate (RR: 0.22; 95% CI: 0.08–0.62; P = 0.004; 1 groups. The remaining seven trials reported mild adverse
trial). One trial36 showed acupoint catgut embedding com- events in the intervention and control groups (Table 1), such
bined with herbal medicine was superior to herbal medicine as thirst, dizziness, redness and swelling of the treated site,
ACUPOINT STIMULATION FOR ACNE 191

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
FIG. 3. Funnel plot of eight trials for the outcome of number of studies. Consequently, any positive finding needs to be in-
patients cured of acne. SE, standard error; RR, relative risk. terpreted cautiously. Researchers of future studies should
consider applying more robustly defined intervention re-
sponse measurements, such as one of the existing acne
and pain or itching in the acupoint area. Serious adverse grading scales.58 None of the trials reported sample-size
events were not reported. calculation. The current authors strongly recommend that
future RCTs include sample-size estimates to ensure ade-
Funnel-plot analysis. Funnel-plot analysis of eight quate statistical power. Furthermore, sample-size calcula-
trials showed significant asymmetry (Fig. 3). tion and analysis of outcomes should be based on the
principle of ITT.
Twelve trials13,14,16,19,21,23,24,30,44–46,50 used skin-lesion
DISCUSSION (‘‘ouch’’ point) areas as the main targets for stimulation,
while other studies10–12,15,17,18,20,22,25–29,31–43,47–49,51,52 es-
This study’s data demonstrated that, in the studies that tablished acupoint prescriptions that were followed
were evaluated, acupuncture and cupping therapy used alone throughout the duration of the trials. The limited number of
or in combination with pharmaceutical medication appeared trials precluded the current authors from ascertaining the
to be more effective than pharmaceutical medication alone in differences in therapeutic effects among these three types of
increasing the number of cured patients with acne. However, acupoint-selection methods.
further studies are needed to confirm this finding. The ther- The potential asymmetry of the funnel-plot test (Fig. 3) of
apeutic effects of acupoint injection, acupoint catgut em- eight trials that examined acupuncture plus herbal medicine,
bedding, and moxibustion were unclear because there was compared with herbal medicine alone may have been
insufficient evidence from the available studies. caused by small study effects or even heterogeneity in in-
Results of nine meta-analyses found that acupoint- tervention effects. Furthermore, as ongoing trials were not
stimulation therapies combined with other treatments were included, and, as all trials were conducted in China, there is
significantly more efficacious than other treatments applied a high potential for publication bias in the current review.
alone. Cupping therapy and acupoint injection appeared to In summary, most of the existing trials were of small size
be superior to pharmaceutical medication, whereas no dif- and had a high risk of bias. Further high-quality, large-scale
ference in efficacy was seen between acupuncture and studies are needed to confirm the effectiveness of acupoint-
pharmaceutical medication. Although across studies, the use stimulation therapy for treating acne. Randomization
of pharmaceutical medication was not guideline-based or methods need to be described clearly and reported fully.
dosage-consistent (Table 1), acupoint-stimulation therapies, Blinding of outcome assessors should be attempted as fea-
including acupuncture, cupping, and acupoint injection may sibly as possible to minimize performance and assessment
have an equivalent therapeutic effect as medication (anti- biases. Outcome (response) measures utilizing acne-grading
biotics, antiprotozoal, licorsinc, isotretinoin) for acne. scales should be applied and should include contiguous
Given that no severe adverse events were reported in the data, such as skin-lesion scores from baseline to study
included studies, the current authors believe that it would be completion. Analysis of outcomes based on the ITT prin-
worthwhile to conduct further, rigorously designed trials on ciple is vital as is the application of sample-size calculation.
acupoint-stimulation therapies for the treatment of acne. Reporting of trials should adhere to the Consolidated
This current review revealed that there remains a lack of Standards Of Reporting Trials (CONSORT)59 to ensure
well-designed studies on the treatment of acne using acu- clarity and completeness of reporting.
192 CAO ET AL.

CONCLUSIONS 12. Cheng L. Clinical study of 50 cases of auricular acupressure

with vaccaria seed for acne: Nursing guidance [in Chinese]. J
Acupoint-stimulation therapy—especially when it is Qilu Nurs. 2010;16(11):39–40.
combined with other treatments—appears to be effective for 13. Fan Y, Huang Y. Clinical Research on Treatment of Acne
treating acne. However, further large, rigorously designed Using Fireneedle Acupuncture [in Chinese; Master’s thesis].
Chengdu, China: Chengdu University of Traditional Chinese
trials are needed to confirm these findings.
Medicine; 2010.
14. Gong SB, Huang BY. Clinical Study on Treatment of Acne
ACKNOWLEDGMENTS Vulgaris with Scattered Needling Combined with Auricular
Point Adhesion [in Chinese; Master’s thesis]. Fujian. China:
Fujian University of Traditional Chinese Medicine; 2005.
H.-j. Cao and J.-p. Liu were supported by the Research
15. Han B, Mi JP. Clinical Study on Acupuncture of Abdominal
Capacity Establishment Grant (number 101207007) of Acupoints for Treatment of Acne by Regulating the Liver and
Beijing University of Chinese Medicine. This work was also Kidney [in Chinese; Master’s thesis]. Guangzhou, China:
supported by the grant numbers 2009ZX09502-028 and Guangzhou University of Chinese Medicine; 2010.
2011ZX09302-006-01-03(5). The authors thank Nissi 16. He XY. Clinical observation of acupuncture of abdominal and
S. Wang MS, for content editing of this manuscript. facial acupoints for treatment of 24 cases of facial acne [in
Chinese]. Nei Mongol J Traditional Chinese Med. 2009;
28(8):33.
DISCLOSURE STATEMENT 17. Hong TT, Wu LX. Cupping with bloodletting combined with
Chinese medicinal facial mask for treatment of acne [in
No competing financial interests exist. Chinese]. Shanghai J Acupunct Moxibustion. 2011;30(16):
387–388.
18. Hou GY, Cao L, Liu YP, Li HJ. Observation on the thera-
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