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An overview of acupuncture for psoriasis vulgaris,

2009–2014

Yu Xiang, Xing Wu, Chuanjian Lu & Kaiyi Wang

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JOURNAL OF DERMATOLOGICAL TREATMENT, 2016
http://dx.doi.org/10.1080/09546634.2016.1224801

ORIGINAL ARTICLE

An overview of acupuncture for psoriasis vulgaris, 2009–2014

Yu Xianga, Xing Wub, Chuanjian Luc and Kaiyi Wangd
a
School of Medical Information Engineering, Guangdong Pharmaceutical University, Guangzhou, China; bClinical Medical College of
Acupuncture, Moxibustion and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou, China; cDepartment of Dermatology,
Guangdong Provincial Hospital of Traditional Chinese Medicine, Guangzhou, China; dChina-Australia International Research Centre for Chinese
Medicine (CAIRCCM), School of Health and Biomedical Sciences, RMIT University, Melbourne, VIC, Australia

ABSTRACT ARTICLE HISTORY

Psoriasis is a chronic, proliferative, and inflammatory skin disease which affects around 2–3% of the global Received 12 May 2016
population. Current pharmacotherapy is effective, however medication with safe and long-lasting thera- Revised 15 July 2016
peutic effects is needed. Acupuncture for psoriasis is widely used in China as well as other Asian countries, Accepted 25 July 2016
and is gradually becoming accepted globally. To determine the characteristics and advantages of acu- Published online 13 Septem-
ber 2016
puncture treatment for psoriasis, and to improve the clinical outcomes of this disease in the future, this
review summarizes literature on acupuncture treatment for psoriasis published between 2009 and 2014. KEYWORDS
Databases search was conducted with the China National Knowledge Infrastructure (CNKI), MEDLINE, and Acupuncture therapy;
PubMed databases over a time period ranging from January 2009 to December 2014. The condition term psoriasis; review
was “psoriasis” and the key intervention terms were “needling”, “moxibustion”, “auriculotherapy”, “cupping
and bloodletting therapy”, “catgut embedding therapy”, “point-injection therapy”, “traditional Chinese
medicine fumigation therapy”, “fire needling therapy”, and “vesiculation moxibustion”. Languages were
limited to English and Chinese. Therapeutic mechanisms, therapy, therapeutic characteristics, advantages
and limits of acupuncture for psoriasis are discussed. The conclusion is that acupuncture therapies for
psoriasis are simple, convenient, and effective, with long-lasting therapeutic effects as well as minimal
side effects and toxicity.

Introduction results or reached a conclusion benefiting in controlling the symp-

Psoriasis is a chronic, proliferative, and inflammatory skin disease
which affects around 2–3% of the global population (1). Many
patients with severe psoriasis may suffer from social anxiety, occu-
pational stress, emotional distress, and other personal issues
because of the appearance of the skin and the chronic recurrent
nature of this disease. Psoriasis is still a difficult condition to treat
worldwide, as its exact etiology and pathophysiology are not
fully understood. Currently, there are no available conventional
medications with safe and long-lasting therapeutic effects on
psoriasis (2).
Acupuncture for psoriasis is commonly used in China and other
Asian countries, and is gradually being accepted around the world
because of its simplicity, convenience, and effectiveness. In recent
experimental studies and clinical trials, acupuncture has shown
long-lasting therapeutic effects on controlling the symptoms of
psoriasis, as well as minimal side effects and toxicity (3).
To further understand the characteristics and advantages of
acupuncture for psoriasis, we searched related articles in the data-
bases China National Knowledge Infrastructure (CNKI), MEDLINE,
and PubMed between January 2009 and December 2014. The con-
dition term was “psoriasis” and the key intervention terms were
“needling”, “moxibustion”, “auriculotherapy”, “cupping and blood-
letting therapy”, “catgut embedding therapy”, “point-injection
therapy”, “traditional Chinese medicine fumigation therapy”, and
“fire needling therapy”. Only literatures written in Chinese or
English were considered. Those articles which reported effective
toms of psoriasis were accepted. Individual or case report studies
were not included, even if a satisfied clinical outcome was
reached. Experimental studies demonstrating the efficacy of acu-
puncture and high quality retrospective surveys of acupuncture
for psoriasis with validated outcomes were also included. Figure 1
shows the detailed results of the search process.
Acupuncture therapy for psoriasis
Needling
In needling for psoriasis, Fengchi (GB 20), Quchi (LI 11), Hegu
(LI 4), Xuehai (SP 10), and Feishu (BL 13) are the acupuncture
points usually selected. According to Chinese medical theory,
the points can activate blood circulation to dissipate blood sta-
sis, dispel wind and arrest itching, and moisturize dryness by
nourishing blood in order to accelerate deflorescence. Wu (4)
randomly divided 40 patients with psoriatic arthritis into two
groups. The control group (18 cases) was treated with narrow-
band ultraviolet (311 nm) alone, once every other day for 10
treatments per cycle. The treatment group (22 cases) was
treated with acupuncture and narrow-band ultraviolet B. The
main acupuncture points were Dazhui (DU 14), Zhiyang (DU 9),
and Yaoyangguan (DU 3). The adjunct points were Huatuojiaji
(EX-B 5), Fengchi (GB 20), Quchi (LI 11), Hegu (LI 4), Xuehai (SP
10), and Feishu (BL 13), as well as the points surrounding the
involved joints, 10 treatments per cycle. Based on the psoriasis

CONTACT Chuanjian Lu luchuanjian888@vip.sina.com Department of Dermatology, Guangdong Provincial Hospital of Traditional Chinese Medicine,
Guangzhou 510120, China
ß 2016 Informa UK Limited, trading as Taylor & Francis Group
2 Y. XIANG ET AL.
Figure 1. Flow chart of study selecting process.
area and severity index (PASI), the scores decreased from
21.45 ± 10.52 pretreatment to 2.68 ± 2.70 post-treatment in the
treatment group. The results also showed that the rate of effect-
iveness of the treatment group (97.6%) was superior to that of
the control group (86.8%) with a significant difference (p < .05),
where the minimum threshold for effectiveness was 20% reduc-
tion in PASI scores from the baseline. This indicates that the
combination of acupuncture and narrow-band ultraviolet B is
effective and safe for psoriatic arthritis. In another study, Liu (5)
treated 60 blood-heat syndrome psoriasis vulgaris patients with
acupuncture and traditional Chinese medicine (TCM) formula
(Liang xue di huang tang 凉血地黄汤). Dazhui (DU 14), Yangxi
(LI 5), Hegu (LI 4), Feishu (BL 13), Quchi (LI 11) points were
selected as the main points. Based on the Standard of Diagnosis
and Therapeutic Effect of TCM Diseases 中医病证诊断疗效标准,
where the minimum threshold for effectiveness is 50% reduction
in lesions, the total rate of effectiveness was 98.3% (6).
According to current clinical evidence, acupuncture therapy of
general needling is widely used in the management of all the
stages of psoriasis. People in any age group with psoriasis may
get benefit from the general needling therapy.
Moxibustion
Modern medicine presumes that the heat of moxibustion can open
the follicular orifice, relax the epidermis, and improve local micro-
circulation, which can elevate surface immunity. Han et al. (7) found
that combining moxibustion with narrow-spectrum UVB ray irradi-
ation in treating psoriasis vulgaris can relieve psoriasis skin damage
and improve quality of life (QoL). Eighty psoriasis vulgaris patients
were randomly divided into two groups in this study. The control
group was given only narrow-spectrum UVB ray irradiation treat-
ment, and the treatment group was treated with an additional
bird-pecking moxibustion therapy on Dazhu (DU 14), bilateral
Sanyinjiao (SP 6), Xuehai (SP 10), and Quchi (LI 11) points. Results
showed improvement in three aspects: (a) The PASI scores of the
intervention group (decreased from 49.5 ± 8.8 to 17.3 ± 3.9) were
much lower than the control group (decreased from 49.3 ± 9.1 to
32.1 ± 6.8) post-treatment (p < .05); (b) The anxiety emotion (HAMA
score), depression emotion (HAMD score), and pain emotion
(NRS score) of the treatment group were all shown to have been
ameliorated compared to the control group (p < .05); (c) The life
quality subjective feeling, health condition subjective feeling,
physiological, psychological, social relations, and environmental
scores of the treatment group were higher than those of the con-
trol group (p < .05). Jie and Yue (8) randomized 80 psoriasis vulgaris
patients in active stage into two groups: 40 cases in the treatment
group were treated by acupuncture at Back-Shu points combined
with cotton-posting moxibustion at the affected areas, and 40
cases in the control group were orally administered the Chinese
medicine compound Qing-Dai capsules, as well as and Baibi
Ointment for application. These were administered in 2-week
cycles, and 8 weeks in total. The rate of effectiveness of the treat-
ment and control groups were 82.05% and 77.50%, respectively,
where the minimum threshold for effectiveness was 30% improve-
ment of PASI scores. The local symptoms in both groups improved,
and at the same time the PASI and dermatology life quality index
(DLQI) both dropped (p < .05), however no significant difference
between the two groups was seen (p > .05). Isomorphic response
did not appear in any patient in the treatment group. After 3
months, the follow-up survey showed that both the therapeutic
effect index and the DLQI improvement rate of the treatment
group were higher than those of the control group (p < .05). This
study indicated that the treatment of acupuncture at Back-Shu
points combined with cotton-posting moxibustion for psoriasis vul-
garis in active stage is effective and safe, and that the long-term
effects are better than those of the control group. Additionally,
psoriasis patients with cold substance deficiencies and long-term
disease are more suitable for and receptive to moxibustion.
Auriculotherapy
Auricular therapy is an auxiliary therapy of traditional acupunc-
ture, and over the last 60 years it has developed into a distinct
treatment modality based on a set of anatomical maps superim-
posed onto the ear. By stimulating a point on the ear, a promising
therapeutic effect is believed to occur on the gross anatomical
organ associated with that point. Studies have demonstrated that
auricular therapy can dredge meridians, and also promote general
qi and blood circulation, hence it can eventually improve the

blood flow (9). The auricular points described in the following
articles have been reported to be effective primarily in treating
psoriasis. Lung (CO14), Liver (CO12), Shenmen (TF4), Endocrine
(CO18), and Pizhixia (AT4) are the auricular points reported to be
effective primarily in treating psoriasis. According to modern
research and CM, “Lung (Fei) governs the skin and hair”. In add-
ition to treating respiratory-related disease, the auricular point
Lung (CO14) also works on relieving itchiness from skin disease.
Liver (CO12) and Shenmen (TF4) work on regulating emotion and
reducing stress, anxiety, and excessive sensitivity. Endocrine
(CO18) and Pizhixia (AT4) can balance endocrine hormones, hyper-
sensitivity, and rheumatism (9,10). Lu et al. (10) discovered that
the therapeutic effects of auricular therapy combined with opti-
mized Yinxieling Formula was superior to optimized Yinxieling
Formula alone, with no obvious adverse events. She conducted a
randomized controlled single-blind clinical trial on 84 outpatients
with psoriasis vulgaris. The patients were randomized to a treat-
ment group (43 cases treated by auricular therapy combined with
optimized Yinxieling Formula) and a control group (41 cases
treated by optimized Yinxieling Formula alone). Eight weeks later,
the PASI reduction rate in the treatment group was 74.4% (32/43),
which was higher than the control group (36.6%, 15/41, p < .01).
The PASI scores decreased in both groups after treatment and
they were lower in the treatment group than the control group
(p < .01) (treatment group: from 11.68 ± 6.01 to 6.16 ± 3.60, and
control group: from 11.45 ± 8.24 to 9.03 ± 6.25). With stratified ana-
lysis, there were significant differences between the PASI scores in
the following subgroups: age 18–30, baseline PASI >10, and sta-
ble stage (p < .05). DLQI scores decreased in both groups on some
categories after treatment, but there were no significant differen-
ces between the two groups in the SDS (Self-Rating Depression
Scale), SAS (Self-Rating Anxiety Scale), or VAS (Visual Analog
Scale/Score) (p > .05). No obvious adverse events were found
besides 3 cases of isomorphic response (a few local erythrema) in
the treatment group. Li et al. (11) randomized 56 psoriasis
patients with blood stasis-type into 4 groups. In addition to the
regular treatment of TCM decoction in the 4 groups, the com-
bined therapy group was treated with acupuncture and the aur-
icle cutting method. The auricle cutting group was treated with
sham-acupuncture and the auricle cutting method, and the acu-
puncture group was treated with acupuncture and sham-auricle
cutting method. Meanwhile, the control group was treated with
sham-acupuncture and the sham-auricle cutting method. The acu-
puncture was applied at Dazhui (GV 14), Feishu (BL 13), Ganshu
(BL 18), and Geshu (BL 17) as well as several other points. In the
auricle cutting, erbeixin (P1) from the unilateral auricle was
selected and cut by a Chan needle for bloodletting. After 14 days
for 2 sessions of treatment, the rate of effectiveness where the
minimum threshold for effectiveness was 30% improvement of
PASI scores, was 57.1% (8/14) in the combined therapy group,
superior to the 14.3% (2/14) in the auricle cutting group, the 7.1%
(1/14) in the acupuncture group, and the 0% (0/14) in the control
group (p < .05). The PASI scores in each group dropped after the
treatment, and the data was most significant in the combined
therapy group (p < .05). Factorial analysis showed that the com-
bined therapy of acupuncture, the auricle cutting method and
TCM decoction can effectively reduce the PASI scores of patient
with Blood stasis type psoriasis, which was more effective than a
single therapy. Liu et al. (12) reported that ear incision therapy
combined with Decoction (Qing re liang xue tang 清热凉血汤) for
treating psoriasis with blood heat syndrome is better than
treating with decoction only. He randomized 60 patients into two
groups. The treatment group (30 cases) adopted the combination
of ear incision therapy by Chan needle and oral administration
JOURNAL OF DERMATOLOGICAL TREATMENT 3
Qing re liang xue tang, while the control group (30 cases) took
Qing re liang xue tang only. After two treatment cycles, based on
PASI, the rate of effectiveness for treatment group was 80%, while
the control group’s rate was 57% (p < .05), where the minimum
threshold for effectiveness was 30% improvement of PASI scores.
The PASI assessment of the treatment group (decreased from
28.74 ± 7.70 pretreatment to 10.59 ± 6.28 post-treatment) was
lower than that of the control group (decreased from 28.74 ± 7.70
pretreatment to 10.59 ± 6.28 post-treatment), as there was signifi-
cant difference according to statistical analysis (p < .05). Same as
the general needling therapy, auricular therapy is also widely used
in clinical practice based on current clinical evidence.
Cupping and bloodletting therapy
Previous studies have demonstrated that bloodletting therapy
activates blood circulation to remove blood stasis, which improves
microcirculation and induces vasodilatation (13). Additional studies
have also suggested that bloodletting punctures on the back of
ear for psoriasis have the effect of activating blood circulation to
dissipate blood stasis (14,15). Cupping therapy is a traditional
medical therapy dating back thousands of years, and is one of the
important components of complementary and alternative medi-
cine, particularly related to acupuncture. Cupping produces a gen-
tle drawing sensation in the skin promoting the flow of qi when a
vacuum is created by heating the air inside a jar with a flame. The
jar is quickly applied to the skin, creating suction blisters. In add-
ition, cupping therapy can change the biomechanical properties
of the skin, adjust blood flow to the skin, and increase local imme-
diate pressure pain thresholds (16). It can also quickly reduce
inflammation and adjust serum P substance. This appears to play
a role in the modulation of the cellular part of the immune sys-
tem, as well as in the activation of the complement system (17).
Tang et al. (18) treated 64 plaque psoriasis patients with bloodlet-
ting and cupping therapy, 33 with blood-stasis syndrome and 31
with blood-dryness syndrome. The treatment consisted of blood-
letting with percussopunctator in areas where the skin lesions
were located, followed by cupping with a cup filled with “Tu huai
tang” (土槐汤) for 8 min, once every 2 days, and 5 times per ses-
sion. After 2 sessions, the rate of effectiveness was 93.8%. Yang
et al. (19) treated 30 psoriasis patients with acute stage, blood-
heat syndrome, using bloodletting and cupping therapy. Dazhui
(DU 14), Feishu (BL 13), Geshu (BL 17), and Pishu (BL 20) were
selected. Bloodletting was performed first, and then cupping for
10 min, once every 2 days, and 10 times per session. After 3 ses-
sions, based on the Standard of Diagnosis and Therapeutic Effect of
TCM Diseases 中医病证诊断疗效标准 (6), the rate of effectiveness
was 100%, and the significant improvement rate was 80% without
any obvious adverse event. Cupping and bloodletting therapy are
more suitable for psoriasis patients with blood-stasis or blood-
heat syndrome, in the paracmasis or stable stage.
Catgut embedding therapy
Catgut embedding therapy consists of using a special needle to
embed catgut at the appropriate acupuncture points. It requires
an interlude for the catgut to be absorbed by the tissue.
Therapeutic effects can be achieved from the continuous stimula-
tion caused by the catgut at the acupuncture points. Therefore,
compared with conventional acupuncture, a prolonged needling
sensation could be obtained with this therapy. Kong and Wang
(20) found that catgut embedding therapy at acupuncture points
is more curative in the treatment of psoriasis vulgaris by the
inhibition of VEGF (vascular endothelial growth factor) expression
4 Y. XIANG ET AL.
and PDGF-BB (platelet-derived growth factor) expression. He
treated 42 psoriasis vulgaris patients with catgut embedding at
acupuncture points once every 2 weeks, and with continuous
treatment for five sessions. The levels of VEGF and PDGF-BB in the
patients as well as 20 normal volunteers were evaluated by ELISA
(enzyme-linked immunosorbent assay [ELISA]) before and post-
treatment. Results indicated that based on PASI, the rate of effect-
iveness was up to 83.4% post-treatment, where the minimum
threshold for effectiveness was 30% improvement of PASI scores.
The levels of VEGF and PDGF-BB in the sera of the normal volun-
teers were (114.95 ± 20.21 ng/mL) and (12.44 ± 2.90 pg/mL). The
levels of VEGF post-treatment dropped significantly in patients
compared with the data before the therapy (from
184.87 ± 47.63 ng/mL to 129.36 ± 51.24 ng/mL, p < .01), as well as
compared to the levels of PDGF-BB (from16.96 ± 3.33 pg/mL to
35.03 ± 11.05 pg/mL, p < .01). Moreover, Ren et al. (21) found that
catgut embedding on acupuncture points can decrease the
relapse rate and cut down the serum levels of TNF-a (tumor
necrosis factor) and IL-8 (interleukin-8). This may contribute some
of the mechanisms in this therapy. Chen et al. (22) randomly div-
ided 86 psoriasis vulgaris patients into a treatment group
(43 cases) and a control group (43 cases). The control group was
only given the compound glycyrrhizin intravenously guttae, and
the treatment group was given acupuncture point catgut embed-
ding therapy in addition to the pharmacotherapy. The PASI in the
treatment group decreased significantly more than control group
after three cycles of treatment, with scores decreasing from
20.58 ± 3.14 pretreatment to 3.45 ± 1.05 post-treatment in the
treatment group, and 19.86 ± 2.43 pretreatment to 10.32 ± 1.69
post-treatment in control group. The rate of effectiveness of the
treatment group was 83.72%, while that of the control group was
53.49%, where the minimum threshold for effectiveness was 20%
improvement of PASI scores. Significant statistical difference
between these two groups was detected. Acupuncture point cat-
gut embedding therapy and compound glycyrrhizin for psoriasis
have remarkable clinical effects and no obvious adverse effects.
Du and Li (23) treated 100 psoriasis vulgaris patients with blood-
heat syndrome by acupuncture point catgut embedding com-
bined with a Liang Xue Xiao Yin pill for 3 months. For catgut
embedding, 4 groups of acupuncture points were selected: (a)
Dazhui (DU 14), Lingtai (DU 10), Fengmen (BL 12), and Geshu (BL
17); (b) Xinshu (BL 15), Quchi (LI 11), and Fengshi (GB 11); (c)
Shenshu (BL 23), Ganshu (BL 18), and Sanyinjiao (SP 6); (d) Pishu
(BL 20), Guanyuanshu (BL 26), and Xuehai (SP 10). Results showed
the PASI scores dropped from 16.19 ± 3.3 pretreatment to
7.56 ± 2.3 post-treatment (p < .05). Catgut embedding therapy is
more suitable for psoriasis patients with a longer course of disease
in the paracmasis or stable stages based on current studies.
Point-injection therapy
Acupuncture point injection is a therapy which combines acu-
puncture and medication. The integrated effect from the pharma-
cological action of medications and needling the acupuncture
points can stimulate the human body and enhance the drug’s
effect. This effect excites meridian qi, dredges meridians and col-
laterals, and regulates Zang-fu organs so as to cure the disease.
Chen et al. (24) reported that self-blood point injection is effective
in treating rare forms of psoriasis. It can decrease the level of
TNF-a and IL-8 in peripheral blood, and this may be one of the
therapeutic mechanisms. He randomly divided 200 patients with
psoriasis vulgaris into a treatment group and a control group,
each with 100 cases. The treatment group was administered self-
blood point-injection therapy on Quchi (LI110), Zusanli (ST36), and
Xuehai (SP 10) on one side. The adjunct points included Dazhui
(DU 14) for blood-heat syndrome, Geshu (BL17) for blood-stasis
syndrome, and Sanyinjiao (SP6) for blood-dryness syndrome. The
control group was administered intravenously guttae the com-
pound glycyrrhizin along with topical Tretinoin therapy for 60
days. Based on the Standard of Diagnosis and Therapeutic Effect of
TCM Diseases 中医病证诊断疗效标准 (6), the rate of effectiveness
for the treatment group was 85%, and for the control group it
was 71%, with statistically significant difference between the two
groups (p < .05). The levels of IL-8 and TNF-a in both groups
showed significant differences when comparing the data of pre-
and post-treatment within the same groups (p < .05). However,
there were no significant differences between the two groups on
the level of IL-8 and TNF-a after the treatment. In addition, Chen
et al. (25) discovered that self-blood point injection can lower the
level of CD3-CD19 þ (cluster of differentiation), CD3þ,
CD3 þ CD4þ, CD3 þ CD4þ/CD3 þ CD8þ, and raise the level of
CD3 þ CD8 þ in the peripheral blood of psoriasis patients. The
effects on B- and T-lymphocyte subpopulation in peripheral blood
may also be part of the therapeutic mechanism. Zhou et al. (26)
randomly divided 80 patients with psoriasis vulgaris into a treat-
ment group and a control group, each with 40 cases. In the basic
topical Tretinoin therapy, the control group was only given peros
xiao yin granules, while the treatment group was given peros xiao
yin granules and point-injection therapy with bcg-polysaccharides
nucleic acid on bilateral Zusanli (ST 36). After 2 sessions of treat-
ment, the PASI scores decreased in both groups (from baseline
scores of 8.56 ± 0.22 to 2.88 ± 0.47 post-treatment in intervention
group, compared with that from 8.67 ± 0.35 to 4.29 ± 0.38 in con-
trol group), and were lower in the treatment group than in the
control group (p < .05). The rate of effectiveness of the treatment
group (89.74%) was superior to that of the control group
(66.67%), where the minimum threshold for effectiveness was
30% decrease of PASI scores, with statistically significant differen-
ces between these two groups (p < .05). Acupuncture point-injec-
tion therapy is therefore more suitable for psoriasis patients with
long-term disease in the paracmasis or stable stage. The most fre-
quent used points are Quchi (LI11), Zusanli (ST36), and Xuehai
(SP10).
Traditional Chinese medicine fumigation therapy
The therapeutic mechanisms of TCM fumigation therapy for psor-
iasis vulgaris can be illustrated in 3 points. First, the pharmaceut-
ical ions of TCM fumigation can affect the skin lesions with their
ability to eliminate inflammation, alleviate itching and relieve
pain. Second, the TCM can be absorbed by the epidermis, perme-
ating from the stratum corneum, and transporting via the corium
into blood circulation to produce a remarkable effect. Finally, heat
stimulation can dilate the capillaries, promoting blood and lymph
circulation. The therapeutic mechanisms of TCM fumigation ther-
apy include dredging meridians, coordinating qi and blood, and
strengthen healthy qi, in order to eliminate pathogens (27). Zhao
(28) has found that narrow-band ultraviolet irradiation combined
with TCM fumigation therapy for psoriasis vulgaris is effective,
safe, and has few adverse reactions. In this trial, eighty patients
with psoriasis vulgaris were randomly divided into two groups.
The control group was only given the narrow-band ultraviolet
irradiation, and the treatment group was given the narrow-band
ultraviolet irradiation combined with TCM fumigation therapy. The
results showed that the total rate of effectiveness was 92.5% in
the treatment group and 77.5% in the control group, with a statis-
tically significant difference between the two groups (p < .01),
where the minimum threshold for effectiveness was 25% decrease

of PASI scores. However, this study did not provide the details of
PASI scores pre- and post-treatment. According to current clinical
evidence, TCM fumigation therapy is recommended for psoriasis
covering a large area.
Fire needling therapy
Fire needling therapy is used to puncture red-hot needles into
acupuncture points. This therapy can warm channels and expel
the cold, tonify Yang qi and dredge meridians. This helps Yang
provide living things with functional activities, dredge activities of
qi and liquid, remove slough, and promote tissue regeneration
(29). Huang et al. (30) reported that fire needling acupuncture for
stationary plaque psoriasis is effective, and has a low relapse rate.
They randomly divided 120 patients with stationary plaque psoria-
sis into a treatment group and a control group, with 60 patients
in each. The treatment group was treated with fire needling acu-
puncture, while the control group was treated topically with
Tazarotene cream, both for 30 days. Results showed that the sig-
nificant improvement rates and total effective rates were 76.8%
and 94.6%, respectively, in the treatment group versus 71.9% and
96.5% in the control group, with the minimum thresholds for sig-
nificant improvement and effectiveness were 70% and 30%
decrease of PASI scores, respectively. There was statistically signifi-
cant difference between the two groups (p < .05). Three months
later, by comparing the relapse rates of the recovered and the
markedly improved, a significant difference was shown (p < .05).
Fire needling therapy is therefore suitable for psoriasis covering a
small area and for long-term disease in the paracmasis or stable
stage.
Other combined therapies
There are several other special therapies and combined therapies
of acupuncture. For example, Hua (31) treated 250 blood hot type
(赤巴偏盛型) psoriasis patients with traditional Tibetan bloodlet-
ting therapy. The patients were administrated the Tibetan propri-
etary medicine San guo tang san (三果汤散) for preparation for
3 days, and then bloodletting on the blood vessels where the skin
lesions were located were performed. After a treatment session,
the total rate of effectiveness was 92%. Yang et al. (32) found that
the glycyrrhizin combined with fumigation and narrow-band ultra-
violet light has a significant effect on treating psoriasis, and thus
should be recommended. He randomly divided 124 psoriasis
patients into two groups. The treatment group was given glycyr-
rhizin in combination with fumigation and narrow-band ultraviolet
light, while the control group was only given the glycyrrhizin. The
results showed that the PASI score of the treatment group was
(4.0 ± 2.1), lower than that of the control group (7.6 ± 2.4) (p < .05).
The recurrence rate of the treatment group was 17.7%, signifi-
cantly lower than the control group’s 45.2% (p < .05). The total
rate of effectiveness of the treatment group was 87.1%, higher
than the control group’s 74.19% (p < .05). In addition, Wang et al.
(33) treated 12 plaque psoriasis patients with the Opening Xuan
fu Removing the Toxic Substance (the Opening Xuan fu Removing
the Toxic Substance formulas combined with bloodletting ther-
apy). After 3-week treatment, the results showed that the total
rate of effectiveness was 66.67%, and the PASI scores had
dropped (p ¼ .005). By using ELISA, the concentrations of TNF-a
and IL-8 in lesion sites after treatment were determined, and were
significantly lower than those before treatment. However, there
was no noticeable change in SP concentrations. Li et al. (34) found
that the vesiculation moxibustion paste of cantharides and indigo
naturalis could produce better clinical outcomes when stored for
JOURNAL OF DERMATOLOGICAL TREATMENT 5
longer durations (over 2 years). They randomized 120 patients
with psoriasis into an observation group, control group 1, and
control group 2, with 40 individuals in each group. Vesiculation
moxibustion paste of cantharides and indigo naturalis which had
been stored for 2 years was used in the observation group,
paste stored for 1 year was used in control group 2, and the
temporary-made paste was used in control group 1. Based on
PASI scores, the results indicated that the total rates of effective-
ness in these three groups were 97.5%, 52.5%, and 37.5%,
respectively, with a significant difference between the three
groups (p < .01). In addition, Zhang and Zhang (35) reported that
electro-acupuncture on Five-shu points combined with
bloodletting and cupping therapy for psoriasis was effective. This
therapy not only relieved the skin lesions, but also improved the
body’s immune function and reduced the inflammatory reactions
in this study.
Therapeutic mechanisms of acupuncture for psoriasis
Although the exact cause of psoriasis and the mechanisms behind
acupuncture are not clear yet, there are at least three key compo-
nents being implicated in acupuncture stimulation: the brain-
derived neurotrophic factor, the autonomic nervous system and
the hypothalamus–pituitary–adrenal axis (36). Functional magnetic
resonance imaging has demonstrated that manual needle acu-
puncture can distinctively activate the hypothalamus–limbic sys-
tem. The therapeutic mechanisms of acupuncture for psoriasis are
considered to be itching relief, immune response regulation,
endocrine and vascular function regulation (37), benign regulation
of cell kinetics, mental status adjustment, and nervous system
regulation. In some studies, it has been indicated that acupunc-
ture for psoriasis can decrease high IL-8, make TNF-a closer to
normal than before, while increasing IL-10 over the normal thresh-
old. That is to say, acupuncture is helpful in regulating the
immune response of psoriasis (38). Furthermore, electro-acupunc-
ture may induce b-endorphin and corticotrophin to be released
into the peripheral blood. Acupuncture may also increase serum
levels of cortisol. Lastly, some studies have shown that acupunc-
ture can decrease the pruritic and inflammatory effects of
histamine.
Therapeutic characteristics of acupuncture for psoriasis
Method of acupuncture point selection
Eight principal syndromes’ differentiation combined with local
lesion selection was the general principle of selecting acupunc-
ture points. Usually, dispelling wind and arresting itching are the
principles for temporary solution, while moisturizing dryness by
nourishing blood, activating blood circulation to dissipate blood
stasis, and removing heat to cool blood are the basic therapeutic
principles. Regardless of the type of therapy, the acupuncture
points on the Urinary Bladder Channel of Foot-Taiyang and the
DU meridian, the Back-Shu-acupuncture points and the paraverte-
bral point are the main choices. These include points such as
Dazhui (DU 14), Feishu (BL 13), Geshu (BL 17), and Shenshu (39).
In addition, the coordination of acupuncture points is selected
according to type, stage, position of local lesions, severity, and
differentiation of symptoms and signs, with the main acupuncture
points being Quchi (LI 11), Zusanli (ST 36), and Sanyinjiao (SP 6).
For example, if the psoriasis patient is wind-heat and blood-dry,
Fengchi (GB 20), Hegu (LI 4), Dazhui (DU 14), Quchi (LI 11), and
Xuehai (SP 10) will be chosen to remove heat to cool blood and
eliminate wind.
6 Y. XIANG ET AL.
Recommendations of acupuncture therapy in clinical practice
for psoriasis
There are many kinds of acupuncture therapies for psoriasis with
different functions. According to current evidence, needling and
auriculotherapy could be generally recommended to people with
psoriasis of any stage or severity. Moxibustion, cupping and
bloodletting therapy, catgut embedding therapy, and point-injec-
tion therapy may be beneficial for psoriasis patients with long-
term disease, either in paracmasis or stable stage. When people
with psoriasis lesion covering a large area, TCM fumigation ther-
apy is recommended. In contrast, when the lesion covering a
small area and for long-term disease in the paracmasis or stable
stage, fire needling may be complementary choice for treatment.
Combined therapies adjusted to the clinical situation are
widely used. Popular selections are a combination of two different
acupuncture therapies, or one acupuncture therapy plus pharma-
cotherapy. More importantly, most studies show that combined
therapy can produce better clinical effects than a single therapy.
Efficacy analysis of acupuncture therapy
The clinical effects of acupuncture therapies for psoriasis differ
according to type, stage, position of local lesion, severity, and dif-
ferentiation of symptoms and signs. Generally, their efficacy on
psoriasis vulgaris is better than on other types. The efficacy on
paracmasis at the psoriasis stage is better than at the stationary
stage, and the stationary stage is better than active stage (40).
The efficacy in the short-term and acute onset is better than on
chronic and long-term effects of disease.
Advantages of acupuncture therapy
Four advantages of acupuncture therapy for psoriasis have been
highlighted in this review. The first is entirety. We find that when
a local lesion is being healed with acupuncture therapy, the func-
tion of whole body will be improved and become healthier. The
effects of acupuncture not only affect the local lesion, but also
improve physiological protection and the immune system (41).
The second advantage is that there have been no severe side
effects reported in the included studies. Acupuncture for psoriasis
avoids severe side effects, drug resistance, diminishing effects, and
tendency to relapse. Moreover, there is good protective efficacy,
which can lower the relapse rate, shorten the duration of relapse,
and prolong the duration between relapses. Lastly, acupuncture
for psoriasis is simpler and cheaper than many other therapies
easily accepted by patients. In summary, acupuncture therapy for
psoriasis is effective, safe, simple, economical, and can be easily
applied.
Blinding method and placebo in acupuncture trials
Blindness and placebo in the evaluation of the efficacy of acu-
puncture therapy for psoriasis is a difficult topic globally. This is
because most acupuncture therapy, such as cupping and blood-
letting therapy, catgut embedding therapy, point-injection ther-
apy, and fire needling therapy is difficult to replicate. The
evidence of clinical trials may be limited by the blinding methods.
For needling therapies, most researches have focused on the
three main kinds of placebo-needle therapies, the Streitberger
needle, the Park sham needle, and the double-blind placebo nee-
dle (42). The design principles of the three methods are more or
less the same as in trochar, in which patients cannot differentiate
based on the shape of the needle. In fact, the needle tip is blunt,
and cannot pierce the skin. However, because of the limitations of
the tube, three of them can only do perpendicular needling, and
not oblique needling, horizontal needling, or deep needling.
Therefore, the patients cannot feel “deqi”. In this case, it is hard to
design an ideal placebo-control method and double-blind princi-
ples in clinical trials of acupuncture therapy for psoriasis. In add-
ition, there are several improving placebo-needles, such as that
used in Yu’s study (43) based on the Streitberger’s single-blind
method. No significant difference between acupuncture group
and placebo needle-controlled group was found. The
Streitberger’s single-blind method may be reliable in evaluating
the efficacy of acupuncture in the management of psoriasis in the
trial design.
Counterindication and side-effects of acupuncture
therapies
Isomorphic response (consisting of a small amount of local eryth-
rema) is a phenomenon unique to psoriasis. Therefore, in the
acute stage, it is better to avoid using needling, bloodletting, cat-
gut embedding therapy, point-injection therapy, and fire needling
therapy, which would all cause wounds. However, moxibustion,
auriculotherapy, cupping, and TCM fumigation therapy could all
be chosen without causing wounds in the acute stage. There
were few adverse side effects reported on acupuncture therapies
for psoriasis. However, several practice guidelines should be fol-
lowed by practitioners (44). (i) Acupuncture syncope. This can be
prevented by avoiding hunger or fatigue. Proper explanation is
necessary for patients receiving acupuncture therapy for the first
time. (ii) Pregnant women should not receive have acupuncture
therapy. (iii) Patients with severe complications such as hematono-
sis, diabetes, and coronary artery disease should avoid strong
stimulation from acupuncture therapy. In sum, well-versed skills,
sound anatomy knowledge, diagnosis, and treatment based on an
overall analysis of the illness and the patient’s health can improve
the effects of acupuncture therapy for psoriasis (45).
Limitations
The mechanism behind acupuncture therapy for psoriasis has
been difficult to uncover due to flaws in design, small sample
sizes, and the inherent difficulty in the use of controls such as
placebo. However, there have only been a small number of stud-
ies on acupuncture therapy for psoriasis, and especially few con-
ducted outside China. One of the reasons for this may be
concerns for the development of the Koebner phenomenon. In
fact, acupuncture with fine needles on ordinary acupuncture
points rarely causes bleeding, and the Koebner phenomenon is
not usually observed. Perhaps this is because the therapeutic
effects of the therapy suppress the phenomenon (46). Most of
the studies on acupuncture therapy for psoriasis have been clin-
ical observations without blinding, and there have been few
empirical studies or studies on the mechanisms behind
acupuncture.
Conclusion
Acupuncture therapy for psoriasis is effective, safe, simple, eco-
nomical, and easy to apply. It has long-lasting therapeutic effects
on controlling the symptoms of psoriasis, as well as few side
effects or toxicities. In the future, research on acupuncture therapy
for psoriasis would benefit from a large sample of randomized,
controlled, blinded clinical trials, including both studies on its
mechanisms, as well as empirical studies.

Disclosure statement
The authors report no conflict of interest for this manuscript
submission.
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