Acupuncture for chronic urticaria: a systematic review and meta-analysis with trial sequential analysis

Chronic urticaria is a dermatologic condition characterized by recurrent episodes of welts and intense itching that persist for at least 6 weeks, significantly affecting patients' quality of life. With a global prevalence between 0.5% and 1.0% and annual costs that can reach nearly 3,000 dollars per patient, it represents an important public health problem. Although second-generation antihistamines are first-line treatment, they do not always provide complete symptom relief, and options such as omalizumab, although effective, carry a high cost that limits its use.

This systematic review and meta-analysis investigated the efficacy of acupuncture as an alternative treatment for chronic urticaria, using a rigorous methodological approach that included trial sequential analysis (TSA) to validate the robustness of the results. The researchers conducted a comprehensive search in eight databases, including PubMed, Cochrane, and Chinese databases, through September 2025, identifying 18 randomized controlled trials with 1,829 patients.

Participants were 18-65 years of age, with disease duration ranging from 1.5 to 250.8 months. Acupuncture treatments included techniques such as manual acupuncture, electroacupuncture, and moxibustion, applied for 2-8 weeks. Control groups received Western medications (primarily antihistamines), sham acupuncture, or remained on a waiting list.

Primary outcomes were assessed using the Weekly Urticaria Activity Score (UAS7), a validated scale that measures symptom severity. Acupuncture demonstrated significant superiority, reducing UAS7 by 6.22 points compared with controls. Specifically, it was more effective than sham acupuncture (-5.85 points) and waiting list (-8.56 points), although it did not differ significantly from conventional medications.

Quality of life, measured by the Dermatology Life Quality Index (DLQI), showed substantial improvement with acupuncture across all comparison groups: -3.43 points versus medications, -3.60 points versus sham acupuncture, and -5.04 points versus waiting list. Trial sequential analysis confirmed that the sample size was sufficient for robust conclusions for both UAS7 and DLQI.

Regarding safety, adverse events were mild and infrequent, occurring in 2.76% of acupuncture patients, primarily consisting of minor bruising and pain at needle insertion sites. This rate was higher than sham acupuncture (2.95%) but not significantly different from Western medicine (5.12%).

Limitations include heterogeneity among studies, possible publication bias identified by Egger's test, and quality of evidence rated as moderate for UAS7 and low for DLQI by the GRADE system. Most studies were conducted in China, limiting generalization to other populations. In addition, there was variability in acupuncture protocols, including point selection, frequency, and duration of treatment.

Clinical implications suggest that acupuncture can be considered a promising complementary therapeutic intervention for chronic urticaria, especially for patients who do not respond adequately to conventional treatments or experience side effects. The technique demonstrated the ability to reduce the frequency of urticarial episodes and significantly improve patients' symptoms and quality of life.