Chronic spontaneous urticaria (CSU) is a dermatologic condition that affects between 0.5% and 1% of the world population, manifesting as erythematous plaques, recurrent angioedema, and intense pruritus for six weeks or more, without identifiable external cause. Although antihistamines constitute the first line of treatment, a significant fraction of patients does not respond adequately or presents frequent relapses after discontinuation. A meta-analysis published in Frontiers in Medicine in 2025 offers the broadest portrait ever compiled on the use of medical acupuncture for this condition: 22 randomized clinical trials, 1,867 patients, and outcomes ranging from clinical response to immunologic modulation.
The study was registered in PROSPERO (CRD42024557552) and conducted a systematic search in eight databases — CNKI, VIP, WanFang, and CBMDisc in the Chinese databases, plus PubMed, Cochrane Library, Embase, and Web of Science in the international ones —, without language restriction, covering publications from the inception of each database through August 20, 2024. The 22 included trials evaluated acupuncture as the principal treatment (without restriction of technique, duration, or selection of acupoints), compared to standard medications, sham acupuncture, or placebo. Methodologic quality was assessed by the ROB2 (Risk of Bias 2) tools and the GRADE system.
META-ANALYSIS RESULTS (FRONTIERS IN MEDICINE, 2025)
Clinical and Immunologic Outcomes
The meta-analysis evaluated a broad range of outcomes. Clinically, acupuncture significantly improved the overall response rate to treatment and reduced the relapse rate — two of the most relevant criteria for the patient with CSU who oscillates between periods of remission and exacerbation. The Urticaria Activity Score (UAS), which combines the frequency of appearance of lesions and intensity of pruritus, also decreased significantly. The pruritus VAS score, the count and size of urticarial plaques, and the symptom scores of traditional Chinese medicine presented consistent reduction.
In the immunologic domain, acupuncture significantly reduced serum levels of total IgE — the principal mediator of immediate allergic response —, of IFN-γ (interferon-gamma, proinflammatory), and of IL-4 (interleukin-4, involved in Th2 polarization and promotion of IgE production). This modulation of the Th1/Th2 axis offers a plausible mechanistic explanation for the observed clinical benefits: acupuncture relieves symptoms and, in experimental studies, has been associated with modulation of the immune dysregulation underlying CSU — an effect that still requires additional clinical confirmation. Hamilton Depression Scale scores also improved — a relevant datum, considering the high psychiatric comorbidity of chronic urticaria.
Safety and Comparison with Medications
One of the most relevant findings of the meta-analysis for clinical practice is the safety profile of acupuncture: the incidence of adverse events did not differ significantly from the control groups. Note that no direct head-to-head trial compared acupuncture with these pharmacologic agents in the CSU context; the considerations that follow are based on general safety profiles described in the literature: second-generation antihistamines — the standard of treatment — frequently cause residual drowsiness, dry mouth, and interference with work activities. Second-line immunosuppressive agents (cyclosporine, omalizumab) present high costs and more substantial risk profiles. The analysis of 18 additional studies with 1,829 patients confirmed the advantage of acupuncture over sham acupuncture and over waiting lists, reinforcing that the effect is not attributable exclusively to therapeutic expectation.
Frequently Asked Questions
Acute urticaria lasts less than six weeks and has an identifiable cause in most cases (food, medication, infection). Chronic urticaria persists for six weeks or more, frequently without a clear cause (spontaneous) or with an identifiable physical cause (pressure, cold, heat). This meta-analysis specifically evaluated the chronic spontaneous form. For acute urticaria, supportive treatment with antihistamines is sufficient in most cases. For chronic urticaria with recurrent course, acupuncture may have a relevant adjuvant role, especially when antihistamines do not produce complete remission.
The studies included in this meta-analysis used varied protocols. In general, the trials that demonstrated benefit employed between 8 and 20 sessions, with frequency of 2 to 3 times per week in the first weeks, followed by weekly maintenance. The medical acupuncturist will assess the individual clinical profile — immunologic pattern, frequency of crises, response to previous treatments — to propose an adequate therapeutic plan. Assessment of response after 4 to 6 weeks of treatment is recommended for decisions about continuity.
There is not sufficient evidence to indicate acupuncture as a substitute for first- or second-line drug therapies. The position most supported by current evidence is adjuvant use: acupuncture may potentiate the effect of antihistamines, reduce the dose necessary for control, and decrease the frequency of crises. In cases of incomplete response to omalizumab or contraindication to immunosuppressive treatment, the physician may consider acupuncture as a complementary strategy within a coordinated multidisciplinary plan.
Founded in 1989 by physicians trained at the University of São Paulo (USP) and specialized in China, CEIMEC is a Brazilian national reference in the teaching and practice of medical acupuncture. With more than 3,000 physicians trained over 35 years, it collaborates with HC-FMUSP and is recognized by the Brazilian Medical College of Acupuncture (CMBA/AMB).