TABLE 1.

Efficacy of acupuncture and moxibustion for alopecia.

Study	Study design, number of subjects	Interventions	Etiology of alopecia	Mean age (SD), years	Assessed outcomes	Definition of assessed outcomes	Duration of treatment	Main findings	Adverse events	Key takeaways
Gao et al. (14)	RCT, 84	Catgut embedment-Moxibustion-Bloodletting with plum blossom needling (Cohort 1) vs. Finasteride 1 mg/day qd for 3 months with 5-day rest between each course of treatment (Cohort 2)	Androgenetic	NA	Testosterone, Estradiol, D-value HAMD reductive rate composited as the total effective rate (TER)	D-value HAMD reductive rate equal to (value before treatment - value after treatment)/value before treatment × 100 where value is the ratio of testosterone/estradiol	3 months	In the catgut embedment-Moxibustion-Bloodletting with plum blossom needling cohort, testosterone and estradiol decreased from 1259.5 ± 1009.5 ng/dL and 62.09 ± 50.45 pg/mL to 405.1 ± 483.39 ng/dL and 33.38 ± 29.32 pg/mL, respectively. Testosterone and estradiol decreased in the Finasteride cohort as well (1247 ± 554 ng/dL and 58.74 ± 54 pg/mL to 555.19 ± 944.26 ng/dL and 50.21 ± 35.9 pg/mL) but to a lesser extent. Testosterone and estradiol were significantly lower in the ACU + TRAD group (p < 0.05). Based on reduction in HAMD scores, TER in the ACU + TRAD cohort was significantly greater than the finasteride cohort (97.62 vs. 83.3%. p < 0.05).	NA	The catgut embedment-Moxibustion-Bloodletting with plum blossom needling resulted in significant reduction in testosterone and estradiol compared to finasteride. Clinical images showed improvement in alopecia areata but investigators did not quantify differences in hair loss and growth between groups. The efficacy of acupuncture alone cannot be assessed in this study as investigators used a combination of traditional treatments.
Jin et al. (18)	RCT, 70	Combined electroacupuncture and acupoint injection of Mecobalamin (Cohort 1) vs. seven-star needle tapping once every day and a couple of times of rubbing the affected area using a fresh ginger piece daily for 30 days (control) (Cohort 2)	Alopecia areata	35 (4) in Cohort 1, 39 (5) in Cohort 2	Recovery, Marked effect, Failure, composited as the TER.	Recovery was defined as complete growth of new normal hair and a negative test of hair pull test. Marked effect was defined as >50% anagen hair growth, thickening of the new anagen hairs and negative result of hair pulling test. Failure was defined as no new anagen hairs; new hair growth was less than 10% or concurrent hair growth and hair loss.	30 days	In the combined electroacupuncture and acupoint injection of Mecobalamin cohort, recovery, marked effect and failure was observed in 15, 18, and 2 patients, respectively, for a composite TER of 94.3%. In the seven-star needle tapping (control) cohort, recovery, marked effect and failure was observed in 10, 17 and 8 patients. The TER in this cohort was significantly less than the electroacupuncture group (94.3 vs. 77.1%, p < 0.05).	NA	Electroacupuncture with acupoint injection was more effective in eliciting hair growth than the seven-star needling technique (control) group. Use of electroacupuncture at specific acupoints in combination with acupoint injection may be more efficacious than application of seven-star needling at areas of hair loss in the treatment of alopecia areata. The efficacy of acupuncture alone cannot be assessed in this study as investigators used a combination of traditional treatments.
Kawashima et al. (20)	CR, 1	Japanese Kampo medicine (JKM) formulas in combination with acupuncture. After “relapse,” (163 days after discontinuing treatment) self-administration of pine-needle acupuncture was initiated in combination with the JKM formulas.	Alopecia areata	34	Severity of Alopecia Tool (SALT) score	SALT score measures the percentage of hair loss in 4 areas: vertex (40%), right and left profile (18% each) and posterior scalp (24%) to provide a composite score. A decrease in the SALT score indicates regrowth.	327 days	SALT score was 19% at diagnosis and decreased to 9% on day 124 of treatment with JKM and acupuncture. The patient experienced complete resolution of hair loss on day 159 and treatment was discontinued. Symptoms returned on day 322 (SALT 13%) and the patient resumed JKM in combination with self-administered pine-needle acupuncture. Sequential SALT scores were 11%, 5% (>50% recovery from baseline at relapse), 4%, and 2% (>75% recovery) on days 392, 420, 448, and 490, respectively. The patient remained in remission and is receiving JKM formulas as of 4/2021.	NA	JKM and acupuncture was associated with reduction in hair loss in a patient with alopecia areata. JKM in combination with self-administered pine-needle acupuncture was also efficacious in this case and may be a more sustainable treatment regimen for maintaining long-term results.
Li et al. (22)	RCT, 87	Plum blossom needling with qi-invigorating botanical therapies (Cohort 1) vs. Oral cystine 50 mg TID, Vitamin B6 10 mg TID (Cohort 2)	Seborrheic dermatitis	NA	Testosterone, Estradiol, Hair loss, Hair growth	Quantitative scoring of hair loss: Minimal hair loss (<100 hairs) was scored as 0 points; loss of 150–100 hairs was considered a small amount of hair loss and was scored as 2 points; loss of 200–150 hairs was considered moderate and scored as 4 points; and loss of ≥200 hairs was considered severe and scored as 6 points. Quantitative scoring of hair growth (higher score indicates less regrowth): Complete regrowth in area of hair loss, with normal hair thickness and color after 2 months of treatment was scored 0 points; >2/3 new hair regrowth in areas of hair loss but with non-uniform hair color and thickness was scored 2 points; 1/3 hair regrowth in areas of hair loss with pale hair color and soft texture was scored 4 points; no regrowth or presence of few hairs was scored 6 points. Evaluations were performed after the patients washed their hair in the morning,	2 months	Patients in the plum blossom needling with traditional Chinese medicine experienced a greater reduction in testosterone than the medication cohort (6.38 ± 1.12 vs. 8.92 ± 1.62 μg/L, p < 0.05). Additionally, estradiol in the ACU + TRAD was significantly greater than the medication cohort after treatment (72.02 ± 4.13 vs. 68.63 ± 5.29 pg/mL, p < 0.05). There was no significant difference in testosterone and estradiol between cohorts at baseline. Likewise, both cohorts experienced comparable degrees of hair loss and growth at baseline. Following treatment, the patients in the ACU + TRAD cohort had a significantly lower hair loss score than the medication group (1.69 ± 0.96 vs. 2.65 ± 1.06), indicating less hair loss. Quantitative hair growth score was significantly lower in the ACU + TRAD cohort than the medication cohort (2.21 ± 1.16 vs. 3.56 ± 1.2), indicating less regrowth in the medication group.	The incidence of emotional disorders (11.6 vs. 0%) and sexual dysfunction (9.3 vs. 0%) was significantly lower in the ACU + TRAD group (p < 0.05).	Plum blossom needling in combination with traditional Chinese medicine was associated with a greater reduction in testosterone and increase in estradiol than cystine and vitamin B6. Additionally, the ACU + TRAD treatment resulted in less hair loss and promoted more growth in patients with hair loss secondary to seborrheic dermatitis. However, patients in the ACU + TRAD also experienced higher rates of sexual dysfunction and emotional disturbances than the medication group during treatment. It is unknown how the efficacy of acupuncture for hair loss in seborrheic dermatitis compares to first-line agents including topical antifungals and corticosteroids.
Su et al. (23)	CR, 3	5% 5-aminolevulinic acid-based photodynamic therapy (ALA-PDT) combined with oral isotretinoin (10 mg) TID. Fire needle intervention was used as a pretreatment for ALA-PDT.	Perifolliculitis capitis abscedens et suffodiens (PCAS)	27.7 (13.3)	Qualitative description	NA	2 weeks to 4 months	At 2 weeks, 2 of 3 cases reported a significant reduction in nodules, cysts and pain after initiation of treatment. Resolution of PCAS and hair regrowth was observed at 6, 8 weeks and 4 months in the 3 cases. No patients had recurrence with minimum one year follow up. Two of 3 cases experienced no recurrence at 2 year follow-up as well.	Local redness, swelling and pain after PDT, which resolved in a week. All 3 patients experienced dry lips, mucous membranes and skin but reported symptoms did not affect their quality of life.	Isotretinoin is first line for moderate-severe refractory PCAS but works slowly and is known to have harmful side effects with prolonged use. In these 3 cases, combining isotretinoin with PDT pretreated by fire needle improved symptoms early, shortened the course of treatment, consolidated efficacy and reduced disease recurrence.
Wu et al. (15)	CR, 1	Acupuncture	Alopecia areata universalis	62	Qualitative description	NA	3 months	After the 13th session, there was an increase in hair on the scalp with small patches of black vellus hair present. After 3 months of treatment, regrowth occurred in all areas of hair loss. Results were maintained at 2 month follow-up.	NA	Acupuncture was associated with complete regrowth in areas of hair loss after 3 months of treatment in a patient with alopecia universalis.
Zhang et al. (16)	CR, 1	Medicated thread moxibustion using the traditional Zhuang medicine method	Alopecia areata	36	Qualitative description	NA	3 months	One week after treatment, a small amount of vellus hair regrew in areas of hair loss. At 3 weeks, patches of hair loss were covered with hair of different lengths and colors. 4 weeks after treatment (final session), complete regrowth was observed in area of hair loss albeit with decreased density compared to the circumferential area. Results were maintained at 3 months follow-up with negative hair pull test.	NA	Moxibustion was associated with complete hair regrowth at 4 weeks in a patient with alopecia areata.
Zhu and Wu (17)	RCT, 78	Acupuncture and plum-blossom needle therapy (Cohort 1) vs. Cystine tablets 0.1 g TID, Vitamin B1 20 mg TID and 2% Minoxidil Solution applied topically BID (Cohort 2)	Alopecia areata	NA, age ranged from 17–60 years	Cure, Remarkable effect, Effect, Failure, composited as the TER.	Cure was defined as 100% new hair growth, with dense distribution, normal color, and a negative hair-pulling test. Remarkable effect was defined as 70% of new hair growth, with normal density, size and color. Effect was defined as 30% of new hair growth, including fine hair and gray hair, and cessation of additional hair loss with treatment. Failure was defined as less than 30% of new hair growth or continual hair loss after 4 courses of treatment.	4 months	In the acupuncture and plum-blossom needling cohort, the cure rate and TER was 58.1 and 97.7%, respectively. This was significantly greater than the corresponding cure rate and TER in the medication cohort (34.3 and 77.1%, respectively. In the ACU + TRAD group, cure, remarkable effect, effect and failure was reported in 25, 13, 4, and 1 patient compared to 12, 11, 4, and 8 patients in the medication group.	NA	Acupuncture in combination with plum blossom needling may be more efficacious than cystine, vitamin B1 and 2% topical Minoxidil solution in patients with alopecia areata. The majority of patients in the acupuncture cohort experienced complete hair regrowth vs. only one-third in the medication group after 4 months of treatment.

Abbreviations: Pro, prospective; RCT, randomized controlled trial; CR, case report; BID, twice a day; TID, three times a day; QD, once a day; SD, standard deviation; NA, not available; TER, total effective rate; JKM, Japanese Kampo medicine; SALT, severity of alopecia tool; PCAS, perifolliculitis capitis abscedens et suffodiens; ALA-PDT, 5-aminolevulinic acid-based photodynamic therapy; ACU, acupuncture alone; ACU + TRAD, acupuncture in combination with traditional therapy.