A comprehensive literature search was conducted using four electronic databases: PubMed, Web of Science, China National Knowledge Infrastructure (CNKI), and Wanfang Data. Publications available up to January 2025 were considered. The search was limited to studies published in English or Chinese.

The following search terms and their synonyms were used: “hyperuricemia”, “gout”, “external therapy of TCM”, “acupuncture”, “bloodletting”, “tuina (massage)”, “fire needle”, and “topical herbal application”. Boolean operators (“AND”, “OR”) were used to optimize retrieval across various combinations.

Studies were selected according to the following inclusion criteria: (1) Population: Adults diagnosed with hyperuricemia or gout; (2) Interventions: External TCM therapies including but not limited to acupuncture, electroacupuncture, bloodletting, pricking-cupping, tuina massage, fire needle, and topical herbal formulations; (3) Comparators: Conventional pharmacotherapy, placebo/sham interventions, usual care, or baseline controls; (4) Outcomes: At least one of the following—serum uric acid levels, pain intensity (e.g., VAS/NRS), joint swelling/function, gout flare frequency, inflammatory markers (e.g., CRP, ESR), renal function indices, or adverse events; (5) Study types: Randomized controlled trials (RCTs), quasi-randomized trials, cohort studies, case–control studies, and relevant systematic reviews or meta-analyses.

The following studies were excluded: Editorials, letters, conference abstracts without full data, and non–peer-reviewed materials; Case reports or case series with fewer than 10 participants; Studies unrelated to external TCM therapy (e.g., oral decoctions only) or not focused on hyperuricemia/gout; Duplicated publications or studies with irreconcilable or missing outcome data; Pediatric-only populations when adult data were unavailable.

Two reviewers independently screened the titles, abstracts, and full texts of the retrieved articles. Disagreements were resolved by consensus through discussion. Relevant data were extracted, including: Study characteristics (author, year, country); Participant demographics and diagnostic criteria; Details of interventions and comparators; Reported outcomes and adverse events. The evidence was synthesized narratively, and no quantitative meta-analysis was conducted due to expected clinical and methodological heterogeneity among studies.

In TCM theory, qi (vital energy) and blood are considered fundamental to sustaining physiological function and health. Qi serves as the driving force behind various bodily processes, while blood provides nourishment to tissues. When qi and blood flow freely through the meridians (energy channels), the body maintains homeostasis. However, modern lifestyle factors such as poor diet, stress, and sedentary habits can lead to qi stagnation and blood stasis, contributing to metabolic disorders such as hyperuricemia.

In TCM theory, qi (vital energy) and blood are considered fundamental to sustaining physiological function and health. Qi serves as the driving force behind various bodily processes, while blood provides nourishment to tissues (36). Qi, usually understood as the “qi of life”, is the driving force to promote various physiological activities in the body, while blood is the carrier of nutrients and undertakes the task of nourishing the whole body (37). The generation and application of qi and blood is one of the cores of TCM theory. In a healthy state, qi and blood are full, qi flows smoothly, and various systems of the body can operate in harmony, forming a good physiological state (38). However, in modern society, due to the change of lifestyle, unreasonable diet structure and the increase of psychological pressure, many people are facing the problem of imbalance between qi and blood (39). Hyperuricemia is a health problem closely related to the imbalance of qi and blood. In the theory of TCM, In TCM theory, hyperuricemia is considered a manifestation of damp-heat or qi stagnation and blood stasis—patterns that describe internal imbalance and impaired metabolic waste clearance. These correspond to inflammation, poor circulation, and metabolic dysfunction in biomedical terms (40). The accumulation of metabolic waste in the body is caused by damp heat, which affects the excretion of uric acid; qi stagnation may lead to poor blood circulation, and then affect the metabolism of uric acid. Therefore, it is particularly important to regulate qi and blood and dredge meridians for the treatment of hyperuricemia (41). In TCM, “dredging the meridians” refers to restoring the unobstructed flow of qi and blood through specific pathways in the body. It is believed to eliminate pathogenic factors, relieve pain, and normalize internal organ function by stimulating acupoints to open blocked channels. Biomedically, this may correspond to enhanced circulation, anti-inflammatory modulation, and neuromuscular regulation (42).

External therapies of TCM, such as acupuncture, massage and bloodletting, all achieve therapeutic purposes by regulating qi and blood and dredging meridians (43). Acupuncture stimulates specific acupoints to promote the flow of qi (vital energy) and blood, which in TCM theory supports the body’s self-regulation and repair. Biomedically, this may correspond to enhanced neurovascular activation and modulation of immune-inflammatory responses (44); Massage acts on muscles and meridians through manipulation to improve local blood circulation and relieve pain (45); Bleeding can expel damp-heat and blood stasis accumulated in the body through acupuncture bleeding, and promote human metabolism (46). On the whole, the theory of qi and blood plays an important guiding role in the external therapy of TCM. By regulating the state of qi and blood, the clinical symptoms of patients with hyperuricemia can be effectively improved, the excretion of uric acid can be promoted, and the patients can be helped to recover (47).

Acupuncture, as an important part of external therapy of TCM, its basic principle and mechanism of action are of great significance in the treatment of hyperuricemia (48). It can regulate the flow of qi and blood, promote metabolism and achieve the effect of improving diseases by stimulating specific acupoints (49, 50). Meta-analysis shows that acupuncture has a good effect in treating hyperuricemia, and its analgesic effect is very significant (51, 52). TCM believes that hyperuricemia is related to spleen, liver and kidney. Acupuncture treatment often combines whole acupoint selection with local acupoint selection, and the main points commonly used are Foot Taiyin Spleen Meridian, Foot Yangming Stomach Meridian and Foot Jueyin Liver Meridian (53).

For asymptomatic hyperuricemia, acupuncture is primarily configured to lower serumuric acid and optimize renal urate handling. Acupuncture has a good therapeutic effect on asymptomatic hyperuricemia patients (54). Clinical studies have confirmed that acupuncture at five points on both sides of spleen meridian can increase urine volume and urine pH value, inhibit the level of URAT-1 enzyme, and then reduce the serum uric acid level of asymptomatic hyperuricemia patients (55). Animal studies have found that acupuncture at Five Shu Points of Spleen Meridian can reduce blood uric acid level by promoting uric acid excretion and increasing urine volume (56). Preclinical studies in hyperuricemia rat models have shown that acupuncture at “Shenshu” and “Taixi” points can inhibit the expression of URAT1 in the kidney of rats, thus reducing uric acid reabsorption, increasing the expression of OAT1 in the kidney, and thus reducing the level of serum uric acid (57). In hyperuricemia rat models, acupuncture at the original point and the point for raising blood can inhibit the level of xanthine oxidase, thereby reducing the production of uric acid and the level of serum uric acid in rats (58).

For symptomatic gout (acute flares), the plan prioritizes rapid analgesia and anti-inflammatory effects. Patients with gout should acupuncture Zusanli, Sanyinjiao, Quchi, Xuehai, Yanglingquan and Ashi points once a day, and at the same time cooperate with local infrared lamp irradiation, which can obviously relieve local pain and promote the recovery of normal nerve function (59). The results of metabonomics analysis show that acupuncture at Zusanli and Sanyinjiao can obviously reduce the level of serum uric acid in rats with gouty arthritis and relieve the pain in rats (60). Moreover, it has been suggested that acupuncture may have a good therapeutic effect on early gout by adjusting metabolism and improving renal function, thus reducing renal damage (61).

Electroacupuncture is the most commonly used method in acupuncture. By connecting electroacupuncture instruments to traditional acupuncture points and outputting pulse currents with different waveforms, the therapeutic effect of acupuncture can be enhanced (62). In the treatment of hyperuricemia, electroacupuncture has shown remarkable curative effect, and low-frequency (2 Hz) electroacupuncture has a better curative effect (63–65). Studies have shown that electroacupuncture stimulation of specific points, such as Zusanli and Sanyinjiao, can regulate the metabolic function of human body and promote uric acid excretion, and its mechanism may be related to improving the excretion ability of uric acid by kidney and regulating the level of inflammatory factors in vivo (66, 67). It is found that electroacupuncture at Zusanli, Fenglong and Ashi points can not only promote the excretion of uric acid, but also inhibit the synthesis of uric acid, thus reducing the content of sodium urate in joint tissue, thus eliminating the swelling and heat pain of patients’ joints (68). Clinical trials have demonstrated that electroacupuncture combined with diclofenac sodium significantly relieves joint pain within 10 minutes of treatment and maintains analgesic effect for up to 6 hours (69). Moreover, in patients with hyperuricemia with renal insufficiency, electroacupuncture at Shenshu, Xuehai and Sanyinjiao improves the permeability of blood on the renal cell membrane, thus restoring the uric acid excretion ability of the kidney itself (70). Animal experiments show that electroacupuncture at Zusanli and Sanyinjiao can down-regulate the expression of Cathepsin-B, thus inhibiting the activation of inflammatory corpuscles of NLRP3, reducing the expression of IL-1β and IL-18, and further inhibiting inflammatory reaction and relieving pain (71). Clinical studies have demonstrated that electroacupuncture at Zusanli and Sanyinjiao can promote the expression of Arginase-1 by activating AMPK signal pathway, induce the polarization of M2 macrophages, increase the release of anti-inflammatory cytokines, and inhibit the expression of NLRP3, thus reducing the inflammatory reaction (72). Studies have shown that electroacupuncture can also inhibit the excessive activation of NLRP3 inflammatory bodies by inhibiting the production of reactive oxygen species(ROS), and at the same time increase the up-regulation of transient receptor potential vanilloid 1(TRPV1) channels in sensory neurons to alleviate joint pain (73). In addition, it is found that electroacupuncture at Sanyinjiao, Jiexi and Kunlun points can inhibit the signal transduction of Toll-like receptor/myeloid differentiation primary response 88 (TLR/MYD88) and then the nuclear factor-κB (NF-κB) signal pathway, thus exerting anti-inflammatory effects (74). At the same time, it has been found that electroacupuncture at Sanyinjiao, Jiexi and Kunlun points can block the signal pathway of TREM-1 and reduce the inflammatory reaction (75). 2/100 Hz electroacupuncture at Zusanli and Kunlun points also significantly reduced the persistent pain behavior and ankle swelling of model rats (76).

Fire needle is an evolutionary form of acupuncture therapy in TCM. After burning a special needle, it quickly pierces the human acupoints or diseased parts. With the warm effect of high temperature, it quickly plays the roles of warming meridians, dispelling cold and removing dampness, reducing swelling and relieving pain (77). Fire acupuncture has a significant effect in dealing with gouty arthritis caused by hyperuricemia (78). When the fiery needle body quickly pierces the acupoints around the joint, such as Ashi point and Yanglingquan, it can quickly play the role of warming the meridians, dispelling cold and removing dampness, reducing swelling and relieving pain with the help of the warming effect produced by high temperature (79). Animal studies have shown that fire-needle acupuncture at Ashi points can inhibit the activation of NALP3 inflammasomes and reduce IL-1 secretion, thereby alleviating inflammation and joint swelling (80). In addition, the study found that acupuncture and moxibustion can directly act on the affected part, which can quickly improve the blood circulation around the joints, promote the absorption and dissipation of inflammatory substances, and then effectively alleviate the symptoms of redness, swelling and heat pain of the joints (81, 82).

As an important part of TCM therapy, massage has shown unique value and remarkable effect in the treatment of hyperuricemia and gouty arthritis caused by it (83). Massage acts on meridians and acupoints of human body through specific manipulations, regulating the metabolic function of the body and promoting uric acid excretion (84). Massage focuses on massaging the acupoints on the kidney meridian and bladder meridian, such as Taixi point, Shenshu point and Weizhong point, etc., to stimulate kidney function, enhance kidney’s excretion ability of uric acid, and regulate kidney’s gasification function at the same time, which is helpful to improve uric acid metabolism. Stimulating these acupoints through a series of professional massage techniques, such as kneading, pressing and pushing, can promote the smooth circulation of qi and blood, regulate the function of viscera, and thus reduce the level of blood uric acid (85). In the acute stage of gouty arthritis, massage can be done by gentle methods, such as one-finger Zen and massage, around the joints, which can effectively improve local blood circulation, promote the absorption of inflammatory substances and reduce the swelling and pain of joints (86). In the remission period of gouty arthritis, massage techniques will be aggravated appropriately, and the muscles and tendons around the joints will be massaged by rolling and pressing, so as to enhance the stability of the joints and prevent the recurrence of pain (87). Animal experimental data confirm that massage therapy can effectively inhibit the release of peripheral pain mediators K+, dopamine (DA) and norepinephrine in rats with acute gouty arthritis, thus playing an anti-inflammatory and analgesic role (88). This fully shows that massage therapy can bring positive therapeutic effect to patients with hyperuricemia and gouty arthritis, which is helpful to improve the quality of life of patients and alleviate the disease.

Although individual studies report differing technical parameters (e.g., technique definitions, operator-applied pressure, anatomical targets, symptom severity, and reporting detail), the overall operational approach can be reasonably summarized as follows and should be understood as a synthesis across multiple studies rather than a uniform protocol (42, 80, 89, 90). First, perform regional warming and tissue preparation with rolling and palm/circular gliding over peri-articular soft tissues until a gentle heat sensation is achieved (~2–3 minutes per region, intensity tailored to patient tolerance). Second, apply focused acupoint manipulation at commonly used sites for gout/gouty arthritis—Yinlingquan, Xuehai, Heding, the medial and lateral Xiyan, Zusanli, Ququan, Yanglingquan, and peri-lesional Ashi points—using press-kneading or thumb-kneading for ~1 minute per point, two sets, once daily for 7 days during the acute window. Third, use brief joint techniques as tolerated (gentle mobilization that does not provoke pain or heat; avoid vigorous manipulation directly over inflamed joints). For example, wax therapy may be applied to the affected joint at ~50 °C for 30 minutes once daily for 7 days; pricking-cupping or fire-needle bloodletting at locally engorged venules may be performed every 2 days, with a typical per-session bleeding volume ≤10 mL. Document parameters (minutes per region/point, sets, daily frequency, adjuncts), and ensure delivery by qualified clinicians to promote safety and reproducibility.

Bloodletting therapy is a TCM therapy with a long history. It uses tools such as triangular needle and plum blossom needle to release proper amount of blood at specific acupoints or superficial blood collaterals of human body, so as to regulate the circulation of qi and blood and achieve the purpose of treating diseases (91). In the field of hyperuricemia treatment, bloodletting therapy has a unique mechanism and remarkable effect (92). Based on multiple clinical studies and data-mining analyses, bloodletting sites can be broadly classified into local Ashi points and distal, specific meridian acupoints; these categories exhibit distinct profiles of efficacy with respect to lowering serum uric acid (UA) concentrations and providing analgesia.

Ashi points are the most frequently employed sites in bloodletting therapy. By definition, the puncture target is the locus of maximal joint erythema, swelling, warmth, and pain (93), embodying the therapeutic principle of “treat where it hurts” (yi tong wei shu). Contemporary studies indicate that Ashi-point bloodletting not only modulates inflammatory signaling pathways and reduces inflammatory cell infiltration (94), but also suppresses the release of peripheral pain mediators (e.g., K⁺, 5-hydroxytryptamine (5-HT), dopamine), thereby effectively alleviating swelling and pain—a profile particularly suitable for acute gout flares (95). By contrast, meridian acupoint bloodletting exerts more pronounced systemic regulatory effects. In gouty arthritis, commonly selected points include Taichong (LR3), Xingjian (LR2), Neiting (ST44), Sanyinjiao (SP6), Xuehai (SP10), Yinlingquan (SP9), and Weizhong (BL40), distributed along the Liver, Spleen, Stomach, Gallbladder, and Bladder meridians. These acupoints may improve whole-body metabolic status via soothing the Liver and regulating qi, clearing heat and draining dampness, and invigorating blood to unblock collaterals. Among them, Taichong and Xingjian can dissipate excess heat from the Liver meridian; Xuehai and Yinlingquan promote blood circulation and facilitate uric acid excretion; and Sanyinjiao may modulate vasomotor tone and relieve pain (96, 97). Weizhong (BL40), a He-Sea point of the Foot Taiyang Bladder meridian, is traditionally indicated for dispelling dampness, resolving stasis, and relieving pain. Clinically, Weizhong bloodletting combined with cupping plus febuxostat achieved an overall response rate of 93.33%, significantly higher than 63.33% with febuxostat alone; this combined regimen lowered serum uric acid (SUA) and C-reactive protein (CRP), improved joint mobility and pain, and likely acted by enhancing microcirculation and promoting urate excretion, thereby delivering an integrated urate-lowering and anti-inflammatory/analgesic effect (35). These observations suggest that meridian-point bloodletting not only contributes to analgesia but also facilitates meridian–viscera regulatory pathways that support urate homeostasis, making it suitable for remission or subacute management.

Beyond limb acupoints, auricular sites (e.g., the auricular helix) show unique value for urate reduction. A clinical study reported that auricular pricking bloodletting plus auricular seed pressing combined with dietary counseling produced significantly lower SUA levels than dietary counseling alone, indicating that auricular bloodletting—as a distal, specialized approach—has distinctive advantages in modulating systemic urate metabolism (98).

In summary, convergent evidence indicates that site selection materially influences clinical outcomes: local Ashi-point bloodletting primarily affords rapid analgesia for acute symptoms, whereas distal/meridian (including auricular) bloodletting emphasizes longer-term urate regulation. A combined strategy may produce synergistic benefits in both pain control and urate lowering (35).

Dose and frequency parameters. In current clinical practice, there is no unified quantitative standard for the volume of bloodletting, which renders therapeutic outcomes uncertain. In general, insufficient volume removes too few pro-inflammatory mediators and fails to produce adequate microcirculatory benefits, resulting in suboptimal efficacy; conversely, excessive volume may “injure essence and deplete qi,” raising safety concerns. Published clinical protocols report a wide per-session range that depends on technique and disease severity: approximately 2–10 mL for mild presentations, with 30–60 mL reported in selected severe cases. Several comparative cohorts have explored graded single-session doses of 20/40/60 mL and observed a dose–response relationship, i.e., greater improvement in gouty-arthritis symptoms and larger reductions in UA at higher volumes (99). Accordingly, we propose a routine cap of ≤ 10–20 mL for localized venous bloodletting, and an upper limit of 30–50 mL when systemic manifestations are prominent and close clinical monitoring is ensured.

Bloodletting frequency also varies across studies. For asymptomatic or mild cases, a typical schedule is once per week. For acute, severe flares, several clinical protocols perform sessions every 3–4 days (i.e., ≤i sessions/week) as a short course (typically three sessions), followed by clinical reassessment (99, 100).

In summary, the choice of bloodletting volume and frequency should be closely individualized to the patient’s constitution and disease severity. Moreover, bloodletting should be performed by qualified clinicians, with per-session volume and weekly frequency strictly regulated and documented to ensure treatment safety and effectiveness.

Topical Chinese herbal therapy is a kind of external therapy of TCM. These drugs penetrate through the skin, run along the meridians and qi and blood, and play a role in treating diseases (101). Ttai (102, 103). It is found that Luo Qing powder (Qingluo San), a topical herbal preparation typically composed of Sinomenium acutum (Caulis Sinomenii), Stephania tetrandra (Radix Stephaniae tetrandrae), Artemisia anomala (Herba Artemisiae Anomalae), and Atractylodes lancea (Rhizoma Atractylodis), combined with diclofenac sodium, can relieve the joint swelling and pain of patients with acute gouty arthritis more quickly and improve the clinical efficacy. The total effective rate is as high as 96.55% (104). External therapy of compound Qingbi granule, which often includes herbs such as Smilax glabra (Rhizoma Smilacis Glabrae), Angelica pubescens (Radix Angelicae Pubescentis), Saposhnikovia divaricata (Radix Saposhnikoviae), and Ligusticum chuanxiong (Rhizoma Ligustici), can quickly relieve swelling and pain, prolong the time of pain relief and inhibit inflammatory reaction, and there is no obvious adverse reaction at the same time (105). In addition, the research shows that topical hot compress with Sihuangshuimi, a decoction containing Coptis chinensis (Rhizoma Coptidis), Scutellaria baicalensis (Radix Scutellariae), Phellodendron chinense (Cortex Phellodendri), and Gardenia jasminoides (Fructus Gardeniae), can dilate local blood vessels, improve local blood circulation, increase metabolism, and make drugs penetrate and absorb through the skin and directly enter the lesion, thus playing a therapeutic role (106). Xinhuang patch, a transdermal formulation composed of herbal ingredients such as Commiphora myrrha (Myrrha), Boswellia carterii (Olibanum), Borneolum (Borneolum Syntheticum), and realgar (Arsenicum), may improve joint pain and swelling in patients with gouty arthritis by reducing C-reactive protein and erythrocyte sedimentation rate (107). Moreover, the external therapy of Tibetan medicine Qingpeng Ointment, which contains herbs such as Aconitum kusnezoffii (Radix Aconiti Kusnezoffii Preparata), Ephedra sinica (Herba Ephedrae), Angelica dahurica (Radix Angelicae Dahuricae), and Rheum palmatum (Radix et Rhizoma Rhei), has been shown to be effective in improving joint pain and dysfunction of patients with gouty arthritis, except for skin irritation in some patients, and there is no obvious adverse drug reaction (108, 109). Most importantly, topical Chinese herbal therapy the application as an external therapy method avoids the irritation of oral drugs to the gastrointestinal tract, reduces the adverse drug reactions, and provides a safe and effective green treatment option for patients with hyperuricemia and gout (110). A summary of clinical and preclinical evidence for various external therapies of TCM in the treatment of hyperuricemia is presented in Table 1.

Note: ↑ = increased; ↓ = decreased. SUA = Serum uric acid; CRP = C-reactive protein; ESR = Erythrocyte sedimentation rate. URAT1 = Uric acid transporter 1; OAT1 = Organic anion transporter 1; ROS = Reactive oxygen species; TRPV1 = Transient receptor potential vanilloid 1. Acupoints are labeled using WHO standard nomenclature.