Comparative effectiveness of acupuncture, fire needle, and herbal therapies for melasma: A Bayesian network meta-analysis

BACKGROUND: Melasma is a prevalent pigmentary disorder among reproductive-age Asian women. Although various treatment modalities exist, most demonstrate limited efficacy and carry the risk of adverse effects. In recent years, external Traditional Chinese Medicine (TCM) therapies (including acupuncture, fire needle, and herbal external applications) have attracted increasing attention as alternative interventions. However, their comparative effectiveness remains uncertain due to the lack of systematic evaluation. METHODS: A Bayesian network meta-analysis was conducted to assess the relative efficacy of different external TCM therapies for melasma. A total of 10 randomized controlled trials involving 944 participants were included. Primary outcomes were changes in melasma lesion area and pigmentation color. Subgroup analyses and surface under the cumulative ranking probabilities were employed to compare intervention rankings. Heterogeneity, publication bias, and consistency were assessed using standard meta-analytic methods. RESULTS: Compared with conventional treatments, external TCM therapies (including body acupuncture, fire needle, and herbal applications) did not demonstrate statistically significant improvements in melasma area or pigmentation color (all mean differences included or approached zero). Subgroup analysis indicated that fire needle therapy may offer relative improvement in pigmentation, while body acupuncture combined with conventional treatment showed a slight advantage in reducing lesion area; however, the overall strength of evidence was low. The presence of study heterogeneity, small sample sizes, and potential publication bias likely contributed to the lack of statistical significance. CONCLUSION: Current evidence does not support a definitive advantage of external TCM therapies over conventional treatments in the management of melasma. Clinical decision-making should be individualized, and the application of external TCM therapies should be considered with caution. High-quality, large-sample, and methodologically standardized randomized controlled trials are warranted to further explore the therapeutic potential of these interventions.