Internal Imbalances vs. External Invaders: A TCM View of Acne and Folliculitis 痘痘与毛囊炎的中医视角：内因失衡与外邪侵袭

Acne is viewed in Traditional Chinese Medicine (TCM) as a sign of internal disharmony, particularly involving “heat,” “dampness,” and “toxicity.” within the body. TCM theory attributes acne to pathogenic factors such as excessive heat in the lung and stomach meridians, damp-heat accumulation, and stagnation of qi and blood, which result in inflammation and pustule formation on the skin. This TCM framework is supported by the frequent use of herbal formulas designed to “clear heat,” “remove dampness,” and “detoxify” the skin, such as Tangs Derma Formula, series cases (reports 1, reports 2, reports 3, reports 4) have demonstrated anti-inflammatory and anti-bacterial effects in clinical settings.

TCM also recognizes the role of diet and constitution (yin-yang balance) in acne pathogenesis, with certain foods and dietary habits believed to exacerbate or ameliorate acne depending on the individual’s underlying constitution [1]. The therapeutic approach is highly individualized, aiming to restore systemic balance through herbal medicine, acupuncture, and lifestyle modification, rather than targeting the skin lesions alone [2,3].

 

 

Modern pharmacological studies of TCM formulas for acne have identified mechanisms such as inhibition of inflammatory pathways (e.g., IL-17, NF-κB, TLR signaling), regulation of sebum production, and modulation of immune responses, which align with the traditional concepts of clearing heat and resolving toxicity [4-8]. Thus, TCM conceptualizes acne as a disorder of internal disharmony manifesting externally, and treatment is directed at correcting these underlying imbalances.

Distinguishing Acne from Folliculitis in TCM

Facial acne and folliculitis are distinct entities in both Western dermatology and Traditional Chinese Medicine (TCM), differing in pathogenesis, clinical presentation, and treatment approaches.

Pathogenesis (Causes):
Facial acne is a chronic inflammatory disorder of the pilosebaceous unit, driven by increased sebum production, follicular hyperkeratinization, Cutibacterium acnes colonization, and inflammation [9-11]. TCM conceptualizes acne as an internal imbalance, often attributed to “heat,” “dampness,” and “toxicity” in the lung and stomach meridians, with pathogenic factors such as damp-heat and qi stagnation leading to skin eruptions [4-6,12,13].
Folliculitis, in contrast, is an inflammation of the superficial hair follicle, most commonly due to infection (bacterial, fungal, or viral), mechanical irritation, or occlusion [14]. In TCM, folliculitis is considered a manifestation of “wind-heat” or “damp-heat” invasion, often with a focus on external pathogenic factors and less on internal constitutional imbalance [15,16].

Clinical Presentation:
Facial acne presents as comedones (open and closed), papules, pustules, nodules, and sometimes cysts, often with scarring and post-inflammatory hyperpigmentation. Folliculitis typically manifests as small, discrete erythematous papules or pustules centered on hair follicles, often with a more superficial distribution and less tendency for scarring. Malassezia (Pityrosporum) folliculitis may present with monomorphic papules and pustules, often pruritic, and is distinguished histologically by the presence of fungal spores.

 

Treatment Approaches:

TCM treatment for acne focuses on clearing internal heat, resolving dampness, and detoxifying, using Tangs Derma-Zema herbal formulas, which target inflammatory and lipid metabolic pathways. Dietary modification are also employed, tailored to the individual’s constitution.

For folliculitis, TCM emphasizes clearing wind-heat or damp-heat and may use topical herbal cream and systemic herbal formula with antibacterial or antifungal properties. Treatment is more focused on eradicating external pathogens and restoring skin barrier function.

In summary, acne is primarily an internal disorder of the pilosebaceous unit with systemic TCM treatment, while folliculitis is an external, often infectious process with TCM therapies targeting pathogen elimination and local inflammation.

 

Reference 

  1. An Investigation of the Association Between Diet and Occurrence of Acne: A Rational Approach From a Traditional Chinese Medicine Perspective.
    Law MP, Chuh AA, Molinari N, Lee A. Clinical and Experimental Dermatology. 2010;35(1):31-5. doi:10.1111/j.1365-2230.2009.03360.x.
  2. Acupuncture in Dermatology: An Historical Perspective. Tan EK, Millington GW, Levell NJ. International Journal of Dermatology. 2009;48(6):648-52. doi:10.1111/j.1365-4632.2009.03899.x.
  3. Observation for Clinical Effect of Acupuncture Combined With Conventional Therapy in the Treatment of Acne Vulgaris. Kou L, Yu N, Ren J, Yang B, Tao Y. Medicine. 2020;99(18):e19764.
  4. Network Pharmacology, Transcriptomics, and Biological Validation Reveal a Lipid Secretion Inhibitory and Anti-Inflammatory Mechanism of Tanreqing Gel in the Treatment of Acne. Ren X, Zhou N, Li D, et al. Journal of Ethnopharmacology. 2025;340:119278.
  5. Network Pharmacology-Based Investigation on the Mechanism of the JinGuanLan Formula in Treating Acne Vulgaris. Gholais NS, Shi C, Zhang J, et al.  Evidence-Based Complementary and Alternative Medicine : eCAM. 2022;2022:6944792.
  6. Network Pharmacology and Experimental Validation to Explore the Molecular Mechanisms of Compound Huangbai Liquid for the Treatment of Acne. Di H, Liu H, Xu S, Yi N, Wei G. Drug Design, Development and Therapy. 2023;17:39-53.
  7. Identification of Biomarkers of Acne Based on Transcriptome Analysis and Combined With Network Pharmacology to Explore the Therapeutic Mechanism of Jinhuang Ointment. Li M, Gao X, Miao T, Sun H. Medicine. 2023;102(44):e35642.
  8. A Skin Lipidomics Study Reveals the Therapeutic Effects of Tanshinones in a Rat Model of Acne. Chen T, Zhu Z, Du Q, et al. Frontiers in Pharmacology. 2021;12:675659.
  9. Management of Acne Vulgaris: A Review. Eichenfield DZ, Sprague J, Eichenfield LF. JAMA logoJAMA. 2021;326(20):2055-2067. doi:10.1001/jama.2021.17633.
  10. Recent Advances in Understanding Inflammatory Acne: Deciphering the Relationship Between Cutibacterium Acnes and Th17 Inflammatory Pathway. Mias C, Mengeaud V, Bessou-Touya S, Duplan H. Journal of the European Academy of Dermatology and Venereology : JEADV. 2023;37 Suppl 2:3-11.
  11. Acne Vulgaris. Zaenglein AL. The New England Journal of Medicine. 2018;379(14):1343-1352. doi:10.1056/NEJMcp1702493.
  12. Identifying Chinese Herbal Medicine Network for Treating Acne: Implications From a Nationwide Database. Chen HY, Lin YH, Chen YC. Journal of Ethnopharmacology. 2016;179:1-8. doi:10.1016/j.jep.2015.12.032.
  13. Anti-Inflammatory and Antioxidant Chinese Herbal Medicines: Links Between Traditional Characters and the Skin Lipoperoxidation “Western” Model. Prieto JM, Schinella GR. Antioxidants (Basel, Switzerland). 2022;11(4):611. doi:10.3390/antiox11040611.
  14. Folliculitis: Recognition and Management. Luelmo-Aguilar J, Santandreu MS. American Journal of Clinical Dermatology. 2004;5(5):301-10.
  15. The Role and Mechanism of TCM in the Prevention and Treatment of Infectious Diseases. Zou Q, Chen Y, Qin H, et al. Frontiers in Microbiology. 2023;14:1286364.
  16. Antifungal Activity of 40 TCMs Used Individually and in Combination for Treatment of Superficial Fungal Infections. Yang F, Ding S, Liu W, et al. Journal of Ethnopharmacology. 2015;163:88-93.