J. Acupunct. Tuina. Sci.
2014, 12 (2): 125-132
DOI: 10.1007/s11726-014-0759-9
Hypothesis, Modern Researches and Clinical
Applications of Cutaneous Regions in
Traditional Chinese Medicine
Fan Lei, Yin Lei-miao
Shanghai Research Institute of
Acupuncture and Meridian, Shanghai
200030, China
Author: Fan Lei, doctorate candidate
Corresponding Author: Yin Lei-miao,
M.D., associate professor.
E-mail: collegeylm@shutcm.edu.cn
© Shanghai Research Institute of Acupuncture and Meridian and Springer-Verlag Berlin Heidelberg 2014︱● 125
CRITICAL REVIEW
CLC Number: R245.2 Document Code: A
Abstract
As one of the most important concepts in traditional Chinese medicine,
cutaneous regions have a close relationship with skin in modern medicine.
According to the doctrine of traditional Chinese medicine, the cutaneous
regions are the corresponding projections of twelve meridians in the
superficial layer of the body and play an important role in body
surface-viscera correlation. The symptoms of visceral disorders will reflect
on cutaneous regions and one of the major patterns of manifestation is
referred visceral pain accompanied by tenderness and hyperalgesia on the
body surface. On the contrary, cutaneous regions participate in the
treatment of visceral disorders. As major clinical applications of the
cutaneous regions hypothesis, superficial acupuncture, subcutaneous
needling, massage (tuina), moxibustion, and wrist-ankle acupuncture have
achieved favorable therapeutic outcomes in clinical practice. Modern
researches have gained insights into the biological background of
cutaneous regions, however, further studies are needed to clarify the
mechanisms.
Key Words
Cutaneous Regions; Body Surface-viscera Correlation; Superficial
Acupuncture; Subcutaneous Needling; Massage; Tuina; Moxibustion
Therapy; Wrist-ankle Acupuncture
The hypothesis of cutaneous regions is one of the most important
concepts in traditional Chinese medicine, which is an ancient medical
system but has a close relationship with skin in modern medicine[1]. The
cutaneous regions are subsidiary parts of the twelve meridians[2]，which was
first documented in Huang Di Nei Jing (Yellow Emperor’s Classic of Internal
Medicine)[3]. The distribution pattern of cutaneous regions on the body
surface is based on the pathways of twelve meridians and the cutaneous
regions communicate with each other between hand and foot meridians,
which share the same name among the hand and foot meridians and then
converge into six regions, named ‘Taiyang-Guanshu’, ‘Shaoyang-Shuchi’,
‘Yangming-Haifei’, ‘Taiyin-Guanzhe’, ‘Shaoyin-Shuru’, ‘Jueyin-Haijian’,
respectively[4]. As the corresponding projections of twelve meridians on
surface skin, the cutaneous regions distribute more extensively than
meridians and collaterals, which are not linearly distributed. In this way, the
cutaneous regions-collateral-meridian-viscera constitute an organic whole
maintaining body homeostasis.
●

Based on the same biological basis, cutaneous
regions are in close relationship with the skin in the
modern medicine, which is the largest organ of the
body[5]. Skin has been well documented to contain
multiple sensory receptors for temperature,
mechanical stimuli, electric potentials, and other
stimuli[6]. These skin sensory receptors produce
changes in membrane potential and activate signal
transduction pathways such as mitogen-activated
protein kinase signal transduction pathway[7], and
nitric oxide-cyclic guanosine monophosphate
transduction pathway[8], thus lead to a variety of
biological effects[9]. The sensory information induced
by stimulation of skin transmits to the prefrontal
cortex and hypothalamus, then transforms into
signals regulating the diverse organs of the body via
its control over the autonomic nervous system[10] and
its powerful metabolic and endocrine capabilities[11].
Cutaneous resident and recruited cells express a wide
range of hormones, neuropeptides, and steroid
receptors through which the central nervous system
(CNS) can communicate with the skin[10]. As for the
well-known hypothalamus-pituitary-adrenal axis, the
skin cells express corticotropin-releasing hormone,
urocortin, and pro-opiomelanocortin, with its
products adrenocorticotropic hormone, α-
melanocyte-stimulating hormone, and β-endorphin,
which altogether regulate stress reaction[12]. The
neuropeptide Y expressed by skin cells is also
responsible for regulation of the hypothalamic-
pituitary-thyroid axis[13]. Therefore skin is a complex
organ able to maintain internal homeostasis through
multidirectional communications between the
endocrine, immune, and CNS which share agents of
neuropeptides, cytokines, hormones, and other
effector molecules, known as the neuro-immuno-
cutaneous-endocrine system[14]. The cutaneous
regions-collateral-meridian-viscera network may have
identical effect as the neuro-immuno-cutaneous-
endocrine system in maintaining the homeostasis. We
propose that the cutaneous regions may have a
similar function with the skin and form a
signal-gathering network, which plays a key role in
whole-body homeostasis in response to the changing
environment. An investigation into this area may help
us better interpret the underlying mechanisms of
therapeutic effects of traditional Chinese medicine.
The study aims to summarize the relationship
between cutaneous regions and visceral organs,
collect evidences for the biological basis of the
cutaneous regions by investigating a variety of
sensory receptors, and clarify the possible role of
cutaneous regions in clinical applications of
traditional Chinese medicine therapies.
● 126 ●︱© Shanghai Research Institute of Acupuncture and Meridian and Springer-Verlag Berlin Heidelberg 2014
J. Acupunct. Tuina. Sci. 2014, 12 (2): 125-132
1 Cutaneous Regions Reflect the Body Surface-
viscera Correlation
1.1 From inside to outside: symptoms of visceral
disorders will reflect on cutaneous regions
According to the doctrine of traditional Chinese
medicine, the cutaneous regions are the outermost
layer of the body. It is not only the body's first barrier
against the exogenous pathogenic factors, but also
the surface reaction areas of visceral organs. As a
result, visceral disorders are reflected on cutaneous
regions, manifested as referred visceral pain
accompanied by tenderness and hyperalgesia on the
body surface[15]. Previous researches summarized
referred visceral pain, such as the left shoulder pain
occurred in myocardial ischemia, and interscapular
pain occurred in stomach and pancreas diseases[16].
Pain associated with angina pectoris, or myocardial
infarction is referred to the left chest, left shoulder,
and left arm, which cover the cutaneous regions of
Yangming, Taiyin, Jueyin, and Shaoyin Meridians.
Further research is needed to clarify the specificity of
the cutaneous regions and referred pain. Apart from
referred pain, there are tenderness and hyperalgesia
observed in many visceral disorders, and
manipulation or needling at these sensitive points can
often relieve the pain and discomfort associated with
the visceral disorders[17].
Except fore sensory changes such as referred pain
and hyperalgesia, ancient practitioners had often
detected the activities of organs and meridians by
observing the color, touching and pressing cutaneous
regions to percept special pathological responses
such as papules, maculopapule, and nodules. Some of
these cutaneous pathological changes have been
verified by modern researches. For instance, visible
changes on the body surface such as scleroderma[18]
and lupus erythematosus[19] are bound up with
various immune-related diseases. Furthermore,
hepatitis B virus infection was reported to elicit
cutaneous damages manifested as skin rash, urticarial
or maculopapular, purpuric and petechial lesions[20].
It’s also found that diarrheal disorder caused by vibrio
cholera infection is companied with skin lesion[21],
which further proves that cutaneous regions are
associated with internal organs and the changes of
cutaneous regions may reflect the visceral disorders.
1.2 From outside to inside: cutaneous regions play
an important role in the treatment of visceral
disorders
Exogenous pathogenic factors can affect viscera
function through cutaneous regions. For instance, it’s
J. Acupunct. Tuina. Sci. 2014, 12 (2): 125-132
suggested that streptococcal skin infection can elicit
acute nephritis or unexplained hematuria[22]. In terms
of treatment, various forms of therapeutic
approaches can be implemented on cutaneous
regions, such as plum-blossom needles, blood-letting
puncture, direct scarring moxibustion, indirect
moxibustion, wrist-ankle acupuncture, massage
(tuina), and cupping. Cutaneous regions have played
an important role in the treatment of visceral
disorders using various traditional Chinese medicine
therapies, which can rearrange the function status of
vital energy (meridian-qi) and visceral organs by
means of transmitting diverse stimulation through
cutaneous regions. Modern clinical studies
demonstrate that plum-blossom needles can acquire
satisfactory therapeutic benefits in the treatment of
craniofacial diseases such as juvenile myopia[23], and
acute facial paralysis[24]. The face belongs to the
cutaneous region of Yangming Meridian, which
indicates that plum-blossom needles are effective in
treating diseases located in cutaneous region of
Yangming Meridian. Some study found the
therapeutic benefits of combining encircling needling,
bloodletting with cupping therapy for patients with
localized scleroderma[25].
2 Major Clinical Applications of the Hypothesis of
Cutaneous Regions
2.1 Cutaneous regions are the sites where
acupuncture manipulation gets initiated
The superficial acupuncture and subcutaneous
needling take effect through the cutaneous regions
which are the sites where acupuncture manipulation
gets initiated. The mechanical coupling between the
needle and the cutaneous regions transmit a
mechanical signal to various organs via
mechanotransduction[26]. The mechanoreceptors and
mechanosensitive ion channels of the skin detect
mechanical stimuli of acupuncture and transduce
these stimuli into electrical signals in sensory
neurons[27]. Study also demonstrates that stimulation
excitation induced by the deformation of collagen
bundle appears in mechanoreceptors innervated by
Aδ and C fibres[28]. Sharp edge of acupuncture needle
leads to a pinprick-like sharp pain sensation in the
superficial skin related to A fiber afferent
activity[29-30].
Various kinds of receptors and nerve fibers are
involved in the acupuncture biological process via the
cutaneous regions. Pervious study demonstrates the
co-localization of the transient receptor potential
vanilloid subfamily member 1 (TRPV1) and neuronal
nitric oxide synthase in both the subepidermal nerve
© Shanghai Research Institute of Acupuncture and Meridian and Springer-Verlag Berlin Heidelberg 2014︱● 127
fibers and in the dermal connective tissue cells by
means of double immunostaining. The higher
expression of TRPV1 is found in the subepidermal
nerve fibers after acupuncture treatment, which may
play a key role in mediating the transduction of
acupuncture signals to the CNS[31]. All of the
peripheral somatosensory inputs are transmitted to
the spinal cord via dorsal root ganglion (DRG) sensory
neurons. Acupuncture stimulation activates DRG
sensory neurons by inducing signals of axonal
growth-associated protein 43 and phosphorylation of
Erk1/2, which suggests that acupuncture stimulation
may generate physiological effects on the autonomic
nervous system via the activation of somatosensory
pathways[32].
Both superficial acupuncture and subcutaneous
needling achieve satisfactory therapeutic benefits
compared with conventional treatment or deep
needling approaches. For instance, Itoh K, et al
observed that there was no statistically significant
difference between direct myofascial trigger points
needling and superficial needling at the end of two
phases of treatment of chronic low back pain[33].
Previous study also revealed that patients with
idiopathic anterior knee pain benefit equally from
both subcutaneous needling and electroacupuncture
treatment with a long-term pain-relieving effect for at
least 6 months. The treatment effects may result from
central pain inhibition caused by afferent stimulation
induced by subcutaneous needling[34].
2.2 Massage (tuina) therapy has significant
anti-stress effects
Massage therapy could regulate nerve function by
rearranging the balance of activity and inhibition of
mechanoreceptors of cutaneous regions. As massage
therapy relies on cutaneous regions to receive
stimulation and take effect, its biomedical basis is
associated with the widely distributed cutaneous
mechanoreceptors that respond to mechanical
pressure or distortion[35]. It is demonstrated that
mechanical deformation of the skin leads to the
release of ATP from keratinocytes, fibroblasts and
other cells, then the mechanoreceptors are activated
through purinergic receptors[36]. It is the activation of
mechanoreceptors in the periphery caused by
mechanical pressure and tissue distortion that induce
activity in the afferent nerve fibers which transmits
signals to the brain[36].
Cutaneous regions also participate in the human
psychological reaction to environments as positive
effects of massage on anxiety have been shown in
many studies[37-38]. Previous study demonstrated that
innocuous stimulation induced by light to moderate
massage resulted in a decreased activity of the
●

adrenal glands, lowered levels of adrenaline and
noradrenaline, and anti-stress effects characterised
by a decreased adrenergic activity, release of oxytocin,
sedation and an increase of gastrointestinal
hormones[39]. On the contrary, noxious stimulation
such as trigger point massage therapy was shown to
affect the release of either the corticotrophin causing
increased adrenal activity or higher levels of the stress
hormone cortisol[39].
Cutaneous regions play a key role in massage
therapy for the treatment of hypertension. As cortisol
and catecholamine release involved in stress
reactions are positively correlated with blood
pressure, and the reduction of them could contribute
a great proportion to the therapeutic benefits of
massage therapy in the treatment of hypertension[40].
Similar to the role of massage therapy in stress
response, its significant regulatory effects on blood
pressure was reported to be determined by the
certain form of massage[41]. Strong massage such as
trigger point therapy and sports massage are
significantly associated with an increase in systolic
blood pressure[41], whereas reflexologic foot massage
is effective to reduce blood pressure and improve
sleep of the elderly with essential hypertension[42].
2.3 Moxibustion-induced therapeutic effects are
associated with cutaneous regions
Skin is abundant in thermoreceptors that respond
to changes in temperature within the innocuous
range[43]. Collagen deformation caused by thermal
stimulation activates mechanoreceptors and thereby
leads to series of biological effects[44]. The
thermoreceptors responding to warmth elicited the
activity of unmyelinated C-fibres with low conduction
velocity, while those responding to cold excite both
C-fibers and thinly myelinated Aδ fibers with faster
conduction velocity[45].
Moxibustion has been frequently used to warm
regions, as it’s believed to stimulate circulation and
induce a smoother flow of blood and qi and dispel
cold and dampness in the body according to the
doctrine of traditional Chinese medicine. Heat
stimulation induced by indirect suspended
moxibustion activates thermoreceptors that express
the TRPV1 channels and excited autonomic nerve
endings ultimately leading to axon reflex-mediated
vasodilatation[46]. Specifically, substance P (SP) and
calcitonin gene related peptide (CGRP) are co-
released. SP modulates the prolonged vasodilator
activity of CGRP via release of proteases from
cutaneous mast cells and serves to increase the local
production and availability of NO[47]. This may explain
the mechanisms of moxibustion-induced local
engorgement and cutaneous temperature
improving[48].
● 128 ●︱© Shanghai Research Institute of Acupuncture and Meridian and Springer-Verlag Berlin Heidelberg 2014
J. Acupunct. Tuina. Sci. 2014, 12 (2): 125-132
Different from indirect suspended moxibustion,
direct scarring moxibustion can elicit thermal and
nociceptor activities which may involve a more
complex process of taking effect. Direct scarring
moxibustion places a small cone of mugwort on the
skin and burns it until the skin blisters, which then
scarred after healed. During this process, nociceptors
that respond to damaging stimuli by sending nerve
signals to the spinal cord and brain played an
important role[49]. The peripheral terminal of
nociceptors under the skin is where the noxious
stimuli are detected and transformed into electrical
energy driven towards the CNS, which leads to the
perception of pain. Direct scarring moxibustion can
induce heat pain perception by the responses of
thermal nociceptors, mechanothermal nociceptors,
polymodal nociceptors. Most nociceptors including
unmyelinated, slowly conducting C fibres and
myelinated, more rapidly conducting Aδ fibres have
polymodal characteristics, which share the same
transducers for noxious mechanical stimuli and
chemical stimuli, such as acid or capsaicin[50]. During
the healing process of scarring after direct scarring
moxibustion, the immune non-neural components
play an important role in inflammation response.
2.4 Antinociceptive effect of wrist-ankle acupuncture
relies on the cutaneous regions
Wrist-ankle acupuncture as the name implies is a
style of acupuncture using specific points at the wrists
and ankles, and is mostly frequently used for pain
relief in various disorders[51-53]. When a needle is
inserted into a designated point on surface skin and
manipulated in different directions under epidermis,
it is assumed to cause local tissue injury and
biochemical reactions, with the release of various
inflammatory and immune mediators such as
noradrenaline (NA), β-endorphin, SP, CGRP[54].
Compared with conventional analgesic treatment,
wrist-ankle acupuncture generates more favorable
results with respect to treatment outcome.
Wrist-ankle acupuncture was reported to be effective
for perineal pain relief after mediolateral
episiotomy[55], and showed an obvious anti-
nociceptive effect on cancer pain[53,56] and acute
lumbago[52], especially with no side effects and a
longer analgesic period[56].
The involvement of diffuse noxious inhibitory
control which refers to an endogenous pain
modulatory pathway that has often been described as
‘pain inhibits pain’ has been suggested to account for
part of the wrist-ankle acupuncture-induced pain
relief[57]. Noxious stimulation such as penetration of
the skin by wrist-ankle acupuncture activates high
threshold mechanoreceptors and activity in Aδ fibres.
J. Acupunct. Tuina. Sci. 2014, 12 (2): 125-132
This afferent stimulation extends from the
spinothalamic tract to the nucleus of the
periaqueductal grey in the midbrain, resulting in
activation of the descending inhibitory control system
and thereby reduction of pain perception[39].
Wrist-ankle acupuncture therapy has also been
used in the treatment of immune and metabolic
diseases other than pain relief. Previous research
indicated that wrist-ankle acupuncture in
combination with Chinese herbal medicine acquired
satisfactory therapeutic outcome in treating chronic
urticaria and showed obvious advantages in
decreasing relapse rate and prolonging the remission
time[58]. It was also reported that wrist-ankle
acupuncture achieved therapeutic effects for diabetic
peripheral neuritis which improved the metabolisms
of blood sugar and blood lipid, lowered down blood
viscosity, and restored the functions of peripheral
nerve cells[59].
2.5 Other forms of traditional Chinese medicine
therapies applied on cutaneous regions
Other forms of traditional Chinese medicine
therapies applied on cutaneous regions include
encircling needling, plum-blossom needle, guasha
(scrapping) treatment and cupping etc. Similar to
wrist-ankle acupuncture, encircling needling and
plum-blossom needling are applied to the surface skin
and were reported to be effective in the treatment of
diseases such as psoriasis[60], alopecia[61], and facial
paralysis[24]. Guasha employs skin scraping to cause
subcutaneous microvascular blood extravasation and
bruises[62]. It has been commonly used for treating
breast engorgement[63], chronic neck pain[64], and was
reported to achieve hepatoprotection in chronic
active hepatitis B[65].
3 Discussion
Cutaneous regions can be stimulated in a variety of
ways, including superficial acupuncture, subcu-
taneous needling, massage (tuina), moxibustion,
wrist-ankle acupuncture, encircling needling, plum-
blossom needle, guasha treatment and cupping and
so on, determining the corresponding physiologic
response. There is a huge potential for using
cutaneous regions to help us treat diseases. By
modulating hypothalamic-pituitary-adrenal axis
activity and autonomic nervous system activity,
stimulation to cutaneous regions could affect
neuroendocrine function, immune function,
corticosteroid production (adrenal cortex), and
catecholamine function (adrenal medulla). Previous
studies demonstrated that stimulation to cutaneous
regions by various needling approaches achieved
satisfactory therapeutic outcomes in neurological
© Shanghai Research Institute of Acupuncture and Meridian and Springer-Verlag Berlin Heidelberg 2014︱● 129
diseases such as juvenile myopia[23], acute facial
paralysis[24], and diabetic peripheral neuritis[59], as
well as various pain such as chronic low back pain[33],
idiopathic anterior knee pain[34], acute lumbago[52],
perineal pain after mediolateral episiotomy[55], and
cancer pain[53, 56]. Except for the therapeutic benefits
mentioned above, stimulation on cutaneous regions
has an obvious advantage for treating skin diseases
such as scleroderma[25], chronic urticaria[58],
psoriasis[60] and alopecia[61] when current therapies
are not as effective or as safe as the physicians or
patients would like them to be or if current medical
therapies have severe side effects. Moreover, due to
its regulatory effects on adrenal activity and the stress
hormone cortisol[39], non-invasive stimulation to
cutaneous regions such as massage (tuina) has an
anti-stress effect and is frequently used in treating
anxiety by psychologists[37-38]. However, we should
not neglect the big gap between clinical practice and
evidence-based medicine. Although there have been
more and more studies reporting the effectiveness of
classic traditional Chinese medicine therapies applied
to cutaneous regions, the study quality is
inhomogenous and some of the studies are
insufficient to provide conclusive evidence for clinical
practice. Physicians and researchers need to
recognize that better-designed strictly-conducted
clinical trials are needed to establish the true efficacy
of acupuncture and other approaches on cutaneous
regions.
The hypothesis of the cutaneous regions not only
constitutes an important supplement to the doctrine
of traditional Chinese medicine, but also brings great
implications and impacts on further research and
clinical applications.
It is undeniable that nowadays there are some
diseases that conventional Western interventions fail
to achieve satisfactory therapeutic outcome despite
of the rapid development of modern science.
Fortunately, traditional Chinese medicine therapies
based on the hypothesis of the cutaneous regions
provide us with an alternative for treating those
bothersome problems such as neurological diseases,
various chronic pain, stress-related skin diseases, and
psychological problems. Combining conventional
Western medical therapies and traditional Chinese
medicine therapies based on the hypothesis of the
cutaneous regions may lead to a higher response rate
and less side effects and thus bring physicians many
implications on further clinical applications.
What is the mechanism underlying region-
specificity when treating diseases according to the
hypothesis of the cutaneous regions? As examples
mentioned before, pain associated with angina
pectoris, or myocardial infarction is referred to the
left chest, left shoulder, and left arm, which cover the
●

cutaneous regions of Yangming, Taiyin, Jueyin, and
Shaoyin Meridians. Further researches are needed to
clarify the specificity of the cutaneous regions and
referred pain.
The hypothesis of cutaneous regions provides us
with more evidence for better understanding the
meridian doctrine[66-70]. The twelve meridians are
deeply linearly distributed, while cutaneous regions
distribute more extensively and cover the whole body
surface. However, the cutaneous regions are the sites
where acupuncture manipulation gets initiated. When
treating diseases by deeply inserted needles, the
stimulation induced by insertion of the needle not
only leads to biological effects of cutaneous regions,
but also constitutes an important part of the
therapeutic effects of acupoints based on the
meridian doctrine. Interestingly, clinical studies
sometimes provide paradoxical evidences. It was
shown that both superficial acupuncture and
subcutaneous needling achieved satisfactory
therapeutic benefits compared with conventional
treatment or deep needling approaches. It is too early
to draw a conclusion based on limited evidence, and
better-designed strictly-conducted clinical trials are
needed to establish the biological effects of the
cutaneous regions and the twelve meridian system.
Conflict of Interest
The authors declare that there is no potential conflict of
interest in this article.
Acknowledgments
This work was supported by National Natural Science
Foundation of China (No.81001548, No. 81173341, No.
81173332 and No. 81202753); Shanghai Rising-star Program
(No. 12QA1403000); Shanghai Key Research Program of
Traditional Chinese Medicine Development (No. ZYSNXD-
CC-ZDYJ039); The Scientific Research Funds for Young
Scholar of the Health System in Shanghai (No.
XYQ2013081).
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Received Date: January 8, 2014