756 Chin Med J 2013;126 (4)

Review article
Mechanism of traditional Chinese medicine in the treatment of
allergic rhinitis
GUO Hong and LIU Ming-ping

Keywords: allergic rhinitis; traditional Chinese medicine; acupuncture; immune modulation; comments

Objective To review the major progress in mechanism of traditional Chinese medicine (TCM) in the treatment of allergic
rhinitis (AR).
Methods Contents about the treatment mechanism of TCM in the therapy of AR in this article were obtained from 22
original articles and reviews published in Chinese- and English-language journals. All of the references were searched by
use of Pubmed (1997–2012).
Results AR is one of the most common and most serious public health problems in children and young people. Many
AR patients were worried about the possible adverse effects of synthetic drugs they were taking. Thus, they seek
complementary and alternative therapy, such as TCM. TCM emphasized on the importance of holistic convalescence, not
just the disease itself. The favorable safety profile of TCM makes well-acceptance by the general population. In the
recent decade, more and more studies of TCM for AR are developed. These studies indicated that the treatment of
allergic disorders with TCM therapy including herbal medicines and acupuncture are of safety and efficacy. The
mechanism of TCM in the treatment of AR has been discussed. It has been reported that a number of the herbs in the
Chinese herbal formulae used in the treatment possess anti-allergic, anti-inflammatory or immune modulation activity.
Such function include the inhibition of the release or the activity of mast cell mediators (such as histamine), inhibition the
induction of inflammation reaction by chemical agents, and down regulation of serum (immunoglobulin E) IgE levels or
the activity of lymphocyte and/or macrophage.
Conclusion
Conclusions s TCM are frequently used concurrently to improve the clinical efficacy. This review is focuses on the
description of the actions mechanism of Chinese medicine's approach relevant to the treatment of AR.
Chin Med J 2013;126 (4): 756-760

A llergic rhinitis (AR) is an allergic reaction which

happens when the immune system overreacts to
certain substances that you are inhaled. Nowadays, AR
has become a common and most serious public health
problem. It is urgency to find new and safe treatments for
these diseases.1,2 It is current lack of definitive preventive
and curative therapies for AR. The chronic nature of these
diseases and the current conventional medications for
allergic disorders are always accomplish with adverse
effects,3 thus many patients seek complementary and
alternative therapy, such as TCM. TCM therapies are
generally considered to be safe and efficacy by general
population.
Despite the finding that TCM has significant clinical
benefits in AR, the underlying mechanisms of therapeutic
action still remain largely unexplored. AR is a chronic
inflammatory condition of the nasal cavity that causes
hyper-responsiveness. The immune response of helper T
cell (Th)1 and Th2 has been believed to be mutually
antagonistic, which normally exist in equilibrium and
cross-regulate each other. An optimum balance of
Th1-Th2 has been suggested to be necessary to immune
homeostasis.4 The imbalance of Th1-Th2 has been
hypothesized to underlie AR through a shift from Th1
pattern immune responses toward a Th2 pattern immune
profile, which promote IgE production, activation and
survival eosinophilic inflammation.5 Some researchers
have reported that the Chinese herbal formulae used in
the treatment of AR have the activity of anti-allergic,
anti-inflammatory and immune modulation.6-8
ANTI-ALLERGIC TREATMENTS BY HERBAL
MEDICINE INTERVENTION
In the past decade, many researchers began to study the
potential treatment of AR by herbal medicine intervention.
Biminne is the first herbal preparation internationally to
be clinically tested for AR. Its main composition includes
the extracts of Scutellaria baicalensis, Ginkgo biloba,
Epimedium sagittatum, Schizandra chinensis, Prunus
Mume, Ledebouriella divaricata and Astragalus
membranaceus. These active ingredients have effect on
antiallergic and anti-inflammatory not only through
DOI: 10.3760/cma.j.issn.0366-6999.20121844
Department of Otolaryngology, Guangdong Second Provincial
Traditional Chinese Medicine Hospital, Guangzhou, Guangdong
510095, China (Guo H)
Guangzhou University of Chinese Medicine, Schoool of Chinese
Pharmaceutical Sciences, Guangzhou, Guangdong 510006, China
(Liu MP)
Correspondence to: Prof. GUO Hong, Department of
Otolaryngology, Guangdong Second Provincial Traditional
Chinese Medicine Hospital, Guangzhou, Guangdong 510095,
China (Email: guo256@yahoo.cn)
Chinese Medical Journal 2013;126 (4)
restrain inflammatory cells degranulation and
antagonistic inflammatory medium, but also can reduce
and remove the serum IgE. So the Biminne can
improving the body tolerance to allergens and control the
allergy and then effectively reduce and control the
allergic dermatitis. To test the effects of the Chinese
herbal formulation Biminne in patients with moderate to
severe perennial AR, Hu et al9 randomized 58 patients to
receive either Biminne capsules (n=26) or placebo (n=32)
treatment in a randomized, double-blind, placebo-controlled
clinical trial. Main outcomes were measured by changes
in symptom diaries, quality of life scores, patients’
evaluations of improvement on visual analog scores, and
physicians’ overall evaluation. Total serum IgE was
measured in all patients without knowledge of which
group they were in. After 1 year, they performed a
randomized, double-blind, dose-response study in 22
patients who had previously received placebo. The trial
outcomes evaluated by four instruments showed a
statistically significant improvement in some of the
symptoms of AR, whereas others exhibited a positive
trend that did not reach statistical significance. The
benefits of the treatment persisted after 1 year follow-up
after completion of the trial. A pilot dose-response study
showed both half and full strengths were effective. Total
serum IgE was reduced after the herbal treatment. The
results suggested the Biminne formulation is effective in
regulating immunity and decreasing serum IgE level.
Liu et al10 investigated the effect and mechanism of
Biminne, for treatment of AR. They found biminne
showed effects in reducing the frequency of sneezing and
nasal rubbing, inhibiting the proliferation of splenic
lymphocyte stimulated by phyto-hemagglutinin (PHA)
and ovalbumin (OVA), and lowering the levels of serum
total IgE and OVA specific IgE. The result suggested
biminne could inhibit the proliferation of splenic
lymphocyte and reduce serum level of IgE in mice with
AR .
A type of herbal formula in TCM named as
Gyokuheifusan (GHS, Jade Windscreen Powder in
English, Yupingfengsan in Chinese) is a consolidated
resistance to stave off external pathogens. GHS appears to
have effects on AR holistically, which has been reported
to possess preventive and curative effects in AR induced
by Japanese cedar pollen in guinea pigs when
administered orally. The GHS has been considered to be
of immunopharmacologic properties, which can affect
human homeostasis and constitution, although this
function remains to be demonstrated, but the effects of
GHS on murine antibody production has been evaluated
in a study using OVA as antigen. When mice were
sensitized intraperitoneally to OVA, the sera
concentration level of OVA-specific immunoglobulins
significantly increased when treated by GHS. When these
mice were sensitized intranasally to OVA, GHS can
significantly decrease the sera concentration of
OVA-specific antibodies. These results suggested that
757
when the antigen had already invaded the body, GHS can
stimulate immune responses, OVA-specific antibodies in
sera was suppressed might because GHS might
consolidate the resistance of nasal mucosa to protect from
OVA invasion. All of above facts suggest that GHS play
their role on the treatment of AR by a immune
modulation approach.11
Lenon et al12 has demonstrated that a Chinese herbal
formula developed from a TCM formula, which have
been then refer to as RCM-101 can reduced nasal and
non-nasal symptoms of seasonal AR. They cultured cells
to investigate the effects of RCM-101 on the
production/release of inflammatory mediators which was
known to be involved in seasonal AR. They studied
compound 48/80-induced histamine released by rat
peritoneal mast cells. Using an high-performance liquid
chromatography (HPLC) assay to studied the production
of leukotriene B4 induced by the calcium ionophore
A23187 in porcine neutrophils and using an
immune-enzyme assay to studied the production of
prostaglandin E2 stimulated by lipopolysaccharide in
murine macrophage (Raw 264.7) cells. Using western
blotting techniques, they determined the expression of
cyclooxygenase (COX)-1 and COX-2 in Raw 264.7 cells.
They found that the produced concentration of RCM-101
(1–100 mg/ml) dependent inhibition of compound
48/80-induced histamine release from rat peritoneal mast
cells, and also dependent inhibition of
lipopolysaccharide-stimulated prostaglandin E2 release
from Raw 264.7 cells. The Chinese herbal formula
inhibited A23187-induced leukotriene B4 production in
porcine neutrophils once the concentration is over the
range of 1–10 mg/ml. In addition, the expression of
COX-2 but not COX-1 protein also been inhibited by
RCM-101. These findings indicated that the release
and/or synthesis of histamine, leukotriene B4 and
prostaglandin E2 in cultured cells can be inhibit by
RCM-101, the interactions of RCM-101 with multiple
inflammatory mediators are likely to be related to its
function in reduce certain symptoms of AR.
Yang et al13 evaluate the effect of Xin-yi-san (XYS) in the
treatment of patients with perennial AR and explored the
potential molecular mechanism of anti-allergic
activity.They used placebo as control,evaluated the
effectiveness of XYS by nasal symptoms, nasal airflow
resistance, nostril dissection area, and serum titer of
specific IgE antibodies against house dust mite allergens
in a randomized double-blind study.The production of Th
1 (represented by interferon-γ (IFN-γ)) and Th2
(represented by interleukin (IL)-4, IL-10, and IL-13)
cytokines, the proinflammatory cytokine IL-8, soluble
intercellular adhesion molecule (sICAM), and
arachidonate metabolites prostagladin E2 (PGE2) and
leukotriene C4 (LTC4) by polymorphonuclear neutrophils
(PMNs) were compared before and after treatment
between the XYS group and placebo group. They found
that XYS attenuated nasal symptoms (sneezing and
758
rhinorrhea) and nasal congestion through reduction of
nasal airflow resistance and increase in nostril dissection
areas. XYS also been found exerted diverse
immunomodulatory effects, including suppression of
serum IgE levels and increased production of IL-10,
sICAM-1, and IL-8 compared to placebo group. However,
XYS treatment did not affect the release of PGE2 and
LTC4 from PMNs.
Bu-zhong-yi-qi-tang is an ancient formula of Chinese
medicine always been used in the treatment of allergic
diseases. Yang et al14 evaluated Bu-zhong-yi-qi-tang in
the treatment of patients with perennial AR. They
recruited and randomized 60 patients allergic to house
dust mite allergen, which confirmed by skin test and the
Michigan Alcohol Screening Test (MAST). An
experimental group of 36 patients was treated with
Bu-zhong-yi-qi-tang, whereas a control group of 24
patients was treated with a non-effective formula
Ping-wei-san for 3 months. The nasal symptomatic scores
and the responses of PMN to IL-4-stimulation were
measured after treatment. They found that the nasal
symptomatic scores in the Bu-zhong-yi-qi-tang group
were significantly improved. In contrast, no change was
found in symptomatic scores in the control group.
Moreover, total serum IgE and the IL-4-stimulated
production of PGE2 and LTC4 by PMN were
significantly suppressed in the Bu-zhong-yi-qi-tang group
after treatment compared to the control group. The
COX-2 mRNA expression in IL-4-stimulated PMN was
also significantly suppressed after Bu-zhong-yi-qi-tang
treatment. Their results suggest that Bu-zhong-yi-qi-tang
rather than Ping-wei-san was beneficial to the patients
with perennial AR via suppressed nasal inflammation by
an anti-inflammatory effect.
Yang et al15 found that the new mixed formula of Chinese
herbs containing Shin-yi-san + Xiao-qing-long-tang +
Xiang-sha-liu-jun-zi-tang treatment significantly
enhanced IL-10 but decreased IFN-γ and IL-5 production
by PHA-stimulated mononuclear cells. The IL-5
production was also decreased by PHA-stimulated
lymphocyte. In addition, the COX-2 mRNA expression in
stimulated PMN was significantly suppressed after the
new mixed formula treatment. These results suggest that
the new mixed formula treatment is beneficial to the
patients with perennial AR via modulating the function of
lymphocytes and neutrophils.
Aqueous extract from the fruiting body of Cryptoporus
volvatus has been reported to present anti-tumor,
anti-allergy, anti-inflammation and immunomodulatory
qualities. However, the mechanisms of anti-allergy and
anti-inflammation processes are poorly understood. Xie et
al16 evaluate the effect of Cryptoporus polysaccharides
(CP) extracted from fruiting body of Cryptoporus
volvatus in the decreasing of the development of nasal
symptoms, airway hyperresponsiveness (AHR) to
methacholine (MCh) and the infiltration of eosinophils in
Chin Med J 2013;126 (4)
nasal mucosa in rat model of AR, and investigate a
possible action mechanism of CP by detecting the
expression of eotaxin mRNA in nasal mucosa and lung
tissues. After repeated intranasal ovalbumin challenge
caused rhinitis symptom, AHR to MCh, eosinophil
infiltration and histological alterations into the nasal
mucosa and increase of eotaxin mRNA expression in
nasal mucosa and lung tissue were examined.
Pretreatment with CP decreased the numbers of sneezing
and nasal rubbing comparison with model group,
respectively. CP caused a dose-related inhibition of
MCh-induced AHR and decreased the expression of
eotaxin mRNA in the nasal mucosa. The results suggest
CP can relieve eosinophil infiltration and injury of tissue
in nasal mucosa and lung tissue and AHR of AR in rats.
Its action mechanism may be associated with the decrease
of eotaxin mRNA expression.
ACUPUNCTURE TREATMENT OF AR
The negative side-effects of anti-allergic medicines drive
many patients with AR to TCM, such as Chinese herbs or
acupuncture. Nowadays, acupuncture therapy is well
accepted by the majority of the population. Despite the
finding that acupuncture has significant benefits in AR,
the potential mechanisms of therapeutic effect are still
unclear. Some researchers presume that acupuncture may
help to improve the hemorheology indexes and increase
the volume of blood flow as well as regulate the
immunological function of the human body to provide
therapeutic effects for AR.
Shiue et al17 assessed the effect of acupuncture for
treatment of AR. They treated 18 patients with AR with
acupuncture and analysis of gene expression in peripheral
blood of these patients via cDNA microarray. To estimate
the therapeutic effect of acupuncture objectively, patients
completed the rhinoconjunctivitis quality of life
questionnaire (RQLQ) before and after acupuncture
therapy. Based upon patients’ response to the RQLQ,
acupuncture therapy significantly reduced AR symptoms,
including nasal symptoms, non-hay fever symptoms, and
sleep and practical problems (associated with daily
activities). In addition, expression of interleukin-1
receptor-α (IL1R1) in peripheral blood was significantly
decreased at 2 hours, 24 hours, and 4 weeks after
acupuncture treatment in these patients. The results
suggest that the balance between Th1 and Th2
cell-derived proinflammatory versus anti-inflammatory
cytokines might be improved by acupuncture treatment.
Acupuncture therapy corrects the equilibrium deviation
using the bidirectional regulative actions in treating
syndromes by inserting needles into acupoints. To study
the mechanism of acupuncture in the treatment of AR and
studied the clinical outcomes and gene expression
profiles of Phadiatop (Ph)-positive (+) and -negative (–)
AR patients who were treated with acupuncture. Shiue et
al18 assessed the therapeutic effect of acupuncture in
Chinese Medical Journal 2013;126 (4)
patients with perennial AR. The investigate involved 21
patients with AR (13 Ph(+), 8 Ph(–)), all of patients
received 8 courses of acupuncture treatment over 4 weeks.
They collected blood samples of the patients during the
course of acupuncture and used of affymetrix human
U133A chips to global analysis of gene expression
profiles. All of patients also been asked to completed the
quality of life questionnaire before and after the therapy
to objectively measure the therapeutic effect of
acupuncture. The gene expression profile in patients with
Ph(+) and Ph(–) AR treated before and after acupuncture
was analyzed by unsupervised and supervised clustering
pattern. The results of the quality of life questionnaire and
the gene expression profiles were different between the
two groups after receiving treatment with acupuncture.
The nasal symptoms showed significant improvement in
the Ph(+) group versus the Ph(–) group. Moreover, genes
involved in active immune response,differential of Treg
and cell apoptosis, were different in Ph(+) and Ph(–)
groups after acupuncture treatment. The results of this
study suggest that Ph(+) and Ph(–) AR groups have
distinct physiologic responses after receiving acupuncture
treatment,immune adjustment may be involves in the
mechanism of acupuncture treatment in patients with AR.
Brinkhaus et al19 evaluate the effectiveness of
acupuncture in addition to routine care in patients with
AR compared with treatment with routine care alone.
Patients with AR were randomly allocated to receive
acupuncture sessions or receiving no acupuncture in a
randomized controlled trial. The Rhinitis Quality of Life
Questionnaire (RQLQ) and general health-related quality
of life (36-Item Short-Form Health Survey) were
evaluated at baseline and after 3 and 6 months. At 3
months, the RQLQ improvement in the acupuncture
group is more significant than in the control group.
Similarly, quality-of-life improvements were more
pronounced in the acupuncture group versus the control
group. Six-month improvements in both acupuncture
groups were lower than they had been at 3 months. The
results suggest that treating patients with AR in routine
care with additional acupuncture leads to clinically
relevant and persistent benefits. In addition, it seems that
physician characteristics play a minor role in the
effectiveness of acupuncture treatment.
The biological plausibility to the use of acupuncture for
allergies has also been ascertained by other studies. It was
suggested that acupuncture can modulate levels of
cytokines and other anti-inflammatory mediators.8
According to the theory of Han JS, acupuncture can
stimulate the release of β-endorphin, which is coupled to
the release of adrenocorticotrophic hormone. The
adrenocorticotrophic hormone acts on the adrenal cortex
to stimulate the release of cortisol and offering another
possible anti-inflammatory effect.20 Magnusson et al21
conducted a randomized controlled clinical trial to
investigate the therapeutic effect of acupuncture on AR.
The studies involved a total of 55 patients in the
759
intervention group and 57 in the control group. The
heterogeneity between the two groups was negligible.
The serum IgE levels before and after acupuncture
treatment was measured. The results and the effect
estimate was modestly in favor of the intervention but
was not significant. They also investigated the plasma
cytokine levels and found the IL-10 level in plasma was
reduced after treatment in the active acupuncture group.
The result of another study showed a significant
improvement in long term cumulative score of symptom
before and after treatment and a significant decrease of
IgE and IL-4 for the acupuncture and standard care
groups, but there have no significance between the
acupuncture treatment group and standard care groups.22
CONCLUSION AND COMMENTS
Investigation of TCM therapy for AR is an active and hot
focus of research. Chinese herbal medicine and
acupuncture are the major components of TCM and both
of which have been used to treat symptoms similar to
those of AR for centuries and now are still broadly
administered for treating AR in China.
The investigation of the curative effect of Chinese herbal
medicine and acupuncture in the case of AR is faced with
problems like that the control group was not entirely
inactive. According to the principles of Traditional
Chinese herbs medicine, patients in the control group
should be treated with herbs (Chinese herbal medicine
used different from the treatment group) or fake (“sham”)
acupuncture, although study found the benefit with real
(specific) traditional Chinese herbs combined with real
acupuncture as opposed to nonspecific Chinese herbs and
fake (“sham”) acupuncture are sometimes significant, the
nonspecific Chinese herbs and fake (“sham”) acupuncture
has yet to be confirmed as a valid placebo and thus is still
a matter of controversy.
Several recent studies reported that most of AR formulas
are safe and had a positive effect on symptoms and/or
beneficial effect of immunomodualtory when used as
monotherapy or complementary therapy. The majority of
research results demonstrated that TCM herbal formulas
have potential for AR treatment. Traditional Chinese
herbal medicine such as the herb Astragalus
membranaceus has shown some promise for the treatment
of AR. Despite the finding that Chinese herbal medicine
used alone or in combination with acupuncture has a
significant clinical benefit in AR, the underlying
mechanisms of action is uncertain and still need further
in-depth study.
Some scholars believe that certain Chinese herbs used to
treat AR probably work as conventional anti-histamines,
which block the release of histamine that cause adverse
clinical symptoms of anaphylaxis, and some
compositions in complex Chinese herbs may possess
mediated anti-inflammatory, antibacterial and
760
immunological effects. Acupuncture is believed to
modulate the immune system, by resulting in lymphocyte
subpopulations shifts towards an increased number of
CD3+ CD4+ T lymphocyte cells, and also by modulating
the cytokine secretions patterns towards an increase of
IL-8 and decrease of IL-6 and IL-10. Acupuncture also be
recognized can stimulate the release of certain hormones,
such as adrenocorticotrophic hormone, beta-endorphin,
substance P and somatostatin and to change the activity of
the autonomic nervous system.
Although several studies carried out in China and the
West have suggested that Chinese herbal medicine and
acupuncture may be beneficial in the treatment of a
variety of AR, one concern involves the side effect of it.
In fact, it is very difficult to get an accurate description of
the adverse reactivity of a treatment without keeping
systematic records. The controlled clinical trials that
investigate the efficacy and adverse reactivity of TCM
herbal in the treatment of AR are seriously lacking.
Generally speaking, the greater the number of
medications, the greater the risk of harm, because when
complex multiple medications are used together and harm
does result, it is difficult to distinguish which drug result
in the adverse reactivity, so conventional medicine
warrants parsimony without affecting the overall
effectiveness.
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(Received July 9, 2012)
Edited by GUO Li-shao