This systematic review and meta-analysis evaluated the efficacy and safety of acupuncture for chronic spontaneous urticaria (CSU) based on randomized controlled trials from seven databases up to March 2025. The studies included 564 participants. Compared to antihistamines, acupuncture significantly improved the clinical effectiveness rate (RR 1.19, 95% CI 1.10–1.29, p < 0.0001), interferon-γ levels (MD 5.96, 95% CI 3.92–8.00, p < 0.0000), reduced the Dermatology Life Quality Index (DLQI) score (MD −3.39, 95 % CI −6.53 to −0.26, p = 0.03), immunoglobulin E levels (MD −13.95, 95% CI −17.20 to −10.00, p < 0.00001), interleukin-10 (MD −6.24, 95% CI −6.82 to −5.67, p < 0.00001) and recurrence rate (RR 0.25, 95% CI 0.01–0.62, p = 0.003). The incidence of adverse events was not significantly different between groups (RR 0.80, 95% CI 0.23–2.80, p = 0.73). Possible publication bias was observed for clinical effective rate and DLQI. The certainty of the evidence was low, so the findings require further validation.