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Objectives: Understand xanthelasma pathogenesis from both Western and TCM views, focusing on phlegm damp and Qi stagnation. Learn the principles of Zhuang medicated thread moxibustion. Apply TCM based therapy safely and effectively in dermatologic settings. Introduction: Xanthelasma palpebrarum is a benign lipid rich lesion, often seen in middle-aged women. In TCM, it reflects phlegm accumulation and Qi stagnation around the eyes. Zhuang medicine applies medicated thread moxibustion threads soaked in herbal decoctions and ignited to deliver heat and medicinal effects. This technique aims to resolve stagnation, transform phlegm, and restore local balance. This study explores its role as a non-invasive treatment in clinical dermatology. Materials / method: Middle-aged female patients diagnosed with bilateral upper eyelid xanthelasma received Zhuang medicated thread moxibustion as an alternative to conventional treatment. A total of three patients (aged 34, 45, and 55) underwent three treatment sessions at 10-day intervals. Threads made from 0.7 mm ramie, soaked in herbal decoctions, were ignited and briefly tapped on lesions using the “pearl fire” technique. Topical lidocaine was applied prior to treatment. Outcomes were assessed via a 4 point clearance scale, clinical photography, and patient feedback over a 3 month follow up. Results: All patients achieved full resolution by the third session, with visible reduction after the second. Mild transient edema resolved within 24 hours. No scarring, pigment changes, or infections occurred. At 3 month follow up, no recurrence was seen. Compared with TCA peeling or laser therapy, Zhuang moxibustion provided safer, well tolerated outcomes and greater patient satisfaction. Conclusion: Zhuang medicated thread moxibustion is a traditional TCM therapy with promising dermatologic use in xanthelasma. It likely works by heat induced disruption of dermal foam cells and enhancing circulation, plus transdermal herbal absorption. The technique avoids pigment changes or scarring, is low cost, and requires no complex equipment. As a bridge between tradition and integrative dermatology, it warrants wider clinical recognition.