Metabolic dysfunction-associated steatotic liver disease (nonalcoholic fatty liver disease) is one of the most active fields of Chinese medicine. This review aims to assess the effect of Chinese medicines in the treatment of metabolic dysfunction-associated steatotic liver disease. Methods The relevant databases were comprehensively searched up to August 30, 2024, including Pubmed and China National Knowledge Infrastructure for published articles and Chinese Clinical Trial Registry for ongoing studies. Identification the authentic of the study through contact the investigators. Only randomized controlled trials were included. The risk of bias and quality of evidence were assessed based on Cochrane tools and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) profile. Results A total of 214 studies were relevant for our question. Of these, 188 are pending for inclusion for further identification due to an unstated ethics approval status, 6 studies are ongoing, and 9 studies were excluded due to a lack of eligible reporting on outcomes. Finally, 11 studies, with a total of 1320 patients, were included in this version of the review. Combination analysis was not performed due to substantial heterogeneity, such as the different Chinese medicines and different control treatments involved. Of the 11 included studies, 9 compared the tested Chinese medicines with drugs that have uncertain effects; therefore, the effects of these tested Chinese medicines are very uncertain. Of the two studies comparing Chinese medicineChinese medicine plus lifestyle modification versus lifestyle modification, the JianPi ShuGan formulaJianPi ShuGan formula (spleen-strengthening and liver-draining formula, SLF) (Hui 2023) showed benefit in the liver Controlled Attenuation Parameter (CAP) (P = 0.002) and liver stiffness measurement (LSM) (P = 0.001), respectively, but not in alanine aminotransferase (ALT) (P = 0.663) and gamma-glutamyl transferase (P = 0.136), respectively. FuGan XiaoZhi decoction (Zhou 2016) showed benefit in terms of both cure rate (Relative risk [RR] 1.02, 95% CI: [CI] 1.02 to 3.91), triacylglycerol (mean difference [MD] −0.55, 95% CI −0.88 to −0.22), and high-density lipoprotein cholesterol (MD 0.32, 95% CI 0.19 to 0.45), respectively, but not in ALT (MD −7.80, 95% CI −19.65 to 4.05), aspartate transaminase (MD −6.69, 95% CI −18.13 to 4.75), and total cholesterol (MD −0.71, 95% CI −1.47 to 0.05). However, due to the potential high risk of selection bias, performance bias, detection bias, and conflict of interest, the quality of evidence from these two studies remains very low. Conclusion Some Chinese medicines might be effective at increasing the cure rate or improving liver function or lipid metabolism; however, because most of the included studies compared these Chinese medicines with drugs that have uncertain effects, and/or some studies carry a potential high risk of bias, the effects of the Chinese medicines in the included studies remain very uncertain.