Background: Realgar, a traditional mineral medicine containing arsenic, has been utilized for a long time in Asian nations like China and India. Realgar is primarily excreted in proto-form, and its active components are believed to be the soluble portion. The biological events involved in absorption, transportation, metabolism, and excretion are poorly understood. Objective: In this review, we attempt to systematically elaborate the in vivo process of realgar from absorption to excretion and investigate its possible mechanism, so that people can gain a better understanding of the chemical substance basis of realgar and serve as a reference for realgar efficacy, toxicity research, and clinical application. Methods: The relevant information and literature were extracted and retrieved from the National Library of Medicine (PubMed), Elsevier, the National Knowledge Infrastructure (CNKI), Wiley Analytical Science, Springer Link, the Web of Science, the Science Guide Chinese Pharmacopoeia, and other databases, using realgar, arsenic, absorption, transport, distribution, metabolism, excretion, intestinal flora, and anticancer as keywords. The process and possible mechanisms of realgar from absorption to excretion in vivo were summarized. Results: Realgar has a low bioavailability and only soluble arsenic is dissolved in the gastrointestinal tract. Arsenic is mostly absorbed by ion and molecular mimicry, transported to the bloodstream by carrier proteins, and distributed throughout the body's organs. The metabolism of arsenic in realgar includes reduction, oxidation, methylation, and mercaptan. Arsenic and its metabolites are mainly distributed in the blood and various organs, among which the blood is the highest level of arsenic distribution. Ultimately, the majority of arsenic and its metabolites are removed in the urine, whereas unabsorbed realgar is eliminated in the feces. Conclusion: The main ingredient of realgar (As4S4) is mainly found in its primary form in the gastrointestinal tract and excreted with feces in vivo, where it has little to no therapeutic effect. Realgar's efficacy and toxicity may be attributed to the soluble arsenic it contains, which includes inorganic arsenic such as AsIII and AsV as well as organic arsenic such as MMA and DMA, which are metabolites of inorganic arsenic. In vivo, soluble arsenic is absorbed, distributed, metabolized, accumulated, and excreted, and there is hepatoenteric circulation.