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Allergic Contact Dermatitis (Type IV Hypersensitivity) and Type I Hypersensitivity Following Aromatherapy with Ayurvedic Oils (Dhanwantharam Thailam, Eladi Coconut Oil) Presenting as Generalized Erythema and Pruritus with Flexural Eczema |
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Allergic Contact Dermatitis (Type IV Hypersensitivity) and Type I Hypersensitivity Following Aromatherapy with Ayurvedic Oils (Dhanwantharam Thailam, Eladi Coconut Oil) Presenting as Generalized Erythema and Pruritus with Flexural Eczema
Dr Chembolli Lakshmi,  05 September 2019
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#Allergy and Immunology #Dermatology

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Herbal and Ayurvedic medications, believed to be “mild” and “natural” are usually sought as the first line of treatment before resorting to “stronger” allopathic medication. There are very few reports of adverse reactions to either topical and/or systemic Ayurvedic medications. Massage aromatherapy with ayurvedic oils plays an important role in alleviation of pain, but may cause allergic contact dermatitis. This is the second case report of allergic contact dermatitis to ayurvedic oil.

 

Introduction

It is important to document adverse reactions to Ayurvedic medication so that the misconceptions of this “safe” therapy are corrected. Ayurvedic aromatherapy is a very popular form of treatment for painful muscle and joint conditions, especially in Kerala and other states of Southern India. This report hopes to create awareness of the rare possibility of adverse reactions to Ayurvedic medication.

Case Report

A 52-year old lady with rheumatoid arthritis undergoing massage aromatherapy with a combination of 3 ayurvedic oils (Dhanwantharam thailam, Eladi coconut oil, and Murivenna) presented two weeks later with generalized erythema and intense pruritus. The flexures showed accentuation with eczematous changes (Figure 1). The possibility of allergic contact dermatitis (type IV hypersensitivity) to the medicated oil used for aromatherapy was suspected and she was advised to temporarily stop the aromatherapy. Systemic corticosteroids (prednisolone 20 mg daily for a week) rapidly controlled the symptoms.

Since the patient had good relief of pain, she desired to continue therapy. She was advised that she may continue the aromatherapy with the medications to which she tested negative by patch testing. Two weeks after stopping systemic corticosteroids, patch testing was done with each of the three oils “as is” with petrolatum as control. The results were interpreted as recommended by the ICDRG. The patches were applied using aluminum chambers on micropore tape (Systopic Pharmaceuticals, New Delhi, India) and were removed after 2 days. She tested positive (+) to two (Dhanwantharam thailam and Eladi coconut oil) of the three oils on D3. The readings on Day 2 (D2) readings were negative (Figures. 2 and 3). To rule out an irritant effect, patch testing was carried out with the above oils in 10 healthy volunteers who showed no untoward reaction.

Since she had generalized pruritus, the possibility of added type I hypersensitivity was considered and prick testing with the oils was carried out with the oils “as is” and histamine and saline as positive and negative controls respectively. She showed a positive reaction at the prick tested site to Dhanwantharam thailam and Eladi coconut oil at 30 minutes (Figure 4). The Murivenna tested site was negative. Table 1 lists the reactions seen at the prick tested sites.

She was advised to continue the massage aromatherapy with Murivenna only. She has no further complaints.

Table 1. Maximum Wheal Diameters at the Prick Tested Sites at 15 and 30 Minutes
Test substance15 min (mm)30 min (mm)
Dhanwantharam thailam66
Eladi coconut oil4.55
Murivenna44
Saline31
Histamine95
Table 2. Ingredients of Dhanwantharam Thailam
Sida retusa
Gmelina arborea roxb
Aegle marmelos linn. Corr
Euphorbia dracunculoides
Oroxylum indicum vent.
Desmodium gangeticum
Pseudarthria viscida w&a
Solanum indicum linn.
Solannum melongena linn.
Tribulus terrestris
Hordeum vulgare linn
Zizyphus mauritiana lam
Vigna unquiculata
Polygonatum verticillatum
Cedrus deodara
Azadirachta inaica a.juss.
Lilium polyphyllum
Inthuppu
Trigonella foenum graecum
Kanmadham
Acorus calamus
Aquilariaagallocha roxb
Boerhaavia diffusa linn
Withania somnifera dunal
Asparagus recemosus wild
Cassia angustifolia
Glyeyrrhiza glabra
Terminalia chebula
Emblica officinalis
Terntinalia belerica
Santalum album lin
Hemidesmus indicus
Saussuorea lappa
Valeriana wallichii.
Malaxis acuminata
Narumpasa
Anethum sowa roxd
Vigna radiate

Vigna unguiculata

Elettaria cardamomum

Cinnamomum zeylanicum
Cinnamomum verum
Black sesame oil
Milk
Table 3. Ingredients of Murivenna
Aloe vera
Piper betle
Moringa oleifera
Erythrina indica
Pongamia glabra
Allium cepa
Borreria hispida
Asparagus recemosus
Cocos nucifera
Oryza sativa
Table 4. Ingredients of Eladi Coconut Oil
Chittelam
Amomum subulatum roxb
Boswellia serrata
Saussuorea lappa
Callicarpa macrophylla vahl
Nardostachys jatamamsi
Plectranthus vettiveroide
Nanmukhapullu
Chonakapullu
Hedychium spicatum ham.
Cinnamomum zeylanicum blume
Cinnamomum verum
Valeriana wallichii dc.
Taxus baccata linn
Myristica fragrans houtt.
Narumpasa
Muthuchippi
Pulichuvadi
Cedrus deodara
Aquilariaagallocha roxb
Thiruvattapasa
Crocus sativus linn
Perumchandakizhangu
Commiphora mukul
Sambhrani
Acacia catechu
Celastrus paniculatus willd
Mesua ferrea linn
Coconut oil

Discussion

Daily Massage aromatherapy (“abhyanga”) with oils is a popular method of treatment of joint and muscle pain.1 The base oil used traditionally for “abhyanga” is sesame oil. Sesame oil comprises 40% linoleic acid and has antibacterial and anti inflammatory actions.2 Ayurvedic oil is made by cooking Ayurvedic plants in one of the base oils like sesame oil or coconut oil.

Dhanwantharam thailam named after the patron deity of Ayurveda is the most popular massage oil and found to be useful in rheumatic and neurological disease. The base oil is sesame oil. The ingredients of this massage oil are listed in Table 2.3

Murivenna is a medicated oil also used in musculoskeletal pain in which the base oil is coconut oil.4 The ingredients are listed in Table 3.

Eladi coconut oil which contains a variety of herbal essences in coconut oil is considered to be a “safe” massage oil for routine aromatherapy for adults and children. The ingredients are listed in Table 4.4

Adverse reactions to topical and systemic Ayurvedic medications are observed but have not been properly documented or reported. Allergic contact dermatitis to Valiyanarayana thailam was the first reported case to ayurvedic oil.5 This patient showed type IV hypersensitivity to the ayurvedic oils as evidenced by a positive patch test. In addition she also tested positive to prick testing with two of the oils, indicating added type I hypersensitivity.

Massage aromatherapy, the essence of ayurvedic therapy, dates back about 3500 to 5000 years which is one of the oldest systems of medicine that has with stood the test of time. Modern Ayurveda is practiced widely in the United States, India, Europe and Asia and alleviates chronic pain in millions of sufferers. The holistic approach addressing the body, mind and spirit is extremely popular in this subset of patients and finds widespread use in ayurvedic spa centres. Thus it becomes more important to recognize that the seemingly “safe” herbal remedy can also cause an adverse reaction. It would be wise to recommend patch testing and prick testing with the constituent oils to detect sensitization and recommend the oils which tested negative for massage aromatherapy.

References

  1. Lawrence, F-Aromatic Indian Head Massage (2004). NAHA Aromatherapy Journal Issue 13.2.
  2. Sharma H and Clark C - Contemporary Ayurveda (1988) Churchill Livingstone.
  3. http://www.chamakkattherbal.com/medicated-oil. htm. [Last accessed on 2012 Jul 23].
  4. http://www.kairaliproducts.com/murivenna.html. [Last accessed on 2012 Jul 23].
  5. Lakshmi C, Srinivas CR. Allergic contact dermatitis to Valiyanarayana thailam: An Ayurvedic oil presenting as exfoliative dermatitis. Contact Dermatitis 2009;61:297-8.
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