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

Abstract

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

What was known?

Ayurvedic medication is widely considered to be of herbal origin and thus safe. Although adverse reactions are occasionally observed, there is no accurate documentation. An earlier report published in Contact Dermatitis documents allergic contact dermatitis to Valiya narayana thailam.

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.

Figure 1.

Flexural accentuation of eczema

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 aluminium 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.

Figure 2.

Negative patch test reading on D2

Figure 3.

D3 reading showing + reaction at Dhanwantharam thailam and Eladi coconut oil tested site

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.

Figure 4.

Positive prick test to Dhanwantharam thailam and Eladi coconut oil

Table 1.

Maximum wheal diameters at the prick tested sites at 15 and 30 minutes

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

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]

Table 2.

Ingredients of Dhanwantharam thailam

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.

Table 3.

Ingredients of Murivenna

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]

Table 4.

Ingredients of Eladi coconut oil

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 withstood 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.

What is new?

Ayurvedic medication is very popular in the treatment of painful joint and muscle ailments. Although reasonably effective in alleviating pain, the misconception that is herbal and absolutely safe should be corrected as any topical medication on repeated application as in aromatherapy may predispose the predisposed individual to contact allergy (type IV hypersensitivity) or type I hypersensitivity.