A Case Study of Furunculosis following an Ayurvedic Oil Massage, Sudation Therapy, and Lessons to Learn

India has a long history of using sudation therapy and oil massage as Ayurvedic treatments. However, nothing is known about its side effects, and just two studies have identified side effects as cutaneous adverse drug reactions brought on by Ayurvedic oil massage. We are presenting the example of a 72-year-old adult man who visited our hospital and had his right knee massaged with Nirgudi oil followed by sudation therapy. Erythema, papules, itchiness, and scorching pain were some of his symptoms. However, these sensations only partially abated once we quit sudation therapy. Our investigation demonstrates that a Nirgudi oil massage or sudation causes the skin reaction associated with furunculosis. This case report illustrates the necessity of being aware of Panchakarma-related consequences and suggests that medical practitioners, patients, and product makers take into account the likelihood of such a reaction following Nirgudi oil massage and sudation therapy as a precaution.


Introduction
Massage and sudation therapy are popular treatments in Ayurveda and other traditional therapies for various disorders like arthritis, muscle pain, body aches, skin diseases, and even for health [1].Ayurveda recommends massage with specifc Ayurvedic medicated oils prepared from various herbs.Te Ayurvedic physician chooses the medicated oil as per the disease conditions.Te Ayurvedic oil massage is followed mainly by sudation therapy.Te method and the drugs for the sudation therapy are also disease specifc.
Nirgudi oil is an Ayurvedic medicated oil used frequently for massage for joint disorders.It is prepared from the herb Nirgudi (Vitex negundo).It is a herb found almost all over India and is efcacious in arthritis, gout, and other joint pains [2].Nirgudi oil massage and sudation therapy are believed to be safe practices.
Furunculosis is a common skin and soft tissue infection that can lead to local or systemic complications rarely.Teir early recognition and management are very important to avoid further complications.It is a primary infection of hair follicles leading to abscess [3].It is an erythematous, tender, and frm eruption like a carbuncle.Te purulent material generally comes out of a furuncle.It can occur anywhere on the body but tends to appear on the body areas exposed to friction.Mostly S. aureus is the pathogen causing furunculosis.Eventually, a furuncle will open through the skin spontaneously or after incision.It appears over the hair-bearing skin and is unrelated to trauma or foreign body [3].Poor personal hygiene is a contributing factor to the development of furunculosis [4].
Previously, only two cases of Panchakarma complications have been reported as Cutaneous Adverse Drug Reactions (CADR) due to Ayurvedic oil massage [5,6].
Wertman et al. reported furunculosis due to a pedicure footbath at a North Carolina nail salon [7].
Terefore, we report furunculosis, possibly due to the massage with an Ayurvedic medicated oil, "NirgudiTaila," and sudation therapy.In this case study, a 72-year-old male got furunculosis over his right knee joint following a local massage and sudation therapy at our hospital.Te takeaway message is to improve hygienic conditions in the Panchakarma theatres and ensure a proper history of allergy before performing Panchakarma procedures.

Symptoms and Diagnosis.
A 72-year-old man presented on 13 th April 2022 for low backache, right knee joint pain, and occasional body ache for two years.He was a farmer from a nearby village.Te low back pain was moderate after overactivity and strain over the low back region.In addition, he experienced mild body aches in the whole body and mild to moderate pain in the right knee joint.A local physician examined and treated him with modern medicines; however, he wanted Ayurvedic treatment.So, he visited our hospital.
Tere was no history of injury or medication except the medication for these complaints.Te patient was nondiabetic and nonhypertensive.Tere was no history of psychiatric, cardiac, nervous, or urinary disorders.Te individual has no known history of allergies, including allergies to medications, food, or pollen (Table 1).
Te examination of knee joints revealed the presence of crepitus and no edema over any of the knee joints.Any scar was absent over the knee joints.Te knee joint pain was seen while sitting and lifting from the chair and was absent during walking.Te general examination revealed no specifc fndings of the disease.
As per Ayurveda, this condition was diagnosed as "Janusandhigata Vata with Katigraha."Te following Samprapti Ghataka (Pathogenic factors) were seen.Dosha-Vata dominant Dhatu, Asthi-Majja, Mamsa Marga-Madhyama Avastha-Nirama 2.2.Management.We recommended local oil massage with Nirgudi oil over the right knee joint and plain sesame oil over the lower back, followed by sudation and oral Ayurvedic medicines (Table 2).Te patient's written consent was obtained for an oil massage and sudation.

An Incidence of a Cutaneous Adverse Drug Reaction (ADR).
After massaging with Nirgudi oil over the right knee joint and sudation therapy, the red papules appeared approximately within an hour, with mild itching and redness over the knee joint.Te symptoms gradually increased, with an increase in redness and burning pain (Figures 1 and 2), and after three days of consecutive massage and sudation, the burning pain and itching were unbearable; so, suspecting an allergy, we stopped the oil massage and sudation.We added an Ayurvedic medicine for allergies.
Te patient was discharged and given the same medications at home.He was advised to visit after seven days but avoided it.At frst, we suspected that it was an allergic reaction, but as it began to exhibit suppuration, it became clear that it was a case of furunculosis.

Preparation of the Medicated Oil.
Our staf collected the raw material needed to prepare the medicated oil in the pharmacy attached to our hospital.It is a usual practice in our hospital that we prepare the required Ayurvedic medicated oils in the pharmacy attached to our hospital.

Sudation Terapy.
We advised Swedana (sudation therapy) to the whole body for multiple joint pain and restricted movements.Immediately after the massage, the patient was asked to sit inside the sudation box.Te sudation box is a specially made wooden box attached to a pressure cooker inside which Ayurvedic herbal decoction is boiled.Te endpoint of this procedure was perspiration all over the body.It took less than 10 minutes for this patient.

Assessment Parameters. Te patient's main concerns
were pain in their right knee joint and lower back, which were treated with Ayurvedic oil massage and sudation.However, after three consecutive days of massage, the patient experienced burning pain, eruption, and severe itching over the right knee joint.As a result, massage and sudation were stopped, and Ayurvedic medicines were prescribed to address a possible allergic reaction.Te patient requested to be discharged.
We used a self-reported visual analogue scale (VAS) for their right knee joint and lower back pain to assess the patient's pain levels.We compared the VAS score from the  frst day to the sixth day and measured the severity of itching using the VAS scale from the fourth day to the sixth day.Te VAS scale ranged from 0 to 10, with 10 indicating severe pain or itching and 0 indicating no pain or itching.

Observations
Results showed that on the frst day, the patient's right knee joint pain was at a level of 6, which increased to 7 on the sixth day.In contrast, the patient's lower back pain decreased from 5 on the frst day to 4 on the sixth day.Te VAS scale also showed a decrease in itching severity, dropping from 7 on the fourth day to 4 on the last day.

Discussion
Panchakarma therapies in Ayurveda are in more demand as Ayurveda gains popularity in India and worldwide.Panchakarma treatments can be used to treat illnesses and promote good health.Even though the term "Panchakarma" only refers to fve treatments, many allied procedures (about 25-30) have been carried out in the Panchakarma theatres.Among these, Panchakarma preoperatives include massage and sudation therapy.As a result, practically every patient receiving Panchakarma performs them.Tere is a lot of discussion about Panchakarma's benefcial efects.Panchakarma problems have not been documented, though.
Tree cases of furunculosis caused by M. bollettii or M. masiliense due to pedicure footbaths were reported by W. Rebecca and M. Melissa.All three patients had recently undergone pedicure footbaths at a nail parlor in North Carolina.Footbaths taken before pedicures were determined to be caused symptom of infection by the authors.In our scenario, the Panchakarma theatre can be a reservoir for an infection that causes furunculosis [7].
In a community in Alaska, L.G. Michael, M.J. Barbara, A.D. Elvin, and others reported a boil outbreak.An environmental culture evaluation and case-control research were conducted in this cohort study of a village.One family was interviewed from each of the 92 homes or 77 of them.Residents who did not have boils served as the control group.
Te study concluded that steam baths were linked to boil breakouts and recommended wearing a towel in a steam bath.A steam bath is performed during sudation therapy in the Panchakarma theatre.Te creation of steam using Ayurvedic concoctions is the only distinction [8].
Ayurvedic oil adverse medication efects on the skin have been documented [7] and verifed using patch tests.As a result, one of the difculties of Panchakarma that must be addressed is allergies.
Patients, therapists, and consultants who practice Ayurveda should be aware of any possible hazards associated with Panchakarma therapy.Several lessons came from this situation.First, we need to keep the Panchakarma theatre clean and hygienic.Before the operation, we must obtain a thorough history of any allergies to Ayurvedic oil.Tird, we must provide patients with information about the dangers and advantages of Panchakarma therapies and only administer them with their permission.Fourth, before beginning Panchakarma treatments, the written consent form needs to be modifed.

Conclusion
Tis case study highlights the signifcance of Panchakarmarelated consequences, which are uncommon and typically mild but can result in new diseases.To reduce the possibility of infection spreading through Panchakarma theatres, further cleanliness and hygiene should be kept.To preserve the doctor-patient relationship, it may be benefcial to adopt a positive mindset when dealing with potential complications of Panchakarma, such as furunculosis or an allergic reaction to Ayurvedic oils.In addition, it is important to educate the patient about these risks.