# Immunoglobulin A vasculitis and pustular psoriasis precipitated by Tawon Liar: a case report

## TL;DR

A man developed IgA vasculitis and worsened psoriasis after using an unregulated herbal supplement called Tawon Liar, which contained hidden medications.

## Contribution

This case report highlights the health risks of unregulated herbal supplements with undisclosed pharmaceutical ingredients.

## Key findings

- Tawon Liar contained meloxicam, ketorolac, and dexamethasone, which were not disclosed on the label.
- The patient's symptoms improved after discontinuing the supplement and using topical corticosteroids.
- The case emphasizes the need for better regulation and awareness of herbal supplement contents.

## Abstract

Unregulated herbal supplements can pose significant health risks due to undisclosed ingredients. Tawon Liar, an Indonesian product marketed as an "all-natural" remedy, claims to alleviate pain and boost immunity but lacks stringent regulatory oversight. We report a unique case of Tawon Liar-induced Immunoglobulin A (IgA) vasculitis and exacerbation of psoriasis, highlighting the potential dangers associated with misadvertised supplements.

A 53-year-old migrant worker from Mexico with a history of psoriasis and ankylosing spondylitis, effectively managed with adalimumab, presented with new-onset rashes on his extremities. Physical examination revealed palpable purpura on the lower legs and erythematous papules and plaques with pustules on the upper extremities. Dermoscopic analysis suggested IgA vasculitis and pustular psoriasis. The patient denied recent infections, new medications, or over-the-counter drug use. However, after thorough questioning, it was revealed that he had been intermittently ingesting Tawon Liar for chronic musculoskeletal pain. The supplement, obtained from a coworker, contained undisclosed ingredients including meloxicam, ketorolac, and dexamethasone. Laboratory tests ruled out renal involvement, and biopsies were not performed due to financial constraints. The patient was advised to discontinue Tawon Liar and was treated with topical corticosteroids, leading to substantial improvement and resolution of symptoms within one week.

This case underscores the potential dangers of herbal supplements containing hidden pharmacologic agents. It highlights the need for clinicians to diligently inquire about supplement use during patient evaluations, especially for vulnerable populations facing language barriers and limited access to healthcare. Public health authorities should enhance efforts to disseminate drug safety information across diverse languages and platforms to mitigate health risks associated with such products.