Introduction
Fournier’s gangrene (FG) is a severe, life-threatening infection that typically affects the perineum, scrotum, and penis, characterized by obliterative endarteritis of subcutaneous arteries, leading to gangrene of the overlying skin [1]. FG is rare, with an estimated incidence of 1.6 per 100,000 men annually and an overall population incidence between 0.001% and 0.004%. It shows a strong male predominance (male-to-female ratio of approximately 10:1) [2], with an average age of onset around 50 years [3]. It may progress rapidly and extend beyond the perineum to involve adjacent structures, leading to life-threatening complications if not managed promptly. The cause of the condition is usually polymicrobial, with common pathogens including Escherichia coli and Bacteroides fragilis.
Clinically, FG presents with fever, scrotal edema, erythema, and crepitus. Because these symptoms can mimic less severe conditions such as cellulitis, early recognition of FG is challenging, and delayed diagnosis worsens prognosis [4]. A high index of suspicion is required, particularly in patients with risk factors such as diabetes or immunosuppression. Overcoming these diagnostic challenges requires a combination of clinical assessment and advanced tools. Useful diagnostic aids include elevated white blood cell count, C-reactive protein, and serum lactate levels. The Fournier’s Gangrene Severity Index (FGSI) helps assess disease severity and prognosis [5]. Timely and accurate diagnosis is critical, as delayed intervention increases the risk of sepsis and multi-organ failure.
The standard approach to treating FG relies on broad-spectrum antibiotics, surgical debridement, and tissue reconstruction [6]. These interventions are crucial for stabilizing critically ill patients, controlling infection, and preventing sepsis. Surgical debridement removes dead tissue, and antibiotics help suppress polymicrobial infection. However, the aggressive and rapidly spreading nature of FG often results in extensive tissue loss, slow healing, and the need for multiple interventions, which prolongs hospital stays and increase medical costs. Prolonged antibiotic use can also contribute to resistance [7], sometimes causing additional complications. Even with the best medical care, the risk of organ failure remains high, especially in severe cases [8]. Moreover, conventional treatments primarily focus on acute infection control and patient survival, often giving less emphasis to long-term wound healing, restoration of tissue vitality, immune resilience, and post-discharge quality of life.
In this context, Ayurveda offers valuable adjunctive principles that can complement modern medicine. Drawing from the descriptions of Kotha (gangrene), Visarpa (cellulitis), and Dushta Vrana (chronic infected wounds) in the Sushruta Samhita, Ayurvedic wound management (Vrana Chikitsa) emphasizes both Shodhana (purification) and Ropana (healing). These time-tested strategies not only target local wound care but also support systemic recovery, bridging the gaps left by conventional therapies [9]. There are 60 treatment methods (Shashtirupakrama) and numerous drugs and formulations described for wound management, covering both Shodhana (purification) and Ropana (healing), most of which remain relevant today.
An integrative approach combining Ayurvedic principles with modern medicine helps address issues such as delayed wound healing, infection recurrence, and inadequate systemic rehabilitation by enhancing wound healing, reducing complications, and supporting systemic recovery. Panchavalkala Kashaya Kshalana, a herbal decoction-based wound cleansing method, promotes effective debridement [10], minimizes bacterial load, and encourages granulation tissue formation, which can reduce the need for repeated surgical interventions. Jatyadi Taila, a medicated oil, supports faster wound healing and tissue regeneration [11], helping to prevent severe scarring and secondary infections.
Beyond localized wound care, systemic Ayurvedic support also plays a crucial role in recovery. Punarnava Mandura acts as a hematinic with anti-inflammatory actions [12], while Shigru Guggulu supports inflammatory control and tissue healing [13]. Amalaki Rasayana and Ashwagandha Churna boost immunity and aid both local wound and systemic recovery [14], while Guduchi helps vital organs from sepsis-related damage [15].
This case series presents eight cases of FG where an integrative treatment approach was applied, demonstrating faster healing, reduced complications, and improved patient outcomes. The results highlight the potential of combining Ayurvedic therapies with standard treatments to create a more effective, accessible, and sustainable management strategy for these life-threatening infections. Future research can explore additional Ayurvedic principles to further enhance treatment effectiveness and optimize long-term patient care.
Methods
Study design and setting
This is a single-center, retrospective case series involving eight male patients diagnosed and treated for FG between 2022 and 2024. All cases were managed initially with standard surgical and antibiotic protocols, followed by Ayurvedic interventions aimed at enhancing wound healing and systemic recovery. All Ayurvedic interventions used in this study are part of the officially recognized Indian Systems of Medicine (AYUSH), which are widely practiced in India under government regulation. These were prescribed by licensed practitioners, and all patients received them as part of standard clinical care in our hospital. Ethical approval was waived in accordance with the guidelines of the Institutional Ethics Committee of the All India Institute of Ayurveda. Informed consent was obtained from all participants, including permission to use and publish clinical images. Given its retrospective design, small sample size, and absence of a control group, the study was not intended to establish causality but rather to share clinical experience and generate hypotheses for future research.
Diagnostic criteria and initial management
The diagnosis of FG was established based on clinical features, laboratory investigations, and assessment through the FGSI. After obtaining informed consent, treatment was implemented. The initial phase of management focused on infection control and stabilization of hematological parameters through surgical debridement, broad-spectrum antibiotics, and supportive care.
Integrative Ayurvedic management
Ayurvedic management was initiated after patient stabilization. Local wound care involved cleansing with Panchavalkala Kashaya Kshalana and topical application of Jatyadi Taila. Systemic Ayurvedic support included the oral administration of Punarnava Mandura (500 mg twice daily), Shigru Guggulu (500 mg twice daily), Amalaki Rasayana (1 teaspoon twice daily), Ashwagandha Churna (1 teaspoon twice daily), and Giloyghana Vati (500 mg twice daily), each selected for their respective roles in promoting immunity, hematinic activity, and wound healing.
Statistical analysis
Statistical analysis was conducted to evaluate the effect of integrative treatment on key clinical parameters. The distribution of continuous data was tested for normality using the Shapiro–Wilk test. Depending on the results, either the paired t-test (for normally distributed variables) or the Wilcoxon signed-rank test (for non-parametric data) was applied to compare pre- and post-treatment values of FGSI scores, total leukocyte counts (TLC), and hemoglobin (Hb) levels. Statistical significance was defined at a threshold of P<0.05. All analyses were performed using SPSS version 25.0 (IBM Corp.).
Results
Patient demographics and clinical characteristics
The mean age of the eight patients in this study was 54.5 years (range, 41–72 years). The most prevalent comorbidities were diabetes mellitus (one patient), alcohol use (three patients), and tobacco use (one patient). With a range of 2 to 5, the mean FGSI score for all patients was 3.75. The mean TLC count at admission was 21,312 cells/mm3, indicating a severe infection. With a median duration of 10 days, the duration of symptoms prior to presentation varied from 3 to 25 days.
Timeline of clinical events and treatment response
A weekly summary of clinical progression, interventions, and changes in laboratory parameters across all eight patients is provided in Table 1, along with serial photographic documentation of wound healing and recovery in Fig. 1, illustrating a representative case demonstrating the impact of the standardized integrative treatment protocol. Clinical outcomes after treatment of FG were assessed regarding wound healing, surgeries, and other laboratory parameters. Complete wound healing at a mean of 1.5 months occurred in all patients (100%) after treatment. Among them, five cases (62.5%) needed scrotoplasty, which involved reconstruction using available local scrotal skin and one case (12.5%) needed complex flap coverage together with scrotoplasty for reconstruction, in which a medial thigh advancement flap was used to reconstruct the extensive tissue defect along with scrotal restoration. Two cases (25%) healed by secondary intention after conservative treatment. Laboratory findings, evaluated after the initial stabilization with conventional treatment and during the course of Ayurvedic interventions, showed significant improvements. The TLC decreased from 21,312±3,684 cells/mm3 pre-treatment to 9,620±3,239 cells/mm3 post-treatment (P=0.01). The increase in Hb levels approached statistical significance (P=0.09) and may be clinically relevant in supporting systemic recovery (pre-treatment: 10.38±1.49 g/dL, post-treatment: 11.96±1.87 g/dL). The FGSI score decreased very significantly, falling from 3.75±0.70 pre-treatment to 0.00±0.00 post-treatment (P<0.001). Interestingly, there was no relapse at the 6-month follow-up (0/8 patients).
Initial stabilization with surgical debridement and antibiotics led to partial improvement, whereas subsequent Ayurvedic therapy coincided with sustained normalization of TLC and upward Hb trends during the recovery phase. Overall, these findings indicate that after initial conventional stabilization, the integrative protocol incorporating Ayurvedic management was resulted in promoting wound healing, enhancing systemic parameters, and preventing recurrence.
Discussion
FG is a type of polymicrobial necrotizing fasciitis that affects the perineum, perianal area, and external genitalia. It progresses quickly and can be fatal. Despite prompt surgical intervention and broad-spectrum antibiotic therapy, it is marked by tissue destruction, a systemic inflammatory response, and significant mortality rates [16]. Clinical results are frequently less than ideal, despite the fact that traditional management—which includes intensive supportive care, empirical antibiotic regimens, and rapid surgical debridement—remains the cornerstone of treatment [17].
In this single-center retrospective case series of eight patients, all achieved complete wound healing and survival, with no recurrence at 6-month follow-up. While these outcomes are noteworthy, they must be interpreted with caution. The results may largely reflect the effect of timely surgical and antibiotic therapy, while the contribution of Ayurvedic interventions should be regarded as adjunctive and hypothesis-generating rather than conclusive.
All patients underwent urgent surgical debridement as the initial and essential step. Subsequent reconstructive choices depended on the extent of tissue loss and the condition of surrounding structures. Patients with limited superficial defects were managed conservatively or allowed to heal by secondary intention. Those with extensive scrotal tissue loss underwent scrotoplasty (five patients), and one patient with wider tissue destruction required complex flap reconstruction in addition to scrotoplasty. These decisions were guided by the viability of residual tissue, degree of exposure of testes or perineal structures, and overall stability of the patient. Thus, while the Ayurvedic protocol was uniformly applied across cases, the surgical management varied according to individual clinical needs, underscoring the importance of tailoring reconstructive decisions to defect size and severity of infection.
According to Ayurveda, the clinical picture of FG is similar to that of illnesses such Dushta Vrana, which is a persistent infected lesion with systemic signs, Visarpa (cellulitis), and Kotha (gangrene). Ayurvedic management of such complex pathologies follows a multi-dimensional strategy involving Chedana (surgical debridement), local wound management (Vrana Shodhana and Vrana Ropana) [18], and systemic rejuvenation via Rasayana therapy. However, Ayurvedic treatments must be used sparingly and at the right moment for the disease’s clinical course.
Local wound care involved Panchavalkala Kashaya irrigation, a polyherbal decoction with astringent, anti-inflammatory, and antimicrobial effects [19]. Once wounds were clean and granulating, Jatyadi Taila, a medicated oil with analgesic (Vedanasthapana), cleansing (Shodhana), and healing (Ropana) properties, was applied to promote granulation and epithelialization [20].
Systemic Rasayana support with formulations such as Amalaki Rasayana, Ashwagandha Churna, Shigru Guggulu, Giloy, and Punarnava Mandura was incorporated to enhance immunity, promote tissue repair, and support recovery in debilitated patients. These classical preparations are traditionally described to strengthen systemic resilience and may have contributed to improved wound healing and reduced postoperative morbidity; however, their specific role in FG remains to be elucidated through controlled studies [21-25].
Our integrative treatment approach, combining conventional surgical and antibiotic, Ayurvedic interventions and suturing resulted in complete cure and healing of life-threating FG. However, we acknowledge that this study has important limitations. As an exploratory study, this single-center retrospective case series involving only eight patients is limited in its generalizability. The absence of a control group makes it difficult to determine whether the favorable outcomes observed were due to the integrative approach or could have been achieved with conventional surgical and antibiotic treatment alone. Variability in patient presentations and surgical reconstructions may also have influenced results. Therefore, the contribution of Ayurvedic therapies should be interpreted as a possible adjunctive benefit rather than a proven determinant of outcome. Future research should focus on larger, prospective, multicenter trials to validate the efficacy of combining Ayurvedic and conventional therapies for FG, standardize integrative protocols, and investigate the mechanisms through which Ayurvedic interventions may support immune response and wound healing.
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