Hair dye poisoning

After insecticides and pesticides, hair dyes are now the most frequently used poisoning agent among people due to their low cost and easy availability. This write-up based on a case study from  Indian Journal of Forensic Medicine and Pathology by Bardale R. is an effort to bring more awareness about the diagnosis and treatment protocol to be followed when a patient presents with suspected hair dye poisoning.

Recently in the news, there was a case in which a 27-year old Indian male consumed hair dye and died due to cardiorespiratory arrest. This is not an isolated incident. Many such cases of accidental or intentional hair dye poisoning due to Paraphenylenediamine (PPD) have been reported all over India.

In easy terms, PPD is a coal tar derivative which on oxidation produces Bandrowski’s base. This base is allergic, mutagenic, and highly toxic, leading to dose-dependent systemic toxicity on ingestion.

A large dose will cause death within 6-24 hours of ingestion. The exact lethal dose of PPD in unknown, but it is estimated to be in the range of 7 to 10 g.

In India, PPD is the most commonly used toxic ingredient in hair dyes since decades. Moreover, PPD containing dyes are far cheaper than other hair dyes. Moreover, apart from PPD, the cheap hair dyes contain other toxic agents like naphthalene, toluene diamine, arsenic, bismuth, lead, pyrogallol, mercury, and silver.

Recognising a PPD poisoning

The initial symptoms of PPD poisoning usually develop within 6 hours of ingestion. It includes nausea, vomiting, abdominal pain, lacrimation, redness of eyes, swollen tongue, respiratory distress, and angioedema.

If left untreated, the condition may quickly worsen within 12 hours or sometimes over the next few days or week. If not managed on time, the patient might develop methemoglobinemia, rhabdomyolysis, acute tubular necrosis, arrhythmias, and intravascular haemolysis.

Diagnosing a case of PPD poisoning

There is no specific diagnostic test available for diagnosing PPD poisoning. An individual is suspected of PPD poisoning if the patient has angioedema with stridor, acute renal failure, and rhabdomyolysis. These three symptoms are considered as the characteristic triad for suspecting PPD poisoning. The physician should do a complete blood count, renal, and liver functions test for confirming the diagnosis.

Treatment and management protocol for PPD poisoning

There is no specific antidote available for PPD poisoning. Therefore, early recognition and interventions are very important in managing PPD poisoning cases. Respiratory and gastric distress, arrhythmias and kidney failure are the major challenges that present during treatment.

Gastric lavage with 2% sodium bicarbonate has been found to be effective in some PPD cases. Rinsing the patient’s mouth with water and administration of milk have also been found to be effective in managing gastric symptoms. Supportive treatments such as tracheotomy, haemodialysis, oxygen therapy, mechanical ventilation and calcium correction were found to effective in managing the complications of PPD poisoning cases.

However, activated charcoal should not be used as PPD has low absorbability owing to its low molecular weight and hydrophilic nature.

Off late, the number of PPD poisoning cases are increasing in India. Apart from intentional or accidental poisoning, long-term regular use of PPD containing hair dyes can also cause toxicity. While increasing awareness about PPD poisoning can decrease the frequency of accidental poisoning, the lack of a specific diagnostic test and antidote are major concerns that also need to be addressed because early identification and interventions can prevent a fatal outcome.

This article was originally published on 13.08.18

Reference: Bardale Rajesh et. al. “Fatal hair dye poisoning: A case report. Indian Journal of Forensic Medicine and Pathology Volume 3 Number 1, January – March 2010

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