Suicide is a growing public health and economic problem. The consumption of hair dye has emerged as a predominant cause of self-harm, especially in developing countries, due to its easy availability and low cost. Despite this growing trend, there is a lack of clinical knowledge regarding clinical manifestation, treatment, and prognosis, especially in rural parts of developing countries where pesticide poisonings are still dominant. The precise composition of hair dye varies widely depending on the brand and country of origin, making it challenging to pinpoint its exact clinical manifestation.

I am reporting a case of suicidal consumption of hair dye by a 36-year-old male from Tamil Nadu in southern India, and the protocol followed to prevent deterioration of the patient, ensuring a better long-term outcome.

In conclusion, this article supports the notion of preventive therapy rather than symptomatic therapy, as hair dye poisoning is a field that is less explored, especially in rural regions.

Hair dye poisoning, Toxicology, Forced alkaline diuresis, Gastric lavage, Renal function test, Acute renal failure (ARF), Rhabdomyolysis

Suicide is a preventable public health problem, but its ever-growing trend has been posing a great threat to the public and it also affects the respective family’s mental and economic state. It’s been estimated that there are more than 700,000 suicidal deaths every year, and for every single suicidal death, there are more than 20 more suicidal attempts [1]. It is among the top causes of mortality for people between the ages of 15 and 44, with women more likely than males to commit suicide [2]. Pesticides are the poison of choice in developing countries, but recently, there has been a change in this trend with the increase in the number of hair dye poisonings, especially in rural India.

The use of henna-containing hair dyes dates back to before 5000 years BC. Around 1856, a lab produced the first synthetic hair color, which has been used on a commercial basis for more than a century, mostly in the subcontinents of Africa and India [3,4]. The Para-phenylenediamine (PPD), a chemical present in the hair dye, reduces the amount of darkening agent required, reducing the production cost and increasing the profit margin as well as its toxicity.

Due to our innate need to look better, hair dye is a popular product that is regularly ingested by millions of people, unlike in industrialized nations where its manufacture is strictly regulated to include no more than 2% PPD (paraphenylenediamine) whereas such stringent laws don’t exist in India [3,4]. In India, hair dyes are made by an amalgam of compounds, each contributing to their toxicity, and since no antidote is present to combat their effects [3]. The severity of clinical manifestation and the patient’s progress mainly depend on two factors- the amount of hair dye consumed and the duration between consumption and seeking medical aid [1].

Here we describe the case of a 36-year-old male who was brought to the emergency department after consumption of hair dye “Super Vasmol 33.”

A 36-year-old male from Tamil Nadu in the southern part of India, working as a daily wage laborer with no significant medical history,y was brought to the casualty with an alleged history of consumption of hair dye, “Super Vasmol 33”, presenting with the chief complaint of vomiting. The patient was brought by his relatives within 30 minutes after the ingestion. On arrival, the patient was conscious, ill-looking, not dyspneic, and not tachypneic.

Investigation: Vitals were stable- blood pressure: 120/80mmhg, pulse rate:88/min, oxygen saturation- 98% under room air. All his laboratory findings, especially his RFT (Table 1) and urine output, were under normal limits.

Table 1: RFT remained the same throughout the hospital stay

Treatment: The patient was initially given gastric lavage and was later shifted to the intensive care unit (ICU) for 24 hours’ close monitoring. In the ICU, the patient’s urine output and saturation level were strictly monitored and were NPO (Nill Per Oral) for 24 hours. For the first 24 hours, renal function test (RFT) was taken every four hours and was later taken on each day to monitor his serum creatinine levels.

The patient was treated with IV ondansetron 8 mg BD, IV pantoprazole 40 mg OD for the first two days, along with forced alkaline diuresis as a preventive measure. He was administered 500 ml of 0.9% normal saline over one hour, followed by 400 ml of 5% dextrose with 100 ml of NaHCO₃ over one hour, followed finally by 500 ml of 0.9% normal saline with 10mEq of KCL over one hour.

Outcome: A total of six cycles were given, and the patient was advised to take plenty of oral fluids throughout his hospital stay. He was shifted to the general ward from the ICU after 24 hours once the RFT and urine output fell within normal limits. After one day in the hospital, he was instructed to start oral feedings again. Day seven saw the patient’s release from the hospital following psychiatric counseling about suicidal thoughts and strategies for preventing them.

“Super Vasmol 33” is an emulsion-based dye that also contains propylene glycol, resorcinol, and ethylene diamine tetraacetic acid (EDTA). It contains 4 gm of paraphenylenediamine (PPD). In India, the most popular hair coloring formulation is this hazardous mixture. Since there is no known antidote, each component adds to its own toxicity, making it crucial to offer extremely careful supportive care [5,6]. The main compound contributing to its toxicity is PPD. The most common clinical manifestations are acute renal failure (ARF), rhabdomyolysis, cervicofacial edema, and metabolic acidosis. In some cases, we also see myocarditis, hepatitis, methemoglobinemia, hemolysis, hemoglobinuria, convulsions, mucosal injury, and hypotension [1,2,3,4,5,6,7,8].

There are many mechanisms through which each compound of the hair dye contributes to different clinical manifestations. The primary cause of rhabdomyolysis is PPD, an aromatic amine [5]. The renal tubules are affected in three ways. Firstly, there is a direct toxic effect on the kidneys due to the aromatic structure of the substance, which allows for easy resorption and leads to increased concentration. This results in the deposition of myoglobin cast in the tubules. Secondly, the substance promotes the release and leakage of calcium ions from the smooth endoplasmic reticulum, causing irreversible changes in the musculature due to constant contraction. These factors contribute to the clinical presentation, which includes hemoglobinuria (presenting as chocolate brown colored urine), oliguria, Acute Renal Failure (ARF), metabolic acidosis, and hypovolemia [5,8].

Propylene glycol, yet another compound, is a highly nephrotoxic substance that causes metabolic acidosis as it creates a high anion gap and ARF [5]. A substance called resorcinol is a derivative of phenol. It is known to be highly corrosive and can denature proteins. When it comes into contact with mucous membranes, it can cause injury and lead to inflammatory cervicofacial edema. This inflammation can then result in respiratory difficulties and stridor. Some studies have even suggested that it may have neurotoxic effects, causing generalized tonic-clonic seizures [2,6,8].

The treatment is mostly supportive and symptomatic, as there is no specific antidote. The treatment paradigm involves tracheostomy for respiratory distress as well as renal replacement therapy in the case of ARF. Between patients are treated with gastric lavage, antihistamines, steroids, anti-emetics, proton pump inhibitors, and alkaline diuresis [1,2,3,4,5,6,7,8,9,10]. Forced alkaline diuresis is said to be a very efficient treatment as it is both preventive and curative, as it involves flushing out toxins by increasing the urine output. The rationale behind this is intravenous sodium bicarbonate increases the urinary pH making it alkaline as studies have shown that renal excretion is better in an alkaline medium (63 ml/min at pH 8.3) than in acidic conditions (0.14 ml/min at pH 5.1) for an increase in each unit of urinary pH that is directly proportional to five times the renal clearance. Administration of Sodium bicarbonate increases urinary outflow by 4-6 ml/minute, hence increasing the excretion of renal toxic substances by increasing the glomerular filtration rate. As patients undergoing forced alkaline diuresis are more prone to hypokalemia, it should be administered along with potassium [1,9].

Globally, suicide rates have increased by 60% over the past 50 years, hence, it is very important to provide proper psychological support, as studies have shown future suicidal attempts are preventable with proper psychotherapy and counselling [11,12].

In this case, the diagnosis was made based on the history, and the prognosis was good due to timely intervention (reaching a tertiary care hospital within 30 minutes of consumption), especially gastric lavage, and the amount of hair dye consumed was less than 5ml [6]. Serum creatinine is the most effective indicator to assess kidney damage [4]. Therefore, the patient’s RFT was regularly monitored and was treated with forced alkaline diuresis. Thus, a major crisis was averted due to prompt diagnosis and management of the patient. It is very important to remember that the development of ARF in PPD intoxication does not occur in all patients, and it varies from 47.3% to 100% [5].

Understanding the impact of this toxin on individuals, especially those living in rural areas, is crucial. Additionally, it is imperative to implement stringent government regulations to control its production. It is important for healthcare workers to have a thorough understanding of the different treatment options that are available. By being knowledgeable about these options, they can ensure that patients receive timely and appropriate treatment, which can greatly improve their chances of a positive outcome.

The author would like to thank the patient for approving the publication of his case details.

No funding obtained.

Dr. Bhavatharini Sumugan
Department of Medicine
Dr. MGR Medical University, Chennai
Government Theni Medical College – Kanavillaku, Theni
Email: duraibhavatharini@gmail.com

The author contributed to the conceptualization, investigation, and data curation by acquiring and critically reviewing the selected articles and was involved in the writing – original draft preparation and writing – review & editing to refine the manuscript.

Institutional approval is not required to publish the case details.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

No conflict of interest

None

https://doi.org/10.63096/medtigo3062242

Sumugan B. Crisis Averted: An Unusual Presentation of Hair Dye Poisoning. medtigo J Med. 2024;2(3):e3062242.
doi: 10.63096/medtigo3062242 Crossref