|Year : 2014 | Volume
| Issue : 2 | Page : 82-86
Clinical profile and mortality determinants in hair dye poisoning
Deepak Balasubramanian1, Saravanan Subramanian2, Kani Shanmugam2
1 School of Public Health, PGIMER, Chandigarh, India, India
2 Department of Medicine, Thoothukudi Government Medical College, Thoothukudi, Tamil Nadu, India
|Date of Web Publication||16-Mar-2015|
New No 8, Old No 43, Ganga Nagar 2nd Main Road, Kodambakkam, Chennai - 600 024, Tamil Nadu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: India has a high suicide rate, and a large proportion of these suicides occur through poisoning. Poisoning by hair dye has been increasing, and in some regions, constitutes a large proportion of the poisoning cases.
Aims: To determine the clinical and biochemical features of hair dye poisoning, and to identify factors affecting mortality among these cases of hair dye poisoning.
Subjects and Methods: A cross-sectional study conducted from April to December 2010 in Thoothukudi, Tamil Nadu, among 125 cases of hair dye poisoning. Cases with the prior history of cardiac/respiratory illness, seizure disorder, and those consuming a mixture of poisons were excluded from the study. A standardized questionnaire was administered. Biochemical and other investigations were carried out; and patient outcomes were documented.
Statistical Analysis Used: The results were compiled and analyzed using Statistical Package for the Social Sciences (version 20) software. Chi-square test, Mann-Whitney U-test, and Kruskal-Wallis test at 5% level of significance was used to analyze the data.
Results: Among the 125 cases, 68.8% were females, and the overall median age was 24 (20-30.5) years. The median time of presentation was 155 min (40-275), and the average amount of hair dye consumed was about 50.0 mls (25-55 mls). Almost 68.8% of the cases developed oropharyngeal edema, and among them, 57 (66.28%) had an emergency tracheostomy performed. About 27.2% of the patients died.
Conclusions: The time of presentation to the hospital is an important risk factor for developing oropharyngeal edema, which in turn determines the risk of mortality. Females, especially those in the younger age groups should be targeted for supportive and preventive strategies, so as to reduce the incidence of hair dye poisoning.
Keywords: Hair dye, India, mortality, poisoning
|How to cite this article:|
Balasubramanian D, Subramanian S, Shanmugam K. Clinical profile and mortality determinants in hair dye poisoning. Ann Nigerian Med 2014;8:82-6
|How to cite this URL:|
Balasubramanian D, Subramanian S, Shanmugam K. Clinical profile and mortality determinants in hair dye poisoning. Ann Nigerian Med [serial online] 2014 [cited 2021 May 6];8:82-6. Available from: https://www.anmjournal.com/text.asp?2014/8/2/82/153359
| Introduction|| |
The suicide death rates (11.2/100,000) in India are among the highest in the world, with the total number of suicide deaths in the year 2012 amounting to nearly 135,445.  The cumulative risk of dying before 80 years of age by suicide is high in South India, with males having a risk of 3.5% and females having a risk of 1.8%.  Poisoning accounts for about 29.5% of all suicide cases.  Number of cases of poisoning by hair dye has been rising over the past few decades, possibly due easier availability of the dye. In some centers, hair dye poisoning accounts for the largest share of the poisoning cases.  The areas where large numbers of cases are being reported include Jhansi (Uttar Pradesh),  Kanpur (Uttar Pradesh),  Nellore (Andhra Pradesh), Kadapa (Andhra Pradesh),  Tirupati (Andhra Pradesh)  and Thoothukudi (Tamil Nadu).  Large numbers of cases are also being reported from the Middle East, Egypt, Sudan, and Morocco. Apart from the morbidity, the mortality rates are also high, ranging from 6.8% to 22.48%. ,, Hence, this study was carried out to determine the clinical and biochemical features of hair dye poisoning, and to identify factors affecting mortality among these cases of hair dye poisoning.
| Subjects and Methods|| |
A cross-sectional study conducted in the Intensive Medical Care Unit of a Medical College Hospital in Thoothukudi, Tamil Nadu, from April to December 2010. Confirmed cases of hair dye poisoning who were admitted in the hospital were included in the study. Hair dye poisoning was defined as the presence of symptoms and signs suggestive of hair dye poisoning, the hair dye bottle bought along with the patient, or the presence of dark material on gastric lavage. Cases with the prior history of cardiac/respiratory illness, seizure disorder, and those consuming a mixture of poisons were excluded from the study. Ethical approval from the Institutional Ethical Committee of Thoothukudi Government Medical College was obtained prior to conducting the study. To calculate the sample size, the mortality from hair dye poisoning was assumed to be 10%, with a precision of 5%, and type 1 error of 5%, to arrive at a sample size estimate of 138. A written informed consent was taken from the patients or relatives, in cases where the patient was unable to provide consent. All the patients admitted during the study period, satisfied the inclusion criteria, and had given written informed consent were selected. We attained a sample size of 125 cases. Nearly, 11 cases (8.1%) presented after consuming a number of poisons (including hair dye) or were bought dead, and were excluded from the study. A standardized questionnaire administered to the patient/relatives was used to collect information on the background characteristics of the patients, amount of hair dye consumed, and time taken to reach the hospital [Appendix 1]. [Additional file 1] Each patient was followed up to the time of discharge. The clinical features, biochemical and other investigations done, along with the outcome of the patient were noted. The results were compiled and analyzed using Statistical Package for the Social Sciences (version 20, IBM Corp., Armonk, NY) software. Tests of normality (Shapiro-Wilk test) were applied prior to performing inferential statistics. Chi-square test, Mann-Whitney U-test, and Kruskal-Wallis test at 5% significance level were used; and 95% confidence intervals were considered for calculating probability.
| Results|| |
A total of 125 cases were studied. More than two-thirds of the cases were females, and overall median age was 24 years (20-30.5). Females were of a younger age than males (P = 0.001). The median time of presentation was 155 mins (40-275). Females presented later as compared to the males (P = 0.99), but this was not statistically significant. The average amount of hair dye consumed was 50.0 mls (25-55) [Table 1]. Almost 80% were alleged to have consumed only the hair dye, whereas 13.6% consumed it along with alcohol, while 6.4% consumed the dye with water. The cases consuming the dye with alcohol were older and mostly males [Table 2]. Nearly, 68.8% of the patients developed oropharyngeal edema [Figure 1], 61.4% had altered urine color, 56.8% had muscle tenderness, 6.4% had oliguria, 4.8% developed carpopedal spasms, and 2.4% required dialysis. A higher proportion of females (76.7%) developed edema, when compared to males (51.3%) (P = 0.007). Those developing edema presented late (185 min (60-292)), when compared to those not developing edema (60 min (35-220)) (P = 0.12), but this was not statistically significant The proportion of patients who developed edema was higher in those who consumed alcohol with hair dye, as compared to patients consuming hair dye alone or hair dye together with water (P < 0.001). The results of the biochemical investigations are given in [Table 3]. Almost 41.7% of the patients investigated showed hypocalcemia. Patients with edema had higher alanine aminotransferase (ALT) values than those without edema (P = 0.03). There was no significant difference in other biochemical parameters among those with edema and those without, and also among those who died and those who survived. Electrocardiogram (ECG) changes observed in 9.6% of patients ranged from bradycardia, T wave inversion, ST segment depression, bundle branch blocks, to ventricular tachycardia. Among the 86 cases developing edema, 57 (66.28%) underwent emergency tracheostomy, with a significant higher proportion of the females (72.7%) undergoing tracheostomy as compared to the males (45.0%) (P = 0.03). The treatments received by the patients included inhaled oxygen; intravenous steroids, anti-allergens for the edema, and forced alkaline diuresis cycles. All the patients were managed in the wards as high risk patients. They were provided psychiatric consultation and advised to have follow up visits to the psychiatric out-patient department on discharge.
|Figure 1: Photograph of the patient showing swollen, protruding tongue, severe oropharyngeal edema; with tracheotomy done and supplementary oxygen given through nasal prongs|
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|Table 2: Comparison of the characteristics of patients consuming hair dye with alcohol, water and hair dye only|
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Among the 125 cases, 34 (27.2%) died. The deaths were due to acute respiratory distress and cardiorespiratory arrest. The cases that died presented late (P = 0.08). On comparing the mortality rate among three groups: Group with no edema, group with edema but not undergoing tracheostomy, and the group having edema and undergoing tracheostomy, it was found that mortality rate was highest in the group which had edema and did not undergo tracheostomy, and lowest in the group without edema (P < 0.001). The time of presentation of this group was 220 min (110-293) as compared to 60 min (35-220) for cases with no edema, and 170 min (44-270) for cases that developed edema and underwent tracheostomy (P = 0.13). There was no significant difference in the amount of hair dye consumed in the three groups. The mortality in the subjects who consumed hair dye along with alcohol was lower (11.8%), when compared to subjects who consumed the hair dye alone or along with water [Table 2].
| Discussion|| |
Among the 125 cases, most were females, of young age, who presented late to the hospital. Nearly two-third developed oropharyngeal edema and among them, two-thirds underwent tracheostomy. Almost one-fourth of the cases died. Mortality was higher in the group that developed edema and did not undergo tracheostomy. Biochemical investigations could not be carried out in all the patients.
The main components of hair dye include paraphenylenediamine (PPD), ethyelene diamine tetra acetic acid, cetostearyl alcohol, propylene glycol, liquid paraffin, sodium laurylsulfate and resorcinol.  Poisoning with hair dye manifests as oropharyngeal edema, rhabdomyolysis, methemoglobinemia, acute renal failure, with a small proportion developing the myocarditis, hypocalcemic tetany, hepatitis, hypotension, convulsions, coma and sudden cardiac death. ,, As seen in other studies, a higher proportion of females ,, were seen, and the majority of the patients were of younger age groups. ,, The presentation of cases varied from 5.05 h ± 1.7 h to 8.9 h ± 10.9 h in other studies. ,, Although our cases presented earlier as compared to previous studies, females presented later. It was observed that most of the females consumed the hair dye while they were alone at home, and hence the delay in presentation, while the males consumed the hair dye in some public place. The amount of dye consumed was about 50 ml in our study, comparable to amounts reported by Kondle et al.  Oropharyngeal edema was the commonest symptom, as was observed in other studies.  Risk factors, for developing edema, include female sex and delayed presentation, as observed in our study. The reasons for a higher proportion of females developing oropharyngeal edema may be due to their late presentation, and probably from increased sensitivity arising from regularly application of hair dye to their hair. The proportion of patients with hypocalcaemia was comparable to what was observed in other studies, which was around 38.0%. , Our study observed that patients with edema had higher ALT values. A study by Prasad et al. observed a significant association between the amount of hair dye consumed and renal function parameters i.e. urea, creatinine, and serum potassium levels; however, no significant association was observed between the amount of hair dye consumed and serum levels of creatine phosphokinase, aspartate aminotransferase (AST), ALT, Lactate dehydrogenase (LDH).  ECG changes were observed in a small proportion (9.6%), as compared to 15.0% and 23.3% observed in other studies. , Nearly 57 (66.3%) of the 86 cases developing edema underwent emergency tracheostomy. The decision to perform tracheostomy was taken by the ear, nose and throat specialist, and this was based on the time of presentation of the patient to the hospital, severity of the edema, rate of progression of edema, and respiratory distress. A mortality rate of 27.2% was observed, which is slightly higher when compared to other previous large studies, where mortality rates ranged from 5.0% to 22.48%. ,,,, The mortality rate was highest in the group that had edema and did not undergo a tracheostomy. This may be due to the delayed presentation of those cases, thus, resulting in delays in performing tracheostomy. Those presenting late to the hospital had a greater risk of developing oropharyngeal edema, and this increased the mortality risk among this group of patients. The reasons for reduced incidence of edema and mortality in the group consuming hair dye along with alcohol may be due to: PPD being soluble in ethanol, which dilutes the dye enhancing urinary clearance,  reduced susceptibility and sensitivity of the male gender to PPD (a higher proportion of the females developed oropharyngeal edema in the study), and earlier presentation compared to subjects who consumed hair dye alone or with water.
Delay in presentation to the hospital increases the risk of oropharyngeal edema, which ultimately increases the mortality risk for the patient. Females, especially those in younger age groups should be targeted for supportive strategies, to reduce the incidence of hair dye poisoning. History regarding consumption of the hair dye along with any other substance (especially alcohol) should be elicited. To reduce the incidence of hair dye poisoning, domestic use of PPD based hair dyes should be banned, and measures taken to regulate the sale of the dye. Safer and harmless alternatives should be made available. High prevalence of psychiatric disorders has been found in suicide attempters.  Measures to address the underlying factors behind hair dye poisoning should be taken up, and this should include toll-free helplines manned by health officials, and in cooperating stress management techniques into school and college curricula. Furthermore, programs in schools and colleges to screen for psychiatric illness should be included into the national health policy. Further research to determine predictors of developing edema and mortality; and to understand the interaction between alcohol and hair dye are required.
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[Table 1], [Table 2], [Table 3]