Paraphenylenediamine Hair Dye Poisoning
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Direct answer
Paraphenylenediamine hair dye poisoning follows ingestion of the permanent black hair dye containing paraphenylenediamine, an aromatic amine whose oxidised metabolites are toxic. In India the dye is known locally as kala pathar and is taken mostly in deliberate self-poisoning. The classic picture is rapidly progressing cervicofacial oedema that threatens the airway, followed by rhabdomyolysis and acute kidney injury.
What you must remember
- Source: paraphenylenediamine, or PPD, is the aromatic amine in permanent black hair dyes, and ingestion is usually deliberate.
- Cervicofacial oedema: angioedema of the face, neck and tongue that can progress quickly and threaten the upper airway.
- Rhabdomyolysis: muscle injury with high creatine kinase and myoglobinuria, which adds to renal damage.
- Renal failure: acute kidney injury from pigment nephropathy and direct toxicity, with dialysis needed in refractory cases.
- Airway planning: early tracheostomy or intubation is favoured when oedema threatens the airway, because swelling progresses.
- Supportive care: intravenous fluids to maintain urine output and dilute myoglobin are central to management.
- No specific antidote: management is supportive, so airway, muscle and kidney care are the priorities.
- Immunosuppression: cyclophosphamide and corticosteroids have been used in case series, but the evidence is limited.
Managing the poisoning in stages
Paraphenylenediamine poisoning is managed by stages, with the airway and kidneys treated first. The steps below set out the usual order. Several steps run in parallel, because a patient may need an airway plan and dialysis at the same time.
- Assess the airway at once. Stridor, voice change or tongue swelling demand an airway plan before the oedema progresses.
- Secure the airway early. Intubation or tracheostomy is planned early, because the swelling can rise and make intubation difficult.
- Measure muscle and kidney markers. Creatine kinase, creatinine, potassium and urine colour identify rhabdomyolysis and kidney injury.
- Give supportive fluids. Intravenous fluids maintain urine output and dilute the myoglobin that injures the kidney.
- Start renal replacement if needed. Dialysis is started for refractory acidosis, hyperkalaemia or oliguria.
- Consider immunosuppression selectively. Cyclophosphamide with steroids has been used in case series, and it is decided case by case given the limited evidence.
Where the exam tries to catch you
Examiners test whether you recognise a multi-organ toxic syndrome rather than a simple allergic reaction, and whether you secure the airway in time.
- Trap: waiting for the swelling to settle before securing the airway Correct: cervicofacial oedema can progress rapidly, so the airway is secured early.
- Trap: treating the poisoning as a simple allergic reaction Correct: it causes multi-organ injury, including rhabdomyolysis and renal failure, that needs monitoring beyond the skin.
- Trap: searching for a specific antidote Correct: there is none, so management is supportive, with the airway and kidneys as priorities.
Frequently asked questions
What is the characteristic early feature of paraphenylenediamine hair dye poisoning?
Cervicofacial oedema is the characteristic early feature of paraphenylenediamine hair dye poisoning, and it can progress rapidly to threaten the airway. It is often followed by rhabdomyolysis and acute kidney injury.
Why does paraphenylenediamine poisoning cause acute kidney injury?
Paraphenylenediamine poisoning causes acute kidney injury through direct toxicity together with myoglobin pigment injury from rhabdomyolysis. Early intravenous fluids and dialysis for refractory cases form the core of renal support.
Is there a specific antidote for paraphenylenediamine poisoning?
There is no specific antidote for paraphenylenediamine poisoning, so management is supportive and focuses on the airway, muscle injury and kidneys. Immunosuppression and blood purification have been reported in case series, but the evidence is limited.
When is tracheostomy considered in paraphenylenediamine hair dye poisoning?
Tracheostomy is considered early when cervicofacial oedema threatens the upper airway, because the swelling can progress and make intubation difficult. Many centres favour an early airway plan, and the timing is guided by how quickly the oedema is advancing.
Which laboratory markers track rhabdomyolysis in this poisoning?
Serum creatine kinase and urine myoglobin track rhabdomyolysis in paraphenylenediamine poisoning, alongside creatinine and potassium for kidney function. A rising creatine kinase with myoglobinuria signals the need for more aggressive intravenous fluids.