What is Paraphenylenediamine Toxicity (Henna Body Art)?

Paraphenylenediamine is a substance found in Kala Pathar, also known as “black stone”. When pure, it looks like a white crystal that turns brown or dark brown when exposed to air. Though it’s mainly produced in Japan, Germany, and the UK, it’s mostly used for dyeing in certain parts of East Africa, Middle East, and the Indian subcontinent. In these areas, it’s often used in traditional customs like making henna. However, it’s becoming a common household poison and method for suicide in these regions, probably because it’s cheap, easy to get, and very toxic.

But like all harmful substances, how harmful it is and what symptoms it causes can change depending on how it’s taken in, how much is used, and how long the exposure lasts. Most literature focuses on the two most common ways it’s used – through the skin and by swallowing. When used on the skin, it can cause different types of skin problems, depending on the severity. But when swallowed – which usually happens by accident or with suicidal intentions, especially in high amounts – it can cause severe damage to multiple organs.

What Causes Paraphenylenediamine Toxicity (Henna Body Art)?

Paraphenylenediamine is a substance often used as an additive in various industries like cosmetics, textiles, and film to dye products. However, you’re most likely to encounter it in henna, a temporary skin dye common in many parts of the world.

Derived from the henna plant, which produces a potent red-orange dye, henna has been used for centuries in Asia, the Middle East, Eastern Africa, and Australia. Henna is often crushed into a paste and applied to skin, fingernails, and hair to create decorative patterns for festive or cultural events.

Recently, some people have started adding paraphenylenediamine to henna to create “black henna”. This change makes the henna darker, uses less paste, and speeds up the coloring process. Unfortunately, many places do not regulate this addition to the henna paste.

Paraphenylenediamine is also used in hair dyes as a dark pigment. By varying the concentration of paraphenylenediamine and using an oxidizing agent like hydrogen peroxide, hair dyes can achieve a range of colors from golden blonde to jet black. Most developed countries control the amount of paraphenylenediamine in hair dye, typically allowing a maximum of 2% in a 100 mL solution to prevent toxicity. However, in some underdeveloped and developing countries, these concentrations may be as high as 90% due to a lack of regulation.

In some places, particularly in underdeveloped and developing countries, there has been an increase in people consuming products containing paraphenylenediamine, such as black henna or hair dye, for self-harm. This trend has been documented in multiple case reports and reviews, especially in countries like Egypt, India, Morocco, Pakistan, Sudan, and Tunisia. In the 1990s, paraphenylenediamine toxicity was reported as the leading cause of poisoning in Morocco. This issue seems to be related to the cheap cost, easy accessibility, and high toxicity of products with paraphenylenediamine.

Risk Factors and Frequency for Paraphenylenediamine Toxicity (Henna Body Art)

Paraphenylenediamine toxicity is a worldwide problem that typically affects individuals between the ages of 21 and 30. It is mostly seen in females. The most common way people are exposed to it is through swallowing it. Those at higher risk include individuals with low socioeconomic status, those living in rural areas, people experiencing personal and social conflicts, and those without social support.

In the United States, information about the usage and sources of paraphenylenediamine is provided by the Environmental Protection Agency. However, there isn’t much data available regarding how often paraphenylenediamine toxicity occurs in the Western world, including the United States specifically.

Despite its high incidence, information on paraphenylenediamine toxicity in children is also limited, particularly in regions where it is commonly used. As in adults, it primarily affects females among the pediatric population. The most common reason for toxicity in children is accidental swallowing or, particularly among teenagers, intentional swallowing. Non-accidental injury should also be considered in children as there have been cases where paraphenylenediamine was used with harmful intent. On average, affected children are around 13.8 years old, but cases have been reported in children from 2 to 18 years old.

Signs and Symptoms of Paraphenylenediamine Toxicity (Henna Body Art)

Diagnosing paraphenylenediamine toxicity—a rare occurrence in Western countries—requires a detailed medical history and careful examination. Doctors must find out when the person was exposed, how they were exposed (for example, if they ate the product), how much they consumed, and if they also consumed anything else. Information about packaging can help identify the exact substance and its concentration. If the person took the substance intentionally—such as an attempt to harm themselves—a mental health history, information from others, and information about the event can be useful. It’s also important to find out the precise product the person was exposed to because it affects the concentration of the paraphenylenediamine, but this might be hard.

Physical examination findings can vary as there are no giveaway signs of paraphenylenediamine toxicity. Common symptoms might include swelling of the face and neck, swelling of the upper airway, widespread muscle pain that can indicate a condition called rhabdomyolysis, and changes in kidney function like diminished or lack of urine output or dark brown urine. People with toxicity only on their skin may have inflammation at the site of exposure—typically the scalp or hairline—and possibly a skin infection called cellulitis.

While evaluating a person for paraphenylenediamine toxicity, health officials will check for important symptoms related to various body systems:

Neurologic: Coma and seizures
Cardiac: Changes in heart rhythm, including both fast and slow heart rate, irregular heart rhythms, and inflammation of the heart muscles
Respiratory: Breathing difficulties related to swelling in the throat and face
Gastrointestinal: Difficulty swallowing, belly pain, and liver injury
Renal: Dark brown urine or changes in urine output
Musculoskeletal: Pain, stiffness of limbs, tissue breakdown in muscles
Integumentary (Skin): Itching, redness, blisters in areas exposed to the chemical, often involving the scalp, face, hands, and legs

Testing for Paraphenylenediamine Toxicity (Henna Body Art)

If your doctor thinks you might have been poisoned by paraphenylenediamine, a chemical commonly found in hair dye and henna tattoos, they will first look for any immediate life-threatening issues. They’ll check for problems like difficulty breathing, problems with your heart and circulatory system, or signs of a severe allergic reaction. They can use a variety of tests to do this, including monitoring your heart rhythm, taking an X-ray of your chest, and analyzing a sample of your blood.

Beyond these immediate concerns, your doctor will also be looking to rule out other potential causes for your symptoms. Because there’s no specific test for paraphenylenediamine poisoning, doctors have to rely on a combination of tests based on your symptoms and their clinical judgement.

For example, if you’ve ingested the chemical, tests might show elevated levels of certain enzymes in your blood, indicating damage to your muscles, liver, or kidneys. In particular, serum creatinine is often used to assess kidney function, with increased levels potentially pointing to kidney trouble. Other tests might show changes in your blood chemistry, like a high white blood cell count, imbalanced acid levels, low calcium, or high phosphate levels.

If you’ve only had skin contact with paraphenylenediamine and aren’t showing signs of a systemic reaction, the focus will likely shift to determining whether you’re allergic to it. You might undergo a patch test, where a small amount of paraphenylenediamine is applied to a patch on your skin. If you have an allergic reaction to the patch after two to four days, it confirms an allergy to this substance. There are alternatives for those at high risk for severe reactions that require less exposure to the chemical. Additionally, there’s another test that involves checking your white blood cells’ response to paraphenylenediamine, but it’s not as commonly used. Allergy tests are usually carried out in outpatient settings.

Treatment Options for Paraphenylenediamine Toxicity (Henna Body Art)

There isn’t a specific cure or treatment for paraphenylenediamine poisoning. The main way to handle such poisonings is to quickly recognize what’s happened and provide supportive care. This might include making sure the patient can breathe properly, balancing their electrolytes and body’s acid levels, and providing other supportive measures, especially in serious cases.

If someone has been poisoned, it’s very important to remove any visible remnants of the toxin once they arrive at the hospital. Activated charcoal, which can be used to treat some types of poisoning, hasn’t been specifically studied for use in paraphenylenediamine poisoning. While its properties indicate that it could be useful, there’s also a concern that it might actually be harmful because of the nature of paraphenylenediamine.

Using something called gastric lavage to cleanse the body of the toxin is also controversial, because it could block the airway and cause serious breathing problems. It could also potentially cause additional injury to the esophagus, because paraphenylenediamine is corrosive and caustic.

Paraphenylenediamine can also cause severe swelling in the airways, leading to choking or difficulty breathing, which are often the main causes of death from paraphenylenediamine. It’s very important to manage the patient’s airway in order to prevent these complications. However, because the swelling makes it difficult or sometimes even impossible to insert a breathing tube in the usual way, other methods are often used. For example, a breathing tube might be inserted directly into the windpipe through the neck (a procedure known as a tracheostomy). Greater research is needed to determine whether other techniques or equipment may also be beneficial in securing the airway.

Paraphenylenediamine can also cause severe allergic reactions or anaphylaxis. In these cases, corticosteroids and antihistamines are typically part of the initial treatment plan. For anaphylaxis, a shot of epinephrine (also known as adrenaline) should be given and the condition should be managed according to local anaphylaxis protocols.

Finally, a common complication of paraphenylenediamine poisoning is rhabdomyolysis, a condition where muscle tissue breaks down and can cause kidney damage. To prevent this, it’s essential to avoid dehydration and low oxygen levels in these patients. Administering ample amounts of isotonic fluids early can help prevent kidney damage due to rhabdomyolysis. Kidney dialysis, where a machine is used to filter the blood when the kidneys can’t, has also been reported to aid in recovery in severe cases.

If someone shows symptoms of paraphenylenediamine (PPD) toxicity, it can be challenging to determine the cause because the signs can be quite general. Key indicators of this condition are muscle tissue breakdown (rhabdomyolysis), swelling of the face and neck (cervicofacial angioedema), and sudden kidney failure (acute kidney injury). However, there are several other conditions and situations that can cause similar symptoms, including:

Drug misuse, for example synthetic cannabinoids, amphetamines, cocaine, and heroin
Bad reactions to certain medications such as cyclosporine, vancomycin, and aminoglycosides, which can harm the kidneys
Alcohol toxicity
Exposure to harmful substances at work, like agrichemicals
Poisoning from heavy metals like calcium, lead, mercury, and uranium
Snake bites, especially from Viperidae and Elapidae families
Viral hepatitis
Lack of blood supply to tissues (vascular ischemia)
Allergic reactions and severe immune responses (hypersensitivity and anaphylaxis)
Injuries, including trauma and crush syndrome
A serious type of fever caused by an adverse reaction to certain drugs (malignant hyperthermia)
Metabolic myopathies (muscle diseases)
Muscle tissue breakdown caused by intense physical activity
Heat-related illnesses, including heat stroke and heat exhaustion
Severe dehydration

These are only some of the possibilities; other conditions can also show similar symptoms, which makes paraphenylenediamine (PPD) toxicity difficult to diagnose.

What to expect with Paraphenylenediamine Toxicity (Henna Body Art)

The long-term effects of paraphenylenediamine poisoning depend on several factors, such as the extent of exposure, how quickly medical aid was given, and the patient’s health status. Outcomes can be significantly improved if the condition is identified and treated quickly. Many people fully recover with the right care. Mild cases, which may show as localized skin reactions, usually get better with treatments aimed at relieving symptoms and avoiding more exposure to the chemical.

However, more severe cases may lead to life-threatening complications such as muscle breakdown (rhabdomyolysis), kidney failure, or a severe allergic reaction (anaphylaxis), and may need intensive medical care. Faster recovery and better outcomes may be seen with early detection, immediate care to secure the patient’s airway and provide supporting treatments like fluids, steroids, antihistamines, and kidney dialysis; and quick referral to specialists.

Long-term effects can include ongoing kidney disease or unhindered allergies, which can affect the person’s quality of life. Regular monitoring and care to manage any continuing health concerns are key to improve long-term outcomes.

Death rates from paraphenylenediamine poisoning can vary widely, with some reports showing rates between 0.03% and 60%. The most common causes of death include severe swelling causing difficulty in breathing (angioneurotic edema), failure of the respiratory process, and dangerous irregular heart rhythms (arrhythmias). Factors linked to worse outcomes include delay in reaching the hospital, absence of a procedure to clean out the stomach (gastric lavage), the need for a breathing tube or hole in the neck to assist breathing (tracheostomy or intubation), seizures or low score on a scale used to assess consciousness level (Glasgow Coma Scale), existing kidney disease, the need for dialysis, and the need for intensive care.

Possible Complications When Diagnosed with Paraphenylenediamine Toxicity (Henna Body Art)

Paraphenylenediamine poisoning can cause serious, even life-threatening, effects to different parts of the body like the nervous, heart, respiratory, kidney, and liver systems. While it’s rare, there have been reports of people having seizures or falling into comas because of this poisoning. There might also be severe swelling that can affect the airway and require a tracheostomy, or a procedure to create an opening in the neck for breathing. Kidney and liver failure may also occur and might necessitate dialysis.

Heart problems can arise, such as inflammation of the heart, heart attacks, and dangerous irregular heartbeats which may include atrial fibrillation and ventricular tachycardia or fibrillation. Severe allergic reactions, including anaphylaxis, can happen, creating immediate threats to life. Long-term exposure to the chemical can result in sensitization and persistent skin conditions.

The same complications can occur in children, like the onset of respiratory failure that requires tracheostomy and acute kidney and liver failure that necessitates dialysis. It is crucial to quickly identify and manage these complications to reduce harmful effects and ensure patient safety.

Human Body Systems Affected by Paraphenylenediamine Poisoning:

Nervous system
Heart system
Respiratory system
Kidney system
Liver system

Potential Complications of Paraphenylenediamine Poisoning:

Seizures or coma
Airway obstruction from severe swelling
Kidney and liver failure
Heart problems (myocarditis, myocardial infarction, fatal arrhythmias)
Severe allergic reactions (including anaphylaxis)
Long-term skin conditions
Respiratory failure in children

Preventing Paraphenylenediamine Toxicity (Henna Body Art)

In the last five years, the rate of suicide globally has increased by 60%. It’s critical to bring attention to this alarming trend. It has been observed that the use of paraphenylenediamine, a chemical often found in hair dyes and some workplace products, for self-harm is rising, especially in less developed countries. The data is particularly worrisome as it shows that children, teenagers, and young adults are the most impacted. Despite this, many people remain unaware of the risks associated with products containing paraphenylenediamine. To make matters worse, in certain regions, the production of this chemical is not well regulated, leading to the availability of products with dangerously high concentrations.

Given the serious potential risk of death from toxicity connected to paraphenylenediamine, it’s crucial to raise public awareness and educate those in relevant industries. If people understood the potential dangers of this chemical, often found in hair dyes and certain workplace products, it could significantly decrease their exposure. We need to make sure people know to read product labels carefully and to choose alternatives that do not contain paraphenylenediamine. It’s also important for healthcare providers to inform patients about early signs of toxicity from this chemical. These include swelling, difficulty breathing, and dark urine. They need to ensure that patients understand the urgency of getting medical help if these symptoms occur. Running effective public awareness campaigns can play a big role in reducing the occurrences of toxicity from paraphenylenediamine, thus better protecting people’s health. Lastly, more research is needed to create effective strategies to discourage use and improve public health awareness programs.

Frequently asked questions

Paraphenylenediamine toxicity refers to the harmful effects caused by the substance when used in henna body art.

Paraphenylenediamine toxicity in henna body art is a worldwide problem, particularly in underdeveloped and developing countries.

Signs and symptoms of Paraphenylenediamine Toxicity (Henna Body Art) include: - Swelling of the face and neck - Swelling of the upper airway - Widespread muscle pain, indicating rhabdomyolysis - Changes in kidney function, such as diminished or lack of urine output or dark brown urine - Inflammation at the site of exposure on the skin, typically the scalp or hairline, and possibly a skin infection called cellulitis In addition to these common symptoms, health officials will also check for important symptoms related to various body systems: - Neurologic symptoms: Coma and seizures - Cardiac symptoms: Changes in heart rhythm, including both fast and slow heart rate, irregular heart rhythms, and inflammation of the heart muscles - Respiratory symptoms: Breathing difficulties related to swelling in the throat and face - Gastrointestinal symptoms: Difficulty swallowing, belly pain, and liver injury - Renal symptoms: Dark brown urine or changes in urine output - Musculoskeletal symptoms: Pain, stiffness of limbs, and tissue breakdown in muscles - Integumentary (Skin) symptoms: Itching, redness, blisters in areas exposed to the chemical, often involving the scalp, face, hands, and legs

Paraphenylenediamine toxicity from henna body art can occur through swallowing the substance.

The doctor needs to rule out the following conditions when diagnosing Paraphenylenediamine Toxicity (Henna Body Art): - Drug misuse, such as synthetic cannabinoids, amphetamines, cocaine, and heroin - Bad reactions to certain medications, like cyclosporine, vancomycin, and aminoglycosides - Alcohol toxicity - Exposure to harmful substances at work, like agrichemicals - Poisoning from heavy metals like calcium, lead, mercury, and uranium - Snake bites, especially from Viperidae and Elapidae families - Viral hepatitis - Lack of blood supply to tissues (vascular ischemia) - Allergic reactions and severe immune responses (hypersensitivity and anaphylaxis) - Injuries, including trauma and crush syndrome - A serious type of fever caused by an adverse reaction to certain drugs (malignant hyperthermia) - Metabolic myopathies (muscle diseases) - Muscle tissue breakdown caused by intense physical activity - Heat-related illnesses, including heat stroke and heat exhaustion - Severe dehydration

The types of tests that a doctor would order to properly diagnose Paraphenylenediamine Toxicity (Henna Body Art) include: - Monitoring heart rhythm - Taking an X-ray of the chest - Analyzing a sample of blood to check for elevated levels of certain enzymes indicating damage to muscles, liver, or kidneys - Assessing kidney function using serum creatinine levels - Checking blood chemistry for changes such as high white blood cell count, imbalanced acid levels, low calcium, or high phosphate levels - Patch test to determine if the patient is allergic to paraphenylenediamine - Checking white blood cells' response to paraphenylenediamine (less commonly used) - Allergy tests carried out in outpatient settings - Gastric lavage to cleanse the body of the toxin (controversial) - Managing the patient's airway to prevent complications from severe swelling in the airways - Corticosteroids and antihistamines for severe allergic reactions or anaphylaxis - Administering ample amounts of isotonic fluids to prevent kidney damage due to rhabdomyolysis - Kidney dialysis in severe cases to aid in recovery.

There isn't a specific cure or treatment for paraphenylenediamine poisoning. The main way to handle such poisonings is to quickly recognize what's happened and provide supportive care. This might include making sure the patient can breathe properly, balancing their electrolytes and body's acid levels, and providing other supportive measures, especially in serious cases. Activated charcoal and gastric lavage are not recommended for treatment. Managing the patient's airway is important to prevent complications, and other methods like a tracheostomy may be used. Corticosteroids, antihistamines, and epinephrine are used for severe allergic reactions. To prevent rhabdomyolysis, it's important to avoid dehydration and low oxygen levels, and administering isotonic fluids early can help prevent kidney damage. Kidney dialysis may be used in severe cases.

The side effects when treating Paraphenylenediamine Toxicity (Henna Body Art) include: - Seizures or coma - Airway obstruction from severe swelling - Kidney and liver failure - Heart problems (myocarditis, myocardial infarction, fatal arrhythmias) - Severe allergic reactions (including anaphylaxis) - Long-term skin conditions - Respiratory failure in children

The prognosis for Paraphenylenediamine Toxicity (Henna Body Art) can vary depending on several factors, such as the extent of exposure, how quickly medical aid was given, and the patient's health status. Faster recovery and better outcomes may be seen with early detection, immediate care to secure the patient's airway and provide supporting treatments like fluids, steroids, antihistamines, and kidney dialysis; and quick referral to specialists. Mild cases usually get better with treatments aimed at relieving symptoms and avoiding more exposure to the chemical, while more severe cases may lead to life-threatening complications and may need intensive medical care.

A toxicologist or a dermatologist.