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MINI REVIEW

:
:

POISONING OF PARAPHENYLENE DIAMINE “KALA PATHAR”: BLACK STONE, A LETHAL

Masood Ahmed Unar1
SUICIDAL AGENT: MINI REVIEW

ABSTRACT
OBJECTIVES
To objective of review was to gather the knowledge about the clinical aspects
of PPD poisoning as suicidal agent and its treatment and outcomes.
METHODOLOGY

The data regarding the poisoning cases was collected from online
databases, the toxicological effects of paraphenylene diamine Kala Pathar
poisoning (Scopus, Dimensions, Google Scholar, Science Direct, and Web of
Science using these keywords Kala Pathar poisoning, Paraphenylene
Diamine). The duration of the study was July - December 2023. This review

mortality and morbidity, poor countries have little sources of research to do
over it, so wealthier countries should come forward to invest in creation of
antidote and improve the treatment options.
KEYWORDS: Toxicological Effects, Kala Pathar, Paraphenylene Diamine

How to cite this article

Unar MA. Poisoning Of
Paraphenylene Diamine - “Kala Pathar”:
Black Stone, A Lethal Suicidal Agent:
Mini Review. J Gandhara Med Dent
Sci. 2025;12(3):67-71. https://doi.org/

Date of Submission: 29-11-2024
Date Revised: 15-03-2025
Date Acceptance: 18-03-2025

Correspondence

1Masood Ahmed Unar, Assistant
Professor, Department of
Pharmacology, SMBBMU Larkana

+92-334-7092779
fastmasood7@gmail.com

INTRODUCTION

The World Health Organization (WHO) reports that
suicide is becoming more common each year, raising
public health concerns.1 Intentional suicide with
poisoning is the most common method. A study
observes, every 20 seconds a suicide death occurs, and
every 1-2 seconds, a suicide attempt occurs this number
will rise to almost 1.53 million deaths.2 Additionally,
there will be 10-20 times more suicide attempts
worldwide. High rate of suicide is primarily due to such
reasons like, socio-economic, psychiatric diseases and
psychological disturbances. In addition, there are a
number of medical conditions that are linked to suicidal
behavior, including chronic illnesses, malignancies,
AIDS, liver, and renal failure.3 Due to a variety of
factors, the suicide trend has transferred from Western
Europe to Eastern Europe and is currently in Asia.4
Suicide and homicide poisoning frequently include the
use of substances or agents that are simple to obtain,
inexpensive, and easy to administer. Suicide is seen as a
legal concern in many Asian countries, where it
accounts for around 1 million mortalities annually.5 In
the past ten years, suicide rates have surged 60%
worldwide, in both developed and developing countries.
One of the most popular and preferred methods of
suicide is poisoning, which is a major source of suicide.
Both men and women kill themselves. Males typically
finish suicide successfully compared to females with
fewer attempts due to their aggressive and violent
tactics.6 However, the method of poisoning differs quite
a little between countries. The most common drugs that
cause poisoning in affluent countries include opiates,

analgesics like Paracetamol, anxiolytics, and
antidepressants. However, one of the most common
causes of suicide poisoning in developing countries is
exposure to organophosphorus chemicals, which are
used in pesticides. Additionally, many visits to
emergency rooms are related to failed suicide attempts.7
Pesticide poisoning continues to be the biggest cause of

8sickness and mortality in Pakistan. Pakistan lacks
accurate data on suicide deaths and has no vital records.
The estimated age-standardized suicide rate in Pakistan
is 4.4 per 100,000 persons, which is lower than the
global suicide death rate for both genders in 2017 of
9.98 per 1 million, India, Bangladesh, and Sri Lanka,
which are neighbors, had suicide death rates of 13.33,
5.73, and 7.55 per 100,000 inhabitants, respectively.9
Socioeconomic factors, masculine gender dominance,
low levels of literacy, lax government employment
rules, and restrictions on the use of illegal drugs or
chemicals are the causes of these incidents.
Paraphenylene Diamine (PPD), also known as Kala
Pathar (Black Stone) in Urdu, has recently become
widely used as a method of suicide poisoning in many
underdeveloped countries of the world. Due of its high
fatality rate, it is one of the suicide methods that the
majority of individuals favor. Due to its inexpensive
cost and cosmetic application, it is also readily
available in the market. In Pakistan, Kala Pathar (PPD)
poisoning is a new kind of deliberate suicide with a
significant death rate. This hair colour is often chosen
for suicide due of its simple availability, low cost, and
swiftly detrimental effects. It can be mistakenly
consumed or used as a suicide tool.11
Paraphenylenediamine (PPD) is an organic compound

10.37762/jgmds.12-3.716

shows that PPD poisoning is very lethal, quick treatment can save the

68 J Gandhara Med Dent Sci

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with chemical formula C6H4 (NH2). It is an aromatic
amine, solid and white in color, which turns black on
oxidation. If ingested it is metabolized in the body
cytochrome P450 system, and is further oxidized to a
toxic product that can lead to multi organ failure.12 And
is a main ingredient of many locally produced hair
dyes. It is produced in Germany, Japan, and the United
Kingdom.13
Uses of Paraphenylenediamine (PPD) as a
Chemical: PPD is a derivative of coal tar that, when
combined with ammonia and hydrogen peroxide,
produces an aromatic amine derivative of aniline and a
par nitro aniline derivative that is used as a hair dye.
Because of darker effect it produces when combined
with henna, it is also used for tattooing.14 Many
industrial operations routinely use PPD in hair dyes, the
photochemical process, hair dye oxidation, dyeing furs,
vulcanizing tyres, and the rubber business are all
examples of hair dyes.15 Since PPD has a significant
tendency to speed up the dying and dyeing processes,
many women have used it since 1863 for cosmetic
purposes. It is frequently utilized in industrial products
like dyes for textiles or fur, dark cosmetics, temporary
tattoos, photographic development and lithography
plates, photocopying and printing inks, black rubber,
oils, greases, gasoline and more.15
Route of Administration of Paraphenylenediamine
(PPD) for Poisoning Purposes.
The most common route of administration of PPD,
found in various articles is Oral ingestion. The majority
of the time, this substance is used for self-suicidal
purposes, however it can also be accidentally consumed
and utilized with homicidal intent.16 PPD consumption
is commonplace, which makes it a popular choice for
suicide. Adult population PPD consumption was
primarily for intentional suicide/suicide.17 On the other
hand, unintentional ingestion was the main reason for
consumption in children. Toxicity might also result
from local absorption. There have been cases of
transdermal absorption, but the main worries are related
to its suicidal consumption; it is extremely poisonous
when taken by mouth, and the outcome is mostly dose
dependent.18 When consumed, PPD is a dangerous and
deadly drug that can be accidently consumed, taken
orally for suicidal purposes, or even given to a person
to try murder.19 Humans are most commonly exposed
to PPD through their skin and through inhalation during
the dyeing process.20 PPD can result in severe edema,
rhabdomyolysis, renal impairment, skin irritation,
contact dermatitis, and rhabdomyolysis. These issues
show that this substance is extremely hazardous.21
Mode of action of Paraphenylenediamine:
Clinical Features and Complication Reported by
Various Research Studies: Depending on the method
of intoxication, the amount consumed, and the length of

time before presenting to the hospital, patients may
exhibit a variety of symptoms and indicators.
Documents reveal that aromatic amines like PPD have
highly common toxicological characteristics. The
triggering of apoptosis through an increase in reactive
oxygen species (ROS) is one of these crucial
characteristics. This poison is very irritant to local
organs like mouth, tongue, lips and pharynx and causes‘
rapid damage of the tissues and ultimately causing
angioedema leading to dysphasia and respiratory
distress, rhabdomyolysis, intravascular hemolysis,
abrupt renal failure, and liver necrosis.22 Angioedema
and chocolate-brown urine are two signs of PPD
poisoning that may be present. PPD produces edema of
the face, neck, tongue, throat, and larynx after
consumption. Rhabdomyolysis, angioneurotic edema,
and renal failure are some effects of its poisoning.23 The
malfunctioning of numerous organs is a documented
effect of PPD. The malfunctioning of numerous organs
is a documented effect of PPD. Due to severe cardiac
toxicity or angioneurotic edema, death might occur
within 6–24 hours.24 For the first time, Chugh reported
on two patients who had PPD intoxication-related oligo
urea and acute renal failure (ARF). In Sudan, 31
patients with PPD poisoning were recorded, all of them
had severe angioneurotic edema; 15 of these patients
required an immediate tracheostomy; there were five
ARF patients; and 13 of these patients passed away in
the hospital within 12 hours.25 Oral ingestion of PPD
for suicide purposes quickly develops edema on the
face, throat, neck, larynx, and tongue at first, and later
results in rhabdomyolysis. In addition, it causes
oliguria/anuria, dysphagia, acute renal failure, asphyxia,
IV hemolysis, toxic myocarditis, and rhabdomyolysis.
Death is caused by myocardial injury and acute renal
failure ARF, brown urine, urine retention, and a
projecting tongue are among symptoms of acute PPD
poisoning. Finally, ARF supervenes as renal tubular
necrosis develops as a result of the buildup of toxic
PPD metabolites, ultimately leading to death if
immediate treatment is not instituted.26 PPD can cause
angioneurotic edema or cardio toxicity, which can
cause lethal arrhythmias and mortality during the first
six to 24 hours of intake.27 Within the first week,
moderate doses can result in acute renal failure. PPD
can also lead to allergies and skin rashes that could
intensify many reactions, including anaphylaxis.
Anaphylaxis reaction with facial and oral cavity edema,
dysphagia, as well as damage to the throat, tongue, and
upper gastrointestinal system, are among the signs and
symptoms (GIT).28 Additionally, it can result in severe
hepatitis, renal failure, various arrhythmias, and
electrolyte imbalance, tissue damage and the
development of hypersensitive allergic responses.29 Due
to myoglobin casts, it causes renal tubular obstruction

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and necrosis of the skeletal and cardiac muscles. Renal
tubules are extremely prone to be damaged by this
poison.30 There are both early and late clinical
consequences of PPD toxicity. Laryngospasm, cardio
toxicity, acute pulmonary edema, and angioneurotic
edema made up the majority of the early clinical
presentation.31 On the other hand, late symptoms of
PPD poisoning include renal failure and liver damage.
Acute and late clinical manifestations, however, depend
on a number of variables, including the quantity of PPD
consumed, the timing of the consumption, the amount
of time it took to get to the hospital emergency room,
and other timely interventions like gastric lavage,
endotracheal intubation, and tracheostomy.32 PPD
poisoning is distinguished by symptoms including
rhabdomyolysis, cervicofacial angioedema, and
swelling of the tongue and lips. Major clinical problems
of the black stone include angioedema, rhabdomyolysis,
and renal failure.33 See Table No: 01

Table 1: Most Common Complications of Paraphenylenediamine
(PPD) Toxicity

Complications Frequency in Published
Articles

Skin Rash 80-90 %
Respiratory Distress 70-60%
Anaphylactic Reaction 60-50%
Swelling of Face/Neck 60-50%
Rhabdomyolysis 50%
Cardiovascular Effects 35%
Gastrointestinal Issues 55%
Neurological Symptoms 35%
Renal Dysfunction 50%
Hepatic Dysfunction 30%
Hematological Effects 30%

Paraphenylenediamine (PPD) Poisoning Diagnosis:
The diagnosis of PPD intoxication is largely dependent
on history, clinical manifestations and some laboratory
findings. The clinical features are rather unique and in
the absence of laboratory facilities in many developing
countries the angio-edema of the face and neck together
with the hard protruding tongue and the chocolate-
brown color of the urine are used for clinical
diagnosis.34 urine can be tested for PPD using thin layer
chromatography which is essential for medico-legal
purposes. However, this test is not routinely available
and there is a need for a rapid test to demonstrate PPD
in blood or urine. Various other tests are also performed
for diagnosis like Blood complete test, serum
creatinine, leucocyte count, SGPT, SGOT, serum
bilirubin, serum alkaline phosphatase, serum potassium
& calcium, serum CPK, and evidence of myoglobinuria
by thorough urine report are all shown in studies.35
Treatment for Paraphenylenediamine (PPD)
Poisoning: Since there is no cure for this illness, all
efforts are focused on symptomatic management in an
effort to lower mortality and morbidity.36All

researchers in papers address this issue and place
emphasis on the need for scientific research in
institutions to develop a remedy for this extremely
lethal and toxic poison. Treatment is based on the route
of administration, the time, the quantity, and the
concentration of the poison consumed. Anti-
inflammatory medications, such as steroids, are given
along with anti-allergic medications to reduce the
edema of the face, oropharynx, tongue, and esophagus.
The possible therapy is the immediate administration of
steroids and water. The tracheotomy is additionally
regarded as effective emergency management.37 Early
diagnosis and therapy are essential for management.
With a focus on airway control and the prevention and
treatment of renal failure, since there was no specific
antidote available, management offered support.
Activated charcoal can be used to lavage the stomach.
If the arterial blood gas study reveals hypoxia or if there
is severe angioedema, oxygen should be provided along
with Chlorpheniramine maleate and injection of
corticosteroids for 3-5 days. For angioneurotic edema,
intravenous corticosteroids
(hydrocortisone/methylprednisolone) is the mainstay of
therapy. If hypotension persists despite receiving
adequate fluid therapy, vasopressors
(dopamine/norepinephrine) should be administered. To
stop myoglobin-mediated renal tubular damage, sodium
bicarbonate and loop diuretics were utilized to force an
alkaline diuresis. Mechanical air conditioning.38 An
investigation in Multan, Bahawalpur, (100%),
Nawabshah, (87.5%), and South India found that 60%
of tracheostomies were inserted. Patients in this study
who had upper airway tract obstruction required an
emergency life-saving tracheostomy in 68.5% cases.39
Depending on the clinical symptoms upon presentation,
the primary form of treatment is supportive. Some
patients may require endotracheal intubation, and a
tracheostomy is a life-saving procedure for an
obstruction of the airway. Due to the potential for a
hypersensitive reaction to PPD, antihistamines and
steroids are frequently employed, however there is no
evidence to support this course of treatment.
Myoglobinuria is managed with alkaline diuresis, with
mixed success, employing sodium bicarbonate, isotonic
saline, and diuretics.40 According to a study the
effectiveness of tests to remove PPD using hem
perfusion and hemodialysis was inconsistent, and there
is no specific antidote available. However, in cases of
oliguria or anuria AKI, dialysis is a useful supportive
therapy.30 See Table No: 02.

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Table 2: Common Signs, Symptoms, and Treatment Options of

Paraphenylenediamine (PPD) Toxicity
Signs and Symptoms Treatment Options
Skin irritation and rash Supportive care
Swelling of the face or neck Intravenous fluids
Itching and burning sensation Oxygen therapy
Redness and blistering Topical corticosteroids for rash
Difficulty breathing Antihistamines
Rapid heart rate Pain relievers
Dizziness and fainting Monitoring and observation
Nausea and vomiting Treatment of complications
Abdominal pain Antispasmodics
Dark urine I/v fluids
Yellowing of the skin fluids
Confusion or agitation Anxiolytics

According to the study by Muhammad Ahmed Khan et
al, 98% of patients had tracheostomies. In the study by
Akbar et al.6 60% of cases had a tracheostomy, and in
the study by Khuhro et al.13 87.5% of cases had one.
There is no known antidote for PPD poisoning, thus
treatment focuses mostly on supportive care. Patients
who experience acute renal failure need dialysis, but
none of patients of that study did. The biggest danger to
life is respiratory failure. Therefore, tracheostomy,
assisted ventilation, and endotracheal intubation were
essential and life-saving procedures.42 A study at
Multan shows 60% of patients at Nishtar Hospital in
Multan had tracheostomies, an other study by Shivani
Nautiya et al shows 108 of patients went under
tracheostomies.43,44 the management of PPD poisoning
requires several specializations assistance for the best
management. Interdisciplinary coordination between
the fields of otolaryngology, anesthesia, nephrology,
medicine, and laboratory medicine is necessary for
effective care. Muhammad Ahmed Khan and
colleagues‘ investigation reveals As a result of the gross
enlargement of the neck, tongue, and intraoral tissue
brought on by this poison, which also causes dyspnea
and stridor, tracheostomies were performed in these
cases to ease breathing difficulties and imminent
suffocation. Nearly 1173 (98.01%) of the cases
received tracheostomy surgery.42

CONCLUSIONS

Paraphenylenediamine ―Kala Patharǁ is a very deadly
chemical, its use in suicide and homicidal cases are
increasing day by day in Pakistan and other developing
countries so governments should impose ban on this
compound and its easy availability should be restricted
because no any antidote is available to rescue the
patients from mortality. The proper awareness
campaign regarding availability and dangerous aspects
of black stone (kala Pathar) also is warranted for future.

CONFLICT OF INTEREST: None

FUNDING SOURCES: None

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Poisoning of Paraphenylene Diamine”Kala Pathar”

Masood Ahmed Unar - Concept & Design; Data Acquisition;
Data Analysis/Interpretation; Drafting Manuscript; Critical
Revision; Supervision; Final Approval

AUTHORS CONTRIBUTION

The authors accept responsibility for all aspects of the work
and will ensure that any concerns regarding the accuracy or
integrity of any part are properly investigated and resolved.