perineal burn

What toxicologic exposure could cause this finding in a 3-year-old child?

  1. Ibuprofen
  2. Miralax
  3. Pseudoephedrine
  4. Senna

Answer: 4

Senna

Discussion

Senna, an over-the-counter laxative, has been well documented to cause perineal skin burns in children, primarily those who are still in diapers. Some of these cases had initially been evaluated as potential non-accidental trauma. Senna has largely replaced phenolphthalein as an over the counter laxative since 1999 when phenolphthalein was discontinued due to carcinogenic concerns [1,2].  Shortly after its introduction, reports of senna-induced skin burns were reported [3-6]. One study found that 11% of pediatric patients with accidental ingestion of senna-containing OTC laxatives developed dermatitis, skin blisters, and sloughing; all of them were still using diapers [1]. Diaper usage allows the stool to contact the skin for a prolonged period of time; the burn’s location and shape as related to the diaper can help distinguish this from a scald injury [4,5,7]. The exact mechanism is unclear, but it has been proposed that senna may cause the burn directly, or may react with digestive enzymes to produce the burn [4,8]. Standard burn care is generally adequate, and further evaluation for other etiology of burns may be considered as well.

Pearls

  • Senna-containing laxatives may cause perineal skin burns in children, particularly in those wearing diapers.
  • The use of over-the-counter laxatives should be included in the history of children with this presentation.
  • Standard burn care is generally adequate.
  • This presentation may be mistaken for non-accidental trauma.

This post has been peer reviewed on behalf of ACMT by Bryan Judge, Louise Kao, and Shan Yin

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References

  1. Spiller HA, Winter ML, Weber JA, Krenzelok EP, Anderson DL, Ryan ML. Skin Breakdown and Blisters from Senna-Containing Laxatives in Young Children. Ann Pharmacother. 2003; 37(5):636-639. PMID: 12708936

  2. U.S. Department of Health and Human Services. “Phenolphthalein. CAS No. 77-09-8.” Report on Carcinogens, 14th ed. 2016.

  3. Smith WA, Taintor AR, Kos L, Drolet B. Senna-Containing Laxatives Inducing Blistering Dermatitis in Toddlers. Arch Dermatol. 2012; 148(3):402-404 PMID: 22431792

  4. Leventhal JM, Starling S,Christian CW, Kutz T. Laxative-Induced Dermatitis of the Buttocks Incorrectly Suspected to Be Abusive Burns. Pediatrics 2001; 107:178-180. PMID: 11134455

  5. Cogley K, Echevarria A, Correa C, De la Torre-Mondragón L. Contact Burn with Blister Formation in Children Treated with Sennosides. Pediatr Dermatol. 2017; 34(2):e85-e88. PMID: 28111797

  6. Durani P, Agarwal R, Wilson D. Laxative-induced burns in a child. Journal of Plastic, Reconstructive, and &Aesthetic Surgery. 2006; 59(10):1129-. PMID: 16996446

  7. McManus J, Urquhart P, Tork O, McBride CA. Accidental, but initially suspicious, injury. J Paediatr Child Health. 2014; 50(8):647-648. PMID: 24372955

  8. Melvin JE, Hickey RW. Laxative-Induced Contact Dermatitis. Pediatric Emergency Care. 2018; 00(00):1-. PMID: 29746360

Michael Keenan, MD

Michael Keenan, MD

Department of Emergency Medicine
State University of New York at Buffalo
Michael Keenan, MD

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Michael Hodgman, MD

Michael Hodgman, MD

Upstate New York Poison Control Center
Syracuse, NY
Michael Hodgman, MD

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