The patient is a 40-year-old male with no significant past medical history who presents to the Emergency Department with perioral rash and swelling. He had been in his normal state of health the day before and woke up in the morning with an itchy rash around his mouth. He denies lip, tongue, or intraoral swelling, throat itching or sensation of throat swelling, trouble swallowing, or swelling or itching of any other part of his face. The rash has not changed locations nor has it spread beyond the perioral area. He noted a similar episode once or twice before in his life, which had improved with taking diphenhydramine. He denies the presence of a rash or itching on any other part of his body, wheezing, shortness of breath, GI symptoms, or dizziness. He denies any exposure to new foods or medications, and he has not been exposed to ACE inhibitors nor ARBs. He has no other complaints at this time.
Vitals: BP 141/97; HR 88; R 19; T 98.2°F; O2 sat 98% on room air.
General: Awake and alert, no distress, speaking in a clear voice.
HEENT: As shown in the images provided. There is no oropharyngeal swelling. There is no stridor.
Respiratory: Clear to auscultation, no wheezes.
Skin: There is no rash or swelling elsewhere on the patient’s body.
Non-contributory
The patient has been dyeing his facial hair.
Para-phenylenediamine.
Upon further questioning, the patient admitted to applying an “instant hair dye shampoo” to his facial hair the day before presentation. Review of the product ingredients revealed para-phenylenediamine. He later recalled that his previous episodes of peri-oral swelling had occurred after exposure to the same product. Para-phenylenediamine can be found in commercial black and dark brown hair dyes, as well as in henna tattoos. Reactions can range from local erythema and contact dermatitis to bullous dermatitis and significant edema in severely affected patients. Symptoms may appear similar to angioedema and may only be distinguished after careful history identifies hair dye or henna exposure. Initial management is to remove the offending dye or henna with thorough washing. Topical steroids or a short course of oral steroids can be used for severe symptoms. Prevention of exposures in sensitized individuals remains the most important tenet of care. Hair dyes recommend consumers test the dye on a small patch of skin prior to using it, which has been proven to help identify those who will develop a reaction.
Take-Home Points
Para-phenylenediamine is a compound found in henna and hair dye that is commonly responsible for adverse skin reactions, but may be under recognized when used for facial hair.
Allergic contact dermatitis from this compound may show a range of clinical skin findings and sometimes may mimic angioedema.
- Mukkanna KS, Stone NM, Ingram JR. Para-phenylenediamine allergy: current perspectives on diagnosis and management. J Asthma Allergy. 2017 Jan 18;10:9-15. doi: 10.2147/JAA.S90265. PMID: 28176912; PMCID: PMC5261844.
- Krasteva M, Cristaudo A, Hall B, Orton D, Rudzki E, Santucci B, Toutain H, Wilkinson J. Contact sensitivity to hair dyes can be detected by the consumer open test. Eur J Dermatol. 2002 Jul-Aug;12(4):322-6. PMID: 12095875.
Rachael Herrera, MD
Emergency Medicine
Temple University Hospital
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Lauren Murphy, MD
Clinician Educator
Temple Universitry Hospital
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- SAEM Clinical Images Series: Perioral Facial Swelling - March 16, 2026
