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Kerosene-Induced Panniculitis in Iraqi Patients

  • College of medicibe University of Baghdad
Journal of Cosmetics, Dermatological Sciences and Applications, 2014, 4, 323-328
Published Online December 2014 in SciRes.
How to cite this paper: Sharquie, K.E., Noaimi, A.A., Younis, M.S. and Al-Sultani, B.S. (2014) Kerosene-Induced Panniculitis
in Iraqi Patients. Journal of Cosmetics, Dermatological Sciences and Applications, 4, 323-328.
Kerosene-Induced Panniculitis in
Iraqi Patients
Khalifa E. Sharquie1*, Adil A. Noaimi1, Maha S. Younis2, Bashar S. Al-Sultani3
1Department of Dermatology, College of Medicine, University of Baghdad, Baghdad, Iraq
2Department of Psychiatry, College of Medicine, Baghdad University, Baghdad, Iraq
3Department of Dermatology, Baghdad Teaching Hospital, Medical City, Baghdad, Iraq
Received 26 September 2014; revised 31 October 2014; accepted 7 November 2014
Copyright © 2014 by authors and Scientific Research Publishing Inc.
This work is licensed under the Creative Commons Attribution International License (CC BY).
Background: Kerosene is a common household stuff that has been used as accidental oral poison-
ing material in children and as suicidal attempt in adults. In the last decade intradermal kerosene
injection has been commonly used to induce dermatitis artefecta as a part of emotional upset. Ob-
jective: To evaluate the clinical cases of intradermal kerosene injection in Iraqi patients. Patients
and Methods: This is a descriptive case study that had been conducted in Department of Derma-
tology Baghdad Teaching Hospital, Baghdad, Iraq during the period from Jan. 2003 to Dec. 2012.
History and full clinical examination were performed including all sociodemographic aspects as-
sociated with this condition. Psychiatric evaluation was done for each patient. Results: All eleven
patients had single lesion except that two had two lesions. They were distributed on accessible
areas on the limbs. The exact diagnosis was not reached for at least few weeks after kerosene in-
jection. The patients denied any kerosene injection, but after a while they all admitted that the
cause of their rash, severe emotional tension was observed at the time of kerosene injection as
they had sociopsychological disturbances. The initial rash was erythematous indurated tender
plaque that was gradually increasing in size simulating the picture of panniculitis and then fol-
lowed by rupture of lesion and associated pyoderma, forming chronic discharging ulcer. Patients
were managed by topical and systemic antibiotics until complete resolution leaving a big ugly scar
that was treated by topical steroids to improve its cosmetic appearance. Conclusions: Kerosene
intradermal injection is an increasing problem among Iraqi adult females and it should be sus-
pected in any patient with chronic discharging ulcer on accessible areas like limbs.
Kerosene, Panniculitis, Emotional Tension
Corresponding author.
K. E. Sharquie et al.
1. Introduction
Kerosene is one of petrolatum products that are commonly used for heating in houses during winter time. Kero-
sene poisoning is frequently encountered in Iraqi hospitals as children and toddlers accidently ingest it, probably
due to its unlabeled containers. In the last few years we have come across cases of kerosene injection as an attempt
for suicide. Kerosene is a hydrocarbon compound that is known to cause toxicity which affects many different
organs according to the dose and route of exposure, whether through ingestion, inhalation, intravenous injection
or dermal injection. The chemical properties of the individual hydrocarbon determine the specific toxicity, while
the dose and route of ingestion affect organs which are exposed to the toxicity. If these hydrocarbons come in
contact with the skin surface, they can cause dryness, scaling and sometimes severe dermatitis [1]. Skin absorp-
tion of kerosene has been demonstrated to be fairly rapid, but it is limited to approximately 10% - 15% after 24
hours of the applied dose [2]. When injected into skin, kerosene causes an intense local inflammatory reaction
with necrosis of the skin, fatty tissue and possibly underlying muscle [3] [4]. Chronic exposure can result in renal
failure and/or degenerative changes of livers or kidneys. Signs and symptoms of overexposure include giddiness,
headache, dizziness, nausea, vomiting, incoordination, narcosis, stupor, coma, unconsciousness, weight loss,
anemia, renal failure, and pains in the limbs peripheral numbness, parasthesia, drying and cracking of skin, and
rashes or spots on skin.
Intradermal kerosene injection causing fasciitis and necrosis is self mutilation practice that has been reported
among adults [5] [6], however only four cases are documented and all of them are in Arab communities.
In Iraq it is not an uncommon problem among children to have accidental oral ingestion or inhalation of ke-
rosene while for adults oral intake or bathing with kerosene is used as a suicidal attempt.
During Iran-Iraqi war 1980-1988 it is a well known practice among soldiers during army attacks to do intra-
dermal injection of kerosene to induce dermatitis in order to have sick leave (Sharquie observations).
In the last ten years and specifically after American occupation of Iraq there is a new trend among young adults
to induce self infliction by intradermal kerosene injection under the pressure of their emotional problems.
Although household kerosene is a familiar tool for committing suicide whether an attempt or complete by self
burning in Middle East countries [7]. Very few literatures report cases using it for self mutilation [8]. General
studies that assess suicidal behavior are rare in the Arab world given the fact that suicide is considered as a dis-
graceful act prohibited by religion, condemned by society and intrigued by legal consequences [7].
Psychiatric evaluation should be done for the attempters in order to assess the presence of any psychological
disorders. In reviewing the clinical picture, time was an important factor [9]. Delay in management would have
allowed the noxious agents to cause much irreversible necrosis and possible suppuration. Since the injected ma-
terial penetrates slowly, immediate and adequate surgical debridement with possible fasciatomy is the best initial
treatment, followed by repeated and relentless debridement with dressings [10].
So the aim of the present work is to report cases of intradermal kerosene injection causing panniculitis and
fasciitis and to evaluate the different clinical and psychological aspects of this self-induced disease.
2. Patients and Methods
This is a descriptive case study that had been carried out in Department of Dermatology and Venereology Baghdad
Teaching Hospital, Baghdad, Iraq during the period from Jan. 2003 to Dec. 2012.
Eleven casesten females and one male were seen, whose ages range from 17 - 25 year with a mean 21.5
years. Full history and examination was carried out to evaluate the sociopsychological aspects and the emotional
tension of the patients and to evaluate the course of the disease from the time of the injection. Digital photo-
graphs were taken using SONY Cyber-Shot T300 10.1 MP for each patient in good illumination.
Formal consent was taken from each patient after full explanation about the nature and the goal of the present
work. Ethical approval was obtained from the Scientific Council of Dermatology and Venereology-Arab Board
for Medical Specializations.
3. Results
All eleven patients (Table 1) had severe emotional tension as a result of social, economical and psychological
problems. All patients denied the self injection of kerosene but when confronted with the injection, they all ad-
mitted the cause. Psychiatric assessment revealed absence of psychotic disorders or cognitive impairment
K. E. Sharquie et al.
Table 1. Showing features of cases with kerosene intradermal injection.
No. Age Gender Site Type
1 23 M Both Forearm Ulcer & Pyoderma
2 19 F Forearm Ulcer & Pyoderma
3 21 F Forearm Ulcer & Pyoderma
4 20 F Thigh Ulcer & Pyoderma
5 17 F Buttock Ulcer & Pyoderma
6 25 F Arm Ulcer & Pyoderma
7 23 F Wrist Ulcer & Pyoderma
8 24 F Both Popliteal Fossae Ulcer & Pyoderma
9 20 F Forearm Ulcer & Pyoderma
10 23 F Forearm Ulcer & Pyoderma
Ulcer & Pyoderma
for any reason. There was no history of alcohol/drug abuse or serious anti-social behavior. The site of injection
was usually on accessible areas and all seen on the limbs. One case study of patient number eleven is reported
here. A thorough psychiatric semi-structured interview has been conducted with one of the patients as a detailed
A 19-year old Iraqi Muslim single girl, a student in the college of education, living in Baghdad with her par-
ents and younger two brothers, was brought to the emergency Department of Baghdad Teaching Hospital Medi-
cal City in March 2010 after three days of outpatient treatment by a private local doctor, where she received cor-
tisone ointment and analgesic tablets for suspected erosive contact dermatitis on her left arm without improve-
ment. The lesion was expanding to involve the whole arm with generalized redness and swelling and in ability to
move it freely with intensifying pain and tenderness for which she was referred for consultation. The Patient
admitted using a 5 ml disposable syringe filled with household kerosene injecting it into her left arm just below
the cubital fossa. This was in response to her total failure in her first term examination four days before consul-
tation. She was taught about this method by a friend in the college. Urgent surgical debridement of the all ne-
crotic and a vascular tissues was done under anesthesia. Minor injury to the flexors of the forearm occurred, but
did not affect full movement. She had neither previous medical or psychiatric problems nor family history of
mental illness. She was described as a pleasant friendly girl by her mother with no record of impulsivity or anti-
social behavior. The patient denied any emotional or family conflict. Both parents were college graduates and
government employees living in comfortable accommodation with a reasonable financial status. On assessing
her mental state, she was fully conscious and alert with the injured arm wrapped up to the wrist and an intra-
venous fluid containing anti-biotic running in the healthy arm, but looked pale and gloomy. Speech was cohe-
rent and logical, there were no thought or perceptual disorders, her affect were sad and congruent with her
mood. She expressed full ignorance of the toxic nature of kerosene and denied any suicidal thoughts justifying
her act as a self punishment for school failure. She denied feeling psychological relief by the injection and ex-
pressed regret and concerns about future disfigurement or paralysis. The patient was jointly followed up in the
skin clinic and psychiatry outpatient clinic in the Medical City Teaching Hospital according to an appointment
In eight cases the injection was on the upper arms specifically on the forearms while three cases on the lower
limbs specifically thigh, buttock, popliteal fossae.
Patients were seen after few days to few weeks following the injection. The course of the disease started as
erythematous plaques that were hot and tender simulating a picture of panniculitis, after awhile there was rup-
ture of the lesions leaving discharging deep ulcers. No smell of kerosene was detected in any lesion. These ulc-
ers were managed by antiseptic clearance, topical and oral antibiotics were given, and the healing time took few
too many weeks. In all cases there was disfiguring scar at the site of injection and one patient with the wrist in-
jection left severe fibrosis and contracture of the wrist and hand.
The scars were managed by strong topical steroid ointment with oral antihistamine to improve the cosmetic
appearance (Figure 1 and Figure 2).
K. E. Sharquie et al.
Figure 1. Showing female patient with kerosene intradermal injec-
tion presented with pyoderma of right upper arm.
Figure 2. Showing panniculitis is and pyoderma in the left wrist in
female patient.
4. Discussion
US Occupation of Iraq caused severe economic, social and psychological problems among population and one of
these medical problems is doing kerosene injection. Kerosene is a mixture of hydrocarbons [11] [12], which can
cause severe inflammation and necrosis of all layers of the skin even and can involve the fascia and the underlying
muscles. But clinically as seen in the present work all features of panniculitis were observed. So we preferred the
term panniculitis rather than fasciitis. As a kind of chronic ulcer it might also simulate the picture of pyoderma
gangrenosum. In searching the medical literatures, we came across only four cases of so called fasciitis and pan-
niculitis, which were all in Arab world [8]-[10]. In Iraq, there is an increasing report about this problem within the
K. E. Sharquie et al.
last ten years [13].
Initial diagnosis is very essential in order to achieve successful management of these cases, so any panniculi-
tis like pictures on accessible area commonly the upper arms of young female, kerosene injection should be
highly suspected. Immediate management including hospital admission and urgent surgical debridement should
be carried out to evacuate the remaining kerosene in the tissue with full antibiotic cover, while the condition is
seen as chronic discharging ulcer and management including cleaning with antiseptic, topical antibiotic and sys-
temic antibiotics cover. In late cases scarring could be managed by topical steroid ointment and cosmetic sur-
gery might be arranged.
Emotional tensions that can lead to skin diseases are those like dermatitis artefecta, trichotillomenia, delusion
of parasitosis and others. These cases are not uncommon problems seen in daily clinical practice.
Self-inflicted dermatosis induced by kerosene is not well documented in Iraqi medical literatures, but during
Iran-Iraq war 1980-1988, cases of intradermal kerosene injection are practiced by soldiers during the army at-
tacks in order to have sick leave [14] [15]. It is well known that children may ingest kerosene instead of water,
while adults may burn themselves by bathing with kerosene [7] [13]-[16].
In the last ten years cases of intradermal kerosene injection had been seen as a part of emotional problems but
unfortunately all cases are misdiagnosed initially as most doctors are not aware of this problem.
So the aim of the present report is to present the clinical picture of these cases to encourage doctors to have
right initial diagnosis.
In conclusion self-induced panniculitis by intradermal kerosene injection is a distinctive entity that should be
managed early to have right treatment and to avoid future complications. Psychological evaluation should be
carried out in all cases.
This study was an independent study and not funded by any drug companies.
[1] Rice, R.H. and Mauro, T.M. (2008) Toxic Responses of the Skin. In: Casarett, L.J., Ed., Casarett and Doulls Toxicol-
ogy: The Basic Science of Poisons, 7th Edition, McGraw-Hill, New York, 143-518.
[2] Baynes, R.E., Brooks, J.D., Budsaba, K., Smith, C.E. and Riviere, J.E. (2001) Mixture Effects of JP-8 Additives on the
Dermal Disposition of Jet Fuel Components. Toxicology and Applied Pharmacology, 175, 269-281.
[3] Nixon, S.A. (1985) Kerosene Induced Abscesses. Archives of Internal Medicine, 145, 1743.
[4] Rao, G.S., Kannan, K., Goel, S.K., Pandya, K.P. and Shanker, R. (1984) Subcutaneous Kerosene Toxicity in Albino
Rats. Environmental Research, 35, 516-530.
[5] Terzi, C., Bacakoglu, A., Unek, T. and Ozkan, M.H. (2002) Chemical Necrotizing Fasciitis Due to Household Insecti-
cide Injection: Is Immediate Surgical Debridement Necessary? Human Experimental Toxicology, 21, 687-690.
[6] Enchsen, H. and Lynge, P. (1979) Chemical Inflammation and Subcutaneous Necrosis after Injection of Benzene.
Ugeskrift for Læger, 141, 1337.
[7] Al-Dabbas, M.H. (2006) Deliberate Self-Burning: The Psychosocial and Clinical Patterns among Patients Admitted to
Burn Unit in King Hussein Medical Center/Jordan. The Arab Journal of Psychiatry, 17, 253-256.
[8] Awe, A.J., Soliman, M.A. and Gourdie, R.W. (2003) Necrotizing Fasciitis Induced by Self-Injection of Kerosene. An-
nals of Saudi Medicine, 23, 388-390.
[9] Nazar, M. (2012) Mohammad Amin, Nashmeel Rasool Hamah Ameen, Reem Abed, Mohammed Abbas. Self-Burning
in Iraqi Kurdistan: Proportion and Risk Factors in a Burns Unit. International Psychiatry, 9, 72-74.
[10] Apex Oil Company, Inc. (2005) Material Safety Data Sheet, Kerosene: (Straight Run, Hydrodesulfurized, Clear or
[11] Wikipedia (The Free Encyclopedia) (2012) History of Petroleum.
[12] Karam, G.E., Hajjar, R.V. and Salamoun, M.M. (2007) Suicidality in the Arab World Part I: Community Studies. The
Arab Journal of Psychiatry, 18, 99-107.
[13] Hosseinian, A, Mahammad, A.T.J. and Alireza, R. (2009) Clinical Finding and Outcome in Suicidal Attempt Due to
K. E. Sharquie et al.
Intravenous Injection of Kerosene. Pakistan Journal of Biological Sciences, 12, 439-442.
[14] Kafaween, H., Rbehat, H. and Hawil, K.N. (2010) Necrotizing Fascitis Induced by Self-Injection of Kerosene, Case
Report. The Middle East Journal of Family Medicine, 8, 35-39.
[15] Khammash, M.R., Hussein, A.D. and Musmer, M. (1997) Management of Kerosene Injection in the Upper Limb. Sau-
di Medical Journal, 18, 188-190.
[16] Younis, M.S. (2012) Self-Mutilation by Subcutaneous Injection of Kerosen: Report from Iraq. 12th Pan Arab Psychia-
tric Conference, 29-30 November-1 December 2012.
[17] Hassan, H.S. (1999) Self Mutilation. The Arab Journal of Psychiatry, 10.
... Most reported cases are in Arab countries (KSA, Jordan, Iraq) (15 cases). [2][3][4][5][6] Iraq is the highest of Arab countries (11 cases). [4] The difficulty arises in management as cases are unique to each exposure in terms of dose injected, site of intended versus actual injection, and quantification of the exact dose of exposure. ...
... [2][3][4][5][6] Iraq is the highest of Arab countries (11 cases). [4] The difficulty arises in management as cases are unique to each exposure in terms of dose injected, site of intended versus actual injection, and quantification of the exact dose of exposure. The lethal dose of kerosene for 70 kg adult is 100 ml. ...
... [2,3] Intradermal injection has been reported in 32% of cases (10 cases). [4] All treated medically as a case of panniculitis and skin ulceration [Chart 2]. Patients recovered without complications except one who has developed injection site fibrosis and contracture in the wrist and hand. ...
Full-text available
Kerosene is one of the most widely used sources of energy in developing countries. Modes of accidental exposure include inhalation, ingestion and through skin or eye contact. There have been few cases reported in literature where kerosene was injected intravenously and subcutaneously with differing outcomes ranging from mild irritation to serious necrotising fasciitis. It remains challenging to predict the outcome of patients who inject kerosene through a non‑venous route as it is difficult to establish the accuracy of tissue layer affected by the injection. The aim of this study is to analyse all the case studies presented with attempt of suicide by self‑injection of kerosene, to establish a method of management available in this rare presentation.
... It is self mutilation practice that has been reported among adults; however only four cases were documented and all of them were in Arab communities. In Iraq it is not uncommon problem among children to have accidental oral ingestion or inhalation of kerosene while in adult oral intake or bathing with kerosene were used as a suicidal attempt [9] [10]. ...
Full-text available
Background: Many skin diseases can be evoked by psychological problems. Dermatological conditions could also lead to psychological disorders; hence psychodermatology is an emerging subspe-cialty that focuses on the interface of psychiatry and dermatology. Objective: To assess the frequency of the major disorders of so-called psychocutaneous disorders which are commonly seen among Iraqi population. Patients and Methods: This case descriptive study had been done in Department of Dermatology-Baghdad Teaching Hospital, Medical City, Baghdad, Iraq during the period from March 2011 to October 2013. All cases were collected and categorized according to the disease problem. Patients were interviewed to search for the main triggering and precipitating factors involved in pathogenesis of these disorders. The clinical picture was well described in order to reach a final diagnosis. Psychological interview and analysis were performed for all patients to reach the specific emotional and psychiatric disease by consultant psychiatrist. Results: A total of 100 patients with major psychocutaneous disorders were seen and evaluated. Nineteen were males and 81 were females with female to male ratio: 4.26:1. Their ages ranged from 7-73 (26.5 ± 5.217) years. The frequency of these diseases was as follows: trichotillomania 53%, dermatitis ar-tifacta 37%, delusion of parasitosis 6% and neurotic excoriation 4%. Conclusions: The major psy-chocutaneous diseases in Iraqi population were: trichotillomania, dermatitis artifacta and these are problems of mainly young females while delusion of parasitosis and neurotic excoriations were diseases of middle age females.
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Biochemical, histopathological, and hematological parameters were studied in male Wistar rats after repeated subcutaneous administration of commercial kerosene (0.5 ml/kg body wt, 6 days a week) for a period of 35 days. At necropsy, treatment-related increases in the weights of liver, spleen, and peripheral lymph nodes were noted. Correspondingly, there was an increase in DNA, RNA, protein, and lipid contents of liver and spleen. Histopathological examination of liver, spleen, thymus, kidney, adrenal, and lymph nodes revealed treatment-related lesions. Similarly, biochemical indices studied in liver revealed an increase in alkaline phosphatase and a decrease in benzo[a]pyrene hydroxylase levels. Furthermore serum cholinesterase, carboxylesterase, and albumin levels were significantly diminished while serum alkaline phosphatase levels were found to be greatly enhanced. The findings might be related as the likely systemic effects in workers upon percutaneous kerosene exposure during work.
To the Editor. —The observations by Rubinstein et al1 in their letter that appeared in the February 1985 Archives are assuredly apt. However, speaking as one of your many family physician readers (and possibly for your many readers who are general internists), the case report is incomplete.Certainly, kerosene smells and causes abscesses, but these characteristics seem far less important to me than the whys and wherefores of this case. Why was the patient's boyfriend injecting her with kerosene? Why did she let him? Under what circumstances were the injections performed? Did her paraparesis resolve? Does she have residual arthritis in her knees? What is her physical and mental status at the present time? What happened to her boyfriend?Case reports are an excellent means of informing and educating colleagues and others. While narrow conclusions may be drawn from them, we must remember that we deal with human beings.
Aliphatic and aromatic components in formulated jet fuels can cause occupational dermatitis. However, the influence of JP-8 performance additives (DIEGME, 8Q21, and Stadis450) on the dermal disposition of fuel components is not well understood. These additives are formulated with commercial Jet-A to form military JP-8 fuel. The purpose of this study is to assess the influence of these additives on the dermal disposition of marker aromatic and aliphatic components, naphthalene and dodecane, respectively. Porcine skin sections in an in vitro system were used to characterize chemical-biological interactions that modulate diffusion of jet fuel components and isolated perfused porcine skin flaps (IPPSFs) were used to evaluate diffusion in a viable skin model with an intact microvasculature. In these 5-h studies, Jet-A, Jet-A + DIEGME, Jet-A + 8Q21, and Jet-A + Stadis450, Jet-A + DIEGME + 8Q21, Jet-A + DIEGME + Stadis450, Jet-A + 8Q21 + Stadis450, and JP-8 mixtures were tested. In general, naphthalene absorption (0.76-2.39% dose) was greater than dodecane absorption (0.10-0.84% dose), while the IPPSFs alone demonstrated that dodecane absorption was significantly greater in JP-8 than in Jet-A. Synergistic interactions with 8Q21 + Stadis450 appear to enhance systemic absorption of either naphthalene or dodecane, while DIEGME + Stadis450 increased naphthalene (1.88% dose) and dodecane (2.02% dose) penetration into the skin and fat tissues of IPPSFs. These findings were supported by the fact that 8Q21 + Stadis450 significantly increased dodecane flux and permeability in porcine skin sections, but 8Q21 alone reduced marker diffusion in both membrane systems. Furthermore, dodecane is more likely than naphthalene to remain in the stratum corneum and skin surface at 5 h, and DIEGME mixtures played a significant role in skin and surface retention of both markers. In summary, the data suggest that various combinations of these three performance additives in JP-8 can potentially alter the dermal disposition of aromatic and aliphatic fuel components in skin. More importantly, products of two-factor interactions were not predictable from single-factor exposures and, by extension, cannot be extrapolated to three-factor interactions.
We describe two cases of chemical necrotizing fasciitis in the upper extremities, anterior chest wall and epigastric region of the abdominal wall caused by household insecticide injection. We suggest that surgical debridement can be successfully performed in the subacute period under close observation in hemodynamically stable patients.
Deliberate Self-Burning: The Psychosocial and Clinical Patterns among Patients Admitted to Burn Unit in King Hussein Medical Center
  • M H Al-Dabbas
Al-Dabbas, M.H. (2006) Deliberate Self-Burning: The Psychosocial and Clinical Patterns among Patients Admitted to Burn Unit in King Hussein Medical Center/Jordan. The Arab Journal of Psychiatry, 17, 253-256.
Mohammad Amin, Nashmeel Rasool Hamah Ameen, Reem Abed, Mohammed Abbas. Self-Burning in Iraqi Kurdistan: Proportion and Risk Factors in a Burns Unit
  • M Nazar
Nazar, M. (2012) Mohammad Amin, Nashmeel Rasool Hamah Ameen, Reem Abed, Mohammed Abbas. Self-Burning in Iraqi Kurdistan: Proportion and Risk Factors in a Burns Unit. International Psychiatry, 9, 72-74.