Wounds Resulting From Intradermal Injection of Sodium Hypochlorite: A Case Report

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Caustic substances can inflict severe damage on tissues upon contact, disrupting their function and histological composition.¹ Skin lesions due to sodium hypochlorite are rare, with only a single case previously documented in the literature.² The current report discusses a case involving multiple self-inflicted intradermal injections of sodium hypochlorite resulting in colliquative necrotic ulcerations.

A 79-year-old female was admitted to the emergency department presenting with multiple skin ulcerations. She had documented severe cognitive decline and a nighttime wandering behavior disorder. Upon clinical examination, the patient exhibited several ulcerative skin lesions characterized by irregular shapes and borders that were symmetrically distributed across her limbs. These lesions were covered by a blackish-greyish eschar and surrounded by a purple erythematous halo (Figure 1), with the exception of a larger ulceration (3 cm × 6 cm) on her left arm, which exhibited tendon exposure (Figure 2).

According to the patient’s medical history, this larger ulceration had initially been covered by an eschar and had been previously treated with collagenase. Another lesion, symmetrically positioned but smaller (1 cm × 3 cm), was observed on the right arm. Additionally, 2 minor oval-shaped lesions were found on the forearms. The most recent lesions, measuring approximately 1 cm × 3 cm, were located on the lower limbs (Figure 3). Global blood analysis showed normal results.

During the medical examination, the patient experienced a moment of mental clarity and confessed to self-inflicting the wounds through injections of bleach at night. Family members corroborated that syringes were readily accessible and that bleach was available in their household bathroom. Analysis of the liquid beneath the eschar from the ulcer swab revealed a high concentration of sodium hypochlorite. Histological examination confirmed colliquative necrosis of the tissue.

The initial approach to managing the lesions by the authors of the current report involved the application of antiseptic medications, particularly nonadherent povidone-iodine dressings. Subsequently, treatment was transitioned to the use of collagenases. Each medical visit involved curettage of the eschar, wound bed, and borders of the lesions. Over the course of a few months, the wounds gradually decreased in size. After that, greasy gauze was used for about 1 to 2 months until the lesions resolved completely.

The harmful effects of sodium hypochlorite can be attributed to several mechanisms.² Firstly, it acts as a strong oxidizing agent and alkali, leading to the coagulation of proteins. Secondly, the active hypochlorite ion, along with free chloride ions, facilitates the denaturation of tissue proteins, resulting in the formation of a necrotic eschar. Lastly, colliquative necrosis occurs due to a localized decrease in tissue pH levels, resulting in the consolidation of surrounding soft tissues, intramural thrombosis, ulceration, and fibrosis.²

Household bleach is available in varying concentrations, typically ranging from 1% to 6%.² With a pH of 11, sodium hypochlorite is classified as a strong alkali and is commonly used for numerous commercial purposes. Additionally, upon interaction with plasma, sodium hypochlorite converts to hypochlorous acid and generates superoxide radicals, potentially leading to cellular death, hemolysis, and complications such as rhabdomyolysis.²

To the authors’ knowledge, intradermal injection of sodium hypochlorite has previously only been reported by Bin and Aldekhayel,² with clinical features mirroring those of the patient discussed in the current case report. Depending on the injection site, several anatomical structures can be involved in the damage.² In the current case, the biceps brachii tendon was exposed but was preserved.

The authors of the current report do not believe that the patient in this case intended to die by suicide. Moreover, the clinical presentation may not fit the classification of dermatitis artefacta, which typically involves the scenario of the patient self-inflicting skin lesions but denying responsibility for their creation.³ In the current case, the patient acknowledged her responsibility for the lesions during a moment of clarity. Specifically, the patient was diagnosed with severe cognitive decline. These self-harm episodes may be part of the so-called behavioral and psychological symptoms of dementia as well as night wandering.⁴

Even though the ulcers were symmetrically located in the current case, each lesion had distinct characteristics. In such cases, a comprehensive approach that considers neuropsychiatric comorbidities is essential, because various causes must be excluded.³ 

This study is limited by involving only a single case. Additionally, it cannot be assumed that the clinical features of lesions caused by sodium hypochlorite described in this report are the only types that occur. There is only 1 previous report of skin damage linked to sodium hypochlorite in the literature.

Intradermal injection of sodium hypochlorite can cause severe damage to the skin tissue, with rapid formation of ulcerations covered by a blackish-greyish eschar. The surrounding skin may have an erythematous, swollen appearance and a purple-colored halo around it. For a patient with a neuropsychiatric medical history, negative laboratory findings, or irregular skin lesions, self-induced ulcerations should always be considered in the differential diagnosis.