Child abuse should be considered as a possible diagnosis in young children who present with burns. Often the history or the absence of a history provides the clue to a correct diagnosis. We recently evaluated 4 children (at 4 different medical centers) who each presented with large buttock burns that were initially diagnosed as abusive scald burns. In each case, a more detailed history revealed that the child's burn was not attributable to immersion in hot water, but rather resulted from the ingestion of Ex-Lax (Novartis, Summit, NJ). To our knowledge there are no previous reports of this type of injury in children.
A previously healthy 23-month-old boy was brought to the emergency department of Yale-New Haven Children's Hospital by his mother with a blistering “rash” on his buttocks. The child's mother reported that she had bathed him at approximately 8 pm the night before admission and at that time the patient had no rashes or blisters. The next morning when she changed the child he had a large diarrheal stool in his diaper, and she noticed a pinkish area with a few small blisters on his buttocks. The mother was concerned about the diarrhea because she had discovered 6 empty Ex-Lax wrappers on the floor of her room that had not been there previously. She had left the Ex-Lax on a dresser that the child sometimes climbed on; therefore, she was concerned that he had ingested the medicine while playing.
Throughout the day the child continued to have red-brown diarrheal stools and worsening blisters on his buttocks. On evaluation in the emergency department, the child was found to have a sharply demarcated area of erythema with multiple bullous lesions over the buttocks. The erythema and bullae extended 5 cm peripherally from the anus. There was sparing of the skin around the anus and the perineum. The child was estimated to have a second-degree burn of 4% of his body surface area. Past medical history revealed that the patient had been to the emergency department 6 months before with an electrical burn to his lip. Because of concern that the child's burn was attributable to an immersion injury, he was admitted to the hospital and Child Protective Services was notified.
During the child's hospitalization, the mother provided a similar history to several different interviewers. On reexamination of the child, the bullae had sloughed and the erythema along the left buttock formed a linear demarcation that was closely aligned with the inner absorbent pad of the child's diaper (Fig 1). Child Protective Services and the police investigated the child's home and were able to retrieve the foil from the Ex-Lax wrappers but not the box of Ex-Lax. They then accompanied the mother to the store who was able to demonstrate which box she had purchased. The box contained 9 squares of Ex-Lax wrapped in foil, and each square contained 15 mg of senna as the active ingredient. Novartis Company, the manufacturer of Ex-Lax, was contacted and had 1 case on file with no details in which a 5-year-old child had sustained burns to the buttocks after ingesting a box of Ex-Lax.
Based on this information, the hospital's child abuse team concluded that the child's injury was a chemical/contact dermatitis secondary to the ingestion of Ex-Lax containing senna. The involved skin was treated with local care (aquaphor and xeroform gauze). The patient was discharged to the care of his mother, who applied silver sulfadiazine topical treatment. Child Protective Services kept the case open. At follow-up 3 days after the hospitalization, the erythema was still present but less pronounced.
Cases 2 Through 4
The clinical features of the other 3 cases are similar to case 1. The children were ages 27 (Fig 2), 29, and 42 months old, respectively. In each case, the child ingested Ex-Lax, and on the next day when the diaper was changed, diarrheal stool was noted by the caretaker. The presence of erythema and blisters were noted at that time or developed over the next several hours. The blisters eventually developed into large bullae. On physical examination, the area around the anus and the gluteal cleft were spared in 2 of the 3 cases, the lesion appeared diamond- or pear-shaped on the buttock rather than circumferential, and the lateral borders aligned with the outer edge of the diaper. In 2 of the cases, the incident was reported to Child Protective Services because of suspected child abuse resulting from an immersion burn, and in one of these cases the child was placed in relative care under protective supervision.
These 4 cases highlight the importance of a detailed history in determining the cause of an apparent injury. Although the findings on physical examination were suggestive of an immersion burn, on more careful examination there were 3 findings that were unusual: the diamond-shaped lesion on the buttock, the linear borders that lined up with the diaper edge, and the sparing of the perianal tissue and the gluteal cleft. In general, sparing of skin folds and creases in the diaper area is consistent with an irritant contact dermatitis.
The use by adults of laxatives, such as Ex-Lax, is certainly common, and it is likely that many young children have ingested Ex-Lax. Our cases were between 23 and 42 months old; such young children are at the highest risk of ingesting medications or poisons. The preparation of Ex-Lax that was ingested seems to be particularly attractive to young children because it comes as chocolate squares wrapped in foil.
It is unclear, however, how frequently the skin reaction that we noted occurs. The pathogenesis of this reaction also is unclear. In each case, the buttock area had been exposed for a period of a few hours to diarrheal stools resulting from the ingestion of the Ex-Lax. The active ingredient in Ex-Lax is senna, which is an anthraquinone laxative and has been used in children for decades. The active ingredient in Ex-Lax had been phenolphthalin, but this was replaced by senna in 1997. This recent product reformulation is likely the reason why this adverse event had not been reported previously.
An important characteristic of the anthraquinone laxatives is that the active ingredient interacts with microorganisms in the large intestine to produce its laxative effect.1 What role this interaction might play in the development of the lesions is uncertain. A possible pathogenic mechanism to explain the dermatitis is injury from digestive enzymes.2 The diarrhea resulting from the laxative overdose could have increased the concentrations of these enzymes because of increased gut transit time. Because anthraquinones are partially absorbed from the gastrointestinal track and are excreted in the urine, the irritant effects that resulted in the dermatitis may have been attributable to this excretion. This explanation, however, seems less likely because of the location of the lesions on the buttocks area.
Although there have been no previous reports of reactions to senna, laxative-induced dermatitis from Danthron (an anthraquinone) has been reported in 2 elderly patients3 and in 1 infant.4 In each case, there was erythema, but no blisters or bullae, as in our patients.
The identification of these cases at separate medical centers was facilitated by SIGCA-MD-L, a child abuse Internet mailing list for physicians, which is located at Cornell University and co-managed by Ann S. Botash and Tom Hanna. The presentation of one of these cases on the list-serv prompted a discussion of the injury and aided the physician in making the correct diagnosis. This same discussion brought the 4 cases together and resulted in this report.
In summary, we report 4 children who sustained chemical/contact dermatitis of their buttock region after ingesting Ex-Lax. In each case, although an abusive scald burn was initially suspected, the history of the ingestion provided the necessary information to clarify the correct diagnosis. These cases also highlight the importance of Internet-facilitated communication among physicians in helping make the correct diagnosis in unusual cases.
- Received December 19, 1999.
- Accepted May 11, 2000.
Reprint requests to (J.M.L.) Department of Pediatrics, Yale University School of Medicine, 333 Cedar St, New Haven, CT 06520-8046. E-mail:
- Breimer DD,
- Baars AJ
- Verbo V
- Copyright © 2001 American Academy of Pediatrics