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Year : 2021  |  Volume : 24  |  Issue : 2  |  Page : 96-98

Neonatal lower limb gangrene: Effect of local cosmetic agent

Federal Medical Centre, Birnin Kebbi, Kebbi State, Nigeria

Date of Submission10-Jan-2020
Date of Acceptance29-Jun-2020
Date of Web Publication13-Jul-2021

Correspondence Address:
Dr. Oni Nasiru Salawu
Department of Surgery, Federal Medical Centre, Birnin Kebbi, Kebbi State
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/smj.smj_2_20

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Limb gangrene is a common orthopedic emergency in this part of the world, but neonatal limb gangrene is a rare pathology. Sepsis is a common complication of limb gangrene which can lead to mortality if not managed early. Here is a case of left leg gangrene in a 16-day-old female neonate following the application of local cosmetic agent ("lele") by the mother prior to naming ceremony. The patient presented with features of septicemia; she was resuscitated, and left below-knee amputation was done for her. Harmful and unnecessary cosmetics should be avoided in neonates.

Keywords: Cosmetics, gangrene, neonate

How to cite this article:
Salawu ON, Ibraheem G H, Mejabi J O, Nwosu C, Ahmed B A, Suleiman A K, Babalola O M. Neonatal lower limb gangrene: Effect of local cosmetic agent. Sahel Med J 2021;24:96-8

How to cite this URL:
Salawu ON, Ibraheem G H, Mejabi J O, Nwosu C, Ahmed B A, Suleiman A K, Babalola O M. Neonatal lower limb gangrene: Effect of local cosmetic agent. Sahel Med J [serial online] 2021 [cited 2023 Dec 4];24:96-8. Available from: https://www.smjonline.org/text.asp?2021/24/2/96/321241

  Introduction Top

Many studies have reported traditional bone setter's intervention for fractured limbs as the most common cause of limb gangrene necessitating amputation in Nigerian children. In neonates, other causes of limb gangrene include thromboembolic events, sepsis, congenital bands, umbilical arterial cannulation, and idiopathic causes.[1],[2],[3],[4]

The standard treatment for a gangrenous limb is amputation. This must be done as soon as possible to prevent septicemia, which can lead to mortality. Neonates with lower limb amputation will require serial change of limb prostheses in childhood as they grow older, to ensure proper ambulation.[1],[5]

Application of a local cosmetic agent "lele," is a common practice for females in the northern part of Nigeria, where it is used to beautify the hands and feet. It is mainly used by adults but sometimes applied on neonates. Lele is made from natural products, though recently, synthetic agents are sometimes added to make it darker when it is applied on the skin. To the knowledge of the authors, this is the first report of neonatal limb gangrene as a result of lele application.

  Case Report Top

A 16-day-old female neonate presented to the state general hospital, Birnin Kebbi, on account of a 1-week history of multiple blisters in the lower limbs, which were worse on the left. There was also progressive darkening of the skin on the left lower limb.

She was a product of 40 weeks' gestation delivered through spontaneous vaginal delivery by a 26-year-old para two (two alive) woman. The pregnancy was booked in the hospital, and pregnancy and the delivery were uneventful.

On the 6th day of life, a local cosmetic agent (lele) was applied on to the feet and hands of the neonate by the mother. The mother added a black hair dye to the lele mixture to make it darker on the skin [Figure 1]. She applied the mixture first to the left leg of her baby, after which she diluted the mixture with water because she felt it was too concentrated. She applied the diluted mixture on the right foot, leg, and the hands. By the following day, she noticed blisters on all the areas where the lele was applied with the left leg most severely affected. A few days later, she noticed progressive darkening of the skin on the left leg, while the blisters on the other limbs resolved progressively [Figure 2]. There was no history of fever prior to application of lele, the patient was not given any injection (yet to be given any form of immunization drug) before the onset of blisters, neither was there history of peripheral or central vein cannulation in this patient prior to onset of this pathology.
Figure 1: Synthetic hair dye (used as part of “lele” component in this patient)

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Figure 2: The neonate with gangrenous left leg

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At presentation, 1 week after the onset of the blisters, there was gangrene of the left leg up to about 6 cm below the knee joint, with associated features of sepsis. Full blood count was done which showed elevated white blood cell count with relative neutrophilia, electrolyte, urea, and creatinine showed feature of normal renal function. She was placed on intravenous antibiotics, and she had emergency guillotine left below-knee amputation. The sepsis resolved a few days after surgery with daily wound dressings and antibiotics. Stump refashioning was done a week after the primary surgery, and she was discharged home after 3 weeks of admission.

  Discussion Top

The basic health needs of a neonate include exclusive breastfeeding, adequate immunization, and to keep them warm in a clean environment.[6] These ensure proper growth and help to avoid sepsis which is a major cause of mortality in neonates in this environment. Applying mixtures of cosmetic agents on the skin of neonates should be done with caution as the chemical constituents are often unclear and may be toxic to the fragile skin of the neonates. In the index case, the synthetic agent added to the mixture of lele probably was too toxic to the skin of the neonate leading to circumferential cellulitis on the limb with likely compartment syndrome and occlusion of blood supply to the limb leading to the eventual gangrene.

Early presentation at the hospital after the onset of the blistering with appropriate intervention may have halted the cascade of events that eventually lead to the gangrene. At the eventual time of presentation, however, there was no viable option of limb salvage. Delay in amputation for the already established gangrene would have been dangerous for the neonate as has been pointed out in a previous report.[7]

A two-stage below-knee amputation was done in this patient (rather than closed knee disarticulation) to preserve the knee joint and the proximal tibial physis. The preservation of the knee joint, even with a short stump, is justified in children because there is a good growing potential due to the proximal tibial physis, which is responsible for 60% of the total growth of this bone. Besides this, the gait of children with knee disarticulation, while acceptable in moderate activities, is worse for activities eliciting larger physical performance, such as racing and practicing sports.[8] The possibility of appositional bone overgrowth which could necessitate stump refashioning during growth was explained to the parents prior to the surgery.

The long-term management of such patients should be multidisciplinary. While infant amputees tend to have less psychological problems from the loss of their limbs, proper psychiatric evaluation and care is important, especially when the child grows to teenage years. The parents also need adequate psychosocial support, especially in the years following the loss of the child's limb. Special physiotherapy and prosthetic services are required to ensure appropriate prosthetic fitting. Frequent change of prosthesis will be required as the child grows, and the services of the orthopedic surgeon will continuously be needed to manage any stump complications that may arise as the child grows.[9] The parents should be ready to support the child psychologically and physically as she grows older.

  Conclusion Top

Care should be taken in mixing different agents for cosmetic purposes. Because of their particularly sensitive skin, lele should be avoided in the neonates.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.


The authors would like to thank all doctors in the Orthopedic Unit, Federal Medical Centre, Birnin Kebbi.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Salawu ON, Babalola OM, Mejabi JO, Fadimu AA, Ahmed BA, Ibraheem GH, et al. Major extremity amputations: Indications and post surgery challenges in a Nigeria institution. Sahel Med J 2019;22:8-12.  Back to cited text no. 1
  [Full text]  
Ayyad A, Messaoudi S, Amrani R. Congenital gangrene: A rare condition during the neonatal period: A case study. Pan Afri Med J 2019;28:33-59.  Back to cited text no. 2
Quddus AI, Nizami N, Razzaq A, Husain S. Bilateral gangrene of lower limb in a neonate. J Coll Physicians Surg Pak 2014; 24 ( Suppl 2):s119 s120 .  Back to cited text no. 3
Singh J, Rattan KN, Gathwala G, Kadian YS. Idiopathic unilateral lower limb gangrene in a neonate. Indian J Dermatol 2011;56:747-8.  Back to cited text no. 4
[PUBMED]  [Full text]  
O'Keeffe B, Rout S. Prosthetic rehabilitation in the lower limb. Indian J Plast Surg 2019;52:134-43.  Back to cited text no. 5
Labib A. Sepsis care pathway 2019. Qatar Med J 2019;2019:4.  Back to cited text no. 6
Salawu ON. Neonatal lower limb gangrene: Avoidable causes noticed in North-West Nigeria. J Orthop Traumatol Rehabil 2017;9:53-5.  Back to cited text no. 7
  [Full text]  
Loder RT, Henry JA. Disarticulation of the knee in children: A functional assessment. J.Bone Joint Surg 1987;69A: 1155.  Back to cited text no. 8
Khan MA, Javed AA, Rao DJ, Corner JA, Rosenfield P. Paediatric traumatic amputation: The principles of management and optimal residual limb lengths. World J Plast Surg 2016;5:7-14.  Back to cited text no. 9


  [Figure 1], [Figure 2]


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