Henna tattoo: infection or allergy?

Several types of alopecia may be triggered by scalp allergic contact dermatitis (ACD) including telogen effluvium1 and scarring alopecia.2 We hereby describe an unusual case of alopecia areata (AA) activated by severe ACD to a permanent hair dye. A 24-year-old male patient with no personal/family history of autoimmune disease, but with a history of henna tattoo reaction at the age of 12, presented with acute exudative dermatitis on his scalp, ears and neck following the first self-application of a black-coloured hair dye. Two weeks later, he suddenly developed patchy non-scarring scalp and beard hair-loss compatible with AA. Hair re-growth was slowly achieved upon treatment with oral and topical corticosteroids, and topical minoxidil (Figure 1) within 5 months. Patch tests were performed 15 months after the ACD reaction with the Spanish Contact Dermatitis Research Group (GEIDAC) baseline series (TRUE Test, AllergEaze, SmartPractice), supplementary allergens (AllergEaze) and a hairdressing series (AllergEaze), on Finn Chamber (SmartPractice) occluded for 48 h. Scoring readings were conducted according to the European Society of Contact Dermatitis (ESCD) guidelines.3 We observed intense reactions to p-phenylenediamine (PPD), PPD-related substances, hydroquinone and pyrogallol (Table 1; Figure S1). Two years after the events of ACD and AA, the patient was subsequently diagnosed with multiple sclerosis (MS). No flare-ups of the AA were observed within an 8-year follow-up. The likelihood of sensitization to PPD through the exposure to temporary ‘black henna tattoos’ is high (2.5%)4 and ACD reactions elicited by PPD among patients sensitized this way are often severe. Concomitant reactions to other p-aminoaryl compounds are also more frequent among individuals sensitized to PPD through exposure to henna tattoos than among hairdressers or hair dye users.5 Our patient likely became sensitized to PPD in the ‘black henna tattoo’ as a child and rapidly developed intense ACD after the first use of a black hair dye many years later. Strong patch test reactions suggested severe sensitization to hair dye components. We observed severe sensitization to PPD-chemically-related compounds likely due to co-sensitization or cross-reactivity. AA is an autoimmune disease that targets hair follicles leading to inflammatory non-scarring hair loss. AA may improve at the areas involved by other dermatoses such as psoriasis or ACD, the latter being the basis for the immune therapy with potent allergens such as diphenylcyclopropenone (diphencyprone). This is explained by a Rënbok6, 7 (reverse Koebner) phenomenon, originally described in patients with AA and psoriasis,7 which reflects a competition between different T-cell populations leading to a switch in the local cytokine milieu. Conversely, the Koebner phenomenon has also been described to cause AA relapse, for example, after performing perilesional trichograms.8 There is one prior report on AA developing 2 weeks after the second self-application of a permanent hair dye.9 The patient noticed slight burning but no other reactions. A ‘use test’ on his arm with the dye as is performed by the patient 3 weeks thereafter, triggered intense contact dermatitis at his face, arm and hand as well as a worsening of scalp hair loss.9 The authors hypothesized that ‘irritation’ caused by the dye could have disrupted the normal hair follicle immune privilege increasing the risk of AA.9 We believe that another possible explanation is that the initially subtle burning reaction experienced by the patient was truly allergic, as in our patient. Hypothetically, interactions among overlapping inflammatory pathways underlying ACD and AA could have played a role in the AA elicitation in both cases. Interestingly, our patient was subsequently diagnosed with MS, which has rarely been described as a co-morbidity of AA. In predisposed individuals, MS may be diagnosed prior to or after AA.10 AA may also be triggered by alemtuzumab, a therapy used in MS. This case further illustrates a possible association between AA and MS. We believe ACD should be considered a trigger for AA in predisposed individuals. Interactions among inflammatory pathways may likely be involved. Maria-Elena Gatica-Ortega: Conceptualization; formal analysis; funding acquisition; investigation; methodology; supervision; validation; visualization; writing – review and editing; writing – original draft. Elena Vera-Iglesias: Investigation. Blas Gómez-Dorado: Investigation. Cristina Pérez-Hortet: Investigation. María Antonia Pastor-Nieto: Conceptualization; investigation; funding acquisition; writing – original draft; validation; visualization; methodology; writing – review and editing; formal analysis. The authors declare no conflict of interest. The authors obtained informed written consent from the patient for the photographs to be published. FIGURE S1 Patch tests with readings performed on day (D) D2 (A) and D4 (B). Strong reactions to p-phenylenediamine (PPD), p-aminodiphenylamine, p-aminophenol, toluene-2,5-diamine sulphate and o-nitro-p-phenylenediamine; moderate reactions to 3-aminophenol and hydroquinone; and, weak reactions to pyrogallol, N-isopropyl-N-phenyl-4-phenylenediamine, disperse Blue 106 and rubber mix. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

In Africa, henna tattooing is generally practiced on the hands and feet during ceremonies such as weddings and baptisms. Many allergic reactions including allergic contact dermatitis have been described, not directly linked to pure henna, but especially to the addition of para-phenylenediamine. We report the case of a 35-year-old female patient who presented with allergic contact dermatitis following the application of a black henna tattoo. A 35-year-old woman presented with very itchy vesiculobullous lesions on the backs of the hands and forearms with a burning sensation 48 hours after the application of a black henna tattoo containing paraphenylenediamine (PPD) vesiculo-bullous, edematous lesions which sat at the tattoo site and exactly followed the initial design on the hands and forearms. The diagnosis retained was contact dermatitis allergic to black henna. Black henna tattooing is an ancient practice, responsible for a large number of allergic contact dermatitis due to the various products mixed with henna. It is therefore important that there be information, especially among young people, about the skin risks of this practice.

The black henna tattoo has been of use in Mexico for a long time. It has become popular in the last few years mostly in young children and adolescents. The traditional henna tattoo is obtained from the Lawsonia alba and inermis plant. However, para-phenylenediamine (PPDA) is added to this so it can last longer, look darker, and look like a permanent tattoo. This increases its allergic potential since it has no sanitary regulation of the concentration of PPDA that it is used. We present three cases of children with contact allergic dermatitis caused by black henna which resolved with low potency topical steroids. The objective of this is to educate contact health-care professionals to be aware of this adverse effect on black henna and also to educate patients and patients' families about the risk of applying it, since it can have severe allergic reactions.

Temporary 'black henna' tattoos, an increasingly popular body decoration in pediatric population, are associated with a growing incidence of adverse events. Black henna does not exist naturally, it is obtained from original henna after the addition of other compounds, among them paraphenilendiamine (PPD), which serves to darken the tattoo and allows greater precision to the design. PPD is known to be a strong sensitizer and increases the risk of allergic contact dermatitis. They may present as long lasting local reactions, and pigmentary sequels apart from problems with the future use of many products present in the daily life, as a result of sensitization by PPD. We report the case of an eleven-year old girl with an allergic contact dermatitis to black henna tattoo with a positive patch test to PPD, in order to warn against these types of temporary tattoos.

Henna, the dried and powdered leaf of Lawsonia inermis, is widely used as a dye for the skin, hair, and nails, and as an expression of body art, especially in Islamic and Hindu cultures. As it stains the skin reddish-brown, it is also called red henna. Black henna is the combination of red henna with p-phenylenediamine (PPD), and is used for temporary 'black henna tattoos'. This article provides a full review of the side-effects of topical application of red and black henna, both cutaneous (allergic and non-allergic) and systemic. Red henna appears to be generally safe, with rare instances of contact allergy and type I hypersensitivity reactions. In children with glucose-6-phosphate dehydrogenase deficiency, topical application of henna may cause life-threatening haemolysis. Black henna tattoos will induce contact allergy to its ingredient PPD at an estimated frequency of 2.5%. Once sensitized, the patients may experience allergic contact dermatitis from the use of hair dyes containing PPD. There are often cross-reactions to other hair dyes, dyes used in textiles, local anaesthetics, and rubber chemicals. The sensitization of children to PPD may have important consequences for health and later career prospects. Systemic toxicity of black henna has been reported in certain African countries.

To Tattoo or Not: That is the Question

A distinction needs to be made between ‘henna tattoo’ and ‘BLACK henna tattoo’. The injury seen on the 9 yr old boy was caused by ‘black henna’. Black henna contains little or no henna, instead it contains Paraphenaline-diamine, or PPD, a strong sensitizer which causes severe allergic reaction in a large percent of the population. It's part of a vascular surgeon's job to advise smokers to stop smoking, and 98% of members of the Vascular Surgical Society of Great Britain and Ireland do give advice ( Annals of the Royal College of Surgeons of England 2000;82:424–7). Only a minority give out written information, however, and even fewer (11%) run an antismoking clinic or group. Over half of the surgeons in this survey also counsel their junior staff about smoking. Whether the juniors take any notice could be the subject of another investigation. Researchers from Oklahoma took advantage of an “animal damage control” exercise to test 21 of the state's wild coyotes for infectious diseases ( Emerging Infectious Diseases 2000;6:477–9). Nearly three quarters carried Ehrlichia chaffeensis , the ricketsial pathogen responsible for human monocytotropic ehrlichiosis. White tailed deer are the best known carriers of E chaffeensis , which jumps to humans and domestic animals on board the lone star tick. Digestive surgery has …

Hypersensitivity to para-phenylenediamine (PPD) and related compounds induced by temporary black henna tattoos has become a serious health problem worldwide. Different patterns of sensitization with various clinical aspects are described in literature due to PPD associated to henna tattoo and these manifestations are likely correlated with the immunological and dermatological pathomechanisms involved. Henna is the Persian name of the plant Lawsonia inermis, Fam. Lythraceae. It is a woody shrub that grow in regions of North Africa, South Asia, India and Sri Lanka. Nowadays it is rather frequent to see temporary “tattoos” performed with henna. To make tattoos darker and long-lasting PPD has been associated to henna in tattoo drawings mixtures, so obtaining “black henna”. In these years there has been a rise of contact sensitization to PPD and in medical literature an increased number of cases have been reported on temporary henna tattoo application. Here we review the various clinical patterns related to PPD and henna tattoo, to investigate the possible link between clinic-morphological pictures and the immunological response to PPD and henna. The literature underlines that different clinical manifestations are related to black henna containing PPD, and its derivative products may cause delayed-type as well as immediate-type reactions. Further studies are needed to investigate the relationship between clinical and morphological aspects of PPD contact dermatitis and the T cell subsets predominance.

Henna is the powdered leaf of Lawsonia Inermis, and has been widely used as a dye for the skin, hair and nails. Black henna is composed of henna itself with p-phenylenediamine (PPD) and used for temporary black henna tattoos. The PPD compound of the henna transforms the harmless henna to an allergenic material and generalized erythema multiforme, Sweet’s syndrome, acquired leucoderma, urticaria and angioneurotic edema are the other reported rare complications of black henna tattoos. Localized hypertrichosis on the temporary henna tattoo is not a usual side effect and there are a few reports about this topic. The common point of these cases is disappearance of the hypertrichosis within 4-5 months. Notwithstanding the fact that the treatment is not certainly necessary, it could be a problem for some patients because of its cosmetic concern. This case is an example of localized hypertrichosis after henna tattoo and treated immediately with 755 nm Alexandrite Laser in one session.

The increased frequency of case reports of allergic contact dermatitis from non-permanent black henna tattoos in recent years shows the popularity of this form of body painting. Seven patients presented with allergic contact dermatitis after initial hair or eyelash dyeing. They all had a history of a previous reaction from a black henna tattoo. All were patch tested with the European standard patch test series and the standard supplemental series, as well as special series for dyes and hairdressers. All seven patients showed a positive reaction in patch testing with para-phenylenediamine (PPD) (0.3 % and/or 1.0 % in pet.). Five patients also had positive reactions to other dyes such as aminophenol, para-toluene diamine, disperse orange and yellow and four patients reacted to benzocaine. These were interpreted as cross-reactions. The time from sensitization by the black henna tattoo to the onset of allergic contact dermatitis after hair dyeing was an average of 6.2 years. The most common cause of allergic contact dermatitis after black henna tattoos is PPD. Both the long skin contact and the high concentrations of PPD increase the risk of sensitization. Allergic contact dermatitis may be followed by post-inflammatory hyper- or hypopigmentation, scarring and lifelong sensitization, which can have occupational impact, especially for hair dressers and cosmeticians.

Traditionally practiced in East Asian and Southeast Asian countries, Henna tattooing has gained western popularity in creating temporary decorative patterns on the skin. Derived from the Lawsonia inermis shrub prevalent in Asia/Southeast Asia, the leaves of this plant are ground to create a paste with a brown pigment commonly called Mehndi or Henna which have deep-rooted cultural values/practices. The pure organic form of these compounds has few reported side effects. However, with gaining western popularity, synthetic additives to the natural paste to create color variation, shorten application times, and increase shelf-life have led to an increase in the incidence of adverse reactions. Namely attributed to synthetic compounds like para-phenylenediamine (PPD) or para-toluylenediamine, this synthetic type of mixture is called black henna. Although multiple types of adverse reactions with black henna have been documented as an eczematous type of reaction, few if any cases of adverse reactions of black henna affecting patients with sickle cell disease (SCD) have been documented. In this case, we aim to present an atypical mixed bullous-eczematous contact dermatitis reaction secondary to a PPD containing black henna dye applied to the skin of a patient with homozygous SCD. We intend to raise awareness of the deleterious cosmetic sequelae and chronic post-dermatitis pain manifestations which may arise in patients with SCD, as the popularity of black henna tattooing grows in the United States where SCD is one of the most prevalent hemoglobinopathies amongst black Americans.

Henna has a very low allergic potential, and severe allergenic contact dermatitis is mainly caused by p-phenylenediamine (PPD), which is added to temporary black 'henna tattoos', and potentially also by some heavy metals. To determine the presence of, and quantify, Lawsone, PPD and heavy metal contaminants (cobalt, nickel, lead, and chromium) in commercial temporary black henna tattoo mixtures (n = 25) sold in Turkey. Lawsone and PPD concentrations were analysed with high-performance liquid chromatography, and heavy metal quantification was performed with inductively coupled plasma mass spectrometry. PPD was found in all 25 black henna tattoo samples purchased from tattoo shops; levels varied between 3.37% and 51.6%. Lawsone was detected (0.002-88.2%) in 21 of the 25 temporary black henna tattoo samples analysed. Heavy metal contaminant levels were 0.44-3.11 ppm for Co, 1.13-2.20 ppm for Ni, 1.59-17.7 ppm for Pb, and 35.0-76.9 ppm for Cr. Our results suggest that commercial temporary black henna mixtures containing PPD levels up to 51.6% pose a risk of contact sensitization and severe allergic contact dermatitis among users. It is important to identify both the additives and metallic contaminants of black henna tattoo products; the significance of metal contaminants has still to be assessed.

Herein are reported two cases of a previously healthy fourteen-year-old girl and a nine-year-old boy who presented to the Pediatric Emergency Department with a cutaneous reaction after applying a temporary black henna tattoo. Diagnosis of delayed hypersensitivity to black henna was established. Black henna tattoos are known for their temporary and harmless nature, but henna usually contains paraphenylendamine (PPD), originating black henna. PPD induces skin sensitization and causes allergic contact dermatitis.

Active sensitization to paraphenylendiamine (PPD) and related compounds from temporary black henna tattoos has become an epidemic in the recent years. Hair dyes also include PPD like black henna tatoos which cause allergic contact dermatitis. Skin lesions of allergic contact dermatitis from PPD are mostly seen as an exudative erythema, an erythema multiforme-like eruption or a bullous contact dermatitis. We, herein, report a 27 year-old woman with an angioedema-like reaction occurring after the first exposure to hair dye who was unaware of being previously sensitized to PPD from black henna tattoo.

Allergic skin diseases