Contact dermatitis to henna (Lawsonia)

Erythematous Linear Lesion on the Course of Superficial Fibular Nerve After the Topical Application of Black Henna: A Case Report

Henna is commonly used in body arts, where it produces orange-brown color. It is often mixed with chemicals such as para-phenylenediamine (PPD) to fasten the dyeing process and produce a black color. However, PPD has many allergic and toxic effects. We present a case of henna-induced cutaneous neuritis, which is not reported before. A 27-year-old female presented to our hospital, complaining of pain in her left great toe after applying black henna. Upon examination, the proximal nail fold was inflamed, and an erythematous non-palpable tender lesion was noticed on the dorsum of the foot. The lesion had an inverted-Y shape that was confined to the course of the superficial fibular nerve. Cutaneous nerve inflammation was favored after excluding all the anatomical structures in the region. Black henna should be avoided since it contains PPD, which can be absorbed through the skin and affect the underlying cutaneous nerves.

Adolescent and Young Adult Tattooing, Piercing, and Scarification

Tattoos, piercing, and scarification are now commonplace among adolescents and young adults. This first clinical report from the American Academy of Pediatrics on voluntary body modification will review the methods used to perform the modifications. Complications resulting from body modification methods, although not common, are discussed to provide the pediatrician with management information. Body modification will be contrasted with nonsuicidal self-injury. When available, information also is presented on societal perceptions of body modification.

Temporary Black Henna Tattoos and Sensitization to para-Phenylenediamine (PPD): Two Paediatric Case Reports and a Review of the Literature

Background: The use of temporary henna tattoos has increased dramatically in recent years, especially in children and adolescents. To obtain a darker colour and prolong the life of the tattoo, red henna, a plant-derived substance, is typically added to para-phenylenediamine (PPD). The mixture is called temporary black henna tattoo (TBHT). Because of its molecular characteristics, PPD can induce skin sensitization that may cause various clinical manifestations with successive exposures, among which the most common is allergic contact dermatitis (ACD). This report describes two paediatric cases of PPD sensitization and ACD after the exposure to TBHT and summarizes the literature on this emerging clinical problem. Case Presentation: We describe two cases of childhood-onset ACD that occurred 2 and 10 days, respectively, after the application of a TBHT during the summer holidays. Patch tests showed an evident positive response to 1% PPD in both cases. Sensitization to PPD occurred in the first case because a previous henna tattoo did not result in overt symptoms; in the second case, the reaction occurred after the same tattoo was retouched. In both cases, hypopigmentation persisted and both the patients and their families were advised to avoid further contact with PPD-containing materials and substances that could lead to cross-reactions. Conclusions: Sensitization to PPD is a growing phenomenon in children. The most common cause appears to be exposure to TBHT in which PPD might be present at unknown or high concentrations. Once sensitization occurs, patients may experience severe clinical symptoms which can present with a persistent hypopigmentation when they are re-exposed to substances that contain or cross-react with PPD. Given the widespread use of PPD, TBHT could adversely affect the daily life of paediatric patients; thus, for this reason, this practice as a fashion accessory must be discouraged. In addition, it is extremely important to provide scientific information on the risks of TBHT to consumers, especially to adolescents and to the parents of younger children to prevent PPD sensitization.

[Para-phenylenediamine allergic contact dermatitis due to henna tattoos in a child and adolescent population]

INTRODUCTION

Henna tattoos are a very common practice in the adolescent population. Henna is very often admixed with para-phenylenediamine (PPDA) to improve the appearance of the tattoo. PPDA is a potent allergen, and is a frequent cause of allergic contact dermatitis (ACD).

MATERIAL AND METHOD

A study was conducted on the results of 726 consecutive children who had been patch tested in the University General Hospital Consortium of Valencia between 1980 and 2015.

RESULTS

Almost half (49.7%; (361 cases) of the children had one or more positive patch test findings, with 4.7% (34) being allergic to PPDA. Mean age of patients allergic to PPDA was 12.4 years, and 44.2% were male. There were 2 cases (5.9%) of atopic dermatitis. Of the positive reactions, 73.5% were considered to be current clinically relevant. The sensitisation origin was a Henna tattoo in 50% of cases.

CONCLUSION

PPDA sensitisation is relatively common in the child and adolescent population. The most frequent origin is the performing of Henna tattoos adulterated with PPDA. Adolescents are at the higher risk of developing ACD due to Henna tattoos. Henna tattooing should be strongly discouraged in children.

Lawsonia inermis L. (henna): ethnobotanical, phytochemical and pharmacological aspects

ETHNOPHARMACOLOGICAL RELEVANCE

The use of Lawsonia inermis L. (henna) for medicinal and cosmetic purposes is inextricably linked to ancient and modern cultures of North Africa and Asia. Literature and artwork indicates that Lawsonia inermis played an important holistic role in the daily lives of some ancient cultures, providing psychological and medicinal benefits, as well as being used for personal adornment. Although henna was historically applied to the hands and feet to protect against fungal pathogens and to hair to combat lice and dandruff, other traditional uses include the treatment of liver and digestive disorders, reduction of tissue loss in leprosy, diabetic foot disorders and ulcers.

PHYTOCHEMISTRY

Almost 70 phenolic compounds have been isolated from various parts of the plant. Naphthaquinones, which include the dyeing principle lawsone, have been linked to many of the pharmacological activities. The terpene, β-ionone is largely responsible for the pungent odour of the essential oil isolated from the flowers. In addition to other volatile terpenes, some non-volatile terpenoids, a single sterol, two alkaloids and two dioxin derivatives have also been isolated from the plant.

BIOACTIVITY

Henna is a pharmacologically important plant with significant in vitro and in vivo biological activities. Although a myriad of pharmacological activities have been documented, the antioxidant and antimicrobial activities are the most thoroughly investigated. Some incidents of adverse reactions following application to the skin have been reported, but these are mainly confined to cases involving individuals with glucose-6-phosphate dehydrogenase deficiency and reactions to adulterants added to henna products.

CONCLUSIONS

Adulteration of henna is very common and may have resulted in unwarranted scientific findings. Phytochemical profiling studies of the plant, which are crucial for the establishment of proper quality control protocols, are lacking and hamper the development of medicinal products. Although many in vitro studies have been conducted to evaluate the pharmacological activities and many in vivo studies have focussed on the toxicity of extracts, more in vivo studies to validate pharmacological activities are needed. The roles of specific compounds and their synergies have not been comprehensively investigated.

Side-effects of henna and semi-permanent 'black henna' tattoos: a full review

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.

Determination of para-phenylenediamine (PPD) in henna in the United Arab Emirates

Henna is very popular in the United Arab Emirates (UAE); it is part of the culture and traditions. Allergy to natural henna is not usual; however the addition of para-phenylenediamine (PPD) to the natural henna increases the risk of allergic contact dermatitis. The objectives of the study were to identify the presence and concentration of PPD in henna available in UAE. Fifteen henna salons were selected randomly from three cities in UAE. Twenty five henna samples were acquired from these selected salons. The presence of PPD in henna samples was determined qualitatively and quantitatively using High Performance Liquid Chromatography (HPLC). The study showed that PPD was present in all of the black henna samples at concentrations ranging between 0.4% and 29.5% and higher than that recommended for hair dyes in most of the black henna samples. The presence of PPD in the black henna increases the risk of allergic contact dermatitis among users of black henna and a number of cases have already been reported in UAE.

Body-modifying concepts and dermatologic problems: tattooing and piercing

Recently, piercing and tattooing have gained increasing popularity worldwide, through all social classes and age groups. Besides pierced ear lobes, piercing of the tongue, nose, nipples, belly button, and even the genitals is quite common. The variety of tattoos range from temporary henna tattoos to permanent makeup and permanent tattoos, where the pigments are deposed in the dermis. These trends are supplemented by more invasive methods of body modification such as implanting, scarification, or branding. Parallel with the increasing popularity of piercing and tattoos, the knowledge about associated complications rose. Complications depend substantially on the circumstances in which body modifications are applied, the materials used, and the body region concerned. This article gives an overview of the most common complications of body modification methods, which mainly result from shortcomings in the application itself or in hygiene regimens. Consequences may be as severe as life-threatening events or permanent malfunction of different organs.

Vesicular erythema multiforme-like reaction to para-phenylenediamine in a henna tattoo

Allergic contact dermatitis reaction to topical "black henna" tattoo is usually described secondary to the organic dye para-phenylenediamine, a derivative of analine. Allergic contact dermatitis reactions to para-phenylenediamine are well recognized and most commonly involve an eczematous reaction that may become generalized and an acute angio-edema. Only four previous instances have been reported of an erythema multiforme-like reaction to para-phenylenediamine and its derivatives, including only one mild reaction to a tattoo. A vesicular erythema multiforme-like reaction has not been reported. An erythema multiforme-like reaction to contact allergens is usually caused by potent allergens including plant quinolones in Compositae and sesquiterpene lactones in exotic woods, and it is also reported to topical drugs, epoxy resin, metals (particularly nickel), and various chemicals. A generalized vesicular erythema multiforme-like reaction is unusual, and rarely reported. We describe a 6-year-old boy who developed a localized, eczematous and severe generalized vesicular erythema multiforme-like contact allergy to para-phenylenediamine secondary to a henna tattoo. As henna tattoos are becoming increasingly popular, one should be aware of the possibility of such a reaction. This presentation also highlights the call to ban the use of para-phenylenediamine and its derivatives in dyes.

Atopy to henna tattoos in children

Temporary henna tattoos are a popular fashion accessory in recent years. The tattoo dye consists of henna extract from the plant Lawsonia, and p-phenylenediamine to create a darker shade to the tattoo. Increasingly, emergency departments are seeing children with atopic reactions to these tattoos. The p-phenylenediamine component can cause a spongiotic dermatitis with lympho-histiocytic infiltrates. I present two cases of reactions to temporary tattoos in children attending the emergency department. The acute management of these cases and the possible future consequences of sensitization to p-phenylenediamine are discussed.

Acute allergic contact dermatitis due to para-phenylenediamine after temporary henna painting

The use of temporary natural henna painting for body adornment and hair dyeing is very common in several countries of the Indian subcontinent, Middle East, and North Africa, and the fad is spreading in other parts of the world. Several cases of para-phenylenediamine (PPD) contaminated, temporary traditional/natural henna induced sensitization and acute allergic reaction have been reported, along with occasional serious long term and rare fatal consequences. We report here a 17-year-old girl with blisters over her hands of five-days duration that appeared within 72 hours of applying a temporary henna paint to her hands during a social occasion. Similar lesions were noted on her face. She had previously applied black henna only once, a year earlier without developing any lesions. Clinical diagnosis of acute allergic contact dermatitis (ACD) was made. After a short course of oral corticosteroids, topical mometasone furaote 1.0% cream, and oral antihistamines, the lesions healed completely over the next four weeks leaving post-inflammatory hypopigmentation. Patch testing done with standard European battery, PPD 1% in petrolatum, and commercially available natural henna powder revealed a 3+ reaction to PPD at 48 hours. No reaction was seen at the natural henna site. Awareness of the condition among physicians and the public and regulation regarding warnings of the risks of using such products is urgently warranted.

Sensitization to para-phenylenediamine from a streetside temporary tattoo

"Temporary" henna tattoos (skin painting or pseudotattooing) are in vogue among American and European youngsters, particularly when vacationing. A 17-year-old girl presented with a severe contact dermatitis of her scalp and face after having dyed her hair with a permanent oxidative hair dye. She denied previous use of oxidative hair dye. Eight months earlier she had a "temporary" henna tattoo applied on her shoulder by a transient artist in downtown Montreal and developed an acute, erythematous, edematous eruption that resolved with residual, prolonged hyperpigmentation. As henna tattooing is a lengthy and tedious procedure, para-phenylenediamine (PPD) may be added to the mixture to accelerate the process, to darken, and to give more precision to the design. This short-lived fad can have longer-term sequelae then expected, ranging from postinflammatory hyperpigmentation of the tattoo site to permanent sensitization to PPD and related compounds.

[Allergic contact eczema caused by henna tattoo]

INTRODUCTION

Henna dye is obtained from the leaves of an indigenous tree, Lawsonia inermis. Contact dermatitis to henna is rarely reported. It is usually related to additives, especially oils or paraphenylenediamine. We report the case of a 9-year- old boy who developed an eczematous reaction at the site of application of a henna tattoo.

CASE REPORT

A henna tattoo was applied on the arm of a healthy 9-year-old boy on a Mediterranean beach. Four days later, the child noted pruritus followed multiple small papules and vesicles overlying the pattern of tattoo. He was treated with topical mometasone for 20 days, which produced gradual improvement and resolution.

MATERIAL AND METHODS

Two months later, a patch test (True test) was performed on the upper back. The results were observed after 48 and 96 hours and showed positive reactions to p-phenylenediamine, PPD mix (black rubber mix) and paraben mix and was negative to natural henna.

DISCUSSION

Skin painting with henna is traditionally performed in Muslims or Hindus. The painting is usually performed on the hair, palms, soles of the feet and nails with henna that gives a red color. The addition of p-phenylenediamine to the henna mixture darkens the color. The mixtures used by the "artists" contained natural henna (a rare sensitizer) and chemical coloring agents: diaminotoluenes and diaminobenzenes such as paraphenylenediamine. Today, paint-on tattoos drawn on the skin by street or beach artists are very fashionable among Europeans in holiday resorts. Because of the worldwide fashion of skin painting, future cases of sensitization to p-phenylenediamine are expected.

Allergic reactions to decorative skin paintings

BACKGROUND

Dye mixtures containing henna, P-phenylenediamine (PPD), and indigo are applied to the skin in various parts of the world for religious purposes, social recognition or fun.

AIM

To identify eventual allergens responsible for contact sensitization to skin decoration in three young children. Lesions remained strictly limited to the site painted during the summer holiday. None of the children had a previous history of contact dermatitis, but two of them suffered from severe seasonal allergic rhinoconjunctivitis.

FINDINGS

Patch testing revealed severe contact hypersensitivity to PPD in all three patients, and one child presented a positive prick test to 1% henna in water. The eruptions resolved following spontaneous elimination of the dyes and topical applications of corticosteroids, but left residual depigmentation.

CONCLUSION

PPD is the main allergen identified in allergic reactions to decorative skin paintings.

Occupational skin disease in hairdressers

Hairdressers belong to an occupational group that is commonly affected by occupational skin disease, specifically contact dermatitis, which may be allergic or irritant and, less commonly, contact urticaria. Occupational contact dermatitis predominantly affects apprentices, and atopy is a recognized risk factor associated with a poor prognosis. Repetitive wet work leading to irritant contact dermatitis, followed by exposure to allergens and the development of allergic contact dermatitis, are the main factors contributing to occupational contact dermatitis. Once developed, it is often difficult to manage and is a cause of significant morbidity. Early education, training and prevention is the best approach to the management of this disorder that is endemic among hairdressers.

Severe allergic contact dermatitis induced by paraphenylenediamine in paint-on temporary 'tattoos'

Paraphenylenediamine (PPD) is a black dye with well known sensitizing properties. Its increasing use as a skin paint to produce temporary 'tattoos' has led to recent reports of allergic contact dermatitis. Hitherto, such cases of allergic contact dermatitis due to PPD have been localized to the original site of application of the skin paint. We report two cases of severe allergic reactions to paint-on 'tattoos'. Both of these patients had no prior history of sensitivity to PPD, although case 2 had previously used permanent hair dyes. In both cases, the primary eruption at the 'tattoo' site was followed within days by a generalized eruption which ultimately required treatment with oral corticosteroids, because the initially prescribed topical corticosteroids proved ineffective.

Henna (Lawsonia inermis Linn.) inducing haemolysis among G6PD-deficient newborns. A new clinical observation

Over a 10-year period, 15 glucose-6-phosphate dehydrogenase (G6PD)-deficient male newborns were admitted to Al-Jahra Hospital with acute haemolysis a few days after applying henna dye over the body, which is a unique Bedouin tribal practice to celebrate the arrival of the first-born boy. Laboratory investigations revealed significant anaemia, reticulocytosis and indirect hyperbilirubinaemia among the index newborns as compared with controls (p < 0.001). The mean (SD) haemoglobin concentration in index patients was 113.4 (13.4) g/l vs 171.2 (11.2) g/l in controls, reticulocytic count 13.8% (4.2%) vs 1.4% (0.74%), and indirect bilirubin 382.8 (58.7) mumol/l vs 63.7 (61.4) mumol/l. G6PD-deficient newborns with haemolysis linked to henna application had delayed age at presentation and a higher reticulocytic count and hyperbilirubinaemia compared with non-henna-induced haemolysis (p < 0.05). Percutaneous henna absorption is well recognized and clinical findings support the harmful effect of henna on G6PD-deficient red blood cells. A local health education programme has been established to prevent the use of henna dye in infancy.

Occupational asthma and rhinoconjunctivitis caused by senna

Occupational sensitization to senna is seldom reported. We describe a 21-year-old male atopic factory worker who developed IgE-mediated asthma and rhinoconjunctivitis 5 months after exposure to senna while he was working for a company manufacturing hair dyes. In the bronchial challenge test with senna, he exhibited a strong reaction. The skin prick test gave a 12-mm wheal reaction. The radioallergosorbent test (RAST) with senna was highly positive (33.6 PRU/ml, class 4), and could not be inhibited with pollens or foods. In protein staining with SDS-PAGE, two heavy bands were detected in senna at about 14 and 25 kDa, and two faint bands were visible at 19 and 21 kDa, In IgE immunoblotting with the patient's serum, one heavy band was detected at about 16 and four faint bands at 23, 25, 28, and 38 kDa. The patient became symptom free after he had changed his job within the same company.

Contact dermatitis in hairdressers

18 cases of hand dermatitis in hairdressers seen over a 5-year period are reviewed. The diagnoses in these patients are discussed with reference to other studies of hand dermatitis in hairdressers. Contact allergy due to paraphenylenediamine and related hair dyes was the presenting complaint in younger hairdressers, while formaldehyde allergy occurred in those who were older. The prognosis in the former group of workers with respect to continued employment in the trade tended to be poorer than the latter. Follow-up revealed that hand dermatitis often resulted in the worker not continuing to work in the hairdressing trade.