Allergic contact dermatitis from nonpermanent black henna tattoos has been frequently reported, particularly in children. Contamination or adulteration of the dyes with para-phenylendiamine has been identified as major cause of active sensitization and elicitation of severe allergic contact dermatitis. Sequelae include permanent sensitization, hyper- or hypopigmentation, scarring, keloids, and hypertrichosis. We report a rare case of irritant dermatitis to an unknown ingredient in a black henna tattoo with consecutive hypopigmentation. Sensitization to para-phenylendiamine and other para-compounds was excluded by patch test evaluation. This is relevant for future exposure to consumer products such as hair dyes or in occupational settings. Generally, black henna tattoos, particularly if done with dyes of unknown composition, should be strongly discouraged.
- PPD —
Para-phenylendiamine (PPD) is a well-known contact sensitizer, particularly present in hair dyes and in black henna tattoos.1 Undeclared concentrations between 1% to 63% PPD have been demonstrated in dyes used for henna tattoos.1,2 This may result in active sensitization in young individuals with long-term sequelae and consequences.3 We present an unusual irritant reaction from a black henna tattoo without sensitization to PPD but residual hypopigmentation.
While on holiday in Turkey, a 10-year-old white boy had a black henna tattoo applied to his upper arm. It was the first application of such a henna tattoo. One day later, he felt mild burning sensations without skin lesions. Four days later, he presented to our clinic. He had no history or signs of contact dermatitis, atopy, other allergic disorders, or vitiligo. On examination, mild erythema and black crusts exactly where the ornamental tattoo had been placed were present, without any infiltration, papules, vesicles, or spreading beyond its borders. The black ornament itself was raised and had the aspect of an eschar (Fig 1). After a 7-day treatment with mometasone furoate 0.1% cream, the necrotic epidermis had peeled off, and after 3 weeks a hypopigmented noninflamed exact outline of the tattoo persisted (Fig 2).
Patch tests including the European baseline series and PPD 0.3% in petrolatum were performed 3 weeks after healing of the reaction and obtaining informed consent. Readings at day 2 and 3 were negative apart from a positive test reaction to nickel sulfate. In consecutive patch tests, PPD was tested at 1.0% in petrolatum and a hairdresser and a textile dye series3 were applied, all test agents gave negative results.
Typically, patients who have applied black henna tattoos may become sensitized to PPD, and may then cross-react with other para-amino compounds such as p-toluene diamine, aminophenols, antioxidants used in black rubber (N′-isopropyl-N′phenyl-PPD),4 dyes used in textiles,5 and, more rarely, to local anesthetics of the ester family such as benzocaine.3,4
Other long-term sequelae after allergic contact dermatitis from PPD in henna tattoos include scars, keloids,6,7 hyper- and hypogmentation,1,8–11 and temporary hypertrichosis,12,13 particularly in children. Rarely, disseminated erythema multiforme has been observed.6
Our patient suffered from a mild localized burning without any inflammatory skin lesions within 1 day of applying a black henna tattoo. The black dye induced an escharlike circumscribed necrosis of the epidermis similar to a superficial chemical burn. Patch tests did not reveal sensitization to PPD or other para-compounds.2 According to the morphology, which was sharply confined to the site of application, the absence of any eczematous changes, the necrotic epidermis and its evolution, and finally the twice negative patch tests, we concluded that the patient suffered from an acute toxic reaction resulting in a superficial epidermal necrosis with consecutive hypopigmentation. The composition of the tattoo dye was unknown; apparently, it contained an irritant ingredient. Agents used in henna tattoo dyes to enhance the color intensity or shorten the time of drying may include lemon juice, eucalyptus and olive oils, vinegar, tea leaves, tannins, charcoal powder, lampblack, and, most often, PPD.14
A similar case with acquired leukoderma without any erythema or vesiculation 3 days after a dark-colored Arabian henna tattoo has been reported in an Indian girl.15 A toxic reaction was suggested because of the short time interval and the lack of erythema and vesicles.
Acquired chemical leukoderma has also been reported after long-term use of PPD-containing hair dyes.16 In our patient, topical corticosteroids to minimize inflammation and cutaneous sequelae were initiated, and a later patch test with PPD was negative. PPD may cause depigmentation by direct chemical action after allergic contact dermatitis and may aggravate vitiligo.17 Hair dyes and textiles containing PPD have been implicated as a common cause of leukoderma in a large study including >800 patients; however, confirmatory patch testing was not performed.17 Other allergens (eg, rubber components such as thiuram, natural rubber latex, and fragrances) have been reported to cause active sensitization or allergic contact dermatitis from black henna tattoos.18,19 Our patient had negative prick (latex) and patch tests to these substances. Heavy metals identified in henna tattoo dye mixtures include nickel, cobalt20 and lead.21 Our patient was sensitized to nickel; therefore, an allergic reaction to nickel traces cannot be definitely excluded. However, the morphology, the time pattern, and the evolution render an allergic contact dermatitis unlikely. Because of the relevance of sensitization to PPD and other para-compounds (eg, in occupational settings), we recommend performing patch tests in children who have had a cutaneous reaction to a henna tattoo. This is relevant for future exposure to consumer products such as hair dyes or in occupational settings. We strongly urge, however, that so-called black henna tattoos with dyes of unknown composition be completely avoided.
- Accepted February 27, 2013.
- Address correspondence to Andreas J. Bircher, MD, Allergy Unit, Department of Dermatology, University Hospital, Petersgraben 4, CH-4031 Basel, Switzerland. E-mail:
Dr Kind followed the patient, performed the patch tests, drafted the initial manuscript, and approved the final manuscript as submitted; Dr Scherer supervised the patient’s management and patch tests, reviewed and revised the manuscript, and approved the final manuscript as submitted; and Dr Bircher coordinated and supervised the whole procedure, critically reviewed, and finalized and submitted the final manuscript.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
- Copyright © 2013 by the American Academy of Pediatrics