Temporary Henna Tattoo Could Leave an Indelible Mark

[[{"type":"media","view_mode":"media_crop","fid":"49388","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_1796434603502","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"5953","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 334px; width: 435px; float: right;","title":"","typeof":"foaf:Image"}}]]While on vacation in the Caribbean, a man got a decorative temporary henna tattoo. The following day he developed pruritus and an eczematous dermatitis at the site of the tattoo. Six days later he scrubbed the tattoo off with soap and water, however the rash remained for several days.

What is the most likely diagnosis?

A. Sarcoid 

B. Allergic contact dermatitis

C. Impetigo

D. Sunburn on tattoo

Please leave your answer below; for answer and discussion, click here.

Answer: Allergic contact dermatitis caused by temporary henna tattoo

Henna tattooing (also known as mehndi, from the Sanskrit word mendika) is an ancient skin adornment custom practiced by Middle Eastern and South Asian cultures that has recently gained popularity as a temporary and painless alternative to permanent tattoos.¹ Henna is a natural reddish-brown pigment (Lawsone; 2-hydroxy-1,4-naphthoquinone) derived from the dried leaves of the Lawsonia inermis plant.^2,3 These leaves are ground into a fine powder and mixed with oil or water to create a paste that is applied directly to the skin in various patterns and designs.^2,3 With the increasing popularity of henna tattooing have come increasing reports of allergic contact dermatitis (ACD) associated with the practice.³  While 100% pure henna is pretty safe and is associated with very few reports of allergic reactions,^2,3 the vast majority of henna tattoo-induced ACD cases have been attributed to p-phenylenediamine (PPD), an additive commonly used in commercial henna products.^2,3 Since natural henna typically produces an orange or reddish-brown pigment, additives such as PPD are used to create “black henna” which produces a darker color, enhances the design pattern of the tattoo, and accelerates the dying process.^1,3 Other substances, including coffee or black tea, lemon juice, eucalyptus, clove or mustard oil, are also used, however PPD is the most commonly identified sensitizing agent.²

According to the Food and Drug Administration (FDA), the only legal use of henna and PPD in cosmetics is as a hair dye and neither is approved for direct application to the skin.⁴ Additionally, studies have indicated that the concentrations of PPD in temporary henna tattoo products (approximately 15%) is considerably higher than the recommended concentration of up to 5% PPD in hair dyes.¹ While hydrogen peroxide is used in hair salons to inactivate PPD in hair dyes, this practice is not used in the temporary henna tattooing process.³ The high concentrations of sensitizing materials, long duration of skin contact, and lack of a neutralizing agent dramatically increase the risk of skin sensitization to henna tattoo products containing PPD.²

[[{"type":"media","view_mode":"media_crop","fid":"49385","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_4340018545179","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"5952","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"width: 341px; height: 240px; float: right;","title":" ","typeof":"foaf:Image"}}]]Caution: cross-sensitization

PPD is a known skin and respiratory tract sensitizer and can induce cross-sensitization to other structurally-related compounds such as para-amino benzoic acid (PABA), sulfonamides, sulfonylureas, dapsone, azo dyes, and benzocaine.² Reactions to PPD in temporary henna tattoos are primarily type IV delayed-type hypersensitivity reactions. Type I reactions, presenting as angioedema, have also been reported.² Patients can present from 1 to 2 weeks after first exposure, however induction times can be as short as 24 to 48 hours if the patient had previous exposure to PPD-containing products or cross-reacting substances.² These reactions typically start with erythema and pruritus at the site of application and can develop into an eczematous, vesicular or bullous dermatitis following the pattern of the tattoo.⁵ Lichenoid or erythema multiforme-like reactions have also been reported.² These reactions carry a high risk of prolonged postinflammatory hyper- or hypopigmentation and can even result in hypertrophic or keloidal scarring.^2,3,6 Patch testing, which usually shows a strongly positive response to PPD, is not necessary for establishing the diagnosis.² However, if any question exists regarding the cause, patch testing can identify an allergy to PPD and be instrumental in guiding patient behavior.⁶ Treatment typically involves the use of oral antihistamines, topical corticosteroids and in severe cases oral corticosteroids.^5,7

Just say, "no"

With the increasing popularity of temporary henna tattoos, the incidence of PPD-induced ACD cases is expected to increase. Patients should be advised against this practice, as it is unregulated and the public is largely uninformed about the additives used in henna dye preparations.³ It is of paramount importance that the application of temporary henna tattoos be discouraged in infants and individuals with glucose-6-phosphate dehydrogenase deficiency, as Lawsone and its metabolites are capable of inducing life-threatening oxidative hemolysis.^2,6 Both practitioners and patients should be aware of the hazards associated with this practice and the potential for serious long-term complications.

References:

1.       Brancaccio RR, Brown LH, Chang YT, Fogelman JP, Mafong EA, Cohen DE. Identification and quantification of para-phenylenediamine in a temporary black henna tattoo. Am J Contact Dermat. 2002;13(1):15-18.

2.       Kazandjieva J, Grozdev I, Tsankov N. Temporary henna tattoos. Clin Dermatol. 2007;25(4):383-387.

3.       Ramirez-Andreo A, Hernandez-Gil A, Brufau C, et al. [Allergic contact dermatitis to temporary henna tattoos]. Actas Dermosifiliogr. 2007;98(2):91-95.

4.       US Food and Drug Administration. Temporary Tattoos, Henna/Mehndi, and "Black Henna": Fact sheet.  http://www.fda.gov/Cosmetics/ProductsIngredients/Products/ucm108569.htm. Accessed May 5, 2016.

5.       Yap F. An itchy erythematous temporary holiday tattoo. Tzu Chi Medical Journal. 2011;23(2):58-59.

6.       Jindal M, Davis B. Temporary henna tattooing--a risky procedure. Case report and literature review. Burns. 2003;29(8):866-867.

7.       Ip N, Hoddes J. Henna tattoo: infection or allergy? Lancet. 2014;383(9926):1436.