Invest Clin 47(3): 295-299, 2006 Contact dermatitis due to Para-Phenylenediamine (PPD) on a temporal tat too with Henna. Cross re ac tion to azoic dyes. María Cristina Di Prisco 1, Lluis Puig 2 and Agustín Alomar 2. 1 Instituto de Biomedicina (MSDS-UCV), Laboratorio de Inmunopatología y Consulta de Alergia, Universidad Cen tral de Ven e zuela. Ca ra cas, Ven e zuela y 2 Servicio de Dermatología, Hos pi tal de la Santa Creu i Sant Pau. Bar ce lona, España. Correo electrónico: mdiprisco@telcel.net.ve Key words: Henna, tem po rary tat toos, p-phenylendiamine, con tact der ma ti tis Abstract. Henna is used as a hair dye and to make tem po rary tat toos on the skin. It is usu ally mixed with p-phenylendiamine (PPD) to in crease col our in ten sity and to re duce the time of fix a tion on the skin pro teins. PPD can cross re act with azoic dyes which are used as tex tile dyes. We stud ied a pa - tient with skin ec zema in the area of a henna tem po rary tat too. The epicutaneous tests per formed with the stan dard Trolab and Chemotecnique hair dress ing and tex tile bat ter ies, showed pos i tive re sults to PPD, p-toluendiamine, 5-4aminophenol, Yel low 3, Or ange Red and Red 1, and neg a - tive re sults to three types of henna. The ec zema in this pa tient was due to sensi ti sa tion to PPD on a henna tat too with cross re ac tion to azoic dyes. The re cent fash ion of ap ply ing tem po ral tat toos in oc ci den tal coun tries may pro - duce an in crease in the fre quency of con tact der ma ti tis due to henna mix - tures with cross- re ac tion to re lated com pounds and pos si bly pro duc ing per - ma nent skin changes. Correspondence author: María Cristina Di Prisco. Instituto de Biomedicina (Ministerio de Salud y Desarrollo Social-Universidad Central de Venezuela). Apartado 4043, Caracas 1010 A, Venezuela. Correo electrónico: mdiprisco@telcel.net.ve
296 Di-Prisco y col. Der ma ti tis por contacto a para-fenilendiamina en un tatuaje tem po ral con Henna. Reacción cruzada con colorantes azoicos. In vest Clín 2006; 47(3): 295-299 Palabras claves: Henna, tatuajes temporales, p-parafenilendiamina, der ma ti tis por contacto. Resumen. La hen na se uti li za como tin te para el ca be llo y para rea li zar ta tua jes tem po ra les so bre la piel. Con fre cuen cia se le agre ga para-fe ni len dia - mi na (PPD) para acor tar el tiem po de fi ja ción del tin te a las pro teí nas de la piel y au men tar la in ten si dad del co lor. La PPD pue de oca sio nar reac ción cru - za da con los co lo ran tes azoi cos uti li za dos como tin tes en los pro duc tos tex ti - les. Estu dia mos un pa cien te con ec ce ma en el área de piel don de se ha bía prac ti ca do un ta tua je tem po ral. Las prue bas epi cu tá neas se rea li za ron con la ba te ría es tán dar de Tro lab y ba te rías de pe lu que ría y tex ti les de Che mo tec ni - que. Se ob tu vie ron re sul ta dos po si ti vos a PPD, p-to luen dia mi na, 5-4 ami no fe - nol, Ama ri llo 3, Na ran ja-rojo y Rojo 1 y ne ga ti vos a tres ti pos de hen na. El ec - ce ma en este pa cien te se de bió a la sen si bi li za ción a PPD en un ta tua je con hen na con reac ción cru za da a co lo ran tes azoi cos. La re cien te moda de apli car ta tua jes tem po ra les en paí ses oc ci den ta les está ori gi nan do un au men to de la fre cuen cia de der ma ti tis por contacto debida a mezclas con henna con reacción cruzada con compuestos relacionados y posiblemente ocasionando cambios permanentes en la piel. Received: 05-09-2005. Ac cepted: 16-02-2006. IN TRO DUC TION Henna (Lawsonia inermis) is a plant from the Lythracea fam ily cul tured in North Amer ica, In dia, Sri Lanka and sub trop i cal zones of Af rica. The pow der ob tained from its dry leaves is mixed with wa ter to ob tain a paste which pro duces a brown ish-red dye that has been used as a hair dye and for pro duc ing dec o ra tive de signs on the skin in the form of tem po rary tat toos. In In dia and the Magreb there is a tra di tional cus tom of per form ing col oured de signs on the skin due to so cial and re li gious mo tives. The ac - tive in gre di ent is 2-hydroxy-1,4- naphtoquinone (lawsone), has been used with cu - ra tive pur poses in sev eral skin dis eases, due to its ef fect of de creas ing the tem per a ture when the liq uid con tent evap o rates (1). Al ler gic re ac tions to henna are well known; nev er the less, even though var i ous clin i cal forms have been de scribed as ex - pres sion of these al ler gies, the fre quency of these re ac tions seems to be rare. Para-phenylenediamine (PPD) is a sensi tis ing com po nent com monly used in hair and tex tile dyes, and is also fre quently added to henna mix tures. This mix ture has the pur pose of in creas ing the in ten sity of the col our and re duc ing the time for fix a - tion on the skin, but it is for bid den in the United States be cause of its PPD con tent (2, 3). Azoic dyes, which in clude ap prox i - mately 40% of all tex tile dyes, can cross re - act with PPD. These prod ucts are among the most com mon causes for al ler gic con - tact der ma ti tis to tex tile dyes. Investigación Clínica 47(3): 2006
Con tact der ma ti tis on a tem po ral tat too with Henna 297 Since the chem i cal struc ture of lawsone is dif fer ent from that of azoic dyes such as Sol vent Red 1 and Sol vent Red 3, the pos si bil ity of cross-re ac tion be tween these dyes and lawsone is not prob a ble. Nev er the less, si mul ta neous sensitisations due to these mol e cules have been de - scribed, prob a bly due to the henna/ p-phenylene diamine mix ture (4). The fash ion of car ry ing tem po rary tat - toos has de ter mined that in re cent years henna be used more fre quently in oc ci den - tal coun tries. Even though its use is fre - quent, the re ac tions pro duced by this com - pound are rare. This pa per pres ents the study of a pa - tient who at tended at the Der ma tol ogy De - part ment, Sant Pau Hos pi tal be cause of ec - zema in the area of a col oured de sign made with henna. CLINICAL CASE An atopic, 32 years old, pro fes sional the ater ac tor pa tient, pre sented with an acute ec zema fol low ing ap pli ca tion of a henna base tat too on the left fore arm. Af ter six days a new ap pli ca tion of the henna base was per formed on the fig ure edges. A pruritic edem a tous ec zema ap peared af ter 4 days. The pa tient was treated with top i cal corticosteroids, and symp toms dis ap peared within a week. Nev er the less, at a threemonth eval u a tion a slight hy per pig men ta - tion per sisted on the af fected area, con serv - ing the mor phol ogy of the orig i nal de sign which sug gest chronic or per ma nent skin changes. Epicutaneous tests with the stan dard Trolab bat tery and the Chemotecnique hair dress ing and tex tile bat ter ies were ap - plied. The 96-hour read ing gave the follow - ing re sults: p-phenylendiamine (PPD) +++, p-toluendiamine +++, 5-4-aminophenol ++, Yellow3 +++, Or ange Red +++ and Red 1 +++. It is prob a ble that sensi ti sa tion oc - curred at the ap pli ca tion of the orig i nal tat - too, since the pa tient had no back ground of pre vi ous use of hair dyes and no clinic his - tory of tex tile al ler gies. Un for tu nately, it was not pos si ble to ob tain from the man u fac tur ers the orig i nal henna mix ture ap plied to this pa tient to per form epicutaneous tests. Nev er the less, we car ried out epicutaneous tests with three types of henna ob tained from a herb grower, i.e., ma hog any henna (Lawsonia alba), neu tral henna and a type called black henna, a type of pure henna with - out PPD con tent ac cord ing to the in for ma - tion ob tained from the man u fac tur ers. These henna pow ders were used in 1% and 10% wa ter di lu tions for epicutaneous tests which were neg a tive at 48 and 96 hours. DIS CUS SION The pres ent fash ion of us ing tat toos has in creased henna use in oc ci den tal coun - tries. Few con tact der ma ti tis cases due to this prod uct have been re ported (1, 5). This sug gests that ei ther henna al lergy is not fre quent, or that the cases oc cur ring have not been pub lished. In ter na tional lit er a ture points out ad verse side ef fects due to henna; a va ri ety of dif fer ent clin i cal pic - tures have been re ported such as asthma re ac tions me di ated by type I hy per sen si tiv - ity (6, 7), con tact re ac tiv ity due to im me di - ate hy per sen si tiv ity (8), ab nor mal pig men - ta tion of nails (9) and se vere tox ic ity with acute re nal in suf fi ciency and tu bu lar ne cro - sis (5), among oth ers. A re cent re port de - scribes two pa tients with per sis tent skin hy - per pig men ta tion at the henna tat too site sev eral months af ter the ap pli ca tion, which could pro duce per ma nent skin changes (10). Vol. 47(3): 295-299, 2006
298 Di-Prisco y col. It is only since 1997 that pub li ca tions be gan to ap pear dem on strat ing the mix ture PPD and henna and out stand ing its im por - tance as the cause of sensi ti sa tion in in di - vid u als who carry tem po rary tat toos (2, 11, 12). The pa tient stud ied by us showed strong pos i tive re ac tions to p-phenylen - diamine, p-toluenediamine, 5-4-amino - phenol and some azoic dyes. Even though we were not able to ob tain the henna mix - ture used for do ing the tat too, tests with the var i ous types of henna were neg a tive. As the pa tient was sensi tised to PPD, dem on - strated by the strong pos i tive patch test to the PPD an ti gen, the neg a tive re sults to the epicutaneous tests per formed with the var i - ous types of henna: ma hog any henna (Lawsonia alba), neu tral henna and a type called black henna, a type of pure henna with out PPD con tent ac cord ing to the in for ma tion from the man u fac tures, dem on strate that these types of henna did not con tain PPD. Oc ca sion ally, a hair dye called in digo is mar keted as black henna and do not con tain PPD, this may be the case in the black henna used by us. There fore, our re sults sug gest the pos - si bil ity that the mix ture used for the tat too con tained PPD and prob a bly some other sub - stances used to fix dyes to tis sues. The pos i - tive re ac tions to azoic dyes can be ex plained by the pres ence of cross-re ac tions to PPD (13). How ever, the pa tient had no clinic his - tory of re ac tions to tex tile al ler gies. There is no pos si bil ity of cross re ac - tions be tween henna and azoic dyes be - cause, even though we can see si mul ta - neous pos i tive re ac tions, the chem i cal struc tures of lawsone and azoic dyes are dif - fer ent (4). Rai son-peyron et al. (14) de scribed a clin i cal case of con tact der ma ti tis pro duced by the ap pli ca tion of a henna tat too where the epicutaneous tests were pos i tive for the henna paste used, for PPD, for N-isopropyl- N phenyl-para-phenylenediamine and for five tex tile dyes. On the other hand, the test with pure henna was neg a tive. The au - thors stud ied the mix ture used for tat too - ing us ing a liq uid chro ma tog ra phy tech - nique, and it was not pos si ble to de tect the pres ence of ei ther PPD or azoic dyes, which sug gests the pos si bil ity that some other non-iden ti fied hapten was in cor po rated in the mix ture. Mar tin et al. (15) have re cently re - ported the case of a pa tient with a henna tat too and pos i tive patch tests to PPD and thiuram and a pos i tive prick test to la tex, these find ings sup port im por tant ev i dences on the pos si bil ity that other sub stances might be also im pli cated in the skin re ac - tions to henna pseudo tat toos. The ad di tion of PPD to hair dyes is al - lowed in the United States and in the Eu ro - pean Com mu nity to a max i mum 6% con - cen tra tion in the re con sti tuted prod uct be - cause in these cases, when the mix ture is ox y gen ated, the pe riod of con tact with the skin is very short, thus de creas ing its sensi - tis ing po ten tial. With tat toos, con tact with the skin is much more pro longed and, there fore, the in cor po ra tion of PPD is for - bid den in prod ucts for top i cal use. The quan ti fi ca tion of PPD in tem po rary henna tat too has been sig nif i cantly higher than in com mer cial hair dye prep a ra tions (16). Nev er the less, it is dif fi cult to con trol the as - so ci a tions of these com pounds from di verse or i gins, so it is pos si ble that PPD or some of its de riv a tives may be pres ent in henna mix tures, and they may not be nec es sar ily men tioned in the doc u men ta tion in cluded with the prod ucts, if it ex ists. The re cent fash ion of ap ply ing tem po - rary henna tat toos has grown in oc ci den tal coun tries, which may orig i nate an in crease in the fre quency of oc cur ring con tact der - ma ti tis due to the use of henna mix tures, em pha siz ing the im por tance of this pub li ca - tion (17). Investigación Clínica 47(3): 2006
Con tact der ma ti tis on a tem po ral tat too with Henna 299 REFERENCES 1. Pasricha JS, Gupta R, Panjwani S. Con - tact der ma ti tis to henna (Lawsonia). Con - tact Dermatitis 1980; 6:288-289. 2. García-Ortiz JC, Terron M, Bellido J. Con tact Al lergy to henna. Int Arch Al lergy Immunol 1997; 114: 298-299. 3. Le Coz CJ, Lefebvre C, Keller F, Grosshans E. Al ler gic con tact der ma ti tis caused by skin paint ing (pseudotattooing) with black henna, a mix ture of henna and p-phenylenediamine and its de riv a tives. Arch Dermatol 2000; 136:1515-1517. 4. Wantke F, Götz M, Jarisch R. Con tact Der ma ti tis due to henna, Sol vent Red 1 and Sol vent Red 3. A case re port. Con tact Dermatitis 1992; 27:346-347. 5. Nigam PK, Saxena K. Al ler gic con tact der - ma ti tis from henna. Con tact Der ma ti tis 1988; 18:55-56. 6. Pepys J, Hutchcroft BJ, Breslin AB. Asthma due to in haled chem i cal agents, per sul fate salts and henna, in hair dress ers. Clin Al lergy 1976; 6:399-404. 7. Starr JC, Yunginger J, Brahser GW. Im - me di ate type I asth matic re sponse to henna fol low ing oc cu pa tional ex po sure in hair dress ers. Ann Al lergy 1982; 48:98-99. 8. Cronin E. Im me di ate type hipersensitivity to henna. Con tact Der ma ti tis 1979; 5: 198-199. 9. Dan iel CR, Osment LS. Nail pig men ta tion ab nor mal i ties; their im por tance and proper examination. Cutis 1982; 2:348-360. 10. Matulich J, Sullivan J. A tem po rary henna tat too caus ing hair and cloth ing dye al lergy. Con tact Der ma ti tis 2005; 53:33-36. 11. Tosti A, Pazzaglia M, Corazza M, Virgili A. Al ler gic con tact der ma ti tis to mehindi. Con tact Der ma ti tis 2000; 42:356. 12. Sidbury R, Storrs FJ. Pruritic Erup tion at the Site of a Tem po rary Tat too Am J. Con - tact Der ma ti tis 2000; 11:182-183. 13. Rietschel RL, Fowler JF. Tex tile and Shoe Der ma ti tis. In: Fisher s Con tact Der ma ti tis 5 th ed. Lippincot Wil liams & Wilkins. 2001. Chap ter 19. pp: 279-319. 14. Rai son-peyron N, Meunier L, Meynadier J. Eczéma de con tact à un tatouage la bile contenant du henné. Ann Dermatol Venereol 2000; 127:1083-1086. 15. Mar tin JA, Hughes TM, Stone NM. Black henna tat toos: an oc cult source of nat u ral rub ber la tex al lergy? Con tact Der ma ti tis 2005; 52:145-146. 16. Brancaccio R, Brown LH, Chang YT, Fogelman JP, Mafong EA, Co hen DE. Iden ti fi ca tion and quan ti fi ca tion of paraphenylenediamine in a tem po rary black henna tat too. Am J Con tact Dermat 2002; 13:15-18. 17. Lauchli S, Lautenschlager S. Con tact der - ma ti tis af ter tem po rary henna tat toos-an in creas ing phe nom e non. Swiss Med Wkly 2001; 131:199-202. Vol. 47(3): 295-299, 2006