Cutaneous reactions to temporary tattoos
1. The Dermatology Unit, Kaplan Medical Center, Rechovot, and the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel. 2.The Pediatric Outpatient Clinic, Hasharon Region, Kupat Holim, Israel. firstname.lastname@example.org
While allergic reactions to henna painting are extremely rare, we have witnessed an increasing number of reports of cutaneous reactions after henna tattooing, also called temporary tattooing. The reason for this lies in the contemporary composition of the paint, which contains paraphenylenediamine (PPD). We present six patients who developed allergic contact dermatitis after skin painting with "black henna", and who showed hypersensitivity to PPD. We discuss the issue of the short sensitization period of our patients and the reported ones.
Dermatologists should know that there is no such thing as black henna. The mixtures used by contemporary artists contain PPD, to speed up the tattooing process and to achieve an ebony tone. We believe that the benefits of speeding the process and darkening the color are not worth the end result of increasing allergic reactions.
Report of cases
An 11 year old male was admitted to our outpatient clinic because of an erosion on his right arm, which appeared one day after application of a temporary henna tattoo.
Patch tests were performed with the European Standard Series and with the Textile Color & Finish Series (TCFS) (both from Chemotechnique Diagnostics, Sweden), according to the revised guidelines of the International Contact Dermatitis Research Group. The results of the patch tests were observed after 48 and 72 hours. We observed a strongly positive reaction (erosion) to paraphenylenediamine (PPD) and 2+ reactions to benzocaine and fragrance mix. There was no reaction to any TCFS components.
An 18 year old female had a temporary tattoo painted on her left lower leg and lower back. She developed a reaction in both tattoos within four days. There was a raised erythematous plaque within the borders of the tattoo on the lower back while the reaction on the leg was limited to raised erythematous lines at the sites of the tattoo lines. She was patch tested in the same manner as patient 1 and showed a strongly positive reaction (3+) only to PPD.
An 11 year old male developed an erosion confined exactly to the henna tattoo that was made on his right lower leg four days earlier. The European Standard Series showed a strongly positive reaction (3+) to PPD.
A 17 year old female had two temporary tattoos painted onto both her upper arms. Four days later, she noticed elevated, erythematous, itchy papules precisely at the lines of the tattoo. The European Standard Series showed a strong positive reaction (3+) to PPD.
An 18 year old male developed an elevated, erythematous, itchy reaction on his lower back along the lines of a tattoo that had been done one week earlier. The eruption had a papular, lichenoid appearance when we first saw him two weeks later. The European Standard Series showed a positive reaction (2+) to PPD.
A 12 year old girl presented with an erosion on her left upper arm that developed three days after she underwent temporary tattooing. Three weeks later, there was a papular, erythematous eruption confined to the tattoo area and following its lines. No patch tests were performed.
Henna has been used to paint the skin for adornment and for religious reasons for 9000 years and in over 60 countries. Christians, Jews, Muslims, Hindus, and Buddhists have used henna as part of their social and religious customs. Particularly well known is the tradition of "The Night of the Henna" (also called the Mehndi ceremony). It is held sometime before the wedding ceremony and consists of applying mehndi (henna paint) on the hands of the bride. It is a very festive occasion that is accompanied by dancing and feasting. This ceremony probably originated in the Muslim world and was adopted by the Jewish and other religions around 1000 BCE and is actively practiced to this day.
Henna is the Arabic name for a bush whose botanical name is Lawsonia (inermis, alba). It grows only in climates in which the nights are always warm, in Asia, the eastern Mediterranean, and North Africa. The leaves harvested from this bush are dried and powdered. The powder is mixed with oil, lemon, and various other ingredients, and the resultant paste is then applied to the skin and left there for several hours (6-12) in a hot and humid environment. The pigment binds to the skin and achieves the desired stain (tattoo). The longer the henna remains in contact with the skin, the darker will be the resulting color.
Pre-made paste or "do-it-yourself" kits are commercially available. Alternatively, the tattooing paste can be blended from the raw natural powder which is mixed with other ingredients according to an endless number of recipes. The paste releases a dye (hennotannic acid), which has a high affinity for skin keratin, and this is what stains the skin. The henna stain lasts until the outer layer of the skin exfoliates. This takes several weeks for skin as thick as the soles of the feet, about three weeks for ordinary skin, and one week for areas with very thin skin. Henna is also widely used as a hair dye and as a type of nail "polish."
Body decoration with temporary tattoos has become a very popular alternative to the traditional, permanent tattoo, capturing the fancy of people of all ages ever since the Spice Girls decorated themselves with these body designs. In contrast to permanent tattooing, it is a painless procedure that involves no needles. There is no skin penetration or piercing, but rather just the application of a paste. Moreover, since the tattoos are not permanent, no proficiency, specific expertise, skill, or artistic talent is required to apply them. There is no risk of introducing infective agents.
Contact dermatitis as a reaction to pure henna is extremely rare despite its frequent and repeated use over thousands of years all over the world.[3, 4, 5, 6, 7] For example, it has been estimated that at least half the population of India has been exposed to henna at some time in life, so it can be assumed that its sensitizing potential must be negligible.
Since the late 1990's, however, we have witnessed an increasing number of reports concerning reactions to such temporary tattoos, most of them having been presented as case series.[8-29] This raises the question of what happened to the harmless and natural material that suddenly, after thousands of years of safe use on millions of people, has begun to cause so many allergic reactions. The answer clearly lies in the contemporary composition of "black henna." To begin with, we dermatologists should know that there is no such thing as black henna. Henna gives an orange/reddish-brown stain. Any product that calls itself black henna must contain an ingredient in addition to pure henna to achieve its ebony color. In most cases, this added ingredient is PPD, that is also found in many black hair dyes. Another reason for using PPD additives is to speed up the tattooing process. While traditional henna staining takes 2-12 hours, a pure black tattoo can be achieved within an hour or two with the addition of PPD, and there will be a longer lasting effect as well.
The findings of a mass spectrometry analysis of commercial black henna performed by Chung et al. demonstrated a major peak at the mass-charge ratio of 108.1, which corresponds exactly to the molecular weight of PPD. There was no line at the molecular weight 174.2, that of the active agent of pure henna. This was the first sophisticated, scientific proof of what almost every tattoo artist or supplier had known for years.
Another important issue that should be addressed is the very short sensitization period involved. In our cases of temporary tattoo reactions, as well as in many other reported ones, it took 3 to 4 days for the reactions to develop. It is generally accepted that the induction of allergic contact dermatitis takes at least 7-10 days when a new antigen is introduced. The strength of our patients' reactions to PPD makes it very probable that this was the relevant allergen and the cause of their dermatitis. One possible explanation for the short incubation period is that these patients had already been sensitized to PPD, hence the early, severe reactions. Since our patients were all of school age and had neither occupational exposure, nor history of dyed hair, this hypothesis would appear to be incorrect. It seems, however, that Patient 1 was an exception as he had probably been sensitized to other "para" substances (probably benzocaine) before the tattoo was performed. This speculation is also supported by his very short sensitization period of only one day after painting, and by the number of positive test reactions he exhibited. In the other cases, the short sensitization period may be due to the potency of PPD as sensitizer. Patch testing has been shown to actively sensitize patients and when this happens, it not infrequently occurs after only 2-3 days. Thus, although it usually takes more than one week for an individual to become sensitized, there are exceptions, especially with such potent sensitizers as PPD. Furthermore, the recommended concentration of PPD in patch tests is 1%, whereas the concentration of this toxic substance in skin paintings is over five times greater. The possibility of irritancy contributing to the very erosive reactions and the short incubation period cannot be excluded.
Finally, as mentioned earlier, some additional substances that speed up the staining are added to the tattoo mix. They usually consist of eucalyptus, clove or lavender essential oils, lemon oil, vinegar and many other 'secret' additives. PPD is usually dissolved in organic solvents and the mixture is usually kept under a plastic wrap in a humid environment. All these measures that are intended to darken and intensify the color and reduce application time also enhance penetration of the substance and thus are probably also partially responsible for the shorter sensitization time and possibly some irritancy. We believe that all these factors contributed to a shorter onset of reaction than the usual one.
In summary, our forefathers appeared to be in less of a hurry to see results and apparently black staining was not the fashion of the time. As a reward, their cutaneous henna applications did not cause significant reactions. It would serve today's customer well if the appliers of henna would stick to the original formula and respect the lessons of the past.
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