Cosmetic Dermatitis From a Henna "Tattoo"
Case In Point
An Intriguing Diagnosis
A 16-year-old Somali girl presents with a 3-day history of bilateral arm swelling and painful vesicular eruptions; her symptoms are worsening. She reports that 5 days earlier, she and her friends had used henna and black hair dye to “tattoo” their skin. The others have not experienced similar signs or symptoms. This patient has used henna (which is dark red) since childhood for decorative purposes. However, outlining an intricate design with hair dye is new for her.
The patient has no significant personal or family medical history and is not taking any medication. She arrived in the United States 3 years earlier and has had no health concerns. A review of systems reveals no fever, cough, chills, shortness of breath, or other concerns.
Vitals signs are not worrisome. The physical examination is unremarkable except for the bilateral upper extremities. The central part of the tattoo is dark red, but not erythematous, warm, or edematous (Figure). Vesicles containing clear fluid are noted at the edge of the design. There is mild to moderate hand edema. Radial pulses are intact. There is no sign of cellulitis, fasciitis, or compartment syndrome. Results of a complete blood cell count are normal.
This patient is hospitalized and treated for severe cosmetic dermatitis with systemic corticosteroids, diphenhydramine, and daily dry dressing changes. Ibuprofen is instituted for discomfort. Antibiotics are not ordered. The patient remains afebrile and is discharged on hospital day 2 with close follow-up and daily dressing changes. She is advised to avoid contact with all hair-dye products.
Henna is derived from an extract of Lawsonia inermis, a plant ubiquitous in India. It has been used for cosmetic and medicinal purposes since 9000 BC. Historically, headaches, burns, oral cavity ulcers, fungal nail infections, jaundice, splenomegaly, and backaches were treated with henna.1 The most popular modern-day use of henna is by many religious and cultural groups for cosmetic reasons. Orthodox Jewish and conservative Muslim women are allowed to use only henna to color their hair and nails; other dying agents are unacceptable. When making offerings to their gods, Hindus apply henna to their hands. Some African and Middle Eastern cultures use henna for women the night before their weddings in a sacred ceremony. Other religions and cultures have adopted these customs, and members superficially apply extensive designs and symbols to adorn their skin.2 “Skin staining” or “temporary tattooing” refers to this practice.
“BLACK HENNA” AND CONTACT DERMATITIS
Henna is red and temporarily discolors skin. The redness can be modified naturally to darker shades. However, as the popularity of henna has spread, the natural ingredients of henna have been replaced. “Black henna” is very dark and is made by adding components not found in traditional henna. Hair dye is the most commonly used darkening agent. Because of the added chemicals, many conservative groups do not consider black henna acceptable.
The incidence of contact dermatitis caused by henna alone is low. However, studies have proved that para-phenylenediamine—a chemical in hair dye—is responsible for most cases of contact dermatitis associated with black henna.3-5 Other chemicals in hair dye that are related to paraphenylenediamine have been implicated as causes for the contact dermatitis experienced with black henna. However, testing for these other components is unavailable.4
Because of the strong association between para-phenylenediamine and significant contact dermatitis, the Scientific Committee for Cosmetic Products and Non-Food Products Intended for Consumers issued a position statement discouraging the use of para-phenylenediamine for skin staining.6 Any allergic reaction to hair dye sensitizes patients; therefore, future exposure (on the skin or scalp) results in severe dermatitis. In addition, textile dyes may cross-react with para-phenylenediamine.
COSMETIC DERMATITIS
Cosmetic dermatitis affects approximately 3% of the population. Many chemicals found in perfumes, make-up, lotions, and deodorant are allergenic. Patch testing is available to confirm which chemical and/or product is causative. Cosmetic dermatitis is a type of contact dermatitis.
Contact dermatitis can be allergic,irritant, or photosensitive. Hair dye most often results in a delayed-hypersensitivity allergic contact dermatitis. Therefore, initial encounters infrequently cause a significant response; repeated exposure leads to extensive reactions. However, first exposures can induce a delayed hypersensitivity allergic reaction if the allergen remains in contact with the skin for an extended period (days to weeks.)
Removal of the causative agent is the most important factor for successful treatment of contact dermatitis. Once identified, avoiding the offending chemical/product is paramount for preventing relapse. Topical corticosteroid creams or ointments often decrease inflammation and resolve symptoms. Oral or topical antihistamines decrease associated pruritus. Systemic corticosteroids are recommended for severe cases of contact dermatitis or contact dermatitis involving the face or genitals.7
Contact dermatitis is usually benign. However, secondary bacterial infections are common. Scarring is a long-term sequela of severe contact dermatitis. Although uncommon, anaphylaxis and death are possible in patients with delayed hypersensitivity allergic contact dermatitis.
