Para-phenylenediamine-induced lichenoid eruptions

Henna Tattoo: From Cosmetic Purposes to Dermatological Reactions

Introduction

Henna, commonly used as a hair dye, is also used for temporary tattoos. It is commonly mixed with para-phenylenediamine (PPD) to enhance color intensity, which may induce cutaneous sensitization.

Aim

This study aimed to describe the clinicodemographic features of patients with dermatological reactions to henna tattoos.

Materials and Methods

This cross-sectional study, included patients with dermatological reactions to henna tattoos. All the patients were subjected to entire medical history including clinicodemographic data and general and dermatological examinations.

Results

This study included 17 female patients with a mean age of 26.88 ± 6.6 years. Of these 17 patients; 41.2% were suburban residents, 58.8% were housewives, 70.6% were married, and 47.1% were middle socioeconomic class and 53% had type IV Fitzpatrick skin. All used black color and commercial henna for cosmetic purposes, 41.2% used market henna, and 35.3% used coiffeur henna. Many (70.6%) had localized reactions with 23.5% presenting with reaction of hands, 64.7% had acute eczematous reactions, and all had a progressive course. The mean duration of the reaction was 6.76 ± 2.6 days. The mean latency time of the reaction was 2.7 ± 0.85 days.

Conclusion

This study concluded that public awareness of possible cutaneous reactions to henna tattoos should be increased. The health authority legislation should control the use of black henna to minimize the consequences.

Proposed ICDRG Classification of the Clinical Presentation of Contact Allergy

The International Contact Dermatitis Research Group proposes a classification for the clinical presentation of contact allergy. The classification is based primarily on the mode of clinical presentation. The categories are direct exposure/contact dermatitis, mimicking or exacerbation of preexisting eczema, multifactorial dermatitis including allergic contact dermatitis, by proxy, mimicking angioedema, airborne contact dermatitis, photo-induced contact dermatitis, systemic contact dermatitis, noneczematous contact dermatitis, contact urticaria, protein contact dermatitis, respiratory/mucosal symptoms, oral contact dermatitis, erythroderma/exfoliative dermatitis, minor forms of presentation, and extracutaneous manifestations.

Hypersensitivity reactions due to black henna tattoos and their components: are the clinical pictures related to the immune pathomechanism?

Hypersensitivity to para-phenylenediamine (PPD) and related compounds induced by temporary black henna tattoos has become a serious health problem worldwide. Different patterns of sensitization with various clinical aspects are described in literature due to PPD associated to henna tattoo and these manifestations are likely correlated with the immunological and dermatological pathomechanisms involved. Henna is the Persian name of the plant Lawsonia inermis, Fam. Lythraceae. It is a woody shrub that grow in regions of North Africa, South Asia, India and Sri Lanka. Nowadays it is rather frequent to see temporary "tattoos" performed with henna. To make tattoos darker and long-lasting PPD has been associated to henna in tattoo drawings mixtures, so obtaining "black henna". In these years there has been a rise of contact sensitization to PPD and in medical literature an increased number of cases have been reported on temporary henna tattoo application. Here we review the various clinical patterns related to PPD and henna tattoo, to investigate the possible link between clinic-morphological pictures and the immunological response to PPD and henna. The literature underlines that different clinical manifestations are related to black henna containing PPD, and its derivative products may cause delayed-type as well as immediate-type reactions. Further studies are needed to investigate the relationship between clinical and morphological aspects of PPD contact dermatitis and the T cell subsets predominance.

Side-effects of henna and semi-permanent 'black henna' tattoos: a full review

Henna, the dried and powdered leaf of Lawsonia inermis, is widely used as a dye for the skin, hair, and nails, and as an expression of body art, especially in Islamic and Hindu cultures. As it stains the skin reddish-brown, it is also called red henna. Black henna is the combination of red henna with p-phenylenediamine (PPD), and is used for temporary 'black henna tattoos'. This article provides a full review of the side-effects of topical application of red and black henna, both cutaneous (allergic and non-allergic) and systemic. Red henna appears to be generally safe, with rare instances of contact allergy and type I hypersensitivity reactions. In children with glucose-6-phosphate dehydrogenase deficiency, topical application of henna may cause life-threatening haemolysis. Black henna tattoos will induce contact allergy to its ingredient PPD at an estimated frequency of 2.5%. Once sensitized, the patients may experience allergic contact dermatitis from the use of hair dyes containing PPD. There are often cross-reactions to other hair dyes, dyes used in textiles, local anaesthetics, and rubber chemicals. The sensitization of children to PPD may have important consequences for health and later career prospects. Systemic toxicity of black henna has been reported in certain African countries.

Noneczematous contact dermatitis

Irritant or allergic contact dermatitis usually presents as an eczematous process, clinically characterized by erythematoedematovesicous lesions with intense itching in the acute phase. Such manifestations become erythematous-scaly as the condition progresses to the subacute phase and papular-hyperkeratotic in the chronic phase. Not infrequently, however, contact dermatitis presents with noneczematous features. The reasons underlying this clinical polymorphism lie in the different noxae and contact modalities, as well as in the individual susceptibility and the various targeted cutaneous structures. The most represented forms of non-eczematous contact dermatitis include the erythema multiforme-like, the purpuric, the lichenoid, and the pigmented kinds. These clinical entities must obviously be discerned from the corresponding “pure” dermatitis, which are not associated with contact with exogenous agents.

[Patch tests: indications or when testing should be performed]

Patch testing may be desirable or even essential for cases of suspected allergic contact dermatitis. Such testing allows identification with absolute certainty of the causative agent in "supposed" allergic contact dermatitis.

Ranking of hair dye substances according to predicted sensitization potency: quantitative structure-activity relationships

Allergic contact dermatitis following the use of hair dyes is well known. Many chemicals are used in hair dyes and it is unlikely that all cases of hair dye allergy can be diagnosed by means of patch testing with p-phenylenediamine (PPD). The objectives of this study are to identify all hair dye substances registered in Europe and to provide their tonnage data. The sensitization potential of each substance was then estimated by using a quantitative structure-activity relationship (QSAR) model and the substances were ranked according to their predicted potency. A cluster analysis was performed in order to help select a number of chemically diverse hair dye substances that could be used in subsequent clinical work. Various information sources, including the Inventory of Cosmetics Ingredients, new regulations on cosmetics, data on total use and ChemId (the Chemical Search Input website provided by the National Library of Medicine), were used in order to identify the names and structures of the hair dyes. A QSAR model, developed with the help of experimental local lymph node assay data and topological sub-structural molecular descriptors (TOPS-MODE), was used in order to predict the likely sensitization potential. Predictions for sensitization potential were made for the 229 substances that could be identified by means of a chemical structure, the majority of these hair dyes (75%) being predicted to be strong/moderate sensitizers. Only 22% were predicted to be weak sensitizers and 3% were predicted to be extremely weak or non-sensitizing. Eight of the most widely used hair dye substances were predicted to be strong/moderate sensitizers, including PPD - which is the most commonly used hair dye allergy marker in patch testing. A cluster analysis by using TOPS-MODE descriptors as inputs helped us group the hair dye substances according to their chemical similarity. This would facilitate the selection of potential substances for clinical patch testing. A patch-test series with potent, frequently used, substances representing various chemical clusters is suggested. This may prove useful in diagnosing PPD-negative patients with symptoms of hair dye allergy and would provide some clinical validation of the QSAR predictions.

The diagnostic evaluation, treatment, and prevention of allergic contact dermatitis in the new millennium

Identifying the etiology of allergic contact dermatitis is a rewarding yet challenging endeavor. Not all allergic contact reactions are eczematous in appearance. The most reliable clinical clue to the allergic nature of the dermatitis is its geographic distribution. Once a list of culprit allergens has been identified by patch testing, the practitioner must identify the relevant allergen(s) and counsel the patient in avoidance. For most individuals, allergen avoidance results in resolution of the dermatitis; however, some patients will require continuing symptomatic therapy despite avoidance. For those patients unable to avoid known allergens, immunosuppressant therapies (including phototherapy) or barriers can be beneficial. Currently, hyposensitization is not a viable alternative for the treatment of allergic contact dermatitis.