Article, Dermatology

Delayed hypersensitivity reaction from black henna tattoo manifesting as severe facial swelling

Case Report

Delayed hypersensitivity reaction from black henna tattoo manifesting as severe facial swelling

Abstract

We report on a 14-year-old boy who was presented to the emergency department with an acute swelling of the face and scalp 3 days after using a new hair dye. The patient had applied a black henna tattoo 1 year earlier. Patch testing revealed an allergy to the potent skin sensitizer paraphenylenediamine, a common ingredient of hair dyes and also found in black henna tattoo. It is important for emergency physicians to be aware of the possibility of a delayed type-IV hypersensitivity reaction from black henna tattoos manifesting as an acute contact dermatitis. These patients may have gross facial swelling but should not be treated for angioedema.

A 14-year-old boy presented to the emergency depart- ment with a steadily worsening swelling of the face and the scalp of 12 hours’ duration; he denied difficulty in breathing. The patient reported visiting his hairdresser 3 days before, who applied a new oxidative hair dye. Physical examination revealed no signs of respiratory distress and normal vital signs. There was marked erythematous edema of the face and scalp (Fig. 1). The patient was treated with antihista- mines and oral steroids and recovered completely within 2 days (Fig. 2).

Patch testing revealed an allergy to paraphenylenediamine (PPD), a common ingredient of hair dyes. On further questioning, the patient reported that he had applied a black henna tattoo a year earlier, without developing any lesions. Henna is a plant dye derived from the shrub Lawsonia, which grows primarily in India, North Africa, Sri Lanka, and the Middle East. In Islamic and Indian cultures, it is used for skin decoration. Allergic reactions to pure henna, which is found in shampoos, conditioners, and hair dyes, are rare. Black henna tattoos are frequently advertised as “temporary and harmless” and thus have become a popular and fashionable form of temporary body art for children and teenagers. Once applied, they cannot simply be washed off with soap and water; they last 1 to 2 weeks and then fade over a few days. Black henna contains an additive, PPD, which intensifies the dark color, sharpens definition,

speeds up the tattooing process, and makes the tattoo last longer. Paraphenylenediamine is known to be a potent skin sensitizer and to cause allergic contact dermatitis [1-6]. Subsequent exposure to PPD may lead to a delayed type-IV hypersensitivity reaction manifesting as an acute contact dermatitis. The first exposure to the PPD in the black henna tattoo was probably the cause of the intensified skin reaction after the second exposure to the PPD of the hair dye. Severe reactions may also occur; some patients have had such gross facial swelling that they have been treated initially for angioedema [6].

Over the last few years, an increasing number of patients have been reported to have an allergic contact dermatitis to the PPD in “temporary” henna tattoos [5,6]. The rising incidence likely reflects the increased popularity of these tattoos [5]. In Canada, the Food and Drug Act states that it is illegal for cosmetics containing PPD to be sold for direct application to the skin. This would include black henna tattoos with PPD. However, people who apply black henna tattoos at Amusement parks or holiday resorts are not required to disclose ingredients [5].

It is important for emergency physicians to be aware of the possibility of allergic contact dermatitis from temporary

Fig. 1 Facial edema due to acute allergic dermatitis. Typical contact dermatitis is observed around the hairline.

0735-6757/$ – see front matter (C) 2008

515.e4 Case Report

Fig. 2 Resolving facial edema 48 hours postadmission.

tattoos. We recommend that physicians counsel their patients to avoid getting black henna tattoos because these tattoos can cause potent skin sensitization to PPD that may lead to serious skin reactions.

Itai Shavit MD Yoav Hoffmann MD

Yael Shachor-Meyouhas MD Hadas Knaani-Levinz MD

Emergency Department, Meyer Children’s Hospital Rambam Health Care Campus, Haifa, Israel

E-mail address: [email protected] doi:10.1016/j.ajem.2007.08.010

References

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  5. Redlick F, DeKoven J. Allergic contact dermatitis to paraphenylene- diamine in hair dye after sensitization from black henna tattoos: a report of 6 cases. CMAJ 2007;176(4):445-6.
  6. McFadden JP, White IR, Frosch PJ, Sosted H, Johansen JD, Menne T. Allergy to hair dye. BMJ 2007;334:220.