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Clinicopathologic Features of Skin Reactions to Temporary Tattoos and Analysis of Possible Causes
Wen-Hung Chung, MD;
Ya-Ching Chang, MD;
Lih-Jen Yang, MD;
Shuen-Iu Hung, PhD;
Wen-Rou Wong, MD;
Jing-Yi Lin, MD;
Heng-Leong Chan, MD
Arch Dermatol. 2002;138:88-91.
ABSTRACT
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Background Recently, temporary paint-on tattoos have become increasingly popular
as a safe alternative to permanent tattoos in Asia and other regions. The
most common dye for such temporary tattoos is henna, a vegetable dye. Henna
is considered to possess low allergenicity because the incidence of allergic
contact dermatitis to henna has rarely been reported. However, recently, allergic
reactions to henna used in temporary tattoos have been reported frequently.
Observations Ten patients developed inflamed skin eruptions after receiving temporary
paint-on tattoos in either Thailand or Indonesia. The 6 patients who were
patch tested all exhibited moderate to strong positive reactions to p-phenylenediamine (1% in petrolatum). Four of the 6 patients
were then tested with commercial black henna obtained from Thailand, and all
4 had strong positive reactions. A skin biopsy specimen showed lichenoid dermatitis.
Mass spectrometry analysis of commercial black henna for molecular weight
revealed a major peak at the mass-charge ratio of 108.1, which corresponds
to the molecular weight of p-phenylenediamine.
Conclusions The most likely causative agent for the lichenoid reaction associated
with use of commercial black henna for temporary tattooing, currently popular
in Southeast Asia, is p-phenylenediamine. With the
increased popularity of temporary paint-on tattoos, clinicians should be aware
of the possible associated complications.
INTRODUCTION
THE TEMPORARY paint-on tattoo, derived from "the art of henna" used
in India, the Arab world, and Africa for many traditional ceremonies,1 has gained increasing popularity recently. Henna is
a material obtained from the dried leaves of a shrub (Lawsonia
inermis) found in dry tropical and subtropical zones, including North
Africa, India, Sri Lanka, and the Middle East. Henna has been used worldwide
as a hair dye and as a component of some shampoos, and it also has a variety
of other cosmetic uses.1
Contact dermatitis to henna has been previously reported,2-4
but its incidence seems to be low. However, recently, allergic reactions to
henna used in temporary tattoos have been reported frequently.5-10
Although temporary tattoos are not so popular in Taiwan, several people have
been observed at Chang Gung Memorial Hospital, Taipei, to have experienced
a contact allergy arising from application of temporary tattoos. The patients
received tattoos while they were traveling in Thailand or Bali. In this article,
we describe 10 patients who developed unusual skin reactions after application
of temporary paint-on tattoos. Furthermore, we analyze the agent responsible
for such unusual allergic reactions, derived from commercial black henna.
PATIENTS AND METHODS
From February 7, 2000, to August 23, 2000, ten patients seen at the
dermatology clinic (Chang Gung Memorial Hospital) had pruritic, burning, inflamed,
and edematous skin reactions after application of temporary paint-on tattoos
in Thailand or Bali. The following data were collected: sex, age, dye color,
country or location of tattoo application, onset of eruption subsequent to
application, allergy history, clinical appearance of allergic reaction along
tattooed areas, treatment, and follow-up.
Six of the 10 patients agreed to undergo patch testing with the European
standard series (Chemotechnique Diagnostics, Tygelsjö, Sweden). Four
of the 6 patients were also tested with natural henna and commercial black
henna obtained from Thailand, at 10% and 20% aqueous solutions and also as
pure powder. Ten control subjects were also patch tested with natural and
commercial henna. The substances were applied, using an IQ Chamber (Inert
Quadrate & Ideal Quick Test Chamber unit; Chemotechnique Diagnostics),
to the upper back and remained there for 48 hours. Readings were taken after
72 hours. Reactions were scored according to the scale recommended by the
International Contact Dermatitis Research Group.
The sample of commercial black henna was obtained from a local artisan
in Thailand where most of our patients received temporary tattoos during their
trips. Natural powdered henna (Concept Studio, India) was obtained from a
local Taipei beautician. These henna samples were analyzed using mass spectrometry
in electron impact and fast atom bombardment modes. A skin biopsy sample was
obtained from the eruption of the tattooed area on patient 8 a week after
tattoo application.
RESULTS
Three patients experienced a moderate to intense pruritic and burning
sensation on the tattooed areas 2 days after tattoo application, and the remaining
7 experienced only mild pruritus during the first week subsequent to tattooing.
Most patients did not notice any abnormal eruptions from the tattooed areas
until the black discoloration began to fade. Most lesions exhibited raised,
erythematous eruptions along the designs of the specific tattoos, with or
without blister formation in the early stages (Figure 1). For most patients, treatment with or without oral corticosteroids
in addition to antihistamines and potent topical corticosteroids led to variation
in response or resolution. Postinflammatory hyperpigmentation at the former
tattoo site was subsequently noted for most patients. Clinical presentation,
treatment, and follow-up data are summarized in Table 1.
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Figure 1. Skin lesion samples from patient
6 (A) and patient 9 (B) demonstrating erythematous or violaceous, raised (lichenoid)
eruptions along the designs of the tattoos, with or without associated vesicle
formation in the early stages.
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Table 1. Clinical Presentation, Treatment, and Follow-up for 10 Patients
With Reactions to Temporary Tattoos*
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Six patients patch tested with the European standard series all revealed
moderate (++ [erythema, infiltration, papules, vesicles]) to strong (+++ [intense
erythema, infiltration, coalescing vesicles]) reactions to p-phenylenediamine (PPD) (1% in petrolatum). Four of the 6 patients
were also tested with commercial black henna and demonstrated moderate or
strong positive reactions to 10% aqueous solution and strong positive reactions
to 20% aqueous solution and pure black henna powder (Figure 2). Only patient 1 exhibited a positive reaction to natural
powdered henna (+ [erythema, infiltration, possibly papules] to 10% aqueous
solution and moderate [++] to 20% aqueous solution and pure powder). In addition,
of these 6 patients, 2 had a positive reaction to nickel, 1 to cobalt, and
1 to thiuram mix. All results of control patch testing for natural henna and
commercial black henna were negative. Results of patch testing are summarized
in Table 2.
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Figure 2. Results of patch tests. Patient
8, similar to the 5 other patients tested, had a positive reaction to 1% p-phenylenediamine (PPD) in petrolatum. In addition, this
patient also showed a strong positive reaction to commercial black henna.
1 indicates natural henna powder (-); 2, commercial black henna powder
(+++ [intense erythema, infiltration, and coalescing vesicles]); 3 and 4,
natural henna, 10% and 20% aqueous solutions, respectively (-); 5 and
6, commercial black henna, 10% and 20% aqueous solutions, respectively (++
[erythema, infiltration, papules, vesicles]); and 7, PPD (++).
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Table 2. Results of Patch Testing*
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A skin biopsy sample taken from the eruption of the tattooed area of
patient 8 revealed hyperkeratosis, parakeratosis, hypergranulosis, and acanthosis
of the epidermis, with exocytosis and scattered dyskeratotic cells. There
was a dermal perivascular lymphocytic infiltrate with destruction of the basal
layer that caused pigmentary incontinence, indicating a lichenoid dermatitis
(Figure 3).
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Figure 3. Skin biopsy sample from the eruption
of a tattooed area (patient 8) revealing hyperkeratosis, parakeratosis, and
acanthosis of the epidermis with exocytosis and dermal perivascular lymphocytic
infiltrate with the destruction of the basal layer that caused pigmentary
incontinence, indicating a lichenoid dermatitis (hematoxylin-eosin, original
magnification x100).
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The electron impact–mass spectrometry spectrum of the commercial
black henna sample demonstrated a major peak at an m/z ratio (mass-charge)
of 108.1, which corresponds exactly to the molecular weight of PPD. The fast
atom bombardment–mass spectrometry spectrum of natural henna showed
a series of complex peaks, demonstrating a clear difference from commercial
black henna (Figure 4).
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Figure 4. A, The electron impact–mass
spectrometry spectrum of commercial black henna depicting a major peak at
an m/z (mass-charge) ratio of 108.1, corresponding exactly to the molecular
weight of p-phenylenediamine (PPD) (1% in petrolatum).
B, The fast atom bombardment–mass spectrometry spectrum for natural
henna as a series of complex peaks.
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COMMENT
Recently, allergic reactions caused by temporary henna tattoos have
been described in several articles in the English-language literature (Table 3). Although henna was described
as a commonly used paint-on dye in most of those articles, some researchers7-8 found that use of a variety of additives
intended to provide variable coloration, especially PPD, was the principal
cause responsible for eliciting the allergic reaction associated with henna-containing
tattooing. Natural henna, containing an active agent of lawsone (2-hydroxy-1,4-naphthoquinone),
is grayish green; all other colors obtained with henna are due to the addition
of other agents.1 Cross-reactivity between
lawsone and PPD is not likely to occur owing to their different chemical structures
(Figure 5).
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Table 3. Summary of Reported Allergic Reaction(s) to Temporary Paint-on
Tattoos Reported in the English-Language Literature
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Figure 5. The chemical structures of p-phenylenediamine (A) and lawsone, the active ingredient
of henna (B).
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Henna can be used in combination with other materials, such as PPD,
lemon juice, or beet juice, to produce more intense coloration and to reduce
dye fixation time.1 To our knowledge, no previous
reports concerning temporary tattoo allergy analyzed the actual allergen(s)
from commercial paint-on dyes directly, despite their similar positive results
to PPD by using patch testing. To elicit the principal allergen responsible
for the "unusual" reactions to commercial black henna, popular for tattooing
in Southeast Asia, a sample of commercial black henna powder was obtained
from a local artisan in Thailand. However, mass spectrometry of the commercial
black henna revealed only PPD as the major ingredient (molecular weight, 108.1)
and not lawsone (molecular weight, 174.2), the active agent of henna. This
analysis also revealed that the principal ingredient of commercial black henna
is more likely a synthetic dye, as indicated by the presence of 2 simple major
peaks, compared with natural henna, which contains a series of complex peaks.
Although lichenoid reactions to permanent tattoos, especially red dye,
have been well known,11-13
a lichenoid reaction to a paint-on tattoo has rarely been reported. Lestringant
et al7 in 1999 described a clinical lichenoid
eruption due to tattooing with a henna mixture. Rubegni et al8
recently reported a histopathologic finding of lichenoid dermatitis caused
by an allergic reaction to a temporary tattoo. According to the results of
patch tests, both these groups indicated that the possible causative factors
of lichenoid reaction to temporary tattooing were the contained additives
of dyes, especially PPD. In this study, most of the clinical appearances and
the pathologic finding also demonstrated a lichenoid reaction associated with
allergic reaction to temporary tattooing, and the results of patch tests in
our 6 patients all revealed strong positive reactions to PPD. Furthermore,
as a result of mass spectrometry analysis of the commercial dyes used for
temporary tattooing, we speculate that PPD is the major ingredient of commercial
black henna and that the causative agent responsible for most lichenoid reactions
arising from tattooing is PPD, not henna itself.
Buckley,14 in 1958, described lichenoid
eruptions after contact dermatitis among photographic operators who handled
a certain PPD. He further classified such cases into 2 groups according to
their clinical course, these being an acute and a subacute type. The clinical
features described by Buckley are similar to our findings. In our study, the
clinical course may also be divided into 2 groups: (1) an acute response to
temporary tattooing, typically presenting with intense eczematous responses
within 1 to 2 days of tattooing, and (2) a subacute response, that is, developing
lichenoid eruptions slowly in 1 to 2 weeks.
p-Phenylenediamine has been used as a permanent
or semipermanent chemical hair dye for a long time, and allergic contact dermatitis
from PPD has been reported in hair dye users and hairdressers.15-16
Recently, PPD-containing hair dye has been reported17
to be implicated as a causative agent in a series of lichenoid eruptions experienced
by users of specific hair dye preparations.
All the lesions demonstrated by our patients disappeared subsequent
to treatment with antihistamines and potent topical corticosteroids, with
or without oral corticosteroids; however, the clinical responses were notably
different. Some lesions subsided within a few weeks, and others required several
months to subside despite use of short-course oral corticosteroids. Most of
our patients exhibited remnant postinflammatory hyperpigmentation. Although
we speculate that the high incidence of residual hyperpigmentation may be
due to Asian skin type, a prolonged residual pigmentary phase after an intense
lichenoid dermatitis following contact with PPD-containing color developer
has also been described by Buckley.14
Henna was considered to be the paint-on dye causing allergic reactions
in some previous reports5-6; however,
the results of our study reveal that the most likely allergen of tattooing
dye, especially black henna popular in Southeast Asia, is PPD, not henna itself.
With the increased popularity of temporary paint-on tattoos, clinicians should
be aware of the complications associated with the use of paint-on dyes, especially
those containing PPD.
AUTHOR INFORMATION
Accepted for publication May 16, 2001.
We thank Hui Chung-Yee, MD, for patient referral and to Jennifer C.
Lee, MD, for reviewing and editing this manuscript.
Corresponding author and reprints: Ya-Ching Chang, MD, Department
of Dermatology, Chang Gung Memorial Hospital, 199, Tun Hwa North Road, Taipei,
Taiwan (e-mail: hsula{at}ms11.hinet.net).
From the Department of Dermatology, Chang Gung Memorial Hospital (Drs
Chung, Chang, Yang, Wong, Lin, and Chan), and the Institute of Microbiology
and Immunology, National Yang-Ming University (Dr Hung), Taipei, Taiwan.
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