Henna Tattoo: From Cosmetic Purposes to Dermatological Reactions

Abstract

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.

Introduction

The term “tattoo” derives from two Polynesian words, “TA,” which denotes “to draw” and “TOO” which denotes “spirit.” The entire word denotes “the body drawing.” The tattooing techniques have been entirely varied in different age groups, depending on the cultures involved.[1]

Natural henna is a dye, extracted from the plant Lawsonia inermis, which is rich in naphthoquinone compounds (dye molecules), garlic acid, mucilage and traces of alkaloids.[2] It is frequently used in traditional body art in Hindu and Muslim cultures for tattooing. Transient tattooing is frequently used for dyeing the skin, hair, and nails.[2,3]. Although exceedingly used, only a few reports of allergic reactions to pure henna were recorded; usually erythema and slight edema.[4]

The mixture of natural henna, para-phenylenediamine (PPD), and sometimes heavy metals is known as “black henna.” PPD is added to henna to speed up the dyeing and drying processes, to strengthen and darken the color, to increase the design pattern of the tattoos and to make the tattoos last longer.[2] This mixture can induce type IV delayed hypersensitivity reaction based on its concentration and duration of exposure.[5] The concentration of PPD in black henna tattoos (≥64%) is much more than that of hair dyes (<6%).[2] Because of PPD’s high sensitization potential, the application of PPD to the skin is not approved for use.[6]

Clinical presentations depends on prior sensitisation; the first signs of allergic contact dermatitis caused by black henna occur within 1–3 days in those already sensitized and within 4–14 days in patients who become newly sensitized by the tattoo.[7] It has been found that patients sensitized to black henna tattoo should be classified into two groups according to their clinical course, as acute or subacute. Thus, the clinical characteristics define two groups: an acute reaction to transient tattooing, typically presenting with intense eczematous reaction within 1–2 days of tattooing and a subacute reaction, that is, developing lichenoid contact dermatitis slowly in 1–2 weeks.[8,9] Some reactions may appear 45 days later following the application[10] but sometimes reactions may occur a few hours following the henna tattoo.[11]

Morphological clinical reactions of black henna tattoos appear to be more varied and heterogeneous. In addition to the aforesaid classic contact dermatitis, black henna tattoos causing urticaria, angioedema, contact anaphylaxis,[6] lymphomatoid reactions,[12] vesiculobullous lesions[13] and erythema multiforme-like skin eruptions have been described.[14]

Currently, in the literature, there are no sufficient data about the demographic features and clinical presentations of cutaneous reactions of henna tattoos. So, this study aimed to describe the clinicodemographic features of patients with dermatological reactions to henna tattoos.

Materials and Methods

Study design and setting

This cross-sectional study was conducted at Dermatology Outpatient Clinics at Sohag University Hospitals, Egypt. This study included patients of any age and both sexes, who used henna tattoos with dermatological reactions, from January 2022 to January 2023.

Clinical evaluations

All included patients were subjected to the following evaluations: A) Medical history assessments: 1) Demographic data of patients, including sex, age, residence, education, occupation, marital status and special habits (smoking). 2) History of the reaction, including onset, course, duration, site of reaction and latency time, type, and pattern of reaction. 3) History of the used henna, including occasions, type, color, and site of application. 4) Family history of allergic diseases and consanguinity were evaluated. 5) Past history of skin allergy and history of patch tests before using henna were reported.

B) Clinical examinations: 1) General examination was done to exclude any associated medical comorbidities. 2) A complete dermatological examination was done and included the type, site, and pattern of the dermatological reaction.

Ethical considerations

This study was approved by the Ethical and Scientific Committee, Faculty of Medicine, Sohag University. The approval number was (Soh-Med-22-01-34). Informed consent was obtained from all patients after a full explanation of the benefits of this study.

Statistical analysis

The collected data were verified, coded by the researcher, and analyzed using the Statistical Package for Social Sciences (IBM-SPSS/PC/VER. 24). Data were presented as means ± standard deviation (SD), frequencies, and percentages.

Results

This study included 17 female patients who used henna tattoos with dermatological reactions. The mean age of the included patients was 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. There was no family or past history of allergy or henna contact dermatitis. All the patients did not perform patch tests before using henna [Table 1]. Many (53%) had type IV Fitzpatrick skin and 100% used black color and commercial henna for cosmetic purposes, 41.2% used market henna and 35.3% used coiffeur henna. Majority (70.6%) had localized reactions with 23.5% presenting with reaction of hands, 64.7% had acute eczematous reactions and 100% 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 [Table 2 and Figures 1-5]. All the included patients refused to perform patch tests after dermatological reactions.

Table 1.

Sociodemographic characteristics of 17 patients with henna contact dermatitis

Variable	Data
Number	17 patients
Sex	Female: 17 (100%)
Age (year); means±SD	26.88±6.6
Residence	Urban: 6 (35.3%)
	Suburban: 7 (41.2%)
	Rural: 4 (23.5%)
Education levels	High: 4 (23.5%)
	Moderate: 10 (58.8%)
	Low: 3 (17.6%)
Occupation	Housewife:
	10 (58.8%)
	Student: 2 (11.8%)
	Teacher: 3 (17.6%)
	Officer: 2 (11.8%)
Marital status	Married: 12 (70.6%)
	Single: 5 (29.4%)
Socioeconomic class	High: 6 (35.3%)
	Moderate: 8 (47.1%)
	Low: 3 (17.6%)
Special habit (smoking)	No: 17 (100%)
Family history of allergy	No: 17 (100%)
Family history of henna contact dermatitis	No: 17 (100%)
Past of history of allergy, hair dye or henna contact dermatitis	No: 17 (100%)
Patch test before used henna	No: 17 (100%)

Data were presented as number (%) and means±SD

Table 2.

Clinical characteristics of 17 patients with henna contact dermatitis

Variable	Data
Fitzpatrick skin type	II: 4 (23.5%)
	III: 4 (23.5%)
	IV: 9 (53%)
Atopic pattern of skin	No: 17 (100%)
Reaction
Onset of reaction	Acute: 12 (70.6%)
	Subacute: 5 (29.4%)
Course of reaction	Progressive: 17 (100%)
Time of used henna (days); means±SD	9.6±3.54
Duration of reaction (days); means±SD	6.76±2.6
Latency time of reaction (days); means±SD	2.7±0.85
Site of reaction	On hand: 4 (23.5%)
	Both hands: 3 (17.6%)
	One hand and forearm: 2 (11.8%)
	Both hands and forearms: 3 (17.6%)
	Different parts of the body: 5 (29.4%)
Type of reaction	Localized: 12 (70.6%)
	Generalized: 5 (29.4%)
Pattern of reaction	Acute eczematous: 11 (64.7%)
	Subacute eczematous: 6 (35.3%)
Site of used henna	On hand: 4 (23.5%)
	Both hands: 3 (17.6%)
	One hand and forearm: 2 (11.8%)
	Both hands and forearms: 3 (17.6%)
	Different parts of the body: 5 (29.4%)
Used henna
Occasions of used henna	Cosmetic purposes: 17 (100%)
Type of used henna	Commercial: 17 (100%)
Color of used henna	Black: 17 (100%)
Source of henna	Coiffeur: 6 (35.3%)
	Market: 7 (41.2%)
	Pharmacy: 4 (23.5%)

Data were presented as number (%) and means±SD

Figure 1.

27-year-old female patient presented with acute eczematous reaction due to henna tattoo use on both hands and right forearm

Figure 5.

28-year-old female patient presented with subacute eczematous due to henna tattoo use on the left forearm and abdomen

Figure 2.

23-year-old female patient presented with acute eczematous reaction due to henna tattoo use on the right hand

Figure 3.

25-year-old female patient presented with acute eczematous reaction due to henna tattoo use on the left hand and forearm

Figure 4.

30-year-old female patient presented with subacute eczematous reaction due to henna tattoo use on the left hand and forearm

Discussion

Temporary black henna tattoos have become fashionable, especially among children, adolescents and young adults in the past 15 years.[7]

This study is one of few studies that aimed to describe the demographic features and clinical presentations of patients with dermatological reactions to henna tattoos.

This study detected 17 female patients with dermatological reactions due to black henna application. In our community, females have increased desire to be more beautiful and different. It is uncommon for males to apply henna on their hair, scalp, mustache and beard to mask the grey hair associated with old age. This was in agreement with Bregnhøj et al. who reported that black henna tattoo reactions were predominant in females (97%).[15] Also, henna tattoos are associated with occasions like wedding parties and Eid celebrations in Sohag Governorate, Upper Egypt. Calogiuri et al.[16] reported that henna has great significance in all Eastern wedding traditions, and no wedding party is complete without drawing hands and feet.

The mean age of the included patients was 26.88 ± 6.6 years, which is in agreement with the fact that this is the most common age group seeking beauty. However, Peng et al.[17] reported that the first temporary black henna tattoo reaction was presented in three children. Berih and Berhanu[18] reported a 42-year-old, HIV-positive woman presented with an itchy, erythematous swelling of her forearms and hands 1 day after a black henna tattoo application.

Furthermore, 64.7% of the patients were from rural and suburban areas and 77% of the patients had low and moderate educational levels. In Egypt, henna tattoos are associated with many traditional occasions, more so in rural areas and those with lower education. Also, these areas are strongly follow old customs and traditions.

A total of 60% of the patients were housewives. In addition, 82.4% of the patients were from moderate-to-high socioeconomic classes.

Also, all 17 (100%) patients had no family history of allergy. This may be explained by a decrease in the awareness of the importance of positive family history in the occurrence of certain skin diseases or medical problems.

The diagnosis of black henna tattoo reactions is mainly relies on the clinical presentations and can be confirmed by positive patch test reactions to PPD. Mostly, these patients have strong contact allergies to PPD, with strong to extreme bullous patch test reactions to the ordinary test concentration of 1%.[19]

In this study, all 17 (100%) patients did not perform patch tests before using henna. Also, they refused to perform patch tests after the reactions to confirm PPD sensitizations because they were worried about the occurrence of severe cutaneous reactions. Chung et al.[8] reported that four of six patients with cutaneous reactions to henna tattoos, who were then patch-tested with commercial black henna, had strong positive reactions.

In the present study, black henna reaction was an acute onset in 70.6% of the patients and had a progressive course in all patients. Acute eczematous reaction (64.7%) was the most frequent reaction. This is in agreement with Jung et al. who reported that most patients (80%) with black henna tattoo reactions presented with acute allergic contact dermatitis with erythema, edema, papules and vesicles; bullae are often presented.[20]

The latency time of the reaction was 2.7 ± 0.85 days. This is similar to Sidwell et al.[21] and Neri et al.[22] who found the time of onset of eczematous contact dermatitis was 1–2 days after black henna tattoo application.

In the current study, the most commonly affected site by black henna tattoo reaction was the hand in about one-fourth of the patients, it being the most common site of henna tattoo applications.

The cosmetic purpose was recorded in all patients. Badoni Semwal et al.[23] said that henna has been used traditionally for medicinal and cosmetic purposes. For medicinal purposes, it has been used as a bitter tea for stomach or intestinal problems, for fever and headache, as a paste to cure ringworm or nail fungus, to reduce chafing and prevent blisters and to soothe irritated, dry, or chapped skin.

In this study, the localized reaction was found in 70.6% of the patients. This is similar to Matulich and Sullivan[24] who said that the allergic reaction is usually presented in the localized area of the tattoo, but for some serious cases, lesions remote from the tattoo can also be presented.

In addition, 100% of the patients used commercial black henna. About 76.5% of the patients bought henna from the market and coiffeur. Hence there should be strict regulations for getting black henna from nonprofessional places. Berih and Berhanu[18] reported that the use of commercial black henna in East African community is increasingly seen in general practice.

This study had several limitations and recommendations that included a small sample size of the patients, so it is recommended to do multicenter studies on a larger sample size of the patients to assess the clinicodemographic characteristics of patients with dermatological reactions to henna tattoos. Patch test should be performed before use of black henna, to confirm whether the reaction was due PPD, henna itself or coloring agents. Further studies are required to compare the prevalence and clinical presentations of dermatological reactions between natural henna and black henna. Spectrophotometry would have been useful to detect the quantity and incidence of the reaction of black henna based on the concentration.

Conclusion

This study concluded that the diagnosis of henna tattoo reactions mainly relies on the clinical presentations. PPD is a potent allergen and is involved in allergic contact dermatitis-associated henna tattoos. A patch test to diagnose PPD sensitization is necessary for these patients to protect them from exposure to PPD and related compounds. Knowledge of this condition is very important to diagnose it so early and makes patients aware of the need to take preventive measures. By this way, we will be able to reduce the potential impact of this condition on the quality of life of both home users and professional users, especially hairdressers. Dermatologists, pediatricians, and allergists should know about the rising frequency of black henna cutaneous reactions.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.