Case r epo rt K E Y WORDS contact, dermatitis, allergic, mehindi, henna, para- phenylene- diamine Contact dermatitis caused by mehindi Contact dermatitis caused by mehindi A. Schiera, M.L. Battifoglio, L. Rossi, A. Nicoletti and G. Galbiati SUMM ARY Several cases of contact dermatitis from mehindi tattoos have already been reported in recent literature, in which the most frequent cause of sensitisation was para-phenylenediamine {PPD). In fact mixtures called with various names, for example "black henna", used to perform skin-drawings, possibly contain natural henna, a rare and weak sensitizer, and likely contain chemical colouring agents, such as PPD. Our case presented a highly positive patch test reaction to PPD as well as other positive reactions occurring close to the first one, in particular to disperse yellow 3, disperse red 1, balsam of Peru and benzocaine. Introduction Mehindi is an ancient art of painting the skin using a paste made from leaves of Lawsonia inermis. This is the botanical denomination given to a small shru b, which grows in Egypt, Tunisia, Iran, India, Arabia and tropical Africa, also known as henne, al-khanna and al- henna. The leaves of this plant are dried and then pow- dered in order to obtain a yellow-green powder, which is dissolved in hot water at the moment of use. The ap- plication of this paste on the skin for 30-40 minutes leaves tempora1y tattoos. The most probable cause of contact dermatitis due to mehindi is the presence of para-phenylenediamine (PPD), which is added to the paste to strengthen the colour. Among the numerous mixtures containing henna ancl chemical colouring agents, there is the so-callecl "black henna" (1). Case report We report the case of a 39-year-olcl woman, house- wife, presentecl with acute blistering en1ptions respec- tively on her upper back and left arm, the shape of which corresponclecl exactly to tempora1y tattoos made with "black henna" cluring a holiclay in Egypt (Fig.1 ancl 2). The patient complained for intense itching ancl bum- ing localized at the site of the dermatitis. Acta Dermatoven APA Vol 10, 2001, No 2 - --------------------------------- J7 Case report Figure 1 . On the left arm, acute blistering eruption localized in the area of dye application. Figure 2. On the back, erythemato-oedematous reaction that reproduced the original design. Contact dermatitis caused by mehindi The eruption resolved on treatment with systemic steroid and topical antibiotics leaving a slightly atro- phic skin. Patch testing was performed using the GIRDCA se- ries (Trolab), using Haye's Test Chambers, and showed (Fig. 3) the following unexpected results: D2 D3 Para-phenylenediamine +++ +++ (PPD) 1 % pet. Balsam of Peru ++ ++ Disperse yellow 3 1 % pet. ++ ++ Disperse red 1 1 % pet. + + Benzocaine +++ +++ Discussion Severa! cases of contact dermatitis from mehindi tat- toos, in which the most frequent cause of sensitisation was PPD, have already been reported in recent litera- ture. As a matter of fact the mixtures used to perform these skin-drawings possibly contain natura! henna, a rare and weak sensitizer, and likely contain chemical colouring agents, such as PPD (1, 2). Our case presented a highly positive patch test re- action to PPD as well as other positive reactions occur- ring close to the first one. We considered the positive reaction to PPD as in- dicative of a real sensitisation; in fact the patient de- clared a previous use of chemical hair dye, although she didn't remember any related cutaneous problem. A chemical correlation may explain the concomi- tant responses to PPD, benzocaine and aniline dyes, but not to balsam of Peru, even if multiple primary spe- cific sensitivities or concomitant sensitivities to sub- stances, which are unrelated chemically, are frequent among patients with contact dermatitis (3). Another possible interpretatlon of these multiple responses is in a pattern of "angry back" or "excited skin syndrome (ESS). The phenomenon, described by Mitchell in 1975 as ESS, indicates false secondary non-specific reactions close to genuine positive ones (4). This can be due to hyperirritability resulting from pre-existing dermatitis, or from fluctuation of humoral and cellular inflamma- tion-modulating phenomena (5). The underlying mechanisms are not fully understood (6-8). Acta Dermatoven APA Vol 10, 2001, No 2 --- -------------------------------- J9 C ase r epo rt REFERENCES AUTHORS' ADDRESSES Contact dermatitis caused by mehindi The 'false' nature of these reactions can usually be resolved by repeating the patch tests individually, some weeks later and at various dilutions, as irritant reactions tend to stop abruptly below a certain concentration , whereas allergic responses persist albeit proportionally weaker, at lower concentrations. In our case it wasn 't possible to proceed in perform- ing further tests due to a lack of compliance of the pa- tient. Anyway, we suggested avoidance of any possible contact with PPD and chemical related substances. Figure 3. Patch testing in our patient showed multiple reactions. l. Le Coz CJ, Lefebvre C, Keller F, Grosshans E. Allergic contact dermatitis caused by skin painting (pseudotattooing) with black henna, a mixture of henna and p-phenylenediamine and its derivatives. Arch Derm 2000; 136: 1515-7. 2. Tasti A, Pazzaglia M, et al . Allergic contact dermatitis caused by mehindi. Contact Dermatitis 2000; 42: 356. 3. Wilkinson JD, Rycroft RJG. Contact Dermatitis. In: Rook, Wilkinson, Ebling eds. Textbook of Derma- tology. 5th ed. Oxford: Blackwell Science; 1992: 611-715. 4. MitchellJC. The angiy back syndrome. Eczema creates eczema. Contact Dermatitis 1975; 1: 193-4. 5. Mitchell JC, Maibach HI. Managing the excited skin syndrome: patch testing hyperirritable skin. Con- tact Dermatitis 1997; 37: 193-9. 6. Paschee-Koo F, Hauser C. How to better understand the angty back syndrome. Review. Dermatol 1992; 184: 237-40. 7. Hamani I, Marks R. Abnormalities in clinically normal skin-a possible explanation of the angry back syndrome'. Clin Exp Dermatol 1988; 13: 328-33. 8. Bruynzeel DP, Maibach HI. Excited skin syndrome (angry back). Review. Arch Dermatol 1986; 122: 323-8. Alberto Schiera, MD, dermatologist, Department oj Dermatology, San Gerardo Hospital, Via Donizetti 106, 20052 Monza, Italy. Maria Luisa Battifoglio, MD, dermatologist, same address Laura Rossi, MD, same address Annamaria Nicoletti, MD, dermatologist, same address Giuseppe Galbiati, MD, professor and chairman, same address Acta Dermatoven APA Vol 10, 2001, No 2 ----- - - - - -------- ------ ----------- 61