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