Clinicopathologic Features of Skin Reactions to Temporary Tattoos and Analysis of Possible Causes

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.

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.

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.

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.

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.

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).

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).

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 researchers^7,8 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).

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 reports^5,6; 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.

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@ms11.hinet.net).