Images in... Severe type IV hypersensitivity to ‘black henna ’ tattoo

A 16-year-old Bangladeshi girl presented with a 9-day history of an extensive pruritic, erythematous, papulovesicular skin eruption to both fore-arms. Appearance was 5 days following application of a home-made henna preparation. Examination revealed ulceration and scabbing along the whole henna pattern and early keloid formation. A diagnosis of type IV delayed hypersensitivity reaction superimposed by infection was ini-tially made. As in this case, home-made henna preparations commonly combine commercial henna with black hair dye, paraphenylenediamine (PPD). PPD, widely known as ‘black henna’, darkens the pigment and precipitates the drying process. PPD is a potent contact allergen associ-ated with a high incidence of hypersensitivity reactions. Despite treatment the patient was left with extensive keloid scarring in the pattern of the henna tattoo. BACKGROUND The case highlights the potential dangers of using henna skin dyes containing contact allergens in hypersensitive individuals. The scarring may be extensive and will be per-manent and usually in an exposed area. There is little that can be done to minimise appearances. Since this is a com-mon practice inmany cultures we felt there was an imporo-tant public health message to be highlighted from this cas