Subsequent reactions to lawsone have been noted in some patients ( 12). PPD can also sensitize patients to other allergens, inducing hypersensitivity to natural rubber latex, azo dyes, thiurams, PABA sunscreen, para-aminosalicylic acid, and benzocaine ( 9– 11). PPD-sensitized patients should be cautioned about the use of dark hair dyes and darkly dyed clothing ( 10). Since PPD is found in hair and textile dyes, patients sensitized to PPD can manifest long-term contact dermatitis to these products ( 8). Subsequent allergic sequelae are another long-term issue with PPD sensitization. Hypopigmentation on the arm of the patient's cousin, 5 weeks after application of the tattoo ink. These risks alter the notion of these tattoos being “temporary.” The hypopigmentary changes are more frequent in children ( 1) (Figure (Figure4 4). The intense inflammatory reaction can impart scarring, keloid formation, and permanent postinflammatory pigment changes over the site of the tattoo ( 8, 9). Hypersensitivity reactions to PPD tattoos carry long-term risks. Vacationing travelers have often returned home before the dermatitis erupts. By the time the delayed hypersensitivity reactions erupt, the responsible vendor has moved on and can be difficult for public health officials to track. They typically operate from a transient shop or kiosk that moves from town to town following a carnival, fair, or similar troupe. Most countries have no regulation about skin application of PPD ( 8).Ĭompounding the public health management of these reactions is the nature of black henna artisans. Australia requires a warning label for PPD concentrations >5%. European Union countries restrict PPD concentrations in hair products to 6% or less. PPD is not permitted for use as a skin product at any concentration ( 7).Ĭanadian health officials have outlawed PPD for skin use. In the USA, PPD is approved by the Food and Drug Administration (FDA) for human use as a hair dye. The inks are typically left in contact with the skin for several days after application. Black henna tattoo inks have been found to have PPD concentrations as high as 15% to 30% ( 3). One study found that a 10% PPD solution sensitized 100% of the test subjects ( 6). Using the 1.0% concentration for a 120-minute exposure increased the reaction rate to 69% ( 3). Increasing the concentration to 1.0% caused reactions in 37.5% of subjects. 01% PPD for 15 minutes elicited no reaction. Previous studies showed that skin patch testing of. PPD's potency as an allergen is directly related to the concentration and duration of direct exposure. If a patient has been previously sensitized to PPD, the reaction can occur more acutely. Clinically, these eruptions are seen 3 to 10 days after application of the PPD-henna preparation. Patch testing patients with PPD shows a reaction consistent with a type IV delayed hypersensitivity reaction. Reports of angioneurotic edema and anaphylaxis exist as well ( 2). Black henna tattoo ink commonly induces hypersensitivity reactions. It is often applied by street artisans at traveling carnivals or fairs ( 4). The combination of PPD and henna is marketed as “black henna.” No natural black henna exists. Contact dermatitis to PPD is common among hair stylists, with an incidence of up to 24% in this group ( 3). It is commonly used in hair dying and photographic film processing. PPD is one of the industrial allergens that most frequently evokes a reaction in patients with contact dermatitis. PPD is a low-toxicity diamine used as a component of synthetic polymers, aramid fibers, cosmetic dyes, latex chemicals, textile dyes, and pigments. The pigmentation henna imparts is not permanent.Ī contemporary technique to darken the henna pigment and hasten the drying time involves adding paraphenylenediamine (PPD). Natural henna can take several hours to dry and fix to the skin. Pure henna alone is a relatively safe product, and reported allergic reactions are rare ( 1, 2). A variety of oils, powders, and dyes are often added to henna to obtain various colors. Natural henna imparts a brownish-orange pigment to the skin when applied. Its use can be traced back at least 5000 years. Henna skin painting plays an important role in various religious and cultural ceremonies. Some cultures utilize henna as a folk remedy as well. In many Eastern and Middle Eastern countries, henna has long been used as a cosmetic dye on the skin, hair, and nails. The active ingredient is lawsone (2-hydroxy-1,4-naphthoquinone). The plant is indigenous to North Africa, the Middle East, and India. Henna is a green powdered extract from the leaves of Law sonia alba.
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