Henna tattoo and Sweet’s syndrome: a possible relation

ARTICLE

Auteur(s) : Aristóteles Rosmaninho, Susana Machado, Isabel Amorim, Inês Lobo, Manuela Selores

Department of Dermatology, Centro hospitalar do Porto-HSA, Rua D. Manuel II s/n°, 4099-001 Porto, Portugal

A 23-year-old Caucasian woman had a henna tattoo applied to her left hand while on holiday in Morocco. Three days later she developed edema, erythema and moderate pruritus over the tattooed area. A diagnosis of allergic contact dermatitis (CD) was made and betamethasone acceponate cream was prescribed to apply on her hand.

Ten days after the tattoo was made, the black discoloration began to fade and a slightly itchy erythematous plaque with the tattoo configuration and discreet scaling was observed. On the fifteenth day she developed an acute skin eruption of red, slightly painful and pruritic papules with a transparent, vesicle-like appearance asymmetrically distributed on her left upper arm and shoulder (figures 1A, B). She denied fever, recent drug ingestion, viral illness or sore throat.

Three years earlier she had had a similar henna tattoo applied on her left shoulder with no problems. The skin lesions did not mimic the drawing of this previous tattoo. Routine laboratory tests and a punch biopsy of the lesions were performed. A presumptive diagnosis of Sweet’s Syndrome (SS) was made and the patient was medicated with prednisolone 1 mg/kg PO once daily in a rapidly tapering scheme. The routine laboratory tests showed leukocytes within the normal range (8,620/uL), neutrophilia (78%), an elevated erythrocyte sedimentation rate (35 mm) and an C-reactive protein of 19.4 mg/L (< 5 mg/L). Hepatic, renal function and urinalysis were normal. Hematoxylin and eosin stains showed a marked edema in the papillary dermis, a diffuse inflammatory infiltrate of neutrophils in the superficial dermis without signs of vasculitis. The lesions disappeared after 11 days of systemic corticotherapy.

Patch tests using the Portuguese Standard Series (Trolab, Almirall, Germany), mixture of henna plus para-phenylenodiamine (PPD) (in 1% petrolatum) and henna powder confirmed the allergic CD to PPD.Researchers found that the use of a variety of additives intended to provide a darker coloration (mostly PPD) were the primary causative factors in the allergic reactions associated with black henna tattoos (a mixture of henna plus PPD and other additives). Reactions to black henna are well documented [1].

SS is a skin disorder characterized by tender erythematous papules, plaques or nodules that may blister and ulcerate. Along with the skin findings there are clinical symptoms, physical features and pathological findings that are needed to establish the diagnosis. Using the diagnostic criteria modified by von den Driesch in 1994 [2], the diagnosis of SS was confirmed.

To our knowledge, so far, no similar cases relating CD to PPD in henna tattoos and SS have been described. We cannot affirm that this SS was the result of immunological mechanisms related with contact sensitivity to PPD in the henna tattoo. However there was a temporal relationship between the CD and the appearance of SS lesions with no other plausible cause for the SS. Moreover, several studies have implicated common cytokines in both dermatoses, namely the G-CSF, GM-CSF, INF-Gamma, IL-1, IL-2, IL-3, IL-6 and IL-8 have been related to the SS pathogenesis [3]. On the other hand, some authors have reported IL-2 and IFN-gamma in nickel-exposed skin [4] and an increased secretion of IFN-gamma by lymphocytes exposed to gold salts [5]. Christiansen et al., conclude that IFN-gamma assessment was the most accurate method for identifying allergic CD to gold [6]. An increase in keratinocyte IL-6 expression in allergic patch test reactions and induced irritant reactions has been reported. This common involvement of cytokines in SS and CD to PPD in a henna tattoo may be a possible explanation for this phenomenon. However, we need to continue to explore other factors that could contribute to this association.

Acknowledgements

References

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