Brothers Who Burn: Two Paediatric Case Reports of para- Phenylenediamine (PPD) Sensitisation to Black Henna.

Dr Rachael  Stokes1, Dr Camille Wu1, Dr  Susan Adams1

1Sydney Children’s Hospital, Randwick, Australia


The addition of para-phenylenediamine (PPD) to red henna to create a cosmetically pleasing temporary black henna tattoo (TBHT) is well established in tourist industries worldwide. This molecular compound can induce severe skin sensitization.  Clinical manifestations of the type IV delayed hypersensitivity reaction vary from erythema, to allergic contact dermatitis (ACD) – most commonly, to chemical burns. Type I hypersensitivity reactions (urticaria, angioedema, or anaphylaxis) with potentially lethal reactions have also been documented, although less frequently.  This report describes two siblings presenting with suspected PPD sensitisation leading to chemical burns, and summarises the literature on this clinical problem. Case Presentation: Two brothers, aged five and eleven, presented with severe chemical burns over multiple limbs following application of TBHT whilst overseas. The reaction was mildest in areas of initial and single application – with hypopigmentation and ACD – and most severe in areas where TBHT was applied sequentially – with skin loss and pustule formation. In addition, some wounds were complicated by infection. Management consisted initially of Hydrogel and Paraffin Gauze, with oral antibiotics, followed by anti-microbial foam and Nanocrystalline silver dressings, and finally, topical steroid cream. Dermatology was consulted regarding chemicals with cross-reactivity to be avoided in addition to PPD-containing products.  Conclusion: The use of PPD is widespread throughout the world, but its presence and concentration is often unknown. Due to difficulty enforcing regulations in other jurisdictions, increasing public awareness of its potential complications, including long-term scarring risk, is likely to be the most effective means of preventing burns secondary to PPD sensitisation.


Rachael completed her Undergraduate MBBS at the University of Western Australia in 2014.She has recently moved from Adult General Surgery to Paediatric General Surgery and is currently a resident at Sydney Children’s Hospital.


ANZBA is a not for profit organisation and the peak body for health professionals responsible for the care of the burn injured in Australia and New Zealand. ANZBA encourages higher standards of care through education, performance monitoring and research.

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