a) CASE REPORT: Occupational asthma (rhinorrhea, sneezing, wheezing, nasal obstruction and itching, hyposmia (diminished sense of smell), dysphonia, conjunctivitis, and dry cough) has been reported in a 35-year-old woman working in an herbal shop. She reported that her symptoms worsened when she inhaled the powder of black henna (Indigofera argentea), a species of henna that is botanically distinct from the more common red henna (Lawsonia inermis). Specific IgE antibodies and skin prick tests performed with a 1/10 dilution of the black henna powder were positive for black henna (Scibilia et al, 1997).

a) CASE REPORT: A 40-year-old woman developed pulmonary edema after applying a henna mixture to her feet. The henna mixture was prepared by a neighbor, who refused to give full details of the preparation. To speed up dyeing, a second dye, paraphenylenediamine (PPD) is usually added to henna. Respiratory distress, angioedema, and asthma have been described in individuals exposed to PPD (Abdulla & Davidson, 1996).

a) Because of the tannin content, henna may cause stomach complaints (Prod Info Henna, 2003).

a) Topical use of henna has been associated with indirect hyperbilirubinemia in infants with glucose 6-phosphate dehydrogenase (G6PD) deficiency (Kandil et al, 1996).
b) CASE REPORT: A 7-day-old boy with glucose 6-phosphate dehydrogenase (G6PD) deficiency developed severe hyperbilirubinemia secondary to hemolysis within 29 hours of henna application for prevention of diaper rash. Following exchange transfusion and phototherapy, he recovered without further sequelae (Katar et al, 2007).

a) CASE REPORT: A 27-day-old G6PD-deficient boy developed hemolytic anemia and acute renal failure after topical use of henna to his abdomen, intertriginous region and legs to treat diaper rash. His condition deteriorated and he died approximately 2 days after admission to the hospital (Devecioglu et al, 2001).
b) Within a few hours of topical application, an allergic reaction in the form of angioneurotic edema (of the face, lips, pharynx, larynx and bronchi) progressing to acute renal failure and ultimately death due to renal tubular necrosis, may occur (Oztass et al, 2001; Rubegni et al, 2000).
c) CASE REPORT: A 32-year-old man presented with a 3-day history of feeling unwell, anorexia, fatigue, and abdominal bloating after ingesting a large amount of boiled henna containing PPD. He also had yellowish discoloration of the sclera and dark-colored urine. Laboratory analysis revealed a reduced hemoglobin (8.8 g/dL), and elevated serum creatinine (more than double). Initially, his renal function and hemolysis deteriorated despite supportive care. However, his condition improved following transfusion with packed red blood cells and hemodialysis. He was discharged on day 13 (Qurashi et al, 2013).

a) In animals, lawsone (2-hydroxy-1,4-naphthoquinone) has been reported to cause severe hemolytic anemia and renal tubular necrosis (Devecioglu et al, 2001).

a) CASE REPORT: A 32-year-old man presented with a 3-day history of feeling unwell, anorexia, fatigue, and abdominal bloating after ingesting a large amount of boiled henna containing PPD. He also had yellowish discoloration of the sclera and dark-colored urine. Laboratory analysis revealed a reduced hemoglobin (8.8 g/dL), and elevated serum creatinine (more than double). Initially, his renal function and hemolysis deteriorated despite supportive care. However, his condition improved following transfusion with packed red blood cells and hemodialysis. He was discharged on day 13 (Qurashi et al, 2013).
b) CASE SERIES: In 15 glucose-6-phosphate dehydrogenase (G6PD)-deficient male newborns, topical henna use was associated with hemolysis, anemia, reticulocytosis, and indirect hyperbilirubinemia. The hemolytic episode occurred within a few hours to 3 days after administration of the henna and reticulocytosis began at about 5 days (Kandil et al, 1996).
c) CASE SERIES: Four glucose-6-phosphate dehydrogenase deficient children developed hemolytic crisis after topical application of henna; a female neonate (hemoglobin 50 g/L, serum bilirubin 700 mcmol/L) and two preschool children (hemoglobin 40 and 41 g/L, respectively) recovered after exchange transfusion; one male infant (hemoglobin 28 g/L) died despite transfusion (Raupp et al, 2001).
d) In vitro studies indicate that lawsone, a chemical constituent of henna, is capable of inducing oxidative injury to G6PD-normal red cells. Since 100 grams of henna is required to dye the palms and soles of an adult, and assuming that the surface area of the infant is approximately 1/10 that of an adult, then an infant, with dyed palms or soles, would probably be exposed to 10 grams of henna (1 gram of lawsone). Therefore, the percutaneous absorption of henna may induce oxidative injury to neonatal red cells (Zinkham & Oski, 1996).
e) CASE REPORT: A 27-day-old G6PD-deficient boy developed hemolytic anemia and acute renal failure after topical use of henna to his abdomen, intertriginous region and legs to treat diaper rash. His condition deteriorated and he died approximately 2 days after admission to the hospital (Devecioglu et al, 2001).
f) CASE SERIES: Two glucose-6-phosphate dehydrogenase (G6PD) enzyme deficient siblings (an 11-year-old boy and a 7-year-old girl) developed hemolytic anemia after the topical application of henna to their whole body to treat skin lesions (ichthyosis vulgaris). Although the 11-year-old boy recovered completely and was discharged after 4 days, his sister's condition deteriorated despite transfusion and she died approximately 2 days after admission (Kok et al, 2004).

a) In animals, lawsone (2-hydroxy-1,4-naphthoquinone) has been reported to cause severe hemolytic anemia and renal tubular necrosis (Devecioglu et al, 2001). This finding has also been suggested following in vitro experiments (Zinkham & Oski, 1996).

a) Topical use of henna and more commonly paraphenylenediamine can cause contact and allergic dermatitis (Nawaf et al, 2003; Chung et al, 2002; Chung et al, 2001; Jellin et al, 2000; Lestringant et al, 1999; Duke, 1985).
b) CASE REPORT: A 38-year-old man developed a patterned lichenoid reaction (a red palpable skin reaction, with the tattooed area raised 0.5 cm above the surrounding skin) on the neck 20 days after receiving a henna non-permanent tribal tattoo during a trip to east Africa (Zanzibar). A biopsy revealed a typical lichenoid dermal infiltrate with erosion of the basal layer of the epidermis (Rubegni et al, 2000).
c) CASE SERIES: Lichenoid reactions in 4 patients with temporary tattoos, from black henna, were found to have high concentrations of para-phenylenediamine (detected by mass spectrometry) in skin biopsy samples (Chung et al, 2002).
d) CASE REPORT: A 17-year-old female developed acute contact dermatitis, consisting of blisters, within 72 hours of applying temporary henna tattoos to her hands. Subsequent skin testing revealed that her allergy was to para-phenylenediamine, not natural henna (Nawaf et al, 2003).

a) Allergy to plain henna is rare; however, it has been reported in several patients. Allergy to henna is usually related to the coloring material itself, a hydroxynaphthoquinone, or the additives such as PPD and a scented oil. There are many case reports in the medical literature describing confirmed allergic reactions to PPD (Nawaf et al, 2003; Wolf et al, 2003; Chung et al, 2002; Chung et al, 2001; Rubegni et al, 2000; Lestringant et al, 1999; Majoie & Bruynzeel, 1996).
b) CASE REPORT: A 10-year-old girl developed allergic contact dermatitis (type IV delayed hypersensitivity reaction) after receiving a henna tattoo to her left arm while in India. A well-demarcated, indurated, erythematous papular eruption confined to the area of the henna tattoo was observed. Patch testing revealed a strong positive reaction to PPD, with additional reactions to a number of substances found in hair products (Bowling & Groves, 2002).
c) An immediate-type hypersensitivity (urticaria, rhinitis, bronchial asthma, sneezing, conjunctivitis, dry cough, and severe dyspnea) to henna was reported in 2 hairdressers (Bolhaar et al, 2001; Majoie & Bruynzeel, 1996). It was reported that the hypersensitivity was due to induction of specific IgE antibodies to henna (Bolhaar et al, 2001).
d) CASE REPORT: A 38-year-old teacher developed severe angioedema (eyelids, face, forehead, scalp, and tongue) within 4 hours of using a commercial hair dye product containing henna (Oztass et al, 2001).
e) CASE REPORT: Fatal anaphylaxis developed in a 15-year-old girl after ingesting an unknown amount of henna in a suicide attempt. Autopsy revealed laryngeal edema and pulmonary congestion (Kok et al, 2005).

a) Refer to "PARAPHENYLENEDIAMINE" management for further information.

a) Consider administration of activated charcoal after a potentially toxic ingestion (Chyka et al, 2005). Administer charcoal as an aqueous slurry; most effective when administered within one hour of ingestion.

a) Use a minimum of 240 milliliters of water per 30 grams charcoal (FDA, 1985). Optimum dose not established; usual dose is 25 to 100 grams in adults and adolescents; 25 to 50 grams in children aged 1 to 12 years (or 0.5 to 1 gram/kilogram body weight) ; and 0.5 to 1 gram/kilogram in infants up to 1 year old (Chyka et al, 2005).
b) ADVERSE EFFECTS/CONTRAINDICATIONS

a) Treatment is symptomatic and supportive.

a) Treatment is symptomatic and supportive. Severe toxicity may occur in glucose-6-phosphate dehydrogenase (G6PD)-deficient patients.
b) Henna is frequently mixed with paraphenylenediamine (PPD) to reduce the cost and drying time. Respiratory distress, angioedema, and asthma have been reported in individuals exposed to henna and PPD mixtures (Oztass et al, 2001; Lestringant et al, 1999; Zinkham & Oski, 1996; Abdulla & Davidson, 1996; Kandil et al, 1996).
c) Refer to "PARAPHENYLENEDIAMINE" management for further information.