electrocautery is usually required to remove the

lesions.

PIH has always been a concern in Asian patients

with pigmented skin who receive ablative treat-

ment. There were no significant differences in the

risk of PIH between wiping and not wiping the

crusts after cautery. PIH occurred on both sides in

two patients. The incidence of PIH after electro-

cautery was 20%. Patients with pigmented skin

should be warned regarding this risk before the

procedure. Sun avoidance and protection should be

advised to minimize the risk of PIH. No scarring

or infections were observed.

In conclusion, removing all of the crusts after cau-

tery can be time-consuming, especially with numer-

ous lesions, and will not alter the outcome. We

propose that the crusts can be safely left alone and

allowed to fall off by themselves. The limitation of

this study is the small sample size.

References

1. Logie A, Dunois-Larde C, Rosty C, Levrel O, et al. Activating

mutations of the tyrosine kinase receptor FGFR3 are associated

with benign skin tumors in mice and humans. Hum Mol Genet

2005;14:1153–60.

2. Herron MD, Bowen AR, Krueger GG. Seborrheic keratoses: a

study comparing the standard cryosurgery with topical

calcipotriene, topical tazarotene, and topical imiquimod.

Int J Dermatol 2004;43:300–2.

3. Hafner C, Vogt T. Seborrheic keratosis. J Dtsch Dermatol Ges

2008;6:664–77.

YONG-KWANG TAY, MD

SIEW-KIANG TAN, MD

Department of Dermatology

Changi General Hospital

Singapore, Singapore

Successful Removal of a Henna Tattoo Using 2,940-nm Ablative Laser Resurfacing

Letters:

Temporary henna tattoos are extremely popular

among children and young adults and are custom

at weddings in certain cultures, but a growing

concern over adverse reactions and lack of regula-

tion of cosmetic tattoos has been recently

reported.1 Although henna is a natural powder

created from the Lawsonia alba plant with low

allergic potential, it is often combined with color-

ing substances with high allergenicity such as

para-phenylenediamine (PPD). Multiple reports of

allergic contact dermatitis, hypertrichosis, general-

ized erythema multiforme, angioedema, and severe

keloidal and inflammatory reactions in association

with henna tattoos have been published. In

addition, long-term complications include postin-

flammatory pigment abnormalities, scarring, and

potential sensitization to antigens. Henna tattoos

typically last 1–4 weeks after application, and to

date there have been no publications discussing

removal of henna tattoos or other aids to eliminate

the design more quickly.

Report of a Case

A 26-year-old woman presented to our clinic with a

henna tattoo on her left dorsal hand and wrist that

had been placed approximately 3 days prior (Fig-

ure 1). Worried about the impact of showing up to

her workplace with the tattoo, she sought treatment

options for removal. A literature review yielded no

therapeutic options for removal of henna tattoos.

After discussion with the patient of potential thera-

pies, she elected treatment with an ablative 2,940-

nm erbium-doped yttrium aluminum garnet (Er:

YAG) laser (1.0 J/cm2, 4-lm micropeel, depth of

4 mm per pass, 20% overlap, 5-mm spot size).

There was significant lightening of the henna tattoo

after one pass (Figure 2), and the design was

virtually undetectable after two passes (Figure 3).

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LETTERS/COMMUNICATIONS

There was still a minimal amount of tattoo remain-

ing in the thicker skin overlying the metacarpopha-

langeal joints, but the patient was pleased with the

results. The treatment was well-tolerated, with

minimal procedural pain without anesthesia, and

no specialized wound care was necessary.

Discussion

Henna tattoos are increasing in popularity but are

not always benign, with reports of multiple derma-

tologic and systemic reactions reported. Specifi-

cally, allergic contact dermatitis has been reported

widely in individuals receiving henna tattoos.

Henna itself is made from the dried flowers and

leaves of the Lawsonia alba plant, possesses a

naturally brown–red coloration, and has low aller-

genicity, but it is often used in combination with

substances such as para-phenylenediamine (PPD)

and others to help darken the color and create a

longer-lasting tattoo. This common practice is

often referred to as a black henna tattoo. In addi-

tion to black henna tattoos, PPD is found in hair

dye, rubber products, dyed leather and textiles,

and color film developing. The American Contact

Dermatitis Society named PPD the allergen of the

Figure 2. Patient’s hand after one pass of 2,940-nm abla-tive laser resurfacing. Photographs were taken immedi-ately after laser irradiation.

Figure 3. Patient’s hand after two passes of 2,940-nm abla-tive laser resurfacing. Photographs were taken immedi-ately after laser irradiation.

Figure 1. A 26-year-old woman presented for removal of ahenna tattoo that hadbeenpresent for approximately 3 days.

DERMATOLOGIC SURGERY814

LETTERS/COMMUNICATIONS

year in 2006, and it is known to cross-react to

para-aminobenzoic acid, aniline or azo dyes, and

sulfonamide drugs (e.g., thiazides, esters).

Individuals who develop contact dermatitis to PPD

in henna have this same risk.

In addition to allergic contact dermatitis, there have

been reports of hypertrichosis, generalized erythema

multiforme, angioedema, and severe keloidal and

inflammatory reactions in association with henna

tattoos. Long-term complications including postin-

flammatory pigment abnormalities, scarring, and

potential sensitization to antigens,2 with more-

severe or systemic reaction upon rechallenge, have

been reported. One study suggests that 100% of 24

test subjects were sensitized after exposure to 10%

PPD2; the typical concentration of PPD in henna is

approximately 6% but can be as high as 15%–30%

in black henna tattoos. Although Sosted and col-

leagues did not find a history of a temporary henna

tattoo to be a significant risk for contact dermatitis

to hair dyes in a Danish adult population,3 a recent

analysis of the side effects associated with hair dyes

from four cosmetic companies revealed that having

had a henna tattoo was a main risk factor for the

severity of a later allergic reaction to a hair dye.4

Despite all the complications reported in associa-

tion with semipermanent henna tattoos, the major-

ity of individuals who acquire them perceive their

risk for complications to be low. Henna tattoos are

inexpensive, easily applied with minimal discom-

fort, and increasing in popularity in touristic areas

in addition to their use in certain cultures. No pub-

lished studies have suggested ways to help remove

or accelerate the natural fading process of the

tattoo as the epidermis turns over. Home remedies

to help remove the design more quickly include var-

ious forms of exfoliation combined with soaking in

water or salt water. Nonetheless, henna tattoos can

last for up to 4 weeks in the epidermis depending

on the site of the body, the ingredients of the paste,

the quality of the henna, and the application

method. In the event that a patient desires quick

removal of the tattoo out of cosmetic concern, or if

a reaction to the tattoo develops, the use of the

2,940-nm ablative laser set on a micropeel depth

appears to remove the remaining design in the epi-

dermis. Benefits include a quick procedure with

minimal anesthesia or wound care required. Addi-

tional benefits may include removal of PPD from

the skin before sensitization. We hypothesize that

this could limit development of allergic contact der-

matitis in patients who might be concerned with

the risk. Limitations include the expense of the

device and potential laser complications. Caution

should be taken if treating a henna tattoo with an

associated allergic reaction, because cases of gener-

alized allergic reactions after laser treatment have

been reported. Of note, these reports have been

with the use of nonablative lasers with which the

tattoo pigment remains in the body after treatment.5

Additional data are needed to assess this potential

risk. We report the first case of henna tattoo

removal using the Er:YAG ablative laser. Further

studies are needed to evaluate the feasibility of this

method and to evaluate its effectiveness when used

in individuals with a henna tattoo reaction.

References

1. Ortiz AE, Alster TS. Rising concern of cosmetic tattoos.

Dermatol Surg 2012;38:424–9.

2. Klingman AM. The identification of contact allergens by human

assay. The maximization test: a procedure for screening and

rating contact sensitizers. J Invest Dermatol 1966;47:393–409.

3. Sosted H, Hesse U, Menne T, et al. Contact dermatitis to hair

dyes in a Danish adult population: an interview-based study.

Br J Dermatol 2005;153:132–5.

4. Krasteva M, Bons B, Tozer S, Rich K, et al. Contact allergy to

hair colouring products. The cosmetovigilance experience of 4

companies (2003–2006). Eur J Dermatol 2010;20:85–95.

5. Ashinoff R, Levine VJ, Soter NA. Allergic reactions to tattoo

pigment after laser treatment. Dermatol Surg 1995;21:291–4.

ASHLEY WYSONG, MD, MS

JUSTIN GORDON, MD

DAVID PENG, MD

ZAKIA RAHMAN, MD

Department of Dermatology

School of Medicine

Stanford University

Redwood City, California

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LETTERS/COMMUNICATIONS