Intended for healthcare professionals

Endgames Picture Quiz

A blistering eruption after a holiday in India

BMJ 2011; 343 doi: (Published 20 December 2011) Cite this as: BMJ 2011;343:d7474
  1. F S Worsnop, senior house officer,
  2. E E Craythorne, specialist registrar,
  3. Anthony W P du Vivier, consultant
  1. 1Department of Dermatology, King’s College Hospital, London SE5 9RS, UK
  1. Correspondence to: E E Craythorne emma_craythorne{at}

A 33 year old woman presented with an intensely itchy, erythematous, blistering eruption bilaterally on the distal upper and lower limbs a week after coming back from a holiday in India. The rash was associated with oedema. She had attended a friend’s wedding while in India, and as part of the festivities she took part in the ritual of “mehndi,” which involved having an intricate henna design painted on her hands and feet. Five days after this ritual she developed a sharply demarcated erythematous, itchy, papulovesicular swelling in the proximal distribution of the tattoo design, which spread distally (figure). Other than the skin irritation, she had no other symptoms and was systemically well.


  • 1 What is the diagnosis?

  • 2 What investigations should be performed?

  • 3 How is this condition managed?


1 What is the diagnosis?

Short answer

The diagnosis is contact dermatitis to paraphenylenediamine (PPD). This chemical is widely used in hair dye and is an ingredient in many other products, including black henna, which is used in temporary tattooing.

Long answer

PPD is an aromatic amine compound that is primarily used as a hair colouring agent. It is also found in a variety of products including textile dyes, photography development agents, certain local anaesthetics, cosmetics, and printing inks. It is becoming increasingly used in temporary tattoos as an addition to henna.1

Henna is a greenish brown vegetable colouring from the leaves of the plant Lawsonia inermis or L alba, which grows in India, North Africa, and Sri Lanka.2 The active ingredient is lawsone (2-hydroxy-1,4-naphthoquinone). On its own, …

View Full Text

Log in

Log in through your institution


* For online subscription