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Pearls of Cross Cultural Care: Skin Decorations in East African Patients

April 1998

Have you noticed that many of your East African patients have a yellow orange discoloration of the fingers, toes or palms of their hands? This discoloration is caused by the application of Henna, a natural dye used as a decorative substance for skin and hair throughout the world. Among our East African patients it is commonly used as a skin decoration at the time of celebrations such as weddings, circumcisions, or at the end of Ramadan among the Muslim population. In older teens and adult women the decorations may be very elaborate and detailed. Everyday use of Henna on the tips of the fingers and toes is very common. It is occasionally applied to children and to infants.

Henna is obtained from the dried leaves of a shrub, Lawsonia alba, which is very common throughout the Middle East and Africa. The dried leaves are soaked in water and applied to the hair, skin or nails to create the reddish, yellow-orange color, or black color. The dying process may require several hours and approximately 100 grams of henna are usually used to stain the hands and feet of an adult.

Lawsone has been tested in vitro and found to be an oxidizing agent which can cause hemolysis of red blood cells. It is capable of inducing oxidative injury in glucose-6-phosphate dehydrogenase (G6PD) normal red cells, but produces more marked injury in G6PD-deficient red blood cells. The oxidative changes from lawsone are similar to those reported for naphthalene which has been documented to cause severe hemolysis in G6PD-deficient patients. There have been cases of red blood cell hemolysis in Bedouin newborns with henna dye applied over their bodies. Use in older children and adults rarely produces contact dermatitis.

Henna combined with a para-phenylenediamine (PPD) mixture has been associated with angioneurotic edema, shock and renal failure in children and adults in Sudan. The PPD improves the cosmetic effect of henna. Since henna is applied to the finger tips where pulse oximetry measures are taken, researchers have looked at the impact of henna on accuracy of pulse oximetry measurements. They found that black henna caused major errors in oxygen saturation readings while red henna did not. Use of ear oximetry was recommended if patients had black henna applied to their fingertips.

References:

• Zinkham WH and Oski FA. Henna: A potential cause of oxidative hemolysis and neonatal Hypebilirubinemia. Pediatrics 1996;97:707-709.
• Sir Hazshim M, et al. Poisoning from henna dye and para-phenylenediamine mixtures in children in Khartoum. Ann Trop Paediatr 1992;12:3-6.
• al-Majed SA, Harakati, MS. The effect of henna paste on oxygen saturation reading obtained by pulse oximetry. Trop Geogr Med 1994;46(1);38-39.
• Kandil HH, al-Ghanem MM, Sarwat MA, al-Thallab FS. Henna (Lawsonia inermis Linn.) inducing haemolysis among G6PD-deficient newborns. A new clinical observation. Ann Trop Paediatr. 1996; 16(4):287-291.
• Garc'ia-Ortiz JC, Terron M, Bellido J. Contact allergy to henna. Int Arch Allergy Immunol. 1997; 114(3):298-299.