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Journal of Pakistan Association of Dermatologists. 2016;26 (1):58-65.

Review Article
Henna beyond skin arts: Literatures review
Fahad Al Saif

Department of Dermatology, College of Medicine, King Saud University, Riyadh, Saudi Arabia

Abstract Henna is the dried and powdered leaf ofLawsonia inermisand is a natural dye for hair, nails and
skin for body arts in Islamic and Hindu cultures. Recently, it has been widely used in western
countries as temporary black henna tattoo. Different experimental in vitro studies showed many
pharmacological effects of L. inermis. Topical pure henna is generally safe and well-tolerated in
humans but oral and topical henna with additives like para-phenylenediamine have many side
effects some of them life threatening. This review highlights pharmacological effectiveness and
adverse effects of henna.

Key words
Henna, Lawsonia inermis, para-phenylenediamine.

Introduction and modified henna products such as black


henna are available by adding para-
The World Health Organization (WHO) has phenylenediamine (PPD) to henna powder. In
defined herbal medicines as finished labeled addition, several medicinal properties of L.
medicinal product that contain an active inermishave been documented through in vitro
ingredient, aerial, or underground parts of the studies. It has been used as an antimicrobial,
plant or other plant material or antidiarrheal, anti-inflammatory, and
1
combinations. Henna is the dried and analgesic; it has antipyretic effects.In this
powdered leaf ofLawsonia inermis.The plant review, the author summarizes the effects
henna (Lawsonia inermis, family Lythraceae) attributed to henna regarding its non-
is a shrub that is naturally grown or cultivated dyingproperties including pharmacological
from North-East Africa to India.2,3 The properties and side effects.
chemical constituents of its extract include
naphthalene derivatives, quinoids, beta Pharmacology
sitosterol, flavonoids and gallic acid.4 Henna is
very popular in many countries especially in 1. Antimicrobial Activity
Middle East and South Asia; it is part of the
culture and traditions in these countries and Natural antimicrobial therapy is an important
widely used in body art to dye skin, hair and research area because of antibiotic overuse and
fingernails. In addition, temporary henna antibiotic resistance. Many invitrostudies have
tattoos or pseudo-tattoos have become evaluated the pharmacological activities of L.
increasingly widespread worldwide.5 inermis. Its leaves, stem bark, roots, flowers
and seeds have been used in traditional
The mechanism of dyeing is mainly related to medicine.Henna leaves have a great potential
the staining properties of constituent lawsone, to be used as a source of a potent eco-friendly
antimicrobial agent.6Habbalet al.7 reported that
Address for correspondence Omani henna has antibacterial activity against
Dr. Fahad Al Saif
Staphylococcus aureus,Escherichia coli and
Consultant Dermatologist
Department of Dermatology (82) Pseudomonas aeruginosa.7Abdullmomein8
College of Medicine, King Saud University found that anthraquinones are a major
P.O. Box 7805, Riyadh 11472 constitute of henna leaves, and this compound
Saudi Arabia
has antimicrobial activities. Another study
Email: fsaif1000@hotmail.com / falsaif1@ksu.edu.sa

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Journal of Pakistan Association of Dermatologists. 2016;26 (1):58-65.

done by Christyet al.9 showed that the ethyl isolate and characterize specific compounds to
acetate and ethanol extracts of fruit and flower further assess antioxidant activity.
of L. inermisare potentially better source of
antibacterial agents.Awadhet al.10 investigated 3. Wound healing activity
the Yemeni medicinal plants for antibacterial,
and they found that ethyl acetate extract of L. The ethanol extract of L. inermis has been used
inermis had activity against all bacteria in their to evaluate wound healing in rats. One group
study. In vitro studiesassessed the effect of treated with an ethanol extract of L. inermis
henna powder on the growth of E. coli. There showed increased collagen and enhanced
was obvious antibacterial activity againstE. wound contraction.21,22 The methanolic extract,
coli.11The tuberculostatic activity of henna was isoplumbagin and lawsaritol isolated from
tested in vitro and in vivo and this study stem bark and root of L. inermisL. showed
showed significant activity against anti-inflammatory activity against
Mycobacterium tuberculosis andM. carrageenan-induced paw edema in mice.23,24
12,13
chelonae. Hexane extractsof L. inermis
showed strong antifungal activity 4. Antiinflammatory, analgesic and
againstTrichophyton tonsurans, T. rubrum, and antipyretic activity
T. mentagrophytes.14Antifungal effects of
chloroformic, methanolic and aqueous extracts The butanol and chloroform fractions of L.
of henna (L. inermis) leaves on Malassezia inermis showed potent anti-inflammatory,
furfur. The study reported that a chloroform analgesic, and antipyretic effects that were
extract of henna completely inhibited the comparable to phenylbutazone.25 Studies found
growth of M.furfur.15These studies confirmed that crude ethanolic extracts of L. inermis in
the antimicrobial activity of henna leaves and concentrations of 0.25-2.0 g/kg cause
supported the traditional use of the plant in significant and dose dependent anti-
therapy of localized cutaneous infections. inflammatory and analgesic effects in rats.26An
interesting clinical study showed significant
2. Antioxidant activity effect of topical henna in hand-foot syndrome
induced by capecitabine, and the clinical
Research has shown that L. inermis extracts improvement in these patients may be related
have antioxidant activities.L. inermisleaves to the anti-inflammatory, antipyretic and
inhibit carbon tetrachloride toxicity in rat analgesic effects of henna.27
liver.16,17In these studies, an ethyl acetate
extract of L. inermisleaves caused a significant 5. Immunomodulatory activity
reduction in hepatic thiobarbituric acid reactive
substances and increased antioxidant enzymes The immuomodulatory activity was studied in
that inhibit the effectsof carbon tetrachloride. vitro.A methanolic extract and naphthoquinone
On the other hand, ethanolic and methanolic fraction of L. inermis leaves showed
extracts of L. inermishave high antioxidant significant immunomodulatory effects through
potential that simultaneously inhibits the promotion of T lymphocyte proliferative
hexavalent chromium-induced oxidative responses. Some of their effect was due to
toxicity and scavenges diphenyl-1- antioxidant and free radical scavenging activity
picrylhydrazyl and inhibit lipid of the henna extract.20
18,19
peroxidation. One study compared
the antioxidant and immunomodulatory 6. Anti-carcinogenic and cytotoxic activity
constituents of henna leaves with ascorbic
acid, and this study showed comparable L. inermisalso has cytotoxic effects.28The in
activity.20 Additional studies are needed to vitro cytotoxic studies of 2-hydroxy-1,4-

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Journal of Pakistan Association of Dermatologists. 2016;26 (1):58-65.

naphthaquinone (lawsone) against two human including black henna. This was caused by
cancer cell lines MCF-7 (human breast cancer) diaminotoluene and diaminobenzene or cross-
and HCT-15 (human colon carcinoma cells) reactions of PPD with para-amino compounds
using MTT assay revealed the cytotoxic effects (benzocaine, sulfa drugs, aminoazobenzene,
in killing cancer cells even at low IPPD, PABA) and hairdressing allergens (2,5-
concentrations.29,30Also, the bicoumarin, diaminotoluene sulfate, 2-nitro-4-
biflavonoid and biquinone isolated from the phenylenediamine, 4-aminophenol, 3-
flower of L. inermis showed cytotoxic activity aminophenol).37,39The clinical manifestations of
against cancer cells.31An in vivo two-stage allergic contact dermatitis varies in severity
mouse skin carcinogenesis study using UV-B from an intensely itchy erythematous with
radiation for initiation and TPA for tumor patches of painful, itchy exudative bullous
promotion showed that oral feeding of henna eruptions.37-42The patch test is the gold standard
(0.0025%) in drinking water ad libitum method for diagnosis of allergic contact
decreased tumor incidence by 66% and dermatitis from henna, while the prevalence of
multiplicity by 40% versus a positive control at the positive patch test in pure henna is 3%, and
10 weeks.32 the prevalence of the patch test positivity to
henna with PPD is 35% or more.43,44 The high
7. Hypoglycemic and hypolipidemicactivity positive patch test results from high
concentrations of PPD (15.7%) despite the
A study to evaluate the effect of ethanolic directive of the European Community
extract of leaves of L. inermis in diabetic rats Cosmetics Directive, which allows the
showed that a L. inermis extract at 400mg/kg maximum concentration to be 6%.The USA
BW had significant hypoglycemic activity in Food and Drug Administration (FDA) advises
diabetic rats after oral administration.33The that PPD should not be applied to the skin of
effect of the ethanolic extract 500 mg/kg of patients with a history of atopy.45
body weight was found to be better
thanglibenclamide (10 mg/kg of body weight). 2. Immediate-type hypersensitivity with
These results suggest that the ethanolic extract urticaria
possess significant antidiabetic effects.34The
hypoglycemic effect may elicited through A few cases have been reported that describe
inhibiting alpha-amylase enzyme.35L. inermis immediate-type hypersensitivity reactions from
hydroalcoholic extract may also show direct contact to henna.46,47The clinical features
significantly improved lipid and lipoprotein are urticaria, rhinitis, acute bronchospasm and
patterns in diabetic rats. This could be due to reported cases of severe, fatal angioneurotic
improvement in insulin secretion.36 edema.48,49,50This reaction was confirmed by
both a skin prick test and radio allergen
Complications of henna sorbent test (RAST), but the pathogenesis of
this reaction is not clear. Immunologic contact
Although most of complications of henna urticaria reactions and non-immunologic
come from topical applications for traditional contact urticaria may have a role.51,52
events or temporary tattoo, some serious
complications have occurred after oral 3. Erythema multiforme
ingestion of henna.
Erythema multiforme is an acute, self-limited,
1.Allergic contact dermatitis skin eruption mediated by type IV
hypersensitivity reaction and associated with
Natural henna is usually hypoallergenic,37,38 certain infections, medications, and other
and allergic reactions occurred in mixed types triggers. Few cases have been reported from

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Journal of Pakistan Association of Dermatologists. 2016;26 (1):58-65.

topical henna. Most reactions are due to dehydrogenase (G6PD)was documented in


additive, especially PPD, which is an aniline many cases.69,70,71Current scientific evidence
derivative that is added to speed up the process suggests that lawsone acts directly as a
of skin dying.53,54,55The clinical features range hemolytic agent to induce oxidative stress.
from classical erythema multiforme to This is consistent with clinical observations of
generalized vesicular erythema multiforme- enhanced susceptibility to henna in G6PD-
like reactions.56,57 deficient individuals.72,73Oral ingestion of
hennaeither accidentally, deliberate (suicidal),
4. Post-inflammatory hypo- or or homicidalcan cause acute renal
hyperpigmentation failure,rhabdomyolysis and intravascular
hemolysis.74,75
The henna usually starts to fade within two
weeks and is completely removed within 5 8. Vasculitis and renal impairment
weeks. Cases of persistent hyperpigmentation
have been reported.58The causes are either due Cutaneous vasculitis with rapidly progressive
to subclinical interface dermatitis caused by glomerulonephritis has been described with
henna or its additives or the use of readymade chronic use of henna mixed with PPD for
henna paste of unknown origin. dyeing of the hair. Indeed, hair dressers who
Hypopigmentation after non-permanent henna use henna have been shown to have a high
tattoo has been reported with a positive patch prevalence of renal impairment due to regular
test to PPD. This may explain the residual exposure to PPD.77 Twelve patients ingested
hypopigmentiom.59,60,61 PPD (henna hair dye) in suicidal attempts with
severe acute renal failure.78
5. Hypertrichosis
Teratogenicity
Transient hypertrichosis has been reported in a
few cases.62-65 Hypertrichosis usually occurs Although pure henna is safe, but should be
within the first 20 days after initial application used with caution during pregnancy.Female
of black henna. This often resolves mature BALB/c mice were intraperitoneally
spontaneously after 3 to 5 months.Skin biopsy injected with 100 mg/kg of L. inermis for 7
studies showed an increase in vellus hair days. On the 19th day, their embryos were
follicles with slight peripheral fibrosis.62The examined for abnormalities. There were
pathophysiology is unknown but one of the parietal bones absent in 90% of the embryos,
additive substances may play a part in the and extra ribs were observed in 30%. This may
pathophysiology.62 be related to the 2-hydroxy-1,4-
naphthoquinone in L. inermis extract.79Another
6. Keloids study showed that hydroalcoholic extracts of
henna can cause significant damage in
Extensive keloid scarring in the pattern of the newborn mice livers.80
henna tattoo has been reported.66,67,68Keloid
formation waspresided by severe allergic Conclusion
contact dermatitis, and a positive patch test to
PPDwas documented in all cases. There is some evidence showing the efficacy
of topically applied natural henna, but it is
7. Hemolysis necessary to identify and select a
representative lead ingredient. More studies
Hemolytic crises following external should be established for further observation of
application of henna in glucose-6-phosphate

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Journal of Pakistan Association of Dermatologists. 2016;26 (1):58-65.

the value of henna and to minimize side 13. Sahar Traoré M, Baldé MA, Camara A,
effects. Baldé ES, Diané S, Diallo MS.The malaria
co-infection challenge: An investigation
into the antimicrobial activity of selected
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