Skin Marking in External Radiotherapy by Temporary Tattooing with Henna


Int. J. Radiation Oncology Biol. Phys., Vol. 50, No. 1, pp. 179–181, 2001
Copyright © 2001 Elsevier Science Inc.
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Landesklinik fuer Radiotherapie und Radio-Onkologie, Landeskliniken Salzburg, Salzburg, Austria

Purpose: To guarantee invariable skin markings in patients undergoing a course of external radiotherapy, especially using conformal techniques. Cutaneous markings with henna also increase patient comfort, because washing and showering are allowed. Methods and Materials: Henna, a completely natural product, is a skin colorant with a history of 5,000 years. It is applied to the skin in the form of a paste. While drying, henna stains the superficial skin layers for several weeks, and the marked area can be exposed to water arbitrarily. In case of fading of the stain before the end of radiotherapy, the marking procedure can be repeated. From November 1998 until March 2000, we performed skin markings with henna in 158 patients with different tumor sites. The majority of patients received conformal radiotherapy techniques. All patients have been evaluated concerning durability of the markings, the required number of marking procedures per treatment course, and possible related side effects. Results: The median durability of henna staining is 23 days (range 12–48 days). On average, two marking procedures (range 1–4) are necessary for a patient treated with curative intent. Although washing and showering are freely permitted, no adverse cutaneous side effects (e.g., erythema, allergic reactions) have been observed. Conclusions: Skin marking by temporary tattooing with henna increases the accuracy of external radiotherapy. It yields stable and invariable markings for the entire course of radiotherapy and also increases the comfort of patients. © 2001 Elsevier Science Inc.

External radiotherapy, Conformal radiotherapy, Skin markings, Henna, Quality assurance.


In patients treated with external radiotherapy, stable and invariable skin markings (for treatment portals, isocenters, etc.) are essential. Usually, skin marks are applied to the patient during the simulation procedure by felt-tip pens. When the marks begin to fade, they are retraced under the treatment machine. However, with this conventional method, there is a risk of shifting of the skin marks with time. This may result in an inaccurate coverage of the planning target volume (PTV). Particularly in patients receiving conformal radiotherapy and/or undergoing dose escalation studies, there is a tendency to draw the PTVs as close as possible to the clinical tumor volume to spare normal tissues (1-6). Undesired shifting of skin marks during the course of therapy, even in small amounts, may be detrimental to quality assurance and possibly to treatment outcome. Shifting of skin marks applied by felt-tip pens may be detected and subsequently corrected by periodically performed portal films. However, there will always be a delay in the subsequent correction. Furthermore, there are treatment techniques for which the value of portal imaging

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as a tool to detect geographic inaccuracies is limited, for example the conformal technique of target splitting in lung cancer patients, where generally several small static fields and/or rotational treatment elements are used (6). In addition, skin markings by felt-tip pens contribute considerably to the discomfort of patients, because washing and showering are normally not permitted. An alternative to the current practice of skin marking could be permanent tattooing, which, however, has the disadvantage of possible infection and, above all, remains for the rest of the patient’s life. Therefore, temporary stable skin markings are desirable, and henna (in Hindi mehndi) has this potential. Henna is applied to the skin in the form of a paste, and while drying, it stains the superficial layers of the skin. Henna markings are clear, topographically invariable, and have a red-brown color. They last for several weeks and can be exposed to water arbitrarily.


From November 1998 until March 2000, we performed skin markings in 158 patients by using temporary tattooing

Accepted for publication 20 December 2000.

with henna. All patients have been evaluated concerning durability of the marks, the required number of marking procedures, and possible related side effects. The durability of the marks is defined as the time from the marking procedure to the end of therapy or to the time when the marks cease to be “clearly visible” by fading, and a repetition of the marking procedure has to be done. Clear and unmistakable visibility refers to the condition of the setup procedure at the treatment machine. Henna is the dried and powdered leaf of the dwarf shrub Lawsonia inermis, a member of the Loosestrife family, Lythraceae, which gains a height of about 2.5–3 m (7). It grows in hot climates and is supplied mainly from Arabia, Iran, Ceylon, India, Egypt, and Sudan.
The East has a long tradition of using henna as a skin colorant in the process of temporary tattooing. Its history goes back 5,000 years. It was used in ancient Egypt to color the nails and hair of mummies. In the twelfth century it was introduced in India, where it gained real cultural importance. It was mixed with aromatic oils and applied to the hands and feet to beautify them. Henna became essential for auspicious occasions, in particular for weddings. With the passing of centuries, henna gained significance in all cultures within the Middle East, Asia, and North Africa. More recently, henna has become popular in the West as a fashionable means of decorating the body and is also used by many artists. For generating temporary tattoos, henna powder is mixed with ingredients like lemon juice, tamarind paste, tea, and coffee to produce a moist paste. The paste can be prepared according to different recipes (7), but we prefer readymixed, commercially available products (e.g., Brite Instant Henna, manufactured by Parmanand & Co., Sojat City, India).
The procedure we employ in external radiotherapy for marking patients with henna is as follows:
● On the simulator table, the skin areas to be marked are wiped with a dry cotton pad to gain a superficial peeling. All markings that have to be tattooed with henna are provisionally dotted with a small felt tip pen.
● If required, the patient is then transferred to another couch. For preparation of the definitive henna markings, initially a thin film of eucalyptus oil is applied (this increases the absorption of henna to gain a darker stain). Then henna paste is applied in a 2–3 mm thick layer (using the provided cone mounted to the tube). Thereafter, a mixture of two parts lemon juice and one part sugar is applied. (This keeps the henna paste moist, which also helps to darken the stain.) Then the markings are covered by strips of soft adhesive plaster (e.g., Mefix, Mo¨lnlyncke Clinical Products, Sweden) to protect them from blurring and to ensure an intense contact of the henna paste with the skin for 24 h. This marking procedure takes about 10 min. Afterwards the patient should not dress for about 15 min (the time of the first hardening of the paste). Then, the patient can leave the hospital.

● On the next day, the plaster strips are removed directly on the treatment table. The patient is thereafter allowed to wash and take a shower but should not rub the marked skin (with towels, etc.).


In Table 1 are listed the different anatomic sites to which skin markings with henna have been applied to 158 patients during the past 18 months. The median durability of clearly visible marks is 23 days (range 12–48 days) (Table 2). The durability of the marks according to the different sites is shown in Table 3. On average, two marking procedures (range 1–4) are necessary for a patient treated with curative intent (Table 2). Regarding side effects, henna has been used safely for more than 5,000 years. Because it is a completely natural product, allergic reactions are very rare (7). In our 158 patients, no skin allergies could be observed. Although washing and showering are freely permitted, no other adverse cutaneous side effects, in particular in regard to erythemas, could be observed.


Among the many aspects of quality assurance, the availability of topographically invariable skin markings is a prerequisite for patients undergoing external radiotherapy, unless a mask system is used. Even under daily supervision of patients in the treatment room, a gradual shifting of skin markings applied by felt-tip pens may occur, when they are retraced under the treatment machine (or elsewhere). The use of skin marks has already been associated with higher error rates for complex fields (8), and Byhard et al. felt that error patterns relate to setting-up practices like the use of skin marks (9). The application of stable tattoos instead of other more mobile skin marks led to an increase in precision

of patient positioning (10). In a quality assurance study with more than 4,000 patients, Morgan et al. stated that misapplication and inadvertent removal of skin marks were among the most common causes for field placement errors (11). Before the use of henna marks, in our own facility in a series of about 60 consecutive lung cancer patients, we investigated the potential of gradual shift of felt-tip pen marks by performing routine control simulations every two weeks. We observed shifts usually within the range of 5mm, sometimes exceeding this level (unpublished data). Shiftings of skin marks can be detected by periodically performed portal films, but there will always be a delay in the subsequent correction. Furthermore, there are techniques in which portal imaging is worthless in the detection of geographic inaccuracies (6). In patients undergoing conformal radiotherapy and/or dose escalation studies, in particular, the problem of shifting gains crucial importance because of the narrow drawing of the PTV (5, 6). A simple solution to counteract the shifting of skin mark

ings drawn with felt-tip pens is the use of cutaneous markings by temporary tattooing with henna. Because the skin (upper layers) is stained with this method, the potential problem of shifting during the course of external radiotherapy can be excluded. In addition, there is more patient comfort with henna, because gentle washing can be allowed. The durability of henna markings is about three weeks, and two marking procedures are usually necessary for a patient treated with curative intent. We theorize that excessive sweating predisposes a patient to short durability in henna staining. Although washing and showering are freely permitted to the patients, adverse cutaneous side effects are encountered extremely seldom; regular radiation-induced erythemas as expected in certain anatomic sites are not aggravated. Regarding the improvement of patient comfort, patients often express contentment and gratitude to be allowed to wash and shower freely, sometimes having heard from previously treated patients that exposure of the marked skin areas to water is not permitted. The time required for the skin marking procedure with henna is on average two 10-min sessions per patient treated with curative intent. This is much shorter than the time necessary for a control and for the remarking on the simulator every two weeks, which was required for all of our patients treated with the technique of target splitting before using the method of cutaneous marking with henna. In conclusion, the application of skin markings by temporary tattooing with henna is a safe procedure and has been routinely used by us for 18 months. It contributes considerably to the accuracy of therapy and comfort of patients, and it also saves time in the quality assurance process. Use of henna skin markings became indispensable for all of our patients treated with conformal radiation therapy, but they are also useful for patients irradiated with conventional techniques.


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