Scalp Rupture-related Acute Hair Matting in a Child: A Case Letter

A 10-year-old girl presented with acute hair matting (AHM) condition at scalp, which was initiated 3 weeks after a scalp rupture due to a blunt trauma. She had no significant past medical history. At the time of presentation, there were no new or exacerbated psychiatric issues.

Trauma was through a car accident and caused scalp rupture in size of about 6 cm. The rupture underwent primary repair and was sutured by 0-nylon monofilament and 3 weeks later the stitches were removed successfully. While recovering process, she frequently used Povidone-iodine as an antiseptic for 21 days, three times per day. Also, routinely she used shampoos for dry hair two times per week. No more special substances were used.

Three weeks later, the hair in the ruptured area looked unusual [Figure 1]. On scalp examination, there was a patchy era of compact mass without any abnormal appearance on the scalp except scar line. There were no signs of parasitic infestations. On dermoscopic examination of compact mass, there was an area of broken hair associated with 180º twisted hairs and retained telegenic hairs.

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Figure 1

Corresponding title: Acute hair matting in a 10-year-old girl

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Regarding the clinical appearance and hair examination, a diagnosis of AHM was made. The patient was recommended for haircutting of the affected area, regarding the irreversible nature of the matted hair. Also, Argan oil Repairing Scalpia (Ara Chemi Pars, Tehran, Iran) shampoo was prescribed to her. The shampoo contains non-ionic and amphoteric surfactants, conditioners, Argan, Sweet almond, olive, and avocado oil. The shampoo was Paraben and formaldehyde free. She used the shampoo and cut only the distal part of her hair which was not associated with significant improvement.

AHM also known as Plica Polonica and Plica Neuropathica condition is a rare acquired disorder that presents as a compact uncombable mass of scalp hair due to cuticle damage, similar to “bird′s nest.”[1-3]

Although the exact etiology of AHM is unclear,[1] several conditions in association with this presentation have been reported and it seems to be a multifactorial disease. In reported cases, risk factors such as physical factors (e.g., vigorous friction of hair shaft[4] and rotatory rubbing of hair), chemical ones (e.g., drugs[5] and harsh shampoos[3]), behavioral factors (e.g., neglect of hair,[1] schizophrenia,[6] and autistic patients[7]), and infectious condition (e.g., parasitic infestations and pyoderma scalp) have existed.[89]

Friction of hair as a predisposing factor develops electrostatic forces that make viscous lipotropic liquid and crystal phases and possibly cause cuticle injury.[4] Therefore, the frequent friction of the site of trauma in our case’s hair could be another contributor factor.

Among chemotherapeutic drugs’ side effects, anagen effluvium is induced by systemic abrupt in the miotic process. It also may cause hair shaft damage and result in AHM. Other drugs such as Azathioprine may also correlate to this condition.[5] In our case, the previous history of any drug usage did not exist.

Usage of harsh cleaners and shampoos such as a cationic surfactant, could damage the cuticle of the hair by breakage on disulfide bonds which leads to matting of hair.[10] In our case, post-trauma frequent use of povidone-iodine and frequent use of dry shampoo could be the reason in which cuticle got damaged.

It seems poor hair care is an important risk factor for this condition which can explain the frequent reports of an association between this disorder and psychiatric problems.[67,9] Therefore, it has been suggested in such cases with this presentation consider psychiatric problems as possible contributor factors.[2] In our case, these conditions were checked and were absent.

If we explain the concurrency of scalp rapture and injuries with AHM, because of poor hygiene, inappropriate hair care, intense rubbing of the scalp, and frequent use of povidone-iodine, our case can be considered the first case of scalp rapture who developed AHM following scalp injuries. So that, scalp injuries and povidone-iodine in the post-traumatic phase should be considered as possible risk factors and AHM should be considered as a potential side effect, especially in poor hair care conditions.

Treatment options included cutting the matted hair, completely shaving off the head, overnight application of insecticides such as 1% permethrin lotion for lice infestation, and oral antibiotics to treat bacterial infection. Laser-assisted hair removal for the therapeutic purpose theoretically can be considered for recurrent cases of irregular twisted hair, especially in the localized affected area.[89]

Since the manual separation of the twisted hairs in severe cases is usually unsatisfactory, cutting out the matted hair is mandatory, and other treatment options are insufficient, prevention of hair matting is an important step in the management of AHM.[89] Prevention strategies included using mild cleanser or shampoo, regular use of hair conditioner, gentle hair care including combing, oiling, and drying of the hair, periodic trimming of long hair, and avoiding rotatory rubbing of hair.[29]

Treatment should be focused on both underlying problems and hair condition.[11] In our case, the treatment recommendation was the Argan oil Repairing Scalpia shampoo and cutting the hair which was not completely done and she was lost their follow-up after 6 months.