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Toe Tourniquet Syndrome in Association With Maternal Hair Loss

Department of Pediatrics
Patuxent Medical Group
Columbia, MD 21045
Department of Pediatrics
Johns Hopkins Hospital
Baltimore, MD 21205

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	ABSTRACT

TOP ABSTRACT CASE REPORT DISCUSSION CONCLUSION REFERENCES

 
Increased hair loss a few months after delivering an infant is a common postpartum condition known as telogen effluvium. A much less common condition involving young infants is the hair-thread tourniquet syndrome, or toe tourniquet syndrome, which involves hair or thread becoming so tightly wrapped around an appendage that pain, injury, and sometimes loss of the appendage result. This case report is the first known description of the hair-thread tourniquet syndrome in association with maternal telogen effluvium. A literature review shows that accidental cases involving human hair almost always involve the toes, and usually occur at the age when mothers are experiencing excessive hair loss. This association is significant in that anticipatory guidance of new parents experiencing rapid hair loss may prevent cases of the toe tourniquet syndrome and its associated morbidity.

Key Words: hair-thread tourniquet syndrome • toe tourniquet syndrome • telogen effluvium • hair • appendage

	CASE REPORT

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A healthy 3-month-old male infant was taken to his pediatrician because of excessive fussiness. There was no fever, vomiting, or diarrhea, and the infant’s physical examination was completely normal. The fussiness was attributed to gas and possible constipation, and was treated with simethicone drops and glycerine suppositories. Two days after the office visit it was noted during the infant’s bath that the second, third, and fourth toes of the left foot were entrapped by a hair. The second toe distal to the hair was edematous, violaceous, and tender to the touch. The hair was carefully removed and the wounds were treated with topical antibiotic ointment. The infant’s fussiness resolved immediately, and within 1 week the toes were healing. Of note and of significance is that the infant’s mother was experiencing massive postpartum hair loss during this period.

	DISCUSSION

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Telogen Effluvium
A normal human hair goes through 3 stages of growth. The growing, or anagen, stage is the predominant phase, usually involving 80% to 90% of a person’s hair. The anagen stage is followed by a transitional catagen stage and then a resting, or telogen, stage. When new hair growth is initiated, the new anagen hair pushes the old telogen hair out, and shedding occurs. Typically a person sheds no more than 50 to 100 hairs per day. However, a severe stress such as childbirth can "shock" an excessive number of hairs into the telogen stage. Approximately 3 months after this stress, the postpartum mother experiences excessive hair loss on the order of >100 hairs per day.¹ This excessive hair loss is termed telogen effluvium. Up to 90% of postpartum women experience this condition.¹ The condition can occur immediately after delivery.¹ More typically, however, the increased hair loss occurs between 2 and 6 months’ postpartum.² The shedding rate returns to normal in 4 to 6 months, and mothers should be reassured that the condition is self-limited.³

Hair-Thread Tourniquet Syndrome
The hair-thread tourniquet syndrome occurs when hair, and occasionally thread or fiber, wraps tightly around a young child’s appendage and obstructs the circulation. Although most cases are felt to be accidental, child abuse must be considered in selected cases.⁴ This syndrome has been described to involve the fingers, the toes, and even the genitals.⁵ The offending fiber can cut through the skin making the fiber difficult to see. The only presenting symptom may be irritability, so the index of suspicion needs to be high.⁶ Treatment is prompt removal of the constricting fiber. The fiber can usually be removed by direct inspection. In cases where hair is the offending agent and cannot be completely removed, entrapped hairs have been removed using commercial hair removal agents such as Nair (Church and Dwight Co, Inc, Princeton, NJ).⁷ If the fiber cannot be completely removed, then surgical exploration is mandatory. This disorder can be quite serious if not promptly recognized and treated; permanent tissue damage or loss of the appendage can occur.⁴

Hair-thread tourniquet syndrome can be grouped into 3 broad categories, reflecting the type of appendage involved. In a review of 66 cases there were 3 distinct subsets of the hair-thread tourniquet syndrome: cases involving the toes; cases involving the fingers; and cases involving the genitals.⁵

The largest group of patients was the group with toe involvement. This group contained 28 (43%) of the 66 patients. A total of 22 (79%) of these patients had hair as the offending agent. The median age of these patients was 4 months, exactly when maternal telogen effluvium peaks, with a range of 3 weeks to 15 months. Infants with toe involvement have been said to have the toe tourniquet syndrome.⁸

In the case review there were 16 (24%) patients with finger involvement. Fourteen of these patients (88%) had thread or fiber as the cause. Only 2 (12%) of the fingers were affected by hair. The median age was only 3 weeks, with a range of 4 days to 19 months. The finger injuries therefore do not appear to be as closely associated with maternal telogen effluvium. It is possible that the finger injuries are related to the prolonged use of gloves or mittens in young infants, either for warmth or to prevent infants from scratching.

The third subset, those with genital strangulation, included 22 (33%) patients. These patients had a median age of 2 years with a range of 4 months to 6 years. Child abuse was suspected in most of these cases. These cases therefore did not tend to be accidental and were probably not related to maternal telogen effluvium.

	CONCLUSION

TOP ABSTRACT CASE REPORT DISCUSSION CONCLUSION REFERENCES

 
Hair-tourniquet syndrome involving the toes occurs during the time period when postpartum mothers are experiencing increased hair loss. This condition is also known as toe tourniquet syndrome. It occurs at 4 months of age, when up to 90% of all mothers are experiencing excessive postpartum hair loss. The condition, although very serious, is treatable with prompt diagnosis and is potentially preventable.

A hallmark of pediatrics is anticipatory guidance and the prevention of injury. Postpartum mothers should be counseled about the possibility of excessive hair loss in the first few months after delivery. Mothers with long hair need to be especially vigilant. New parents should be warned that if excessive hair loss should occur, then their infant should be carefully checked on a regular basis to make sure that no hairs are becoming entangled in the fingers or toes. If an infant is not bathed every day, or is wearing extra clothing, checking the fingers and toes regularly becomes even more important. Any clothing that covers the fingers or toes should be turned inside out and examined for loose hairs. At the first sign of entrapment or loss of circulation, medical attention should be sought immediately. Toe tourniquet syndrome is a dangerous but a preventable condition of young infants.

	ACKNOWLEDGMENTS

 
I thank Teresa Strahlman (my wife and the mother of the patient) for making the connection between her condition and that of the infant.

	FOOTNOTES

 
Received for publication Mar 26, 2002; Accepted Sep 3, 2002.

Reprint requests to (R.S.S.) Department of Pediatrics, Patuxent Medical Group, Two Knoll North Dr, Columbia, MD 21045. E-mail: rsstrahlman{at}hotmail.com

	REFERENCES

TOP ABSTRACT CASE REPORT DISCUSSION CONCLUSION REFERENCES

 

1. Lynfield YL. Effect of pregnancy on the human hair cycle. J Invest Dermatol.1960; 35 :323 –327[ISI][Medline]
2. Headington JT. Telogen effluvium. New concepts and review. Arch Dermatol.1993; 129 :356 –363[Abstract]
3. Schiff BL, Kern AB. Study of postpartum alopecia. Arch Dermatol.1963; 87 :609 –611
4. Wang M, Schott J, Tunnessen WW. Picture of the month. Arch Pediatr Adolesc Med.2001; 155 :515 –516[Free Full Text]
5. Barton DJ, Sloan GM, Nichter LS, Reinisch JF. Hair-thread tourniquet syndrome. Pediatrics.1988; 82 :925 –928[Abstract/Free Full Text]
6. Trocinsky DR, Pearigen PD. The crying infant. Emerg Med Clin North Am.1998; 16 :895 –910[CrossRef][ISI][Medline]
7. Douglas DD. Dissolving hair wrapped around an infant’s digit. J Pediatr.1977; 91 :162[CrossRef][ISI][Medline]
8. Quinn NJ Jr. Toe tourniquet syndrome. Pediatrics.1971; 48 :145 –146[Abstract/Free Full Text]

This article has been cited by other articles:

				R. A. Haene and M. Loeffler Hair tourniquet syndrome in an infant J Bone Joint Surg Br, February 1, 2007; 89-B(2): 244 - 245. [Abstract] [Full Text] [PDF]

				J. C. O'Quinn, R. L. Friedman, and K. L. Wilms Acquired constriction ring syndrome. J Am Podiatr Med Assoc, May 1, 2006; 96(3): 253 - 255. [Abstract] [Full Text] [PDF]

				M. T. SULIMAN The Thread-Tourniquet Syndrome J Hand Surg Eur Vol., December 1, 2005; 30(6): 658 - 658. [Full Text] [PDF]

This Article Abstract Full Text (PDF) P3Rs: Submit a response Alert me when this article is cited Alert me when P3Rs are posted Alert me if a correction is posted Citation Map Services E-mail this article to a friend Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Strahlman, R. S. Search for Related Content PubMed PubMed Citation Articles by Strahlman, R. S. Related Collections Premature & Newborn

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