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Case Report : Acute Hair Matting in a Libyan Girl from the Outskirts

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Acute hair matting (AHM) is an acquired encountered condition in the medical setting, rarely seen, presenting as an acute sudden solid mass of irreversible matting of scalp hair on the vertex in otherwise healthy individuals due to vigorous shampooing or neglect of hair or parasitic infestations. Subsequently, other factors such as shampoos including herbs, conditioners are claimed to be the culprit as well (Anisha S, 2016). It’s also called as Plica neuropathica. The condition has irregular hair twists of severely entangled hairs abruptly formed on the scalp (Palwade PK, and Malik AA, 2008).
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CASE REPORT
Case report: Acute hair matting in a Libyan girl from the
outskirts
Ebtisam Elghblawi
Dr Ebtisam Elghblawi
MBBCh, MScRes, ADD, DRH, PGC skin cancer.
Private practice
Dermatology department
Academia title for health professional (QU afliation)
Independent researcher
Correspondence:
Dr Ebtisam Elghblawi
Email: ebtisamya@yahoo.com
Introduction
Acute hair matting (AHM) is an acquired encountered
condition in the medical setting, rarely seen, presenting
as an acute sudden solid mass of irreversible matting of
scalp hair on the vertex in otherwise healthy individuals
due to vigorous shampooing or neglect of hair or
parasitic infestations. Subsequently, other factors such
as shampoos including herbs, conditioners are claimed to
be the culprit as well (Anisha S, 2016). It’s also called as
Plica neuropathica. The condition has irregular hair twists
of severely entangled hairs abruptly formed on the scalp
(Palwade PK, and Malik AA, 2008).
It was previously believed to be a disease peculiar to Poles
and was called bird’s nest hair (plica polonica) according
to Anisha S, et al, 2016 ndings.
Plica neuropathica (polonica) presents as a compact mass
of scalp hair with irregular twists and irreversibly entangled
plaits which are stiff to hard, tightly packed mass of keratin
cemented together with dirt and exudates (Ghodake NB,
Singh N, Thappa DM. 2013).
Plica neuropathica was rst described by Le Page in 1884,
and was thought to be due to hysteria (Gupta L, et al, 2015).
Nonetheless, the term “plica polonica” was very ubiquitous
in Poland in the 19th century (Polish plait), where the
polish tradition of wearing tight fur caps and not washing
their hair contributed to a muddy, lthy and malodorous
compact mass over the head, frequently associated with
lice infection and boggy inammation in the scalp.
On the other hand, other stipulations for the similar
pathology embrace felting, bird’s-nest hair and plica
polonica, which refer to acute matting of hair resulting from
gross neglect (Kwinter J. and Weinstein M., 2006).
Case Report
A 16-year-old otherwise healthy, single Libyan girl from
the outskirts of Libya presented with a foul-smelling boggy
mass of hair on her scalp since a few months, which could
not be combed for ve days. The patient, who wears a
head covering for religious reasons had a distinctive big
head due to hair matting, and had not shampooed her hair
in 6 days. She indicated that routinely she washed her hair
once weekly.
Physical examination; a stiff protuberant solid mass of
matted hair was revealed under the head scarf. The mass
was found to be made of hair entangled into each other
with the presence of a lot of crusting and foul smell and
oozing areas on the scalp, with diffuse non cicatricial hair
loss over the rest of the scalp. The hair mass enclosed
almost 70% of the area on scalp, involving vertex, temple
and occiput, mimicking a “bird’s nest”. The mass was xed
and difcult to move around and hairs were matted together
with crusting and a foul smell. There was presence of plenty
of louse and nits with swelling over the occipital lymph
nodes. She declined having photos taken of her condition.
Hair-pull test was not easy to perform due to extensive hair
matting. Trichoscopic examination was not performed due
to thick matted hairs and she declined such examination.
There was associated pruritus and pain for her condition.
There were no other dermatological ndings. There was
no history of skin or hair disease in past.
There was no history of use of any chemical treatment for
her hair such as streaking or straightening of hair.
CASE REPORT
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There was no history of fever, change of soap, shampoo,
or oil for hair care.
There was no history of mental disorders, or emotionally
and physically neglect or daily intake of medications.
There was no reported history of similar affection in her
family.
Laboratory testing was not requested.
The exact pathology of AHM is still not understood, and
multi factorial speculation can be proposed. For example,
extreme rubbing and rmness in a liquid medium are
thought to cause the assemblage of adjacent hair bers,
also poor hair care and poor hygiene can contribute to this
condition.
However, some cases had been blamed after regular
use of malicious shampoos and following irritant contact
dermatitis of the scalp. The main culprit is neglected hair
cleanliness and care, which may be associated with scalp
inammation and hair infestations with lice. Moreover,
some specic hair habits, like applying sticky materials
over the hair or using dreadlocks, entwined masses of
matted ropes of long hair, which can be misinterpreted as
AHM (Gupta L, et al, 2015).
Trichoscopy can be applied as it is a noninvasive
and practical diagnostic tool which can help to better
understand the hair and scalp conditions and to spot any
explicit features in the hair shafts (Gupta L, et al, 2015).
Treatment of AHM mandates cutting the matted hair, and
manual separation using organic solvent can be tried in
early cases. Prevention of AHM includes regular use of
soft hair cleansers and deep hair conditioners, and gentle
combing to avoid entangling of hair bers (Gupta L, et al,
2015).
This girl was prescribed overnight application of 1%
permethrin lotion, a broad-spectrum oral antibiotic and
advised a thorough shampoo wash and to shave off the
entire scalp where the matted hair was in order to alleviate
her scalp condition.
In some cultures, like India, plica neuropathica, also called
plica polonica, felting or bird’s nest hair was thought to
be a nerve force and some consider it as a “visitation
from God” and is seemingly quite common among Hindu
ascetics (sadhus) in India, where long hair is not trimmed
or combed and proper hair care is not observed, and
thus hair entangles together leading to twisted masses of
matted ropes of hair known as dreadlocks (Ghodake NB,
Singh N, Thappa DM 2013).
Felting is a physical observable fact well known in the
textile and wool industry, which causes gathering of
adjacent bers when exposed to friction and compression
in a liquid medium. The exact etiology of plica neuropathica
(polonica) is not clear. But it can be attributed to longitudinal
splitting or weathering of hair shaft due to vigorous friction
and frequent use of harsh shampoos and harsh cleansers;
also poor hygiene and/or due to keeping long hair with poor
hair care or its neglect resulting in scalp hair infestations
and scalp pyoderma.( Ghodake NB, Singh N, Thappa DM
2013).
It is also probable that sweating associated with matting
condition had moistened the hair enough to allow the
head covering to serve as a frictional force (Kwinter J. and
Weinstein M. 2006).
Some other predisposing factors suggested are kinky hair
and febrile conditions. Also such conditions were found to
be more frequent among psychologically disturbed women
due to the repeated manipulation of the hair (Anisha S, et
al, 2016).
Treatment of this condition is rather difcult, and the only
alternative is to cut the matted hair all together so the scalp
can breathe. The treatment of plica neuropathica involves
cutting the matted hair. In the early cases, manual partition
by organic solvents can be tried. Prevention includes hair
care measures such as regular cleaning of the hair with
mild cleansers or shampoos, placid oiling and combing to
CASE REPORT
Figure 1: Plica polonica
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avoid entangling, and habitual hair trimming. Piling hair
over the vertex while washing and backcombing should be
abandoned (Anisha S, et al, 2016).
Plica neuropathica in general affects healthy persons.
The scalp hair is frequently affected. Additionally the ill
efforts by the patient to comb the disorderly hair escort
to electrostatic attraction and increase the chances of
matting of the long and old hair. (Anisha S, et al, 2016).
Shaving of the matted hair is the most feasible option
accessible. Plica, once developed needs complete hair
removal. However, it can still be prevented from developing
by regular gentle hair care and habitual washing habits. For
instance, adopting simple measures as: regular cleaning
of hair with mild cleansers or shampoos, with gentle
oiling to avoid entangling, also regular long hair trimming,
refraining from hair piling over vertex while washing and
backcombing, and avoid rotatory rubbing of hair and lastly
long hair should be given a backwash or be washed in the
sink.
Matting of hair is not truly a hair disorder; however it is
rather a reaction resulting from the interplay of great
motley of factors.
My case had plica polonica probably due to poor hair
hygiene and care practices and thus I emphasize the
importance of good hair care practices to avoid such
dreadful hair conditions.
To the best of my knowledge, it is the only one encountered
case in the medical setting of the matted hair presenting
for medical help from the outskirts of Libya.
References
Gupta LK, Balai M, Khare AK, Mittal A. Plica neuropathica.
Indian Dermatology Online Journal. 2015; 6(4):310-311.
Anisha S, Sukhjot K, Sunil GK, Sandeep P. Bird’s Nest
View from a Dermatologist’s Eye. International Journal of
Trichology. 2016; 8(1):1-4.
Palwade PK, Malik AA. Plica neuropathica: Different
etiologies in two cases. Indian J Dermatol Venereol Leprol
2008; 74:655-6.
Ghodake NB, Singh N, Thappa DM. Plica neuropathica
(polonica): Clinical and dermoscopic features. Indian J
Dermatol Venereol Leprol 2013; 79:269.
Martins SS, Abraham LS, Doche I, Piraccini BM, Vincenzi
C, Tosti A. Acute hair matting: case report and trichoscopy
ndings. J Eur Acad Dermatol Venereol. 2016. doi:
10.1111/jdv.13951.
Kwinter J. and Weinstein M. Plica neuropathica: novel
presentation of a rare disease. Clinical and Experimental
Dermatology, 31, 790-792.
CASE REPORT
Article
Background: Plica as a disease entity appeared fi rst in the 13th century. Its aetiology is still unknown and not fully understood. Being, in fact, an irreversible condition of tangling and felting the hair, its origin was interpreted in various ways, from religious ones, through lack of hygiene to mental illness. Although p. polonica originates from Eastern and Central Europe, and p. neuropathica, typical of Indian people, was fi rst described in England, many characteristics connect these two conditions. Aim and Objectives: The study aimed to review the plica species over the centuries and to compare p. neuropathica and p. polonica. Materials and Methods: PubMed and Google Scholar databases were searched for medical articles, books and case studies on plica published up 1884 to 2020. We conducted a systematic and critical review of the literature to compare p. polonica and p. neuropathica. Results: Plica polonica and Plica neuropathica are the same disease entity. Conclusion: The variety of names and interpretations of the disease has made plica a condition still to be fully explained.
Article
Full-text available
Acute hair matting (AHM) is a rare condition presenting as a compact mass with irregular twists and severely entangled hairs abruptly formed in the scalp. First reported as “plica neuropathica” by Le Page in 1884, the condition was thought to be due to hysteria1. However, the term “plica polonica” was also very prevalent in Poland in the 19th century, when the polish custom of wearing tight fur caps and not washing the hair contributed to a filthy and malodorous compact mass, usually associated with lice infection and inflammation in the scalp 2. This article is protected by copyright. All rights reserved.
Article
Plica neuropathica also known as 'birds nest' is irreversible matting of hair seen in otherwise healthy individuals and is usually associated with use of ionic/herbal soaps, shampoos, parasitic infestations, psychiatric alterations, or neglect. Anagen effluvium is a known side effect of many immunosuppressive drugs. Rarely matting of hair has been reported following azathioprine. We report plica neuropathica in two chronically ill patients on immunosuppressive drugs, that is, azathioprine and methotrexate along with a review of literature of its etiological factors and pathogenesis. © 2016 International Journal of Trichology | Published by Wolters Kluwer - Medknow.
Article
Plica neuropathica is a rare condition involving complete matting of scalp hair. It typically occurs in otherwise healthy individuals, and in previous cases has been caused by either shampooing or neglect of hair. Cutting off the matted hair is the only solution. We present the case of a 14-year-old girl with a history of chronic illness and an acute infection presenting with plica neuropathica followed by complete hair loss. This unique case illustrates for the first time plica neuropathica in the absence of shampooing, and demonstrates that it can be associated with underlying illnesses and subsequent hair loss.
  • Lk Gupta
  • M Balai
  • Ak Khare
  • A Mittal
  • Plica Neuropathica
Gupta LK, Balai M, Khare AK, Mittal A. Plica neuropathica. Indian Dermatology Online Journal. 2015; 6(4):310-311.
  • L K Gupta
  • M Balai
  • A K Khare
  • A Mittal
  • Plica
Gupta LK, Balai M, Khare AK, Mittal A. Plica neuropathica. Indian Dermatology Online Journal. 2015; 6(4):310-311.