Hair thread tourniquet syndrome (HTTS): A Review for the Hair Specialist

A Closer Look at Hair Torniquet Syndrome

What is Hair-Thread Tourniquet Syndrome?

Hair thread tourniquet syndrome (HTS) is an uncommon condition characterized by strangulation of a toe, finger, or other appendages such as uvula or penis by a hair (or thread) wrapped around the appendage. HTTS has been recognized since the 17th century.

The condition goes by many names including Hair tourniquet syndrome (HTS), Hair thread tourniquet syndrome (HTS). When specific sites are involved it may be known by the specific site. For example, Neck Hair Thread tourniquet syndrome (NHTTS) is a subtype of Hair tourniquet syndrome affecting the neck.

The cause may be hair fibers or thread fibers or both. The causes of HTTS were attributed to hair-related factors in 85.2% of cases, thread-related factors in 13.8% of cases, and both factors in 1% of cases.

What sites are often involved in Hair Thread Tourniquet Syndrome?

Areas involved in HTTS include the toe, finger, penis, clitoris, labia, teeth, tongue, neck and uvula.

A 2012 review by Sivathasan Vijayarajan estimated that the common areas were fingers (24%-47%), toes (25%-43%) or penis (44%). However, a 2006 review of all cases by Mat Saad et al propsed that fingers were much less commonly involved than toes. Theses authors found that 40.4% of the cases were reported in toes, 8.57% were reported in fingers, 44.2% were reported in penis, 3.3% were reported in clitoris and less than 1% were reported in labia, mons pubis, uvula and neck.

When toes are affected, Aslanturk et al found it is often the third or fourth toe and less likely the second and fifth toe.

An example of hair thread tourniquet syndrome. FROM: Okan Aslantürk et al. Hair tourniquet syndrome of toes and fingers in infants. Acta Orthop Traumatol Turc. 2019 Jul; 53(4): 306–309. Used with creative commons license.

How often does it occur?

The exact risk of HTTS is not clear. Approximately 100 cases of HTTS are previously described. A 2009 study by Claudet et al estimated the incidence at 0.02 % ( 2 in 10,000).

What are the risk factors for Hair Thread Tourniquet Syndrome?

The risk factors are not completely understood.

Young age is an important risk factor as most affected individuals are under the age of 5 years, with many under the age of 1 year. HTTS of the digits typically affects individuals under the age of 1 years and HTTS of the genitals is more typical of individual over the age of 5

In reported cases of HTTS affecting the toes, the mean time of affection of toes was the fourth month of life according to a review by Mat Saad et al. This correlates with the period of telogen effluvium (hair shedding type loss) that many mothers experience.

Reports by Claudet et al and Aslantürk et al found that most patients were under 6 months.

Thread like materials such as gauze that may be used in babies kept in hospitals are a risk factor.

An infant or child sleeping with a parent or sibling with long hair can increased the risk for neck- hair-thread tourniquet syndrome (NHTTS).

Poor hygeine has been proposed as a risk factor in some studies.

What are the symptoms of Hair Thread Tourniquet Syndrome?

Symptoms will depend on the site involved. For example, oral HTS may present with difficulty swallowing or difficulty breathing. Neck hair-thread tourniquet syndrome (NHTTS) leads to difficulty breathing. Involvement of the toe can lead to redness and swelling and pain.

How serious is Hair Thread Tourniquet Syndrome?

The conditions can be very serious. The condition leads to loss or reduction of blood supply to affected areas which leads to progressive ischemia and eventually necrosis. This condition is often a medical emergency. Loss of the affected area can occur in hours to weeks depending on the specific site and the degree of ischemia.

In 2005, Milkovich et al reported the death of a child from HTTS.

A 2006 review by Mat Saad et al found that the chance of complications will depend on the organ involved. For example, complication developed with a rate of 54.5% in fingers, with a rate of 52.6% in penis and with a rate of 2.3% in toes.

How is it treated?

Urgent treatment may be needed. Removal of the hair is the treatment as well as addressing associated swelling and pain. This may require sedation, anesthesia and/or surgery to remove hair or free hair from the anatomical structure. In some cases, the hair is trapped within tissues as a result of being there for some time. Therefore, it may be more difficult to remove by simply forceps removal and may require surgical removal in a procedure room or operating room.

REFERENCES

Flores JR. Hair tourniquet syndrome in the dental patient. Anesth Prog 2014;61:111–2. 10.2344/0003-3006-61.3.111

Hair-thread tourniquet syndrome in an infant with bony erosion: a case report, literature review, and meta-analysis. Mat Saad AZ, Purcell EM, McCann JJ. Ann Plast Surg. 2006;57:447–452.

Milkovich SM, Owens J, Stool D, Chen X, Beran M. Accidental childhood strangulation by human hair. Int J Pediatr Otorhinolaryngol. 2005;69:1621–1628

Claudet I, Pasian N, Maréchal C, Salanne S, Debuisson C, Grouteau E. Hair-thread tourniquet syndrome. Arch Pediatr. 2010;17:474–9.

Mat Saad AZ, Purcell EM, McCann JJ. Hair-thread tourniquet syndrome in an infant with bony erosion: a case report, literature review, and meta-analysis. Ann Plast Surg. 2006;57:447–52.

Sivathasan N, Vijayarajan L. Hair-thread tourniquet syndrome: a case report and literature review. Case Rep Med. 2012;2012:171368

Klusmann A, Lenard HG. Tourniquet syndrome--accident or abuse? Eur J Pediatr. 2004;163:495–498; discussion 499

Okan Aslantürk et al. Hair tourniquet syndrome of toes and fingers in infants. Acta Orthop Traumatol Turc. 2019 Jul; 53(4): 306–309.

Claudet I., Pasian N., Debuisson C., Salanne S., Rekhroukh H. Tourniquet syndrome: interest of a systematic analysis of families' social conditions to detect neglect situations. Child Abuse Negl. 2009;33:569–572