Twisted and Rolled Body Hair − An Ultrastructural Study by Means of Scanning Electron Microscopy

Dear Editor, A 5-year-old girl presented with multiple black dot-like skin lesions over both cheeks and back of 1 year duration [Figure 1a and b]. Mother gave history of repeated shaving (with scissors/blade) of the cheeks, back which regrow over a period of 2 months. There was also history of repeated rubbing of the area with a towel. There was no history of massaging with oil over that area or similar complaint in any other family member.Figure 1: (a and b) Multiple dark knots of hair over both cheeks and backOn examination, the child was moderately built and nourished with normal mental status. Multiple black dot-like skin lesions (approximately 80-100) were seen over an area of 5 × 5 cm2 at the upper scapular area and over bilateral cheeks [Figure 1a and b]. Scalp, nails, and oral mucosa were normal. The hair sample was then mounted in 10% Potassium hydroxide (KOH) and was viewed under light microscopy, which revealed numerous tangled hairs, resulting in a single large knot and also tufted hair strands twisted around themselves with unknown pinkish fibers (looking similar to a hair) in 2-3 knots of hair [Figure 2a]. KOH mount revealed no fungal elements. The sample was also sent for fungal culture, which showed no growth even after 6 weeks of incubation. Dermoscopy revealed coiled and twisted hairs [Figure 2b]. Scanning electron microscopy (100μm, ×300, 15 kV) was done for further evaluation. The hair shaft was uniform in dimension with no splits. It also revealed the thick hair knot with unknown pink strands at the center of the observed tangle. Torsion of hair shafts similar to pseudo-pili torti, plait-like figures, and flattening of hair shafts [Figure 3a and b] partly due to mutual contact and partly due to forced bending were also observed. No fungal hyphae/yeast were seen entwined around the hair shaft. A diagnosis of twisted and rolled body hairs was made.Figure 2: (a) light microscopy showing rolled and twisted hair with a pink strand of similar morphology to hair entangled in the center [KOH mount, 10×]. (b) Dermoscope (Illuco, 10×) under non-polarized mode revealed multiple coiled and twisted hairsFigure 3: (a) Scanning electron microscopy (SEM) showing hairs that are stuck together; none of the hairs are twisted on their own (100 µm, ×300, 15 kV). (b) Scanning electron microscopy (SEM) shows the hair does not have any mechanical fracture or fissuring of the hair shaft (100 µm, ×300, 15 kV)Patients’ attenders were educated about the condition and were advised to follow up for further evaluation and management, in case it recurs. The patient did not revisit OPD for further treatment. Twisted and rolled body hairs are an unusual hair malformation, constituted by knots and twists of body hairs. They are considered as an acquired defect of unknown pathogenesis. Reports of knotted and rolled body hairs are described more commonly in Caucasians. In Asians, the body hair tends to be short, of lower density, and straight, thus making it difficult to knot the hair.[1] Knotting of scalp hair (trichonodosis) is a frequent finding where a single or double knot of the hair shaft is present. As a rule, only one hair shaft is involved. Knotting of the hairs is commonly attributed to local trauma, such as combing, brushing, and scratching.[2] Twisted and rolled hairs are frequently found in men older than 50 years.[3] Matting of scalp hair as a result of shampooing and harshly rubbing to make hairs stick together has also been described.[4] Rubbing a powder puff on the skin can also induce knotting of the vellus hairs.[5] Differential diagnosis includes trichonodosis (knotted hair with single or double knot), rolled hairs (circle hairs), pili multigemini (several matrices and papillae with separate internal root sheaths emerging from one follicle), and powder puff hairs (knotted fibers of powder puff entwined with vellus hairs). This case is been reported for its unusual presentation of twisted and rolled body hairs in a 5-year-old girl. The pink fibers entwined in between normal hairs, probably is powder puff fibers, as no yeast colonies were seen in the hair samples and roots of the hairs looked normal in our case. Although further studies are necessary to pinpoint the exact pathogenesis, SEM findings allowed us to confirm that this disorder likely originated from an acquired trait triggered by mechanical cause and the mysterious pink hair could have been a probable cloth strand, morphologically similar to hair. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.