Pressure alopecia

Pressure and Skin: A Review of Disease Entities Driven or Influenced by Mechanical Pressure

Skin perceives and reacts to external mechanical forces to create resistance against the external environment. Excessive or inappropriate stimuli of pressure may lead to cellular alterations of the skin and the development of both benign and malignant skin disorders. We conducted a comprehensive literature review to delve into the pressure-induced and aggravated skin disorders and their underlying pressure-related mechanisms. Dysregulated mechanical responses of the skin give rise to local inflammation, ischemia, necrosis, proliferation, hyperkeratosis, impaired regeneration, atrophy, or other injurious reactions, resulting in various disease entities. The use of personal devices, activities, occupations, weight bearing, and even unintentional object contact and postures are potential scenarios that account for the development of pressure-related skin disorders. The spectrum of these skin disorders may involve the epidermis (keratinocytes and melanocytes), hair follicles, eccrine glands, nail apparatuses, dermis (fibroblasts, mast cells, and vasculature), subcutis, and fascia. Clarifying the clinical context of each patient and recognizing how pressure at the cellular and tissue levels leads to skin lesions can enhance our comprehension of pressure-related skin disorders to attain better management.

Pressure alopecias: A review

Pressure-induced alopecias (PAs) are an infrequent group of scarring and nonscarring alopecias that occur after ischemic obstruction of capillaries that leads to circumscribed areas of hair loss. Initially described after prolonged surgeries or immobilization, type 1 PA occurs after sustained external pressure to the skin, mainly the scalp prominences. Alopecia induced by cosmetic procedures, referred in this review as type 2 PA, is reported with increased frequency in literature and predominantly emerges from pressure exerted by the volume of injectables. It is important to differentiate type 2 PA from vascular occlusion-induced alopecia because they represent distinct entities. Clinically, PA may present with erythema, swelling, and tenderness; however, alopecia might be the sole manifestation. Crusts and ulceration are associated with a worse outcome and a higher risk of scarring alopecia. Prompt diagnosis is paramount to prevent complications. Trichoscopy, although considered nonspecific, may provide relevant clues for an accurate diagnosis. Hair regrows in most cases, but prognosis depends on ischemia severity and timely treatment with reperfusion therapies or mobilization. Treatment of hair loss is usually not necessary because the disease in most cases is self-limited and reversible. The role of topical minoxidil and corticosteroids remains unknown.

Alopecia areata: A psychodermatological perspective

BACKGROUND

Alopecia Areata (AA) is an autoimmune dermatological disease that could be influenced by psychological factors as part of the pathophysiology of the illness.

AIMS

This review article aims to report on psychodermatological and psychopathological aspects involved in the etiopathogenesis and comorbidities of AA, as well as on the psychiatric and psychological management of affected patients.

METHODS

We conducted a literature search on PubMed and Google Scholar from January 1980 to May 2021 employing the search terms of alopecia areata, psychological factors, psychological impact, psychodermatology, and psychopathology. All lists of references from the identified articles were screened for further relevant studies. The search was limited to English and Spanish language articles and was supplemented with themed books and book chapters. No specific quality criteria were used for the studies selection.

RESULTS

Several authors have found a high comorbidity rate between AA and mental disorders, concluding that stress and psychological factors are involved in both the development and exacerbation of the illness. More evidences are needed in order to describe the associations between the immune response, stress, and the physiological factors observed in AA patients.

CONCLUSION

AA is a complex illness characterized by multifactorial etiology. An interaction between genetic, autoimmune, hormonal, neural, and psychological factors is supposed. Psychopathological aspects of illness need to be better described and considered in the clinical setting.

Choosing an optimal headrest for preventing postoperative alopecia - A manikin study

BACKGROUND

Postoperative alopecia is a rare complication after surgery. The etiology is thought to be pressure-induced hair follicles ischemia caused by prolonged immobilized head. Headrest is always used as head positioner during operation. The contact pressure between the head and headrest is believed to be related to the development of postoperative alopecia. The aim of this study was to find a headrest with the minimum contact pressure.

METHODS

Five different materials headrests - folded sheet, foam donut, gel donut, natural latex, and memory foam were examined. The contact pressures between the manikin's head and tested headrests were continuously recorded for 4 h using CONFORMat System sensor. The average and peak pressures over the contact area were measured at 15 min, 30 min, 45 min, 1 h, 2 h, 3 h, and 4 h. A generalized estimating equations (GEEs) analysis and one way repeated measures ANOVA were used to assess the data.

RESULTS

The memory foam headrest showed the lowest average and peak contact pressures over the contact area (p < 0.05), and the natural latex headrest, gel donut headrest, foam donut headrest, and folded sheet headrest revealed increase of the contact pressures in order. The peak contact pressure of the gel donut headrest at 4 h was significantly higher than that of at 15 min (p = 0.032) and 30 min (p = 0.037).

CONCLUSION

Of the five headrests we examined, the memory foam headrest is suggested to be the best choice for surgical patients because of its lowest contact pressure.

Pressure ulcer following circumferential head dressing

PURPOSE

To report four patients with forehead pressure ulcer (PU) following encircling head dressing and review the literature.

METHODS

Uneventful endoscopic forehead lift procedure was performed with moderate skin elevation in three patients. Left upper eyelid crease incision was made to remove the sub-brow dermoid cyst uneventfully in one patient. All procedures were performed under general anesthesia. Mixed topical antibiotic and steroid ointments were placed on the incision sites before putting the encircling forehead dressing (using gauze and elastic bandage). The dressing was then removed on the first postoperative examination.

RESULTS

Forehead and eyebrow PUs were observed on the first follow-up visit (16-72 h) after removing the dressing. Patients were otherwise healthy. They did not have significant pain or burning postoperatively. Management included pressure release, wound debridement, daily dressing, topical antibiotic and steroid, and silicone-based anti-scar cream. None had infected ulcer and all except one ended up with atrophic scar in the last follow-up (2-14 months). External pressure and shearing forces were assumed to be the main causative factors, even though reperfusion injury could contribute in the development of PU.

CONCLUSION

Encircling head dressing can cause PU and result in scar formation in healthy immunocompetent patients. If there is a low risk of postoperative hematoma, encircling dressing should be avoided. Early loosening of the dressing and frequent examination of the skin are the best preventive and diagnostic measures. Treatment includes pressure removal, daily debridement, and topical medications.

Management tools in nursing care for children with pressure injury

ABSTRACT Objectives: to develop and validate management tools for the systematization of nursing care for children with pressure injuries. Methods: methodological study in which the focus group technique was used for validation of tools in three different groups of 17 nurses. Conducted in April and May 2018 at a large pediatric hospital. Results: two management tools were developed. The first was the Nursing care systematization instrument for children with pressure injury with three parts: a) risk factors; b) Psychobiological Basic Human Needs; c) signs of wound infection. The second was the Flowchart of pressure injury risk and prevention in pediatric patients with three categories: a) risk factors; b) Braden Q scale; c) nursing care. Final Considerations: the tools will support nurses in the care of children with pressure injuries by aiming at an individualized and systematized assessment based on a theoretical framework.

Pressure-Induced Alopecia: Presence of Thin Hairs as a Trichoscopic Clue for the Diagnosis

Pressure-induced alopecia (PA) is an unusual pattern of circumscribed hair loss that occurs after ischemic changes on the scalp. Trichoscopic findings described in the literature are scarce, nonspecific, and include black dots, broken hairs, circle hairs, and erythema. However, we report 3 cases of PA in which trichoscopy also showed many vellus and thin hairs. Possibly, the maintenance of these hair shafts may be explained by the more superficial insertion of their bulbs on the skin and/or their lower metabolic rates, making them suffer less from local hypoxia. Therefore, the authors suggest that these relevant signs should be added as a clue for the diagnosis of PA in doubtful cases.

Headgear-induced temporary pressure alopecia

The development of hair loss associated with headgear use is a rare phenomenon. Pressure alopecia is a condition characterised by localised, non-scarring hair loss attributed to a mechanical cause. Factors such as prolonged periods of peri- and postoperative immobility have been implicated, as well as immunological and genetic predisposing factors. If the mechanical trauma is very prolonged, there is a risk of permanent follicle damage due to tissue hypoxia. A 13-year-old boy wore high-pull headgear as part of his orthodontic management. Within four weeks of headgear wear, localised areas of hair loss were seen corresponding with the areas of contact with the force delivery modules of the headgear. The patient experienced bullying at school as a result of this hair loss. Hair regrowth resumed after headgear use was discontinued, therefore confirming the diagnosis of temporary pressure alopecia. Temporary pressure alopecia is a rare side effect of orthodontic headgear. Alopecia can negatively impact an individual's psychosocial wellbeing; therefore, caution should be taken to avoid prolonged or excessive pressure in susceptible individuals and headgear patients should be regularly monitored.

Incidence and risk factors for alopecia in survivors of critical illness: A multi-centre observational study

PURPOSE

To investigate the incidence, nature and risk factors for patient-reported alopecia in survivors of critical illness.

MATERIALS AND METHODS

A multi-centre, mixed methods observational study in the intensive care units (ICU) of ten hospitals in Wales. All patients with an ICU stay of 5 days or more, able to give consent were included. Demographic variables and risk factors were collected. A pre-designed survey was completed at three months post-ICU discharge. Statistical analysis included numbers and percentages (categorical variables) and medians and interquartile ranges (continuous variables). Comparisons between patients with and without alopecia were made using Fisher's Exact test (categorical variables) and Mann Whitney U test (continuous variables). Multivariate logistic regression analysis was used to determine the risk factors for alopecia.

RESULTS

The survey was completed by 123 patients with alopecia reported in 44 (36%) patients. The only risk factor for alopecia on analysis was sepsis / septic shock (p < .001; OR: 5.1, 95%CI: 2.1-12.4).

CONCLUSIONS

Limited research exists examining the incidence, nature and risk factors for patient-reported alopecia in adult survivors of critical illness. The results of this study highlight the need to discuss the potential for alopecia with survivors of critical illness, who had sepsis / septic shock.

A unique case of pressure-induced alopecia following EEG monitoring

We report a unique case of pressure-induced alopecia (PIA) in a 11-year-old boy following the use of electroencephalogram (EEG) electrodes on the scalp for 4 days. PIA is caused by localized ischemia leading to vascular congestion and discrete, often circumscribed patches of hair loss within 3-28 days of pressure interface. The synchronous conversion of follicles from anagen to catagen or telogen phase is the most distinctive finding of PIA. PIA is a nonscarring alopecia which often resolves over time without treatment.

Use of an Alternating Inflatable Head Pad inPatients Undergoing Open Heart Surgery

BACKGROUND Preoperative symptoms like occipital pressure ulcers and alopecia areata (AA) significantly lowered patient quality of life. Therefore, preoperative nursing was in need of investigation. This study aimed to compare effects of an alternating inflatable head pad and a gel pad on occurrence of postoperative pressure ulcers and AA in patients undergoing open heart surgery. MATERIAL AND METHODS This was a prospective study. We allocated randomly 120 patients undergoing surgery (3-7 h) in the Yantai Yuhuangding Hospital affiliated to Qingdao University, China from January to October 2015 to the control (gel head pad) or the experimental (alternating inflatable head pad) group (n=60 per group). The incidence and severity of occipital pressure ulcer were graded by the classification system of the European Pressure Ulcer Advisory Panel (EPUAP). The degree of occipital alopecia was measured by hair pull test. This study used the t test and chi-square analysis. All statistics were analyzed by SPSS 21.0. RESULTS Compared with the control group, there was a significantly lower incidence and severity of occipital pressure ulcer and alopecia in the experimental group (9 cases/60 cases vs. 1 case/60 cases, P<0.01). Moreover, multivariate analysis showed the risk of developing occipital pressure ulcer after surgery was also obviously lower in the experimental group (OR 1.449-120.798; P<0.005). Hair pull test revealed that fewer patients in the experimental group had a hair loss over 10%. CONCLUSIONS The alternating inflatable head pad was effective in reducing the incidence and severity of occipital pressure ulcer and alopecia associated with surgery, which benefited the postoperative nursing and improved patient quality of life.

Analysis of Dermatologic Consultations in a Neonatal Intensive Care Unit Over a 7-Year Period: Retrospective Review of 60 Cases

BACKGROUND/OBJECTIVES

The need for dermatology consultations for neonatal intensive care unit (NICU) patients is increasing, but no study has systemically examined the skin diseases of patients in NICUs. The aim of this study was to analyze dermatology consultations in the NICU of a tertiary medical center in Korea and determine the effect of the dermatology consultation on the clinical course and management of the patients after the consultation.

METHODS

The medical records of patients undergoing dermatologic consultation during their stay in a NICU between March 2009 and February 2016 were reviewed retrospectively.

RESULTS

Sixty patients were enrolled in this study; the male-to-female ratio was 1:1.1, and mean age at the time of consultation was 3.7 weeks. Mean gestational age was 33.7 weeks, and 35 of the subjects (58.3%) were preterm neonates. Mean birth weight was 2.14 kg (range 550-4,200 g). The most-common disease category was birthmarks and neoplasms (20.0%), followed by eczematous dermatoses (18.3%), skin appendageal disease (16.7%), and infectious disease (13.3%).

CONCLUSION

This study identified the dermatologic problems of neonates in a NICU and can raise dermatologists' awareness of the types of patients they may encounter in a NICU.

Trichoscopy of Noncicatricial Pressure-induced Alopecia Resembling Alopecia Areata

Pressure-induced alopecia is an unusual cause of hair loss, and reports of its trichoscopic features are scarce. In this paper, we describe a case of pressure-induced alopecia in which trichoscopic and histopathological findings overlap with those described for alopecia areata.

Regeneration of hair and other skin appendages: A microenvironment-centric view

Advances in skin regeneration have resulted in techniques and products that have allowed regeneration of both the dermis and epidermis. Yet complete skin regeneration requires the adnexal skin structures. Thus it is crucial to understand the regenerative potential of hair follicles where genetic, nutritional, and hormonal influences have important effects and are critical for skin regeneration. The follicular stem cell niche serves as an anatomical compartment, a structural unit, a functional integrator, and a dynamic regulator necessary to sustain internal homeostasis and respond to outside stimuli. In particular, mechanics such as pressure, compression, friction, traction, stretch, shear, and mechanical wounding can influence hair loss or growth. Relevant niche signaling pathways such as Wnt, bone morphogenetic protein, fibroblast growth factor, Shh, and Notch may yield potential targets for therapeutic interventions.

Patient Positioning and Skin Sequelae: Ischemic Epidermal Necrosis from Tight Padding During Cardiac Surgery

Careful positioning and padding of pressure points during surgery are recommended to prevent pressure ulcers, vascular injury, and nerve damage in an immobilized patient. However, overpadding may have unintended consequences. We report a case of ischemia-induced full-thickness epidermal necrosis secondary to tight foam padding during a cardiac surgery.

Can an "Aesthetic" Intervention (Braided Hair Coil) Cause Hair Loss After an Aesthetic Operation?

Postoperative pressure alopecia (PPA), defined as hair loss caused by prolonged pressure on the patient's scalp during surgery, is an uncommon condition after aesthetic surgery. Originally, it was described for patients who underwent lengthy cardiovascular and gynecologic operations. The authors present a rare case, in which hair loss occurred after secondary breast augmentation (replacement of breast implants). The PPA appeared in the occipitoparietal region of the patient's scalp approximately 2 weeks after surgery. The operation was completed in less than 3 hours, without any fluctuations in the patient's blood pressure or any unusual blood loss. There were no other precipitating factors such as anemia or coagulopathies. The probable cause of this unexpected result was the patient's braided hair coil, which had not been noted before the operation. The patient habitually, and on the day of her operation, combed her hair into a braided coil, which placed extra pressure on the occipitoparietal region. The hair loss was temporary, and hair regrowth was complete within 2 months. This incident may have been avoided if the braided hair coil had been noted by nursing or other medical staff preoperatively. Repositioning the head every 30 minutes and providing adequate head padding during surgery are advised to protect the patient and prevent such incidents.

LEVEL OF EVIDENCE

5.

Square alopecia: a new type of transient alopecia of the scalp following fluoroscopically endovascular embolization

Endovascular interventional procedures are the first choice of treatment for many vascular intracranial lesions, especially those with complex anatomy. These procedures may cause numerous skin lesions depending on the dose of radiation to which patients have been exposed. In this report, we presented a case of a 38-year-old man who developed a square plaque of alopecia in the occipital area after two selective embolization of a left posterior parasagittal arteriovenous malformation. The alopecia was transient and the hair grew up 2 months later after the last procedure. This case illustrates one of the effects of radiation on the scalp and expands our knowledge about the clinical manifestation of this transient disease.

Co-presentation of Tapia's syndrome and pressure alopecia--A rare event after septorhinoplasty: A case report and literature review

Tapia's syndrome and pressure alopecia (PA) are two rare but distressing complications associated with orotracheal intubation and positioning of the head during surgery. To our knowledge, simultaneous occurrence of both complications after surgery has not been previously reported. To avoid these disturbing complications, the mechanisms of the injury and the preventive measures should be recognized by anesthesiologists and surgeons. We herein present the case of Tapia's syndrome together with PA following open septorhinoplasty under uncomplicated endotracheal general anesthesia in a 27-year-old man. We review other case reports and discuss the potential underlying mechanisms of injury.

Intensive Care Follow-up in UK Military Casualties: A One-Year Pilot

Military casualties requiring intensive care were reviewed in a pilot follow-up clinic at approximately three to six months post discharge. All patients reviewed had suffered traumatic injuries in Afghanistan with a median New Injury Severity Score (NISS) of 41. Approximately 50% of casualties reviewed reported hallucinations while on ICU which were often intense and unpleasant. The predominant sedative agents used were morphine and midazolam. Occipital alopecia and pressure sores were reported as an unexpected finding in 35% of casualties. This appears to be permanent in 25% of cases and has required surgery in a small number of cases. Personality changes and anger are common and this cohort of patients can be sensitive to perceived stigmatising concerns regarding referral to psychiatric support services. Patient diaries, which were begun on intensive care in Afghanistan and continued through until discharge in the UK, were found to be very helpful. A significant proportion of clinic attendees thought the pilot clinic was helpful with a quarter of survey responders finding it very helpful. However, this was commonly based on the perception that they were helping the defence medical services improve delivery of care.