An 8 month-old, previously healthy circumcised boy, presented to the Emergency Department with his mother for increasing irritability. The mother stated that the patient went to bed the night prior to presentation in his usual state of health, but woke up crying. He refused feeds, but had no vomiting, fevers, cough or difficulty breathing. The mother stated that she saw something abnormal when changing the patient’s diaper, which prompted her visit to the Emergency Department.
Upon arrival, vitals were within normal limits. Cardiopulmonary examination was also normal. The patient was irritable, though not in acute distress. Skin examination was then performed, and upon removal of the patient’s diaper, the following was seen:
Hair Tourniquet Syndrome
Hair tourniquet syndrome is most common around 2 months of age. It has been suggested that the timing coincides with maternal postpartum hair loss, also known as telogen effluvium.  The most commonly involved body parts are fingers and toes, followed by genitalia. In a review of 66 cases of patients with hair-tourniquet syndrome, the median age of those with finger involvement was 3 weeks, while those with toe involvement was 4 months. Of note, the review of these cases found that tourniquets of the fingers were more likely to be synthetic fibers (i.e. clothing), while tourniquets of the toes were more likely to be made of hair.  If left untreated, circumferential tourniquets can impede lymphatic and venous drainage, ultimately impairing arterial flow resulting in ischemia. There are cases of loss of digit due to prolonged ischemic injury.
If the tourniquet is located on the extremity, simple removal with scissors may be attempted. If there is no significant skin breakdown, a depilatory agent (Nair) may be applied. However, if using a depilatory agent, note that it is ineffective when applied to synthetic or cotton fibers. Let the agent stand for roughly 8-10 minutes before attempting to rub away the hair. Consider a dorsal slit if the tourniquet is at risk for causing significant ischemia. If there is uncertainty regarding the complete removal of the tourniquet, surgical exploration is suggested. Reports suggest that involvement of the genitals should raise higher suspicion for non-accidental trauma. 
Urology was consulted due the depth of the erosion caused by the hair tourniquet into the shaft of the patient’s penis. The patient was given intranasal midazolam for sedation, and the hair was unwound using instruments. A knot was visualized and cut using a #11 blade.
Upon removal of the hair, spontaneous void of urine was observed. The patient was monitored for a time and was noted to be interactive, playful, and feeding without difficulty. He was discharged home with follow-up and wound care instructions.
TAKE HOME POINTS
A thorough skin examination is critical in evaluating a crying infant.
Depilatory creams may be effective, though are not to be used for synthetic or cotton fiber (more likely if involvement of fingers) or with significant skin breakdown.
Faculty reviewer: Dr. Jane Preotle
Trahlman RS. Toe tourniquet syndrome in association with maternal hair loss. Pediatr. 2003;111:685–7
Barton DJ, Sloan GM, Nichter LS, Reinisch JF. Hair-thread tourniquet syndrome. Pediatrics. 1988;82:925–8
Sudhan ST, Gupta S, Plutarco C. Toe-tourniquet syndrome – accidental or intentional? Eur J Pediatr. 2000;159:866–74