(127) The Twisted Tail of a Hair Tourniquet

Background: Hair-thread tourniquet syndrome (HTTS) is a rare, potentially dangerous disorder typically involving hair or synthetic fibers wrapped around fingers or toes of infants and children, but can also involve the genitals It is a medical emergency that can result in appendage amputation, it is imperative for PAG, ER physicians, and pediatricians to rapidly identify and consider this as a differential diagnosis.

The goal of this case study is to bring awareness to the clinical presentation of HTTS of the labia, treatment, and review current literature for best management practices.

Case: 11yr old female presents with mother as follow up from urgent care for “painful vaginal polyp”.
Pain worse with with activity. OTC with relief. Mom reported an acute presentation and progressive darkening of area over 3 days.
Tanner Stage: 3.
Vulva: Left labia minora WNL, 3cm x 1cm mass of ecchymotic tissue of the inferior right labia minora. Upon close inspection of the base of the mass, a stricture due to blonde hair was noted. Superior labia tissue viable with good color. Foul odor noted.
Op Note: Constricting hair excised with scissors. Observed for 15 minutes to determine if reperfusion occurred. Remained dusky. Decision for excision with Bovie cautery. Interrupted 3-0 Vicryl sutures to close.

Comments: Reports of HTTS are rare, with only 6.4% of HTTS occurring in the genitals; and of those 6%: the clitoris and 2%: the labia. The pathophysiology of HTTS is hypothesized that wet hair at optimal tensile strength, dries, shortens and causes significant constriction. The constriction restricts lymphatic flow, leading to edema, venous constriction, and eventually arterial tamponade with ischemia and necrosis. Autoamputation is another possible outcome.

Patients with labial HTTS can present with genital pain, wide based gait, redness, edema, bleeding, or dysuria. Differential diagnoses include abuse, trauma, urinary tract infection, insect bite, self-inflicted lesions. Assessment should include capillary refill time, skin color, temperature, edema, and skin integrity. Delay diagnosis is common with differentials like infection. Labial or clitoral hypertrophy, poor hygiene, autism, trichotillomania, and chemotherapy hair loss can put a patient at higher risk for HTTS.

The goal is to remove hair in the shortest possible time sharply or with a depilatory agent. Surgical technique varies and can be done under local or general analgesia. Post operatively, home perineal care and sitz baths are highly recommended. This highlights the possible utility of labiaplasty in patients with necrotic labial tissue where reperfusion of the tissue is absent. HTTS requires prompt recognition; ultimately, time is tissue.