Scalp Burn Post-Beauty Parlor Visit

Abstract: 54 yo woman with localized hair loss after a visit to the beauty parlor

HPI: The patient is a 54-year-old woman who was seen for evaluation of a localized hair loss and dermatitis of the scalp since she had her hair roots bleached 4 – 5 weeks ago.

She notes that the roots of her hair were left exposed to the chemical for about 4 hours after application.  On a next morning, her scalp was sore and burning, and somewhat swollen throughout the day. She was seen at ER  for evaluation that night and told that her scalp was probably burnt by the hair product; and was advised to wash her hair with cool water and was given a topical medication to apply, the name of which she cannot recall today. She has been using icepack and the medication that was given from ER, which helped. She has noticed that her hair was falling out in the mid parietal area since a few days after the insult.. She was reevaluated by her primary care physician two weeks ago for dryness and pruritus of the scalp and was prescribed another topical medication but does not remember the name.

Past medical history reveals bariatric surgery in  four years ago and had an episode of transient hair loss thereafter. She has been using hair products from the same store, JCP salon, since the episode, and has not had any problems until this recent hair dye/bleach treatment. She washes her hair once weekly, and takes multiple vitamins (including biotin) for her health in general.

The patient is quite upset, angry and tearful about the situation. Currently, she is seeing a therapist for the stress. She fears that the condition will be permanent.

O/E: The skin exam shows a healthy but distraught woman with a well-defined 9.5 x 1.3 cm alopecic patch with many scattered black short broken hairs on the mid parietal scalp to vertex region. There is mild erythema on the involved scalp without evidence of atrophy or cicatrix. Her roots of the surrounding hair are dark brown to blackish about 1 cm from the root.

Clinical Photos:

Impression: Irritant dermatitis with alopecia secondary to her recent hair dye/bleach process

Plan: We had a lengthy discussion of her recent hair damage. This is likely irritant dermatitis most likely secondary to the hair dye/bleach. There is no evidence of scarring today, and her hair will likely grow back although it will take some time. We reassured the patient that we will support her while she is recovering from the recent trauma. 

Follow-up Photo: Around 7 months after chemical burn.

Marked improvement, but patient still feels traumatized.

References:

1. Hair highlights and severe acute irritant dermatitis ("burn") of the scalp. Chan HP, Maibach HI. Cutan Ocul Toxicol. 2010 Dec;29(4):229-33. PubMed

2. Chemical burns to the scalp from hair bleach and dye.  Jensen CD, Sosted H.  Acta Derm Venereol. 2006;86(5):461-2.  Free Full Text

3. The hair color-highlighting burn: a unique burn injury.

Peters W. J Burn Care Rehabil. 2000 Mar-Apr;21(2):96-8.

Abstract: A unique, preventable, 2.8 x 3.7-cm, full-thickness scalp burn resulted after a woman underwent a professional color-highlighting procedure at a hair salon. The burn appeared to result from scalp contact with aluminum foil that had been overheated by a hair dryer during the procedure. The wound required debridement and skin grafting and 3 subsequent serial excisions to eliminate the resulting area of burn scar alopecia. The preventive aspects of this injury are discussed.

4.  Curling iron-related injuries presenting to U.S. emergency departments.

Qazi K et. al. Acad Emerg Med. 2001 Apr;8(4):395-7. PubMed.

Post Operative Erosive Dermatitis

Abstract:  22 yo woman with erosive dermatitis beginning shortly after surgery

HPI:  The patient had a ganglionectomy on her right wrist on April 4, 2013.  When she was taken from the operating room she noticed a whitish rectangular indurated plaque on her right triceps.  Over the next couple of days bullae appeared which eventually ruptured and become erosions.  There was moderate pain.  At no point was she febrile.

Surgical procedure: Ganglionectomy performed under regional block anesthesia.  The hand was painted with ChloraPrep ( chlorhexidine gluconate (CHG) 2% w/v and isopropyl alcohol (IPA) 70% v/v).  The wrist was attached to a tower and the area of the erosion was in contact with an arm-rest.  A tourniquet was employed but was not over the affected area.  Tourniquet time was 44 minutes. 

O/E:  A 5 x 2 cm erosion with some purulent material was noted when the patient was seen on 4/11/13.  The areas of purulence corresponded to the bullae.  On the forearm there was a linear dark erythematous macule with no erosion.

Clinical Pictures:

Cell phone photo taken by patient on day after surgery

Taken at doctor's office on day 7 p surgery

Lab:  Would culture grew out Strep agalactiae (Group B strep)

Diagnosis:  Chenical burn (irritant contact dermatitis, ICD) secondary to Chloroprep.  It is postulated that some of the prep dripped down the elevated hand to the affected area which then pressed against the arm rest for at least 45 minutes.

Discussion:  This type of injury is not reported, but makes sense.  A recent article in the Archives of Dermatology reports ICD in newborns exposed to chlorhexidine impregnated catheter dressing.  We speculate that erosive ICD is more common that the paucity of reports, probably because the surgeons who opperated on these patients are loath to report these cases.  Our patient was treated with Dome-Boro wet compresses and silver-sulfadiazione cream.  Penicillin G 250 mg qid was prescribed when culture was reported.

Reference:
Chlorhexidine gluconate–impregnated central access catheterdressings as a cause of erosive contact dermatitis: a report of 7 cases.  Weitz NA, et. al. JAMA Dermatol. 2013 Feb;149(2):195-9. CONCLUSIONS: Erosive contact dermatitis is an under-recognized complication of chlorhexidine gluconate-impregnated dressings. Health care providers should be aware of this risk, particularly in young children and immunosuppressed and/or critically ill patients, who may be more susceptible to the irritant effects of these dressings. When the dressings are used, patients should be monitored closely for skin breakdown.




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