Plica Neuropathica: Bird's Nest under Dermatoscope.

Plica polonica is a rare condition presenting as a mass of scalp hair with irregular twists and irreversibly entangled plaits, which are firm to hard impenetrable mass of keratin cemented together with dirt and exudates. The exact etiopathogenesis of plica neuropathica is not known, but it can be due to longitudinal splitting or weathering of hair shaft due to vigorous friction and frequent use of harsh shampoos and cleansers or long hair with poor hair care Drug-induced hair matting due to chemotherapeutic drugs and due to neurotic illness like hysteria, anxiety, to psychotic illness have also been reported. Dermatoscopy showed interwining of hair shaft with matting and honey-colored concretions mimicking "wrangled mesh of wires" appearance. The treatment of plica neuropathica involves cutting the matted hair and evaluating underlying psychiatric illness to prevent recurrence. Copyright:

INTRODUCTION

Plica polonica is an uncommon condition presenting as a mass of scalp hair with irregular twists and irreversibly entangled plaits, which are firm to hard impenetrable mass of keratin cemented together with dirt and exudates.[1] It is a rare condition with matting of scalp hair commonly seen in religious persons (Sadhus) in India who raise a plica for wish fulfilment or in an otherwise healthy individuals.[23] The exact etiopathogenesis of plica neuropathica is not known but can be due to longitudinal splitting or weathering of hair shaft due to vigorous friction and frequent use of harsh shampoos and cleansers and/or due to keeping of long hair with poor hair care or its neglect.[1] It is a clinical diagnosis, but dermatoscopy can be used to confirm its diagnosis. The treatment of plica polonica is to maintain adequate hygiene, cutting of matted hair, and using mild hair cleanser. We report a case of pilca polonica in a 45-year-old female with dermatoscopic changes.

CASE REPORT

A 42-year-old divorced female presented to skin opd with complaint of falling of full length hair while combing (around 30–40 hair per comb) for the last 20 days. She complained of matting of hairs before this which she tried to comb and disentangle or pull out matted hairs but could not, so she went to hair dresser and got her hairs cut. She also gives a history of hair length being shortened from knee to the shoulder level with loss of those hairs. No history of any repeated episodes of matting of hairs in the past. No history of itching, dandruff, any topical application or change in shampoo, oil or soap before hair fall. No history of any kind of chemical treatment of hair such as dying or straightening or any type of manipulation could be elicited. No history of any comorbidities or any relevant family history was present. Scalp examination was normal with no dandruff, lice, or infection. Bulk of cut hair brought by the patient revealed matted hair tangled with dust and dirt [Figure 1].

Figure 1

Matted hair tangling with dust and dirt

Dermoscopy done with hand held LED ILLUCO dermoscope IDS-1100 having polarized light illumination having ×10 magnification showed matting of hair shaft with honey-colored concretions mimicking “wrangled mesh of wires” appearance [Figure 2].

Figure 2

Dermoscopy showed matting of hair shaft with honey-colored concretions mimicking “wrangled mesh of wires” appearance

DISCUSSION

Plica polonica was first described by Le Page in 1884, also called as plica neuropathica, felting and “bird's nest” hair.[1]

The pathogenesis of matting of hair is not exactly understood. Certain major mechanical factors include.[45]

A physical phenomenon of felting, well known in wool and textile industries, which creates compacting of contiguous fibers exposed to friction and compression in the liquid medium.

Electrostatic attraction between hairs and rubbing of the hair toward the scalp produces positive charge and rubbing toward the tip produces negative charge result in matting

Viscous fluid welding with the formation of viscous lipotropic crystal phases.

Other minor contributory factors include long hair, frequent combing and shampooing, longitudinal splitting and weathering of hair, vigorous rubbing of hair in a rotator manner, and improper care resulting in severe infestations with resultant exudates.

Ksinky hair and febrile illness.

Irritant contact dermatitis of the scalp.

Long hair when not combed or cut, entangles together leading to twisted masses of matted ropes of hair known as dreadlocks. It presents as a compact mass of scalp hair with irregular twists and irreversibly entangled plaits that form a firm to hard impenetrable mass of keratin cemented together with dirt and exudates.

Drug-induced hair matting has been reported due to azathioprine, methotrexate, paclitaxel, carboplatin, doxorubicin,[6] cyclophosphamide, and cisplatin. Chemotherapeutic drugs impair or disrupt the anagen cycle causing hair follicle dystrophy and cuticular damage which may predispose to hair matting.[7]

Immunosuppressive drugs affect hair matrix cells resulting in narrowed or defective hair shaft. Electrostatic bonding between drugs and proteins in hair or drug-induced changes in hair keratin causes hair matting. The psychological risk factors range from neurotic illness such as hysteria and anxiety to psychotic illness. It has been found to be more frequent among psychologically disturbed women due to the repeated manipulation of the hair.[8]

It has to be differentiated from dreadlocks and uncombable hair syndrome.

Reported cases of dermoscopy in pilca polonica showed entangled hair shafts or interwining of hair shaft with matting and honey-colored concretions mimicking “wrangled mesh of wires” appearance.[46] Our case showed similar findings.

The treatment of plica neuropathica involves cutting the matted hair. In early cases, manual separation using organic solvents can be tried. To prevent this condition, hair care measures such as regular cleaning of hair with mild cleansers or shampoos, gentle oiling, and combing to avoid entangling and regular hair trimming should be done. Hair piling over the vertex while washing and back combing should be avoided.[5] Early identification and treatment of underlying psychiatric illness will prevent the formation of plica. All the patients with plica should be screened by a psychiatrist for detailed psychological evaluation.

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Nil.

Conflicts of interest

There are no conflicts of interest.