Citation: Kudzinskas, Aurimas, et al. “Evaluation of Depilatory Agents in the Treatment of Hair-Thread Tourniquet Syndrome.” The Journal of Emergency Medicine (2021).

Link: https://www.sciencedirect.com/science/article/abs/pii/S0736467921005515

Article Summary:

This article is a systematic review that evaluated the use of depilatory agents for treatment of hair-thread tourniquet syndrome. I chose this article because of a patient I saw during one of my pediatric emergency department shifts (H&P#1). The patient was a two-month old female with hair-thread tourniquet on one of her toes for an unknown amount of time. While the emergency medicine physician used a suture removal kit to remove the hair tourniquet, I was interested in other methods available to treat this syndrome. I chose this article as it is recent, published this year and this month (September 2021), and discusses a non-surgical approach to removing the hair tourniquet. 

This review included nineteen articles, five of which reported patient outcomes after the use of depilatory agents and fourteen describing the use of this agent. Depilatory agents, which contain thioglycolate, calcium hydroxide or sodium hydroxide (common brand is Nair), work by breaking disulfide bonds in keratin and weakening its strength. Thus, it makes sense to evaluate this agent for hair tourniquets, as it can weaken the hair and lead to prompt removal. Use of the agent involves applying it for three to thirty minutes and then washing the area with water. Of the articles that reported patient outcomes, 54% of patients (all children, 45 patients), had resolution of the hair tourniquet after one use of the agent. Another 10 patients, or 26%, had resolution after a second application. No complications were reported from using the depilatory agents, except for incomplete removal of the tourniquet. 

The location of the hair tourniquet must be kept in mind when considering using depilatory agents, as it is not recommended on mucosal surfaces or open wounds. It is important to consider the severity of the tourniquet and assess for significant ischemia, which should result in urgent surgical approach instead, as it is a digit-threatening situation. Important aspects to include in assessment and whether a non-surgical approach can be used are capillary refill, edema, temperature, discoloration and skin integrity. Limitations of this review include its small sample sizes and studies with high risk of bias due to being case reports or case series, thus indicating further research into this agent’s use. Below is a useful algorithm in the article for clinicians treating hair-thread tourniquet syndrome. 

Depilatory agents are not commonly used for hair tourniquets, however they are widely available and inexpensive. Additionally, the use of such an agent on an infant may be beneficial, in that it requires less effort to hold the patient still in comparison to using a suture removal kit to try to remove the hair. Since a majority of patients with hair tourniquet syndrome are infants, surgery and anesthesia is the last resort. This makes depilatory agents an ideal initial intervention, in those without significant ischemia, with other approaches if the depilatory agent fails. Thus, clinicians should be aware of depilatory agents and evaluate whether a patient with hair-thread tourniquet syndrome is a good candidate for intervention with the agent.