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Year : 2011  |  Volume : 3  |  Issue : 1  |  Page : 34-37  

Localised acquired trichorrhexis nodosa of the scalp hair induced by a specific comb and combing habit - A report of three cases

Department of Dermatology, Baby Memorial Hospital, Calicut, Kerala, India

Date of Web Publication16-Jun-2011

Correspondence Address:
Abhay Mani Martin
Consultant Dermatologist, Baby Memorial Hospital, Calicut - 673 004, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0974-7753.82138

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Trichorrhexis nodosa is a hair shaft disorder often encountered in clinical practice. Acquired trichorrhexis is commoner of the two types and is most often due to weathering from physical or chemical causes. We report three representative cases of localized acquired trichorrhexis encountered in our clinic attributable to a specific comb, used commonly in Kerala, a Southern state of India.

Keywords: Acquired trichorrhexis nodosa, comb, light microscopy, localized form

How to cite this article:
Martin AM, Sugathan P. Localised acquired trichorrhexis nodosa of the scalp hair induced by a specific comb and combing habit - A report of three cases. Int J Trichol 2011;3:34-7

How to cite this URL:
Martin AM, Sugathan P. Localised acquired trichorrhexis nodosa of the scalp hair induced by a specific comb and combing habit - A report of three cases. Int J Trichol [serial online] 2011 [cited 2023 Mar 24];3:34-7. Available from: https://www.ijtrichology.com/text.asp?2011/3/1/34/82138

   Introduction Top

Trichorrhexis nodosa is a disorder of the hair shaft characterized by easy breakability of hair and microscopically by nodes on the hair shaft 1. Trichorrhexis nodosa may be congenital or acquired. The more common acquired form results from repeated trauma to the hair shaft. Physical trauma like comb and combing habits have not been subjected to detailed scrutiny in the etiopathogenesis of trichorrhexis nodosa. The following three cases are representative of the type of patients we encounter and combing habits have been found to be closely linked to the development of trichorrhexis.

   Case 1 Top

A 28 year old male presented with a history of "broken hairs with glistening tips" on the temporal aspects of the scalp [Figure 1]. The condition was bilaterally symmetrical and asymptomatic. The patient had no systemic medical illnesses and there was no family history of similar illness. There was no history of use of hair cosmetics, hair bleaching, hair dyes, hair perming or straightening. We enquired about his comb and combing habits. The comb was made of plastic, had a round base with a slot to slip the fingers in for gripping. The bristles were short and vertical, arranged in linear rows and equidistant from each other [Figure 2]. We asked the patient to demonstrate his combing technique [Figure 3]. The comb was run over the scalp as vigorous strokes from the frontal aspect, brushed across the vertex and temporal aspects and ended at the occipital region. He combed his hair often, which averaged about 8-10 times a day. Clinical examination showed short stubs of hair focally on the temporal aspect of the scalp and the tips of the hairs had a glistening appearance. The hairs over the rest of the scalp were normal. The damaged hair samples were collected for light microscopic examination which showed breaks of the hair shaft at irregular intervals with fraying of the cut edges.
Figure 1: A glistening white spotty appearance in the temporal region of the scalp in case 1

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Figure 2: The distinctive comb attributed as the cause of trauma, with short and vertical bristles, arranged in linear rows and equidistant from each other. Also appreciate that the comb is made of plastic, has a round base with a slot to slip the fingers in for gripping

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Figure 3: The technique of combing adopted by these patients. (The comb was run over the scalp as vigorous strokes from the frontal aspect, brushed across the vertex and temporal aspects and ended at the occipital region, around 8-10 times a day)

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   Case 2 Top

A 35 year old male patient presented with complaints of "broken hairs with glistening white spots" on the vertex of the scalp noticed for the past 3 months [Figure 4]. He used a similar comb and had a similar combing habit.
Figure 4 : Discrete spotty glistening white areas involving the vertex region with broken hairs in case 2

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   Case 3 Top

A 19 year old engineering graduate presented with an identical hair shaft defect on the temporal aspects of the scalp. He too reported repeated combing of his hair, often during a day and soon after he got off his motorbike to set the ruffled hairs [Figure 5].
Figure 5: Spotty white glistening areas localized strictly to the temporal aspect in case 3

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The clinical examination and light microscopic findings in case 2 and case 3 were similar to case 1. There were no systemic medical illnesses or familial hair defects notable on history in all the three cases. While light microscopic examination was done in all, a trichoscopic examination and electron microscopic examination were not done.

   Discussion Top

Trichorrhexis nodosa is a hair shaft defect that occurs due to weathering. In 1852, Samuel Wilks of Guy's Hospital first described the condition, although the term trichorrhexis nodosa was not proposed until 1876 by M. Kaposi. [1] The term trichorrhexis nodosa refers to the light microscopic appear­ance of a fracture with splaying out and release of individual cortical cells from the main body of the shaft of hair, producing an appearance suggestive of the ends of two brushes pushed together. [2] The condition may be classified into three variants - a primary congenital form, trichorrhexis nodosa as part of other syndromes and acquired trichorrhexis nodosa. [2]

Congenital trichorrhexis nodosa is a congenital hair shaft anomaly inherited as an autosomal dominant trait. However, in a subset of patients, trichorrhexis nodosa may be associated with syndromes like Menke's kinky hair syndrome, argininosuccinic aciduria, trichothiodystrophy and monilethrix. [2]

Acquired trichorrhexis nodosa is a well established entity in medical literature. Several factors including repetitive trauma, extremes of temperature and ultraviolet radiation have been the more commonly implicated factors. [1] Physical traumas that may cause sufficient damage to the hair shaft include excessive brushing, back combing, stressed hairstyles, the application of heat, and prolonged exposure to ultraviolet light. [1] Chemical traumas include excessive exposure to salt water, shampooing, setting, perming, bleaching, and dyeing of hair. [1] Seasonal recurrence of trichorrhexis nodosa has been reported as a result of the cumulative effect of diverse insults to the hair. [3] Hypothyroidism has also been identified in patients with trichorrhexis nodosa. [4]

Comb characteristics and combing techniques have not been subjected to detailed scrutiny by previous authors in relation to acquired trichorrhexis nodosa. The comb in question, in the above cases, was made of plastic, was round or oval in shape, with a slot for easy grip by three fingers-index, middle and ring fingers on the dorsal aspect and the thumb on the ventral aspect. The comb has a compact design, is easy to carry around, and is a cheap and convenient tool used to comb the hair backwards. It is usually carried by individuals on their hip pockets and used on the scalp hair, on an average of about 8-10 times a day. The comb is most often used in India, especially in Kerala, by young men who comb/style their hair soon after getting off their motorcycles. The combing action is in an antero-posterior direction from frontal to occipital region. The hair shaft when brushed with the comb gets entangled amongst the bristles, and is pulled backwards in a forceful stroke. The repeated friction that occurs in the combing process may be a reason for cuticular disruption, breakage of the hair shaft at periodic intervals and fraying of the ends.

The localization of the acquired trichorrhexis nodosa to the vertex (in case 2) and the temporal aspects of the scalp hairs (in case 1 and 3) are attributable to the repetitive trauma at the particular site and the combing technique used by the individuals. The former used to 'set' the hair often on the vertex while the latter two patients repeatedly would 'set' the hair on the temporal aspect. The observations under the light microscope were similar in both cases. A representative photograph from case 1 is shown [Figure 6]. Microscopy of normal hair is shown for comparison [Figure 7]. In cases of trichorrhexis nodosa attributable to trauma, hair analysis shows cuticular cell disruption, which allows the underlying cortical fibers to separate and fray. The cortical fibers splay outwards and fracture, giving the node the microscopic appearance of two brooms or paintbrushes thrust together end to end by their bristles. [5] The nodes occur at the sites of fracture of the hair. There has been no scientific explanation offered for the glistening appearance examined at the tips and along the shafts of the hairs. This is often reported by the patients as "whitish spots" on their hairs. These are identified as "nodes" (at which the hairs are broken) by the physician. The author feels that this is an optical phenomenon and that it is due to diffraction of light by the air trapped in the frayed ends of the shaft or at the nodes. To confirm this premise, we magnified the digital photographs of the hairs and these were seen as "sparkling areas". The glistening at the tips and sides of the hair shaft was accentuated when a black background was placed behind the hairs examined [Figure 8]. However when a white paper was placed as a background, the fluorescence was not obvious [Figure 9]. This justified that this is possibly an optical phenomenon. This hypothesis however needs to be studied further.
Figure 6: The nodes on the hair shaft seen on light microscopy magnification ×40 in case 1

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Figure 7: Light microscopy of a normal hair for comparison magnification ×40

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Figure 8: The glistening appearance at the tips and sides of the hair shaft is well appreciated when the hairs are placed against a dark background

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Figure 9: Glistening appearance of hair shafts is lost when they are placed against a white background, and the fluorescence is not obvious

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Diagnostic options in trichorrhexis nodosa include light microscopy, trichoscopy and electron microscopy. Treatment options in acquired trichorrhexis nodosa are aimed at avoiding the incriminated offending agent. This could be repetitive physical trauma or chemical damage or insults. The patients in the above cases were asked to avoid the comb and use straight combs with elongated bristles. The use of oils and conditioners was recommended to reduce the hair shaft cuticular damage by reducing the hair - comb friction, which is the prime cause of the weathering defect.

   Conclusion Top

Trichorrhexis nodosa is most often acquired and repetitive physical trauma is a major factor for hair shaft breakage. This case highlights a localized acquired cause of trichorrhexis nodosa in Kerala state, India. A distinctive comb used by individuals and a distinct combing habit are implicated as aetiologic factors for the trichorrhexis. The light microscopic characteristics of this hair shaft disorder have been studied and possible explanation for the shiny appearance of the hair shafts offered. Acquired and congenital forms of trichorrhexis nodosa present as hair shaft breakage in a generalized pattern have been described. However, localized variants have not been reported in literature. When one encounters cases of localized hair shaft breakage, the combing habits and the type of comb used by the patient need to be enquired in history.

   Acknowledgments Top

We wish to thank the following for their help and assistance:

Dr. KG Alexander, Chairman and Managing Director, Baby Memorial Hospital Limited, Calicut, Kerala, India for hospital support and services. Dr. Neena Mampilly, Consultant Pathologist, Baby Memorial Hospital for pictures of light microscopy.

   References Top

1.Schwartz RA, Seiff DB. Trichorrhexis Nodosa. Available from: http://emedicine.medscape.com/article/1073664-overview [Last accessed on 2011 March 14].  Back to cited text no. 1
2.Rogers M. Hair shaft anomalies: Part 1. Australas J Dermatol 1995;36:179-85.  Back to cited text no. 2
3.Miyamoto M, Tsuboi R, Oh-I T. Case of acquired trichorrhexis nodosa: Scanning electron microscopic observation. J Dermatol 2009;36:109-10.  Back to cited text no. 3
4.Lurie R, Hodak E, Ginzburg A, David M. Trichorrhexis nodosa: A manifestation of hypothyroidism. Cutis 1996; 57:358-9.  Back to cited text no. 4
5.Papa CM, Mills OH Jr, Hanshaw W. Seasonal trichorrhexis nodosa. Role of cumulative damage in frayed hair. Arch Dermatol 1972;106:888-92.  Back to cited text no. 5


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]

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