LETTERS TO EDITOR Year : 2022  |  Volume : 23  |  Issue : 2  |  Page : 145-147  

A case of positional alopecia following prolonged surgery

Varshini Ravindran, Sunil Rajan, Susmitha Susan Mammen, Lakshmi Kumar
Department of Anaesthesiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India

Date of Submission16-Jan-2022Date of Decision22-Mar-2022Date of Acceptance27-Apr-2022Date of Web Publication10-Jun-2022

Correspondence Address:
Dr. Sunil Rajan
Department of Anaesthesiology, Amrita Institute of Medical Sciences, Kochi, Kerala
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/TheIAForum.TheIAForum_7_22

How to cite this article:
Ravindran V, Rajan S, Mammen SS, Kumar L. A case of positional alopecia following prolonged surgery. Indian Anaesth Forum 2022;23:145-7

Sir,

Postoperative or pressure alopecia (PA) is a group of scarring and nonscarring alopecias which develop following ischemic changes to the scalp and has a pathophysiology similar to that of pressure ulcers.[1],[2]

We report a case of a 24-year-old transgender woman who was on hormonal supplements, which were stopped 2 months before her scheduled surgery. She underwent penile inversion vaginoplasty along with bilateral orchidectomy under general anesthesia. She was placed in a lithotomy position with a head ring placed underneath her head. The total duration of surgery was 8 h, and she had blood loss of around 1.5 L, which was managed with intravenous crystalloids and colloids. She did not require any inotropic support and her blood pressure remained stable throughout the surgery. She was extubated on the table and shifted to the recovery intensive care unit (ICU) and discharged a week later. A month later, she came with complaints of hair loss in the parieto-occipital region. On examination, an oval well-demarcated patch of complete nonscarring alopecia was noticed [Figure 1]. She was reassured about the condition, topical corticosteroids and minoxidil were prescribed, and she had a complete recovery.

PA usually presents as a circumscribed area of hair loss commonly in the occipital region, within a few weeks after surgery or following a prolonged ICU stay. Some patients complain of tenderness, swelling, or ulceration in the scalp before the development of alopecia. However, circumscribed alopecia may be the presenting complaint in others. If recognized early, the condition may be reversible, or even preventable, but a delayed diagnosis could lead to permanent hair loss.[3]

We believe that this patient experienced prolonged localized tissue hypoxia as a result of direct pressure occurring in the setting of prolonged surgery. Tissue hypoxia causes premature termination of the anagen phase of the hair cycle, and the affected hairs uniformly enter into catagenic arrest. Multiple apoptotic bodies within follicular epithelium on histology reflect pressure-induced programmed cell death secondary to tissue hypoxia.

Shear forces due to the extension of the head, Trendelenburg position, etc., also appear to play a role in scalp alopecia as they exert a parallel force that occludes capillary flow. A combination of pressure and shear forces together results in more ischemic damage to the scalp than the pressure effect alone. The use of soft gel foam head rings rather than hard Donut head rings is usually recommended in prolonged surgeries.

The simple act of repositioning a patient's head at frequent intervals during and after surgery effectively eliminates the phenomenon of PA. The duration of pressure is more important than the intensity in causing pressure-related damage.

While many case reports support the resolution of alopecia within a few months, treatment with topical corticosteroids might help in the early stages when erythema is present. Minoxidil may be used as an adjuvant treatment. The exact role of corticosteroids and minoxidil still needs to be further investigated.[4],[5]

It is concluded that PA is a totally preventable condition, and anesthesiologists should be vigilant about the condition during positioning of the patient's head and repositioning at frequent intervals should be practiced during prolonged surgeries.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 

  References 
1.Davies KE, Yesudian P. Pressure alopecia. Int J Trichology 2012;4:64-8.  
    2.Loh SH, Lew BL, Sim WY. Pressure alopecia: Clinical findings and prognosis. J Am Acad Dermatol 2015;72:188-9.  
    3.Tortelly VD, Melo DF, Ghedin BS, Lima CD, Garcia TU, Barreto TM. Pressure-induced alopecia: Presence of thin hairs as a trichoscopic clue for the diagnosis. Skin Appendage Disord 2020;6:48-51.  
    4.Ravaioli GM, Starace M, Alessandrini AM, Guicciardi F, Piraccini BM. Pressure alopecia in pediatric and adult patients: Clinical and trichoscopic findings in 12 cases. J Am Acad Dermatol 2019;81:1021-3.  
    5.Goodenough J, Highgate J, Shaaban H. Under pressure? Alopecia related to surgical duration. Br J Anaesth 2014;113:306-7.  
    
  [Figure 1]