Authors: Mezni L, Elhadadi F, Meziane M, Ismaili N, Benzekri L, Senouci K
Afflication: Mohammed V University of Rabat, Ibn Sina University Hospital, Dermatology Department

Acute hair matting (AHM), is an acquired disorder of the hair shaft, it is marked by entangled and sticky mass of hair mimicking a bird’s nest [1]. It’s also known as Plica polonica or Plica neuropathica. This report aims to remind the doctors of this puzzling entity as it has rarely been described and has a considerable psychological impact on the patient and his entourage.

55-year-old woman presented a sudden onset of matting hair overnight after piling her hair on the top of the scalp and vigorously washing it. She denied itching, discharge, scaly patches or a prior dermatological condition. She reported a change in hair care one month before the onset, she used a new hair conditioner along with an olive and garlic oil bath. There were a history of hospitalization for a severe SARS-CoV-2 infection two months ago, neglect in hair care during this period and acute telogen effluvium. No mental disorders, no daily use of medication, and no remarkable religious or cultural practices have been reported by the patient or her family.

Figure 1. Compact masses with irregular twists and entangled wet hair on the vertex

On examination, compact masses with irregular twists and severely entangled hair (figure 1 above). The hair was clean, the scalp was lesion free and there were no signs of lice infestation. Apart from the "wrangled mesh of wires" appearance, we noted a decrease in density and a positive hair-pull test. In addition, no abnormalities on blood tests have been found. The diagnosis of Plica polonica was made. It seems that it has been initially triggered by a neglect in hair care, then friction and chemical factors. The treatment suggested was cutting off the matted hair and regular use of soft hair cleansers. The follow-up period has been marked by a complete resolution of the symptoms in 3 months.

Plica polonica is an uncommon condition, first described by Le Page in 1884 as plica neuropathica following the sudden onset of entangled hair in a patient with hysteria [1]. In 1970, it was called by Bogaty and al [2] “Matting of hair”. As for the wool, hair shaft undergoes felting when exposed to mechanical and chemical factors. The etiopathogenesis is poorly understood, usually described along with mental disturbance, poor hygiene and hair care habits, contact and seborrheic dermatitis of the scalp, pediculosis capitis and “Coral reef” psoriasis.

Moreover, drug-induced (azathioprine), the use of chemical (cationic surfactants) and herbal shampoos, harsh rubbing of wet hair in circular motions using a liquid medium thus inducing a conglomeration of contiguous hair fibres [1,2,3]. This disorder has also been described in healthy women with long curly hair. Uncut hair is characterized by longitudinal splitting, cuticular irregularities, weathering and tends to mat easily. In the context of religious or spiritual convictions as applying sticky materials or using dreadlocks and cultural practices concerning washing, combing and cutting the hair.

Plica polonica is an acute and irreversible affection where hair gets felted, entangled creating knots [3]. The diagnosis is clinical, trichoscopy may be used to detect lice and nits and to pinpoint hair shaft abnormalities such as thickened, twisted and fractured hair, trichorrhexis nodosa and the honey-colored concretions [4].The treatment is difficult, especially in psychologically disturbed cases and patients with religious beliefs. It involves cutting the matted hair and in the early cases, gentle and manual partition by organic solvents and education to avoid trigger factors [1,2].

Plica polonica is a multifactorial disease, nowadays it is more associated with the haircare practices. Given the importance of hair throughout history; as a symbol of juvenescence, beauty, and virility a deep understanding of scalp-related diseases is important for the early management in order to soften patient’s frustration and cosmetic concerns.

References
1. Le Page JE. Neuropathica plica. Br Med J. 1884;1:160
2. Bogaty H, Dunlap FE. Matting of hair. Arch Dermatol. 1970;101:348–51
3. Elghblawi E et al. Case report: Acute hair matting in a Libyan girl from the outskirts. Middle East Journal of Family Medicine 2016; 14(9): 21–3
4. Nuria Setó-Torrent MD et al Plica neuropathica in severe reactive depression: clinical and trichoscopic features Dermatology online journal Volume 27 Number 5| May 202127(5):17