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Three Part Question

In [children presenting with hair tourniquet] can [hair removal cream] be applied to [remove the hair tourniquet]?

Clinical Scenario

An 8 week old infant presents to the paediatric emergency department with a toe tourniquet formed from a hair thread. You struggle to unwind the thread but wish to avoid removing it via incision, and so consider the use of hair removal cream - but could it be effective?

Search Strategy

OVID Interface: EMBASE [1980 to 2019, Week 50]
[tourniquet syndrome.mp. OR hair tourniquet.mp. OR thread tourniquet.mp. OR hair-thread tourniquet.mp. OR hair thread tourniquet.mp. OR Toe tourniquet.mp.] AND [exp depilation/ OR exp depilatory agent/ OR depilatory.mp. OR exp cream/]

Search Outcome

8 items returned of which 3 publications were identified which detail the use of hair removal cream in cases of children with suspected hair tourniquet.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Alruwaili, N., Alshehri, H. & Halimeh B. 2015 Saudi Arabia	Two case reports were presented: Case 1; a 6-month-old boy with suspected hair tourniquet of his toe who was treated with an application of a depilatory agent. Case 2; a 15-day-old boy with hair tourniquet of his left ring finger was treated with application of hair removal cream.	Case reports	In both these cases of hair tourniquet, hair removal cream was applied, the patient was reviewed ten minutes later, and then the thread was seen to have been removed and the constriction alleviated.	Case 1: a depilatory cream (Nair) was applied to the site of the suspected hair touniquet which, following review ten minutes later, was credited with the removal of the hair thread which was subsequently discovered. Case 2: hair removal cream (the key ingredients being calcium hydroxide and sodium hydroxide) was applied to the site of the suspected hair touniquet which, following review ten minutes later, was credited with the removal of the hair thread which was subsequently discovered.	Both case reports do not detail any efforts to remove the hair tourniquet prior to the application of the depilatory cream, thus it is less determinable as to what additional advantage the cream provides in the removal of the hair compared to attempts to simply unwind the hair thread - which would likely be attempted in the first instance.
O'Gorman, A. & Ratnapalan, S. 2011 Canada	A 12-week old presented to the emergency department with a suspected hair tourniquet affecting his left third toe.	Case report	Hair removal cream was used to successfully detach a hair tourniquet after an unsuccessful attempt to unwind the thread.	The thread proved difficult to unwind and so 0.5 microlitres of hair removal cream (the active ingredient was calcium thioglycolate) was applied to the affected area. The cream was applied for 30 minutes with the thread then being removed by rubbing and washing the area.	The capillary refill time of the affected limb was less than 2 seconds and the cream was applied for 30 minutes; this approach demands a lot of time for a syndrome which is generally considered an emergency. However, this may indicate the use of hair removal cream in cases where limb perfusion is not compromised to a catastrophic degree.
Bean, J. F., Hebal, F. & Hunter, C. J. 2015 United States	A single centre retrospective review of all patients who presented with a hair tourniquet from May 2004 till March 2014 (n = 81). Age range of 2 weeks to 22 years, sites of tourniquet ranged from toes (n = 69), fingers (n = 5) and genitalia (n = 7). 50 patients received depilatory treatment for the tourniquet – which was applied for 3 minutes, with a second application being applied 10-15 minutes afterwards if required.	Single centre retrospective study	Depilatory agents (eg. Nair) are effective as first-line agents in the treatment of tourniquet syndrome when not contraindicated due to involvement of mucous membranes. If chemical tourniquet release fails, then the patient should undergo mechanical tourniquet release. A downside identified by the use is the agent is skin irritation if applied for too great an amount of time.	50 of the 78 children (64%) eligible for depilation of their tourniquet (i.e. no tissue ischaemia, no female genital involvement) had successful resolution with either 1 (40 of 78; 51%) or 2 depilatory agents (10 of 78; 13%). Further attempts with chemical application were never successful.	The study does not detail any efforts to remove the hair tourniquet prior to the application of the depilatory cream, thus it is less determinable as to what additional advantage the cream provides in the removal of the hair compared to attempts to simply unwind the hair thread - which would likely be attempted in the first instance.

Comment(s)

Only a few case reports detailing the use of hair removal cream in suspected hair tourniquet syndrome are present in existing literature; however in these cases this approach has been found to be effective. Prolonged application of depilatory creams can be associated with skin irritation. Contraindications may include allergies to the depilatory agents, deep tourniquets, involvement of mucous membranes or significantly compromised limb perfusion (for example, if the capillary refill time is more than 2 seconds).

Clinical Bottom Line

Depilatory cream could be considered in cases of suspected hair tourniquet syndrome to achieve the removal of the thread in a simple and painless way.

References

1. Alruwaili, N., Alshehri, H. & Halimeh B. Hair tourniquet syndrome: Successful management with a painless technique. International Journal of Pediatrics and Adolescent Medicine 2015; pp. 34-37.
2. O'Gorman, A. & Ratnapalan, S. Hair tourniquet management Pediatric Emergency Care 2011; pp. 203-204.
3. Bean, J. F., Hebal, F. & Hunter, C. J. A single center retrospective review of hair tourniquet syndrome and a proposed treatment algorithm Journal of Pediatric Surgery pp 1583-1585