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Table of Contents
CASE REPORT
Year : 2018  |  Volume : 26  |  Issue : 3  |  Page : 135-138

Barber's syndrome: Plenoidal sinus with nonpatient hairs


Department of Plastic, Reconstructive and Aesthetic Surgery, Balikesir Atatürk City Hospital, Balıkesir, Turkey

Date of Web Publication2-Jul-2018

Correspondence Address:
Bilgen Can
Department of Plastic, Reconstructive and Aesthetic Surgery, Balikesir Atatürk City Hospital, Balıkesir
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjps.tjps_23_18

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  Abstract 

Barber's syndrome is a plenoidal sinus that occurs in the interdigital space resulting in penetration from the epidermis by exogenous hairs. As an occupational disease, it is named so because of its prevalence in barbers. The penetration of short and hard hairs into the epidermis and the subsequent accumulation in the interdigital space triggers infection and leads to the classic plenoidal sinus pattern. However, unlike the classical plenoidal sinus, this pattern is formed in the interdigital space free of hair follicles and with exogenous, nonpatient hairs. Here, we present the case of a 31-year-old male patient who had plenoidal sinus in the second interdigital space for 1½ years. We would like to emphasize that it is a rare occupational disease which occurs in barbers with exogenous hairs and wanted to show the diagnostic and treatment modalities of this rare syndrome.

Keywords: Barber, exogenous, plenoidal


How to cite this article:
Can B. Barber's syndrome: Plenoidal sinus with nonpatient hairs. Turk J Plast Surg 2018;26:135-8

How to cite this URL:
Can B. Barber's syndrome: Plenoidal sinus with nonpatient hairs. Turk J Plast Surg [serial online] 2018 [cited 2019 Sep 17];26:135-8. Available from: http://www.turkjplastsurg.org/text.asp?2018/26/3/135/235793


  Introduction Top


Barber's syndrome is a plenoidal sinus that occurs in the interdigital space resulting in penetration from the epidermis by hard and short hairs. As an occupational disease, it is named so because of its prevalence in barbers. [1],[2]

It was first described by Temptation in 1942 as interdigital foreign body granuloma. [3] Literature review shows that not all interdigitally plenoidal sinuses are Barber's syndrome. [1] Other than that, it can be seen in pet groomers [4],[5] and Sheep Shearers. [6],[7],[8]

The penetration of short and hard hairs into the epidermis and the subsequent accumulation in the interdigital space triggers infection and leads to the classic plenoidal sinus pattern. However, unlike the classical plenoidal sinus, this pattern is formed in the interdigital space free of hair follicles and with exogenous, nonpatient hairs. [1],[2],[9],[10],[11],[12]

The clinical symptoms of barber's syndrome include pain, drain, and swelling in the interdigital space. Short and hard hairs can be seen in the drainage.

The treatment of choice is surgical excision. Then, the defect can be left open for secondary healing, primary suturing can be done, or full-thickness skin grafts or local flaps can be used to cover the defect. Antibiotic therapy alone is not enough. [1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12]

In this study, we present the case of a barber with interdigital plenoidal sinus who underwent surgical excision and repair with skin graft with diagnostic and treatment stages.


  Case Report Top


A 31-year-old male patient has been being a barber for 15 years. He presented to various centers with complaints of swelling and draining at the second interdigital space for 1½ years [Figure 1]. He had only antibiotherapy, and there was no regression in his complaints. In magnetic resonance imaging taken at the external center, the second interdigital space showed a heterogeneous mass sized 2 cm × 1.5 cm which can be clearly separated.

The patient underwent extensive excision under local anesthesia with fistula and unhealthy skin [Figure 2], [Figure 2], [Figure 3], [Figure 4]. Thick-walled cysts and short, thick hairs were observed in the excised material at the mouth of the fistula [Figure 5]. The defect site after the excision was repaired with full-thickness skin graft taken from the bicipital groove. He was observed again on the postoperative 5 th and 7 th days and, on the 7 th day, follow-up was taken without medical dressing. The patient had started his occupation on the postoperative 14 th day. He was examined again in the postoperative 3 rd month, 1 st year, and 2 nd year. No recurrence or any complication was encountered in the patient [Figure 6].
Figure 1: Swelling involving the fistula mouth in the second interdigital space

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Figure 2: Excision involving unhealthy skin and fistula mouth, hairs coming out from the mouth of fistula at the Pensete tip

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Figure 3: Cystic mass observed to have a fairly smooth boundary and thick capsule

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Figure 4: Defect area consisted in the interdigital space after excision

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Figure 5: Excised cyst and hair scattered around

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Figure 6: Postoperative 2nd.year image

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In the pathologic examination of specimens, a superficially squamous epithelium-fitted sinus tract, deep chronic inflammatory granulation tissue, and numerous hair shafts were observed. In addition, foreign body granulomas developed against the hair shaft [Figure 7] and [Figure 8].
Figure 7: Histological image of the lesion (H and E, ×4). The arrow points to the pilonidal sinus orifice. A sinus tract with a benign squamous epithelium is seen

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Figure 8: In chronic inflammatory granulation tissue, hair shaft (arrows) surrounded by foreign body-type giant cells is seen (H and E)

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  Discussion Top


Barber's syndrome is an interdigital plenoidal sinus that occurs in barbers as an occupational disease. [1],[2]

Penetration of the epidermis with short and hard hairs leads to sinus formation, hair accumulation triggers infection and discharge through sinus which can contain hairs can be seen. Over time, as the formation is covered with the foreign body granulation texture, the cyst with exogenous hairs occurs. [1],[2],[9],[10],[11],[12]

The fact that it is a rare case has led to confusion in diagnosis and treatment. The patient presented to various centers for 1½ years and had long-term antibiotic treatment. Isolated antibiotic therapy is not curative for the plenoidal sinus. [1],[2],[3],[4],[5],[6],[7],[8],[9],[10] Antibiotics are used in the presence of active presurgical infection, for the eradication of infection, [8] or prophylactically in the postoperative term. [8],[9]

Fistulography can be performed to determine the depth of the cyst before surgery. [1] As in the classic plenoidal sinus, the width of the surgery can be determined perioperatively with methylene blue injection. [12] Since the lesion content, size, and healthy tissue differentiation can be determined clearly, ultrasonography is also used to assist the diagnosis and in determining the width of the surgery.

We took advantage of the MRI exam from another clinic. However, we did not find a case in the literature that used MRI for diagnostic purposes or to determine the width of the surgery. We presume that other methods evaluating preoperative size and spread are more cost-effective.

After excision of the plenoidal sinus, repair can be performed by leaving for secondary recovery, primary suturing, full-thickness skin grafts, or local flaps. There is no definite rule about which treatment to choose. We preferred full-thickness skin graft which is harvested from the bicipital groove. Of course, the size of the defect, the condition of the wound, and the likelihood of recurrence should be considered. Uysal et al. performed rotational flap for the defect that formed after excision to get better esthetic result. [1] However, it has been noted that recurrence is less visible in cases which were left for the secondary recovery. [1],[2],[9],[10],[11],[12] This may be due to the fact that the scar tissue formed by the secondary recovery constitutes a stronger barrier for penetration of the hair in the interdigital space.

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 Top

1.
Uysal A, Alagöz S, Unlu E, ªensoz O. Hair Dresser's syndrome: A case report of interdigital plenoidal sinus and review of the literature. Dermatol Surg 2003;29:288-90.  Back to cited text no. 1
    
2.
Patel MR, Bassini L, Nashad R, Anselmo MT. Barber's interdigital pilonidal sinus of the hand: A foreign body hair granuloma. J Hand Surg Am 1990;15:652-5.  Back to cited text no. 2
[PUBMED]    
3.
Templeton H. Foreign body granuloma or interdigital cyst with hair formation. Arch Dermatol Syphilol 1942;46:157-8.  Back to cited text no. 3
    
4.
Papa CA, Ramsey ML, Tyler WB. Interdigital pilonidal sinus in a dog groomer. J Am Acad Dermatol 2002;47:S281-2.  Back to cited text no. 4
[PUBMED]    
5.
Mohanna PN, Al-Sam SZ, Flemming AF. Subungual pilonidal sinus of the hand in a dog groomer. Br J Plast Surg 2001;54:176-8.  Back to cited text no. 5
[PUBMED]    
6.
Meneghini CL, Gianotti F. Granulomatosis fistulosa interdigitalis of Milkers' hands. Dermatologica 1964;128:38-50.  Back to cited text no. 6
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7.
Phillips PJ. Web space sinus in a shearer. Med J Aust 1966;2:1152-3.  Back to cited text no. 7
[PUBMED]    
8.
Vaiude P, Dhital M, Hancock K. A true pilonidal sinus in the hand of a sheep shearer. J Surg Case Rep 2011;2011:6.  Back to cited text no. 8
    
9.
Hueston JT. Pathology of the interdigital pilonidal sinus. Aust N Z J Surg 1952;21:226-9.  Back to cited text no. 9
[PUBMED]    
10.
Joseph HL, Gifford H. Barber's interdigital pilonidal sinus: The incidence, pathology, and pathogenesis. AMA Arch Derm Syphilol 1954;70:616-24.  Back to cited text no. 10
[PUBMED]    
11.
Powell HD. Interdigital sinuses in Barber's hand. Br J Surg 1956;43:520-1.  Back to cited text no. 11
[PUBMED]    
12.
Uysal AC, Orbay H, Uraloglu M, Sensoz O, Hyakusoku H. Rare occupational disease of hair dressers: Interdigital pilonidal sinus. J Nippon Med Sch 2007;74:364-6.  Back to cited text no. 12
[PUBMED]    


    Figures

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



 

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