When Patients Present With Hair Slivers In The Foot

Given that hair slivers can lead to infected wounds, pain and chronic drainage, these authors present case studies of several patients who presented with hair slivers in the foot.

Material such as glass, plastic, metal objects and wood comprise 90 percent of all foreign bodies that can enter into the foot.¹ However, there are many other objects that the podiatrist should be concerned with as well. One foreign body in particular that is unusual but seems to occur more frequently in our practice than one would imagine is the hair sliver.

Foreign bodies can be diagnostic dilemmas since many may not be visible on X-ray.  One may employ many other modalities for diagnosis such as computed tomography (CT) scans, magnetic resonance imaging (MRI) or tangential X-rays, but these imaging tools can often be unsuccessful as well. However, if suspicion is high, surgical exploration may be warranted for the area in question. Overlooking a foreign body is the second most common reason that patients file malpractice lawsuits against emergency room physicians.^1,2

In 1942, Allington and Templeton described a pilonidal sinus, which was an important step leading to the discovery of an occupational acquired disease seen in barbers and hair dressers.³ Studies in the 1950s found a rate of approximately 13 percent problems with hair slivers among these two groups.⁴ The hair slivers in these groups are unusual in that they occur in non-hair-bearing areas such as between the toes or on the bottom of the foot. Other occupations such as dog groomers and sheep shearers are also at risk, but hair slivers can occur in anyone who owns an animal. We have seen them in runners who get pet hairs in their shoes as well.^5,6

The method of penetration is controversial but it can be related to the old trick of pushing a needle through a coin. Drive a needle through a cork stopper of equal length and then place the cork on the coin. The cork acts as a splint and prevents the needle from breaking apart or bending as the needle drives through the coin. One can relate this to the penetration of the hair sliver as well. The mesh of the sock combined with the pressure between the foot and the shoe allows the hair to pass into the foot with the repeated blows of ambulation.^5,6

Hair slivers can be a source of pain, infection and chronic drainage. In our office, we have found they can mimic a wart, an interdigital tinea or bacterial infection. The number of bacteria needed to start an infection is 10² for a foreign body. Therefore, treatment may involve excision as well as oral antibiotics.^1,2 The best time to remove a hair sliver is as soon as one discovers it via clinical examination and history (including an occupational history). Waiting may only drive the sliver deeper into the tissue, requiring more aggressive surgical exploration and removal.

Case Study: When There Are Recurrent Hair Slivers From Pets

A 55-year-old male presented with a history of a wart that he had been self treating with topical anti-wart medications with limited results. The patient’s family physician detected a purulent, sanguineous drainage in the area and the patient had a pain level of 6 out of 10 on the Visual Analogue Scale (VAS).

At that point, the patient got a referral to our office for further treatment. On inspection, an apparent sinus tract developed in the fourth webspace to the dorsum of the foot. At the time of presentation, a dry eschar was present in the location of the sinus tract. After anesthetizing the patient's fourth interspace, we removed four individual pieces of what appeared to be dog hair from within the fourth interspace. We placed the patient on antibiotic therapy postoperatively.

There was an immediate reduction in the patient’s pain level and the wound appeared to heal two months later. At that time, the patient presented to our office with a black spot on the dorsum of the fourth interspace with increasing pain at 3 out of 10 on the VAS. We then lanced the area and collected another apparent dog hair as well as purulent drainage. Culture results were negative for bacterial growth. This appeared to be a foreign body reaction to the hair sliver that was in the foot. The area healed uneventfully with local wound care.

Again, one month later at follow-up, the patient presented with similar findings, which resulted in multiple hair structures being removed from the area. Due to the recurrent nature and location of the issue, we performed an open, deep incision of the foreign body. After surgical intervention of the fourth interspace and removal of what appeared to be a foreign body hair inclusion cyst, we closed the incision wound. Both the pilonidal sinus and the incision went on to heal uneventfully without recurrence. 

Case Study: When A Hair Sliver Looks Like A Wart

A 43-year-old female presented to our office with a painful area underneath the fifth metatarsophalangeal joint, which had been increasingly tender over the last few weeks. She described the pain as a dull ache that radiated up to 6 out of 10 on the VAS with any type of ambulation and running. The physical exam revealed a focal lesion consistent with a porokeratosis or wart-like lesion. Upon debridement of the area, we noted a black dot centrally, which appeared to be a possible foreign body hair.

At this point, after the administration of appropriate local anesthesia, curettage of the wart-like lesion revealed a foreign body hair in the area. Removal of the foreign body hair resulted in resolution of all symptoms. 

In Conclusion

Hair slivers can be a diagnostic challenge. After obtaining a thorough history and physical examination (including the patient’s occupation as well as exposure to any type of foreign body, including animal hair), one should institute aggressive early treatment. Encourage barbers and hairdressers to wear socks and closed-toed shoes on a regular basis to prevent hair sliver penetration. Also encourage patients to clean their feet and interdigital spaces regularly.

Dr. Mozena is in private practice at the Town Center Foot Clinic in Portland, Ore. He is a Fellow of the American College of Foot and Ankle Surgeons, and is board certified in foot and ankle surgery. He is a Clinical Assistant Professor of Surgery at the Western University of Health Sciences.

Dr. Jones is in private practice at the Town Center Foot Clinic in Portland, Ore. He is a Diplomate of the American College of Foot and Ankle Surgeons, and is board certified in foot surgery. He is a Clinical Assistant Professor of Surgery at the Western University of Health Sciences.

References

1. Mozena JD, Brower R. Essential treatment tips for foreign bodies. Podiatry Today. 2000; 14(12):82–85.
2. Zirm RJ. Retrieval of foreign bodies. Podiatry Institute Update. 1990; 34–36. Available at https://www.podiatryinstitute.com/pdfs/Update_1990/1990_06.pdf .
3. Allington HV, Templeton HJ. Foreign body granuloma or interdigital cysts with hair formation. Arch Dermatol Syph. 1942; 46(7):157–8.
4. Schulz. Hair as a penetrating foreign body in the plantar surface of the foot. Arch Dermatol Syph. 1950; 61(4):668.
5. O'Neal AC, Purcell EM, Regan PJ. Interdigital pilonidal sinus of the foot. The Foot. 2009; 19(4):227-228.
6. Efthimiadis C, Kosmidis C, Anthimidis G, et al. Barbers hair sinus in female hairdressers: uncommon manifestation of an occupational disease: a case report. Case J. 2008; 1:214.