To the Editor:
Barber’s sinus, or interdigital pilonidal sinus, is an occupational dermatosis with a pathognomonic clinical picture. Nearly all reports of barber’s sinus in the literature have involved the hands of male barbers and hairdressers. We present an uncommon case of barber’s sinus between the toes of a female hairdresser. If left untreated, potential complications of barber’s sinus include abscess formation, cellulitis, lymphangitis, and osteomyelitis. Clinicians should advise patients with an occupational risk of barber’s sinus to wear protective footwear and maintain hygiene in the interdigital spaces.
A 23-year-old female hairdresser was referred to our outpatient dermatology clinic by general surgery for evaluation of an asymptomatic interdigital toe lesion of several months’ duration. She was otherwise healthy. Physical examination revealed a 3-mm sinus in the interdigital web space between the fourth and fifth digits of the left foot, creating a partial fistula terminating in an umbilicated pink papule on the dorsal aspect of the interdigital space (Figure). While at work, the patient reported that she usually wore open-toed flip-flops. A diagnosis of barber’s sinus was made clinically. She returned for follow-up to the referring surgeon within 2 months and was offered surgical debridement, but the patient declined treatment, instead opting to wait and monitor for any potential complications. The lesion showed no change in clinical appearance and remained asymptomatic.
Barber’s sinus is caused by sharp fragments of clipped hair that penetrate the fragile interdigital skin and cause a foreign-body reaction. Males are almost exclusively contributory to the reported cases of barber’s sinus in the literature.1,2
The clinical picture of barber’s sinus is pathognomonic, as demonstrated in our case. Other potential diagnoses to consider include atypical mycobacterial infection, deep fungal infection, other foreign-body granuloma, and erosio interdigitalis blastomycetica. Although thorough removal of embedded hair fragments may be curative, most cases require surgical excision, often by curette, and subsequent skin closure. Pathology shows a foreign-body granulomatous reaction to hair fragments. If left untreated, potential complications of barber’s sinus include abscess formation, cellulitis, lymphangitis, and osteomyelitis. This lesion is preventable by maintaining hygiene of the interdigital spaces, use of barrier creams, and wearing protective footwear.3,4