Bird's nest view from a dermatologist's eye

Plica neuropathica also known as "birds nest" is irreversible matting of hair seen in otherwise healthy individuals and is usually associated with use of ionic/herbal soaps, shampoos, parasitic infestations, psychiatric alterations, or neglect. Anagen effluvium is a known side effect of many immunosuppressive drugs. Rarely matting of hair has been reported following azathioprine. We report plica neuropathica in two chronically ill patients on immunosuppressive drugs, that is, azathioprine and methotrexate along with a review of literature of its etiological factors and pathogenesis.