Red for danger: the effects of red hair in surgical practiceBMJ 2010; 341 doi: http://dx.doi.org/10.1136/bmj.c6931 (Published 09 December 2010) Cite this as: BMJ 2010;341:c6931
- Andrew L Cunningham, foundation programme doctor, general surgery,
- Christopher P Jones, foundation programme doctor, general surgery,
- James Ansell, registrar in general surgery,
- Jonathan D Barry, consultant surgeon
- 1Welsh Institute of Metabolic and Obesity Surgery, Department of General Surgery, Morriston Hospital, Abertawe Bro Morgannwg NHS Trust, Swansea SA6 6NL, Wales, UK
- Correspondence to: J D Barry
Traditionally, surgeons and anaesthetists regard red haired patients with some trepidation because of their reputation for excessive bleeding, a reduced pain threshold, and an, albeit anecdotal, increased tendency to develop hernias.
An estimated 1% to 2% of the general population worldwide has the phenotype for red hair, increasing to between 2% and 6% in the northern hemisphere.1 The typical phenotype associated with red hair is fair skin, freckles, and light coloured eyes. This colouration results from high levels of the red pigment phaeomelanin and reduced levels of the dark pigment eumelanin. Red haired people are also sensitive to ultraviolet light.2 Despite several validated methods to stratify surgical risk and outcome on the intensive care unit, such as the American Society of Anaesthesiology score3 and the acute physiological and chronic health evaluation score,4 none take into account the effect of red hair. We discuss the magnitude of risk posed to clinicians by patients with red hair.
A brief history of red hair
Red hair is referred to several times in ancient literature. Xenophanes, a Greek philosopher and poet, mentioned the blue eyes and red hair of the Thracians. Boudica, the Celtic queen of the Iceni, was described by the Roman historian Dio Cassius as “tall and terrifying in appearance . . . a great mass of red hair . . . over her shoulders.” Homer included several red haired mythical characters in his epic poem The Iliad, particularly Achilles, whose fate is the stuff of legends.
Several notable paintings depict Judas with red hair, such as the Kiss of Judas by Giotto di Bondone3 and The Last Supper by Carl Heinrich Bloch.4 In Jacopo da Ponte Bassano’s depiction of the last supper, one of the disciples, who is asleep on the table in front of Jesus, has red hair (fig 1⇑). Jesus appears to be admonishing this disciple (probably Judas) with the back of his hand, although no firm conclusions can be drawn from this.
The unwelcome stereotype of someone with red hair continues in modern times, as recently highlighted by the deputy leader of the Labour Party Harriet Harman with her controversial reference to the chief secretary to the Treasury Danny Alexander as the “ginger rodent” (fig 2⇑).5
Objective assessment of the behaviour of people with red hair is complicated by the ability to artificially colour hair.
We carried out a literature search through Google using the terms “redhair”, “pain”, and “surgery”. All relevant scientific or otherwise related papers identified were extracted for review.
The genetic basis of red hair was identified in 1997 in association with the melanocortin-1 receptor (MC1R) located on chromosome 16. Two copies of a recessive gene on chromosome 16 changes the MC1R protein leading to the red hair phenotype. Overall, 80% of people have the MC1R gene variant.2 The alleles identified (Arg151Cys, Arg160Trp, Asp294His, and Arg142His) on MC1R are recessive for red hair phenotype,6 although the HCL2 gene present on chromosome 4 may also be related.7
Many anecdotes have been recounted about the clinical behaviour of people with red hair. Reports of increased tendencies to bleed are, perhaps, apocryphal although some studies have sought to elucidate the link between red hair phenotype and haemorrhage.
One study attempted to show a link between red hair and bleeding after tonsillectomy (together with full moons and Friday the 13th).8 The incidence of post-tonsillectomy bleed was almost 7% but this was indistinguishable from that of the control group. In another study, the bleeding tendencies between 50 women (half of whom had red hair and half black or brown hair) by using objective coagulation testing did not differ, despite the red haired women reporting significantly more subjective bruising in the perioperative period.9
An association was observed between natural red hair and the incidence of laparoscopically confirmed endometriosis in women with no known infertility.10 This was the only association found (including parity, race, and body mass index) at 10 year follow-up.
More conclusive perhaps is the relation between red hair and requirements for anaesthesia. Mice carrying mutant MC1R and humans with red hair (both with non-functional MC1Rs) were shown to have a reduced sensitivity to noxious stimuli and an increased responsiveness to opiate based analgesia.11
One study focused on the increased need of patients with red hair for anaesthetic agents during surgery.12 This study was limited by its small sample size but showed that the need for desflurane was significantly higher in the group of patients with red hair than in the group with other coloured hair. Moreover, this study showed that of the cohort of 10 patients in the red haired group, nine were either homozygous or compound heterozygous for mutations on the MC1R gene. Supplementary work by these authors in a larger study population looked at the difference in local anaesthetics requirements between people with red hair and a control group of people with black or brown hair.13 Subcutaneous lidocaine (lignocaine) was significantly less efficacious in the red haired cohort. That cohort were also more sensitive to the perception of pain from cold and heat than the control group. The authors postulated that the dysfunction of the MCIR gene associated with red hair triggers the release of more of the α-melanocyte stimulating hormone that stimulates these cells, but this particular hormone also stimulates a brain receptor related to pain sensitivity (both of these hormones are derived from the same precursor molecule pro-opiomelanocortin).12
Possibly the most difficult association to identify is the postulated increase in the rate of hernia formation in people with red hair. Collagen synthesis may be implicated in the cause of hernia formation,14 although we could find no firm links between red hair phenotype and hernia development in our literature search. Research on brittle cornea syndrome has, however, shown a link between this autosomal recessive condition and red hair.15 Further work from Israel has shown the gene for brittle cornea syndrome to be on chromosome 16 (16q24)—the chromosome responsible for red hair. What are the chances of that? Probably 46 to 1.16 Indeed, the authors had previously identified the brittle cornea syndrome to be located on chromosome 16 close to the MC1R gene for hair.17 It follows that red hair may be associated with increased rates of hernia formation, but in all honesty it would be difficult to prove.
Despite sporadic reports to the contrary, the clinical implications of red hair phenotype remain questionable. Red hair phenotype may confer an increased requirement for anaesthetics but is associated with no greater operative risk than the remainder of the population. It would seem that the reputation of people with red hair for having increased perioperative risk is without any basis in fact and should only be used as an excuse of last resort by surgeons defending problematic bleeding or recurrent hernias.
Cite this as: BMJ 2010;341:c6931
Contributors: ALC and CPJ carried out the literature search and drafted the initial manuscript. JA drafted the initial and final manuscript. JDB conceived the study and approved the final manuscript. He is guarantor.
Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years, no other relationships or activities that could appear to have influenced the submitted work, although JDB’s third child is red haired.
Provenance: Not commissioned; peer reviewed.