Hair & Nail Disorders
Folliculitis Decalvans
- chronic pustular eruption of the scalp resulting in patchy permanent alopecia
Adrenal Androgenic Female-Pattern Alopecia
- chronic, progressive, diffuse hair loss in women in their 20s and 30s - typically have normal menstrual cycle and lack any abnormalities on PE - some have increased levels of the serum adrenal androgen dehyroepiandrosterone sulfate (DHEA-S) - gradual loss of hair on the central scalp with retention of the normal hairline without frontotemporal recession (reverse of males) Treatment: Minoxidil
Alopecia Areata
- common asymptomatic disease characterized by the rapid onset of total hair loss in a sharply-defined, usually round area - cause is unknown - likely autoimmune
Chronic Cutaneous (Discoid) Lupus Erythematous
- common cause of scarring alopecia - early discrete bald patches in patients with lupus - Bx for diagnosis
Habit-tic Deformity
- common finding caused by biting or picking a section of the proximal nail fold - thumb most common Tx: attempt to discontinue nail fold biting/picking
What is the prognosis for alopecia areata?
- course is unpredicatable - recovery may be complete or partial - most pts regrow hair within 1 year w/o treatment - 10% develop chronic disease & never regrow hair - pts with family hx of alopecia areata, young age at onset, immune diseases, nail dystrophy, atopy, or extensive hair loss = poorer prognosis
Drug-induced Hair Loss
- cytotoxic drugs that directly affect hair matrix cell proliferation cause profound hair loss
Chronic Telogen Effluvium
- diffuse hair loss all over the scalp - differentiated from acute version based on duration (long and fluctuating course) - persists for more than 8 months! - abrupt onset & fluctuating course - most common in 30-60 yo women
How do you treat Tichotillomania?
- establish good physician-patient relationship - inquire about trichophagia (eating of hair) - psychiatric referral - evaluate pharmacotherapy
How do you perform an examination/testing for alopecia?
- examine scalp and hair shafts - microscopically examine the hair - "Hair Pull Test" - daily hair counts - part width test - hair growth window test
Hirsuitism
- excessive terminal hair that appears in a male pattern in women - "hirsute female" 5-10% of women
Describe the anagen phase of the hair growth cycle.
- growing phase - 90-95% of hairs are in anagen phase - hair length proportional to the anagen phase length
Explain the hair growth cycle.
- growth phase of scalp hair is approx. 1000 days - scalp hair grow 0.3 to 0.4mm/day (about 6in a yr) - hair in other areas (eyebrows, eyelashed, etc) have shorter growth phases (1-6 months) - human hair growth is not cyclic or seasonal; hair loss is continuous
Trichomycosis
- hair shaft infection - asymptomatic infection of axillary or pubic hair caused by Corynebacterium - hair shaft becomes coated with adherent yellow, red, or black concretions - hyperhidrosis is often present
Virilization Hirsutism
- hirsutism + other signs of mazculization - markedly increased androgen production by the ovaries or adrenal gland (or both) and markedly increased levels of plasma androgens (could be sign of ovarian or adrenal tumor)
How do you dx trichotillomania?
- increasing level of stress immediately before hair pulling or during attempts to avoid pulling - sensation of relief, pleasure, or gratification during hair pulling - pulling is not better explained by any other general medical condition or other mental disorder - significant distress or impairment in occupational, social, or other areas of functioning is experienced as a result of the pulling
Ingrown Nail - "Pincer Nail"
- large toe most freq affected TX: excision of lateral nail wall
Oil Spot Lesions
- localized separation of the nail pate; cellular debri and serum accumulate in space - tends to brown-yellow in color resembling a "spot of oil"
Median Nail Dystrophy
- longitudinal split appears in center of nail plate with several fine cracks projecting from line laterally - unknown origin; common in thumb - no tx; should return to normal
What does pathology for alopecia areata show?
- lymphocytic infiltrate on biopsy - non-scarring - acute follicular inflammation of the hair bulb in subcutaneous fat * usually taken if no regrowth w/in 1-3 months
Lichen Planus of the Nails
- may involve matrix, nail bed, & nailfolds - longitudinal grooving and ridging may respond to intralesional triamcinolone acetonide
Proximal Subungual Onychomycosis
- microorganisms enter the posterior nail fold (cuticle area) migrate to underlying matrix, and eventually invade the nail plate from below - nail surface remains intact - hyperkeratotic debris accumulates & causes nail to separate - most common pathogen: T. rubrum - commoni in HIV pts
Nail Melanoma
- nevi at nail matrix produce a brown pigmented band *can be normal in people of African descent --> biopsy!
Nail Tumors
- occur about and under the nails Malignant variations: SCC Bowen's Disease Melanoma - "Hutchinson's Sign" - Several benign variations as well
Androgenic Alopecia (Male-pattern Baldness)
- physiologic reaction induced by androgens in genetically predisposed men - can occur in women w/ androgen excess - inheritance pattern is polygenic - thinning begins between 12-40 yo - progressive shortening of successive anagen cycles of androgen-sensitive follicles
Traction Alopecia
- prolonged tension created by certain hairstyles (such as braids or ponytails), hair rollers, and hot hair-straightening - result in temporary or permanent hair loss in an area of stressed hair - scalp generally appears normal
Dissecting Cellulitis
- rare scalp cellulitis - multiple inflammatory nodules are concentrated on the crown, vertex, and occiput - lesions evolve into coalescing, boddy, fluctuant lesion that can discharge purulent - results in hypertrophic scarring with permanent hair loss
Loose Anagen Hair Syndrome
- rare, sporadic, or familial hair disorder that affects children (rarely adults) - female to male ratio 6:1 - defective anchorage of the hair shaft to the follicle that results in easily pluckable hair - caused by premature keratinization - signs: reduced hair length, inc hair shedding, multiple hair textures, up to 300 hairs shed daily - microscopic exam shows anagen hair without sheath
Pseudomonas Nail Infection
- related exposure to soap and water causes maceration of the hyponychium and softening of the nail plate - acts as growth site for Pseudomonas - nail plate assumes a green-black color - presents like subungal hematoma but absence of pain with Pseudomonas infection
Describe the telogen phase of the hair growth cycle.
- resting phase - 5-10% are in the telogen phase - on scalp phase last 2-3 months, hair ejected, and follicle re-enters anagen phase
How can you cosmetically treat hirsutism?
- shaving - chemical depilatory agents - plucking/waxing - bleaching - topical eflornithine - photoepilation * treating the problem can stop future growth but doesn't stop the growth of hair thats already there
Acne Keloidalis
- small follicular papules with occassional scalp and posterior neck that coalesce, thick & elevated - abscesses and sinuses with pus may develop - common with frequent hair cuts (men in military common)
How does alopecia areata present?
- sudden onset of one to several 1-4cm areas of hair loss on the scalp - skin is smooth and white or may have short stubs of hair - may have itching, tenderness, or burning sensation before the patches appear - regrowth begins in 1-3 months new hair is usually same color and texture but may be fine & hypopigmented
White Superficial Onychomycosis
- superficial invasion of the nail plate by T. mentagrophytes - surface of nail is soft, dry, powdery - nail can easily be scraped away - nail plate is not thickened and remains adherent to the nail bed
Describe the catagen phase of the hair growth cycle.
- transitional phase (end of anagen phase) - involution (cell death in follicular keratinocytes)
Beau's Lines
- transverse depressions of all the nails that appear at the base of th elunula weeks after a stressful event has temporarily interrupted nail formation - lines profress distally with normal nail growth and eventually disappear
What are the Hamilton Male-Pattern Baldness Classifications?
- triangular frontotemporal recession occurs normally in most young men (type I) and women after puberty - first signs of balding are increased frontotemporal recession accompanied by midfrontal recession (type II) - hair loss in a round area on the vertex follows - density of hair decreased over the top of the scalp (types III-VII)
How do you treat alopecia areata?
Commonly: Minoxidil Observation: most pts with a few small areas of hair loss can be assured there is a good prognosis for regrowth
How do you treat chronic cutaneous (discoid) lupus erythematous?
Intralesional steroids Hydrocychloroquine (oral med for lupus)
How do you treat dissecting cellulitis?
Isotretinoin
How can you differentiate nail fungal infections from dystrophic changes of nail psoriasis?
KOH prep Cx Bx
How do you treat chronic telogen effluvium?
Men - 5% Minoxidil solution (Rogaine) Premenopausal women - 5% minoxidil solution, spironolactone, & ethinyl estradiol Postmenopausal women - 5% minoxidil solution + spironolactone (can't give estrogen to someone postmenopausal)
What are the three signs of psoriasis in the nails?
Onychyolysis Oil Spot Lesions Pitting
What is the Hutchinson's Sign in nail melanoma?
Periungual extension of brown-black pigmentation from longitudinal melanonychia onto the proximal and lateral nail folds
Scarring Alopecia
Primary scarring alopecias: follicle inflammation (lymphocytic or neutrophilic) Secondary scarring alopecias: follicle destroyed by a non-follicular process
How many telogen hairs are shed each day?
Typically 25-100; up to 2x this number are lost from washing hair
What are some common causes of telogen effluvium?
acute blood loss childbirth rapid diet change drugs high fever hypo/hyperthyroidism physical stress psychologic stress severe illness
How do you treat pseudomonas nail infections?
apply a few drops of a mixture of one part chlorine bleach/four parts water or acetic acid (vinegar) under the nail 3x a day
Idiopathic Hirsutism
hirsute pt w/ normal ovulatory function and circulating androgen levels - <20% - due to inc sensitivity of the pilosebaceous unit to normal plasma levels of androgens - respond to Finasteride
Distal Subungual Onychomycosis
most common pattern of nail fungal infection - fungi invade the hyponychium - distal nail plate turns yellow or white - accumulation of hyperkeratotic debris causes nail to rise and separate from nail bed
Candida Onychomycosis
nail plate infection caused by C. albicans is almost seen exclusively in chronic mucocutaneous candidiasis - typically involves all fingernails - thicken, turn yellow-brown, may separate from nail bed
Onycholysis
painless separation of the nail from the nail bed Tx: removal of separated portion of nail recommended to prevent infection Yeast: antifungal tincture (miconazole) or oral fluconazole
Nail Pitting
pin point depressions in the nail plate is the most common finding in psoriasis
Acute Paronchyia
rapid onset of painful, bright red swelling of the proixmal and lateral nail fold; extremely painful sometimes - accumulation of the purulent material behind the cuticle
How do you treat trichomycosis?
shave hair antiperspirants Naftifine hydochloride (antifunal and antibacterial properties)
Dermatophyte (fungal) infection of the nails is called...
tinea unguium (onychomyocosis) * can also get Candida infection in nails
What is alopecia universalis?
total body hair loss - very rare, regrowth is unlikely
What is alopecia totalis?
total hair loss of the scalp - seen most frequently in young people - may be accompanied by cycles of growth and loss - prognosis for long-term regrowth is poor
Hangnail
triangular strips of skin may separate from lateral nail folds - worse in winder months Tx: constant lubrication of the fingertips with skin creams
Hirsutism tends to improve with...
weight loss
Onchyolysis
yellow, scaly debri causing elevation of the nail plate - commonly mistaken for fungal infection - separation of nail from nail bed
Nail Clubbing
"Hippocratic nails" Tx: changes are permanent
Koilonychia
"Spoon Nails" - lateral elevation & central depression of nail plate - can be congenital *associated with iron deficiency anemia* Tx: nails return to normal after anemia is corrected
Distal Nail Plate Splitting
"brittle nails" causes: repeated water immersions; frequent use of nail polish removers Tx: nail hydration; change polish weekly, B-complex vitamin biotin, orthosilicic acid
Leukonychia Punctata
"white spots" in nail plate - from trauma
How do you treat Onychomycosis?
*always oral agent for nail infections* - Terbinafine - Itraconazole - Fluconazole
How do you treat androgenic alopecia?
*no benefit for men who are already bald; if treatment stopped, benefits lost w/in 6-12 mo - Minoxidil - Finasteride (caution in women) - Hair transplants, scalp reduction & flaps, hair weaves, wigs
Postpartum Hair Loss
- # of hairs in telogen phase progressively decreases during pregnancy - diffuse (primarily frontotemporal) hair loss occurs 1-4 mo after childbrith; loss can be quite significant - recovery in less than 1 year to pre-pregnancy state
Name the 6 types of localized alopecia.
- Androgenic Alopecia - Andrenal Androgenic Female-Pattern Alopecia - Alopecia Areata - Trichotillomania - Traction Alopecia - Scarring Alopecia
What is the etiology behind folliculitis decalvans?
- Chronic bacterial folliculitis or altered immune responses - S. aureus commonly cultured
Herpetic Whitlow
- HSV infection of the fingertip - usually result of autoinoculation following herpetic gingivostomatitis - extreme pain from vesicles and swollen finger tips Tx: same antivirals as other HSV infections
How do you treat acne keloidalis?
- Povidone-iodine shampoo - Topical AB: Clindamycin, Minocycline, Cephalexin, SMP/TMX - Topical & intralesional steroids - excisional surgery
How can you treat hirsutism?
- Spironolactone *first li ne - Oral contraceptives - Finasteride - second-line
How do you treat folliculitis decalvans?
- Systemic antibiotics against Steph - topical AB: Mupirocin
Name the 6 types of generalized alopecia.
- Telogen effluvium - Chronic telogen effluvium - Postpartum hair loss - Drug-induced hair loss - Anagen effluvium - Loose anagen hair syndrome
What are the three types of hair?
- Terminal Hair: thick, pigmented; top of head, beard, axillary, and pubic areas; influenced by androgens - Lanugo Hairs: fine hairs found on the fetus; independent of androgens - Vellus Hairs: short, fine; relatively non-pigmented; covers much of the body, independent of androgens
Telogen Effluvium
- abormally high number of normal hairs enter telogen (resting) phase - non -scarring & non-inflammation alopecia - telogen hair loss occurs approx 3 months after the event that terminated normal hair growth - typically lasts one month - full recovery expected w/ no treatment
Anagen Effluvium
- abrupt loss of hair follicles that are in anagen (growing) phase; LARGE hair loss - cancer chemo & radiation therapy are most common cause - only hairs lef are those in telogen phase (which will eventually fall out too) - Minoxidil topical has no benefit
How do you treat acute paronchyia?
- abscess draining - may treat prophylactically for MSSA or MRSA
Common effects of hirsutism on women..
- anxiety & depression - women with polcystic ovarian syndrome may have anovulatory infertility, type 2 diabetes, and an inc risk of CVD & endometrial cancer
Subungal Hematoma
- blood under nail - caused by trauma to nail plate - if insufficient blood supply, may cause separation and loss of nail plate Tx: puncture nail
How do you treat nail psoriasis?
- can be fairly resistant Triamcinolone Acetonide Calcipotriol & Clobetasol Tazarotene
Trichotillomania
- chronic impulse control disorder characterized by repetitive hair pulling resulting in alopecia - most common in young children, adolescents, and women - adults: increased prevelance of anxiety and affective disorders - typically hair twisted around finger and pulled or rubbed until extracted or broken - most common over frontoparietal region of the scalp - may also pull eyebrows and eyelashes