Treatment of Disorders of Hair and Nails. Dr. Letassy

Describe clinical presentation of alopecia areata

-Clumps of hair falls out leaving a totally smooth, round, hairless patch OR hair thins out -Body hair can be lost also -Hair usually grows back but may fall out in another area -New hair may be the same or it may be finer and white

Identify the adverse effects of topical immunity for alopecia

-Severe dermatitis -Vesicular or bullous reaction -Lymphadenopathy -Urticaria -Vitiligo -Dyschromia

Identify topical immunotherapy products for alopecia

Diphenylcyclopropenone (DPCP), Squaric acid dibutyl ester (SADBE), Dinitrochlorobenzene (DNCB)

Define DSO

Distal subungual onychomycosis (DSO): Most common infection of the nail plate and bed. Matrix may be affected in severe disease. T. rubrum most common cause.

Identify efinaconazole, tavaborole, and ciclopirox as a topical antifungal

Efinaconazole (Jublia), Tayaborole (Kerydin), and Ciclopirox (Penlac) are all topical antifungal agents.

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Identify the behaviors associated with paronychia Overzealous manicuring, Nail biting, Thumb sucking, Diabetes mellitus, Wet work

Identify the adverse effects of injectable Steroids

Injectable Steroids: Local skin atrophy, Telangiectasis, Hypopigmentation

Identify corticosteroids as first line therapy for alopecia areata.

Intralesional or topical corticosteroids are the initial treatment for most patients with patchy alopecia areata.

What is an altervative to terbinafine?

Itraconazole (Sporonox) is an alternative for Terbinafine (Lamisil). Spectrum: Greatest activity against dermatophytes, molds, and candida.

Define itraconazole pulse therapy

Itraconazole 200 mg BID x 1 week/month repeating for a total of 2 pulses for finger and 3 pulses for toes.

State the place in therapy for topical immunity.

MOST effective treatment for patients with extensive or recurrent scalp involvement.

Given a patient with a phototoxic reaction to a drug, select the appropriate treatment regimen.

MOST phototoxic reaction can be treated as sunburn. ¬ Photoallergic reactions should be treated in a manner similar to contact allergy.

State that mid to super high potency topical steroids are the first line therapy for limited vitiligo.

Mid- to super-high-potency topical corticosteroids are commonly used as a first-line therapy for the treatment of limited vitiligo. Their efficacy is attributed to modulation of the immune response.

Define MED

Minimal Erythemal Dose (MED): The minimum dose of ultraviolet radiation that produces clearly marginated erythema on the irradiated site, given as a single exposure. It is a parameter used to calculate the SPF of a sunscreen.

Identify adverse effects of topical minoxidil and anthralin.

Minoxidil (Rogaine): Pruritus, Dermatitis, Chest pain, Rapid heart rate, Faintness, Dizziness, Weight gain (sudden, unexplained), Swelling of the hands or feet, Scalp irritation. Anthralin: Erythema and scaling and Staining of hair, skin, and clothing brown

Identify second line therapy for alopecia

Minoxidil and anthralin.

What is the product used for depigmentation of vitiligo?

Monobenzone: Monobenzyl ether of hydroquinone; Used as a depigmenting agent for patients with extensive vitiligo. Monobenzone causes permanent destruction of melanocytes and induces depigmentation locally and remotely from the sites of application. ADR: Irritant contact dermatitis, pruritus, xerosis, alopecia, and premature graying.

State that ____________ is the treatment of choice for vitiligo covering >10% BSA and for repigmentation for vitiligo.

NB-UVB phototherapy

Identify the expected clinical response to injectable steroids.

New growth is usually visible within 6-8 weeks. The treatment may be repeated as necessary every four to six weeks, and is stopped once regrowth is complete. If there is no response after six months, treatment should be discontinued and alternative treatments may be attempted.

Identify the skin lightening agents used to treat melasma

Non-Pharmacologic Treatment-Sun avoidance-Wearing a wide-brimmed hat-Using broad spectrum sunscreen. Pharmacologic Treatment-Hydroquinone (Lustra) -Azelaic Acid (Finacea, Azelex)-Mequinol-Kojic Acid

State the treatment of choice for chronic paronychia

Non-Pharmacological Treatment: Keep hands dry as possible and use gloves for all wet work. Pharmacological Treatment: Topical corticosteroids (Betamethasone 0.1% ointment) Topical Tacrolimus if corticosteroids are not tolerated or contraindicated, Systemic antifungal therapy, Antibiotics if superinfection occurring

Given a patient history and a patient picture, identify the skin reaction as a phototoxic reaction.

Nonallergic cutaneous response that results from direct tissue or cellular damage following ultraviolet (UV) irradiation of a phototoxic agent that has been ingested or applied to the skin. -They appear as an exaggerated sunburn. -Reaction usually evolves within minutes to hours of sun exposure and is restricted to exposed skin. -In severe cases, vesicles and Bullae may be seen. -Most occur due to UVA rather than UVB radiation.

Identify the duration of topical antifungal therapy

Patients are treated for 48 weeks.

Identify conservative therapy for mild to moderate ingrown toenail

Place a cotton wedging or dental floss underneath the lateral nail plate to separate the nail plate from the lateral nail fold, thereby relieving pressure.Soak the affected foot in warm, soapy water for 10 to 20 minutes, three times per day for one to two weeks, pushing the lateral nailfold away from the nail plate. Alternatively, a solution of water mixed with 1 to 2 teaspoons of Epsom salts can be used. A medium to high potency topical corticosteroid can be applied after soaking to reduce inflammation.

Identify the risk factors for ingrown toenails

Poorly fitted shoes, Excessive trimming of lateral nail plate, Pincer nail deformity, Trauma

Define PSO

Proximal subungual onychomycosis (PSO): Fungal invasion of the nail through the proximal nail fold spreading to the nail plate and matrix. This is uncommon and occurs in severely immunocompromised patients. T. rubrum the most common cause.Considered a marker for AIDS.

Identify the role of potent topical steroids in the treatment of alopecia.

Reserve first-line therapy with topical corticosteroids for children and adults who cannot tolerate intralesional injections.

Define Water Resistant

Resistant to water effective for 40-80 minutes as indicated on the label while a person is swimming or sweating. These tests determine that UVA protection is proportional to UVB protection. Terms such as "waterproof" and "sweat proof" may not be used on sunscreen labeling.

Identify the adverse effects of topical steroids.

Skin atrophy, Telantiectasis, Hypopigmentation, Adrenal suppression (rare, but possible)

Define SPF

Sun Protection Factor (SPF): SPF describes the amount of UVB protection (i.e., protection against sunburn) that a sunscreen provides. SPF = MED on protected skin / MED on unprotected skin.

Define Broad Spectrum

Sunscreen has passed test procedures for measuring effectiveness against both UVA and UVB radiation.

Identify adverse reactions for terbinafine and itraconazole

Terbinafine: GI Upset - Diarrhea, Dyspepsia, nausea, abdominal pain. Itraconazole: CHF due to negative ionotropic effect. Terbinafine & Itraconazole: Rare, severe hepatotoxicity

Identify the use of topical anesthetics as the preferred pretreatment before intralesional corticosteroid injections

The affected area may be pretreated with a topical anesthetic cream (eg, lidocaine 2.5% and prilocaine 2.5% EMLA cream). -The cream is applied generously and is placed under occlusion with a tightly fitting shower cap or plastic wrap 1.5 to 2 hours before treatment. The cream is removed immediately before injection.

Identify the maximum dose of triamcinolone per injectable treatment session

The dose per visit is largely determined by the extent of disease and patient tolerance but is usually around 20 mg or less on the scalp. The dose of triamcinolone administered should not exceed 40 mg per treatment session.

Identify the topical antibiotic for treatment of moderate to severe ingrown toenail

Treatment consists of removing the nail wedge, cleaning the site and application of bacitracin or mupirocin ointment. An additional option is the placement of a soft plastic tube stent along the affected nail edge (gutter method).

Identify the primary dermatophyte that causes onychomycosis

Trichophyton rubrum is the most common causes of onychomycosis. Yeast (Candida albicans) and nondermatophyte molds can also cause onychomycosis.

Given the clinical presentation (medication history, symptoms, and timeline), identify the skin reactions as photoallergic reaction.

A delayed, cell-mediated immune response elicited by small amounts of compound in previously sensitized individuals. Once formed, the subsequent pathogenesis seems identical to allergic contact dermatitis. Rash is typicaly pruritic and eczematous eruptions in sun-exposed areas. Occur 24-48 hours after sun exposure. Most occur due to UVA rather than UVB radiation.

Identify the general mechanism of topical immunity.

A potent contact allergen is applied weekly to the scalp to precipitate an allergic contact dermatitis. The resultant mild inflammatory reaction is associated with hair regrowth. The reason for this response remains unknown.

Identify the appropriate recommendations for using sunscreen in an infant

Babies under six months old should be kept out of direct sunlight. A small amount of sunscreen (SPF 15 or higher) may be applied to limited areas of infants under six months old if there is no way to avoid the sun.Consider zinc oxide or titanium dioxide as these don't chemically bind to the skin, and may be less irritating. Lightweight clothing that covers the arms and legs and brimmed hats should also be worn by infants to protect them from sun.

Identify the administration process of topical immunity for alopecia

Begins with the application of solution to a small (eg, 4x4 cm) area, usually on the scalp, to sensitize the patient. One to two weeks later, treatment is initiated with the application of a very dilute concentration of the allergen to the affected areas. Patients should be instructed to wash off DPCP after 24 to 48 hours. Treatments are usually repeated once weekly for at least 4 to 6 months with slowly increasing concentrations.

What is the preferred antifungal for children?

Ciclopirox

Identify candidates for topical therapy antifungal

Consider when there are contraindications to systemic antifungal therapy. Consider when there is a risk for drug-drug interactions with systemic antifungal drugs. Preference to avoid systemic treatment (especially with three or fewer nails involved). Children may be more favorable candidates for topical therapy than adults because of a thinner nail plate and potentially faster nail growth rate.

Select the appropriate antibiotic for treatment of acute paronychia: Digit NOT exposed to Oral Flora

Coverage of Skin Flora: Cephalexin (500 mg TID-QID) or High Prevalence of MRSA TMP-SMX (Double strength BID)

Select the appropriate antibiotic for treatment of acute paronychia: Digit HAS been exposed to Oral Flora

Coverage to include S. aureus, E. corrodens, H. influenzae, and Beta-lactamase anaerobes: Low Prevalence of MRSA Anti-staphylococcal agent such as Dicloxacillin (250 mg QID) or Cephalexin (500 mg TID-QID). High Prevalence of MRSA TMP-SMX (Double strength BID)

Identify the recommended SPF for regular sunscreen use on body and lips, when to apply, and when to reapply.

Use a sunscreen with SPF 15 or higher (the American Academy of Dermatology recommends SPF 30 or higher) on a regular basis. Sunscreen should be applied at least every two hours, or more often for those who are sweating or swimming. it should be applied 15 to 30 minutes before sun exposure, since it does not work instantly. Clothing should be worn to protect the body from sun as well, such as long-sleeved shirts, pants, and broad-brimmed hats. A lip balm with SPF 30 or higher should be used to protect the lips from sun damage.

Identify a sunscreen containing PABA, topical NSAID, sulfonamides, or thiazides as the medication causing a photoallergic reaction.

Usual drug culprits include: -Sulfonamide antibiotics -Para-amino benzoic acid (PABA; ingredient in sunscreen) -Quinolones thiazide diuretics -NSAIDs (Ketophrofen, Diclofenac) -Fragrances (6-methylcoumarin, musk ambrette, sandalwood oil)

Define WSO

White superficial onychomycosis (WSO): Infection localized to the surface of the nail plate. Caused by T. mentagrophytes

State ________ is preferred treatment of onychomycosis and the duration of therapy.

terbinafine. Because of the higher cure rate and shorter course of treatment, oral Terbinafine (Lamisil) is first-line therapy.

Identify common medications that cause a photoxic reaction

tetracycline, thiazide, retinoid, NSAID

Identify intralesional corticosteroids as the preferred route of administration

¬ Intralesional Corticosteroids Preferred therapy for adults with isolated patches of hair loss. Intralesional injections should be performed on both existing and newly forming patches of alopecia with the goal of promoting new hair growth and limiting hair loss.