HAIR AND NAILS

1. HAIR AND NAILS CM I- Dermatology Module Tory Davis, PA-C

2. Hair Loss • Normal = 100 hairs/day • Not noticeable among the 100,000 we have • Grows 1 cm/month • Permanent loss • Androgenic alopecia • Scarring alopecia • Temporary loss • Telogen effluvium • Traction alopecia • Alopecia areata

3. Alopecia Areata • Autoimmune disease, cause unknown • Possibly trigger (viral, other) in predisposed people • Usually temporary hair loss • Can be recurrent loss

4. Male Androgenic Alopecia • A physiologic reaction induced by androgen in genetically predisposed men • Gradual recession of hair on central scalp and frontotemporal region

5. Female Pattern Alopcia • Central scalp hair loss with retention of normal hair line • Studies suggest adrenal dysfunction as one possible cause

6. Androgenic Alopecia • TREATMENT • Minoxidil (Rogaine) solution • Ideal in men under 30 who have been losing hair for less than 5 years • Approx. 1/3 of these pts will regrow hair long enough to be cut or combed • May stop or retard progression • Effective in female pattern as well

7. Cicatricial (scarring) alopecia • Rare condition • Inflammation damages and scars the hair follicle, causing permanent hair loss. • Patchy hair loss can be associated with slight itching or pain. • Cause unknown, can be assoc with lupus or lichen planus

8. Telogen Effluvium • Telogen stage of hair growth is “resting stage.” 15% of hair is in telogen at any given time • 85% of follicles are in anagen (growth phase) • Telogen effluvium is a loss of a larger than normal percent of hair in telogen phase

9. Telogen • Caused by change in normal hair cycle • Event causes more hair to be moved from anagen to telogen at one time, followed by a larger-than-normal loss of hair about 2-4 months later • Like a reset button has been hit • Lost hair appears normal

10. Childbirth Severe illness Crash diets Drugs High fever Acute blood loss Thyroid disease Physiologic stress Physical stress Psychologic stress Causes of Telogen Effluvium

11. Anagen Effluvium • Less common • Caused by • Chemotherapy • Poisoning • Radiation therapy

12. Alopecia Areata • Rapid onset of total hair loss in sharply defined (usually round) area • Dx by observation • Most pts under 40 • Regrowth in 1-4 months, usually • Cause unknown • Whole scalp = alopecia totalis • Whole body = alopecia universalis

13. Alopecia Areata Treatment Options • Observation • Intralesional injection of steroid • Systemic steroids • PUVA: Psoralen (a photosensitizing agent) plus UVA • Minoxidil

14. Trichotillomania • The act of manually removing hair • Defined in the DSM IV as “an irresistible urge to pull the hair and a sense of relief after the hair has been plucked” • Thinned in irregular pattern • Cases may resolve spontaneously • Treatment aimed at behavior

15. Making the Dx in Hair Loss • HISTORY • Drugs, diet restriction, vitamin A, illness, recent childbirth • Thyroid symptoms • Time of onset and duration • Abrupt = telogen • Gradual = anagen or localized

16. Making the Dx • PHYSICAL EXAM • Examine scalp surface and hair shafts • Observe pattern, thinning, • Microscopic examination of hair • Hair pull • Daily counts • Part width

17. HIRSUTISM • Appearance of excessive coarse hair in pattern not normal in females • May be sign of endocrine disorder • Most cases mediated by androgens, which originate in adrenals or ovaries in women • Many pts have no physiologic cause

18. Hirsutism Etiologies • Polycystic Ovarian Syndrome • Endocrine disorder involving abnl hormone levels, irregular menses, infertility and ovarian cysts • Cushing’s Disease • Overproduction of cortisol from pituitary gland • Ovarian or adrenal gland tumors

19. Hirsutism Dx/Tx • PHYSICAL EXAM • Look for signs of virilization • Like what? • Pelvic exam for ovarian tumors • Abdomen for adrenal tumors • Lab evaluation of hormonal levels • Ovarian ultrasound • Tx aimed at underlying cause

20. Nails and skin ds • PSORIASIS • 10-50% • Pitting (ice pick-like depressions) • LICHEN PLANUS • Longitudinal grooving and ridging • Severe, early destruction of nail matrix • with scarring • ALOPECIA AREATA • Shallow pitting or stippling

21. Aquired nail disease • Paronychia • Usually Staph infection • Rapid onset of painful, bright red swelling of the proximal and lateral nailfold. • Relieved by draining • May require antibiotics

22. Onychomycosis • A.k.a. tinea unguium • Fungal infection of nail (toe more common than finger) Some, but not all nails- if all nails, seek other dx • 6-8% of population affected • Increases with age • Thickened, yellow, cloudy nails • Difficult to treat • Topical vs systemic

23. Beau’s Lines • Transverse depressions of the nails • Appear weeks after a stressful event • Caused by temporary interruption of nail growth • Stressors may include syphilis, uncontrolled DM, myocarditis, high fever, PVD, zinc deficiency

24. Nail changes with systemic disease • YELLOW NAIL SYNDROME • Response to respiratory disease • Nail growth slows to half normal rate • SPOON NAILS- koilonychia • Lateral elevation and central depression • Can be seen in normal children • May be caused by iron-deficiency anemia

25. Finger Clubbing • Distal phalanges become enlarged and bulbous • Angle of proximal nail fold increases • Associated with lung ds, CVD, cirrhosis, colitis, and thyroid disease

26. Terry’s nails White or light pink nails with no lunula • Associated with liver failure, CHF, diabetes, malnutrition • Decrease in vascularity and increase in connective tissue in nail bed