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71 Cards in this Set
- Front
- Back
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hair type:
– Androgen dependent – Thick, pigmented – Beard axilla, pubic areas – no terminal hairs until puberty |
terminal hairs
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hair type:
– Fine hairs (peach fuzz) – Newborns |
lanugo hairs
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hair type:
– Androgen independent – Short, fine, non-pigmented (generally) – Covers body |
vellus hairs
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• In a normal healthy person's scalp about 90-95% of the hair follicles are actively growing hair and 5-10% are resting.
• A hair follicle usually grows on the scalp for 2-6 years. • Eyebrows and eyelashes grow on average 1-6 months. • _________ or transitional phase is about 2-3 weeks. • ________ phase on the scalp averages 2-3 months, but is longer for eyebrows and eyelashes. • most concerned with ________ phase in hair loss |
catagen
telogen telogen |
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"resting, to flow out"
Precipitating stressor that leads to shift to up to 50% of telogen hairs or resting phase. Presents with increased diffuse shedding of hair and eventual widened part. -temporal areas and crown will more likely be pattern baldness Shedding lasts about 2-4 months with a recovery period of 4-9 months. -hair will come back, no scarring, more common in adults, more common in females No scarring or inflammation is noted. Occurs at any age, more common in adults More common in females |
telogen effluvium
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Precipitating stress can include:
Illness Operation Accident Childbirth Emotional trauma Weight loss or unusual crash diet Oral contraceptive pill also accutane |
telogen effluvium
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History & Physical
Sudden vs gradual loss Localized vs generalized loss Duration of hair loss less than a year from the stressor Medications oral contraceptives, accutane Severe diet restriction Vitamin A supplements Thyroid symptoms hypothyroid Recent illness Family history of hair loss family history in pattern baldness Scarring vs non-scarring alopecia on exam Hair density/part width Hair pull test (< 6 hairs per pull) > 6 is abnormal Daily counts (between 100-250) (normal hair loss is between 100 - 250 a day) Labs: CBC, serum ferritin (tells what iron stores are like, anything less than 100 needs iron supplementation, ferritin > 30 person can make blood ok but probably not high enough to make good hair) thyroid, Hb, Hct |
telogen effluvium
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Treatment : Reassurance hair will regrow
Ensure healthy diet to promote hair growth Cosmetic ways to make hair look thicker Minoxidil (shifts hairs back into anagen phase, stops some of shedding until normal growth returns) |
telogen effluvium
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• Loss of hair in growth phase
• (usually patients in chemotherapy, hair comes out in patches) • Abrupt insult from cancer chemotherapeutic agents and radiation therapy to the metabolic and follicular reproductive apparatus • Once therapy is discontiued, hair will regrow. • Doesn't necessarily come back the same: color, texture, thickness, etc |
anagen effluvium
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• Male pattern
Pt profile: family history Onset 12 – 40 years of age Morphology Two follicle types Top: androgen sensitive will lose hair in androgen sensitive areas Sides/back: androgen independent In the presence of androgens, terminal hairs are replaced by vellus hairs |
androgenic alopecia
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• Management
2 - 5% minoxidil (topical) Dizziness and tachycardia have been reported 30% stop losing more hair, 30% regrow and 30-40% don’t respond (have to keep using, otherwise hair loss returns at accelerated rate) side effects: hirsutism on face, others: Propecia (oral) originally for BPH Inhibits 5 alpha-reductase Type II 6-12 months for results No significant results in post-menopausal women ($60 per Rx) 20-30% of men don’t respond 4% sexual dysfunction (retrograde ejaculation) Cannot be used in women with child-bearing potential (off label in post menopausal) (blocks all testosterone in fetus) |
adrogenic allopecia
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• Female pattern
Pt profile Family history Morphology: Loss on vertex Not as complete as male More likely to include entire scalp (mostly androgen independent) Etiology: Usually begins at menopause Drop in estrogens-relative increase in androgens |
adrogenic allopecia
female |
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• Management
Same as telogen effluvium Draw DHEAS levels (androgen in women) Total serum testosterone-normal in female thinning Serum prolactin (can cause marked hair loss) CBC, serum ferritin telogen effluvium tx: Reassurance hair will regrow Ensure healthy diet to promote hair growth Cosmetic ways to make hair look thicker Minoxidil (shifts hairs back into anagen phase, stops some of shedding until normal growth returns) |
adrogenic allopecia
female |
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• Sudden/localized/generalized/ universal hair loss in discrete, round or oval areas
• Clinical findings: < 25 years of age Family history No inflammation, tenderness or adenopathy Minimal erythema if any Exclamation point hairs hair thins toward scalp |
alopecia areata
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exclamation point hairs
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alopecia areata
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• Diagnosis:
Clinical findings: Perform Serum iron, Thyroid profile, ANA, KOH prep to R/O other causes • used when loss localized to scalp or facial hair or body hair (not all three) • Alopecia totalis used when loss is on the scalp and facial hair • Alopecia universalis used when loss is throughout the entire scalp, face and body • Loss in the temporal and occipital areas is referred to as the ophiasis pattern (makes prognosis worse) -autoimmune disorder |
alopecia areata
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• Management
Trial of Class I topical or intralesional steroids Anthralin (causes contact dermatitis, causes burning and gradually increase time and hope is that WBC attack but leave hair follicles alone) Topical immunomodulators such as Tacrolimus, Pimecrolimus Topical or oral PUVA IM/Oral steroids |
alopecia areata
• Management Trial of Class I topical or intralesional steroids Anthralin (causes contact dermatitis, causes burning and gradually increase time and hope is that WBC attack but leave hair follicles alone) Topical immunomodulators such as Tacrolimus, Pimecrolimus Topical or oral PUVA IM/Oral steroids |
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• Prognosis
The older the patient, the better the prognosis Worse if totalis, universalis or ophiasis pattern • Regrowth Starts as vellus hairs which progress to terminal hairs (they will be blonde) • Differential diagnosis Tinea capitis especially in kids (won't be primary in adults, consider other ddx) Secondary syphilis is scalp has moth-eaten appearance |
alopecia areata
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• Pt profile
tight braiding of hair, pony tails, hot comb straightening or rollers • Morphology fracture of shaft due to traction follicle can be damaged or destroyed receding hair line • Treatment no tension |
Traction Alopecia
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• Hair twisted around finger and pulled out or rubbed until broken off
(anxiety disorder) • Patient obtains pleasure, gratification or relief with recurrent pulling out of hair • Prevalence 0.6 –13% • Young children, adolescents and females with an onset generally around 11-13 years of age |
Trichotillomania
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• Scalp, eyebrows, eyelashes
• Irregular, angulated border (used to distiguish it from other disorders) • Hair density is decreased but the area is not bald • Comorbid mood or anxiety disorder • Skin biopsy is often warranted |
Trichotillomania
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• Findings:
Hair loss on crown/vertex Progressive disease with eventual burnout Symmetrical expansion Most active disease at the periphery |
Cicatricial Alopecia (Irreversible Hair Loss)
a scarring alopecia |
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• Types:
Follicular degeneration syndrome – generally seen in African Americans with premature desquamation of inner root sheath Pseudopelade – slowly progressive cicatricial alopecia without clinical evidence of folliculitis |
Cicatricial Alopecia (Irreversible Hair Loss)
a scarring alopecia |
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types:
Folliculitis decalvans – chronic pustular eruption of scalp resulting in patchy permanent alopecia (Tx rifampin, clindamycin, dapsone, topical mupirocin) Tufted folliculitis – end-stage of folliculitis decalvans or acne keloidalis, a scarring alopecia in which multiple hair tufts emerge from dilated follicular orifices |
Cicatricial Alopecia (Irreversible Hair Loss)
a scarring alopecia |
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Occurs on the occiput after shaving,
Predominantly in African Americans, Tx - Topical antibiotics (Erythromycin/Clindamycin); Oral antibiotics (Tetracyclines/Erythromycin); Topical/intralesional steroids (never cut out) |
• Acne Keloidalis -
a scarring alopecia |
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Most often young adult, African American males,
multiple inflammatory nodules that coalesce into boggy fluctuant areas that eventually discharge purulent material, eventual fibrosis, scarring and permanent hair loss, occurs in a triad with Hidradenitis and acne conglobata. Tx – Isotretinoin |
• Dissecting Cellulitis –
a scarring alopecia |
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Lichen planus affected the scalp,
biopsy necessary to make the diagnosis, Tx – plaquenil, cyclosporine |
• Lichen Planopilaris –
a scarring alopecia |
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Women more affected than men,
atrophic areas with erythema, scaling, telangiectasias and mottled hyperpigmentation, Follicular plugging is also common. Biopsy is warranted. Tx – intralesional steroids and Plaquenil |
• Discoid Lupus Erythematosus –
a scarring alopecia |
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mature terminal hairs in male pattern on female
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hirsutism
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mature terminal hairs in area not usually hairy
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hypertrichosis
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Genetic:
PCOS (polycistic ovarian syndrome) Racial Familial Physiologic: Puberty Pregnancy Menopause Endocrine: Hypothyroidism Acromegaly Congenital lesions Porphyria Drugs: Androgens Diazoxide Glucocorticoids Minoxidil OCPs Phenytoin CNS lesions: MS Encephalitis |
• Hisutism without virilization
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Ovarian
PCOS Hyperthecosis HAIR-AN syndrome (hyperandrogenism, insulin resistence, acanthosis nigricans) Tumors Adrenal Congenital Adrenal Hyperplasias 21-hydroxylase deficiency 11-hydroxylase deficiency (rare) 3beta hydroxysteroid dehydrogenase deficiency (rare) Tumors ACTH-dependent Cushing’s syndrome |
• Hirsutism with virilization
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• Work up
Age of onset, severity, rate of progression Virilization present or absent Family history of similar pattern Initial labs: DHEA-S and free and total serum testosterone |
hirsutism
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If virilization present:
TeBG 17-hydroxyprogesterone LH FSH thyroxine androstenedione ovarian US |
hirsutism with virilization present
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Vaniqa
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enzymes that inhibit hair growth
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Cosmetic intervention
Shaving Waxing Plucking Bleaching Depilatories Vaniqa (enzyme that inhibits hair growth) Electrolysis Lasers (only permanant form of hair loss) OCPs (can help it, but it can also cause it) Finasteride (DO NOT USE in women of child-bearing potential) Spironolactone (antiandrogen, CI: pregnancy) Flutamide (temporary chemical castration) |
hirstutism
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• Combination of acne, hirsutism, weight gain and infertility or irregular menses
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Polycystic Ovarian Syndrome
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• 6% of women of reproductive age
• Virilization generally absent • Associated with insulin resistance |
Polycystic Ovarian Syndrome
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• Labs:
Elevated testosterone elevated LH and LH:FSH ratio 3:1 elevated DHEA-S serum prolactin |
Polycystic Ovarian Syndrome
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• Treatment:
weight reduction diet and exercise low dose OCP spironolactone flutamide Clomiphene Metformin |
Polycystic Ovarian Syndrome
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• over-processed hair
• Pt profile brittle due to over working hair small bead on hair • Treatment stop all hair treatments in African Americans can cause permanent loss due to scarring |
Trichorrhexis Nodosa
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Longitudinal ridging
Pigmented bands Beading |
normal nail variants
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• Separation of nail plate from nail bed
• Potential space for infection |
Onycholysis
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• Etiology:
psoriasis-pitting and oil spots atopic eczema candidiasis trauma Treatment : Based on underlying etiology: Psoriasis: Intralesional steroids monthly injected into the matrix, Calcipotriol, Tazarotene, Anthralin Candidiasis: Fluconazole |
Onycholysis
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• Rapid onset
• Red,painful area to proximal/lateral nail fold post-trauma usually due to Staph mild and localized • Treatment: I & D, po antibiotics with penicillinase-resistant antibiotics |
Acute Paronychia
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• Seen in individuals whose hands are subjected to moist local environments
• Redness, edema of nail fold, several fingers, long term dystrophy of nail • Cuticle separates from the proximal nail fold, increasing risk of infection nail changes seen edema but it is not purulent |
Chronic Paronychia
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• Treatment:
Avoid exposure to contact irritants Keep proximal nail fold dry use cotton liner gloves Control inflammation with class 5 steroid Miconazole or Thymol in ETOH placed on the proximal nail fold Fluconazole if it appears to have candidal overgrowth |
Chronic Paronychia
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• Clinical findings:
Prodrome - tingling, itching, burning Grouped vesicles on an erythematous base Dentists and nurses high risk before advent of glove use Regional adenopathy Herpetic Whitlow nearly always caused by herpes Course - 7-10days • Diagnosis: History Clinical findings Tzanck prep DFA Culture • Treatment: Acyclovir |
Viral Paronychia
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• Frequent moist environments allows introduction of this bacteria
• Nail develops green-yellow or black color due to infection in areas of onycholysis • No inflammation, little to no discomfort • Treatment dry area One part chlorine bleach/4 parts water under nail TID or vinegar Ciprofloxacin |
Pseudomonas
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• Also known as tinea unguium
• Generally due to Trichophyton rubrum or Trichophyton mentagrophytes • 50% of thickened nails are not due to fungal infection (psoriasis; need to culture - part of nail or debris under nail) |
Onychomycosis
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• Distal subungual ______________ – most common
Yellow or white, hyperkeratotic debris Crumbly and fragment |
Onychomycosis
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a type of onychomycosis:
Surface invasion of the nail plate which is soft, dry and powdery |
white superficial
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Infection starts at proximal nail fold and migrate to matrix and invade nail plate
Transverse white bands begin proximally reverse of distal subungal - starts proximally Usually white Most commonly seen in AIDS |
• Proximal subungual onychomycosis
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Thickened, yellow-brown nail plate
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• Candida onychomycosis
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Treatment:
KOH and culture (need confirmatory culture: can look like psoriasis, drug coverage) Griseofulvin (takes up to 1 year for therapy) Itraconazole 200mg, 2 PO qd x 1 week, off for 3 weeks, total off 3 months) RR 38.3% Terbenifine 250 mg qd x 3 months (can be used with children) RR 75.5% Fluconazole 150mg Q week x 12 – 24 weeks RR 32% Ciclopirox nail laquer Used best as added agent to orals and to prevent recurrence Surgical removal Vicks Vapor Rub? |
Onychomycosis
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• Nail is severly distorted, thickened, opaque, brownish, spiralated and without attachement ot the nail bed
• Nail of the great toe is particularly vulnerable. • Usually caused by pressure from footwear in the elderly or DM |
Onychogryphosis
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• Appears during 5th or 6th decade of life
• Minimal inflammation of the matrix induces longitudinal grooving and ridging • A pterygium caused by adhesion of the nail matrix with scarring can develop • Treatment with intralesional TAC • Oral prednisone in severe cases • usually irreversible |
Lichen Planus
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nail:
cuased from trauma |
leukonychia punctata
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genetically predisposed
may have nail removed and destroy nail bed matrix to prevent regrowth of nail |
pincer nails
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Median Nail Dystrophy
if nail matrix injured, will have permanent ______ in nail |
groove
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coincide with some other issue
nails: transverse linear depressions illness or extreme stress |
• Beau’s lines
associated with internal disease |
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nails:
Elderly Pulmonary complaints Pleural effusion, bronchiectasis bronchitis, COPD Facial or lower extremity edema Abnormal lymphatics light or deep yellow Slow growth of nails thick and ridged Treatment: Vitamin E orally or topically has shown some improvement |
yellow nails
associated with internal disease |
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nails:
look for in pulmonary disease distal finger enlarged nail convex May occur as a normal variant Associated with lung/cardiac disease Cirrhosis Thyroid disease |
clubbing
associated with internal disease |
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nails:
Spoon nails-central depression of nail plate -normal variant unless anemic -iron deficiency |
koilonychia
associated with internal disease |
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nails:
transverse white line in plate -sepsis -renal failure -arsenic poisoning |
Mee's nails
associated with internal disease |
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nails:
proximal white distal red/brown – associated with renal disease |
Half and half nails
associated with internal disease |
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nails:
liver disease |
Terry's nails
associated with internal disease |
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nails:
Azure Lunula an autosomal recessive disorder, with a male preponderance. Its main feature is accumulation of copper in tissues, which manifests itself with neurological symptoms and liver disease |
Wilson's diease
associated with internal disease |
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nails:
usually occurs around puberty a rare, multi-system genetic disease that causes benign tumours to grow in the brain and on other vital organs such as the kidneys, heart, eyes, lungs, and skin. A combination of symptoms may include seizures, developmental delay, behavioural problems, skin abnormalities, lung and kidney disease |
Koenen’s Tumors in Tuberous Sclerosis
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nails:
abnormal vascular collection benign lots of bleeding, may want to refer to hand surgeon |
pyogenic granuloma
-nail tumor |
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nails:
very difficult to get rid of aldera or nevus nail |
periungual wart
-nail tumors |
