HAIR AND NAILS

CM I- Dermatology Module

Tory Davis, PA-C

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

Alopecia Areata

Autoimmune disease, cause unknown Possibly trigger (viral, other) in

predisposed people Usually temporary hair loss Can be recurrent loss

Male Androgenic Alopecia A physiologic reaction induced by

androgen in genetically predisposed men

Gradual recession of hair on central scalp and frontotemporal region

Female Pattern Alopcia Central scalp hair loss with retention of

normal hair line Studies suggest adrenal dysfunction

as one possible cause

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

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

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

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

Causes of Telogen Effluvium

Childbirth Severe illness Crash diets Drugs High fever

Acute blood loss Thyroid disease Physiologic stress Physical stress Psychologic stress

Anagen Effluvium Less common Caused by

– Chemotherapy– Poisoning– Radiation therapy

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

Alopecia Areata Treatment Options

Observation Intralesional injection of steroid Systemic steroids PUVA: Psoralen (a photosensitizing

agent) plus UVA Minoxidil

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

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

Making the Dx PHYSICAL EXAM

– Examine scalp surface and hair shafts– Observe pattern, thinning, – Microscopic examination of hair– Hair pull– Daily counts– Part width

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

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

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

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

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

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

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

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

Finger Clubbing Distal phalanges become enlarged

and bulbous Angle of proximal nail fold increases Associated with lung ds, CVD,

cirrhosis, colitis, and thyroid disease

Terry’s nailsWhite 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