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

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