eczema and hair and nails Flashcards
AD caused by
Caused by skin barrier dysfunction AND immune dysregulation
“Allergic March”
progression from AD to allergic rhinitis to asthma
risk factors for AD
fillagrin gene, family hx
80% of childhood AD does not persist past the age of
12
TCS in AD, s/e
Suppress inflammation, BID. Children have a higher BSA:Weight ratio ➡ higher degree of absorption• Striae • Cataracts • Adrenal insufficiency • Growth Delay in Children • Osteoporosis
TCI
2nd line, Pimecromilus (Elidel) BID x 6 weeks for > 2 years. Tacrolimus 0.03 > 2, 0.1 > 16
Eucrisa
BID > 2 years, can burn on application, wet wrap
Dupilimumab
- IL-4 & IL-13 (1+3=4) receptor antagonist (inhibits IL-4 & IL-13 signaling)
- 12 years and older
- No labs required
- Not an immune suppressing medication
- Loading dose then every other week dosing
Irritant Contact Dermatitis (ICD)
burning, stinging, pain
immediate
• 80% of occupational contact dermatitis cases are localized to area of exposure
• Most frequent cause of hand dermatitis (”wet work”)
Allergic Contact Dermatitis (ACD)
- IMMUNE MEDIATED!
- Delayed-type hypersensitivity reaction- Requires sensitization!
- 20% may initially present as localized eruption but then become generalized
- T-cell mediated reaction elicited by contact with a previously sensitized chemical agent
- The dominant symptom is PRURITUS!
- Reaction typically occurs 48-72 hours after exposure
Onychomycosis- management
oral terbinafine is first line, if they dont want systemic - cicloperox or kerydin, topical urea
terbinafine and dose
Continuous: 250mg/day 12 wks for toenails,
6 wks fingernails, LFT’s/CBC baseline; repeat at 6wks
s/e terbinafine
Elevated LFT’s, taste disturbance, exacerbation of psoriasis, headache, dizziness, contraindicated with statins or excessive alcohol
fluconazole dose
Pulsed: 150mg
1 day/week for 9 months, good for yeast, interacts with many drugs
Itraconazole dose
200mg day 12 wks for toenails
6 weeks for fingernails Contraindicated w/meds metabolized through CYP-450 Many drug interactions Take with a full meal
80/20 nails
terry nails, liver disease
half and half nails
kidney disease
dilated capillary loop nails
lupus
pitting nails
AD, pso
onycholysis seen in this systemic disease
pso
longitudinal ridging and pterygium
LP
patchy non scarring hair loss
• Alopecia areata • Trichotillomania • Tinea capitis
diffuse non scarring hair loss
• Androgenic alopecia (AGA) • Telogen or anagen
effluvium
patchy scarring hair loss
- Discoid lupus erythematosus
- Central centrifugal cicatricial alopecia (CCCA)
- Acne keloidalis
- Traction alopecia (end stage)
- Infections
- Trauma
diffuse scarring hair loss
- Lichen planopilaris
- Chronic cutaneous lupus
- Dissecting cellulitis
Male Pattern Hair Loss (MPHL)
minoxidil bid to damp scalp, can take months, scalp irritation. or finasteride - may drop PSA by 50 percent, sexual side effects
clinical presentation AA
- Abrupt onset; well circumscribed/demarcated, round patches (can be generalized)
- Exclamation mark hairs; shedding is prominent
- Nails: pitting, ridging, trachyonychia
Telogen Effluvium
• Shift of hair follicles from anagen (growing) to telogen (resting) • Can be triggered by stress, medications and hormonal changes
hair pull positive, spontaneous resolution, diffuse shedding 3 mo after trigger
Traction Alopecia
Traction or pulling that causes inflammation Initially- temporary broken shaft
Advanced- scarring without inflammation
• Usually frontal and/or temporal
• Can take years/decade to develop
mgmt traction alopecia
stop tension, permanece depends on how long
Central Centrifugal Cicatricial Alopecia (CCCA)
- Premature desquamation of inner root sheath → scarring
- Attributed to trauma, chemicals and heating
- Most common hair loss in AA females
CCCA presentation and mgmt
• Poorly defined areas of vertex and crown, w/centrifugal expansion
• Shiny, smooth, white/gray peripilar halos and broken hairs
• +/- inflammation
Management
• Stop stressful hair processing and grooming practices
• Can still progress even though stop
• High potency topical corticosteroids, tetracycline class abx
Lichen Planopilaris (LPP)
Clinical Presentation
• 2 subtypes: classic and frontal fibrosing (FFA)
• Perifollicular erythema and hyperkeratosis and scarring
• FFA frontotemporal loss of both terminal and vellus hair
• more than half also have alopecia of the eyebrow (may precede)
LPP dx
Diagnostics
• MUST take punch bx from area of active disease. Both horizontal & vertical
LPP mgmt
- Chronic, unpredictable, no cure, goal is prevention worsening
- Treatment in earlier active (inflammatory) stage
- First line:
- High or super high potency topical steroids, tapered when erythema subsides; intralesional triamcinalone, q6wks 10mg/ml (5mg/ml if frontal areas); Using 30g needle, deposition of 0.1ml every 1cm into dermis 1-2mm (not to exceed 40mg in a single treatment)
Dissecting Cellulitis
• Most common AA young adult males; follicular occlusion tetrad
Clinical Presentation
• Firm boggy nodules and plaques • Sinuses and drainage Management
• Intralesional corticosteroids, abx, oral isotretinoin, surgical
Hirsutism
• Increased number of terminal hairs in male pattern distribution
• Caused by adrenal (tumor or hyperplasia), pituitary or ovarian tumors; medications
Clinical Presentation
• Terminal hairs androgen-dependent areas
• Signs of virilization which can help differentiate diagnosis
Hirsutism dx and mgmt
Diagnostics
• Labs: testosterone (free & total), LH, FSH, DHEA-S, androstenedione, fasting glucose
Management
• Based on underlying cause: i.e. OCPs for hormonal imbalance or dexamethasone for adrenal
• Topical: efluornithine cream (Vaniqa)
• Systemics: Spironolactone
• Other: electrolysis or laser hair removal, waxing
