Hair and Digit Tip Disorders Flashcards
MISSING SOME NAIL STUFF!!
phases of hair growth cycle
- Anagen - growth stage, phase of normal active growth
- Catagen - degenerative stage, brief transition in which hair growth stops
- Telogen - resting phase
- Exogen - hair shedding phase
Phases of growth are followed by periods of inactivity and then expulsion
Duration and rate of growth of anagen phase determines what?
ultimate length of hair in that area
Duration and rate of growth of scalp?
legs?
arms?
eyelashes?
- Scalp: 2-8 y
- Legs: 5–7 m
- Arms: 1.5–3 m
- Eyelashes: 4-6 w
soft, fine hair that covers much of the fetus; usually sheds before birth
Lanugo hair
fine, non-pigmented hair that covers the body of children and adults; not affected by hormones - aka “peach fuzz”
Vellus hair
characteristics of vellus and terminal hairs (occur on scalp)
Intermediate hair
thick, pigmented hair found on the scalp, beard, axilla, pubic area; eyelash and eyebrow hair in which growth is influenced by hormones
Terminal hairs
w/u for hair loss
- hair pull
- scalp bx - scraping or shave
- Trichogram
nml and abnml finding for hair pull
- Normal: 3 - 5 hairs are dislodged
- Abnormal: > 5 hair suggest pathology
goal of Trichogram ?
determine the anagen to telogen ratio
hair loss
trichogram shows growing hairs with a long encircling hair sheath
what type of hair?
Anagen hairs
Trichogram reveals resting hairs with an inner root sheath and roots usually largest at the base.
what type of hair?
Telogen hairs
normal findings of Trichogram
80-90% of hairs are anagen
MC form of alopecia
androgenic - Male and female pattern baldness
classifications for androgenic alopecia?
- women: Ludwig-savin classification
- men: norwood hamilton
Androgenic Alopecia MC in who and when?
- Men > Women - white > black > Asian men
- Men - after puberty (early as 20’s) - Typically fully expressed by 40
- Women - MC after 50
what hormone causes terminal follicles to transform into vellus like hair follicles
- atrophy
DHT
During successive follicular cycles - hairs produced are _____ lengths and of _____ diameter
- shorter
- decreased
w/u for androgen alopecia?
findings?
- Bx - telogen phase follicles & atrophic follicles
- Trichogram - ^ telogen hairs
- Hormones - Testosterone total and free, DHEAS, Prolactin
3 treatable conditions that could be causing androgen alopecia
- Thyroid
- Anemia
- Autoimmune
tx for androgenic alopecia
- Minoxidil /Rogaine 2 or 5% solution BID; Warn about hair loss
- Finasteride - MEN ONLY
- Spironolactone - Females
- hair transplant, wigs
MOA of Finasteride
- Inhibits testo to DHT
- Slows hair loss in 3 months, regrowth in 6 months
- localized loss of hair in round or oval areas with no apparent inflammation of the skin
- T cell mediated autoimmune disorder - Non scarring; +/- nails
Alopecia Areata
MC for of hair loss in children
< 25 yo MC
Alopecia Areata
pathology of Alopecia Areata
- damage to hair follicle in anagen stage
- rapid transformation to catagen and telogen = dystrophic
- Active = cannot progress beyond anagen
- No scarring
s/s of Alopecia Areata
MC areas
- Patchy hair loss
- Weeks to months
- Oval/round
- Defined borders
- Bald patches
- Skin seems normal = no scarring
MC areas: Scalp, Beard, Eyebrows, Extremities
- “Black dots”
- Dermoscopy - breaks before surface
- Exclamation hairs
- Blunt distal end and taper proximally
- Appear when broken hair are pushed out of the follicle
Alopecia Areata
subtypes of Alopecia Areata
- Alopecia areata (AA) - Solitary or multiple areas of hair loss
- AA totalis (AAT) - Total loss of terminal scalp hair
- AA universalis (AAU) - Total loss of all terminal body and scalp hair
- Ophiasis - Bandlike pattern of hair loss over periphery of scalp.
- Nails - Fine pitting (“hammered brass”) of dorsal nail plate.
w/u for alopecia areata
- Biopsy
- RPR – syphilis
- KOH – fungal
- ANA – autoimmune
- Thyroid Panel – endocrine
mgmt and prognosis for Alopecia Areata
- Spontaneous Remission: Onset – after puberty = 80%; Recurrence happens
- Psych consult
- Noninvasive - Wigs, Hair piece
- Topical CS: Class 1 & 2 w/ Minoxidil; ILK
- Systemic: Short term; Pred 20-40 mg daily; Taper by 5mg daily with a few weeks
- Minoxidil 5% - best with CS
- Anthralin - Safe in kids, avoid face
- Poor prognosis: Childhood onset, Body hair involvement, Nail, Atopy, Family hx
- A common condition resulting from hyperkeratinization of the skin and keratotic follicular plugging
- Affects nearly 50-80% of all adolescents and approximately 40% of adults
- Genetic predisposition with 30-50% having a positive family history
- Worsen in winter and improves in summer
Keratosis Pilaris
pathophys of Keratosis Pilaris
An excess formation and/or buildup of keratin leads to the abrasive goose-bump texture of the skin
associated conditions with Keratosis Pilaris
ichthyosis vulgaris, xerosis, and, less commonly, atopic dermatitis, asthma and allergies
presentation of Keratosis Pilaris during early childhood
- Affects the face and arms
- Gradual improvement in later childhood or adolescence
presentation of keratosis pilaris during adolescence
- Affects the extensor arms and legs
- Improves by the mid-20s
- chicken/goose bumps or chicken/goose skin
- asx with occasional pruritus
- Small 1-2 mm rough papules scattered over affected area
- MC Upper outer arm and thighs - (+/-) Erythema if associated inflammation
Keratosis Pilaris
w/u for Keratosis Pilaris
- Bx can be utilized if presentation is atypical
- histology - follicular orifice distended by a keratin plug
tx for keratosis pilaris
- Mild soaps
- unscented lotions 2-3 x/d
- OTC - Cetaphil, Lubriderm
- Rx - Lac-Hydrin - Steroid cream 1-2x/d x 7-10 d
- Keratolysis - SA, topical urea, topical retinoids
Nail grows into one side or both of the paronychium or nail bed
MC in males
MC in 20’s
MC on great toe
Onychocryptosis
pathophys of Onychocryptosis
- impingement of the nail into the dermal tissue distally or into the distolateral nail groove
- Nail = FB inflammation - Erythema, Edema, Purulence, Granulation tissue
RF Onychocryptosis
- Shoes
- Sweating
- Genetics
- Dystrophy
- Fungus
- Improper cutting
- Neuropathy/diabetes
complications of onychocryptosis
- Paronychia
- Cellulitis
- Osteomyelitis
- Bacteremia
- Sepsis
mgmt for onychocryptosis
- Warm soaks
- mupirocin BID until healed
- Trimming of nail (properly)
- Training (cotton)
- Surgical - Complete or partial nail; Matrixectomy
after procedure mgmt for Onychocryptosis
- Keep clean with normal soap and water
- Antibacterial
- Mupirocin
- Resume activity after 48-72 hours
Aka tinea unguium
Fungus of the nail
MC on toes
Fungus invades the nail via the hyponychium
Onychomycosis
cause of Onychomycosis
trichophyton rubrum
s/s Onychomycosis
- Asymptomatic
- Discoloration MC complaint
- Thickening
- Lifting of the nail from the bed
RF Onychomycosis
- Family History
- Old age
- Poor health
- Trauma
- Climate
- Fitness
- Immunosuppression
- Communal bathing
- Footwear
what needs to be r/o with ANY discoloration of the toenail
MELANOMA
needs to be ruled out clinically off history or biopsy
w/u for Onychomycosis
Nail clipping or scraping
- Clip toenail - bx
- Scrap from under the nail - KOH
- No Antifungals for 2 wks prior to sample
mgmt for Onychomycosis
- Ciclopirox (Penlac)
- Efinaconazole (Jublia) Daily x 48 weeks
- Home: 50/50 apple cider vinegar + water x 10 mins/d soaks
- Terbinafine - 6 wks for fingers; 12 wks for toes
labs for Terbinafine
CBC and LFT’s @ baseline and then monthly
Risks: hepatotoxicity, pancytopenia, agranulocytosis
onychomycosis may take how long to be resolved?
a year for nail to completely grow out therefore discoloration may still be present
Detachment form the nail bed
Onycholysis
causes of Onycholysis
- primary: idiopathic, mechanical/chemical damage
- trauma
- secondary: vesiculobullous dz, nail bed hyperkeratosis, nail bed tumors
- Whitish or opaque discoloration
- NO inflammation
- Smooth nails
Onycholysis
gray/black Onycholysis indicates ?
green?
- Gray/black = air
- Green = bacteria
- Inflammation of the proximal or lateral nail fold
- Begins as cellulitis and progresses to abscess
- MCC Trauma - Secondary bacterial infection
Paronychia
RF Paronychia
- Nail biting
- Sucking
- Trauma
- Chemical irritants
- Nail glue
- Sculpted nails
- Frequent hand washing
MC pathogen of Acute Paronychia
staph
Green = pseudomonas
w/u for Acute Paronychia
- Gram stain
- C&S
- KOH
- Tzanck = HW
- Xray
tx for Acute Paronychia
- Warm soaks 3-4x daily
- Fluctuant = I&D
- Oral abx when cellulitis (DM, PVD, Immunocomp)
- Augmentin 500mg/125mg BID x 10 d
- Clindamycin
- Cephalexin
when to consult hand surgeon for Acute Paronychia
- Significant cellulitis or lymphangitis
- Tenosynovitis
- Deep space infection
- Osteomyelitis
s/s of chronic paronychia
- Fungal/mechanical/chemical - From repeat exposure
- Inflammation waxes and wanes
- Pain
- Swelling - Usually x 6 weeks
- Swelling, Erythema, Tenderness, +/- thickening or discoloration (Possible fungal infection also)
mgmt for Chronic Paronychia
- Avoid RF’s
- Keep dry
- Avoid manipulation
- Warm antiseptic soaks – then dry
- Topical antifungals if necessary; Severe – PO antifungals
Herpetic Whitlow MC what viruses?
- MC HSV -1 or gingivostomatitis children
- RF: sucking thumb or finger - MC HSV -2 adults
- RF: Healthcare worker
2-14 day incubation
s/s of herpetic whitlow
Before lesions begins..
- Burning
- Pruritus - Vesicular, Tender, Swelling, Induration
w/u for herpetic whitlow
- clinical
- Tzanck
mgmt for herpetic whitlow
- Do not I&D
- Self limiting x 3 wks
- Contagious
- OTC pain meds
- Acyclovir, Valacyclovir
- Soft tissue infection of pulp space of distal phalanx
- Caused by infection (created by fibrous septa passing between the skin and periosteum)
- Hx: penetrating injury, splint, and paronychia
Felon
distribution of Felon?
- Thumb
- Index finger
complications of felon
- Osteitis
- Osteomyelitis
- Septic joint
- Tenosynovitis
w/u and mgmt for felon
- Gram stain with C&S; Tzanck if Herpetic Whitlow suspected; X ray
- Augmentin BID x 10 d; Surgical decompression
