Hair and Digit Tip Disorders - Exam 2 Flashcards
What is the normal cycle of hair growth?
cycles of intermittent activity
Phases of growth are followed by periods of inactivity and then expulsion
What are the 4 phases of hair growth? Give a brief description of each
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
What determines the ultimate length of hair? Give the lengths for the following types of body hair: scalp, legs, arms, eyelashes
Duration and rate of growth of anagen phase
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 hair
What am I?
vellus hair
What am I?
lanugo
How you do evaluate hair loss? What are normal and abnormal results?
gently pull scalp
Normal: 3 - 5 hairs are dislodged
Abnormal: > 5 hair suggest pathology
When should you do a scalp biopsy?
Scraping or shave biopsy to offer insight into pathogenesis
What is the goal of a trichogram? How do you perform it? What are the difference between anagen and telogen hairs?
determine the anagen to telogen ratio
Performed by epilating (plucking) 50 hairs or more from scalp
Anagen hairs - growing hairs with a long encircling hair sheath.
Telogen hairs - resting hairs with an inner root sheath and roots usually largest at the base.
What is a normal result for a trichogram?
80-90% of hairs are anagen
_____ is hair loss. What is the most common form?
Alopecia -> comes in a variety of patterns and causes
androgenic alopecia
What is androgenic alopecia? What is happening ? Usually _____ predisposition due to ______ effect on the hair follicle
Male and female pattern baldness
Gradual conversion of terminal hairs into indeterminate vs vellus hairs
genetic predisposition due to ANDROGEN effect on hair follicles
What is the classification system for female pattern hair loss? What age?
ludwig
Women - MC after 50
What is the male pattern hair loss classification system? What age? What ethnicity?
hamilton
Men - after puberty (early as 20’s)
Typically fully expressed by 40
Incidence is highest in white men, followed by black & Asian men
In androgenic alopecia, _____ causes terminal follicles to transform into vellus like hair follicles. What happens during successive follicular cycles?
DHT
hairs produced are shorter lengths and of decreased diameter
What is appreciated on PE in androgenic alopecia? What are some additional findings in women?
gradual thinning noted and typically everything else is normal
women: increased androgen, acne, hirsutism, irregular menses
What will the bx show of a pt with androgen alopecia? What will the trichogram show?
Will see telogen phase follicles & atrophic follicles
^ telogen hairs
What are some treatable causes of androgen alopecia? What is the tx? What is the pt education?
Thyroid
Anemia
Autoimmune
Minoxidil (Rogaine) 2% or 5% solution BID
warn about hair loss
What is the PO tx for androgenic alopecia in men only? What is the MOA? When can they expect to see results?
Finasteride 1mg PO daily
MOA: Inhibits testo to DHT
Slows hair loss in 3 months, regrowth in 6 months
What is the PO tx for androgenic alopecia in women? What is the MOA?
Spironolactone 50-100 mg QD
blocks action of DHT
______ localized loss of hair in round or oval areas with no apparent inflammation of the skin. What is the underlying condition?
Alopecia Areata
T cell mediated autoimmune disorder that does NOT scar and may/may not involve the nails
_____ is the MC for of hair loss in children
and those <25 yo
Alopecia Areata
What am I?
This there a genetic component?
alopecia areata
YES! usually a family hx
stress might be a contributing factor
What is the pathology behind alopecia areata? What does it lead to? Does it scar?
damage to hair follicle in anagen stage
Leads to rapid transformation to catagen and telogen = dystrophic
Active = cannot progress beyond anagen
NOT scarring
patchy hair loss over weeks to months
oval/round with defined borders
bald patches with normal skin
no scarring
What am I?
What are the top 4 MC areas?
Alopecia Areata
Scalp
Beard
Eyebrows
Extremities
_____ are usually seen on dermoscopy with alopecia areata. What does it mean?
“black dots”
hair breaks before reaching the surface
What are exclamation hairs? What dx are they associated with?
Blunt distal end and taper proximally
Appear when broken hair (black dots) are pushed out of the follicle
What are the 5 different 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.
_____ Solitary or multiple areas of hair loss
Alopecia areata (AA)
_____ Total loss of terminal scalp hair
AA totalis (AAT)
______ Total loss of all terminal body and scalp hair
AA universalis (AAU)
_____ Bandlike pattern of hair loss over periphery of scalp.
ophiasis
_____ Fine pitting (“hammered brass”) of dorsal nail plate.
nails alopecia areata
What are approperiate tests to order when trying to confirm dx of alopecia areata?
Biopsy
RPR – syphilis
KOH – fungal
ANA – autoimmune
Thyroid Panel – endocrine
What is the tx goal for alopecia areata? What is the prognosis for alopecia areata?
NO CURE!! goal is to decrease inflammation and reduce growth inhibitors
spontaneous remission
but if it occurs after puberty likely 80% remission with recurrence
What are poor prognosis factors for alopecia areata?
Childhood onset
Body hair involvement
Nail
Atopy
Family hx
What are the tx options for alopecia areata?
class 1 or 2 topical steroids WITH minoxidil
ILK
oral predinisone 20-40mg daily and then taper by 5mg
minoxidil 5% solo
anthralin cream: kids only
_____ is used in kids with alopecia areata and is a _____ agent. When can they start seeing results? Should avoid use on ______
Anthralin
keratolytic agents
Hair regrowth = 2-3 months
avoid face
What am I? What does it result from?
keratosis pilaris
A common condition resulting from hyperkeratinization of the skin and keratotic follicular plugging
How common is keratosis pilaris? Is there a genetic component?
Affects nearly 50-80% of all adolescents and approximately 40% of adults
Genetic predisposition with 30-50% having a positive family history
______ is an excess formation and/or buildup of keratin leads to the abrasive goose-bump texture of the skin. When does it get better and worse?
Keratosis Pilaris
worse in winter and improves in summer
What are the 2 patterns of onset for keratosis pilaris? What areas of the body do each affect? When do each start to improve?
early childhood and adolescence
early childhood:
face and arms
Gradual improvement in later childhood or adolescence
adolescence:
Affects the extensor arms and legs
Improves by the mid-20s
What am I? What is it often referred to as? What will the pt complain of?
keratosis pilaris
Referred to as chicken/goose bumps or chicken/goose skin
Often asymptomatic with occasional pruritus, (+/-) Erythema if associated inflammation
What size are keratosis pilaris? Where are the 2 MC locations?
Small 1-2 mm rough papules scattered over the affected area
Upper outer arm and thighs - MC
How do you dx keratosis pilaris?
usually clinical
can bx if presentation is atypical
What is the tx for keratosis pilaris? What is inflammation present?
mild gentle soap (dove)
unscented moisturizer 2-3 times a day
inflammation: steroid cream
keratolysis: Salicylic acid, topical urea, topical retinoids
_____ is a prescription moisturizer lotion, a lactic acid lotion - provides moisture and gentle exfoliation; use BID. What dx?
Lac-Hydrin
Keratosis Pilaris
_____ is nail grows into one side or both of the paronychium or nail bed. What is the MC pt population?
Onychocryptosis
males in their 20’s
What is the pathology behind Onychocryptosis?
impingement of the nail into the dermal tissue distally or into the distolateral nail groove that causes inflammation, erythema, edema, purulence and granulation tissue
What are risk factors for onychocryptosis?
Shoes
Sweating
Genetics
Dystrophy
Fungus
Improper cutting
Neuropathy/diabetes
What digit is onychocryptosis the worst on? What makes it worse?
MC on great toe
movement or pressure
What are complications of Onychocryptosis?
Paronychia
Cellulitis
Osteomyelitis
Bacteremia
Sepsis
What is the tx for onychocryptosis?
What should you do after the onychocryptosis procedure? When can you resume normal activity?
After procedure
Keep clean with normal soap and water
Antibacterial is best
Mupirocin (antibiotic ointment)
Resume activity after 48-72 hours
What is onychomycosis? Where is it MC? What is the underlying cause?
tinea unguium
fungus of the nail
MC on the toes
trichophyton rubrum
In onychomycosis, how does the fungus invade the nail? What is the MC complaint?
via the hyponychium
The hyponychium is the thin layer of skin located beneath the free edge of the nail plate, at the tip of the finger or toe
discoloration! but usually asymptomatic with thickening and lifting of the nail from the bed
What are risk factors for onychomycosis?
Family History
Old age
Poor health
Trauma
Climate
Fitness
Immunosuppression
Communal bathing
Footwear
If there is any discoloration of the nail/toenail, what needs to be ruled out?
need to rule out melanoma!!
What is the w/u for onychomycosis? What should you NOT do before?
nail clipping or scraping -> send off for bx
scrap from under the nail -> KOH prep
no antifungals for 2 weeks prior to sample
What is the tx for onychomycosis? What is the home remedy?
Topical or oral antifungal
Ciclopirox (Penlac)
Efinaconazole (Jublia)
home:
50/50 apple cider vinegar and water
10 minutes a day soaks
What is the strong antifugal used in onychomycosis? How long do you use it in fingers? toes? What is the associated monitoring?
Terbinafine (Lamisil)
6 weeks for fingers
12 weeks for toes
CBC and LFT’s @ baseline and then monthly
very hard on your liver
**What is the pt education for onychomycosis?
**may take up to a year for nail to completely grow out therefore discoloration may still be present
What is onycholysis? What are the 3 categories?
Detachment from the nail bed
primary, trauma or secondary
What is considered primary onycholysis?
idiopathic or fake fingernails in women that pull real nail away from bed
What are some secondary causes of onycholysis?
contact derm, HSV, onychomycosis, psoriasis, nail bed tumors
What will onycholysis look like on PE? How do you dx?
Whitish or opaque discoloration
gray-black = air
green = bacteria
NO inflammation and nail will be smooth
dx is clinical
What is the tx for onycholysis?
eliminate the cause of why the nail is lifting
What is paronychia? What does it begin as? What does it progress to?
Inflammation of the proximal or lateral nail fold
Begins as cellulitis and progresses to abscess
What is the MC cause of paronychia? What is the MC pathogen? What does green discharge indicate?
trauma that leads to secondary bacterial infection
staph
green = pseudomonas
What are risk factors for paronychia?
Nail biting
Sucking
Trauma
Chemical irritants
Nail glue
Sculpted nails
Frequent hand washing
What diagnostic tests should you order for acute paronychia?
can order:
gram stain
C&S
KOH
Tzank: for Herpetic whitlow
xray
What is the tx for acute paronychia?
Warm soaks 3-4x daily until resolution may need abx for cellulitis
What is the abx of choice for acute paronychia?
Augmentin 500mg-> first choice
clinda or keflex
When should you consult a hand surgeon for acute paronychia?
Significant cellulitis or lymphangitis
Tenosynovitis
Deep space infection
Osteomyelitis
What are causes of chronic paronychia? What will it present like? For how long?
Fungal/mechanical/chemical
From repeat exposure
Inflammation waxes and wanes
Pain
Swelling and erythema
+/- thickening or discoloration
Usually x 6 weeks
What is the tx for chronic paronychia?
avoid risk factors
keep dry and avoid manipulation
warm antiseptic soaks -> then dry
topical antifungals if necessary
What am I? What causes it? Where is it found? What is the incubation?
herpetic whitlow
MC: HSV
found on the distal finger
2-14 day incubation
herpetic whitlow HSV 1 is found in what population? What are the 2 risk factors?
MC in children, gingivostomatitis
risk factors: sucking thumb or finger
herpetic whitlow HSV 2 is found in what population? What is the risk factors?
adults
healthcare workers
What will happen in herpetic whitlow before the pt physically has the lesion? ____ is used to dx
Burning
Pruritus
tender
swelling
induration
Tzanck can help dx
What is the tx for herpetic whitlow lesion? What should you NOT do?
self limiting in about 3 weeks
CONTAGIOUS!!
Acyclovir
Valacyclovir
DO NOT I&D
What am I?
herpetic whitlow
What is a felon? What is it caused by? What 3 things are likely in the pt’s history?
Soft tissue infection of pulp space of distal phalanx
Caused by infection (created by fibrous septa passing between the skin and periosteum)
penetrating injury, splint, and paronychia
What am I? Where are the 2 MC places to see them?
felon
thumb and index finger
What are 4 complications of felon? Describe the course?
Osteitis
Osteomyelitis
Septic joint
Tenosynovitis
rapid and severe
What is the management of felon?
Augmentin
may need surgical decompression
What are splinter hemorrhages caused by?
caused by blood that is enclosed in the subungual keratin
They develop either from thrombosed or ruptured capillaries that run longitudinally in the nail bed
What am I?
Splinter hemorrhages are narrow red to almost black longitudinal lines in the distal nail bed
What are some underlying conditions that can cause splinter hemorrhages?
trauma
psoriasis
lupus
RA
antiphospholipid syndrome
bacterial endocarditis
What am I? Describe it in words
Beau lines
horizontal dents in fingernails and toenails
What causes beau’s lines?
illness/trauma or severe stress interrupts nail growth
long term health problems that interfere with blood flow to the nail
severe skin conditions that damage nail matrix
What am I? What conditions can cause it?
pitting of the nails
nail psoriasis: deep
alopecia areata: shallow
atopic derm: shallow
What am I?
terry’s nails
Terry’s nails is when most of your fingernail or toenail looks white, like frosted glass, except for a thin brown or pink strip at the tip
What are some underlying conditions that lead to terry’s nail?
can be part of the normal aging process
liver disease
CHF
DM
kidney failure
viral hepatitis
What are some underlying conditions that cause clubbing of the nails?
lung cancer
heart defects
chronic lung infects
celiac dz
cirrhosis of the liver
graves disease
overactive thyroid gland
hodgkin lymphoma
