Hair and Nail Disorders

Question 1

1. Onychomycosis aka?
2. Definition?
   (majority caused by what?)
3. Most common location?

Answer 1

1. (Tinea Unguium)
2. Definition: nail infections caused by ANY fungus (vast majority caused by Trichophyton rubrum)
   - Most of the time, due to dermatophytes
3. Most common location is the distal subungual region

Seldom are all nails affected, toenails much more common than fingernails

Question 2

Onychomycosis
Very little data on risk factors
(most important?)
7

Answer 2

1. Older age
2. ***Diabetes
3. Swimming
4. Tinea pedis
5. Psoriasis
6. Immunodeficiency
7. Living with family members who have onychomycosis

Question 3

1. Onychomycosis
   Presentation? 3
2. Describe what the nail will look like?
3. Most common concerns? 2

Answer 3

1. Presentation
   - Brittle
   - Lusterless
   - Hypertrophic
2. Begins with whitish, yellowish, or brownish discoloration in one region of the nail and gradually spreads to involve the entire width of the nail plate
   Nail plate then starts to break away or is picked away by the patient
3. • Mostly cosmetic concern only
   • Can cause physical discomfort for some

Question 4

Onychomycosis
Dx? 3
(First test? most sensitive test?)

Answer 4

1. KOH examination if able to obtain scrapings**
2. Nail culture (often performed when patients have a negative KOH examination)
3. Nail plate biopsy (most sensitive test)**
   - Clip nail just distal to the nail bed, place in 10% formalin

Nail dystrophies are often clinically indistinguishable from onychomycosis and occur frequently. Nail dystrophies can occur with psoriasis, eczematous conditions, senile ischemia, trauma, and lichen planus
Studies have found that onychomycosis is responsible for only 50-60% of abnormal appearing nails (Make the diagnosis before treating!)

Question 5

Onychomycosis: How long does a culture usually take?

What kind of medium do you use?

Answer 5

Traditional culture takes 4-6 weeks

Dermatophyte Test Medium (DTM)

Question 6

Onychomycosis
Treatment is recommended in the following groups?
4

Answer 6

1. Patients with history of cellulitis of the LE who have ipsilateral toenail onychomycosis
2. Patients with diabetes who have additional risk factors for cellulitis (i.e. prior cellulitis, venous insufficiency, peripheral artery disease, edema)
3. Patients with discomfort and/or pain
4. Patients who desire treatment for cosmetic reasons

Question 7

Onychomycosis Treatment

1. DOC?
2. Alternatives? 3

Answer 7

1. Oral Terbinafine (Lamisil) (treatment success around 75%) is the treatment of choice as it has greater efficacy and fewer side effects than alternative oral regimens.
2. Alternative oral medications include
   - Itraconazole (Sporanox),
   - Griseofulvin, and
   - Fluconazole (Diflucan)

Question 8

Onychomycosis treatment length:

1. Fingernails?
2. Toenails?

Treatment monitoring

3. Can cause what complications? 3
4. So monitor what?
5. Cannot use with what??
6. Describe the Recurrence rate?

Answer 8

Treatment is anywhere from:

1. Fingernails: 1½ -3 months
2. Toenails: 3-12 months

Treatment monitoring

3. Can cause increased
   - LFTs,
   - hepatotoxicity,
   - hepatic failure
4. Many providers will also assess LFTs during the course of treatment
5. Cannot be used with statins!
6. Recurrence rate is 20-50%
   * **There is a high rate of treatment failure and recurrence with oral therapy

Question 9

Digit Tip Infections? 3

Answer 9

1. Paronychia
2. Herpetic Whitlow
3. Felon

Question 10

1. What is Paronychia?
2. Usually what bug?
3. Treatment? 3
4. What is the most important thing you need to do for dx?

Answer 10

1. Infection around a fingernail
2. Usually caused by Staph. aureus
3. Treatment
   - Antibiotics and
   - warm soaks for mild, well-localized cases
   - May require I&D in more serious cases
4. What’s most important?
   The most important thing is to differentiate a paronychia from a felon.

Question 11

1. What is a felon?
2. What will it look like? 3
3. What is the biggest complication with felon?
4. Treatment? 3

Answer 11

1. Pulp space infection
   - Infection in a closed compartment comprising the pulp space of the tip of the digit
2. • swollen,
   • exquisitely tender, and
   • erythematous
3. ***The edema due to a felon can compromise arterial supply and lead to necrosis of the fingertip
4. treatment includes
   - I&D,
   - antibiotics, and
   - referral to hand surgeon for definitive treatmen

Question 12

1. What is Herpetic Whitlow?
2. Commonly seen in who? 2
3. Usually on how many fingers?
4. Treatment?
   (if immunocompromised?)

Answer 12

1. Herpetic infection by inoculation of the virus in the cuticle region
2. Commonly seen in
   - children and
   - healthcare workers
3. Usually one finger
4. Treatment
   -Usually a self-limited disease
   (Oral Acyclovir….particularly if immunocompromised. NOT TOPICAL)

Question 13

1. What is Onychocryptosis (Ingrown nail)?
2. Presentation? 4
3. Predisposing factors? (most important) 3

Answer 13

1. Lateral nail plate pierces the lateral nail fold and enters the dermis
2. Presentation:
   - Pain,
   - edema,
   - exudate, and
   - granulation tissue
3. Predisposing factors:
   - ***Poorly fitting shoes
   - Excessive trimming of the lateral nail plate
   - Trauma

Question 14

Ingrown Toenail Treatment:

1. Mild to Moderate? 2
2. Moderate to severe? 1
3. If infected?

Answer 14

1. Mild to moderate?
   - Cotton wedging or dental floss underneath the lateral nail plate to separate the nail plate from the lateral nail fold, thereby relieving pressure
   - Soak the affected foot in warm water for 20 minutes, three times per day, pushing the lateral nail fold away from the nail plate.
2. Moderate to severe?
   -Often needs removal
   (You can do this….but consider referral to podiatry if complicated)
3. May need antibiotics if infected

Question 15

What kind of Local Anesthesia after Prepping Toe for Onychocryptosis?

Treat with what to destroy the matrix?

Answer 15

2% xylocaine without epinephrine

phenol

Question 16

What is Onychogryphosis?

Answer 16

deformed, curved nail)

Question 17

1. What is Alopecia?

2. What are the different kinds? 4

Answer 17

Definition: loss of hair in areas where it normally grows

1. Androgenic alopecia
2. Alopecia areata
3. Telogen effluvium
4. Trichotillomania

Question 18

1. Androgenic Alopecia what is?
2. Begins where and progresses where?
3. Three main factors? 4

Answer 18

1. Symmetrical hair loss
2. Begins in the fronto-parietal scalp with progressive recession
3. Three main factors
   - Genetic predisposition
   - Hormonal activity
   - Age
   - Gender…more common in men

Question 19

Androgenic Alopecia

1. Reversible?
2. What inhibits growth of scalp hair (also stimulates the growth of facial hair)?
3. *Male-pattern hair loss in women suggests what?

Answer 19

1. Permanent
2. Dihydrotestosterone (DHT)
3. androgen excess

Question 20

Androgenic Alopecia

1. Treatment?
   - How long do you need to use it?
   - When will effects be seen?
2. Second line?
   - Works best in who?
   - Requires what kind of treatment?
   - Persists only as long as what?

Answer 20

1. Finasteride (Propecia) 1mg QD
   - Continued use necessary to sustain regrowth
   - Effects may not be seen until 6 mos or more of use
2. Topical Minoxidil (Rogaine) 5% soln OTC
   - Works better in younger men who have been balding for less than 10 years
   - Requires 6 mos of treatment before hair growth becomes apparent
   - Persists only as long as b.i.d. applications continued

Question 21

1. Finasteride (Propecia) 1mg QD MOA?

Answer 21

1. 5-alpha-reductase inhibitor…blocks conversion of testosterone to DHT

Question 22

1. Alopecia Areata is caused by what?
2. Describe the type of hairloss?
3. Short hairs broken off a few millimeters from the scalp are found only where?

Answer 22

1. Thought to be an autoimmune process directed against the hair follicle
2. Rapid hair loss in distinct, well-defined round or oval patches of COMPLETE hair loss (this is not just thinning of the hair)
3. at the edges of expanding patches

Question 23

Alopecia Areata
1. Assciated with other autoimmune diseases including what? 4

2. Clinical course is variable
   Describe the ways it can present? 3

Answer 23

1. Associated with other autoimmune diseases including
   - vitiligo,
   - Hashimoto’s thyroiditis*
   - Addison’s disease, and
   - pernicious anemia**
2. • May have one episode followed by spontaneous regrowth
   • May progress to Alopecia totalis (loss of all scalp hair) or
   • Alopecia universalis (complete loss of scalp and body hair)

Question 24

Alopecia Areata
Treatment?
4

(second line?) 2

Answer 24

1. Up to 80% of patients with alopecia areata that is limited and of less than 1 year’s duration may expect spontaneous regrowth of hair.
2. Intralesional steroids (best for isolated patches)
3. Potent Topical steroids (isolated patches)
4. Topical immunotherapy (extensive >50% hairloss)

2nd line: Minoxidil, Anthralin

Question 25

Alopecia Areata
Make sure to differentiate from another cause of balding such as what? 2

Consider screening for what?

Answer 25

1. irritant or
2. tinea capitis
3. Consider screening for thyroid disease and pernicious anemia as well as any other autoimmune diseases suggested by history and physical

Question 26

1. What is Telogen Effluvium?
2. Latency period of what?
3. Risk factors? 5
4. Treatment?

Answer 26

1. Alteration of the normal hair cycle
   - Thinning/shedding of hair resulting from the early entry of hairs into the telogen phase
2. Latency period of 3-4 months
3. Risk factors
   - Stress
   - Postpartum
   - Malnutrition
   - Crash dieting
   - Metabolic changes
4. No treatment

Question 27

What kind of metabolic changes that could cause telogen effluvium? 4

Answer 27

1. TSH,
2. ferritin,
3. CBC,
4. CMP

Question 28

1. What is Trichotillomania?
2. Presents how?
3. What specifically could tip us off to this?
4. Treatment? 2

Answer 28

1. Impulse control disorder
2. Irregular, short growth hairs
3. Unilateral to patient’s dominant hand
4. Treatment
   - SSRI
   - Cognitive therapy