Hair and Nail disorders

Question 1

What is onychomycosis (tinea Unguium)?

Answer 1

• nail infections caused by any fungus (MC Trichophyton rubrum): most of the time, due to dermatophytes, prevalene anywhere from 4-18% depending on age
• MC location is distal subungual region
• seldom are all nails affected, toenails much more common than fingernails

Question 2

RFs for onychomycosis?

Answer 2

very little data on RFs

• older age
• diabetes***
• swimming
• Tinea pedis
• Psoriasis
• immunodeficiency
• living with family members who have onychomycosis

Question 3

Presentation of onychomycosis?

Answer 3

• brittle, lusterless and hypetrophic nails
• begins with whitish, yellowish, or brownish discoloration in one region of the nail and gradually spreads to involve entire width of nail plate - the nail plate than starts to break away or is picked away by the pt
• This is mostly a cosmetic concern but it may cause physical discomfort for some

Question 4

What should be in ddx of Onychomycosis?

Answer 4

• 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, subungual squamous cell carcinoma
• studies have found that onychomycosis is responsible for only 50-60% of abnormal appearing nails (so make the dx b/f tx)

Question 5

Dx onychomycosis?

Answer 5

• • can help make dx by getting KOH (if able to obtain scrapings)
• nail culture - if negative KOH - can take up to 4-6 wks
• nail plate bx (most sensitive test) - clip nail just distal to nail bed, place in 10% formalin

Question 6

recommneded groups for Tx of onychomycosis?

Answer 6

recommended in the following groups:

• pts w/ hx of cellulitis of LE who have ipsilateral toenail onychomycosis
• pts w/ diabetes who have additional risk factors for cellulitis (ex prior cellulits, venous insufficiency, PAD, edema)
• pts with discomfort and/or pain
• pts who desire tx for cosmetic reasons

Question 7

is topical therapy effective for onychomycosis? How effective is oral therapy?

Answer 7

• topical therapies generally ineffective - unable to penetrate nail plate
• there is a high rate of tx failure and recurrence even with oral therapy
• oral terbinafine (lamisil) tx success 75%, TOC b/c greater efficacy and fewer SEs than other tx
• alt oral meds: itraconazole, griseofulvin, and fluconazole

Question 8

Duration of tx for onychomycosis? Montioring? Can’t be used with what drug? Recurrence rate?

Answer 8

• tx:
  fingernails - 1.5-3 months
  toenails - 3-12 months
• tx monitoring:
  can cause elev LFTs, hepatotoxicity, hepatic failure, many providers also will assess LFTs during tx
• CAN’T be used with STATINs
• recurrence rate: 20-50%, there is high rate of tx failure and recurrence with oral therapy

Question 9

What is paronychia? Tx? Have to diff it from what?

Answer 9

• infection around fingernail
• usually caused by staph aureus
• tx:
  abx and warm soaks for mild, well-localized cases
  may reqr I&D in more serious cases
• Have to diff it from a felon

Question 10

What is a felon? Presentation? Complication? Tx?

Answer 10

• pulp space infection (infection in a closed compartment comprising the pulp space of tip of the digit)
• swollen, really tender, erythematous
• the edema due to felon can compromise arterial supply and lead to necrosis of fingertip
• tx: I&D, abx, and referral to hand surgeon for definitive tx

Question 11

What is a herpetic whitlow? Commonly seen in what pop? Tx?

Answer 11

• herpetic infection by inoculation of virus in cuticle region
• commonly seen in kids and healthcare workers (dentists)
• usually one finger - tingle sensation, viral sxs - may be febrile

tx

• usually self-limiting
• topical acyclovir not effective
• oral acyclovir - esp if immunocompromised

Question 12

What is a onychocryptosis? Presentation? Predisposing factors?

Answer 12

• lateral nail plate pierces the lateral nail fold and enters the dermis
• presentation: pain, edema, exudate, and granulation tissue
• predisposing factors:
  **poorly fitting shoes
  excessive trimming of lateral nail plate, trauma

Question 13

Tx of ingrown toenail depending on severity?

Answer 13

mild to mod:

• cotton wedging or dental floss underneath the lateral nail plate from lateral nail fold, thereby relieving pressure, soak the affected foot in warm water for 20 min, 3x a day, pushing the lateral nail fold away from the nail plate
• moderate to severe: often needs removal (you got this!) - use 2% xylocaine w/o epi, cut and remove nail adjacent to ingrown segment and tx with phenol to destroy matrix
• may need abx if infected

Question 14

What is an onychogryphosis?

Answer 14

• deformed, curved nail

Question 15

What is alopecia? diff types?

Answer 15

• loss of hair in areas where it normally grows
• adrogenic alopecia
• alopecia areata
• telogen effluvium
• trichotillomania

Question 16

What is androgenic alopecia? 4 main factors?

What inhibits growth of scalp hair?

Answer 16

• symmetrical hair loss (male pattern baldness)
• begins in fronto-parietal scalp with progressive recession
• 4 main factors:
  genetic predisposition
  hormonal activity
  age
  gender (more common in men - obvi!)
• Hair loss is permanent
• dihydrotestosterone (DHT) inhibits scalp hair growth (and stim. growth of facial hair)

Question 17

What does male pattern hair loss in women suggest?

Answer 17

• androgen excess

Question 18

Tx of androgenic alopecia?

Answer 18

• finasteride (propecia) 1 mg QD: 5-alpha-reductase inhibitor: blocks conversion of testosterone to DHT (also goes by Proscar at higher dose - used for BPH).
  Cont. use necessary to sustain regrowth.
  Effects may not be seen until 6 mos or more of use
• topical minoxidil (rogaine): 5% soln OTC - works better in younger men who have been balding for less than 10 yrs, reqrs 6 mos of tx b/f hair growth becomes apparent
• persists only as long as bid applications cont.

Question 19

What is alopecia aerate?

Answer 19

• thought to be an autoimmune process directed against the hair follicle
• rapid hair loss is distinct, well defined round or oval patches of complete hair loss (not just thinning of hair)
• short hairs broken off a few mm from scalp found only at edges of expanding patches

Question 20

What autoimmune disesases is alopecia areata assoc with? Clinical course of alopecia areata?

Answer 20

• assoc with vitiligo, hasimoto’s thyroiditis, addison’s, pernicious anemia
• clinical course is variable:
  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 21

Tx of alopecia areata?

Answer 21

• up to 80% of pts will have limited alopecia, and in less than a yr may expect spontaneous regrowth of hair
• intralesional steroids (best for isolated patches)
• potent topical steroids (isolated patches)
• topical immunotherapy (if extensive alopecia, over 50%)
• 2nd line: minoxidil, anthralin

Question 22

What should you consider screening for if pt has alopecia areata? What other cause of balding should be in your differential?

Answer 22

• other cause: tinea capitis or irritant

- screen for thyroid disease and pernicious anemia, and any other autoimmune disease suggested by H&P

Question 23

What is telogen effluvium? RFs? Tx?

Answer 23

alteration of the normal hair cycle: thinning/shedding of hair resulting from early entry of hairs into telogen phase
- latency period: 3-4 months
- RFs:
stress
postpartum
malnutrition
crash dieting
metabolic changes: TSH, ferritin, CBC, CMP
- tx: tx underlying cause

Question 24

What is trichotillomania? Tx?

Answer 24

• impuse control disorder: irregular, short hairs. Unilateral to pt’s dominant hand
• tx:
  SSRI
  cognitive therapy

Question 25

What screening should be done in a pt with onychomycosis?

Answer 25

• diabetes