HAIR & NAIL DISORDERS

Question 1

tinea unguium

Answer 1

onychomycosis

Question 2

all tineas (except for versicolor) = caused by what fungus

Answer 2

trichophyton

almost always caused by dermatophytes

Question 3

most common locations for onychomycosis

Answer 3

distal subungual region

Question 4

RISK FACTORS FOR ONYCHOMYCOSIS

Answer 4

⦁	DIABETES**
⦁	older age
⦁	swimming
⦁	tinea pedis
⦁	psoriasis
⦁	immunodeficiency
⦁	living with family members who have onychomycosis

Question 5

CLINICAL PRESENTATION OF ONYCHOMYCOSIS

Answer 5

• brittle
• lusterless
• hypertrophic

Begins with whitish, yellowish or brownish discoloration in one region of the nail, then 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
⦁ mostly cosmetic concern, but can cause physical discomfort for some

Question 6

DIAGNOSIS OF ONYCHOMYCOSIS

Answer 6

• nail dystrophies often clinically indistinguishable from onychomycosis
• nail dystrophies can occur with psoriasis, eczematous conditions, senile ischemia, trauma and lichen planus
• onychomycosis = responsible for only 50-60% of abnormal appearing nails, so HAVE to make the diagnosis before treating

⦁ KOH prep
⦁ nail culture
⦁ Nail plate Biopsy

Question 7

onychomycosis is often clinically indistinguishable from

Answer 7

nail dystrophy

Question 8

nail dystrophies can occur with

Answer 8

psoriasis, eczematous conditions, senile ischemia, trauma and lichen planus

Question 9

most sensitive test for diagnosis of onychomycosis

Answer 9

⦁ Nail plate Biopsy

Question 10

who should get treatment for onychomycosis

Answer 10

⦁ patients with hx of cellulitis of the LE who have an ipsilateral toenail onychomycosis
⦁ patients with diabetes who have additional risk factors for cellulitis (prior cellulitis, venous insufficiency, PAD, edema)
⦁ patients with discomfort or pain
⦁ patients who desire tx for cosmetic reasons

• onychomycosis can trigger cellulitis

Question 11

terbinafine for onychomycosis = CANNOT BE USED WITH

Answer 11

STATINS

Question 12

TREATMENT FOR ONYCHOMYCOSIS

Answer 12

• topical therapies = generally ineffective - unable to penetrate nail plate
• there is a high rate of treatment failure & recurrence even with oral therapy

⦁ Oral Terbinafine (Lamisil) - success = about 75% = treatment of choice - has greater efficacy and fewer SE than alternative oral regimens

⦁ Alternatives = Itraconazole (Sporanox), Griseofulvin, and Fluconazole (Diflucan)

**Careful with the liver - no alcohol!
and don’t take with a statin - will make LFTs skyrocket

Treatment Monitoring

• can cause increased LFTs, hepatotoxicity, hepatic failure
• assess LFTs prior and during course of treatment
• CANNOT USE WITH STATINS***

recurrence rate = 20-50%; high rate of treatment failure & recurrence with oral therapy

Question 13

digit tip infections =

Answer 13

paronychia = infection around the nail

Question 14

DIGIT TIP INFECTIONS ARE USUALLY CAUSED BY

Answer 14

STAPH AUREUS

Question 15

paronychia treatment

Answer 15

• antibiotics
• warm soaks for mild, well-localized cases
• may require I&D in more serious cases

Question 16

pulp space infection in a CLOSED COMPARTMENT - comprising the pulp space of the tip of the digit
- swollen, exquisitely tender, erythematous

Answer 16

FELON

Question 17

paronychia vs felon

Answer 17

paronychia = just around nail bed

felon = whole finger is swollen / red / tender

Question 18

herpetic infection in cuticle region = herpes infection of the finger

Answer 18

herpetic whitlow

Question 19

HERPETIC WHITLOW

Answer 19

herpetic infection in cuticle region = herpes infection of the finger; is very infectious / contagious

• commonly seen in children & healthcare workers
• dewdrop on rose petal - usually only on one finger
• difference between whitlow & paronychia = paronychia is right around the nail

Question 20

HERPETIC WHITLOW TREATMENT

Answer 20

oral acyclovir, particularly if immunocompromised; (topical acyclovir not shown to be effective)

no point in treating past 72 hours; self-limited disease

Question 21

the lateral nail plate pierces the lateral nail fold and enters the dermis

Answer 21

ONYCHOCRYPTOSIS

Question 22

PRESENTATION OF ONYCHOCRYPTOSIS

Answer 22

• pain
• edema
• exudate
• granulation tissue

Question 23

PREDISPOSING FACTORS FOR ONYCHOCRYPTOSIS

Answer 23

⦁ poorly fitting shoes***
⦁ excessive trimming of lateral nail plate
⦁ trauma

Question 24

after removing nail, treat with

Answer 24

treat with PHENOL to destroy matrix - nail will never grow there again

Question 25

nail grows curved rather than laterally

Answer 25

onychogryphosis

Question 26

loss of hair in areas where it usually grows

Answer 26

ALOPECIA

Question 27

TYPES OF ALOPECIA

Answer 27

Androgenic alopecia Alopecia areata Telogen effluvium Trichotillomania

Question 28

androgenic alopecia begins in the

Answer 28

begins in fronto-parietal scalp --> progressive recession

Question 29

4 main risk factors for androgenic alopecia

Answer 29

⦁ genetic predisposition ⦁ hormonal activity ⦁ age ⦁ gender - more common in men

Question 30

androgenic alopecia

Answer 30

The hair loss is permanent - Dihydrotestosterone (DHT) inhibits the growth of scalp hair (also stimualtes the growth of facial hair); have loss of scalp hair, but stimulates hair growth in other locations - Male-pattern hair loss in women suggests androgen excess (PCOS, hirsutism, etc)

Question 31

_______________ inhibits the growth of scalp hair (also stimualtes the growth of facial hair); have loss of scalp hair, but stimulates hair growth in other locations

Answer 31

Dihydrotestosterone

Question 32

Male-pattern hair loss in women suggests

Answer 32

androgen excess

Question 33

treatment for androgenic alopecia

Answer 33

⦁ Finasteride (Propecia) = 5-alpha reductase inhibitor - blocks the conversion of testosterone to Dihydrotestosterone (also known as Proscar in greater doses - used for BPH) - continued use is necessary for sustained growth - effects may not be seen until 6+ months of use ⦁ Minoxidil (Rogaine) = 5% solution - OTC - works better in younger men who have been balding for < 10 years - requires 6 months of treatment before hair growth becomes apparent - persists only as long as BID applications are continued

Question 34

autoimmune process in which the body is attacking the hair follicles

Answer 34

alopecia areata COMPLETE hair loss, not just thinning of the hair rapid

Question 35

ALOPECIA AREATA

Answer 35

- thought to be an AUTOIMMUNE process - directed against the hair follicle - have rapid hair loss in distinct, well-defined round or oval patches of COMPLETE hair loss (not just thinning of the hair) - the body is attacking hair follicles - can see short hairs broken off a few mm from the scalp at the edges of expanding patches

Question 36

***Alopecia areata is associated with other autoimmune conditions

Answer 36

⦁ Vitiligo ⦁ Hashimoto's thyroiditis ⦁ Pernicious anemia ⦁ Addison's disease

Question 37

clinical course of alopecia areata

Answer 37

- clinical course is variable; may have 1 episode followed by spontaneous regrowth, however, may also progress to Alopecia Totalis (loss of all scalp hair) or Alopecia Universalis (complete loss of scalp & body hair)

Question 38

treatment for alopecia areata

Answer 38

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. Intralesional steroids (best for isolated patches) Potent Topical steroids (isolated patches) Topical immunotherapy (extensive >50% hairloss) 2nd line: Minoxidil, Anthralin

Question 39

- alteration of the normal hair cycle | - thinning / shedding of hair resulting from the early entry of hairs into the telogen phase (resting phase)

Answer 39

telogen effluvium

Question 40

risk factors for telogen effluvium

Answer 40

``` ⦁ stress ⦁ postpartum ⦁ malnutrition (anorexia) ⦁ crash dieting ⦁ metabolic changes (TSH, ferritin, CBC, CMP) ```

Question 41

- impulse control disorder - pull hair out

Answer 41

trichotillomania

Question 42

Trichotillomania

Answer 42

- impulse control disorder - pull hair out ⦁ irregular, short growth hairs ⦁ unilateral to patient's dominant hair

Question 43

Trichotillomania treatment

Answer 43

SSRIs | Cognitive behavioral therapy