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Dermatology Diploma > Hair - too much or too little > Flashcards

Hair - too much or too little Flashcards

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1
Q

What are the 3 types of hair?

A
  • Lanugo hairs - soft hairs of the foetus. Shed by 4 months.
  • Vellus hairs are fine, soft, non-pigmented hairs usually found covering the apparently hairless areas of the body.
  • Terminal hairs are coarser, longer, pigmented hairs making up the eyebrows, eyelashes, scalp hair, pubic and axillary hair in men and women and much of the body and facial hair in men.
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2
Q

What are the 3 phases of hair growth?

A
  1. Anagen - active growth phase. 90% of hairs are in this.
  2. Catagen - Involutional stage.
  3. Telogen - resting and shedding phase. 5-8% of hairs.
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3
Q

How long does the anagen phase last on the scalp compared to the body?

A

2-6 years on the scalp

3-6 months on the body

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4
Q

How long does the catogen phase last on the body and scalp?

A

2-3 weeks

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5
Q

How long does the telogen phase last on the body and scalp?

A

3-4 month

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6
Q

What is the major class of hormone that affects hair growth?

What other hormones affect it?

A

Androgens

Thyroid. & Growth Hormone.

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7
Q

Why do androgens cause less hair on the scalp and more on the body?

A

Scalp anagen phase is less

Body anagen phase is more.

5a-reductase (converting testosterone to DHT) alters skin sensitivity & androgen receptors.

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8
Q

If many follicles go into the telogen phase at the same time, what is this called?

A

Telogen Effluvium

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9
Q

What are the 3 hair types?

A
  1. Nonsexual - grows independently of steroid hormones - eyebrows, forearms, lower legs.
  2. Ambosexual: dependent on female sex hormones (pubic triangle)
  3. Male sexual hair: androgen dependent-beard, nasal tip, ears.
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10
Q

Describe the hair cycle

A
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11
Q

What does an anagen hair look like under dermatoscope?

A

It has a sock.

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12
Q

if an anagen hair is pulled from the scalp, what does this mean?

A

It is pathological.

Look for a cause.

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13
Q

If a patient comes in with hairloss, What are some important questions to ask?

A
  • Is it sudden or gradual?
    • Sudden = telogen effluviu or Alopecia areata
    • Gradual = pattern hair loss, CCCA
  • Is the scalp itchy?
    • Common in scarring alopecias
    • Not common in non-scarring alopecias - tinea capitis.
  • Do you eat meat?
    • Low ferritin can cauise alopecia
  • Do you menstruate regularly
    • PCOS can cause increased androgen.
  • Do both parents and siblings have a normal head of hair?
    • Alopecia Areata runs in families.
  • Medications - some Rx can cause hair loss.
  • What styling processes or colouring do they use?
    • Afro-hair is susceptible to heat and chemical straightening.
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14
Q

Describe the pull test

A
  • 50-60 hairs are pulled gently between thumbs and fingers.
  • Do this in multiple locations.
  • Discard broken hairs.
  • Count the number of hairs:
    • If 2 or less hairs - negative
    • If 3 or more - positive - consider telogen or anagen effluvium.
      • if 3 or more in one location - consider alopecia areata.
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15
Q

Describe the Bulging Hypothesis

A
  1. Stem cells are in the bulge area.
  2. These stems cells regenerate hair follicles, sebaceous glands and epidermis.
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16
Q

What are the causes of non-scarring alopecia?

A
  • Alopecia Areata
  • Androgenetic alopecia
  • Telogen effluvium
  • Anagen effluvium
  • Tinea capitis
  • Traumatic alopecia
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17
Q

What other autoimmune conditions is Alopecia Areata (AA) associated with?

A
  1. Vitiligo
  2. Psoriasis
  3. Thyroid disease
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18
Q

What signs or conditions are associated with worse outcome in AA?

A
  • Nail pitting
  • Pre-puberty onset
  • Other autoimmune conditions.
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19
Q

What vitamin is often low in patients with AA?

A

Vitamin D

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20
Q

What kind of hair is pathognomonic for AA?

A

Exclamation Mark Hair

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21
Q

What can patients with AA complain about before AA becomes apparent?

A

Buzzing or tingling in hair

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22
Q

What 2 particular types of AA have a bad prognosis?

A

Atop associated AA

Ophiasis (baldness at the occiput of the scalp - see photo)

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23
Q

What is the best treatment for Alopecia Areata?

A

There is no proven single effective treatment.

  1. Under 5 years - no treatment
  2. 5-10 year - minoxidil 5% BD plus elocon
  3. Over 10 years:
    1. Less than 50% involvement
      • Triamcinolone 2.5% with Minoxidil 5% BD, Dermovate.
      • Can try dithranol 1% for 1 hour plus 5% minoxidil BD.
    2. Over 50% - use of wigs.
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24
Q

For patients with less than 50% hair loss, what can you use?

A
  • Topical/Intralesional Steroids
    • 5mg/ml of Triamcinolone for scalp
    • 2.5mg.ml for eyebrows and beard areas.
    • Every 6 weeks.
    • Ensure EMLA cream on eyebrows.
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25
Q

What else can you use if you don’t have access to triamcinolone?

A
  • Diphencyprone - causes an initial dermatitis.
  • Dermovate topically at night
    • 6 weeks on the face
    • 8 weeks on the scalp
    • If using on eyebrows, use a cotton bud and for 4 weeks only.
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26
Q

What other treatments are being used but with little evidence?

A
  • Minoxidil 5%
  • Tacrolimus 1%
  • Systemic therapy - not recommended by the BDA
    • Immunosuppressives.
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27
Q

What is the scale for grading male pattern baldness (Androgenetic Alopecia)?

A
28
Q

What is the treatment for Male Pattern Hairloss?

A
  • Minoxidil
  • 5-Alpha reductase Inhibitors (Finasteride or Dutasteride) -
29
Q

Tell me about the use of 5% minoxidil in male pattern hair loss.

A
  • Regrown hair will fall out on cessation of treatment.
  • Effluvium can occur 4 weeks into treatment (temporary).
  • 9-12 months before any improvement.
  • Take it daiily for 1 year and then consider using 3 times per week.
30
Q

Tell me about the use of Finasteride in male pattern hair loss.

A
  • Its a Type 2 5a reductase inhibitor.
  • 1mg taken daily.
  • Effective in 65-70% of men.
  • Prostate cancer risk - small increase in high grade prostate cancer
    • Check PSA at baseline and then annually.
  • 2% of men will experience loss of libido or erectile dysfunction
    • This cesses on stopping the drug.
31
Q

How can you tell if a female has female pattern hair loss rather than telogen effluvium?

A

She will have gradual thinning over time in FPHL.

In telogen effluvium, it will be more sudden.

32
Q

What is the scale used to classify female pattern hair loss?

A

The Ludwig Scale

33
Q

What is the usual initial presentation in female pattern hair loss (FPHL)?

A

The Christmas Tree Pattern

34
Q

What are the treatment options for FPHL?

A
  • Minoxidil 5% foam at night may help
    • Warn of effluvium
    • Warn of risk of increased facial hair.
    • 9-12 months to see improvement.
  • Anti-Androgenic Treatment
    • Anti-Androgenic COCP - Yasmin or Dianette.
    • Spironolactone 100mg OD or Cyproterone Acetate 50mg on days 1-10 of cycle.
    • Finasteride can be helpful but the evidence is conflicting.
    • NOTE: avoid pregnancy when using these.
35
Q

In FPHL, what should you investigate?

A

Ferritin and Thyroid Disease.

36
Q

What are the main causes of Telogen Effluvium?

A
  • Illness/malnutrition, low protein levels
  • Iron deficiency/low ferritin, low serum zinc levels (although zinc deficiency rarely presents solely with hair loss- there are usually other clinical signs too such as dermatitis)
  • Thyroid, pituitary and parathyroid disease
  • Post partum
  • Drugs
  • Acute lupus
  • A combination of these factors
  • Stress
  • Seborrhoeic dermatitis or contact dermatitis
37
Q

What drugs can cause Telogen Effluvium?

A
  • NSAIDs
  • Antimalarials
  • Anticonvulsants
  • GOLD,
  • Anticoagulants,
  • Thyrostatic drugs
  • Retinoids
  • Allopurinol
  • Beta-Blockers.
38
Q

What is the pathology in Telogen Effluvium?

A
  • Normally we have 5-10% of hair in the telogen (resting phase).
  • These are lost in daily shedding of hair.
  • In Telogen Effluvium up to 30-40% of hairs are in the Telogen Phase.
39
Q

What can you notice, in terms of patterns of hair loss, in patients with Telogen Effluvium?

A

Loss of hair volume at the temples.

40
Q

What blood tests should be done if Telogen Effluvium is suspected?

A
  • Serum iron
  • Ferritin
  • Haemoglobin
  • Vitamin D
  • ANA
  • Thyroid function
41
Q

What is the treatment for Telogen Effluvium?

A
  • Hair will naturally recover by 1 year.
  • Minoxidil topically can help the patient in the meantime.
42
Q

What is this and how is it treated?

A

Tinea Capitis

  • Scrapings
  • Griseofulvin (15-20mg/kg) + Ketoconazole shampoo
  • Treat the rest of the family with Ketoconazole shampoo
  • If trichphyton species - consider Terbinafine daily for 4 weeks.
43
Q

Does Tinea Capitis?

A

It shouldn’t do.

But don’t give the patient false hope that the hair will all come back.

44
Q

What is this and how is it managed?

A

Trichotillosis (it is a form of traumatic alopecia)

  • Due to psychological issues or habits.
  • Managed between psychiatrist and dermatologist.
45
Q

What are 2 useful signs for diagnosing trichotillosis?

A
  1. Preservation of hairs at the periphery
  2. Dermoscopy - look for plucked or broken hairs within areas of alopecia.
46
Q

What is an option for treatment for patients with trichotillosis?

A

N-Acetyl Cysteine - 500mg BD and up to 4000mg Daily.

47
Q

What is this?

A

Traction Alopecia

48
Q

What are the primary causes of scarring alopecia?

A
  • Lichen Planopilaris(LLP)/Frontal Fibrosing Alopecia (FFA)
  • Discoid Lupus Erythemastosus
  • Folliculitis decalvans
  • Dissecting Cellulitis of the Scalp
  • Central Centrifugal Cicatricial Alopecia (CCCA)
49
Q

Describe the features of Lichen Planopilaris (LPP)/Frontal Fibrosing Alopecia (FFA)?

A
  • Tender scalp with Erythema and scaling.
  • Rapid onset.
  • Frontal Fibrosing Alopecia - a form of Lichen planus - almost always in women.
  • Eyebrow loss (common)
  • Facial papules (rare)
50
Q

What is this?

A

Frontal Fibrosing Alopecia (FFA)

51
Q

What does this picture show?

A

The perifollicular scaling and erythema of Lichen Planopilaris (LPP)

52
Q

What are the investigations & treatments if you consider LPP?

A
  • Scalp biopsy for H&E and Direct IMF
  • Potent topical steroids
  • Doxycycline 100mg OD as an anti-inflammatory agent.
  • Consider immunosuppressives by a dermatologist.
53
Q

What are the investigations and treatment for FFA?

A
  • No need to biopsy - obvious diagnosis
  • Consider Triamcinolone 10mg per ml to the frontal margin
  • Repeat every 4 months.
  • Also give Doxycycline 100mg OD
  • Sometimes Hydroxychloroquine.
54
Q

What is this?

How is it investigated and managed?

A

Discoid Lupus Erythematous (DLE)

Ensure Biopsy + Direct IMF.

Potent Topical Steroids and antimalarials

55
Q

What primary scarring alopecia is this?

A

Folliculitis Decalvans

  • Affects both sexes
  • Treatment: oral and topical antibiotics.
    • Always refer to dermatology
56
Q

What primary scarring alopecia is this?

A

Dissecting Celluitis of the Scalp

  • Afro-Carribean Males
  • Fluctuant nodules and pustules occur on the scalp.
  • Treated with:
    • Topical antibiotics
    • Intralesional steroids
    • Oral Antibiotics
    • Dapsone.
57
Q

What primary scarring alopecia is this?

Who gets it?

How is it treated?

A

Central Centrifugal Cicatricial Alopecia (CCA)

  • Middle aged women with Afro-textured hair.
  • Tetracyclines and superpotent topical steroids.
  • Minoxidil

NOTE: They often have Seborrhoeic dermatitis - treat that too.

58
Q

What are some secondary causes of scarring alopecia?

A
  • Radiotherapy
  • Physical trauma
  • Skin cancer.
59
Q

What is thought to be a cause of dandruff?

A

Pityrosporum Ovale

60
Q

What is the treatment for dandruff?

A

Anti-Yeast Treatments like Zinc Pyrithione or ketoconazole.

Massage for 5 minutes.

61
Q

What % of women suffer from hirsutism?

A

15%

62
Q

What are some causes of Hirsutism?

A
  • Ovarian
    • PCOS
    • Androgen Secreting Tumours
  • Adrenal
    • Congenital Adrenal Hyperplasia
    • Cushing’s Syndrome
    • Androgen Secreting Tumours
  • Pituitary
    • Cushing’s Syndrome
    • Acromegaly
    • Hyperprolatinaemia.
  • Iatrogenic
    • Anabolic steroids
    • Glucocorticoid therapy
63
Q

What is the grading system for Hirsutism?

A

The Ferriman and Gallwey Scale.

>6 is thought to be judged as abnormal.

64
Q

What investigations should be done in Hirsutism in primary care?

A
  • Testosterone (SHBG + LH/FSH)
  • Prolactin
  • TFTs
  • Ovarian USS
65
Q

What is the treatment of Hirsutism?

A
  • Lifestyle & Weightloss
  • Eflornithine (Vaniqa) + IPL
  • COCP
  • Consider Cyporterone Acetate (inhibits androgen actviity)
    • Either as low dose in Dianette (2mg CYA)
    • Or CYA can be given during the follicular phase of the cycle.
      • 25,50 or 100mg for the first 10 days of the cycle with Dianette for days 1-21.
    • It is stongly progestogenic
    • Monitor LFTs.
  • Finasteride & Metformin can be used considered.

Dermatology Diploma (39 decks)

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