Lecture 7: Hair and Digit Tip Disorders Flashcards
How does hair grow?
Intermittently
What are the 4 phases of hair growth?
- Anagen: Growth
- Catagen: degenerate/Catabolic stage, stoppage of growth.
- Telogen: resting/timeout phase
- Exogen: hair shedding/exit phase
How long do leg hairs usually grow for?
5-7m
What are the 4 types of hair?
- Lanugo (soft hair in fetus)
- Vellus hair (peach fuzz), not affected by hormones
- Intermediate hair: scalp
- Terminal hairs: thick, pigmented hairs whose growth IS affected by hormones
How many hairs should a normal hair pull dislodge?
3-5
> 5 = sus
What does a trichogram measure?
Anagen to Telogen ratio
Describe a normal trichogram.
- Epilate/plick 50+ hairs from scalp.
- Ideally you see 80%-90% anagens, which are characterized by Long encircling hair sheaths.
Telogen hairs are largest at the base.
Tiny amt of Telogens
What is the most common form of alopecia?
Androgenic alopecia
Aka sex pattern hair loss
What is the underlying pathophysiology of androgenic alopecia?
Terminal hairs are regressed into indeterminate/vellus hairs due to androgens.
Terminal hairs are affected by hormones!
What androgenic alopecia classification describes females?
Ludwig-Savin
MC type is diffuse thinning. Women wear wigs
What androgenic alopecia classification describes males?
Norwood Hamilton
Alexander Hamilton was a man or men have morning wood
When does androgenic alopecia commonly occur for men?
After puberty, done by 40s
When does androgenic alopecia commonly occur for women?
After 50!
Overall, what sex and ethnicity is androgenic alopecia MC in?
White males
toby.
What hormone specifically causes androgenic alopecia and the long-term result of exposure to it?
- DHT
- Successive cycles will produce shorter and thinner hairs
What associated S/S should we ask for a woman regarding androgenic alopecia?
- Acne
- Hirsutism
- Irregular Menses
All hormone related
Generally, how does male androgenic alopecia present?
Anterior or central hair loss.
If I do a biopsy of androgenic alopecia, what do I expect to see?
Telogen phase & atrophic follicles
What hormone studies are indicated for androgenic alopecia workup?
- Testosterone (total & free)
- DHEAS
- Prolactin
What conditions can cause androgenic alopecia?
- Thyroid
- Anemia
- Autoimmune
What is the preferred topical tx for androgenic alopecia?
Minoxidil/Rogaine BID
let pts know hair shedding initially is COMMON.
Can also be taken orally.
What are the oral medications for androgenic alopecia?
- Finasteride for men
- Spironolactone for women
Finasteride slows hair loss for 3 months, then grows it back over 6.
Finasteride inhibits conversion of test to DHT. It is the 5-alpha-reductase inhibitor also used for BPH.
Spironolactone prevents DHT from working.
What are the key descriptors of alopecia areata?
Random hair loss with NO inflammation of skin.
No scarring!
T-cell mediated autoimmune.
AReata = At Random
Who is alopecia areata MC in?
Children < 25 yo
MCC of hair loss in children
Describe the pathology that occurs in alopecia areata
- Hair follicle is damaged in anagen phase.
- Transforms to catagen and telophase rapidly.
- Cannot progress beyond anagen phase if active.
However, no scarring = regrowth is possible.
What is probably the buzzword for alopecia areata?
There is NO SKIN SCARRING
Where is alopecia areata MC found?
- Scalp
- Beard
- Eyebrows
- Extremities
What would dermoscopy show for alopecia areata?
- Black dots representing broken hair pushed out of the follicle.
- Exclamation Hairs
Hair follicle broken early.
What are the subtypes of alopecia areata?
- Alopecia areata: solitary/multiple areas of hair loss
- AA totalis: total loss of terminal scalp hair
- AA universalis: Total loss of all terminal body & scalp hair
- Ophiasis: Headband-shaped hair loss
- Nails: fine pitting/hammered brass of dorsal nail plate
How is alopecia areata typically treated?
- Typically just remits on its own.
- Mainly decreasing inflammation and reducing growth inhibitors (see next card)
- Psych consult
What are the poor prognostic factors for alopecia areata?
- Began in childhood
- Body hair involved
- Nail involvement
- Atopy
- FHx
What medications are used to reduce inflammation in alopecia areata?
- Topical CS (class 1 or 2) with minoxidil
- Intralesional Kenalog Q6wks into alopetic plaques
What is the systemic tx for alopecia areata?
Short term prednisone
What is the specific kid tx for alopecia areata?
Anthralin
Keratolytic agent that regrows hair.
Must avoid face
What is keratosis pilaris?
Hyperkeratinization of skin and keratotic follicular plugging
Goosebumps skin
little pils of keratin
Primary risk factor for keratosis pilaris?
FHx
When is keratosis pilaris worst?
Winter
Better in summer, cold = goosebumps
How does the early childhood pattern of keratosis pilaris present?
- Face/arm involvement
- Improves as they grow
How does adolescence onset keratosis pilaris present?
- Arms/legs
- Improves by mid-20s
Face is only in early childhood!
What is the only symptom usually with keratosis pilaris?
Occasional pruiritis
Can have erythema if associated inflammation
Where specifically is keratosis pilaris MC?
Upper outer arms and thighs.
Dx of keratosis pilaris is made…
Clinically
Biopsy showing follicular orifice distended by keratin plug if atypical.
Main treatments for keratosis pilaris
- Skin hydration via gentle Dove soaps and unscented moisturizer lotions
- Lac-Hydrin (lactice acid lotion) BID
- Reduction of inflmmation (if present) via steroid creams 1-2x/d for 7-10d
- Keratolysis via SA, topical urea, or topical retinoids
What is the main SE of keratolytic agents like SA or topical retinoids?
Inflammation
Nail growth into one or both sides of the paronychium/nail bed is…
Onychocryptosis
creeping in
Who is onychocryptosis MC in?
Males in their 20s
What does the impingement of the nail into the dermal tissue result in?
Onychocryptosis
- Erythema
- Edema
- Purulence
- Granulation tissue
It functions as a foreign body
What is onychocryptosis more commonly known as?
Ingrown nails
Where is onychocryptosis MC?
Big toe
Gotta wear looser shoes
Tx for onychocryptosis
- Warm soaks
- Topical mupirocin BID
- Nail trimming
- Cotton training
- Surgery (nail or matrix removal)
Post-op care for onychocryptosis/ingrown nail
- Antibacterial soap
- Mupirocin
Resume activity after 48-72hrs
Where is onychomycosis/tinea unguium MC?
Prepare yourself
Toes
Causative organism for tinea unguium/onychomycosis
Trichophyton rubrum
Fungi
What structure does tinea unguium/onychomycosis invade specifically in the nail?
Hyponychium
H & M(ycosis)
What is the MC complaint of onychomycosis?
Discoloration
Nail thickens and cause sometimes lift off bed.
No other symptoms really. its just gross.
What kind of person might get onychomycosis?
A daily goer to the Gym who wears no shoes in the shower
Although onychomycosis is mianly just a gross looking condition, what do you need to workup?
MELANOMA WORKUP FOR ANY TOENAIL DISCOLORATION
Either rule out clinically or biopsy it
Especially if its like a dark band
How do you workup onychomycosis?
Toenail clipping under KOH prep
No antifungals 2 weeks prior
Topical tx for onychomycosis
- Ciclopirox (Penlac)
- Efineconazole (Jublia)
48 WEEKS of treatment for jublia
What is the home remedy for onychomycosis?
1:1 ratio of apple cider vinegar and water for 10 mins a day
Soak those dogs
If you want to treat onychomycosis orally, what would you give?
- Terbinafine for 6 weeks for the fingers.
- 12 weeks for the Toes/Dogs
Dogs need lots of care
What do you need to monitor in onychomycosis lab-wise during pharm tx?
- CBC
- LFTs
Baseline & monthly!!
Hepatoxicity
Pancytopneia
Agranulocytosis
How long might it take a nail to regrow with onychomycosis?
1 year
Might be discolored for a while
What is onycholysis?
Detachment from nail bed
What color suggests bacteria caused onycholysis?
Green
Gray-black is just air
What is unique about onycholysis presentation?
- No inflammation
- Nails are smooth
Loose Lysis
How do you treat onycholysis?
Tx underlying cause if there is one
What does paronychia start as and progress to?
Inflammation of proximal/lateral nail fold into cellulitis into abscess
The classic cellulitis => abscess
MCC of paronychia
Trauma
2nd is bacteria
How much hand washing is a RF for paronychia
50-100 times a day?
OCD ppl prob could meet this
MCC bacteria for acute paronychia
Staph
If acute paronychia has GREEN purulence, what might be the bacteria?
Pseudomonas
If you do a Tzanck for acute paronychia, what are you prob considering in your DDx
Herpetic Whitlow
Normal tx of non-cellulitis acute paronychia
- Warm soaks
- I&D if it becomes fluctuant
Tx of cellulitis acute paronychia
Augmentin BID x 10d
Clinda, Keflex
Besides treating acute paronychia, what should u do?
Consult hand surgeon IF significant cellulitis or lymphangitis, Tenosynovitis, deep space infection, osteomyelitis
How does chronic paronychia typically present?
- Waxing and waning inflammation
- Pain
- Swelling for 6 weeks
Tx of chronic paronychia
- Keep dry
- Don’t touch
- Warm antiseptic soaks
- Topical antifungals
Oral antifungals if severe
Where is Herpetic whitlow MC?
Distal finger
Who is HSV1 herpetic whitlow MC in and why?
Children because they suck their fingers
Can also be caused by gingivostomatitis
Who is HSV2 herpetic whitlow MC in?
Adults working in healthcare
PRIOR to the herpetic whitlow lesions, what symptoms occur?
- Burning
- Pruritis
Its like shingles for your fingers
How is herpetic whitlow Dx?
Clinical
Tzanck if ya want
What should you NOT do with herpetic whitlow tx?
DO NOT I&D
How do you tx herpetic whitlow?
- Acyclovir/Valcyclovir
- OTC pain meds
Self-limiting over 3 weeks
What is Felon?
Soft tissue infection of pulp space of distal phalanx due to infection
Where is Felon MC?
- Thumb
- Index finger
Why is Felon scary
Rapid and severe progression
Can turn into osteitis, osteomyelitis, septic joint, or tenosynovitis.
A Felon is much more SEVERE than a misdemeanor
How do you workup Felon
- Gram stain + C&S
- Tzanck to r/o herpetic whitlow
- XR
a thorough bkg check on felons
How do you manage a Felon?
Augmentin BID x 10 days
Surgical decompression
Treat it like its in a CELLulitis
Why do clubbed nails occur?
Primarily idiopathic, but can occur due to prolonged hypoxia.
I have a clubbed pinky :(
What condition is the MCC of clubbed nails besides being idiopathic?
Lung CA
hypoxia?
What is melanonychia?
Nail pigmentation due to melanin
Melanin nails
Who is melanonychia MC in?
Darker skinned
What are the possible underlying conditions that can result in melanonychia?
- Infections
- Skin conditions
- Trauma
- Tumors (Bowens or SCC)
- Addisons/Cushing’s
- Iatrogenic
What is the MCC of melanonychia in children?
Nail matrix nevus
MC associated condition with pitted nails?
Psoriasis
MCC of splinter hemorrhages
Trauma to nail
Medical conditions that can cause splinter hemorrhages
- APS
- IE
- IVDU
- Psoriasis
- Rheumatic HD
- SLE
Who are terry nails MC in?
Liver dz/Cirrhosis
What happens to the nail bed in terry nails?
- Less blood
- More connective tissue
Increased pallor
What does a single beau line suggest in terms of etiology?
Repeated trauma/infection
What do multiple beau lines suggest for etiology?
- Acute kidney failure
- Mumps
- Thyroid
- Syphilis
- Chemo
- Endocarditis
- Melanoma
- DM
- PNA
- Scarlet Fever
- Zinc Deficiency
not memorizing this grrr
