Nail, Hair And Scalp Disorders Flashcards
Pigmentation of the nail plate is where?
Suprabasalar layers of the distal matrix
- high levels of melanocytes
Beaus lines
Transverse furrows that progress dismally
- due to temporary arrest of the nail matrix
- depth = extent of damage, width = duration for systemic insult
Usually bilateral but can be single nails
Causes = mechanical trauma is most common but can also be eczema or paronychia issues
- also systemic illness or major illness that are febrile and last decently long
Onychomadesis
Essentially more severe beaus lines. Shows proximal detachment of nails and a sulcus forms (looks kind of like a new nail is growing underneath the actual nail
- complete arrest of nail matrix activity
Most common cause = trauma to the nail
less common Causes:
- very common in infants with hand/foot/mouth disease that isnt treated well
- the fever associated causes onychomadesis
- neurological damage or marathon runners are also common
**takes 6-8 months to look normal again though since that’s how long it takes for a brand new nail to grow
Pitting
Abnormal keratinization of proximal nail matrix
- clusters of parakeratotic cells in the dorsal nail plate
common in psoriasis, eczema and alopecia areata
Onychorrhexis
Longitudinal ridging of the nail plate
- diffuse damage to the nail matrix and thinning of the nail
Casues = aging, reptitive trauma and vascular diseases
Trachyonychia
Proximal nail matrix damage
- looks like worse onychorrhexis
Causes = alopecia areata is #1 but also psoriasis, eczema and autoimmune disorders
Treatment = treat underlying cause and it resolves spontaneously
Leukonychia
Opaque discoloration of the distal nail matrix
- signifies nail matrix damage
- **looks white and does not disappear with pressure to the nail
usually caused by trauma but can also be due to onychomycosis
mee’s lines
True type of Leukonychia
- single broad transverse white band
- always should signify possible arsenic poisoning**
- can also be sepsis, thallium poisoning, AAA/TAA, parasitic infections, chemotherapy
Koilonychia
Thinning and “spooned-shaped” (concave) nails
Is normal in children!!
- however in adults means pathology = ****chronic iron deficiency!!
- can also be hemochromatosis and hyperthyroidism
Onycholysis
Seperation of the nail plate form the nail beds
- shows nail discoloration of the nails (looks more white and yellow (like nail is being peeled off kinda))
causes
- bacterial/fungal infections (especially candida/pseudomonoas)
- however #1 = trauma and psoriasis**
- **thyroid dysfunctions
- malignancy
Apparent Leukonychia
Leukonychia that is false
- goes away with pressure and DOES NOT grow with the nail or move distally
Half and half (Lindsay nails)
Apparent Leukonychia
Very heavily tied to renal dysfunctions and hemodialysis patients
Muehrckes lines
Apparent Leukonychia with narrow multiple white transverse bands
- must grow in pairs
Chronic hypoalbuminemia (nephrotic syndromes) and combo chemotherapy are the msot common causes
Terry nails
Apparent Leukonychia where almost the whole nail is taken up by white nail
Due to telangiecasias in the nail beds
Casues = metabolic issues with CHF/diabetes/liver cirrhosis
Splinter hemorrhages
Dark-red thin longitudinal lines on the distal or proximal nails
Proximal causes:
- **endocarditis!!
- also vasculitis and trichinosis or mountain sickness
Distal causes:
- trauma and psoriasis are most common
Hutchinson sign
Hyperpigmentation along the entire nail that also includes the proximal and lateral nail fold
highly suspect of malignant melanoma
Green nail syndrome
Green-blue/black nail discoloration
- caused by pyocyanin pigments due to pseudomonas aeruginosa infections
Treatment = topical quinolone and acetic acid for 1-4 months
Pyogenic granuloma
Red growths under nails that can be cancerous
- common in pregnancy, trauma and drugs
must rule out amelanotic melanoma with biopsy
Clubbing of the nails
Very highly associated with pulmonary or cardiac diseases
*can be asymmetric which leads to likely hood of sarcoidosis or takayasu arteritis
What medications can mimic onychocryptosis (ingrown toe nails)
Isotretinoin
Lamuvidrinae
Phases of hair growth
Anagen
Telegen
Catagen
Telegenic effluvium
Very common in postpartum patients or acute physical illness
- can also be thyroid dysfunction
- occurs within 2-4 months
Hair shifts to telegenic phase which causes hair to shed but scalp appears normal
- treatment = reassurance and it will grow black
- *should check meds and vitamin deficencies however if present
Two components of the nail apparatus
1) epithelia
2) nail palate
- produced by stratum germinativum
Nail immune system
Distal = rich innate and adaptive immune system
- possess onychocorneal band which separates distal from proximal nail
Proximal nail matrix = immune privilege
- upregulation of HLA-G and decreased MHC-2
Anagen effluvium
Disruption of hair matrix cells
- same as telogen effluvium except hair DOESNT grow back
Common in chemotherapy, radiotherapy and heavy metal poisoning
- occurs within 1-4 weeks
Alopecia Areata
Circular area on non-scarring hair loss
- typically multiple hair loss circles
- rarely can involve entire scalp
Regrown hair often is white
Treatment = steroids ultra potent and topical sensitizers
Prognosis = spontaneous regrowth
- poor factors = young age of onset, duration > 5years
Androgenetic alopecia
“Patterned baldness”
Males = frontoparietal recession
Females = widening of the part and preserved frontal hairline
Caused by increased activity of type 2 5-alpha reductase
Treatment:
- finasteride/dutasteerides (type 2 5-alpha reductase Inhibtors)
- minoxidil (increases anagen phase)
- spironolactone (women only)
What labs do you check in women with hair loss?
CBC
Iron panel
Ferritin
TSH
DHEA-S
Free testosterone
B12/folate
Vitamin D
Zinc
Differential diagnosis of hirsutism (excessive male-patterned hair growth)
Ovarian or adrenal androgen excess (PCOS, CAH, Cushings,m tumors)
Pituitary disorders
Iatrogenic medications (anabolic steroids, phenytoin, Diazoxide, cyclosporine, hexachlorobenzene)
Red flags for hirtuism
Rapid virilizarion and hirsutism
New onset hypertension and/or diabetes = signals Cushing syndrome
Galactorrhea = prolactinoma or thyroid dysfunction
Gigantism = pituitary growth
Testosterone > 200 = ovarian or adrenal tumors
DHEAS score > 7000 = adrenal tumors
Congenital adrenal hyperplasia
Most common form of 21 hydroxylase deficiency
- will show testosterone and/or DHEAS elevated
- cortisol will be normal
if rapid symptoms = adrenal tumor instead
Treatment of hirsutism
Correct underlying cause if possible
Medications
- spironolactone 100mg p.o day
- finasteride 2.5-5 mg daily
What medications cause hypertrichosis
1 = cyclosporine
Minoxidil, latanoprost, corticosteroids, streptomycin, topical androgens
6 major components of the nail unit
Nail matrix
Nail plate
Cuticle
Nail bed
Anchoring portion
Framing portion (lateral/proximal/distal folds)
Lunula = only visible portion
Eyebrows, eyelashes and vellus hairs are androgen-dependent?
NO they are the only hairs that are not
Ferritin levels need to be at least what to treat iron-deficiency related telogen effluvium
40ng/dL
Erythronychia
Longitudinal red bands on nails seen in dariers disease
- mutation in ATP2A2 gene
Longitudinal melanonychia
Is casued by melanin in the nail plate
Very common in darkly pigmented skin patients
- 90% of adult African Americans present with this
- 20% of melanomas show this as well
While its usually caused by trauma or normal Variant, need to screen for melanoma if seen
- has a very low threshold for biopsy for potential melanoma (especially if Hutchinson sign is present)
Red lunula
Seen in CO poisoning always
Can also be alopecia areata, SLE or CHF as well
Blue lunala
Seen in Wilson disease of medication most commonly
- medications = 5-FU, minocycline, anti malaria drugs
Yellow nails
Most commonly associated with lymphedema and/or compromised respiratory system
Tx = vitamin E
Trichotillomania
Irresistible urge to remove or pull ones own hair
Most commonly arises as OCD
Shows irregularly shaped patches of alopecia variable lengths of hair
Complications = trichobezoar
Acute chronic lupus hair loss
Shows telogen hair loss and does NOT scar
Can also show ear hair loss
Treatment = IL steroids
Central centrifugal scarring alopecia
Scarring alopecia that begins at the crown and expands over the central scalp
VERY common in African Americans
Unknown etiology
Difficult to treat = antibiotics and steroids
Dissecting cellulitis of the scalp
Hair loss that is accompanied by multiple painful inflammatory nodules over the vertex and occiput regions of the scalp
- produces scaring over time
The nodules can also turn to abscesses that are interconnected via sinus tracts
Treatment = isotretinoin if possible
Sebopsoriasis
Is a hybrid term which covers a spectrum between psoriasis and seborrheic dermatitis
Can be anywhere but more likely in oily areas of the forehead and scalp line
- most common pathogen = malassezia yeast
Treatment = seborrheic derm = ketoconazole Psoriasis = topical steroids
