Nails and Hair Questions Flashcards
What is onychomycosis?
A fungal infection of the nails: can sit on the nails, or occur subungally (under the nails, more invasive)
This can happen from direct contact/invasion of nearby skin
Fungus likes to grow in moist/dark places (feet-toenails)
Risk factors: communal showering, diabetes, tinea pedis, ^moisture, repetitive trauma (runners)
What are the physical findings of onychomycosis?
Can occur anywhere in the nail: matrix, nail bed, nail plate (lifting of nails with debris and discoloration)
May be asymptomatic at beginning/come in for cosmetic reasons
Progression can result in pain, numbness, interference with walking, exercise, standing
Subungual hyperkeratosis: crumbly debris under nail (nail itself is thick)
Onycholysis: white/yellow colors caused by nail lifting
Ddx for onychomycosis?
Nail psoriasis: not this because no nail pitting/psoriatic inflammation (differentiate with biopsy)
Trauma (will be more of a bruise under nail, no subungal debris)
Aging toenail
How can you diagnose onychomycosis?
Collect sample of subungal debris
In office: scrape for KOH (potassium hydroxide) look for hyphae
Send away: Nail clip for PAS stain (periodic acid shift) more applicable for ruling out nail psoriasis if KOH is negative
What can be seen in a KOH for onychomycosis?
Fungal hyphae (looks almost like little branches)
What is the treatment for onychomycosis?
Combo of topicals and oral meds (decreases reoccurrence)
Daily for almost a year:
Topicals (ciclopirox, efinaconazole)- alone can be ineffective, hard to penetrate the nail plate
Yet one benefit of nail lifting: easier to try to get medication to nail plate
Risks vs benefits: liver toxicity requiring labs, price $$$, med interactions, side effects
What is the first line treatment for onychomycosis?
Oral treatment Lamisil (terbinafine):
1 pill a day for 6 weeks
(1 a day for 3 months in toenails)
Can also use nail avulsion(removal)/laser if necessary for persistent/chronic cases
What information is important to give a patient when giving treatment for onychomycosis?
Toe nails and fingernails take a significant time to grow (months) and it will take a while before results are seen
What do you need to check for before using Lamisil (terbinafine) for onychomycosis?
Liver function labs (LFT), medication is metabolized by liver
What is paronychia?
Infection of skin on sides of nail (proximal and lateral nail folds)
Can be acute or chronic
What causes paronychia?
A small opening on these surfaces allows bacteria to enter
What are the clinical features of paronychia?
Acute: hot, red, swollen, painful, prurulent (staph aureus)
Chronic: more so at proximal nail fold- swelling, no prurulence, tender but not as painful (candida often found, but not the cause), nail plate thickened/discolored (not going to have subungal debris like onychomycosis)
What is the difference between acute and chronic paronychia?
Difference in presentation and symptoms
Acute- more painful, prurulent
Chrinic- less painful, discoloration of nails
How is paonychia diagnosed?
Collection of prurulent dishcarge
Bacterial culture, KOH smear, imaging (if osteomyelitis is suspected: systemic fever/chills)
What is the treatment for acute paronychia?
Topical or oral antibiotics (OTC bacitracin or prescription), soaks/I&D (separate nail fold from nail plate) to release prurulent discharge
If failure of treatment: culture bacteria and prescribe an oral antibiotic for more specific treatment
What is the treatment for chronic paronychia?
Topical steroids, skin protection (prevent moisture exposure)
-decreasing chronic inflammation
What would you tell a patient with paronychia as far as terms of education?
Avoid nail biting, trim hang nails, trim nails flush to tip, avoid excessive moisture exposure (prevents infection)
What is alopecia universalis?
When all hair bearing areas of body are bald
What is alopecia totalis?
When entire scalp is bald
What is alopecia areata?
“UNSIGHTLY” -Saint Mark
-recurrent but non-scarring hair loss (hair follicle will hopefully regrow as hair follicle will remain intact)
Usually localized, discrete round patches of hair loss (scalp, beard, eyebrows)
Can effect children and adults
What is the cause of alopecia areata?
unknown, most likely autoimmune/genetic (autoimmune attack that affects the hair follicles, not the skin around them),
*other autoimmune diseases may flare as well as alopecia
What are the clinical features of alopecia areata?
patient is usually asymptomatic, mild pruritis/burning, discrete bald patches (yet skin is smooth and NOT inflamed), !exclamation hairs! (broken hairs thinner toward the scalp/follicle than they are at the other end)
-Tinea capitis (yet will be mushy texture/boggy, itchiness, inflamed),
-traction alopecia (hair pulled tightly, frontal scalp usually effected, general distribution but no round patches),
-trichotillomania (hair usually not gone just broken, people pulling out their own hair),
-androgenic alopecia (usually has distinct pattern)
DDx for alopecia areata?
-Tinea capitis (yet will be mushy texture/boggy, itchiness),
-traction alopecia (hair pulled tightly, frontal scalp usually effected, general distribution but no round patches),
-trichotillomania (hair usually not gone just broken, people pulling out their own hair),
-androgenic alopecia (usually has distinct pattern)
How is alopecia areata diagnosed?
Clinical diagnosis
Pull test: if pulled in the patch, hair will come out very easily, may signify active alopecia
Association with other diseases: if symptoms present, test for other autoimmune diseases
How can alopecia areata be treated?
Depends on extent of disease
Small area: watchful waiting
More extensive: topical steroids/IL steroids for alming of inflammatory response (no steroidal use on eyelids/eyelashes)
Immunotherapy: Acid used to induce allergic reaction on skin in order for immune system to rush to area/attacks inflammation (usually only done for extensive disease, can be very irritating)
Can hair grow back after alopecia areata?
It is unpredictable, yet theres a better chance if the degree of alopecia is less extensive (more localized)
(hair will also be white and fine with regrowth)
Non preventative: can’t stop alopecia from coming back
What is androgenic alopecia?
Male or female patterned alopecia which can be hereditary
A gradual progressive conversion of terminal (thick) hair to vellus (fine) hair
probably will continue even with intervention)
What are the clinical features IN MEN with androgenic alopecia?
Androgen dependent (DHT will bind to hair follicles and will cause attack on hair follicle- becomes shorter and thinner)
Pattern hair loss starting in frontal scalp and proceeds back (more hair in frontal scalp with affinity for DHT)
What are the clinical features IN WOMEN with androgenic alopecia?
Unclear hormonal component
Present with thinning at crown of the scalp (widening of part, hair shedding)
How is androgenic alopecia diagnosed?
Labs/hormonal testing (DHEAS and testosterone): may want to do this for women for adrenal tumors
Scalp biopsy: want to take 2 samples/punches of scalp (to section them horizontally and vertically) to give two different views of the hair follicle
What are treatments for FEMALE androgenic alopecia?
No cure, want to preserve/maintain hair rather than hope for regrowth (may or may not regrow, need consistent regimen for regrowth and it may take a while)
Topical Minoxidil (rogaine): OTC, 2% works best for women
Oral spironolactone: interrupts androgen production
Hair transplant: punches are transferred from hair growth areas to areas of hair loss *not guaranteed
Wigs
What are treatments for MALE androgenic alopecia?
No cure, want to preserve/maintain hair rather than hope for regrowth (may or may not regrow need consistent regimen for regrowth and it may take a while)
Topical Minoxidil (rogain): OTC, 5% works best for men
Oral Finasteride (Propecia): disrupts hormonal influence on hair follicles (terratogenic: causes significant negative effects to unborn fetus, feminization of male fetus) **erectile dysfunction common
Hair transplant: punches are transferred from hair growth areas to areas of hair loss *not guaranteed
Wigs
What is telogen effluvium?
A prolonged resting (telogen) phase of hair cycle where patients have excessive hair shedding, and don’t have regrowth to support the amount of hair loss
Non-patterned (no bald spots), and non-scarring, no inflammation
What is a normal amount of hair loss?
100-150 hairs per day on average, can vary from person to person
What can promote telogen effluvium?
Telogen phase can be prolonged by:
-surgery/general anesthesia
-pregnancy, especially childbirth
-intentional or unintentional significant weight loss (certain diets/dietary restrictions)
-medications (ex. isotretinoin)
-Significant stress (deaths, divorce, losing a job, etc.)
-high fever/febrile illness (102,103)
How is telogen effluvium diagnosed?
Examining the scalp, making sure no other problems could be promoting hair loss
Workup: CBC, thyroid function, iron levels
Just to make sure/rule out nothing is systemically wrong that is causing hair loss
Is there a treatment for telogen effluvium? How can it be managed?
No treatment will speed up resolution, will resolve on its own (6-12 months)
-if necessary: address any nutrition, associated illness, and emotional/psychological effects
What is central centrifugal cicatricial alopecia (CCCA)?
Permanent scarring alopecia, usually happens faster that female androgenic alopecia
What are the signs/symptoms of CCCA?
Alopecia starts at crown of scalp (top,back) and progresses outward/laterally
-Brittleness and breakage of hair/thinning
Will also have effect on the scalp:
-Burning/pruritis (itching)/pain sensations
-redness/flaking
-may see inflammatory papules
Who is more vulnerable to CCCA?
Black women 30y/o+
Due to hair care practices (chemical relaxers, hot combs for straightening of hair) and genetics
How is CCCA diagnosed?
Usually a clinical diagnosis, but can biopsy
What is the treatment for CCCA?
Reinforce need for gentle hair care, hair that is remaining will be very fragile
Early diagnosis/intervention has better prognosis (biopsy is a good option for differentiating between
CCCA and female pattered hair loss)
Topical/IL steroids: Calm inflammatory component
Oral antibiotics: Anti-inflammatory for a few months, usually same abx used for acne (ex. doxycycline)
Hair transplant (for stable disease with halting of hair loss)
Avoiding friction/damaging chemicals/heat
