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Transcript of Common Challenges in Hair and Nail Disorders - acponline.org · • Ciclopirox nail lacquer. Quick...
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Common Challenges in Hair and Nail Disorders
ACP Virginia Chapter- Annual Meeting and Clinical Update
March 17, 2018
Kimberly S. Salkey, MD
Associate ProfessorDepartment of Dermatology
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Kimberly S. Salkey, MD
Common Challenges in Hair and Nail Disorders
DISCLOSURES
I do not have any relevant relationships with industry.
DISCLOSURE OF RELATIONSHIPS WITH INDUSTRY
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Hair Disorders
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Objectives
• Diagnose and recommend treatment options for common hair and nail disorders
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Patient 1
Chief Complaint: Hair loss
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Patient 1• History
– Excessive shedding– Smaller ponytail– Just married 3 months ago
• Examination– Diffuse ↓ in hair density– Scalp, brows, lashes WNL– Hair pull positive
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Telogen Effluvium
• Excessive and early entry of hairs into the telogen phase
• Triggered by emotionally or physiologically stressful events
• Shedding begins 2-4 months after trigger
• > 25% of hairs in telogen phase
• Hair loss can approach 400-500/day
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Human Hair Cycle
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Telogen Effluvium
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Causes of Telogen Effluvium
• Childbirth
• Severe infection
• Severe chronic illness
• Severe psychological stress
• Major surgery
• Hypo or hyperthyroidism
• Crash diets inadequate protein
• Drugs
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Management of Telogen Effluvium
• Laboratory evaluation– Directed by history– Thyroid studies, CBC, Iron studies
• Check medications– β blockers, NSAIDS, anti-coagulants, HRT
• Reassurance• Reassurance• Minoxidil
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Quick QuizWhich of the following is the most likely cause for this patient’s telogen
effluvium?
A. Knee replacement surgery with general anesthesia done 6 months ago
B. Azithromycin taken for sinus infection 2 weeks ago
C. Grapefruit only diet started for weight loss 2 months ago
D. Death of a family member 1 year ago
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Quick QuizWhich of the following is the most likely cause for this patient’s telogen
effluvium?
A. Knee replacement surgery with general anesthesia done 6 months ago
B. Azithromycin taken for sinus infection 2 weeks ago
C. Grapefruit only diet started for weight loss 2 months ago
D. Death of a family member 1 year ago
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Clinical Pearl
• Acute onset, diffuse hair shedding occurring a few months after a major stressor
• Identify cause
• Offer reassurance re: self limited course
Telogen Effluvium
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Patient 2
Chief Complaint: Toe nail discoloration
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Patient 2 • History
– Discoloration for years– Itchy feet– Healthy– No skin disease
• Examination– Similar findings on both
feet
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Onychomycosis• AKA tinea unguium• 3 types
– Distal/lateral subungual• Most common
– White superficial• Direct invasion of superficial nail plate
– Proximal subungual• Immunocompromised hosts
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Onychomycosis
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Onychomycosis
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Onychomycosis
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Onychomycosis
• White spotting due to superficial dermatophyte infection or trauma
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Onychomycosis Evaluation and Treatment
• Culture to confirm diagnosis
• Terbinafine 250mg PO qd– Fingernails- 6 weeks
– Toenails- 12 weeks
• Itraconazole– 200 mg PO qd x 12 weeks OR
– 200 mg BID x 1 week/month for 3-4 consecutive months
• Griseofulvin
• Fluconazole
• Ciclopirox nail lacquer
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Quick Quiz
Which of the following tests is least accurate at confirming a diagnosis of onychomycosis?
A. PAS stain
B. Visual inspection
C. Culture
D. KOH
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Quick Quiz
Which of the following tests is least accurate at confirming a diagnosis of onychomycosis?
A. PAS stain
B. Visual inspection
C. Culture
D. KOH
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Clinical Pearl:Onychomycosis
• Confirm diagnosis
• Patient education
– Frequent recurrence
– Potential side effects of treatment
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Patient 3
Chief Complaint: Hair loss
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Patient 3• History
– Abrupt onset– Gradually enlarging– Otherwise well, cousin with vitiligo
• Examination– Sharply demarcated round patch of alopecia– Hair pull positive at periphery– “shaggy” pits in the fingernails
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• Autoimmune disorder
– Family history
• Acute onset
• Well circumscribed, round or oval patches
• Males=females
Alopecia Areata
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N Engl J Med 2012;366:1515-25.
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N Engl J Med 2012;366:1515-25.
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Alopecia Areata
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• Diagnosis– Usually based on clinical findings
– Skin biopsy: lymphocytic infiltrate surrounds early anagen hair bulbs “swarm of bees”
• Treatment– Topical, intralesional corticosteroids
– Oral steroids • CAUTION: may experience hair loss after discontinuation
– Immunotherapy
– Phototherapy
– JAK inhibitors
Alopecia Areata
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Divito SJ, Kupper TS. Nature Medicine. 2014; 20: 989–990.
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• Variable course
• Relapses occur
• Poor prognosis– Duration more than one year
– Extensive hair loss
– Onset at age <5 years
– Family history of alopecia areata
Alopecia Areata
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Quick Quiz
Which of the following is an associated finding with alopecia areata?
A. Nail pits
B. Atopic dermatitis
C. Destruction of hair follicles on biopsy
D. Question mark hairs
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Quick Quiz
Which of the following is an associated finding with alopecia areata?
A. Nail pits
B. Atopic dermatitis
C. Destruction of hair follicles on biopsy
D. Question mark hairs
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Clinical Pearl:Alopecia Areata
• Acute onset
• Well defined
• Oval or round patches of alopecia
Gold Standard:
Intralesional
triamcinolone
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N ENGL J MED 2011; 364:E38
Patient 4
Chief Complaint: Toe nail discoloration
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N ENGL J MED 2011; 364:E38
Patient 4
• History– 37yo man
– 4 year history of gradual darkening and widening of pigmented band
• Examination– Brown/Black extension to proximal
nail fold- Hutchinson’s sign
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Acral Lentiginous Melanoma
• Palm, sole or nail bed
• Median age 65
• 50-70% of melanomas in African Americans and Asians
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Minocycline
Anti-malarials
Gold
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Nail matrix nevus
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Nail matrix nevus
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A patient with HIV taking zidovudine
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Subungual hematoma
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Pseudomonas nail infection
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Quick Quiz
Which of the following medications is most closely associated with melanonychia?
A. Aspirin
B. Coumadin
C. Digoxin
D. Hydroxychloroquine
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Quick Quiz
Which of the following medications is most closely associated with melanonychia?
A. Aspirin
B. Coumadin
C. Digoxin
D. Hydroxychloroquine
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Clinical Pearl:Melanonychia
• Check for Hutchinson’s sign- extension of pigment to proximal nail fold
• If negative, consider
– Normal variant
– Traumatic
– Drug induced
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Patient 5
Chief Complaint: Hair loss
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Patient 5
• History – Gradually thinning on top since
age 20’s
– Dad’s hair also thin
– No known medical problems
• Examination– ↓↓ density of frontal scalp with
recession of frontal hair line
– Many miniaturized hairs
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Androgenetic Alopecia-MEN
• 50% by age 50 years
• Androgen dependent progressive decline in anagen duration
• Genetic predisposition
• Hair follicles miniaturize
• Hair loss occurs in the fronto-temporal regions and the vertex
Uptake, metabolism, and
conversion of testosterone
to dihydrotestosterone by 5-
alpha-reductase is
increased in balding hair
follicles.
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Androgenetic Alopecia
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Androgenetic Alopecia• WOMEN
• With or without androgen excess
• Early or late onset
• Hairs of variable diameter
• Top of scalp most significantly involved
Female Pattern Hair Loss
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Female Pattern Hair Loss
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Androgenetic Alopecia
1. Progressive shortening of successive
anagen cycles
2. Miniaturization
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Ludwig
Androgenetic Alopecia
Hamilton-Norwood
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• Topical minoxidil (effective in ~ 40-60%)• Finasteride
– Effective in 66%-83% men– Cannot be used in women
• Spironolactone may be used for women• Hair weaves and extensions• Hair transplant
Androgenetic Alopecia: Treatment
T DHT5 α redcutaseX
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Quick Quiz
Which of the following is FDA approved for treatment of female pattern hair loss?
A. Finasteride
B. Nioxin
C. Minoxidil
D. Spironolactone
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Quick Quiz
Which of the following is FDA approved for treatment of female pattern hair loss?
A. Finasteride
B. Nioxin
C. Minoxidil
D. Spironolactone
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Clinical Pearl:Androgenetic Alopecia
MEN• 50% by age 50 years
• Hair loss occurs in the fronto-temporal regions and the vertex
• Finasteride
WOMEN• 40% by menopause• More diffuse and
located centroparietally– The frontal hairline
is usually intact
BOTH
Minoxidil is FDA approved
Most cases of hair loss are due to androgenetic
alopecia (AGA)
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Common Challenges in Hair and Nail Disorders
ACP Virginia Chapter- Annual Meeting and Clinical Update
March 17, 2018
Kimberly S. Salkey, MD
Associate ProfessorDepartment of Dermatology