Hair and Nail Disorders - GP CME - BayTrust/1400 - 1505... · LSU Health Sciences Center – USA...
Transcript of Hair and Nail Disorders - GP CME - BayTrust/1400 - 1505... · LSU Health Sciences Center – USA...
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Hair and Nail Disorders
E.J. Mayeaux, Jr., M.D., FAAFP
Professor of Family Medicine
Professor of Obstetrics/Gynecology Louisiana State University Health Sciences Center
Shreveport, LA
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LSU Health Sciences Center – USA
Hair Classification
• Terminal (large) hairs
– Found on the head and
beard
– Larger diameters and
roots that extend into
sub q fat
Courtesy of Dr. E.J. Mayeaux, Jr., M.D.
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Hair Classification
• Vellus hairs are smaller in length and
diameter and have less pigment
• Intermediate
hairs have
mixed
characteristics
Courtesy of E.J. Mayeaux, Jr., M.D.
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Life cycle of a hair
• Hair grows at 0.35 mm/day
• Cycle is typically as follows:
– Anagen phase (active growth) - 3 years
– Catagen (transitional) - 2-3 weeks
– Telogen (preshedding or rest) about 3 Mon.
• > 85% of hairs of the scalp are in Anagen
– Lose 75 – 100 hairs a day
• Each hair follicle’s cycle is usually
asynchronous with others around it
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Alopecia Definition
• Defined as partial or complete loss of hair
from where it would normally grow
• Can be total, diffuse, patchy, or localized
Courtesy of E.J. Mayeaux, Jr., M.D. Courtesy of the Color Atlas of Family Medicine
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Classification of Alopecia
Scarring Nonscarring
Neoplastic Medications
Nevoid Congenital
Injury such as burns Infectious
Systemic illnesses
(LE)
Genetic (male pattern)
Toxic (arsenic)
Congenital Nutritional
Traumatic
Endocrine
Immunologic
Physiologic
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General Evaluation of Hair Loss
• Hx is still most important aspect
– Shedding vs. thinning
– Duration of problem
– Pertinent family illness
– Grooming practices
– Medications
– Serious past or current illnesses
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Evaluation
• PE: Focus is on pattern of hair loss
– Patchy or localized = confined to several
areas of the scalp leaving some areas
unaffected
– Diffuse implies uniform density decrease
• Gauge hair fragility
– Squeeze and roll hair within a gauze pad
– If fragile, short fragments remain on the
pad
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• Examine the scalp looking for erythema,
scale, pustules, bogginess, edema, loss
of follicle openings, scarring or sinus
tract formations
• Not all scalp changes relate to alopecia
nor alopecia cause all scalp changes
• May consider scalp punch biopsy
– Trim hair, inject 1-3 cc of lido with epi, use
a 4mm punch, place single suture
– Attempt to get both affected and normal
Evaluation
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Laboratory Studies
• RPR or VDRL
• KOH prep or PAS for fungal elements
– Use in patchy hair loss
– Hair shaft stubs from periphery of lesion
– Can obtain culture for fungi
• Hair pull test
– Lock of hair is grasped firmly in thumb and
forefinger and steady traction applied as
fingers dragged along the lengths of hairs
– Examine hairs microscopically
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Androgenic Alopecia
• AKA as male pattern baldness
• Complain of thinning vs. shedding
• 30-40%
adults
Courtesy of Dr. E.J. Mayeaux, Jr., M.D.
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Androgenic Alopecia
• Multi-allelic trait: obtain history of
baldness in grandparents and 1st
degree
relatives
on both
maternal
and
paternal
sides of
family
Courtesy of Dr. E.J. Mayeaux, Jr.
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Androgenic Alopecia
• Usually crown with sparing of occipital
and lower parietal fringe of hair
• In women
may
need to
consider
androgenic
excess
Courtesy of Dr. E.J. Mayeaux, Jr.
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Androgenic Alopecia Treatment
• Topical Minoxidil or Oral finasteride
– ♂ Finasteride 1mg orally = $60/month*
– ♂ Minoxidil 5% 1ml BID = $17/month*
– ♀ Minoxidil 2% 1ml BID = $30/month* * www.drugstore.com, accessed 4/5/10
• Surgical restoration or excision does
not slow or reverse hair loss
• No head to head comparisons
– Both beneficial compared to placebo
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Alopecia Areata
• Usually circumscribed patches
– Total scalp (Totalis)
– Entire body (Universalis)
Courtesy of the Color Atlas of Family Medicine
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Alopecia Areata
• Scalp may be slightly red or edematous
• Exclamation mark hairs characteristic
– Short hairs that taper as they approach the
scalp surface, then root.
• Poor prognosis
– Severe disease (esp. Totalis/Universalis)
– Nail or peripheral scalp disease
– Onset before puberty
– Duration >1 yr
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Alopecia Areata
Courtesy of the Color Atlas of Family Medicine
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• Reassurance – 80% limited cases regrow
– May ask for tx even for a small patch
• Mild cases (<10% scalp) - intralesional
steroids to decreasing inflammation
around the follicle
– May pretreated with topical anesthetic cream
• Potent topical steroids – little evidence
• Severe forms hard to treat (referral)
Alopecia Areata Treatment
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• Intralesional steroids - triamcinolone
acetonide (Kenalog) 10mg/ml
• Inject while advancing needle using only
enough to blanch the skin momentarily
• Can repeat
q 4 weeks
• Major side
effect is
skin atrophy
Alopecia Areata Treatment
Courtesy of the Color Atlas of Family Medicine
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• Systemic steroids for larger areas
– May lose hair when tapered or D/C
• Minoxidil topically with steroids but
success is varied and is slow
• PUVA, but 1993 study by Healy, et al
noted it was not an effective treatment
• Anthralin applied to induce erythema
has been tried to induce hair growth and
may be tried in combination for
refractory cases
Alopecia Areata Treatment
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Telogen Effluvium
• Acute hair loss (up to 20% at peak)
• Occurs 3-4 months after a trigger
– Pregnancy, severe wt loss, major illness or
Sx, traumatic psych events
• Women > men
• Anagen hairs precipitated into catagen
• As reach the telogen phase, new
anagen hairs develop and cause the
hair to abruptly fall out
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Telogen Effluvium
• Patient complains that the hair comes
out “in handfuls” or pillowcase is
covered in
the morning
with hair
Courtesy of the Color Atlas of Family Medicine
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Telogen Effluvium
• Patients often do not associate with
precipitating illness due to time interval
• Drugs can cause telogen effluvium
– PTU, Tapazol, heparin, and coumadin
– Hypervitaminosis A
• Pull test: > 5 blub (telogen) hairs
• Lab: TSH, Iron studies, RPR or VDRL
• No specific treatment
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Trichotillomania
• First identified 1889 by Hallopeau
• Obsession with hair - pt pulls and plucks
hair =
bald patches
or diffuse
hair loss
• 2-3% of all
people with
hair loss
Courtesy of the Color Atlas of Family Medicine
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Trichotillomania
• Mean onset age 13
• Dx usually by the pattern of loss,
sometimes with unusual shapes
• Women >
men
• Geometric
patterns
Courtesy of the Color Atlas of Family Medicine
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• Broken hairs on physical exam
Trichotillomania
Courtesy of the Color Atlas of Family Medicine
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• Usually not scarring,
but plucking over
years may result in
immune cell infiltrate
• RPR, TSH
• Behavioral tx
• Wear gloves - difficult
to pluck
Trichotillomania
Courtesy of the Color Atlas of Family Medicine
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Traction Alopecia
• Unintentional traumatic hair loss
• Often seen in African-Americans when
hair is placed in tight braids
– Outermost
hairs subjected
to most tension
– Given time, a
zone of alopecia
results between
braids and along
scalp margin
Courtesy of Ed Jackson, M.D.
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Traction Alopecia
• Usually seen
in temporal,
frontal and
periauricular
regions of
scalp
• Rx would be
hair
restoration
techniques
Courtesy of the Color Atlas of Family Medicine
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Scarring Alopecias
• Very heterogeneous group
• Trend for hair destruction in early or
even mild stages of the disease
• Hair loss permanent
• Erythematous
papules, pustules,
scaring, loss
of follicle openings
• Polytrichia
Courtesy of the Color Atlas of Family Medicine
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• Most common scarring allopecia
• Usually affects scalp
• Well circumscribed, erythematous
infiltrated patches w/ follicular
hyperkaratosis
• Later atrophic smooth depressed
hypopigmented patches
• Bx = immune deposits
• Tx = treat lupus
Lupus Alopecia
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LSU Health Sciences Center – USA Courtesy of E.J. Mayeaux, Jr., M.D.
Lupus Alopecia
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LSU Health Sciences Center – USA Courtesy of Dr. E.J. Mayeaux, Jr., M.D.
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Nail Disorders - Introduction
• May be intrinsic to the nail unit,
due to infection, or systemic
disease
• Need careful history and exam
• Laboratory examination
– Biopsies
– Slide examination
– Cultures
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Examining the Nail
• Remove polish
• Examine all 20 nails
• Digits relaxed
– Note shape, contour, and color
– Observe obliquely for superficial
plate changes
– Distal groove, folds, or
eponychium
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Examining the Nail
• Examine lunula
• Squeeze the digit tip
– Assess lesion color changes
– Assess refill
• Transilluminate
• Make simple
drawings
Courtesy of Dr. E.J. Mayeaux, Jr.
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Examining the Nail
• 3mm per month
– 6 months to regenerate a nail
– Toenails grow at 1/2 to 1/3 that rate
• Changes from matrix are concave
– Mimic shape of lunula
• Changes from cuticle are convex
– Mimic shape of cuticle
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Normal Variants
• Longitudinal
ridging
– Benign, parallel,
elevated nail
ridges
– More common
with aging
Courtesy of Dr. E.J. Mayeaux, Jr.
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Normal Variants
• Leukonychia punctata and
transverse striate leukonychia
– Benign, white spots or lines in the nails
– Typically don’t extend width of nail
Courtesy of Dr. E.J. Mayeaux, Jr.
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Normal Variants
• May result from minor trauma
• Most common childhood nail condition
• Reassure no
Tx is necessary
• Behavior
modification
helpful
Courtesy of Dr. E.J. Mayeaux, Jr., M.D.
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Habit Tic Deformity
Courtesy of the Color Atlas of Family Medicine
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Onychogryphosis
Courtesy of Dr. Richard Usatine
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Longitudinal Melanonychia
• Tan, brown, or black stripe
– Runs longitudinally through nail
Courtesy of Dr. Richard Usatine Courtesy of Dr. E.J. Mayeaux, Jr.
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Longitudinal Melanonychia
• Increased nail melanin
deposition
– Simulated by deposition of other
chromagins in or under nail
• Melanoma must
be considered
– Bx if cause
not apparent
Courtesy of Dr. E.J. Mayeaux, Jr.
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Longitudinal Melanonychia
• More common with darker skin
– 77% of African Americans >20
years and ~100% >50 years
– 10% to 20% of Japanese descent
– Common in Hispanics
– Unusual among whites
• More common in
frequently used fingers and
thumb
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Subungual Melanoma
• Small number of
patients with LM
have subungual
melanoma
• Separating benign
from malignant
lesions is often
difficult Courtesy of Dr. Richard Usatine
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LSU Health Sciences Center – USA
Subungual Melanoma
• 45% to 60% arise
on hand
– Most in the thumb
• On foot, occurs on
great toe
• Median age =
60s and 70s
• Males = females
Courtesy of The Color Atlas of Family Medicine
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LSU Health Sciences Center – USA
Subungual Melanoma
• Hutchinson's sign
– Periungual spread of
pigment into the
proximal
or lateral nail folds
– Presumes melanoma
• Pseudo-
Hutchinson's sign
– Benign LM visible
through nail fold Courtesy of the Color Atlas of Family Medicine
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LSU Health Sciences Center – USA
Subungual Melanoma
• Biopsy if etiology uncertain
• Provide adequate tissue
• No single bx method best
– Dystrophy less with distal matrix bx
– Appearance less
crucial in the toes
– Bx more
aggressively in
older patients
Courtesy of the Essential Guide to Primary Care Procedures
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LSU Health Sciences Center – USA
Psoriasis
• Hereditary skin
disorder
– Affects 2% to
3% of U.S.
population
– Prevalence
increases with
age
Courtesy of Dr. Richard Usatine
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LSU Health Sciences Center – USA
Psoriasis
• Chronic scaling
papules and
plaques are
most common
and
characteristic
findings
Courtesy of Dr. E.J. Mayeaux, Jr., M.D.
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LSU Health Sciences Center – USA
Psoriasis
Courtesy of Dr. Richard Usatine
Courtesy of Dr. E.J. Mayeaux, Jr., M.D.
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LSU Health Sciences Center – USA
Psoriasis
• Nail involvement - 10% to 50%
• Usually coexists with skin psoriasis
• Nail involvement = higher incidence
of arthritis
• Nail plate pitting
– Proximal matrix forms superficial plate
– Pinpoints to punched out lesions
– Not specific for psoriasis
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LSU Health Sciences Center – USA
Psoriasis - Nail Plate Pitting
Courtesy of Dr. Richard Usatine Courtesy of Dr. E.J. Mayeaux, Jr., M.D.
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LSU Health Sciences Center – USA
Psoriasis - Nail Plate Pitting
Courtesy of Dr. Richard Usatine
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LSU Health Sciences Center – USA
Psoriasis
• Longitudinal matrix involvement
produces ridging or splitting
• Transverse produces Beau's lines
• Intermediate
produces
leukonychia
and diminished
integrity
Courtesy of Dr. Richard Usatine
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LSU Health Sciences Center – USA
Courtesy of Dr. Richard Usatine
Psoriasis –
Onycholysis/Onychorrhexis
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LSU Health Sciences Center – USA
Psoriasis
• Bed psoriasis = local onycholysis
– Oil drop sign Salmon patch sign
Dr. E.J. Mayeaux, Jr. Courtesy of Dr. Richard Usatine
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LSU Health Sciences Center – USA
Psoriasis
• Vascular
dilatation &
tortuosity
• Splinter
hemorrhages
of bed
Courtesy of Dr. E.J. Mayeaux, Jr.
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LSU Health Sciences Center – USA
Psoriasis
• Distal onycholysis enhances
microbial colonization
– Greenish-blue
discoloration
suggests
Candida or
Pseudomonas
Courtesy of Dr. E.J. Mayeaux, Jr.
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LSU Health Sciences Center – USA
Psoriasis Diagnosis
• Must DDx from onychomycosis
– KOH prep and fungal culture
• Nail biopsy may be necessary
– H&E and fungal staining
• Withhold Tx until a specific
diagnosis is confirmed
– Psoriasis and onychomycosis may
occur concomitantly
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LSU Health Sciences Center – USA
Psoriasis Treatment
• Nail disease often refractory
• Intralesional corticosteroid injection
into the proximal nail fold
– Pain minimized by
precooling or block
– Nail bed ds =
proximal injection
– Matrix disease =
fold injection
Courtesy of Dr. Richard Usatine
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LSU Health Sciences Center – USA
Psoriasis Treatment
• Mid- to high-potency corticosteroid
solution under edge of distal plate
– Don’t force solution under the plate
– Mechanical trauma increases uplifting
• Oral and topical Psoralen (PUVA)
– UVB not effective
• Oral etretinate, acitretin, and
cyclosporine
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LSU Health Sciences Center – USA
Lichen Planus
• Uncertain etiology
Courtesy of The Color Atlas of Family Medicine
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LSU Health Sciences Center – USA
Lichen Planus
• Nail involvement in
10% of patients
– Brittle, ridged nails
most common
– Onychorrhexis or
splitting
Courtesy of Dr. Richard Usatine
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LSU Health Sciences Center – USA
Lichen Planus
• Proximal
matrix ds
produces
onychorrhexis
or splitting
Courtesy of Dr. E.J. Mayeaux, Jr., M.D.
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LSU Health Sciences Center – USA
Lichen Planus
• Diffuse matrix atrophy produces
thinning of the plate
• Tends to predominate centrally,
producing "angel wing"
deformity
• Pterygium results of matrix
scarring
– Specific for lichen planus
– Total matrix scarring - anonychia
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LSU Health Sciences Center – USA
Lichen
Planus -
Pterygium
Courtesy of Dr. E.J. Mayeaux, Jr., M.D.
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LSU Health Sciences Center – USA
Lichen Planus
• Onset at any age
– Most common in fifth or sixth
decade
• Fingernails and toenails affected
• Involvement of nail bed or
hyponychium produces
subungual hyperkeratosis or
distal onycholysis
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LSU Health Sciences Center – USA
Lichen Planus Diagnosis
• Straightforward when the disorder
coexists with cutaneous signs
• Mycologic studies to exclude
onychomycosis
• If negative, a nail biopsy will likely
be needed to confirm the
diagnosis
– Examination should include H&E
and PAS staining
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LSU Health Sciences Center – USA
Lichen Planus Treatment
• Unless matrix scarring has
occurred, the disease is
treatable
• Intralesional corticosteroid
• If this fails, Prednisone 60mg
daily for several weeks then
slow tapering
– Then alternate-day therapy
• Oral etretinate and topical PUVA
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LSU Health Sciences Center – USA
Paronychia
• Acute
inflammation of
the lateral and/or
proximal nail
folds
Courtesy of Dr. Richard Usatine
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LSU Health Sciences Center – USA
Paronychia
• Red, tender, throbbing, intensely
painful
• Usually caused by infection
– Staph aureus, Strep pyogenes, and
Pseudomonas most common
• Small abscess
forms
Dr. E.J. Mayeaux, Jr.
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LSU Health Sciences Center – USA
Paronychia
• Chronic paronychia by Candida
Courtesy of Dr. E.J. Mayeaux, Jr., M.D.
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LSU Health Sciences Center – USA Courtesy of The Essential Guide to Primary Care
Procedures and Dr. E.J. Mayeaux, Jr., M.D.
Paronychia I&D Technique
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LSU Health Sciences Center – USA
Onychomycosis
• Fungal infection of the nails
• Dermatophytes most common
– May be other fungi and Candida
• Single digit or multiple digits
• Very common in adults
– May also occur in children
• Trauma predisposes to infection
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LSU Health Sciences Center – USA
Onychomycosis
• Trichophyton rubrum and T.
mentagrophytes
more frequent
– T. violaceum,
T. tonsurans,
& Scytalidium
species
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LSU Health Sciences Center – USA
Distal Subungual Onychomycosis
• Most common type
– Discoloration
– Debris build-up
Courtesy of Dr. Richard Usatine
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LSU Health Sciences Center – USA
Distal Subungual Onychomycosis
– Plate crumbles
– Accumulation of hyperkeratotic debris
Courtesy of Dr. Richard Usatine
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LSU Health Sciences Center – USA
Onychomycosis Diagnosis
• Tendency to label any process
involving nail as a fungal infection
• Confirm species before treatment
– Sabouraud's medium
– Trim excess nail before samples
taken
• Leukonychia and psoriasis may be
confused with onychomycosis
– Also eczema or habitual picking
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LSU Health Sciences Center – USA
Onychomycosis Treatment
• Treating onychomycosis difficult
– Topical meds ineffective
– Reinfection when oral meds stopped
• Oral therapy has best success
– Beware drug interactions
• Ketconazole and griseofulvin can
cause liver damage
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LSU Health Sciences Center – USA
• A Cochrane review found no evidence
of benefit for topical treatments
compared with placebo
• http://www.mrw.interscience.wiley.com/cochran
e/clsysrev/articles/CD001434/frame.html
• Terbinafine significantly increased the
mycological cure rates compared with
placebo, itraconazole and griseofulvin
• http://www.mrw.interscience.wiley.com/cochran
e/cldare/articles/DARE-20021632/frame.html
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LSU Health Sciences Center – USA
Oral Onychomycosis Tx
Drug Dose Course
Griseofulvin (Grifulvin V) 500mg PO qday or 15-20mg/kg/day
4-9 months (f), 6-12 months (t)
Terbinafine (Lamisil) 250mg PO qday or < 20kg: 62.5mg/day 20-40kg: 125 mg/day
6 weeks (f), 12 weeks (t)
Terbinafine (Lamisil) pulse (not FDA indicated)
500mg 1wk/mo x4mo (not thoroughly studied)
6 weeks (f), 12 weeks (t)
Itraconazole (Sporanox) 200mg daily 2 months (f), 3 months (t)
Itraconazole (Sporanox) pulse
200mg BiD or 5mg/kg/day capsules for 1 wk/month
2 months (f), 3 months (t)
Fluconazole (Diflucan) (not FDA indicated)
150mg or 3-6mk/kg once weekly (not thoroughly studied)
12-16 weeks (f), 18-26 weeks (t)
Ciclopirox 8% nail lacquer (Penlac)
Apply daily to nail and surrounding 5mm skin.
Up to 48 weeks.
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LSU Health Sciences Center – USA
Myxoid Cysts
• Most common ungual tumor except
for HPV lesions
• Dorsum of distal digit
between DIP and
proximal nail fold
• Sermitranslucent,
flesh to pink,
compressible nodules
Courtesy of Dr. Richard Usatine
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LSU Health Sciences Center – USA
Myxoid Cysts
• May be associated with evidence of osteoarthritis (Herberdon's nodes)
• Localized degenerative tissue reaction
• Connecting to joint, complete excision is required
• Impinges on nail matrix
– Produces longitudinal grooves and
thinning
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LSU Health Sciences Center – USA
Myxoid Cyst
Excision
Courtesy of Dr. E.J. Mayeaux, Jr., M.D.
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LSU Health Sciences Center – USA
Myxoid Cysts
• Nonconnecting variety treated with
repeated evacuation with a needle
– Cavity and base injection with 0.1 to 0.2
mL triamcinolone acetonide, 5 mg/mL
– 15- to 20-sec cryotherapy (2 to 3 mm
iceball) freeze-thaw-freeze pattern
– Sclerosants (Na tetradecyl sulfate )
– If unresponsive - excise proximal fold
with 2nd intention healing
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LSU Health Sciences Center – USA
Pincer Nails
• Result of inward folding of the lateral
edges of the nail
Dr. E.J. Mayeaux, Jr.
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LSU Health Sciences Center – USA
Pincer Nails
• Tube-shaped nail
• Nail bed may be painfully
enclosed
• Lateral pressure from shoes is a
likely etiology
• Nail removal or reconstruction
may be necessary if pain is
significant
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LSU Health Sciences Center – USA
Changes Associated with Systemic
Disease
• Beau's lines
– Transverse lineardepressions
– Suppressed nail growth secondary to
local trauma
or severe
illness
– Appear
symmetrically
in several or
all nails
Courtesy of The Color Atlas of Family Medicine
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LSU Health Sciences Center – USA
Changes Associated with Systemic
Disease
• Beau's lines
– Grows out over several months
– Time since
onset of
systemic illness
– Nails grow
1mm every 6
to 10 days
Courtesy of Jeff Meffert and The
Color Atlas of Family Medicine
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LSU Health Sciences Center – USA
Changes Assoc. with Systemic Disease
• Mees’ lines
– Multiple white transverse lines
– Historically arsenic intoxication
– Begins in matrix & extends across nail
– Usually single, but may be multiple
– Move distally as the nail grows
– Bx showed plate
fragmented
– Chemical analysis
of nail or hair
Courtesy of Dr. Richard Usatine