Nails and Hair Questions

Question 1

What is onychomycosis?

Answer 1

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)

Question 2

What are the physical findings of onychomycosis?

Answer 2

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

Question 3

Ddx for onychomycosis?

Answer 3

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

Question 4

How can you diagnose onychomycosis?

Answer 4

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

Question 5

What can be seen in a KOH for onychomycosis?

Answer 5

Fungal hyphae (looks almost like little branches)

Question 6

What is the treatment for onychomycosis?

Answer 6

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

Question 7

What is the first line treatment for onychomycosis?

Answer 7

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

Question 8

What information is important to give a patient when giving treatment for onychomycosis?

Answer 8

Toe nails and fingernails take a significant time to grow (months) and it will take a while before results are seen

Question 9

What do you need to check for before using Lamisil (terbinafine) for onychomycosis?

Answer 9

Liver function labs (LFT), medication is metabolized by liver

Question 10

What is paronychia?

Answer 10

Infection of skin on sides of nail (proximal and lateral nail folds)
Can be acute or chronic

Question 11

What causes paronychia?

Answer 11

A small opening on these surfaces allows bacteria to enter

Question 12

What are the clinical features of paronychia?

Answer 12

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)

Question 13

What is the difference between acute and chronic paronychia?

Answer 13

Difference in presentation and symptoms
Acute- more painful, prurulent
Chrinic- less painful, discoloration of nails

Question 14

How is paonychia diagnosed?

Answer 14

Collection of prurulent dishcarge
Bacterial culture, KOH smear, imaging (if osteomyelitis is suspected: systemic fever/chills)

Question 15

What is the treatment for acute paronychia?

Answer 15

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

Question 16

What is the treatment for chronic paronychia?

Answer 16

Topical steroids, skin protection (prevent moisture exposure)
-decreasing chronic inflammation

Question 17

What would you tell a patient with paronychia as far as terms of education?

Answer 17

Avoid nail biting, trim hang nails, trim nails flush to tip, avoid excessive moisture exposure (prevents infection)

Question 18

What is alopecia universalis?

Answer 18

When all hair bearing areas of body are bald

Question 19

What is alopecia totalis?

Answer 19

When entire scalp is bald

Question 20

What is alopecia areata?

Answer 20

“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

Question 21

What is the cause of alopecia areata?

Answer 21

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

Question 22

What are the clinical features of alopecia areata?

Answer 22

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)

Question 23

DDx for alopecia areata?

Answer 23

-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)

Question 24

How is alopecia areata diagnosed?

Answer 24

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

Question 25

How can alopecia areata be treated?

Answer 25

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)

Question 26

Can hair grow back after alopecia areata?

Answer 26

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

Question 27

What is androgenic alopecia?

Answer 27

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)

Question 28

What are the clinical features IN MEN with androgenic alopecia?

Answer 28

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)

Question 29

What are the clinical features IN WOMEN with androgenic alopecia?

Answer 29

Unclear hormonal component

Present with thinning at crown of the scalp (widening of part, hair shedding)

Question 30

How is androgenic alopecia diagnosed?

Answer 30

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

Question 31

What are treatments for FEMALE androgenic alopecia?

Answer 31

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

Question 32

What are treatments for MALE androgenic alopecia?

Answer 32

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

Question 33

What is telogen effluvium?

Answer 33

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

Question 34

What is a normal amount of hair loss?

Answer 34

100-150 hairs per day on average, can vary from person to person

Question 35

What can promote telogen effluvium?

Answer 35

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)

Question 36

How is telogen effluvium diagnosed?

Answer 36

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

Question 37

Is there a treatment for telogen effluvium? How can it be managed?

Answer 37

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

Question 38

What is central centrifugal cicatricial alopecia (CCCA)?

Answer 38

Permanent scarring alopecia, usually happens faster that female androgenic alopecia

Question 39

What are the signs/symptoms of CCCA?

Answer 39

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

Question 40

Who is more vulnerable to CCCA?

Answer 40

Black women 30y/o+
Due to hair care practices (chemical relaxers, hot combs for straightening of hair) and genetics

Question 41

How is CCCA diagnosed?

Answer 41

Usually a clinical diagnosis, but can biopsy

Question 42

What is the treatment for CCCA?

Answer 42

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