Nail, Hair And Scalp Disorders

Question 1

Pigmentation of the nail plate is where?

Answer 1

Suprabasalar layers of the distal matrix

- high levels of melanocytes

Question 2

Beaus lines

Answer 2

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

Question 3

Onychomadesis

Answer 3

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

Question 4

Pitting

Answer 4

Abnormal keratinization of proximal nail matrix
- clusters of parakeratotic cells in the dorsal nail plate

common in psoriasis, eczema and alopecia areata

Question 5

Onychorrhexis

Answer 5

Longitudinal ridging of the nail plate
- diffuse damage to the nail matrix and thinning of the nail

Casues = aging, reptitive trauma and vascular diseases

Question 6

Trachyonychia

Answer 6

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

Question 7

Leukonychia

Answer 7

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

Question 8

mee’s lines

Answer 8

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

Question 9

Koilonychia

Answer 9

Thinning and “spooned-shaped” (concave) nails

Is normal in children!!

• however in adults means pathology = ****chronic iron deficiency!!
• can also be hemochromatosis and hyperthyroidism

Question 10

Onycholysis

Answer 10

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

Question 11

Apparent Leukonychia

Answer 11

Leukonychia that is false

- goes away with pressure and DOES NOT grow with the nail or move distally

Question 12

Half and half (Lindsay nails)

Answer 12

Apparent Leukonychia

Very heavily tied to renal dysfunctions and hemodialysis patients

Question 13

Muehrckes lines

Answer 13

Apparent Leukonychia with narrow multiple white transverse bands
- must grow in pairs

Chronic hypoalbuminemia (nephrotic syndromes) and combo chemotherapy are the msot common causes

Question 14

Terry nails

Answer 14

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

Question 15

Splinter hemorrhages

Answer 15

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

Question 16

Hutchinson sign

Answer 16

Hyperpigmentation along the entire nail that also includes the proximal and lateral nail fold

highly suspect of malignant melanoma

Question 17

Green nail syndrome

Answer 17

Green-blue/black nail discoloration
- caused by pyocyanin pigments due to pseudomonas aeruginosa infections

Treatment = topical quinolone and acetic acid for 1-4 months

Question 18

Pyogenic granuloma

Answer 18

Red growths under nails that can be cancerous
- common in pregnancy, trauma and drugs

must rule out amelanotic melanoma with biopsy

Question 19

Clubbing of the nails

Answer 19

Very highly associated with pulmonary or cardiac diseases

*can be asymmetric which leads to likely hood of sarcoidosis or takayasu arteritis

Question 20

What medications can mimic onychocryptosis (ingrown toe nails)

Answer 20

Isotretinoin

Lamuvidrinae

Question 21

Phases of hair growth

Answer 21

Anagen

Telegen

Catagen

Question 22

Telegenic effluvium

Answer 22

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

Question 23

Two components of the nail apparatus

Answer 23

1) epithelia

2) nail palate
- produced by stratum germinativum

Question 24

Nail immune system

Answer 24

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

Question 25

Anagen effluvium

Answer 25

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

Question 26

Alopecia Areata

Answer 26

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

Question 27

Androgenetic alopecia | “Patterned baldness”

Answer 27

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)

Question 28

What labs do you check in women with hair loss?

Answer 28

CBC Iron panel Ferritin TSH DHEA-S Free testosterone B12/folate Vitamin D Zinc

Question 29

Differential diagnosis of hirsutism (excessive male-patterned hair growth)

Answer 29

Ovarian or adrenal androgen excess (PCOS, CAH, Cushings,m tumors) Pituitary disorders Iatrogenic medications (anabolic steroids, phenytoin, Diazoxide, cyclosporine, hexachlorobenzene)

Question 30

Red flags for hirtuism

Answer 30

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

Question 31

Congenital adrenal hyperplasia

Answer 31

Most common form of 21 hydroxylase deficiency - will show testosterone and/or DHEAS elevated - cortisol will be normal **if rapid symptoms = adrenal tumor instead**

Question 32

Treatment of hirsutism

Answer 32

Correct underlying cause if possible Medications - spironolactone 100mg p.o day - finasteride 2.5-5 mg daily

Question 33

What medications cause hypertrichosis

Answer 33

#1 = cyclosporine Minoxidil, latanoprost, corticosteroids, streptomycin, topical androgens

Question 34

6 major components of the nail unit

Answer 34

Nail matrix Nail plate Cuticle Nail bed Anchoring portion Framing portion (lateral/proximal/distal folds) Lunula = only visible portion

Question 35

Eyebrows, eyelashes and vellus hairs are androgen-dependent?

Answer 35

NO they are the only hairs that are not

Question 36

Ferritin levels need to be at least what to treat iron-deficiency related telogen effluvium

Answer 36

40ng/dL

Question 37

Erythronychia

Answer 37

Longitudinal red bands on nails seen in dariers disease | - mutation in ATP2A2 gene

Question 38

Longitudinal melanonychia

Answer 38

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)

Question 39

Red lunula

Answer 39

Seen in CO poisoning always Can also be alopecia areata, SLE or CHF as well

Question 40

Blue lunala

Answer 40

Seen in Wilson disease of medication most commonly | - medications = 5-FU, minocycline, anti malaria drugs

Question 41

Yellow nails

Answer 41

Most commonly associated with lymphedema and/or compromised respiratory system Tx = vitamin E

Question 42

Trichotillomania

Answer 42

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

Question 43

Acute chronic lupus hair loss

Answer 43

Shows telogen hair loss and does NOT scar Can also show ear hair loss Treatment = IL steroids

Question 44

Central centrifugal scarring alopecia

Answer 44

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

Question 45

Dissecting cellulitis of the scalp

Answer 45

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

Question 46

Sebopsoriasis

Answer 46

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 ```