Disorders of the Hair and Nails - Clin Med

What does this refer to

• Partial or complete absence of hair from areas of the body where it normally grows; baldness

• Rapid onset and in a sharply defined area

• Condition attacks but does not destroy hair follicles

• Common classifications

  • Androgenetic alopecia (male)

  • Androgenetic alopecia (female)

  • Alopecia areata

Alopecia

What does this refer to

• Larger than vellus hair follicles

• Extend into the subcutaneous fat

• (Usually) at least 0.06mm in diameter

• At birth

  • Scalp

  • Eyebrows

  • Eyelashes

Terminal Hair type (Alopecia)

What does this refer to

• Lowest portions extend only into the reticular dermis

• Short, fine

• (Usually) < 0.03mm in diameter

• Location

  • Remaining hair-bearing areas

• During puberty

  • Stimulated to become terminal hairs in the genital area & axilla

Vellus Hair Types (Alopecia)

What does this refer to

• Common form of non-scarring alopecia

• Autoimmune disorder

• Usually occurs in patches

• May also progress to loss of all scalp or body hair

• May also occur at the occiput scalp margin (ophiasis)

Alopecia areata

What does this refer to

• Male pattern hair loss

• Slow progressive loss of hair in a characteristic distribution

Androgenetic alopecia in men

What does this refer to

• Hair loss most frequently presents as hair thinning

  • Frontal and crown areas of the scalp

  • Relative sparing of the occipital scalp

Female pattern hair loss

What does this refer to

• Disorder in which individuals repeatedly pluck hairs from the scalp or other hair-bearing areas

• Psychiatric disorder included in the DSM

• Areas of alopecia may have irregular, bizarre shapes

Trichotillomania

What does this refer to

• Common disorder

• MC in those under 30yo

  • Includes children and teenagers

• Early onset (5-10yo) is most severe

• MC AA or Hispanics, especially in women

Epidemiology of Alopecia Areata

What does this refer to

• Autoimmune

• Genetic

EtiologyAlopecia Areata

What does this refer to

• May have burning or tingling in the area

• Hair loss is rapid

Clinical historyAlopecia Areata

What does this refer to

• Round or oval patches of baldness

• Healthy looking skin where hair loss occurred

• Co-occurring symptoms of fingernails or toenails

  • Softer or brittle nails

  • Dents or ridges across the nail

  • Nails that feel rough or "sandpaper-like"

  • Red coloration of the nail bed

Physical examAlopecia Areata

What does this refer to

WorkupAlopecia Areata

What does this refer to

• Minoxidil (Rogaine or Theroxidil) foam or solution

  • Applied to affected areas

  • Does not stop disease

  • Considered safe tx and is good choice for children

• Topical contact sensitizers

  • Designed to produce a contact dermatitis

Clinical interventionAlopecia Areata

What does this refer to

• JAK inhibitors (currently in clinical trials) blunt inflammation by blocking the signaling pathways during the immune response

  • Tofacitinib

  • Ruxolitinib

  • Baricitinib

Clinical managementAlopecia Areata

What does this refer to

Complementary & alternative medicine (CAM)Alopecia Areata

What does this refer to

• Fungal infection of the toenails or fingernails

• May involve any component of the nail unit

  • Matrix, bed, or plate

Onychomycosis

What does this refer to

• Equally affects all races

• M > F

• MC in adults

• MC affects the great toe

EpidemiologyOnychomycosis

What does this refer to

EtiologyOnychomycosis

What does this refer to

• Complains of nail appearance

• Disease progression = symptoms

  • Interfering with standing, walking and exercising

  • Further progression

    • Paresthesia

    • Pain and discomfort

    • Loss of dexterity

Clinical historyOnychomycosis

What does this refer to

• Distal lateral subungual onychomycosis

• Subungual hyperkeratosis and onycholysis

  • Yellow-white in color

  • Yellow streaks and/or yellow onycholytic (nail detachment) areas in the central portion of the nail plate

Physical examOnychomycosis

What does this refer to

• Endonyx onychomycosis

• Milky white discoloration of the nail plate (small, white, speckled)

• No subungual hyperkeratosis or onycholysis is present

Physical examOnychomycosis

What does this refer to

• Proximal subungual onychomycosis

• Leukonychia in the proximal nail plate that moves distally with nail growth

• Leukonychia caused by molds

  • Marked periungal inflammation

Physical examOnychomycosis

What does this refer to

• Total dystrophic onychomycosis

  • Thickened

  • Opaque

  • Yellow-brown

• Periungal inflammation

• Multiple digits involved

• Bulbous or drumstick appearance

• Image shows Candida onychomycosis associated with Chronic mucocutaneous candidiasis

Physical examOnychomycosis

What does this refer to

WorkupOnychomycosis

What does this refer to

• History and physical exam

• KOH or PAS + culture

DiagnosisOnychomycosis

What does this refer to

• Appropriate footwear

• High exposure areas include communal bathing facilities and health clubs

Clinical interventionOnychomycosis

What does this refer to

• Fungal infection should be confirmed by culture + rapid test (KOH or PAS)

• Can initiate tx before cultures result if KOH or PAS is positive

• Systemic antifungals

  • Terbinafine (Lamisil) (1st line for dermatophytes)

  • Itraconazole (dermatophytes and candida)

• Topical antifungals

  • Efinaconazole (Jublia)

  • Tavaborole (Kerydin)

Clinical managementOnychomycosis

What does this refer to

• Tea tree oil (topical)

• Vitamin E (topical)

• Oil of bitter orange (topical)

Complementary & alternative medicine (CAM)Onychomycosis

What does this refer to

• Residual nail changes

• Onychomycosis with mold etiology usually not responsive to systemic therapies

• Recurrence is common

• Fungal infections of fingernails have more favorable prognosis than toenail infections

PrognosisOnychomycosis

What does this refer to

• Inflammation/infection involving the lateral and proximal fingernail folds (the cuticle)

Paronychia

What does this refer to

• Fingernails MC than toenails

• MC hand infection in the US

• F > M

• Appearance of the hand (or foot) often greater issue than severity of infection

• Occurrence of cracks, fissures or trauma allows organisms to enter moist nail crevice

EpidemiologyParonychia

What does this refer to

• Overzealous manicuring, including acrylic nails and glue

• Nail biting

• Thumbsucking

• Diabetes mellitus

• Frequently immersing hands in water

• Bacterial and fungal etiology MC

  • What do you think the most common bacterial pathogen is

Etiology/risk factorsParonychia

What does this refer to

• Initial presentation may be simple, uncomplicated cellulitis (< 24hrs)

• Characterized by the onset of pain and erythema of the posterior or lateral nail folds

• Subsequent development of a superficial abscess

• Fluctuant paronychia usually bacterial infection

Clinical history & presentationParonychia

What does this refer to

• Throbbing pain in pulp of the finger

• Fingertip swelling and redness

• Pain and swelling progressive

• Tense fingertip pulp

• Delay in treatment (ORTHO CONSULT)

  • Can extend toward phalanx (deep)

  • More extensive infection may result in necrosis or involve the palmar tissue/fascia

Felon finger(A CAN’T MISS DIAGNOSIS)

What does this refer to

• Viral infection of the pulp of the fingertip

• Often confused with bacterial paronychia

• Characterized by

  • MC terminal phalanx

  • Clear vesicles grouped on erythematous bases

  • May be on more than 1 finger

Herpetic whitlownot a paronychia

What does this refer to

WorkupParonychia

What does this refer to

• Good hand hygiene

• No nail biting

• Manicures with caution

• Warm soaks, compresses 3-4x daily

Clinical interventionParonychia

What does this refer to

Clinical managementParonychia

What does this refer to

• Warm water soaks

• Apple cider vinegar soaks

• Topical Tea tree oil

• Limit acidic foods/beverages

• Baking soda and water paste (topical)

Complementary & alternative medicine (CAM)Paronychia

What does this refer to

• Good with prompt treatment

• Untreated or delay in treatment

  • May lead to septic tenosynovitis, osteomyelitis or by spreading to the pulp space of the finger

  • May result in loss of nail

  • Secondary nail changes (ridging, thickening and discoloration)

PrognosisParonychia