COMMON HAIR DISORDERS

Hair Cycle Diagnostic Tools for Hair

Anagen (2-7 years)
Hair Pull Test

• Growth phase • Assesses ongoing activity of hair loss

• Genetically determined
• Grasp 50-60 hairs and tug from proximal to distal end

• 1cm/28 days
• (+): 3-6 hairs
• Determines the length of the hair shaft
• Simple test done in opd

• Divided into seven stages (from onset of mitosis until Trichogram (Hair Pluck Test)

stage VII where stable growth is achieved)

• 25-50 hairs should be grasped with a needle holder and plucked sharply
Catagen (2-3 weeks)
• Proximal ends placed on a glass slide in a drop of water and covered

• Onset is marked by cessation of mitotic activity • >35% of hair removed = Telogen effluvium
• Well-coordinated apoptosis that occurs in the cyclic Dermatoscopy

portion of the hair follicle

• Direct visualization of scalp and hair loss pattern

• Short transition
• Alopecia areata: black dots inside yellow dots

• Hair follicle shrinks and detaches from the skin

• Androgenetic alopecia: variability in the hair shaft diameter >20%

• Convert to club hair

Scalp Biopsy

Telogen (3-9 months)

• Invasive procedure

• Resting phase
• Uses a small puncher (3-4mm) to get a sample of the scalp

• Club hair: dead, fully keratinized hair

• Essential for diagnosis of scarring (cicatricial) alopecia
• About 1% of telogen follicles are shed each day
• Warranted since treatment is aggressive

• New follicle begins to develop

Hair Shedding Count

Exogen
• “Bag of hair”

• Highly controlled and timed event

• Patients bring all hair shed during follow-up

• Immediate telogen release • Subjective

• Hair follicle is shed and new follicle continues to grow • <100 is normal

KOH

• Important if fungal infection is considered

Others:

CBC, ferritin, TIBC: IDA can cause hair loss

TSH, FT3, FT4: hypo/hyperthyroidism causes diffuse hair loss which involves entire scalp

Non-Scarring Alopecia Scarring Alopecia • Diverse group of scalp disorders that result in
• More common • Less common
permanent hair loss

• (+/-) Erythema, scaling, or pustules

• (+) Erythema, scaling, or • Characterized clinically by a loss of follicular ostia and
• Possible regrowth
pustules
pathologically by a replacement of hair follicles with
• Generally favorable prognosis
• (+) Atrophy
fibrous tissue
• More responsive to treatment • (+) Loss of follicular openings

• (+) Tufted hair

• No regrowth
• Unfavorable prognosis
 NON-SCARRING HAIR DISORDERS

EPIDEMIOLOGY AND
DISORDER DEFINITION TREATMENT EXAMPLE
PATHOGENESIS

• Epidemiology

• M = F

• Occur at any age

• Clinical Presentation
• Incidence at younger
• Acute onset age is higher

• Oval or round, well- • 15% familial occurrence

• Topical Corticosteroids
circumscribed, bald • Pathogenesis
• Would dampen
patches with a smooth • Chronic, organ-specific immune response

autoimmune disease,
surface in a diffuse • Ultrapotent steroids

mediated by autoreactive
distribution
• Occluded for better
CD8+ T-cells, which
• Classification
absorption

affects hair follicles and

• Alopecia Totalis: loss of sometimes nails
• Sometimes combined
entire scalp hair
• With inappropriate with topical minoxidil

• Alopecia Universalis: immune response to hair • Better results

loss of total body hair

follicle associated • ILSI

ALOPECIA AREATA • Hallmarks

antigens
• Systemic Corticosteroids

Most common form of • “Black dots” (cadaver • Collapse of the normal • Short term

hair loss in children hairs or point noir)

immune privilege of the • For patients with very
• From hair that breaks anagen hairbulb
acute onset

before it reaches skin • When co-stimulatory • Could lead to

circumstances occur immunosuppression,
surface

during anagen, AA
• Premature entry to atrophy, and HPA axis
results

catagen phase
alteration

• Complications

• Exclamation point hairs • Relapsing course

• Topical immunotherapy

• Blunt distal end that • Progression to alopecia • Camouflage, wigs, and

tapers proximally totalis or universalis
hairpieces

• Nail Involvement
• Predisposed to sunburn • For patients with
• Nail pitting and skin cancer
diffuse hair loss
• Sandpaper-like • Diminished sense of well-
appearance being and self esteem

• Leads to depression and

withdrawal from social
situations
 EPIDEMIOLOGY AND
DISORDER DEFINITION TREATMENT EXAMPLE
PATHOGENESIS
• Diagnostics

• Epidemiology
• Scalp exam and history:
• Can start as early as definitive diagnosis

prepubertal period
• Global scalp photography:
assessment of progression of
• Progresses to at least type hair loss and as therapy control

• Characterized by III in 50% for > 40 y.o.

• Hair pull test, trichogram,
videodermoscopy and
progressive decline in • M: 2x increased risk of phototrichogram (for therapy
duration of anagen, developing MPHL if with control), scalp biopsy (not
father with hair loss
routinely done)

increase in duration of • Other labs: ferritin, TSH, free

telogen and miniaturization • W: less common
and total testosterone, DHEA-S
• Pathogenesis
(for women with irregular periods
of scalp hair follicles

• In the scalp: testosterone and signs of androgen excess;

• Classification
→ 5-alpha reductase →
done in the morning during one
day of menstrual period)

• Male pattern hair loss DHT → progressive • Treatment

(MPHL): androgen- shrinking or miniaturization • Pharmacologic:

• Oral Finasteride: FDA

dependent & of terminal hair → vellus approved

ANDROGENETIC genetically determined hair (thinned hair) with • Selective 5α-reductase

ALOPECIA trait
subsequent hair loss
type-2 inhibitor

• Inhibit conversion of
also known as
• Progressive decrease in
• Norwood Scale: testosterone to DHT

Male/Female Pattern anagen duration with each • Used on a long-term basis

characterized by • Ineffective if no
Hair Loss
cycle producing shorter and
recession in both thinner hairs

improvement for 2 years

Most common type of • Topical Minoxidil: a biologic

frontotemporal and • Increased interval between response modifer; FDA
hair loss
vertex of scalp telogen hair shedding and approved; causes
hypertrichosis
• Female pattern hair new hair growth
• Mitogenic effect on
loss (FPHL): • MPHL epidermal cells leading to
prolonged survival time and
requirement for • Due to androgen induced increase
androgen less clear cut hyperactivity
proliferation of hair follicles

• Ludwig Scale: • Genetic predisposition to • Increased shedding in first

4-6 weeks

hair loss-related
characterized by sensitivity to androgen
• Cyproterone acetate

• Spirinolactone

central scalp with action

• 17α- or 17beta-estradiol

preservation of • Androgen-independent
• Non-pharmacologic

• Low-level light therapy

frontal hairline genetic predisposition

• Hair Max Laser Comb (only
DFA approved low-fluence
• FPHL laser light device):
• Due to androgen action
increases blood flow in
• Genetic sensitivity to dermal papilla

• Hair restoration surgery

androgen action • Wigs and hair pieces

 SCARRING HAIR DISORDERS

EPIDEMIOLOGY AND
DISORDER DEFINITION TREATMENT
PATHOGENESIS

• Diagnostics

• Group of idiopathic inflammatory

• History

diseases characterized by a
PRIMARY SCARRING folliculocentric inflammatory • Itch or pain: indicators of
disease activity

ALOPECIA process that ultimately distroys

the hair follicle
• If with sun sensitivity

• Scalp examintion

• Scalp biopsy

• Clinical Presentation
• Epidemiology

• Treatment

• 1 or more erythematous, • Women > Men

atrophic, and alopecic patches • Main goal: stop inflammation

• More common in adults (20-40 and further progression of
on the scalp years old)

the disease

CHRONIC LUPUS • Follicular hyperkeratosis, • SLE will develop

ERYTHEMATOSUS (DLE) hyperpigmentation, • Hydroxychloroquine (HCQ)

• Prognosis

Most common cause of hypopigmentation and • Prednisone: to dampen

• No chance of hair regrowth
inflammatory response

inflammatory cicatricial telangiectasia

• Medical treatment options may
• Intralesional steroid injection
alopecia • Hyperpigmentation at the fail

(triamcinolone acetonide)

center of the lesion • Inflammatory process may

• Acitretin and Isotretinoin
• Active lesions can be sensitive continue and leave the patient
(systemic treatment)

or pruritic with worsening after with a disfiguring permanent

UV exposure • Immunosuppressive therapies
alopecia
• Pathology

• Permanent hair loss caused by other

scalp conditions not related to the hair
follicle

• Primary event develops outside the

follicular unit

• Leads to incidental destruction of the

• Caused by cutaneous follicle

• Possible causes:
• Treatment

inflammatory process of the

SECONDARY SCARRING • Congenital defects
• Hair restoration surgery
scalp skin or by physical trauma,
ALOPECIA • Trauma
techniques

which injures the skin and skin • Inflammatory conditions

• Camouflage and hair pieces
appendages • Infections

• Drugs

• Neoplasms

• Prognosis

• Depends on underlying disease

• Once scar tissue has formed and the

adnexal structures are destroyed,
there will be no hair regrowth
 COMMON NAIL DISORDERS

• Nail Plate
Nail Anatomy • Fully keratinized structure

• Continuously produce throughout life

• Proximal Nail Fold

• Dorsal portion: similar to the skin of the dorsum of the digit but
thinned and devoid of pilosebaceous units

• Ventral portion: cannot be seen from the exterior and proximally

continues with the germinative matrix

• Covers approximately 1/4 of the nail plate

• Nail Matrix
• Specialized epithelial structure that lies above the mid portion of
the distal phalanx

• Nail Bed
• Extends from the distal margin of the lunula to the isthmus and is
completely visible through the nail plate

• Hyponychium
• Marks the anatomic area between the nail bed and the distal
groove where the nail plate detaches from the dorsal digit

NAIL MORPHOLOGY ABNORMALITY

DEFINITION EXAMPLE

• Distortion and discoloration of normal nail plate structure

• Results from traumatic or inflammatory process

DYSTROPHIC NAILS • Association

• Wide spectrum of diseases

• Onychomycosis: most common

• Repeated manipulation of the nail plate

 • Nail plate is thin and spoon-shaped
• Physiologic in the toenails of children
KOILONYCHIA • Association
• Iron deficiency anemia
• Occupational damage (i.e. solvents)

• Angle between proximal nail fold and nail plate is >180deg

• May occur with or without cyanosis

• Bulbous digit, enlarged and excessively curved nail plate

• (+) Schamroth window test
CLUBBING • Association

• Lung disease

• Cardiovascular disease

• Liver disease

• Inflammatory bowel disease

• Wedge-shaped nails

• Association

• Pachyonychia congenita
PACHYONYCHIA • Autosomal dominant
• Mutation in one of five different keratin genes

• Associated with thickened toenails, plantar keratoderma, and

plantar pain

• Association

PINCER NAILS • Familial

• Psoriasis
 • Spicule of lateral nail plate pierces into lateral nail fold

• Causes foreign body inflammatory reaction and secondary

infection

• May have granuloma formation

• Usually caused by a congenital malalignment of the hallux
• Great toenail is most commonly affected

• Predisposing factors

• Poorly fitting shoes

ONYCHOCRYPTOSIS • Excessive trimming of lateral nail plate

also known as
• Pincer nail

Ingrown Toenail • Trauma

• General Measures

• Cut nails square

• Wear properly fit shoes

• Conservative treatment

• Cotton or dental floss wedging

• Toe taping

• Nail bracing

• Permanent Treatment

• Nail avulsion + matricectomy

NAIL SURFACE ABNORMALITY

DEFINITION EXAMPLE

• Small areas of abnormal keratinization of the proximal nail matrix

that produce foci of parakeratotic cells in the superficial nail plate

• Small punctate depressions of the superficial nail plate

PITTING • Non-specific

• Association

• Psoriasis (deep and irregularly distributed pits)

• Atopic dermatitis (deep and irregularly distributed pits)

• Alopecia areata (geometric and superficial pits)

 • Grooved lines that run from side to side
• Association

• Eczema
TRANSVERSE RIDGING
• Psoriasis

• Paronychia

• Parakeratosis pustulosa

• Transverse depression affecting all nails

• Due to acute systemic illness stopping nail growth

• Association

BEAU LINE • Eczema

• Erythroderma
• Paronychia

• Viral illness

• Proximal nail plate is detached from the proximal nail fold by a

whole-thickness sulcus

• Association

ONYCHOMADESIS • Eczema

• Erythroderma

• Paronychia

• Viral illness

• Hand-foot-mouth disease

• Vertical raised lines running up and down the length of the

fingernail

• May be physiologic in aging

LONGITUDINAL RIDGING • Association

• Licen planus

• Darier

• Psoriasis

• Fungal nail infection

 • Thick hard curved nail plate in the shape of a ram’s horn

• Association

ONYCHOGRYPHOSIS • Aging (sometimes neglect)

• Psoriasis

• Trauma

• Distal lamellar or splitting/brittle nails

ONYCHOSCHIZIA • Association

• Chronic exposure to water and/or detergent

• Multiple foci of defective keratinization of the proximal nail

matrix
TRACHYONYCIA • Rough nails due to excessive longitudinal ridging

• Association

• Twenty-nail dystrophy (given keratolytics or apply nail lacquer)

• Lichen planus

NAIL COLOR ABNORMALITY

DEFINITION EXAMPLE

• Diffuse pale yellow to dark yellow-reen discoloration

• Absent cuticles

• Association

YELLOW NAIL SYNDROME • Lymphedema

• Cardiopulmonary disease

• Malignant neoplasms

• Rheumatoid arthritis
 • Green-black nail pigmentation due to pyocyanin staining

GREEN NAILS • Association

• Pseudomonas infection

• Pale white nails due to nail bed discoloration that fades with
pressure

• Abnormal keratinization of the underlying nail matrix

LEUKONYCHIA • Association

• Zinc deficiency
• Liver disease

• Kidney disease

• Partial leukonychia
MEE LINES • Association

• Arsenic intoxication
• Systemic disease

• Detachment of the nail plate from the bed causing a white or

yellow appearance

ONYCHOLYSIS • Association

• Trauma

• Inflammatory disease (fungal infection, contact dermatitis)

• Neoplastic nail bed disorders

 • White proximal nail with reddened distal nail

TERRY NAIL • Association

• Liver cirrhosis

• Plum colored linear structures (brown to black)

• Move superficially
SPLINTER HEMORRHAGES • Distal splinter hemorrhages seen with minor trauma psoriasis,
atopic dermatitis.

• Proximal splinter hemorrhages: trauma, sideropenic anemia,

bacterial endocarditis antiphospholipid antibody syndrome

• Brown-black band
• Occur as normal variants in 90% of black people
LONGITUDINAL • May occur in multiple nails
MELANONYCHIA • Association

• Benign melanocytic nevus

• Melanoma
 • Common in persons with dark skin

• Association

• Subungal Melanoma
• Ask family history of melanoma

EXPANDING VARIABLE • Sudden change in appearance of the bands

SHAPED STREAK • Single nail involvement

• Band width >3mm

• Pigment changes extending onto the cuticle and nail fold

(Hutchingson sign)

• Disruption of the nail plate

NAIL VASCULAR ABNORMALITY

DEFINITION EXAMPLE

• Central areas of erythema with white spots surrounded by

radiating white striae and telangiectasia at the periphery

PERIUNGAL TELANGIECTASIA • Association

• Dermatomyositis (where it is most commonly seen)

• Scleroderma

• SLE
 COMMON INFECTIOUS NAIL CONDITIONS

DEFINITION EXAMPLE

• Fungal infection of the nail caused by dermatophytes,

nondermatophyte molds, or yeasts

• Prevalence increases with age (40% of individuals > 60 years old)

• 3 Types

• Distolateral Subungal Onychomycosis (most common)

• Associated with subungal hyperkeratosis, patchy or linear yellow
discoloration

• Proximal Subungal Onychomycosis

• Proximal leukonychia with normal nail plate surface; periungal
inflammation and purulent discharge; infection with HIV should
be suspected with PSO due to Trichophyton rubrum

• White Superficial Onychomycosis

ONYCHOMYCOSIS • Multiple superficial areas of friable opaque leukonychia

• Candida onychomycosis

•  Dystrophic nail with paronychia; candida species is the causative

agent only in immunosuppressed individuals

• Diagnostics

• KOH examination of subungual debris: for confirmation

• Culture of the nail plate and accompanying debris

• Periodic Acid Schiff stain of nail clippings

• Treatment

• Diagnostic confirmation should be done prior to treatment

because it may be hepatotoxic

• Topical: Amorolfine, Ciclopirox   

• Systemic: Terbinafine, Itraconazole, Fluconazole

 DEFINITION EXAMPLE

• Swollen, painful and erythematous proximal nail fold

• Pus may be discharged after pressure

• Most commonly secondary to infection (Staphylococcus aureus)

• Typically affects a child’s fingernail

• Predisposing factors

• Nail biting or sucking

ACUTE PARONYCHIA • Occupational traumas

• Treatment

• Topical antibiotics

• Incision and drainage

• Oral antibiotics with Gram-positive coverage against S. aureus,

• Cephalexin

• Amoxicillin with clavulanic acid

• Clindamycin
• Erythema and scaling of periungal skin
• Absence of cuticle
• Inflammatory disorder that almost exclusively involves the fingernails
of adult women

• Most commonly secondary to mechanical or chemical factors

• Mechanical or chemical traumas damage the cuticle

• Permit penetration of irritant and allergenic environmental

substances

CHRONIC PARONYCHIA
• Inflammatory reaction of the nail folds and matrix

• Secondary colonization with Candida sp. and /or bacteria occurs

• Most commonly affects the first, second, and third fingers of the
dominant hand

• Treatment

• Hand protection from the environmental hazards

• Topical steroids or tacrolimus

• Topical antiseptics