Derm (1).pptx

PHAS 6300 Family Practice Dermatology Hair and nails are also Derm!! Alopecia Alopecia is the absence or loss of hair in an area where it is expected to be present. Alopecia can be localized or diffuse, temporary or permanent. Alopecias are divided into scarring and nonsca...

PHAS 6300 Family Practice Dermatology Hair and nails are also Derm!! Alopecia Alopecia is the absence or loss of hair in an area where it is expected to be present. Alopecia can be localized or diffuse, temporary or permanent. Alopecias are divided into scarring and nonscarring forms.  Alopecia Vocabulary: Each individual hair follicle perpetually traverses through three stages: (1) growth (anagen) (2) involution (catagen) (3) rest (telogen). Alopecia Androgenetic alopecia is the most common form. Males may present with balding initially in the bitemporal regions, followed by thinning in the vertex region Females present with thinning in the frontal scalp region accompanied by an increase in the part width and retention of the frontal hairline Alopecia Androgenetic alopecia Diagnosis For males, clinical judgement is usually sufficient Occasionally scalp biopsy if there is any doubt that it is not androgenic alopecia Females who present with pattern alopecia should be evaluated for medical conditions or nutritional deficiencies. Alopecia Androgenetic alopecia Management Minoxidil Finasteride If female and there is evidence of androgen excess, antiandrogens or androgen receptor blockers may be useful. Spironolactone is a commonly used option Alopecia Alopecia areata is an immune-mediated disease that targets the bulb region of anagen hair follicles resulting in a shortened anagen cycle. Patients typically complain of asymptomatic patchy hair loss from any hair bearing area.  Alopecia Alopecia areata Limited patchy: Round or oval patches of hair loss  Alopecia Alopecia areata Can also cause diffuse hair loss  Alopecia Alopecia areata Ophiasis pattern: Hair loss in a band like distribution above the ears and lower posterior scalp. Alopecia Alopecia areata Loss of all scalp hair (alopecia totalis) Loss of all body hair (alopecia universalis) Alopecia Diagnosis Alopecia areata is usually quite easy to diagnose. Hair diseases in the differential diagnosis for patchy disease include tinea capitis and trichotillomania Light hair pull test Scalp biopsy if the diagnosis is in doubt Alopecia Alopecia Areata Treatment Corticosteroids Topical or injected into the area of hair loss Prognosis Patients with limited disease usually respond well Extensive disease such as that found with alopecia totalis or alopecia universalis may be more recalcitrant to treatment Alopecia Telogen effluvium The chief complaint is increased hair shedding which is the result of a shortened anagen phase and premature conversion to telogen  Alopeci a Telogen effluvium can be associated with the onset of androgenetic alopecia, the postpartum period, some medications, weight loss, endocrine disorders, physiological and metabolic stress, nutritional deficiencies, acute and chronic illness, after surgeries, and with scalp inflammation. When the inciting trigger can be identified and be removed or treated, hair shedding may diminish and regrowth occur  Alopeci a Diagnosis Hair Pluck Collection of fibers Treatment In most cases the telogen effluvium process will resolve Sometimes it is only when the medical problem causing it is resolved. For some patients it will become chronic Alopecia Cicatrical (Scarring) Affected patients will alopecias frequently complain not The cicatricial or scarring only of hair loss but also alopecias are a group of of severe pain or burning. diverse disorders with a Some patients may common end result – describe their scalp permanent injury to the "being on fire" while hair follicle others will be almost asymptomatic.  Cicatrical alopecia Lichen planopilaris Frontal fibrosing alopecia  Cicatrical alopecia Central Discoid lupus centrifugal erythematosi scarring s alopecia  Cicatrical alopecia Acne Dissecting keloidalis cellulitis  Pediculosis (lice) A parasitic infestation of the skin of the scalp, trunk, or pubic areas Head lice May be transmitted by shared use of hats or combs Epidemic among children of all socioeconomic classes in elementary schools Adults contacting children with head lice frequently acquire the infestation  Pediculosis (lice) Body lice Usually occur among people who live in overcrowded dwellings with inadequate hygiene facilities Trench fever, relapsing fever, and typhus are transmitted by the body louse in countries where those diseases are endemic Pubic lice may be sexually transmitted Pediculosis (lice) Essentials of Diagnosis Pruritus with excoriation Nits on hair shafts; lice on skin or clothes Occasionally, sky-blue macules (maculae ceruleae) on the inner thighs or lower abdomen in pubic louse infestation Pediculosis (lice) Essentials of Diagnosis Pruritus with excoriation Nits on hair shafts; lice on skin or clothes Occasionally, sky-blue macules (maculae ceruleae) on the inner thighs or lower abdomen in pubic louse infestation  Pediculosis (lice) Treatment Permethrin 1% lotion is the treatment of choice Malathion lotion (Ovide) is effective but highly volatile and flammable For involvement of eyelashes, petrolatum (petroleum jelly) is applied thickly twice daily for 8 days, and remaining nits are then plucked off Pediculosis (lice) Treatment Body lice are treated by disposing of the infested clothing and addressing the patient's social situation (eg, housing instability) Sexual contacts should be treated Clothes and bedclothes should be washed and dried at high temperature Folliculitis Folliculitis has multiple causes. It is frequently caused by staphylococcal infection and may be more common in the patient with diabetes. When the lesion is deep-seated, chronic, and recalcitrant on the head and neck, it is called sycosis.  Folliculitis The symptoms range from slight burning and tenderness to intense itching Signs: pustules of hair follicles Folliculitis Gram-negative folliculitis, may develop during antibiotic treatment of acne It may present as a flare of acne pustules or nodules. Klebsiella, Enterobacter, Escherichia coli, and Proteus have been isolated from these lesions.  Folliculitis Hot tub folliculitis (Pseudomonas folliculitis) Caused by Pseudomonas aeruginosa, is characterized by pruritic or tender follicular, pustular lesions occurring within 1–4 days after bathing in a contaminated hot tub, whirlpool, or swimming pool Management: watchful waiting or ciprofloxacin  Folliculitis Nonbacterial folliculitis may be caused by friction and oils. Occlusion, perspiration, and chronic rubbing (eg, from tight-fitting clothing or heavy fabrics on the buttocks and thighs) can worsen this type of Pseudofolliculitis barbae Common synonym ‘razor bumps’ Most frequently seen in men of color and is made worse by shaving Related to curved hair follicles. Cut hair retracts beneath skin surface, grows, and penetrates follicular wall (transfollicular type) or surrounding skin (extrafollicular type), causing a foreign-body reaction. Keloidal scarring in varying degrees occurs at involved sites. S. aureus secondary infection is common.  Folliculitis keloidalis AKA Acne keloidalis Nuchae Commonly seen in black men or men of color but can also be seen in women Management High potency corticosteroids topically or intralesional corticosteroid injections Topical clindamycin or mupirocin if pustules present Prevention The best way to prevent pseudofolliculitis barbae and acne keloidalis nuchae is to avoid shaving  Acne vulgaris Open and closed comedones are the hallmark of acne vulgaris Face, neck, and upper trunk may be affected Closed comedones are tiny, flesh- colored, noninflamed superficial papules that give the skin a rough texture or appearance Open comedones typically are a bit larger and have black material in them  Rosacea Rosacea is a common inflammatory skin disease that often affects convex surfaces of the central face (cheeks, nose, chin, and forehead). It usually occurs in adults aged 30–50 years and typically persists with intermittent flares. It is more common in women, but men tend to have more severe disease.  Rosacea Clinical manifestations: The rosacea diathesis: episodic erythema, “flushing and blushing.” History of episodic reddening of the face (flushing) in response to hot liquids, spicy foods, alcohol, or exposure to sun and heat. Unlike Acne vulgaris, comedones are not present.  Rosacea STAGING (PLEWIG AND KLIGMAN CLASSIFICATION) Stage I: Persistent erythema with telangiectasias. Stage II: Persistent erythema, telangiectasias, papules, and tiny pustules. Stage III: Persistent deep erythema, dense telangiectasias, papules, pustules, and nodules; rarely persistent “solid” edema on the central part of the face.  Rosace aStage Stage Stage 1 2 3 Rosacea Phymata Phymatous rosacea is a persistent, firm, nonpainful, nonpitting swelling of the tissue of the nose (rhinophyma), chin (gnathophyma), forehead (metophyma), or eyelids (blepharophyma) Initially presents as ‘dilated patulous follicles’ Rosacea Rhinophymata Can develop into a “peau d’orange” appearance of the nose. Rhinophyma of the fibrous form can cause severe deformity due to hyperplasia of connective tissue and sebaceous hyperplasia  Rosacea Management Topical Metronidazole gel or cream, Ivermectin cream. Azelaic acid. SYSTEMIC Minocycline or doxycycline first-line antibiotics; very effective. Oral metronidazole 500 mg BID, second line, effective. Oral Isotretinoin is reserved for severe disease (especially stage III) not responding to antibiotics and topical treatments.  Rosacea Management The β-blocker carvedilol reduces erythema and telangiectasia Topical brimonidine 0.5% gel rapidly reduces erythema and telangiectasia, but not in all cases. Rhinophyma and telangectasia can both be treated by surgery or laser surgery with excellent cosmetic results.  Onychomyco sis Fungal infection of the nail plate. More common in the elderly (affects 50% of people over 70 years). Usually, toenails affected.  Onychomycosis ETIOLOGIC AGENTS About two-thirds of onychomycosis caused by dermatophytes (T. rubrum most common, T. mentagrophytes). COURSE AND PROGNOSIS Without effective therapy, onychomycosis does not resolve spontaneously, and usually instead progresses to involve other nails.  Onychomyco sis Diagnosis Clinical diagnoses of onychomycosis should be confirmed by laboratory testing Clippings of affected nail plate and subungual hyperkeratotic debris can be assessed via microscopy (KOH, PAS) or fungal culture, which is less sensitive but can identify the  Onychomycosis Treatment Oral terbinafine is the preferred treatment Itraconazole is also effective and can be taken weekly but costs more than terbinafine and has more drug interactions Efinaconazole (Jublia) and Ciclopirox topical (penlac) is second line due to low cure rate Laser treatment is available but may be more cosmetic than curative Onycholysis Lifting of the nail plate from the nail bed Etiology Inflammatory: Psoriasis contact dermatitis, photodrug reaction Infection (Candida). Trauma. Nail bed tumors.  Onycholysis Nails with onycholysis can become secondary infected with P. aeruginosa, causing a brown or greenish discoloration Alopecia areata nail changes Manifestations: Hammered brass appearance. Red lunulae. Trachyonychia roughness caused by excessive longitudinal striations  Paronychia Acute infection of the lateral or proximal nail fold Findings: Pain, erythema, swelling Course: May be rapid and severe Bacteria: Usually S. aureus Treatment Warm soaks Drainage if an abscess forms Antibiotics if severe or not improving Dicloxacilin, cephalexin, erythromycin, azithromycin