Disorders of Adnexal Structures PDF

PINES CITY COLLEGES- DOCTOR OF MEDICINE 2.01 Disorders of Adnexal Structures Lecturer: Dr. Rita Chan Noble Date: September 25, 2...

PINES CITY COLLEGES- DOCTOR OF MEDICINE 2.01 Disorders of Adnexal Structures Lecturer: Dr. Rita Chan Noble Date: September 25, 2023 Lecture / Important Notes / Verbatim / Books Eyelashes Any other hair-bearing areas Hallmark: Yellow or Black dots (Fig. 5) OVERVIEW: o AKA cadaver hairs, point noir Exclamation point hairs Disorders of Adnexal Structures o Blunt distal end and taper proximally I. Alopecia Areata Nail changes can be seen in an estimated 10– II. Telogen Effluvium 40% of patients and tend to be associated III. Acne Vulgaris with more severe disease (Fig. 6) IV. Hyperhidrosis o Nail pitting and ridging are most common. DISORDERS OF ADNEXAL STRUCTURES o Other nail features include koilonychia, HAIR GROWTH CYCLE REVIEW trachyonychia, Beau’s lines, o Anagen is the Active growth phase onychorrhexis, onychomadesis, lasting one to eight years onycholysis, and red spots in the o Catagen is a short involution phase lunula. lasting several weeks (CUTagen) o Telogen is the resting phase lasting several months (Tamad) o Exogen is the shedding of the hair (Exit) I. Alopecia Areata Alopecia = Hair loss, Areata = patchy o Alopecia is a Latin term meaning hair loss and areata refers to the patchy nature of Fig. 1: Alopecia Areata the hair loss Autoimmune Non-scarring Peak incidence: second and third decades o Lifetime risk of alopecia areata is approximately 2%. It affects children and adults of all skin and hair colours 10-42% (+) family history Exact mechanism responsible for hair loss in alopecia areata remains unclear. Fig. 2: Partial Alopecia It is hypothesized that loss of immune privilege Observed in other areas of the body in anagen hair follicles plays a key role in the pathogenesis, and genetic susceptibility is also thought to contribute Major emotional stress prior to the onset Acute onset Patchy alopecia areata is the most common pattern, producing: o Focal hair loss o Well-demarcated single or several round/oval patches of normal-appearing skin. Trichodynia Fig. 3: Alopecia Totalis o Painful sensation of the scalp related to Loss of the entire scalp hair the complaint of hair loss Risk of progression to alopecia totalis or Round-shaped, well- circumscribed, bald, alopecia universalis is approximately 5–10%, from which recovery is unlikely patches with a smooth surface May affect any hair-bearing area o Most common: Scalp ▪ May also affect the: Beard Eyebrows 1|Page TRANSCRIBERS: AsyMIMItric  PINES CITY COLLEGES- DOCTOR OF MEDICINE 2.01 Disorders of Adnexal Structures Lecturer: Dr. Rita Chan Noble Date: September 25, 2023 3. Trichoscopy o Examination of the hair follicle, hair shaft, and scalp with a dermatoscope o Exclamation point hairs, broken or dystrophic hairs, yellow dots and black dots. 4. Skin Biopsy o “Bee-swarm pattern” of dense lymphocytic infiltrates surrounding anagen hair follicles Fig. 4: Alopecia Areata Universalis Loss of Total Body Hair Fig. 5: Cadaver Hair Fig. 8: Bee-swarm pattern Hallmark of Alopecia Areta Treatments Fig 6. Nail Changes Diagnosis of Alopecia Areata 1. Clinical 2. Hair Pull/ Tug Test Fig 9: Treatment Chart for Alopecia o Positive when more than 10% of hairs CORTICOSTEROIDS are easily pulled out o Topical: superpotent (class I) and o Must be done in scalp that was not potent (class II) under occlusion shampooed for more than 24 hours o Intralesional: first-line therapy for o Involves grasping 40–60 closely adults with less than 50% scalp grouped hairs and applying gentle involvement. Concentrations of 2.5- 10 traction mg/mL every 4 to 6 weeks o The process needs to be repeated in at ▪ Initial response seen after 4 to least 3 scalp areas, including the frontal, 8 weeks. occipital, and temporal regions. ▪ Injections of triamcinolone into areas of patchy alopecia of the scalp, beard, or eyebrow have an immunosuppressant effect and may speed up hair regrowth. ▪ Repeated four to six weekly and Fig. 7: Hair Pull Test and Tug Test stopped once regrowth is complete. 2|Page TRANSCRIBERS: AsyMIMItric  PINES CITY COLLEGES- DOCTOR OF MEDICINE 2.01 Disorders of Adnexal Structures Lecturer: Dr. Rita Chan Noble Date: September 25, 2023 o Systemic: Controversial; Effective, but lymphadenopathy in 100% of patients. Caution regrown hair falls out when in dark skinned individuals discontinued PHOTO(CHEMO)THERAPY (UVB/ PUVA) ▪ Generally reserved for short- term use in refractory or II. Telogen Effluvium severe cases. Most common cause of diffuse hair loss ▪ Limited by well-known adverse Increased telogen club hair shedding effects. Non-scarring ▪ In June 2022, The FDA No clinical or histological evidence of approved baricitinib use in inflammation severe alopecia areata. Can affect up to 50% of the scalp hair ▪ Clinical trials are ongoing, but preliminary results also show Acute onset type of TE promise for other JAK 2-4 months from causative events inhibitors. Effluvium of the newborn “Total replacement of ▪ JAK inhibitors block the T-cell- the first pelage” mediated inflammatory o Starts within 4 months after birth response that is thought to be Febrile Illness responsible for damage to the o Hair shedding appeared 3 to 4 months hair follicle. after illness and continued for 3-4 ▪ Oral tofacitinib, baricitinib, and weeks ruxolitinib seem to be more Pregnancy effective than topical o Postpartum alopecia or telogen preparations. gravidarum TOPICAL MINOXIDIL: Better results can be Weight Loss (Crash Diet) achieved when in combination with topical o 11.7 to 24.75kg within 3 weeks to 3 corticosteroids or anthralin. Shows little months efficacy in alopecia totalis and universalis o 0 to 1200 kcal per day Treatments for extensive alopecia areata Surgery (greater than 50% scalp involvement, alopecia totalis, or universalis) Drugs o Topical immunotherapy Most common: o Chemicals such as discontinuation of oral contraceptives diphenylcyclopropenone are applied to retinoids (acitretin, isotretinoin) and vitamin A affected areas to induce an allergic excess contact dermatitis, which may provoke anticoagulants (especially heparin) hair regrowth. antithyroid (propylthiouracil, methimazole) o T-cells are theorized to be “distracted” anticonvulsants (e.g., phenytoin, valproic acid, from attacking hair follicles due to carbamazepine) antigenic competition. interferon-α-2b o Severe dermatitis, urticaria, heavy metals lymphadenopathy, and depigmentation β-blockers (e.g., propranolol) are potential side effects and may limit May be implicated in acute and chronic use. diffuse telogen hair loss Prostaglandin Ana;ogs (Latanoprost and (See appendix for complete list) Bimatoprost): eyelashes and eyebrows ANTHRALIN: Irritant with anti–Langerhans cell Chronic Diffuse Telogen Hair Loss activity; Good safety profile (especially for Temporal insult usually triggers sudden onset children)- not available in PH diffuse hair shedding as seen in acute TE, o Anthralin (dithranol): Limited use in which recovers after the elimination of fair-haired individuals due to brown triggering stress. However, telogen hair staining of skin and hair. shedding may last longer than 6 months TOPICAL IMMUNOTHERAPY Chronic diffuse telogen hair loss (CDTHL) is (Diphenylcyclopropenone) one such condition that is secondary to various Desired effect of the treatment is the creation causes, including thyroid disorders, of a contact dermatitis. Applied weekly with 3|Page TRANSCRIBERS: AsyMIMItric  PINES CITY COLLEGES- DOCTOR OF MEDICINE 2.01 Disorders of Adnexal Structures Lecturer: Dr. Rita Chan Noble Date: September 25, 2023 acrodermatitis enteropathica, malnutrition, and hairs with the percentage of telogen in drugs excess of 20%. o Hypothyroidism o Telogen count of 15–20% is o Hair regrowth observed around 8 weeks suggestive of abnormal shedding, after the initiation of thyroid hormone >20% is diagnostic. replacement o Aging o Malnutrition (protein-deficient) o Iron Deficiency o Serum ferritin level less than 40ng/ml o Zinc Deficiency (Acrodermatitis enteropathica) o Sexually Transmitted Disease Fig. 10: Trichogram o HIV infection and secondary syphilis o Drugs (previous slide) 5. In an active telogen effluvium, a 60-second o Systemic illness timed vertical combing of the hair with count in o Psychological stress excess of 100 hairs (the mean normal value is 10 hairs). Chronic onset type of Telogen Effluvium o 1-4 are normal Idiopathic o 5-6 (+) telogen effluvium Middle aged women in their fourth to sixth decade Telogen hair shedding extends more than 6 months to several years Telogen club hairs can be pulled out easily from the vertex and occipital areas Diagnosis of TE 1. Clinical 2. Hair Pull/ Tug Test o Positive when 5-6 strands are easily pulled out in 2/more areas 3. Trichoscopy o Decrease in hair density and empty hair openings (active phase) or short velus hairs Fig. 11: Comb Test (recovery phase) 4. Trichogram (Fig. 10) o Semiinvasive technique and represents Treatment the most commonly used technique to evaluate hair cycles in the past.The Normal hair regrowth can be expected patient undergoing this procedure within several months once a triggering cause should not wash her or his hair 3 to 5 is successfully identified and eliminated days before examination. Topical minoxidil may be beneficial; however, o Fifty to 100 hairs were clumped by increase in telogen hair loss may be rubber-armed forceps or needle holder experienced 2 to 6 weeks after treatment and forcibly plucked and investigated initiation for the root morphology under a light microscope. Usually, sites 2 cm from III. Acne Vulgaris the front line and midline are sampled Pimples o Normal values vary among the reports: Multifactorial disorder of the pilosebaceous telogen 13% ranging from 4 to 20% unit. may set a standard.1 Acute TE can be Epidemiology suggested if the telogen rate exceeds 25%. Acne is one of the top three most common o A forcible hair pluck will show a skin diseases mixture of anagen and telogen Adolescents and young adults (12-25): 85% Acne can occur at any age 4|Page TRANSCRIBERS: AsyMIMItric  PINES CITY COLLEGES- DOCTOR OF MEDICINE 2.01 Disorders of Adnexal Structures Lecturer: Dr. Rita Chan Noble Date: September 25, 2023 Neonatal acne- first few weeks of life o Can occur in up to 20% of healthy newborns. Lesions usually appear around 2 weeks of age and resolve spontaneously within 3 months. Infantile acne- 1 to 12 months Family history in 62.9% to 78% Severity may also be genetic There are two indigenous populations that have been described—one in Papua New Guinea and the other in Paraguay—that do not Fig.13: Open Comedones develop acne. o Although this may be genetically Closed comedones determined, environmental factors may o “whiteheads” also be at play because these groups o Cream to white, slightly elevated, small have not been exposed to a papules and do not have a clinically westernized diet. visible orifice Pathogenesis Key elements: 1. Follicular epidermal hyperproliferation 2. Sebum production 3. Propionibacterium acnes/ Cutibacterium acnes 4. Inflammation and immune response Clinical Findings Fig. 14: Closed Comedones Inflammatory Lesions The inflammatory lesions vary from small erythematous papules to pustules and large, tender, fluctuant nodules Some of the large nodules were previously called “cysts,” and the term nodulocystic has been used to describe severe cases of inflammatory acne. True cysts are rarely found in acne; this term should be abandoned and substituted with severe nodular acne Fig 12: Illustration of Clinical Findings Primary site of acne is the face o Also: back, chest, and shoulders Several lesion types: o Non- inflammatory comedones (open or closed) o Inflammatory lesions (red papules, pustules, or nodules) Fig. 15: Examples Non-inflammatory Lesions Upper left: Mild, Upper right: Moderate, Lower Open Comedones left: Moderate-Severe, Lower left: Nodules o “blackheads” o Flat or slightly raised lesion with a Clinical Features – History central dark-colored follicular impaction Typical gradual onset of keratin and lipid. If abrupt onset- potential underlying etiology o Dark due to oxidation Hyperandrogenism Abrupt & monomorphous: drug-induced acne 5|Page TRANSCRIBERS: AsyMIMItric  PINES CITY COLLEGES- DOCTOR OF MEDICINE 2.01 Disorders of Adnexal Structures Lecturer: Dr. Rita Chan Noble Date: September 25, 2023 anabolic steroids, corticosteroids, phenytoin, Topical Antibiotics lithium, isoniazid, vitamin B complexes, o Benzoyl Peroxide halogenated compounds, and EGFR inhibitors ▪ Powerful antimicrobial agent Hormone therapy ▪ Markedly reduce the bacterial Progestin-only contraceptives, DHEA or population via release of free testosterone oxygen radicals o dehydroepiandrosterone (DHEA) ▪ Mildly comedolytic Whey protein supplementation ▪ Can produce significant Hyperandrogenism should be considered in a dryness and irritation and can female patient whose acne is severe, in the bleach clothing and hair jawline or lower face distribution, sudden in ▪ Bacteria are unable to onset, or associated with hirsutism or irregular develop resistance, making menstrual periods. The patient should be asked it the ideal agent for about the frequency and character of her combination with topical or menstrual periods and whether her acne flares oral antibiotics with changes in her menstrual cycle. o Erythromycin and Clindamycin ▪ Increasing resistance over Treatments the years ▪ Never as monotherapy ▪ Combine with Benzoyl peroxide Other Topicals o Salicylic Acid ▪ Lipid- soluble β-hydroxy acid ▪ Comedolytic properties but somewhat weaker than those of a retinoid Retinoids ▪ Causes exfoliation of the o Has both comedolytic and anti- stratum corneum through inflammatory property decreased cohesion of the o ideal for MAINTENANCE THERAPY keratinocytes o Bind to nuclear RAR- targets cell ▪ Mild irritant reactions may proliferation, differentiation, result melanogenesis, and inflammation ▪ Less effective than benzoyl o Tretinoin peroxide ▪ Apply on alternate nights o Azelaic Acid during the first few weeks ▪ Prescription in a 20% to ensure greater cream or 15% gel tolerability ▪ Dicarboxylic acid ▪ Avoid sun exposure with ▪ Antimicrobial and comedolytic regular sunscreen use ▪ Competitive inhibitor of ▪ Photolabile- use at night tyrosinase- decrease ▪ Inactivated by concomitant hyperpigmentation use of benzoyl peroxide, ▪ Generally, well tolerated never apply together ▪ Considered safe in pregnancy o Adapalene ▪ Synthetic retinoid Oral Medications ▪ Greater tolerability and o Tetracyclines (Doxycycline and Photostable Minocycline) ▪ May be used in conjunction ▪ Most commonly used with benzoyl peroxide antibiotics ▪ Adapalene 0.1% gel = ▪ Does not alter sebum Tretinoin 0.025% gel production ▪ Decrease the concentration of free fatty acids decreasing 6|Page TRANSCRIBERS: AsyMIMItric  PINES CITY COLLEGES- DOCTOR OF MEDICINE 2.01 Disorders of Adnexal Structures Lecturer: Dr. Rita Chan Noble Date: September 25, 2023 inflammation and bacterial count ▪ Several weeks of therapy are required to observe maximal clinical benefit. o Isotretinoin ▪ For severe recalcitrant nodular acne, acne unresponsive to oral antibiotics and acne resulting in significant physical or emotional scarring Fig 16: Glycemic Index Chart ▪ Complete remission in almost Complications all cases and the longevity of Although not life threatening, it leads to the remission, which lasts for significant morbidity months to years in the great o Depression majority of patients. o Anxiety ▪ Teratogenic o Psychosocial stress ▪ Produce profound inhibition of o Affecting self-esteem sebaceous gland activity All types of acne lesions have the potential to ▪ Great importance in the initial resolve with sequelae: clearing o Transient macular erythema ▪ Side effects mimic chronic o Post-inflammatory hyperpigmentation hypervitaminosis A o Scarring: Atrophic scars can be further ▪ Pseudotumor cerebri if with categorized based on size and shape concomitant use of ▪ Ice pick scars are narrow, deep tetracyclines scars; widest at the surface of the ▪ Must always be used under the skin and taper to a point in the supervision of a dermatologist dermis; less than 2 mm in diameter (Fig. 17) Procedures ▪ Boxcar scars are wide sharply o Acne surgery demarcated scars that do not taper o Intralesional steroid injection to a point at the base and range in o Chemical Peels size from 1.5 to 4 mm. (Fig. 18) o Phototherapy ▪ Rolling scars are shallow, wide o Lasers scars (often >4–5 mm) that have o Dermabrasion an undulating appearance. (Fig. o Microneedling 19) o Fillers ▪ Hypertrophic and keloidal scars o Subcision (Fig. 20) Dietary Restriction o Still controversial o High glycemic index (Fig. 16 Glycemic Index) o Dairy (Skim milk) o Whey protein o Vitamin B complex Fig. 17: Ice Pick Scars 7|Page TRANSCRIBERS: AsyMIMItric  PINES CITY COLLEGES- DOCTOR OF MEDICINE 2.01 Disorders of Adnexal Structures Lecturer: Dr. Rita Chan Noble Date: September 25, 2023 Neonatal Acne o 20% of healthy newborns. o 2 weeks of age and resolve spontaneously in 3 months. o Typically, small, inflamed papules congregate over the nasal bridge and cheeks o No comedones o Malassezia sympodialis Fig. 18: Boxcar Scars Fig. 19: Rolling Scars Fig. 22: Neonatal Acne Infantile Acne o 3 to 6 months o Open and closed comedones over the cheeks and chin Transient elevation of DHEA o Resolves 1- 2 years of age Fig. 20: Keloidal Scars o Treatment: topical retinoids and benzoyl peroxide. ROSACEA, ACNE VARIANTS AND ACNEFORM ERUPTIONS o Oral therapy with erythromycin, Rosacea azithromycin, trimethoprim, or o Flushing, transient erythema, isotretinoin can be used in persistent erythema, telangiectasia, severe or refractory cases. papules, pustules, phymata, edema, pain, stinging or burning, and (very Acne Conglobata rarely) pruritus. o Conglobate means shaped in a rounded mass or ball o Severe nodular acne o Male teenagers o Comedones, papules, pustules, nodules, abscesses with multi- Fig. 21: Rosacea channeled sinuses, and scars arising in a more generalized pattern o Comedones have multiple openings o Heal with scarring o Pattern over the back, buttocks, chest, and, to a lesser extent, on the abdo- men, shoulders, neck, face, upper arms, and thighs 8|Page TRANSCRIBERS: AsyMIMItric  PINES CITY COLLEGES- DOCTOR OF MEDICINE 2.01 Disorders of Adnexal Structures Lecturer: Dr. Rita Chan Noble Date: September 25, 2023 ACNE FULMINANS (Acute febrile Palms, soles, axillae, craniofacial region, groin, ulcerative acne) etc o Most severe form of acne + The cause of primary focal hyperhidrosis systemic symptoms is poorly understood, but is believed to be o Sudden appearance of a result of sympathetic overactivity inflammatory, tender, oozing, without structural defects of the eccrine friable plaques with hemorrhagic glands. Evidence also suggests that crusts hyperhidrosis has a familial component, o Chest and back proposing a possible genetic cause for the o Rapidly become ulcerative and heal condition with scarring. Males = Females o The patients are febrile; have a Begins in childhood or during puberty and leukocytosis, polyarthralgia, myalgia, continues to persist into adulthood hepatosplenomegaly, and anemia. o Childhood (palmar- plantar) or during Bone pain (clavicle and sternum) puberty (axillary), o Radiologic examination may Increased risk for cutaneous infections demonstrate lytic bone lesions. such o Pitted keratolysis Other Acne Variants o Dermatophytosis o Acne excoriee: variant of skin picking o Verruca disorder Focal visible excessive sweating >6 o Acne mechanica months without apparent cause and atleast TWO of the following: Acneform Eruptions o Bilateral and symmetric o Steroid Folliculitis o Onset: before 25 years old o Drug Induced acne o Cessation of sweating during sleep o Occupational acne/ Chloracne o Frequency: at least once per week o Gram-negative folliculitis o (+) Family history o Radiation Acne o Sweating impairs daily activities o Tropical Acne o Acne aestevalis IV. Hyperhidrosis Excessive Sweating Eccrine glands o Main neurotransmitter: Acetylcholine o Eccrine sweating is regulated by neurohormonal mechanisms; a derangement in any part of the regula- tory pathways, such as the thermal center, central or peripheral nerve transmission, or eccrine gland sweat secretion can alter sweating Condition of excessive sweating beyond what is physiologically necessary to maintain normal body temperature Further subdivided into primary and secondary hyperhidrosis Fig. 23: Treatment for PFH Source: Fitzpatrick Primary focal (essential) hyperhidrosis Neurologic disorder Neurologic disorder that manifests as excessive sweating at baseline in various anatomic locations Idiopathic and symmetric 9|Page TRANSCRIBERS: AsyMIMItric  PINES CITY COLLEGES- DOCTOR OF MEDICINE 2.01 Disorders of Adnexal Structures Lecturer: Dr. Rita Chan Noble Date: September 25, 2023 Secondary Hyperhidrosis o Diabetes mellitus, hypoglycemia, Underlying medical conditions (congenital or thyrotoxicosis, carcinoid syndrome, acquired) hyperpituitarism (acromegaly), o 57% - endocrine disease congestive heart failure, dumping o 32% - Neurologic disease syndrome, menopause Side effect from medications or toxins Malignancy- lymphoma Unilateral or asymmetric, generalized, and Drug withdrawal present nocturnally which usually presents in o Hyperhidrosis can be associated with adulthood serotonin (5-hydroxytryptamine) Localized (Focal or Regional) Secondary reuptake inhibitors, opioids, and Hyperhidrosis or Generalized Secondary prostaglandin inhibitors (naproxen) Hyperhidrosis Exogenous bacterial pyrogens -> elevation of the thermal set point Localized (focal or regional) Secondary o Tuberculosis, malaria, brucellosis, and Hyperhidrosis subacute bacterial endocarditis Gustatory sweating Hyperhidrosis that commonly occurs during o Asymmetric and intense acute and chronic administration of opioids is o It is common to experience localized mainly caused by stimulation of mast cell sweating on the lips, forehead, scalp, degranulation, resulting in the release of and nose while eating hot and spicy histamine foods as a physiologic response via Clinical course and prognosis will depend trigeminovascular reflex. on the underlying disease that is o Frey syndrome, upper thoracic and manifesting symptoms of hyperhidrosis or cervical sympathectomy, facial herpes discontinuing a culprit medication. zoster, chorda tympani injury o ▪ Frey syndrome can also be Riley- Day Syndrome (Familial seen in infants and children, dysautonomia) often after birth trauma o AR; IKAP Gene with forceps delivery, but o Profuse sweating and salivation, cases of familial, bilateral Frey diminished production of tears, red syndrome without birth trauma blotching of the skin, absence of have been reported fungiform papillae of the tongue, Paroxysmal Localized Hyperhidrosis episodic orthostatic hypotension, o Daytime paroxysmal hyperhidrosis arterial hypertension, reduced deep affecting the head, neck and upper tendon reflexes, and behavioral trunk abnormalities o Can occasionally affect older Symptoms may be reduced with any of postmenopausal women and less the previously mentioned modalities commonly, men Bromhidrosis o Hot flashes are typically not associated Body odor, osmidrosis, ozochrotia with paroxysmal localized Common; postpubertal population hyperhidrosis Offensive body odor that is excessive or ▪ Hormonal replacement therapy particularly unpleasant is usually ineffective Apocrine and Eccrine glands ▪ Treatment: Clonidine or topical Bromhidrosis is most often reported in the or oral glycopyrrolate axillae (apocrine bromhidrosis). This Eccrine nevus condition may contribute to impairment of o Rare skin hamartoma with hyperplasia an individual’s psychosocial functioning. or hypertrophy of eccrine glands Apocrine Brohidrosis o Clinical: Normal skin with a o After puberty hyperhidrotic isolated patch of skin o Sweat + Bacteria usually on the forearm ▪ Aerobic Corynebacterium o Treatment: Botulinum toxin injections species. and topical glycopyrrolate Eccrine Bromhidrosis Generalized Secondary Hyperhidrosis o Keratinogenic – Plantar, Metabolic Intertriginous 10 | P a g e TRANSCRIBERS: AsyMIMItric  PINES CITY COLLEGES- DOCTOR OF MEDICINE 2.01 Disorders of Adnexal Structures Lecturer: Dr. Rita Chan Noble Date: September 25, 2023 o Metabolic o SURGERY ▪ Phenylketonuria (musty or ▪ The frequency-doubled, “mousy” odor) quality- switched ▪ Maple syrup urine disease neodymium:yttrium-aluminum- (sweet odor) garnet laser also has been ▪ Methionine adenosyltransferase reported to be an effective deficiency (“boiled cabbage” noninvasive therapy for axillary odor) bromhidrosis ▪ Methionine malabsorption ▪ Upper thoracic sympathectomy syndrome (oasthouse ▪ Surgical removal of the culprit syndrome; "beer-like” odor) apocrine glands ▪ Certain foods (garlic, curry, ▪ Surgical subcutaneous tissue alcohol), drugs (bromides), removal also has been used in toxins, or disorders of amino association with CO2 laser acid metabolism, may result in ablation. eccrine bromhidrosis; the latter ▪ Liposuction curettage can being fish odor syn- drome be considered the primary (trimethylaminuria), choice among surgical phenylketonuria, cat syn- procedures used to treat drome, isovaleric acidemia, patients with bromhidrosis hypermethioninemia, and food, because of its fewer drug, toxin ingestion complications. ▪ Trimethylaminuria (“fishy” ▪ Laser hair removal may be odor) * associated with ▪ Dimethylglycine intensification of dehydrogenase deficiency bromhidrosis (“fishy” odor) ▪ Isovaleric acidemia (“sweaty feet” odor) o Exogenous ▪ Foods, e.g., garlic, asparagus, curry ▪ Drugs, e.g., penicillins, bromides ▪ Chemicals, e.g., dimethyl sulfoxide (DMSO) Treatment o GENERAL MEASURES ▪ Frequent washing of the axillae ▪ Use of a deodorant or antiperspirant (aluminum chloride hexahydrate) and perfumes ▪ Changing of soiled clothing ▪ Removal of axillary hair minimize odor by preventing bacteria and sweat accumulation on the hair shafts ▪ Antibacterial soaps or topical antibacterial agents also may be beneficial o NONSURGICAL THERAPY ▪ Botulinum toxin A injection ▪ NDYAG 11 | P a g e TRANSCRIBERS: AsyMIMItric  PINES CITY COLLEGES- DOCTOR OF MEDICINE 2.01 Disorders of Adnexal Structures Lecturer: Dr. Rita Chan Noble Date: September 25, 2023 APPENDIX/For Picture Exam Practice 12 | P a g e TRANSCRIBERS: AsyMIMItric  PINES CITY COLLEGES- DOCTOR OF MEDICINE 2.01 Disorders of Adnexal Structures Lecturer: Dr. Rita Chan Noble Date: September 25, 2023 13 | P a g e TRANSCRIBERS: AsyMIMItric  PINES CITY COLLEGES- DOCTOR OF MEDICINE 2.01 Disorders of Adnexal Structures Lecturer: Dr. Rita Chan Noble Date: September 25, 2023 14 | P a g e TRANSCRIBERS: AsyMIMItric  PINES CITY COLLEGES- DOCTOR OF MEDICINE 2.01 Disorders of Adnexal Structures Lecturer: Dr. Rita Chan Noble Date: September 25, 2023 15 | P a g e TRANSCRIBERS: AsyMIMItric  PINES CITY COLLEGES- DOCTOR OF MEDICINE 2.01 Disorders of Adnexal Structures Lecturer: Dr. Rita Chan Noble Date: September 25, 2023 16 | P a g e TRANSCRIBERS: AsyMIMItric  PINES CITY COLLEGES- DOCTOR OF MEDICINE 2.01 Disorders of Adnexal Structures Lecturer: Dr. Rita Chan Noble Date: September 25, 2023 17 | P a g e TRANSCRIBERS: AsyMIMItric  PINES CITY COLLEGES- DOCTOR OF MEDICINE 2.01 Disorders of Adnexal Structures Lecturer: Dr. Rita Chan Noble Date: September 25, 2023 18 | P a g e TRANSCRIBERS: AsyMIMItric  PINES CITY COLLEGES- DOCTOR OF MEDICINE 2.01 Disorders of Adnexal Structures Lecturer: Dr. Rita Chan Noble Date: September 25, 2023 Full list of drugs implicated in acute and chronic d diffuse telogen hair loss 19 | P a g e TRANSCRIBERS: AsyMIMItric