Hair & Nails

Jennifer M. Fu, MD, and Vera H. Price, MD, FRCP(C)

Hair loss in women of color represents a unique diagnostic challenge that requires a systematic approach. In women of color, clinical examination of the hair and scalp is most helpful when performed first and used to guide subsequent history-taking to arrive at a clinical assessment. The most common hair problems in women of color are hair breakage, traction alopecia, and central centrifugal cicatricial alopecia. A careful detailed clinical examination and history will guide the clinician to appropriate counseling and management. It is important to recognize that a patient may have more than one of these 3 diagnoses and each requires separate attention. Traction alopecia is completely preventable with appropriate education of the public and medical establishment.

 *For a PDF of the full article, click on the link to the left of this introduction.

Jennifer M. Fu, MD, and Vera H. Price, MD, FRCP(C)

Hair loss in women of color represents a unique diagnostic challenge that requires a systematic approach. In women of color, clinical examination of the hair and scalp is most helpful when performed first and used to guide subsequent history-taking to arrive at a clinical assessment. The most common hair problems in women of color are hair breakage, traction alopecia, and central centrifugal cicatricial alopecia. A careful detailed clinical examination and history will guide the clinician to appropriate counseling and management. It is important to recognize that a patient may have more than one of these 3 diagnoses and each requires separate attention. Traction alopecia is completely preventable with appropriate education of the public and medical establishment.

 *For a PDF of the full article, click on the link to the left of this introduction.

Jennifer M. Fu, MD, and Vera H. Price, MD, FRCP(C)

Hair loss in women of color represents a unique diagnostic challenge that requires a systematic approach. In women of color, clinical examination of the hair and scalp is most helpful when performed first and used to guide subsequent history-taking to arrive at a clinical assessment. The most common hair problems in women of color are hair breakage, traction alopecia, and central centrifugal cicatricial alopecia. A careful detailed clinical examination and history will guide the clinician to appropriate counseling and management. It is important to recognize that a patient may have more than one of these 3 diagnoses and each requires separate attention. Traction alopecia is completely preventable with appropriate education of the public and medical establishment.

 *For a PDF of the full article, click on the link to the left of this introduction.

Philippe Assouly, MD, and Pascal Reygagne, MD

Lichen planopilaris (LPP), a follicular form of lichen planus, is a rare inflammatory lymphocyte mediated disorder. Although the physiopathology is unclear, an autoimmune etiology is generally accepted. Women are affected more than men, and the typical age of onset is between 40 and 60 years. LLP is a primary cicatricial alopecia whose diagnosis is supported in the early stage by both clinical and histopathological findings. Within the margins of the expanding areas of perifollicular violaceous erythema and acuminate keratotic plugs, the histology can show the lichenoid perifollicular inflammation. LPP can be subdivided into 3 variants: classic LPP, frontal fibrosing alopecia (FFA), and Lassueur Graham-Little Piccardi syndrome. With the exception of FFA, the hairless patches of the scalp can be unique or can occur in multiples and can present with a reticular pattern or as large areas of scarring. This condition can have major psychological consequences for the affected patients. The therapeutic management often is quite challenging, as relapses are common after local or systemic treatments. Further research is needed on the pathogenesis, and randomized controlled trials of treatment with scientific evaluation of the results are necessary to appreciate the proposed treatment.

*For a PDF of the full article, click on the link to the left of this introduction.

Philippe Assouly, MD, and Pascal Reygagne, MD

Lichen planopilaris (LPP), a follicular form of lichen planus, is a rare inflammatory lymphocyte mediated disorder. Although the physiopathology is unclear, an autoimmune etiology is generally accepted. Women are affected more than men, and the typical age of onset is between 40 and 60 years. LLP is a primary cicatricial alopecia whose diagnosis is supported in the early stage by both clinical and histopathological findings. Within the margins of the expanding areas of perifollicular violaceous erythema and acuminate keratotic plugs, the histology can show the lichenoid perifollicular inflammation. LPP can be subdivided into 3 variants: classic LPP, frontal fibrosing alopecia (FFA), and Lassueur Graham-Little Piccardi syndrome. With the exception of FFA, the hairless patches of the scalp can be unique or can occur in multiples and can present with a reticular pattern or as large areas of scarring. This condition can have major psychological consequences for the affected patients. The therapeutic management often is quite challenging, as relapses are common after local or systemic treatments. Further research is needed on the pathogenesis, and randomized controlled trials of treatment with scientific evaluation of the results are necessary to appreciate the proposed treatment.

*For a PDF of the full article, click on the link to the left of this introduction.

Philippe Assouly, MD, and Pascal Reygagne, MD

Lichen planopilaris (LPP), a follicular form of lichen planus, is a rare inflammatory lymphocyte mediated disorder. Although the physiopathology is unclear, an autoimmune etiology is generally accepted. Women are affected more than men, and the typical age of onset is between 40 and 60 years. LLP is a primary cicatricial alopecia whose diagnosis is supported in the early stage by both clinical and histopathological findings. Within the margins of the expanding areas of perifollicular violaceous erythema and acuminate keratotic plugs, the histology can show the lichenoid perifollicular inflammation. LPP can be subdivided into 3 variants: classic LPP, frontal fibrosing alopecia (FFA), and Lassueur Graham-Little Piccardi syndrome. With the exception of FFA, the hairless patches of the scalp can be unique or can occur in multiples and can present with a reticular pattern or as large areas of scarring. This condition can have major psychological consequences for the affected patients. The therapeutic management often is quite challenging, as relapses are common after local or systemic treatments. Further research is needed on the pathogenesis, and randomized controlled trials of treatment with scientific evaluation of the results are necessary to appreciate the proposed treatment.

*For a PDF of the full article, click on the link to the left of this introduction.

Ralph M. Trüeb, MD

Few dermatologic conditions carry as much emotional distress as chemotherapy-induced alopecia (CIA). The prerequisite for successful development of strategies for CIA prevention is the understanding of the pathobiology of CIA. The incidence and severity of CIA are variable and related to the particular chemotherapeutic protocol. CIA is traditionally categorized as acute diffuse hair loss caused by dystrophic anagen effluvium; however, CIA presents with different clinical patterns of hair loss. When an arrest of mitotic activity occurs, obviously numerous and interacting factors influence the shedding pattern. The major approach to minimize CIA is by scalp cooling. Unfortunately, most published data on scalp cooling are of poor quality. Several experimental approaches to the development of pharmacologic agents are under evaluation and include drug-specific antibodies, hair growth cycle modifiers, cytokines and growth factors, antioxidants, inhibitors of apoptosis, and cell-cycle and proliferation modifiers. Ultimately, the protection should be selective to the hair follicle; for example, topical application, such that the anticancer efficacy of chemotherapy is not hampered. Among the few agents that have been evaluated so far in humans, AS101 and minoxidil were able to reduce the severity or shorten the duration of CIA, but could not prevent CIA.

*For a PDF of the full article, click on the link to the left of this introduction.

Ralph M. Trüeb, MD

Few dermatologic conditions carry as much emotional distress as chemotherapy-induced alopecia (CIA). The prerequisite for successful development of strategies for CIA prevention is the understanding of the pathobiology of CIA. The incidence and severity of CIA are variable and related to the particular chemotherapeutic protocol. CIA is traditionally categorized as acute diffuse hair loss caused by dystrophic anagen effluvium; however, CIA presents with different clinical patterns of hair loss. When an arrest of mitotic activity occurs, obviously numerous and interacting factors influence the shedding pattern. The major approach to minimize CIA is by scalp cooling. Unfortunately, most published data on scalp cooling are of poor quality. Several experimental approaches to the development of pharmacologic agents are under evaluation and include drug-specific antibodies, hair growth cycle modifiers, cytokines and growth factors, antioxidants, inhibitors of apoptosis, and cell-cycle and proliferation modifiers. Ultimately, the protection should be selective to the hair follicle; for example, topical application, such that the anticancer efficacy of chemotherapy is not hampered. Among the few agents that have been evaluated so far in humans, AS101 and minoxidil were able to reduce the severity or shorten the duration of CIA, but could not prevent CIA.

*For a PDF of the full article, click on the link to the left of this introduction.

Ralph M. Trüeb, MD

Few dermatologic conditions carry as much emotional distress as chemotherapy-induced alopecia (CIA). The prerequisite for successful development of strategies for CIA prevention is the understanding of the pathobiology of CIA. The incidence and severity of CIA are variable and related to the particular chemotherapeutic protocol. CIA is traditionally categorized as acute diffuse hair loss caused by dystrophic anagen effluvium; however, CIA presents with different clinical patterns of hair loss. When an arrest of mitotic activity occurs, obviously numerous and interacting factors influence the shedding pattern. The major approach to minimize CIA is by scalp cooling. Unfortunately, most published data on scalp cooling are of poor quality. Several experimental approaches to the development of pharmacologic agents are under evaluation and include drug-specific antibodies, hair growth cycle modifiers, cytokines and growth factors, antioxidants, inhibitors of apoptosis, and cell-cycle and proliferation modifiers. Ultimately, the protection should be selective to the hair follicle; for example, topical application, such that the anticancer efficacy of chemotherapy is not hampered. Among the few agents that have been evaluated so far in humans, AS101 and minoxidil were able to reduce the severity or shorten the duration of CIA, but could not prevent CIA.

*For a PDF of the full article, click on the link to the left of this introduction.

Seema Garg and Andrew G. Messenger

Alopecia areata is a common condition causing nonscarring hair loss. It may be patchy, involve the entire scalp (alopecia totalis) or whole body (alopecia universalis). Patients may recover spontaneously but the disorder can follow a course of recurrent relapses or result in persistent hair loss. Alopecia areata can cause great psychological distress, and the most important aspect of management is counseling the patient about the unpredictable nature and course of the condition as well as the available effective treatments, with details of their side effects. Although many treatments have been shown to stimulate hair growth in alopecia areata, there are limited data on their long-term efficacy and impact on quality of life. We review the evidence for the following commonly used treatments: corticosteroids (topical, intralesional, and systemic), topical sensitizers (diphenylcyclopropenone), psoralen and ultraviolet A phototherapy (PUVA), minoxidil and dithranol.

 *For a PDF of the full article, click on the link to the left of this introduction.

Seema Garg and Andrew G. Messenger

Alopecia areata is a common condition causing nonscarring hair loss. It may be patchy, involve the entire scalp (alopecia totalis) or whole body (alopecia universalis). Patients may recover spontaneously but the disorder can follow a course of recurrent relapses or result in persistent hair loss. Alopecia areata can cause great psychological distress, and the most important aspect of management is counseling the patient about the unpredictable nature and course of the condition as well as the available effective treatments, with details of their side effects. Although many treatments have been shown to stimulate hair growth in alopecia areata, there are limited data on their long-term efficacy and impact on quality of life. We review the evidence for the following commonly used treatments: corticosteroids (topical, intralesional, and systemic), topical sensitizers (diphenylcyclopropenone), psoralen and ultraviolet A phototherapy (PUVA), minoxidil and dithranol.

 *For a PDF of the full article, click on the link to the left of this introduction.

Seema Garg and Andrew G. Messenger

Alopecia areata is a common condition causing nonscarring hair loss. It may be patchy, involve the entire scalp (alopecia totalis) or whole body (alopecia universalis). Patients may recover spontaneously but the disorder can follow a course of recurrent relapses or result in persistent hair loss. Alopecia areata can cause great psychological distress, and the most important aspect of management is counseling the patient about the unpredictable nature and course of the condition as well as the available effective treatments, with details of their side effects. Although many treatments have been shown to stimulate hair growth in alopecia areata, there are limited data on their long-term efficacy and impact on quality of life. We review the evidence for the following commonly used treatments: corticosteroids (topical, intralesional, and systemic), topical sensitizers (diphenylcyclopropenone), psoralen and ultraviolet A phototherapy (PUVA), minoxidil and dithranol.

 *For a PDF of the full article, click on the link to the left of this introduction.

Francisco M. Camacho-Martínez

Female pattern hair loss (FPHL) is a clinical problem that is becoming more common in women. Female alopecia with androgen increase is called female androgenetic alopecia (FAGA) and without androgen increase is called female pattern hair loss. The clinical picture of typical FAGA begins with a specific “diffuse loss of hair from the parietal or frontovertical areas with an intact frontal hairline.” Ludwig called this process “rarefaction.” In Ludwig’s classification of hair loss in women, progressive type of FAGA, 3 patterns were described: grade I or minimal, grade II or moderate, and grade III or severe. Ludwig also described female androgenetic alopecia with male pattern (FAGA.M) that should be subclassified according to Ebling’s or Hamilton-Norwood’s classification. FAGA.M may be present in 4 conditions: persistent adrenarche syndrome, alopecia caused by an adrenal or an ovarian tumor, posthysterectomy, and as an involutive alopecia. A more recent classification (Olsen’s classification of FPHL) proposes 2 types: early- and late-onset with or without excess of androgens in each.

*For a PDF of the full article, click on the link to the left of this introduction.

Francisco M. Camacho-Martínez

Female pattern hair loss (FPHL) is a clinical problem that is becoming more common in women. Female alopecia with androgen increase is called female androgenetic alopecia (FAGA) and without androgen increase is called female pattern hair loss. The clinical picture of typical FAGA begins with a specific “diffuse loss of hair from the parietal or frontovertical areas with an intact frontal hairline.” Ludwig called this process “rarefaction.” In Ludwig’s classification of hair loss in women, progressive type of FAGA, 3 patterns were described: grade I or minimal, grade II or moderate, and grade III or severe. Ludwig also described female androgenetic alopecia with male pattern (FAGA.M) that should be subclassified according to Ebling’s or Hamilton-Norwood’s classification. FAGA.M may be present in 4 conditions: persistent adrenarche syndrome, alopecia caused by an adrenal or an ovarian tumor, posthysterectomy, and as an involutive alopecia. A more recent classification (Olsen’s classification of FPHL) proposes 2 types: early- and late-onset with or without excess of androgens in each.

*For a PDF of the full article, click on the link to the left of this introduction.

Francisco M. Camacho-Martínez

Female pattern hair loss (FPHL) is a clinical problem that is becoming more common in women. Female alopecia with androgen increase is called female androgenetic alopecia (FAGA) and without androgen increase is called female pattern hair loss. The clinical picture of typical FAGA begins with a specific “diffuse loss of hair from the parietal or frontovertical areas with an intact frontal hairline.” Ludwig called this process “rarefaction.” In Ludwig’s classification of hair loss in women, progressive type of FAGA, 3 patterns were described: grade I or minimal, grade II or moderate, and grade III or severe. Ludwig also described female androgenetic alopecia with male pattern (FAGA.M) that should be subclassified according to Ebling’s or Hamilton-Norwood’s classification. FAGA.M may be present in 4 conditions: persistent adrenarche syndrome, alopecia caused by an adrenal or an ovarian tumor, posthysterectomy, and as an involutive alopecia. A more recent classification (Olsen’s classification of FPHL) proposes 2 types: early- and late-onset with or without excess of androgens in each.

*For a PDF of the full article, click on the link to the left of this introduction.

Kathrin Hillmann, MD, and Ulrike Blume-Peytavi, MD, PhD

Hair disorders include hair loss, increased hair growth, and hair structure defects with increased breakage, as well as unacceptable cosmetic appearance, such as reduced shine, strength, curliness, and elasticity. It is the task of the dermatologist to choose the right diagnostic tool depending on the suspected clinical diagnosis. Moreover, certain tools are best suited for diagnosis in private practice, whereas others can only be used to monitor hair growth under treatment in clinical studies. The techniques can be classified as either invasive (eg, biopsies in scarring alopecia), semi-invasive (trichogram, unit area trichogram), or noninvasive (eg, global hair counts, phototrichogram, electron microscopy, laser scanning microscopy) methods. Further, one must differentiate between subjective and objective techniques. For the practicing dermatologist, body and scalp hair distribution by use of different grading systems, the hair pull test, and dermoscopy belong in the category of basic diagnostic tools. Basic techniques may be extended by computerassisted phototrichogram and, in selected cases, by use of the trichogram and/or scalp biopsies. For research purposes optical coherent tomography, electron microscopy, biochemical methods, atomic force microscopy, and confocal laser scanning microscopy are optional tools. For clinical studies global photographs (global expert panel), hair weighing, phototrichogram, and different clinical scoring systems have proven to be objective tools for documentation and evaluation of hair growth and hair quality.

*For a PDF of the full article, click on the link to the left of this introduction.

Kathrin Hillmann, MD, and Ulrike Blume-Peytavi, MD, PhD

Hair disorders include hair loss, increased hair growth, and hair structure defects with increased breakage, as well as unacceptable cosmetic appearance, such as reduced shine, strength, curliness, and elasticity. It is the task of the dermatologist to choose the right diagnostic tool depending on the suspected clinical diagnosis. Moreover, certain tools are best suited for diagnosis in private practice, whereas others can only be used to monitor hair growth under treatment in clinical studies. The techniques can be classified as either invasive (eg, biopsies in scarring alopecia), semi-invasive (trichogram, unit area trichogram), or noninvasive (eg, global hair counts, phototrichogram, electron microscopy, laser scanning microscopy) methods. Further, one must differentiate between subjective and objective techniques. For the practicing dermatologist, body and scalp hair distribution by use of different grading systems, the hair pull test, and dermoscopy belong in the category of basic diagnostic tools. Basic techniques may be extended by computerassisted phototrichogram and, in selected cases, by use of the trichogram and/or scalp biopsies. For research purposes optical coherent tomography, electron microscopy, biochemical methods, atomic force microscopy, and confocal laser scanning microscopy are optional tools. For clinical studies global photographs (global expert panel), hair weighing, phototrichogram, and different clinical scoring systems have proven to be objective tools for documentation and evaluation of hair growth and hair quality.

*For a PDF of the full article, click on the link to the left of this introduction.

Kathrin Hillmann, MD, and Ulrike Blume-Peytavi, MD, PhD

Hair disorders include hair loss, increased hair growth, and hair structure defects with increased breakage, as well as unacceptable cosmetic appearance, such as reduced shine, strength, curliness, and elasticity. It is the task of the dermatologist to choose the right diagnostic tool depending on the suspected clinical diagnosis. Moreover, certain tools are best suited for diagnosis in private practice, whereas others can only be used to monitor hair growth under treatment in clinical studies. The techniques can be classified as either invasive (eg, biopsies in scarring alopecia), semi-invasive (trichogram, unit area trichogram), or noninvasive (eg, global hair counts, phototrichogram, electron microscopy, laser scanning microscopy) methods. Further, one must differentiate between subjective and objective techniques. For the practicing dermatologist, body and scalp hair distribution by use of different grading systems, the hair pull test, and dermoscopy belong in the category of basic diagnostic tools. Basic techniques may be extended by computerassisted phototrichogram and, in selected cases, by use of the trichogram and/or scalp biopsies. For research purposes optical coherent tomography, electron microscopy, biochemical methods, atomic force microscopy, and confocal laser scanning microscopy are optional tools. For clinical studies global photographs (global expert panel), hair weighing, phototrichogram, and different clinical scoring systems have proven to be objective tools for documentation and evaluation of hair growth and hair quality.

*For a PDF of the full article, click on the link to the left of this introduction.

David de Berker, BA, MBBS, MRCP

Nail involvement is common at some point in the life of the patient with psoriasis. Simple hand care, keeping nails cut short and avoiding nail trauma, will all help in management. Medical interventions include topical therapies used for psoriasis at other body sites, directed at the location of the disease within the nail unit. Individual digits may require focused intensive treatment, such as steroid injections. Systemic therapy for psoriatic nail disease can be justified when the disease presents in tandem with severe skin disease or where function and quality of life are sufficiently diminished by nail involvement. Biological therapy usually is indicated for widespread psoriasis, but studies show that therapy directed at nail symptoms can be effective in the treatment of coincident nail disease.

*For a PDF of the full article, click on the link to the left of this introduction.

David de Berker, BA, MBBS, MRCP

Nail involvement is common at some point in the life of the patient with psoriasis. Simple hand care, keeping nails cut short and avoiding nail trauma, will all help in management. Medical interventions include topical therapies used for psoriasis at other body sites, directed at the location of the disease within the nail unit. Individual digits may require focused intensive treatment, such as steroid injections. Systemic therapy for psoriatic nail disease can be justified when the disease presents in tandem with severe skin disease or where function and quality of life are sufficiently diminished by nail involvement. Biological therapy usually is indicated for widespread psoriasis, but studies show that therapy directed at nail symptoms can be effective in the treatment of coincident nail disease.

*For a PDF of the full article, click on the link to the left of this introduction.

David de Berker, BA, MBBS, MRCP

Nail involvement is common at some point in the life of the patient with psoriasis. Simple hand care, keeping nails cut short and avoiding nail trauma, will all help in management. Medical interventions include topical therapies used for psoriasis at other body sites, directed at the location of the disease within the nail unit. Individual digits may require focused intensive treatment, such as steroid injections. Systemic therapy for psoriatic nail disease can be justified when the disease presents in tandem with severe skin disease or where function and quality of life are sufficiently diminished by nail involvement. Biological therapy usually is indicated for widespread psoriasis, but studies show that therapy directed at nail symptoms can be effective in the treatment of coincident nail disease.

*For a PDF of the full article, click on the link to the left of this introduction.

Bertrand Richert, MD, PhD, Nadine Lateur, MD, Anne Theunis, MD, and
Josette Andre, MD

Tumors of the nail unit may be difficult to diagnose because of the screening effect of the nail plate. In longitudinal melanonychia, several new promising techniques assist with early diagnosis of melanoma (in vivo matrix dermoscopy and immunohistochemistry) as well as sparing as much of the healthy tissues as is possible (shave biopsy technique). Diagnosing nail disorders is in some instances difficult both for the clinician and the pathologist. New tools such as polymerase chain reaction have been proposed for onychomycosis, which accounts for more than half of nail conditions, will allow quick and accurate diagnosis. However, polymerase chain reaction analysis remains expensive and is not routinely used by clinicians. Scoring nail dystrophy by clinical observation remains very subjective; therefore, severity indexes have been proposed. Another emerging noninvasive technique is forensic analysis of nail clippings for detection of drug intake and abuse, as well as exposure to environmental pollution.

*For a PDF of the full article, click on the link to the left of this introduction.

Bertrand Richert, MD, PhD, Nadine Lateur, MD, Anne Theunis, MD, and
Josette Andre, MD

Tumors of the nail unit may be difficult to diagnose because of the screening effect of the nail plate. In longitudinal melanonychia, several new promising techniques assist with early diagnosis of melanoma (in vivo matrix dermoscopy and immunohistochemistry) as well as sparing as much of the healthy tissues as is possible (shave biopsy technique). Diagnosing nail disorders is in some instances difficult both for the clinician and the pathologist. New tools such as polymerase chain reaction have been proposed for onychomycosis, which accounts for more than half of nail conditions, will allow quick and accurate diagnosis. However, polymerase chain reaction analysis remains expensive and is not routinely used by clinicians. Scoring nail dystrophy by clinical observation remains very subjective; therefore, severity indexes have been proposed. Another emerging noninvasive technique is forensic analysis of nail clippings for detection of drug intake and abuse, as well as exposure to environmental pollution.

*For a PDF of the full article, click on the link to the left of this introduction.

Bertrand Richert, MD, PhD, Nadine Lateur, MD, Anne Theunis, MD, and
Josette Andre, MD

Tumors of the nail unit may be difficult to diagnose because of the screening effect of the nail plate. In longitudinal melanonychia, several new promising techniques assist with early diagnosis of melanoma (in vivo matrix dermoscopy and immunohistochemistry) as well as sparing as much of the healthy tissues as is possible (shave biopsy technique). Diagnosing nail disorders is in some instances difficult both for the clinician and the pathologist. New tools such as polymerase chain reaction have been proposed for onychomycosis, which accounts for more than half of nail conditions, will allow quick and accurate diagnosis. However, polymerase chain reaction analysis remains expensive and is not routinely used by clinicians. Scoring nail dystrophy by clinical observation remains very subjective; therefore, severity indexes have been proposed. Another emerging noninvasive technique is forensic analysis of nail clippings for detection of drug intake and abuse, as well as exposure to environmental pollution.

*For a PDF of the full article, click on the link to the left of this introduction.