Welcome to the Hair and Nail Clinic 2008

Transcription

1 Welcome to the Hair and Nail Clinic 2008 The expectations for each resident rotating through the Hair & Nail Clinic are outlined below. HAIR AND NAIL CLINIC Goals and Objectives for First Year Residents 1. Learn basics of history taking and clinical exam and write clear, concise and structured notes: How to take a history: Is hair coming out by the roots or is it breaking? Increased shedding or increased thinning? Duration Medications Menses, pregnancies, menopause Past health, especially in previous year Hair care, hair cosmetics Family history of similar problem Diet: adequate protein? adequate iron? Clinical examination Hair length: How long does hair grow? All same length? Size of pony tail? Hair texture; silky, shiny, brittle, dull? Pattern and distribution of hair loss Pull test, Tug test Hair Card assessment: Miniaturized hair? Hair tips tapered or broken? Scalp Hair elsewhere: too much or too little Acne, hirsutism, obesity, virilization 2. Familiarity with the hair growth cycle 3. Recognize and manage common hair disorders: alopecia areata, androgenetic alopecia, telogen effluvium, structural hair shaft anomalies, trichotillomania, anagen arrest 4. Classify hair disorders into diagnostic groups: Non-cicatricial (scarring) alopecia vs cicatricial : Non-cicatricial: Hair coming out by the roots or Hair breaking Differential diagnosis of each

2 Cicatricial alopecia: Primary or Secondary 5. Learn basic diagnostic techniques: Hair Pull test, Hair Tug test, Hair Card, Hair mount, Scalp biopsy How to do a Hair Pull test: *With the thumb and forefinger grasp a small swatch of hairs (approx. 5 mm area on the scalp) and grasp the hairs close to the scalp. *Gently but firmly slide the fingers away from the scalp, at a 90 degree angle, along the entire length of the hair swatch. Do not tug or jerk. Warn the patient that you are going to pull the hair. Negative pull test = 1 to 4 hairs Positive pull test = 5 or more hairs *Where to pull? In alopecia areata: At the margin of a patch to see if the patch is active In any unaffected site to see if there is pending activity Pull on a patch of new growth to see if the new hair is serious.. How to use the Hair Card (enclosed) How to make a Hair Mount: Decide if hair shaft or hair bulb are relevant Place hair on contrasting black or white velvet background Select hair segments to be cut (1-2 cm) & mounted Place four to five segments parallel to long axis of slide With wooden end of Q tip, drop 1 or 2 drops of mounting medium on hairs Mounting medium: Permount, Harleco synthetic resin (not oil or KOH) Cover with cover slip, press gently to eliminate bubbles How to do a Scalp biopsy: In all scarring alopecias Occ. in trichotillomania, alopecia areata, androgenetic alopecia Select site, mark with marking pen 1% xylocaine with epinephrine; wait 10 minutes Full thickness biopsy to subcutaneous fat; 3 0 suture, remove in 2 weeks On path requisition write Scalp biopsy: for horizontal sections 6. Familiarity with administration and dosing of intralesional triamcinolone acetonide, immunomodulating agents (topical anthralin, oral hydroxychloroquine, mycophenolate mofetil, cyclosporine, oral corticosteroids), oral antibiotics, oral retinoids, topical minoxidil, finasteride, oral contraceptives in androgen-mediated skin disorders 7. Present at least one patient per month at weekly rounds.

3 Required Readings for First Year Residents Androgenetic alopecia Price VH: Treatment of Hair Loss. NEJM 341: ,1999 Price VH. Androgenetic alopecia in women. J Invest Dermatol Symposium Proceedings 8: 24-27, 2003 Price VH. Androgenetic alopecia in adolescents. Cutis 71: , 2003 Mirmirani P, Price VH. Top 10 misconceptions about androgenetic alopecia in women. Cosmetic Dermatology 30-31, December 2000 Frieden IJ, Price VH. Androgenetic alopecia. In Pathogenesis of Skin Disease,Thiers & Dobson (eds), Churchill Livingstone, NY 41-55, 1986 Alopecia areata Madani S; Shapiro J.Alopecia areata update. JAAD 42(4):549-66,2000 Price VH: Treatment of Hair Loss. NEJM 341: , 1999 Price VH, Colombe BW. Heritable factors distinguish two types of alopecia areata. Dermatologic Clinics 14: , 1996 Colombe BW, Lou CD, Price VH. The genetic basis of alopecia areata: HLA associations with patchy alopecia areata versus alopecia totalis and alopecia universalis. J Invest Dermatol Symposium Proceedings 4, , Shapiro J, Price VH. Hair Regrowth: therapeutic agents. Dermatol. Clin 16: , 1998 Columbe BW, Price VH, Khoury EL, et al. HLA class II antigen associations help define two types of alopecia areata. J Am Acad Dermatol 33: Video: How to inject alopecia areata. Structural hair shaft anomalies Price VH. Structural anomalies of the hair shaft. In Hair and Hair Diseases, Orfanos CE, Happle R (eds). Springer-Verlag, Berlin, Heidelberg, New York, pp , Trichotillomania Sah, DE, Koo J, Price VH. Trichotillomania. Dermatologic Therapy 21: 13-21, 2008 Whiting DA. Traumatic alopecia. International Journal of Dermatology, 1999 May, 38 Suppl 1: Muller Sa. Trichotillomania: A histopathic study in sixty-six patients. J Am Acad Dermatol 23: 56-62, Anagen arrest Van Scott EJ, Reinertson RP, Steinmuller R. J Invest Dermatol 29: 197, Crounse RG, Van Scott EJ. J Invest Dermatol 35: 83, 1960.

4 Goals and Objectives for Second-Year Residents 1. In addition to the goals for first-year residents: 2. Recognize more complex and less common hair disorders such as cicatricial alopecias (including lymphocytic group, neutrophilic group), trichothiodystrophy, loose anagen syndrome, uncombable hair syndrome, bubble hair, hair loss in lupus erythematosus, syphilis, graft vs host disease, thyroid disease. 3. Understand special problems of African-American hair 4. Familiarity with hair follicle and hair shaft morphology; hair bulge 5. Knowledge of vertical and transverse histology of normal scalp 6. Knowledge of transverse histopathology of common scalp disorders 7. Understand basics of hair cosmetics 8. Understand hormonal control of the hair follicle Required Readings for Second-Year Residents Headington JT. Transverse microscopic anatomy of the human scalp. Arch Dermatol 120:339-56, 1984 Whiting DA. Diagnostic and predictive value of horizontal sections of scalp biopsy specimens in male pattern androgenetic alopecia. J Am Acad Dermatol 28:755-63, 1993 Olsen EA, Bergfeld WF, Cotsarelis G, Price VH, Shapiro J et al. Summary of North American Hair Research Society (NAHRS)-sponsored Workshop on Cicatricial Alopecia. JAAD 48: , 2003 Ross EK. Primary Cicatricial Alopecia: Clinical Features and Management. Dermatologic Nursing 19: , 2007 Price VH. Medical treatment of cicatricial alopecia. Semin Cutan Med Surg 25:56-59, 2006 Mirmirani P, Willey A, Headington JT, Stenn K, McCalmont TM, Price VH. Primary cicatricial alopecia: histological findings do not distinguish clinical variants. J Am Acad Dermatol 2005: 52:637-43, 2005 Mirmirani P, Willey A, Price VH. Short course of oral cyclosporine in lichen planopilaris, J Am Acad Dermatol 49:667-71, 2003 Price VH, Odom RB, Ward WH, Jones FT. Trichothiodystrophy. Sulfur-deficient brittle hair as a marker for a neuroectodermal symptom complex. Arch Dermatol 116: , 1980 Chen E, Cleaver JE, Weber CA, Packman S et al. Trichothiodystrophy: Clinical Spectrum, central nervous system imaging, and biochemical characterization of two siblings. J Invest Dermatol 03:154S-8S, 1994 Price VH. Trichothiodystrophy: A defect in transcription. In Trichology: Diseases of the Pilosebaceous Follicle. F. Camacho and W Montagna (Eds). Aula Medica Group, S.A:237-42, 1997 Liang C, Kraemer KH, Morris A, Schiffman R, Price VH, Menefee E, DiGiovanna JJ. Characterization of tiger tail banding and hair shaft abnormalities in trichothiodystroohy. J Am Acad Dermatol: 52:224-32, 2005

5 Price VH, Gummer CC. Loose anagen syndrome. J Am Acad Dermatol 20: , 1989 Price VH. Testosterone metabolism in the skin. A review of its function in androgenetic alopecia, acne vulgaris, and idiopathic hirsutism including recent studies with antiandrogens. Arcg Dermatol 111: , 1975 Sawaya ME, Price VH. Different levels of 5α-reductase type I and II, aromatase, and androgen receptor in hair follicles of women and men with androgenetic alopecia. J Invest Dermatol 109: ,1997 Price V, Sawaya M, Headington J, Kibarian M. Histology and hormonal acivity in sensecent thinning in males. JID Suppl: 117:434, 2001

6 Goals and Objectives for Third-Year Residents 1. Greater depth of knowledge of all the goals of the first and second-year residents: 2. Familiarity with genetic basis of structural hair shaft anomalies 3. Familiarity with current debates on some major issues in hair disorders 4. Familiarity with current hair growth assessment methods, i.e. hair counts, hair weights, global photography 5. Familiarity with hair follicle transplants Required Readings for Third-Year Residents Headington JT. Telogen effluvium: new concepts and review. Arch Dermatol 129:356-63, 1993 Whiting DA. Chronic telogen effluvium. Dermatol Clinics 14:723-31, 1996 Uno H, Cappas A, Schlagel C. Cyclic dynamics of hair follicles and the effect of minoxidil on the bald scalp of the stumptailed macaques. Am J Dermatopath 7: , 1985 Diani AR, Mulholland MJ, Shull KL, et al. Hair growth effects of oral administration of finasteride, a steroid 5α-reductase inhibitor, alone and in combination with topical minoxidil in the balding stumptail macaque. J Clin Endocrinol Metab 1992;74: Kaufman K. Androgen metabolism as it affects hair growth in androgenetic alopecia. Dermatol Clin. 14: , 1996 Price VH, Menefee E. Quantitative estimation of hair growth I: androgenetic alopecia in women: effect of minoxidil. J Invest Dermatol 95:683-7, 1990 Kaufman KD, Olsen EA, Whiting DA, et al. Finasteride in the treatment of men with androgenetic alopecia. J Am Acad Dermatol 1998;39: Price VH, Menefee E. Changes in hair weight and hair count in men with androgenetic alopecia after application of 5% and 2% topical minoxidil, placebo, or no treatment. JAAD 1999; 41: Price VH, Menefee E, Sanchez M, Ruane P, Kaufman KD. Changes in hair weight and hair count in men with androgenetic alopecia after treatment with finasteride 1mg daily. J A, Acad Dermatol 46: , 2002 Price VH, Menefee E, Sanchez M, Kaufman KD. Changs in hair weight in men with androgenetic alopecia after treatment with finasteride (1 mg daily). Three and four year results. J Am Acad Dermatol 55:71-4, 2006 Khoury EL, Price VH, Abdel-Salam MM, Stern M, Greenspan JS. Topical minoxidil in alopecia areata: no effect on the perifollicular lymphoid infiltration. J Invest Dermatol 99:40-47, 1992

7 Price VH, Hordinsky MK, Olsen EA, Roberts JL et al. Subcutaneous efalizumab is not effective in the treatment of alopecia areata. JAAD 58: , 2008 Karnik P, Xu LF, McCormick TS, Price VH, Cooper KD, Mirmirani P. Pro-Inflammatory lipid mediators in the pathogenesis of cicatricial alopecia. JID Suppl 1: 128:914, 2008 Mirmirani P, Price VH, Karnik P. Decreased expression of follicular transglutaminases: A possible cause for loose anchoring of anagen hair in active primary cicatricial alopecia. JID Suppl 1: 128:285, 2008 Ochoa BE, King LE Jr, Price VH. Lichen planopilaris: Annual incidence in four hair referral centers in the Unites States. JAAD 58: , 2008